Breast Cancer Flashcards
What are the risk factors of Breast Cancer?
- Age
- Gender W > M
- Family history, prev history of breast ca (4x risk)
- harmful variant of BRCA1 & BRCA2 tumor suppressor genes
- hormonal factors (ie. increased estrogen/progesterone exposure) - early menarch (<12 y/o), late menopause, no kids or late first pregnancy (>30y/o for prima para)
- benign breast disease
- obesity & dietary fat
- R A D S
- Alcohol consumption
How is breast cancer screened in asymptomatic women?
Screening guidelines for asymptomatic American women:
● Mammography every year beginning at 40; (in Canada, every 2 years at 50-74;
MD to assess risk for 40-49)
● CBE by a HCP every 3 years for women 20-39 and annually at 40; (in Canada,
not routine)
● BSE monthly by all women at 20; (*in Canada, not recommended)
How is breast cancer detected?
● Mammography
● Able to detect cancer in asymptomatic women
● Ultrasound helpful in conjunction to differentiate fluid-filled cyst from solid mass;
● MRI useful as adjunct for evaluation of augmented or dense breasts, or in women
at high risk
● Screening mammography – 2 views; side to side, top to bottom
● Diagnostic mammography – more views to help delineate area of concern
● Clinical breast exam
● Breast self-exam
How do you prevent breast cancer?
● Heterogeneous disease – many characteristics, varying from woman to woman in its
potential for growth, development and metastasis
● Disease is hormonally influenced with duration of exposure to elevated circulating
estrogen being primary factor in promotion
How is primary breast ca classified?
● Non-invasive – confined to ducts or lobules
■ Eg. ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS)
● Invasive (or infiltrating) – when cells penetrate tissue outside of ducts and lobules
■ Infiltrating ductal carcinoma 80% of all breast cancers
■ Infiltrating lobular carcinoma 10%
What are the clinical features of breast cancer?
● Mass – irregular, hard, non-tender ● Unilateral nipple discharge ● Nipple retraction or inversion ● Change in size, shape or texture (asymmetry) ● Dimpling or puckering of skin ● Scaly skin around nipple ● Redness, ulceration, edema, dilated veins ● P’eau d’orange ● Enlargement of lymph nodes in axilla
What are the diagnostic procedures in breast cancer?
● Fine needle aspiration biopsy – preferred technique when dominant masses are
palpable; can lead to diagnosis, but cannot tell if invasive or non-invasive
● Core needle biopsy – core of tissue from dominant mass; helpful after non-diagnostic or
suspicious FNA; can differentiate in situ from invasive
● Stereostatic FNA – can be used on most non-palpable suspicious abnormalities found
on mammography using radiographic guidance
● Incisional biopsy – use when mass is large; remove portion of mass
● Excisional biopsy – removes entire mass and margin of normal tissue around it
How is Breast Cancer Staged?
TMN
●T= size, N= # of regional lymph nodes, M= metastases
●Stage 0 – carcinoma in situ
● Stage I – tumor <2cm, no nodes
● Stage IIA – tumor <2cm, + nodes; or tumor 2-5cm, no nodes
● Stage IIB – tumor 2-5cm, + nodes; or tumor >5cm, no nodes
● Stage IIIA – no tumor or tumor <2cm, + fixed lymph nodes; or tumor >5cm, +
moveable/non-moveable nodes
● Stage IIIB – tumor any size, + direct extension into chest wall/skin, +/- nodes; or
any tumor, + mammary lymph node involvement
● Stage IV – any distant mets
What are tumor markers associated with breast cancer?
CEA (carcinoembryonic antigen), CA 15-3, CA 27-29 – not specific
enough to use for staging or follow up
What are the prognostic factors regarding breast ca?
● Tumor size and lymph node status critical to predicting survival
● Estrogen and progesterone receptors – ER/PR overexpressed in breast cancer; +/-
based on # of binding receptors; high levels have likelihood to respond to hormonal
therapy and chemo, thus increasing survival
● Histopathologic grade – characteristics of cancer cells; lower grade cells (more
differentiated; look more like normal cells) have better prognosis
● DNA content – higher SPF (% of cells in S phase) and aneuploidy (abnormal DNA
content) have higher risk of recurrence and worse prognosis
● Oncogenes –altered proto-oncogenes responsible for cancer cell growth; with
proto-oncogene HER2/neu overexpression have increased tumor growth, more
aggressive cancer, local/distant reoccurrence and poor survival
● Metastasis – adjuvant chemo helps prevent or delay development of mets;
What is the treatment modalities for breast ca?
- surgery
- RT
- chemotherapy
- targeted systemic therapy
- endocrine & hormonal therapy
- supportive therapy
What is the goal of surgery in breast ca?
to achieve local and regional control of the disease
How is primary surgical therapy selected in breast ca?
● Surgery type based on stage of disease, mammographic findings, tumor
location, pt history, available expertise, breast size and shape, and pt
preferences
● Can be considered inoperable if tumor has direct extension into chest wall
or skin; palpable lymph nodes; skin ulceration; and inflamm changes
(stage IIIB, some stage IIIA)
What are the different types of surgeries in breast ca?
● Modified radical mastectomy – aka total mastectomy with axillary node
dissection; nearly all pts candidates for this
■ Total mastectomy – aka simple mastectomy; same as above but no node
dissection or removal of chest wall muscles
■ Breast conserving treatment – for stage I or II, non-invasive breast cancers; same survival rate as modified radical mastectomy; usually followed by radiation
● Lumpectomy – cancer removed with border of surrounding normal
tissue and the major portion of breast is left
● Quadrantectomy – entire quadrant of breast containing tumor is removed along with overlying skin and lining over pec major muscle
■ Prophylactic mastectomy – may be indicated if: strong family history of
breast cancer; biopsy proven DCIS or LCIS or benign breast disease with
family history of breast cancer; personal history of breast cancer in
opposite breast; BRCA1 or BRCA2 mutation
● Subcutaneous mastectomy – preferred; removes 90-95% of
tissue, retaining skin and nipple-areola complex; not
recommended for invasive disease
■ Sentinel lymph biopsy – removal of lymph node that is first to receive
drainage from carcinoma; cancer cells spread to sentinel lymph node
before spreading; if positive, axillary lymph node dissection necessary;
most appropriate for invasive breast cancers of ≤1cm
How is non-invasive breast ca surgically treated?
■ For DCIS, usually treat with mastectomy + low axillary node dissection, or
breast-conserving surgery followed by radiation; may use anti-estrogen to
prevent invasive breast cancer
■ For LCIS, treatment may include no further surgery + close F/U, tamoxifen, or bilateral total mastectomy + reconstruction;
