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Y4 Cancer Care > 7 - Breast > Flashcards

7 - Breast Flashcards

1
Q

What are the risk factors for breast cancer?

A

THINK ABOUT OESTROGEN EXPOSURE

  • Female gender
  • Age
  • Family history
  • Personal history of breast cancer
  • Genetic predispositions (e.g. BRCA 1, BRCA 2)
  • Early menarche and late menopause
  • Nulliparity
  • Increased age of first pregnancy
  • Multiparity (risk increased in period after birth, then protective later in life)
  • Combined oral contraceptive
  • Hormone replacement therapy
  • White ethnicity
  • Exposure to radiation
  • Obesity
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2
Q

What type of HRT increases the risk of breast cancer?

A

Combined!!!!!

COCP also raises risk but risk back to normal after 10 years of stopping

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3
Q

What are the BRCA mutations and what do they increase the risk of?

A

BRCA 1
Mutation on chromosome 17
Breast cancer risk of 65-80%
Risk of ovarian cancer is 40-45%

BRCA 2
Mutation on chromosome 13
Breast cancer risk of 45-70%
Risk of ovarian cancer is 11-25%.

Baseline breast cancer risk is 12%
Base line ovarian cancer risk is 1.3%

Prostate and pancreatic cancer risk worse in BRCA 2
Also known to increase the risk of peritoneal, endometrial, fallopian, pancreatic and prostate cancer.

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4
Q

What type of genes are BRCA1 and 2 and what are some other genes that predispose to breast cancer?

A

Tumour suppressor genes

TP53 and PTEN genes

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5
Q

What are the different types of breast cancer and where in the breast do they arise from?

A
  • Ductal carcinoma in situ
  • Invasive ductal carcinoma (MOST COMMON)
  • Lobular carcinoma in situ
  • Invasive lobular carcinoma
  • Inflammatory breast cancer
  • Paget’s disease
  • Medullary
  • Mucinous
  • Tubular
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6
Q

What is special type vs non-special type breast cancer?

A
  • Non-special type is invasive ductal carcinoma
  • Special type is any lobular carcinomas, any ductal carcinoma in situ and others
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7
Q

What is Paget’s disease of the nipple and inflammatory breast cancer?

A

Inflammatory Breast Cancer

  • 1-3% of breast cancers
  • Cancer cells block lymphatic drainage so inflammed swollen breast
  • Presents similarly to a breast abscess or mastitis
  • Swollen, warm, tender breast with pitting skin (peau d’orange)
  • Does not respond to antibiotics
  • Worse prognosis than other breast cancers

Paget’s Disease of the Nipple

  • Looks like eczema of the nipple/areolar
  • Erythematous, scaly rash
  • Indicates breast cancer involving the nipple
  • May represent DCIS or invasive breast cancer
  • Requires biopsy, staging and treatment
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8
Q

What are the molecular subtypes of invasive breast cancer?

A

Depends on expression of oestrogen receptors, progesterone receptors, HER2 receptors and Ki67

  • Luminal A
  • Luminal B
  • Basal
  • HER2
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9
Q

Who in England is invited for breast cancer screening?

A

Women and trans-men/women aged 47-73 every 3 years (50-70 in the past)

May be invited younger if family history

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10
Q

What does breast screening involve and what are the different results?

A

Mammogram in caudal-cranial and mediolateral oblique views

  • Satisfactory: no radiological evidence of breast cancer
  • Abnormal: abnormality detected, further investigations needed. 25% of these will have cancer
  • Unclear: results or imaging unclear or inadequate. Further investigations required
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11
Q

What are the pros and cons of breast cancer screening?

A

Pros

  • Early detection of cancers
  • Approximately 20% reduction in relative risk of death from breast cancer
  • Can provide peace-of-mind for some patients

Cons

  • Painful and undignified
  • Not 100% sensitive (i.e. false negatives)
  • Over treatment
  • False positive results can be emotionally distressing for patients
  • Exposure to radiation, with a very small risk of causing breast cancer
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12
Q

What patients are classed as being at ‘high-risk’ of breast cancer and need to be offered earlier screening?

A
  • A first-degree relative with breast cancer under 40 years
  • A first-degree male relative with breast cancer
  • A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
  • Two first-degree relatives with breast cancer
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13
Q

What can people at high risk of breast cancer be offered?

A
  • Genetic testing with pre-test counselling
  • Annual mammogram potentially starting from aged 30
  • Chemoprevention: Tamoxifen if premenopausal, Anastrozole if postmenopausal (except with severe osteoporosis)
  • Risk-reducing bilateral mastectomy or bilateral oophorectomy
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14
Q

How may breast cancer present?

A
  • Asymptomatic: picked up on screening
  • Breast pain
  • Axilla or breast lump
  • Changes to skin on breast
  • Changes to nipples: inversion, discharge
  • Lymphadenopathy
  • Metastatic complications: bone pain, headaches, seizures, SOB, jaundice etc
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15
Q

What is the referral criteria for a 2 week wait for breast cancer?

A
  • >30 with unexplained breast lump with or without pain or
  • >50 with any of the following symptoms in one nipple only:
    • Discharge
    • Retraction
    • Other changes of concern
  • With skin changes that suggest breast cancer
  • >30 with an unexplained lump in the axilla
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16
Q

What is the criteria for a non-urgent referral for breast changes?

A

Under 30 with unexplained breast lump with or without pain

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17
Q

What does in situ mean for a cancer?

A

Basement membrane is not breached

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18
Q

What investigations are done for a 2 week wait for breast cancer?

A

One Stop Clinic for triple assessment

  1. History and Examination
  2. Imaging: US if <40, mammogram if >40
  3. Histology: fine needle aspiration or core biopsy
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19
Q

What signs can a mammogram and US pick up that are suggestive of breast cancer?

A
  • Mammogram: calcifications
  • US: can tell cystic from solid lumps
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20
Q

If a triple assessment confirms breast cancer, what further investigations need to be done for the patient?

A

All with the aim to stage and look for metastases

Bloods

  • FBC
  • U+Es
  • LFT
  • Bone profile

Imaging

  • CXR
  • MRI breast: helps to guide treatment and plan surgery
  • CT chest, abdo, pelvis
  • CT brain: In symptomatic patients with suspected neurological spread.
  • Contrast-enhanced liver USS
  • Bone scan

Receptor Testing

  • ER
  • PR
  • HER2 (human epidermal growth receptor)

Axilla Lymph Nodes

  • FNA OR
  • Sentinel node biopsy whilst having surgery

Genetic Testing

  • If <50 and triple negative consider looking for BRCA½
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21
Q

What is gene expression profiling?

A

Assessing which genes are present within the breast cancer on a histology sample

Helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years

Recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative. It helps guide whether to give additional chemotherapy

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22
Q

What are the main sites of metastases for breast cancer?

A

Liver
Lungs
Brain
Bones

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23
Q

How is breast cancer staged?

A

TNM

  • Lymph node assessment and biopsy
  • MRI of the breast and axilla
  • Liver USfor liver metastasis
  • CT of the thorax, abdomen and pelvis
  • Isotope bone scan for bony metastasis
24
Q

What are the principles of management for breast cancer?

A

MDT APPROACH

Treated as early-stage, locally advanced and advanced metastatic disease

25
Surgery is often used in treatment of early breast cancer. What are the different surgeries done?
**_Resection of tumour_** * **Conservative**: wide local excision * **Mastectomy** **_Lymph Nodes_** * Do sentinel lymph node biopsy * Axillary clearance if above shows needed **_Reconstruction_**
26
What needs to be done before resection surgery for breast cancer?
* **If no palpable axillary lymph nodes:** axilla US, if positive need sentinel lymph node biopsy in surgery * If **palpable axillary lymph nodes:** do lymph node clearance regardless
27
What are the risks of axillary node clearance?
* Chronic lymphoedema * Functional arm impairment * Seroma formation
28
How can lymphedema from breast cancer surgery be managed?
* Massage techniques to manually drain the lymphatic system * Compression bandages * Specific lymphoedema exercises to improve lymph drainage * Weight loss if overweight * Good skin care
29
How do you decide between a mastectomy and wide local excision?
**_Wide Local Excision_** _(WLE)_ * Most common, need 1cm margin of macroscopically normal tissue with malignancy * Only suitable for **focal smaller cancers** * Dependent on location and relative size of breast **_Mastectomy_** * Indicated in cases of **multifocal disease, high tumour:breast tissue ratio, disease recurrence, or patient choice** * Amount of skin left behind depends on type of reconstruction planned
30
What are the different types of reconstructive breast surgery?
Immediate or delayed After breast-conserving surgery (WLE) * **Partial reconstruction** (using a flap or fat tissue to fill the gap) * **Reduction and reshaping** (removing tissue and reshaping both breasts to match) After mastectomy: * **Breast implants** * **Flap reconstruction** (using tissue from another part of body to reconstruct breast)
31
What are the different types of flap reconstruction breast surgery?
**_Latissimus Dorsi Flap_** “**Pedicled**”: keeping original blood supply and moving tissue under skin to new location “**Free flap**”: cutting tissue away completely and transplanting it to new location **_Transverse Rectus Abdominis Flap (TRAM Flap)_** Pedicled or free flap Risk of abdominal hernia **_Deep Inferior Epigastric Perforator Flap (DIEP Flap)_** **Free flap**. The **deep inferior epigastric artery**, with the associated fat, skin and veins, is transplanted from the abdomen to the breast. The vessels are attached to branches of the **internal mammary artery and vein** This is a complex procedure involving microsurgery Less risk of an abdominal wall hernia as abdominal wall muscles left intact
32
When is radiotherapy for breast cancer used?
Adjunct to surgery ## Footnote **WLE:** given to all patients, whole breast if invasive, partial breast if in situ **After mastectomy:** Offer only if positive resection margins, tumour size \>5cm, or 4 or more pathological nodes in axilla (T3/T4) **Lymph nodes**: not given if axilla was negative or after lymph node clearance
33
What is the aim of radiotherapy after breast surgery and what are the side effects of this?
Aim is to reduce recurrence, by around ⅔rds * General fatigue from radiation * Local skin and tissue irritation and swelling * Fibrosis of breast tissue * Shrinking of breast tissue * Long term skin colour changes (usually darker)
34
When is chemotherapy given in breast cancer?
* Usually neoadjuvant before surgery to shrink primary tumour so can do breast-conserving surgery rather than mastectomy * If given adjuvantly it is to try and prevent recurrence
35
What hormone therapy is given in breast cancer and how does it work as a treatment?
Patients with **ER/PR positive disease** are offered adjuvant endocrine therapy * **Tamoxifen**: Selective Estrogen Receptor Modulator SERM used first-line in men and pre-menopausal women. It **blocks** oestrogen receptors in **breast tissue**, and **stimulates** oestrogen receptors in the **uterus** and **bones**. Therefore protective against osteoporosis * **Aromatase inhibitors** (e.g. anastrozole): Used first-line in post-menopausal women who are at high or medium risk of disease recurrence. Inhibits peripheral conversion of androgens to oestrogens. Alone they are *not* effective in premenopausal women where oestrogens are primarily synthesised by the ovaries
36
What are some of the side effects of the hormone therapy for breast cancer and how long is hormone therapy used for?
Given after adjuvant chemotherapy, given for 5 years to try to prevent recurrence **Tamoxifen** * Blood clots * Hot flushes * Nausea * Vaginal bleeding * Endometrial cancer * Should *not* become pregnant whilst on it or for 2 months post-treatment **Aromatase Inhibitors** * Menopausal symptoms * Osteoporosis * MSK pain
37
If a pre-menopausal woman has breast cancer that is ER+, what can be done other than giving her tamoxifen?
Ovarian function suppression: * **GnRH analogue** (e.g. goserelin) * **Laparoscopic oophorectomy** * **Fulvestrant** (selective oestrogen receptor downregulator)
38
Give three examples of aromatase inhibitors?
* Letrozole * Anastrozole * Exemestane
39
What biologics (immunotherapy) can be used in breast cancer treatment and when?
Need to be HER2+ve **Trastuzumab** (**Herceptin**): monoclonal antibody that targets the HER2 receptor **Pertuzumab** (**Perjeta**) is another monoclonal antibody that targets the HER2 receptor **Neratinib** (**Nerlynx**) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer
40
What are the side effects of **Trastuzumab?**
Given every 3 weeks for 1 year * **Cardiotoxic:** cardiac function should be assessed prior to and during use * Teratogenicity
41
How is metastatic breast cancer managed other than supportively?
**_Dependent on receptor status, ER, PR and HER2_**_:_ * Endocrine treatment with **tamoxifen** or **anastrozole** and targeted therapy with **Herceptin** may be used where receptor status is positive **_Prevent lytic bone lesions, reduce bone pain and prevent fracture:_** * **Denosumab** and **bisphosphonates**
42
What is the 5 year survival for breast cancer in general?
**_One Year_** 95.8% **_Five years_** 85%
43
How is the prognosis of breast cancer calculated more accurately?
**Nottingham Prognostic Index** **Tumour Size** x 0.2 + **Lymph node score** + **Grade score** In this system the tumour size is weighted less heavily than other major prognostic parameters.
44
What factors determine prognosis in breast cancer?
* Tumour size * Nodal involvement * Grade * Vascular invasion * Receptor status * Type of cancer * Patient's performance status and comorbidities
45
How are DCIS and LCIS usually diagnosed and how are they then managed?
**_DCIS_** * **Dx:** detected as micro calcifications on screening * **Mx**: Wide local excision **_LCIS_** * **Dx:** Incidental finding on biopsy of breast, no micro calcifications * **Mx**: If low grade monitoring rather than excision
46
Why may an MRI instead of a mammogram be done in a triple assessment clinic?
**_Offer MRI to patients with invasive breast cancer:_** – if there is discrepancy between the clinical and imaging assessment of disease extent – if breast density precludes accurate mammographic assessment – to assess tumour size if breast conserving surgery is being considered for invasive lobular cancer
47
What is the difference between FNA and core biopsy for breast cancer?
48
What is the histology of most breast cancers?
ADENOCARCINOMA (ductal or lobular, in situ or invasive)
49
What is the blood supply and lymphatic drainage of the breasts?
Lymph node drainage to axillary or internal mammary chain
50
What questions can you ask someone with a previous history of breast cancer to screen for metastases?
Headaches?
51
How is hypercalcaemia from a malignancy managed?
52
What follow up care should be given to patients following breast cancer treatment?
Annual mammography for 5 years and open access
53
How should brain metastases in breast cancer be managed?
Surgery Whole brain radiotherapy (if very poor prognosis and not suitable for surgery)
54
What are some differentials for a breast lump?
Malignancy
55
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Y4 Cancer Care (17 decks)

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