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Cancer Care > Breast > Flashcards

Breast Flashcards

1
Q

breast cancer is the ? cancer in the UK?

A

most common

mostly women - 1% of cases in men

1 in 8 women will develop breast cancer in their lifetime

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2
Q

what are some risk factors for breast cancer?

A
  • Female (99% of breast cancers)
  • Increased oestrogen exposure (earlier onset of periods and later menopause)
  • More dense breast tissue (more glandular tissue)
  • Obesity
  • Smoking
  • Family history (first-degree relatives)
  • nuliparity - or older at first pregnancy
  • age
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3
Q

describe the increased risk associated with the COCP?

A

small increase in risk of breast cancer

risk returns to normal 10 years after stopping the pill

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4
Q

does HRT increase the risk of breast cancer?

A

yes - particularly combined HRT

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5
Q

What is the BRCA gene and describe the consequences of mutations in BRCA 1 & 2

A

BReast CAncer gene - tumour suppressor genes

mutations in these genes lead to an increased risk of breast cancer (+ovarian and others)

BRCA 1 on chromosome 17 - faulty gene =

  • Around 70% will develop breast cancer by aged 80
  • Around 50% will develop ovarian cancer
  • Also increased risk of bowel and prostate cancer

BRCA 2 on chromosome 13 - faulty gene =

  • Around 60% will develop breast cancer by aged 80
  • Around 20% will develop ovarian cancer
  • men with it have 6% chance of developing cancer
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6
Q

other than BRCA name 2 other genetic abnormalities that are associated with breast cancer?

A

TP53

PTEN

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7
Q

name 7 types of breast cancer?

A
  1. Ductal carcinoma in situ
  2. Lobular carcinoma in situ
  3. Invasive ductal carcinoma - NST
  4. Invasive lobular carcinomas
  5. Inflammatory breast cancer
  6. Pagets disease of the nipple
  7. Rarer types include - medullary, mucinous, tubular
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8
Q

what is ductal carcinoma in situ (DCIS) and describe some features

A
  • Pre-cancerous or cancerous epithelial cells of the breast ducts
  • Localised to a single area
  • Often picked up by mammogram screening
  • Potential to spread locally over years
  • Potential to become an invasive breast cancer (around 30%)
  • Good prognosis if full excised and adjuvant treatment is used
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9
Q

what is lobular carcinoma in situ (LCIS) and describe some features

A
  • A pre-cancerous condition occurring typically in pre-menopausal women
  • Usually asymptomatic and undetectable on a mammogram
  • Usually diagnosed incidentally on a breast biopsy
  • Represents an increased risk of invasive breast cancer in the future (around 30%)
  • Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)
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10
Q

what is invasive ductal carcinoma - NST

A
  • NST means no special/specific type, where it is not more specifically classified (e.g., medullary or mucinous)
  • Also known as invasive breast carcinoma of no special/specific type (NST)
  • Originate in cells from the breast ducts
  • 80% of invasive breast cancers fall into this category
  • Can be seen on mammograms
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11
Q

what is invasive lobular carcinoma (ILC) and describe some features?

A
  • Around 10% of invasive breast cancers
  • Originate in cells from the breast lobules
  • Not always visible on mammograms
  • metastasise to atypical sites - gi, ovary
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12
Q

what is inflammatory breast cancer and describe some features?

A
  • 1-3% of breast cancers
  • 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
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13
Q

what is Paget’s disease of the nipple and describe some features?

A
  • 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, as with any other invasive breast cancer
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14
Q

what is the NHS breast screening program and who is it offered to?

A

mammogram every 3 years to women aged 50 – 70 years

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15
Q

how many women in 100 are diagnosed with breast cancer after going for a mammogram?

A

1 in 100

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16
Q

what are some downsides to screening for breast cancer?

A
  • Anxiety and stress
  • Exposure to radiation, with a very small risk of causing breast cancer
  • Missing cancer, leading to false reassurance
  • Unnecessary further tests or treatment where findings would not have otherwise caused harm

but generally the benefits outweigh the downsides and breast cancer screening is recommended

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17
Q

there are different recommendations for screening patients with a higher risk due to family history of breast cancer

specific criteria for a referral from primary care for patients that may be at higher risk due to family history include:

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

may be seen in secondary care breast clinic or a specialist genetic clinic

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18
Q

for high risk patients, what is required before performing genetic testing?

A

genetic counselling and pre-test counselling

need to discuss the benefits and drawbacks of genetic testing such as implications for family members and offspring

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19
Q

what do some high risk women get as a result of their increased risk for developing breast cancer? some of the options/interventions

A

annual mammogram - offered between specific ages depending on risk level

chemoprevention may be offered for women at high risk with tamoxifen if premanopausal or anastrazole if postmenopausal

risk reducing bilateral mastectomy or bilateral oophorectomy - suitable for small number of women and requires significant counselling and weighing up risks and benefits

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20
Q

how may breast cancer present?

A
  • Lumps that are hard, irregular, painless or fixed in place
  • Lumps may be tethered to the skin or the chest wall
  • Nipple retraction
  • Skin dimpling or oedema (peau d’orange)
  • Lymphadenopathy, particularly in the axilla
  • mastalgia
  • screening
  • mets - confusion (brain mets)
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21
Q

what is peau d’orange

A

skin change seen in cancer

blockage of lymph = oedema

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22
Q

what are the NICE criteria for 2ww for suspected breast cancer?

A
  • An unexplained breast lump in patients aged 30 or above (with or without pain)
  • Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
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23
Q

when should 2ww for breast cancer be considered?

A
  • An unexplained lump in the axilla in patients aged 30 or above
  • Skin changes suggestive of breast cancer

non urgent for pt under 30 with lump

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24
Q

how are women <30 referred?

A

non-urgent referral for unexplained breast lump

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25
Q

what is the triple diagnostic assessment?

A

once referred under 2ww women will receive the triple diagnostic assessment comprising of:

  • Clinical assessment - history and examination
  • Imaging - ultrasound or mammography
  • Biopsy - fine needle aspiration or core biopsy
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26
Q

what are the imaging options used to assess women and who is suitable for which scans?

A

USS - better for use in younger women as they have more dense breasts with more glandular tissue. USS helpful to distinguish solid lumps from cystic lumps

Mammograms - more effective in older women as they can pick up calcifications missed on USS

MRI - used for screening in women at higher risk and to further assess the size and features of a tumour

27
Q

what biopsy options are there

A

FNA - only cytology

sentinel node biopsy - can grade cancer from this

USS guided guided biopsy

28
Q

how are the lymph nodes assessed?

A

All women are offered an ultrasound of the axilla (armpit) and ultrasound-guided biopsy of any abnormal nodes.

A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

29
Q

what is the sentinel lymph node biopsy?

A

performed during breast surgery for cancer

isotope contrast and blue dye injected into the tumour area

travels through the lymphatics to the 1st lymph node

1st node in the drainage of tumour area shows up blue and on the isotope scanner

biospy can be performed and if cancer cells are found lymph nodes can be removed

30
Q

what investigations are done whrn you think somone has cancer?

A

bloods - FBC UE LFT CRP bone profile

imaging - CXR CT bone scan/pet scan

other - hormone receptor and HER2 status

31
Q

describe the role of breast cancer receptors in treatment

A

breast cancer cells may have receptors that can be targeted with breast cancer treatments

receptors are tested for on samples of tumour to help guide treatment

3 types = oestrogen receptors (ER), progesterone receptors (PR), human epidermal growth factor (HER2)

32
Q

what is triple-negative breast cancer and what is the prognosis?

A

where the cancer cells do not express any of these receptors

carries a worse prognosis as it limits treatment options for targeting cancer

33
Q

what is gene expression profiling and who is it recommended for?

A

assessing which genes are present within breast cancer on histology sample

helps predict the probability that the breast cancer will reoccur as a distal metastasis within 10 years

recommended for women with early breast cancers that are ER positive but HER2 and lymph node negative

helps guide whether to give additional chemotherapy

34
Q

where does breast cancer commonly metastasise to?

A
  • L – Lungs
  • L – Liver
  • B – Bones
  • B – Brain

can metastasise anywhere

35
Q

how is treatment for breast cancer decided?

A

fitness of pt

histology and receptors

stage of disease

36
Q

how is breast cancer staged?

A

TNM staging

1st step in staging is triple assessment

additional investigations may be needed:

  • lymph node assessment and biopsy
  • MRI of breast and axilla
  • liver uss for liver mets
  • CT of thorax, abdo and pelvis
  • isotope bone scan for bony mets
37
Q

what are the 2 options for breast surgery?

A
  • Breast-conserving surgery (e.g., wide local excision, 1cm margin, dependent on cancer and the breast tissue), usually coupled with radiotherapy
  • Mastectomy (removal of the whole breast), potentially with immediate or delayed breast reconstruction
38
Q

what is axillary clearance?

A

Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. This increases the risk of chronic lymphoedema in that arm.

39
Q

what is chronic lymphoedema and how is it managed?

A

chronic condition caused by impaired lymphatic drainage of an area - can occur in an entire arm after breast cancer surgery with removal of axillary lymph nodes in armpit

areas of lymphoedema are prone to infection

specialist lymphoedema services can help in management

  • massage techniques to manually drain lymphatic system
  • compression bandages
  • specific exercises to improve drainage
  • weight loss if overweight
  • good skincare

note - avoid bloods/cannulas from side of previous breast cancer removal surgery

40
Q

when is radiation used in breast cancer patients?

A

used in pt with breast-conserving surgery to reduce risk of recurrence

high dose radiation delivered from multiple angles to concentrate radiation to targeted area

pt will have course after surgery - eg everyday for 3 weeks

41
Q

what are some side effects of breast radiation?

A
  • General fatigue from the radiation
  • Local skin and tissue irritation and swelling
  • Fibrosis of breast tissue
  • Shrinking of breast tissue
  • Long term skin colour changes (usually darker)
42
Q

describe 3 scenarios in which chemotherapy is used for breast cancer?

A
  • Neoadjuvant therapy – intended to shrink the tumour before surgery
  • Adjuvant chemotherapy – given after surgery to reduce recurrence
  • Treatment of metastatic or recurrent breast cancer
43
Q

which group of patients are eligible for hormone treatment and give the 2 1st line options

A

Patients with oestrogen-receptor positive breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer.

There are two main first-line options for this:

  • Tamoxifen for premenopausal women
  • Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole or exemestane)
44
Q

what is Tamoxifen?

A

selective oestrogen receptor modulator

either blocks or stimulates oestrogen receptors depending on the site of action

blocks oestrogen receptors in the breast and stimulates in uterus & bones

helps prevent osteoporosis but does increase risk of endometrial cancer

45
Q

what are aromatase inhibitors?

A

work by blocking the creation of oestrogen in fat tissue

after menopause, action of aromatase in fat tissue is primary source of oestrogen

aromatase in an enzyme found in fat tissue which converts androgens to oestrogen

46
Q

how long are tamoxifen and aromatase inhibitors given for?

A

5-10 years

47
Q

what are 3 other options for women with oestrogen-receptor positive breast cancer

A
  • Fulvestrant (selective oestrogen receptor downregulator)
  • GnRH agonists (e.g., goserelin or leuprorelin)
  • Ovarian surgery
48
Q

name 3 targeted treatment examples

A

Trastuzumab (Herceptin)

Pertuzumab (Perjeta)

Neratinib (Nerlynx)

49
Q

what is Trastuzumab (Herceptin)?

A

monoclonal antibody that targets the HER2 receptor

may be used in patients with HER2 positive breast cancer.

Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.

50
Q

what is Pertuzumab (Perjeta)?

A

monoclonal antibody that targets the HER2 receptor.

may be used in patients with HER2 positive breast cancer

This is used in combination with trastuzumab (Herceptin).

51
Q

what is Neratinib (Nerlynx)?

A

tyrosine kinase inhibitor, reducing the growth of breast cancers

may be used in patients with HER2 positive breast cancer.

52
Q

how are women with breast cancer followed up?

A

The NICE guidelines (2018) recommend all patients treated for breast cancer have surveillance mammograms yearly for 5 years (longer if they are not yet old enough for the regular breast screening programme).

Patients treated for breast cancer are given an individual written care plan, including details on:

  • Designated contacts and details
  • Adjuvant treatment review dates
  • Surveillance dates
  • Advice on identifying recurrence
  • Support service details
53
Q

what are the 2 options for reconstructive surgery for women having a mastectomy?

A
  • Immediate reconstruction, done at the time of the mastectomy
  • Delayed reconstruction, which can be delayed for months or years after the initial mastectomy
54
Q

what are the 2 options for women having breast-conserving surgery (reconstruction may not be required)

A
  • Partial reconstruction (using a flap or fat tissue to fill the gap)
  • Reduction and reshaping (removing tissue and reshaping both breasts to match)
55
Q

what are the 2 options for reconstruction following mastectomy?

A
  • Breast implants (inserting a synthetic implant)
  • Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
56
Q

what are breast implants?

A

Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring. It gives an acceptable appearance but can feel less natural (e.g., cold, less mobile and static size and shape). There can also be long-term problems, such as hardening, leakage and shape change.

57
Q

what are the 3 different flap reconstruction options?

A

Latissimus Dorsi Flap

Transverse Rectus Abdominis Flap (TRAM Flap)

Deep Inferior Epigastric Perforator Flap (DIEP Flap)

58
Q

what is a Latissimus Dorsi Flap?

A

The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue. The tissue is tunnelled under the skin to the breast area.

“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location.

“Free flap” refers to cutting the tissue away completely and transplanting it to a new location.

59
Q

what is a transverse rectus abdominis flap?

A

The breast can be reconstructed using a portion of the rectus abdominis, blood supply and skin. This can be either as a pedicled flap (tunnelled under the skin) or a free flap (transplanted). It poses a risk of developing an abdominal hernia due to the weakened abdominal wall.

60
Q

what is a Deep Inferior Epigastric Perforator Flap (DIEP Flap)?

A

The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a 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. There is less risk of an abdominal wall hernia than with a TRAM flap, as the abdominal wall muscles are left intact.

61
Q

what are some terms for describing a breast lump?

6 s

4 c

4 t

A

Site

Symmetry

Scar and skin

Size

Shape

Suraface

Colour

contour

compressibility

consistency

Temp

Tender

Tethering

Transillumination

62
Q

how can some people present if they are presenting with metastatic disease?

A

lung - malignant pleural effusion

brain - seizures, focal neurology, change in personality, confusion

bone - path fractures, confusion, spinal cord compression, hypercalcaemia

liver - mass, jaundice

63
Q

complications of axillary lymph node clearance

A

lymphoedema

immobility, swelling, tightness

manual drainage, massage, compression stockings

Cancer Care (11 decks)

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