Breast Cancer Flashcards
List 4 risk factors for breast cancer
- Female
- Earlier menarche, late menopause
- Family history (first-degree relatives)
- COCP
- HRT
+ More dense breast tissue, obesity, smoking
BRCA 1 and 2 are what type of genes?
Tumour suppressor genes
What chromosome is BRCA 1 vs 2 located on?
- BRCA1 gene is on chromosome 17
- BRCA2 gene is on chromosome 13
What cancers are associated with BRCA 1?
Breast, Ovarian, Bowel and Prostate cancer
What cancers are associated with BRCA 2?
Breast and Ovarian cancer
List the various types of breast cancer
- Ductal Carcinoma In Situ (DCIS)
- Lobular Carcinoma In Situ (LCIS)
- Invasive Ductal Carcinoma – NST
- Invasive Lobular Carcinomas (ILC)
- Inflammatory Breast Cancer
- Paget’s Disease of the Nipple
What is DCIS?
Pre-cancerous or cancerous epithelial cells of the breast ducts which are localised to a single area
Often picked up by mammogram screening
Potential to become invasive (30%)
Prognosis of DCIS?
Good if full excised and adjuvant treatment is used
What is LCIS
Pre-cancerous condition which typically occurs in pre-menopausal women (↑ risk of invasive breast cancer ~30%)
Asymptomatic and undetectable on a mammogram → usually incidental diagnosis on biopsy
Management of Lobular Carcinoma In Situ (LCIS)?
Close monitoring eg. 6 monthly examination and yearly mammograms
What is a Invasive Ductal Carcinoma – NST
- Originate in cells from the breast ducts
- Includes 80% of invasive breast cancers
- Can be seen on mammograms
What is an Invasive Lobular Carcinomas (ILC)?
- Originate in cells from the breast lobules
- Around 10% of invasive breast cancers
- Not always visible on mammograms
What is Inflammatory Breast Cancer?
- 1-3% of breast cancers
- Presents as a swollen, warm, tender breast with pitting skin (peau d’orange)
- Does not respond to antibiotics
- Worse prognosis than other breast cancers
What is Paget’s Disease of the Nipple?
- Presents as an Erythematous, scaly rash around the nipple (looks like eczema)
- May represent DCIS or invasive breast cancer
List 4 Rarer Types of Breast Cancer
- Medullary breast cancer
- Mucinous breast cancer
- Tubular breast cancer
- Multiple others
Breast cancer screening?
Mammogram every 3 years to women aged 50 – 70 years
List 4 downsides of breast cancer screening?
- 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
Screening recommendations for high risk patients
High risk patients: strong family history, BRCA mutation, previous radiotherapy treatment for lymphoma
Annual MRI offered from age 30
List 2 examples of a significant family history which may warrant genetic testing
- First-degree relative with breast cancer < 40 years
- First-degree male relative with breast cancer
- First-degree relative with bilateral breast cancer, diagnosed < 50 years
- Two first-degree relatives with breast cancer
List 2 things which must be done before performing genetic tests
Genetic counselling and pre-test counselling to discuss the benefits and drawbacks ie. implications for family members and offspring
List 2 examples of chemoprevetion which may be offered for women at high risk
- Tamoxifen if premenopausal
- Anastrozole if postmenopausal (except if severe osteoporosis)
List 2 preventative options for women at a high risk of breast cancer
Chemoprevetion:
- Tamoxifen if premenopausal
- Anastrozole if postmenopausal (except if severe osteoporosis)
Surgery (suitable for only a small number of women):
- Risk-reducing bilateral mastectomy
- bilateral oophorectomy
How may breast cancer present?
- Hard, irregular, painless or fixed lump
- 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
NICE 2 week wait referral criteria for suspected breast cancer?
- Unexplained breast lump in patients ≥ 30
- Unilateral nipple changes in patients aged ≥ 50 (discharge, retraction or other changes)
Non urgent referral for suspected breast cancer?
unexplained breast lumps in patients < 30 years
What is the Triple Diagnostic Assessment once reffered?
- Clinical assessment (history and examination)
- Imaging (USS or mammography)
- Biopsy (Core biopsy)
What imaging is recommended to who in the triple assessment and why?
USS scans < 30 because younger women have more dense breasts with more glandular tissue (↓ mammogram sensitivity)
Mammograms in older women
How is lymph node involvement assessed in women diagnosed with breast cancer?
USS of the axilla and ultrasound-guided biopsy of any abnormal nodes
Sentinel lymph node biopsy may be used during surgery where the initial ultrasound does not show anyone abnormal nodes
List the 3 types of breast cancer receptors
- Oestrogen receptors (ER)
- Progesterone receptors (PR)
- Human epidermal growth factor (HER2)
What is triple negative breast cancer?
Breast cancer does NOT express ER, PR or HER2 receptors
Worse prognosis and treatment limitations
What is Gene expression profiling?
Assessing which genes are present on histology
Helps predict the probability that the breast cancer will reoccur as a distal metastasis within 10 years
When is Gene expression profiling recommended by NICE?
For women with early breast cancers that are ER+ but HER2 and lymph node negative
Helps guide whether to give additional chemotherapy
List the 4 common locations of breast cancer metastasis
(2L’s, 2B’s)
- Lungs
- Liver
- Bones
- Brain
Investigations required for staging breast cancer steps
- Triple assessment
- Lymph node assessment and biopsy
- MRI of the breast and axilla
- Investigate for metastasis
List 3 investigations to check for specific breast metastases
- Liver USS for liver mets
- CT TAP for thorax, abdo or pelvic mets
- Isotope bone scan for bony mets
What staging system is used in breast cancer?
TNM system
Surgical options for breast cancer
- Wide local excision + radiotherapy (breast conserving)
- Mastectomy + immediate or delayed breast reconstruction
+/- Axillary Clearance if required
What is Chronic Lymphoedema?
Caused by impaired lymphatic drainage of an area. May occur in an entire arm after axillary node clearance
Areas of lymphoedema are prone to infection
List 4 potential management options for chronic lymphoedema
- Massage techniques
- Compression bandages
- Specific lymphoedema exercises to improve drainage
- Weight loss if overweight
- Good skin care
What MUST be avoided in patients who have had breast cancer surgery?
Avoid taking blood or putting a cannula in the arm on the side of the surgery
What adjuvant therapy may be used alongside breast removal surgery?
Radiotherapy
Course after surgery and sessions every day for 3 weeks
List 4 side effects of Radiotherapy
- General fatigue
- Local skin and tissue irritation and swelling
- Fibrosis of breast tissue
- Shrinking of breast tissue
- Long term skin colour changes (usually darker)
What are the 3 used of chemotherapy in breast cancer?
- Neoadjuvant therapy – shrink tumour before surgery
- Adjuvant chemotherapy – after surgery to reduce recurrence
- Treatment of metastatic or recurrent breast cancer
Hormone treatment for ER+ breast cancer?
Tamoxifen for premenopausal women
Aromatase inhibitors for postmenopausal women (e.g., letrozole, anastrozole)
What is Tamoxofen?
List one potential benefit and risk
SERM - blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones
- Benefit: helps prevent osteoporosis
- Risk: increase risk of endometrial cancer
What is letrozole or anastrozole?
Aromatase inhibitors
- Aromatase (found in adipose tissue) converts androgens to oestrogen.
- After menopause, action of aromatase in fat is the primary source of oestrogen
- Letrozole and anastrozole block this
How long are Tamoxifen or an aromatase inhibitors given for in ER+ breast cancer?
5 – 10 years
List 2 other options for ER+ breast cancer
- Fulvestrant (selective oestrogen receptor downregulator)
- GnRH agonists (e.g., goserelin or leuprorelin)
- Ovarian surgery
List 3 Targeted Treatments which may be used in women with HER 2 + Breast Cancer
Herceptin - monoclonal antibody (requires close monitoring of heart function)
Perjeta - monoclonal antibody used in combination with Herceptin
Nerlynx- tyrosine kinase inhibitor, ↓ growth of breast cancers
Breast cancer treatment follow up?
Surveillance mammograms yearly for 5 years
(longer if not yet old enough for the regular screening programme).
Who is offered reconstructive surgery?
When does this take place?
Offered to all patients having a mastectomy may be Immediate or Delayed reconstruction
Reconstructive surgical options following breast-conserving surgery?
May not be needed. Options include:
- Partial reconstruction (flap or fat tissue to fill the gap)
- Reduction and reshaping
Reconstructive surgical options following mastectomy?
- Breast implants
- Flap reconstruction (using tissue from another part of the body)
List 3 types of Flaps which may be used in a partial reconstruction
- Latissimus Dorsi Flap
- Transverse Rectus Abdominis Flap (TRAM Flap)
- Deep Inferior Epigastric Perforator Flap (DIEP Flap)
