Dear Dr Brown,

Georgina Whetton's diagnosis was confirmed on 16 September 2026 at Royal Stoke Hospital, discussed with her by Miss JafferBhoy and breast care nurse Elena Hill: left breast cancer, 13 x 9mm, provisionally grade 2, working stage 1 (the armpit node biopsy was clear), oestrogen receptor positive, progesterone receptor positive, HER2 borderline on the first test and sent for FISH testing. You will have Miss JafferBhoy’s clinic letter of 17 September, which records ER 8, PR 8 and grade 2 invasive carcinoma of no special type. Planned treatment is a lumpectomy with sentinel lymph node biopsy as a day case, provisionally listed for a couple of weeks’ time at County Hospital, Stafford, subject to pre-operative assessment, followed by radiotherapy and seven to ten years of hormone tablets; a chemotherapy decision will follow the HER2 result and the operation results. I am writing ahead of surgery to flag six points that have been reviewed by Dr Gemma Lewis MRCS MRCGP, a family contact who is a GP and surgeon, so that they can be considered at Georgina's own GP appointment.

The assessment clinic was at Royal Stoke Hospital, University Hospitals of North Midlands NHS Trust (NHS number 454 282 0556). The breast care nurse, Sarah, can be reached on 01782 674077 if you wish to liaise directly.

1. Antihypertensive therapy, bisoprolol 2.5mg and candesartan 8mg, was stopped on 22 August 2026. Off treatment, home blood pressure has averaged 150/64 over 23 readings, with a peak of 176/70 on 5 September. The surgeon has said blood pressure must be adequately controlled before the operation, which may be as soon as 30 September, so this is time-critical. [Dr Lewis's recommendation: candesartan alone]
2. Simvastatin 40mg was stopped on 22 August 2026 as a patient-led trial. QRISK3 is 10.5% and a lipid recheck is due. [Dr Lewis's recommendation: restart simvastatin]
3. Georgina is taking vaginal estradiol pessaries and is asking whether to continue these given the breast findings. [Dr Lewis's recommendation: continue if helping prolapse symptoms] The receptor status above was not known when this recommendation was given; you may wish to confirm with Dr Lewis whether it changes her answer.
4. Metformin was stopped on 22 August 2026. HbA1c is 36, with a repeat due in three months. This is for information. [Dr Lewis's recommendation: no action until the repeat HbA1c result is available]
5. Haemoglobin has fallen from 143 in May to about 132 in August, with red cell count, haematocrit and platelets falling in parallel. All values remain within range and ferritin is 142. [Dr Lewis's recommendation: no action needed, this will be repeated at pre-operative assessment]
6. Wearable data over five months suggests sleep-disordered breathing, with 10 to 15 breathing disturbances an hour and overnight oxygen dips to the low 70s. There has been no formal sleep study. [Dr Lewis's recommendation: sleep assessment at a later date if nasal strips do not help; patient is prepared to use a CPAP device]

Given the likely short timeframe to surgery, I would be grateful if these points could be reviewed ahead of pre-operative assessment. I am happy to provide the full evidence pack behind these six points if that would be useful.