Breast Flashcards
What is the breast cancer screening programme in the UK?
- women aged 50-70 years
- Offered mammogram every 3 years
- women can self refer after age 70
- if increased risk breast ca - eligible for earlier screening.
Which patients with a family history of breast cancer should be referred to breast clinic for further assessment and screening from a younger age?
- one first deg female relative diagnosed at <40
- one first deg male relative diagnosed at any age
- one first deg female relative with bilateral breast cancer first diagnosed at <50
- two first deg relatives, or one first deg and one second deg relative diagnosed at any age
- one first/second deg relative with breast cancer at any age and one first/second deg relative with ovarian cancer at any age (one of the two should be first deg)
- three first deg or second deg relatives diagnosed at any age.
What are the 2ww referral criteria for suspected breast cancer?
- aged >=30 with unexplained breast lump (with or without pain). Or an unexplained lump in the axilla.
- Aged >=50 with any of the following symptoms in one nipple only:
- discharge
- retraction
- other changes of concern.
Any age with skin changes that suggest breast cancer.
Consider non-urgent referral for those aged <30 with an unexplained breast lump (with or without pain).
What are the risk factors for breast cancer?
- BRCA1, BRCA2 genes - 40% lifetime risk of breast or ovarian cancer
- 1st degree pre-menopausal relative with breast cancer
- nulliparity. 1st pregnancy aged >30 years
- early menarche, late menopause
- COCP, combined HRT
- not breastfeeding
- ionising radiation
- p53 gene mutations
- obesity
- alcohol
How is breast cancer managed in general?
Depends on the staging, tumour type and patient background. It may involve any of the following:
* surgery
* radiotherapy
* hormone therapy
* biological therapy
* chemotherapy
What are the contraindications and cautions for tamoxifen?
- pregnancy, breastfeeding
- personal history of VTE - if the indication is only primary prevention of breast cancer, or for infertility. For treatment of breast cancer - this is a caution.
- caution: assoc with reduced bone density in premenopausal women
When is tamoxifen used in the treatment of breast cancer? How does it work?
- tamoxifen is a selective oestrogen receptor modulator (SERM)
- binds to oestrogen receptors, resulting in oestrogen agonist or oestrogen antagonist-like effects of varying magnitudes in different tissues
- In the breast tissue it acts as an oestrogen antagonist
- First line for men and pre-menopausal women with ER+ breast ca
- Licensed for: treatment of oestrogen-receptor-positive breast cancer. Primary prevention of breast cancer in women at moderate or high risk. Treatment of anovulatory infertility. Should be continued for 5 years - specialist advice prior to stopping.
What are the most common adverse effects of tamoxifen?
- hot flushes (reported in about 50% of women), nausea, fluid retention, vaginal bleeding, vaginal discharge, fatigue, and skin rash. Cataracts, retinopathy.
For nausea - take with food/milk or at night. Usually improves after a few weeks.
For menopausal syx - non hormonal Rx: antidepressants, vaginal moisturisers, lubricants, CBT, relaxation techs.
What are the serious adverse effects of tamoxifen?
- rarely causes endometrial cancer (increased endometrial changes - hyperplasia, polyps, cancer, uterine sarcoma) Urgently Ix - abnormal vaginal bleeding, vaginal discharge, pelvic pain or pressure.
- VTE - common. Esp if major surgery/immobility.
What are the important drug interactions with tamoxifen?
- CYP inhibitors - reduce effect of tamoxifen
- hormonal contraceptives - increased risk VTE, also contraindicated in current breast cancer/within 5 years of breast ca.
- HRT or tibolone - increased risk VTE, and CI in current/past/suspected breast Ca
- warfarin- increased bleeding
When are aromatase inhibitors indicated and how do they work?
- anastrozole, letrozole, exemestane.
- ER+ breast cancer in **post-menopausal **women.
- inhibits enzyme aromatase from converting androgens into oestrogens (main source of oestrogen synthesis in post-menopausal women). Continued for 5 years. Specialist advice before stopping.
When is trastuzumab (herceptin) indicated for breast cancer treatment? How does it work?
- Biological therapy- monoclonal antibody directed against HER2 receptor within the breast cancer.
- Indicated for HER2 + breast cancer
- Given IV every 3 weeks for 1 year.
What are the cautions for trastuzumab (herceptin)?
- heart failure
- Hx MI, or angina
- cardiomyopathy
- arrhythmias
- valvular heart disease
- poorly controlled HTN
What is cyclical breast pain?
Cyclical breast pain is related to the menstrual cycle, with symptoms usually starting within 2 weeks of, and improving at the onset of, the menstrual period.
How should cyclical breast pain be managed in primary care?
- reassure
- patient info leaflet
- well-fitting bra, supportive bra during exercise, soft support bra at night.
- PO paracetamol +/- ibuprofen or topical NSAID prn
- keep pain diary
- refer to breast specialist if so severe affecting QoL/sleep and not responded to first-line Rx after 3 months. specialist Options: danazol, tamoxifen.
- consider PMS if other physical and psych premenstrual symptoms.
