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Yr4: Cancer Care > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

Breast cancer is the ____ common cancer in the UK

Around 1 in ___ women develop breast cancer in their lifetime

Occurs mostly in women aged _____

A
  • Most
  • 1 in 8
  • >50yrs
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2
Q

State some risk factors for breast cancer

A
  • Female (90% of breast cancers)
  • Increased oestrogen exposure (early menarche or late menopause)
  • More dense breast tissue
  • Obesity
  • Smoking
  • FH (1st degree)
  • BRCA1, BRCA2
  • Combined HRT
  • COCP (risk returns to normal 10yrs after stopping)
  • Ionising radiation
  • Not breastfeeding
  • Nulliparity
  • 1st pregnancy >30yrs (2x risk of 1st pregnancy <30yrs)
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3
Q

What two genes are associated with breast cancer?

Which chromosome are the genes found on?

Discuss the risk of cancer for pts with each of these genes

A

BRCA1

  • Chromosome 17
  • ~70% breast ca by 80yrs
  • ~50% ovarian ca by
  • Increased risk of bowel & prostate ca

BRCA2

  • Chromosome 13
  • 60% breast ca by 80yrs
  • 20% ovarian ca

*NOTE: there are other faulty genes associated with breast ca too such as TP53 and PTEN genes.

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4
Q

State some signs & symptoms of breast cancer

A
  • Breast lumps
    • Hard, irregular, fixed, painless, tethered to skin or chest wall
  • Nipple retraction
  • Peau d’orange (skin dimpling or oedema)
  • Lymphadenopathy (particularly axilla)
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5
Q

State the different types of breast cancer

A

Most breast cancers arise from the duct tissue followed by the lobular tissue. Then further divided based on whether the cancer has spread beyond local tissue (hasn’t spread is carcinoma-in-situ and has spread is invasive). There are also other rarer types of breast cancer.

  • Ductal carcinoma in situ (DCIS)
  • Lobular carcinoma in situ (LCIS)
  • Invasive ductal carcinoma (also known as invasive breast carcinoma of no special/specific type [NST]) ~80% invasive breast ca
  • Invasive lobular carcinoma (ILC) ~10% invasive breast ca
  • Medullary breast cancer
  • Mucinous breast cancer
  • Tubular breast cancer
  • Inflammatory breast cancer (may be associated with other types)
  • Paget’s disease of the nipple (may be associated with other types)

**NOTE: invasive ductal carcinoma recently been renamed invasive breast carcinoma of no special/specific type (NST) and other cancers (including lobular carcinoma) are classified as special type.

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6
Q

What is the most common type of breast cancer?

A

Invasive ductal carcinoma (invasive breast carcinoma of no special/specific type [NST])

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7
Q

For ductal carcinoma in situ, discuss:

  • What it is
  • Whether it is localised or widespread
  • How it is detected/picked up
  • Prognosis
A
  • Pre-cancerous or cancerous epithelial cells of breast ducts (i.e. hasn’t grown into the breast tissue outside of the ducts)
  • Localised to single area (but has potential to spread locally over yrs)
  • Often picked up on mammogram screening
  • Good prognosis if fully excised and adjuvant treatment given but there is potential to become invasive breast cancer (~30%)
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8
Q

For lobular carcinoma in situ, discuss:

  • What it is
  • How it presents
  • Prognosis
A
  • Pre-cancerous condition
  • Typically in pre-menopausal women. Asymptomatic & undetectable on mammogram so often diagnosed incidentally on breast biopsy
  • Often managed with close monitoring (6 monthly examination, yrly mammogram). Increased risk of invasive breast ca in future (30%)
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9
Q

For invasive ductal carcinoma (invasive breast carcinoma of no special/specific type [NST]), discuss:

  • What it is
  • Whether it is detectable on mammograms
A
  • Cancer that has spread beyond local tissue and originated in cells of breast ducts
  • Can be seen on mammograms
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10
Q

For invasive lobular carcinoma, discuss:

  • What it is
  • Whether visible on mammograms
A
  • Cancer that originates from cells in breast lobules and has spread beyond local tissue
  • Not always visible on mammograms
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11
Q

For inflammatory breast cancer, discuss:

  • How it presents
  • Prognosis
A
  • Presents similar to breast abscess or mastitis (warm, swollen, tender, peau d’orange, doesn’t respond to abx)
  • Worse prognosis than other breast cancers
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12
Q

For Paget’d disease of the nipple, discuss:

  • How it presents
  • What it indicates
A
  • Presents similar to eczema of nipple/areolar region (erythematous, scaly rash)
  • Indicates breast cancer involving nipple; may be DCIS or invasive breast cancer
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13
Q

Discuss the breast cancer screening programme, include:

  • Who is offered screening & how often
  • What is involved
A
  • Women aged 50-70yrs, every 3yrs
  • Mammogram (standard views are bilateral craniocaudal and mediolateral oblique- total of 4 images. Whether all 4 are done varies based on pt and hospital policies)

*After age of 70yrs women can still have mammograms but are encouraged to make their own appointments

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14
Q

NICE have published guidelines about the management of familial breast cancer in 2013 outlining who needs referring to specialist due to increased risk of breast cancer. State some of criteria

A

If the person concerned only has one first-degree or second-degree relative diagnosed with breast cancer when over 40yrs they do NOT need to be referred unless any of the following** **are present in the family history:

  • bilateral breast cancer
  • male breast cancer
  • ovarian cancer
  • Jewish ancestry
  • sarcoma in a relative younger than age 45 years
  • glioma or childhood adrenal cortical carcinomas
  • complicated patterns of multiple cancers at a young age
  • paternal history of breast cancer (two or more relatives on the father’s side of the family)

Referral also indicated if:

  • First degree relative <40yrs with breast cancer
  • First degree male relative with breast cancer
  • First degree relative with bilateral breast cancer first diagnosed <50yrs
  • Two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age
  • One first-degree or second-degree relative diagnosed with breast cancer at any age and one first-degree or second-degree relative diagnosed with ovarian cancer at any age (one of these should be a first-degree relative)
  • Three first-degree or second-degree relatives diagnosed with breast cancer at any age.
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15
Q

If someone is referred to a specialist due to high risk of breast cancer; what may be done?

A
  • Earlier screening (potentially annual mammograms starting from 30yrs if high risk)
  • Genetic tests (will need genetic counselling & pre-test counselling)
  • Chemoprevention for women at high risk
    • Tamoxifen if premenopausal
    • Anastrozole if post-menopausal (except with severe osteoporosis)
  • Surgery: bilateral mastectomy or bilateral oophorectomy
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16
Q

Discuss the 2WW referral criteria for breast cancer

A

2WW referral recommended if:

  • >/=30yrs with unexplained breast lump
  • >/=50yrs with unilateral nipple changes (discharge, retraction or others)

Consider a 2WW referral if:

  • >/=30yrs with unexplained lump in axilla
  • Any age with skin changes suggestive of breast cancer (e.g. peau d’orange)

Consider non-urgent referral in people under the age of 30 with an unexplained breast lump (with or without pain).

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17
Q

What is the triple diagnostic assessment in breast cancer?

A

Includes:

  • Clinical assessment (history & physical examination)
  • Imaging (ultrasound or mammography)
  • Biopsy (FNA or core)
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18
Q

As part of triple diagnostic assessment, women may have an ultrasound or mammography; discuss why women may have each

A
  • Ultrasound: younger women (<30yrs) as they have more dense breasts with more glandular tissue; useful at distinguishing solid lumps from cystic lumps
  • Mammography: more effective in older women; pick up calcifications missed by ultrasound
  • *More dense breasts reduces effectiveness of mammography*
  • **MRI scans may be used to screen women at higher risk of breast cancer and to further assess size & features of a tumour*
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19
Q

What is the difference between a FNA biopsy and a core biopsy?

A
  • FNA: user smaller needle and collects cells; can’t see architecture
  • Core biopsy: larger needle and collects sample of tissue; able to see architecture & perform further tests
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20
Q

State some additional investigations, following triple diagnostic assessment, that may be done to help stage breast cancer

A
  • Lymph node assessment & biopsy
  • MRI breast & axilla
  • Liver ultrasound (for liver metastases)
  • CT TAP (for lung, abdo or pelvic metastases)
  • Isotope bone scan (for bony metastases)
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21
Q

All women are offered an ultrasound of the axilla and ultrasound guided biopsy of any abnormal nodes; true or false?

A

True

22
Q

What is meant by a sentinel lymph node biopsy?

Explain how it is performed

A
  • Sentinel lymph node biopsy= taking biopsy of the first lymph node the tumour drains to
  • Performed during surgery:
    • An isotope contrast, blue dye or both are injected into tumour area
    • Contrast & dye travel through lymphatics to first lymph node (sentinel node)
    • Sentinel node will show up blue and will show on the isotope scanner
    • Biopsy is then performed
    • If cancer is found, the surgeon may remove the lymph node and additional lymph nodes, either during the same biopsy procedure or during a follow-up surgical procedure
23
Q

State 3 breast cancer receptors that are tested for to help guide treatment

A
  • Oestrogen receptors (ER)
  • Progesterone receptors (PR)
  • Human epidermal growth factor (HER2)

**Triple negative breast cancer is when breast cancer cells express none of the receptors; worse prognosis as less treatment options

24
Q

What is gene expression profiling?

Who does NICE recommend gene expression profiling for?

A
  • Assess which genes are present within the breast cancer on a histology sample
  • Helps to predict probability that breast cancer will reoccur as distal metastasis within 10yrs and hence guide as to whether additional chemotherapy will be beneficial
  • NICE recommend it for women with early breast cancers that are ER positive but HER2 and lymph node negative who have been assessed as being at intermediate risk of distant recurrence.
25
Q

Where does breast cancer commonly metastasise?

*HINT 2L’s and 2B’s

A
  • Lungs
  • Liver
  • Bones
  • Brain

*NOTE: breast cancer can spread to any region of body hence in pts with metastatic tumour, regardless of where it is the primary tumour could be breast cancer. The other cancer that can spread practically anywhere is melanoma

26
Q

What staging is used for breast cancer?

A

TNM

27
Q

What score can be used to predict/indicate survival in breast cancer?

Explain how to calculate the score

A

Nottingham Prognostic Index

  • Takes into account: size of tumour, lymph node status/involvement & histological grade
  • Calculation:
    • tumour size (cm) x 0.2 + histological grade (1-3) + lymph node stage (1-3)
28
Q

Broadly outline the management of breast cancer (don’t explain when each is done- these on are separate FCs)

A

MDT management. Treatment may involve:

  • Surgery
  • Radiotherapy
  • Chemotherapy
  • Biological therapy
  • Hormone therapy
29
Q

Most pts with breast cancer will be offered surgery. Discuss, broadly, how surgeons decided whether to remove lymph nodes/perform axially node clearance

A

If prior to surgery woman has:

  • No palpable axillary lymphadenopathy then they should have a pre-operative axillary ultrasound before primary surgery. If this is positive, they should have sentinel node biopsy to assess nodal burden.
  • If there is palpable axillary lymphadenopathy then axillary node clearance is indicated at primary surgery
30
Q

There are two options for breast cancer surgery, discuss these including:

  • What each involves
  • When each is indicated
    *
A

Options include the following +/- axillary node clearance

  • Wide local excision/breast conserving surgery: removal of the tumour with a wide margin
  • Mastectomy: removal of whole breast (with either immediate or delayed breast reconstruction)

*Central lesions can be manged with wide local excision where an acceptable cosmetic result can be achieved; rarely the case with small breasts

31
Q

If a pt has axillary node clearance as part of breast cancer surgery what is there a risk of?

A

Chronic lymphoedema (impaired lymphatic drainage). Can occur in entire arm on the side of axillary node clearance. This not only causes oedema but there is also increased risk of infection in area of lymphoedema as lymphatic system has role in immune system.

32
Q

State some treatment options for chronic lymphoedema following axillary node clearance

A
  • Manual lymphatic drainage (massage techniques to drain lymphatic system)
  • Compression bandages
  • Specific lymphoedema exercises (to improve drainage)
  • Weight loss if overweight
  • Good skin care
33
Q

What must you always avoid doing in the arm of pts who have had previous breast cancer removal surgery?

A

Avoid taking blood, putting cannulas in and taking BP on affect side as there is impaired lymphatic drainage on that side

34
Q

When is radiotherapy commonly used in breast cancer?

A
  • Usually give adjuvant radiotherapy to pts who have had wide local excision/breast conserving surgery to reduce risk of recurrence
  • May also be offered to women who had mastectomy if they had T3–T4 tumours and/or 4 or more positive axillary lymph nodes
35
Q

State some side effects of radiotherapy for breast cancer

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)
36
Q

Discuss how chemotherapy may be given in breast cancer

*HINT: asking about timings around surgery

A

Chemotherapy may be given:

  • Neoadjuvant: to shrink tumour before surgery
  • Adjuvant: after surgery to reduce risk of recurrence
  • In treatment of metastatic or recurrent breast cancer
37
Q

Which patients will be offered hormone treatment for breast cancer?

State some options for hormonal highlighting the two main first line options and indicating when each is used

A

Offer hormone therapy to women with oestrogen-receptor (ER) positive breast cancer. First line options:

  • Tamoxifen: SERM, used in pre-menopausal women
  • Aromatase inhibitors (e.g. anastrozole, letrozole, exemestane): post-menopausal women

… usually given for 5-10yrs.

Other include:

  • Fulvestrant (selective oestrogen receptor downregulator)
  • Goserelin (GnRH agonist)
  • Ovarian surgery
38
Q

Explain how tamoxifen works

A
  • SERM (selective oestrogen receptor modulator) meaning it either blocks or stimulates oestrogen receptors depending on site of action
  • Tamoxifen blocks oestrogen receptors in breast tissue and stimulates them in the uterus & bones
  • Consequently, reduces risk of osteoporosis but increases risk of endometrial cancer
39
Q

State some side effects of tamoxifen

A
  • Hot flushes
  • Vaginal dryness or bleeding
  • Change in periods (irregular, lighter or sotp)
  • Nausea
  • Mood changes (low)
  • Skin rash/itchy
  • Hair thinning
  • Oedema
  • Headaches
  • Nervous system (paraesthesia, dizzy, taste changes)
  • Diarrhoea or constipation
  • Increased risk of blood clots
  • Increased risk endometrial cancer
  • Increased risk TIA
40
Q

Explain why aromatase inhibitors (such as anastrozole, letrozole, exemestane) are given to post-menopausal women with ER positive breast cancer

A

After menopause, primary source of oestrogen is from the adipose tissue where aromatase converts androgens into oestrogen

41
Q

State some biological therapies that may be offered to women with HER2 positive breast cancer

A
  • Trastuzumab (Herceptin): monoclonal antibody that targets HER2 receptor
  • Pertuzumab (Perjeta): monoclonal antibody that targets HER2 receptor (used in combination with Herceptin)
  • Neratinib (Nerlynx): tyrosine kinase inhibitor that can reduce growth of breast cancers

*Herceptin is most commonly used

42
Q

Explain how Trastuzumab (Herceptin) works to treat breast cancer

A

Herceptin works by attaching itself to the HER2 receptors on the surface of breast cancer cells and blocking them from receiving growth signals. By blocking the signals, Herceptin can slow or stop the growth of the breast cancer.

43
Q

State one contraindication to trastuzumab (Herceptin)

A

Hx of heart disorders (including hypertension)

Herceptin can affect heart function so need initial & close monitoring

44
Q

State some common side effects of Trastuzumab (Herceptin)

A

There are lots of side effects!!! Some include:

  • Decreased appetite
  • Arthritis
  • Constipation or diarrhoea
  • Dry eyes & mouth
  • Insomnia
  • Tremors
  • Immunosuppression
  • Increase or decrease BP
  • Anaemia
  • Arrhythmias
45
Q

What follow up is required for pts with breast cancer?

A

NICE recommend pts have mammograms yearly for at least 5 yrs (longer if not old enough for regular breast cancer screening programme)

46
Q

Pts may be offered reconstructive surgery following breast cancer surgery. Reconstruction can be immediate (at time of initial surgery) or delayed (months or years after initial surgery). State the four options for reconstructive surgery and briefly outline when each may be used

A

After wide local excision/breast-conserving surgery:

  • Partial reconstruction (using flap or fat tissue to fill gap)
  • Reduction & reshaping (remove tissue and reshape both breasts to match)

After mastectomy:

  • Breast implants (synthetic implant)
  • Flap reconstruction (using tissue from another part of body to reconstruct breast)

Flap reconstruction could be: latissimus dorsi flap, transverse abdominis flap, deep inferior epigastric perforator flap

47
Q

For each of the the flap reconstruction options, briefly outline what it involves/how it is done:

  • Latissimus dorsi flap
  • Transverse rectus abdominis flap (TRAM flap)
  • Deep inferior epigastric perforator flap (DIEP flap)
A
  • Latissimus dorsi flap: use portion of latissimus dorsi and associated skin & fat (pedicled or free flap)
  • Transverse rectus abdominis flap: use portion of rectus abdominis, blood supply and skin (pedicled or free flap)
  • Deep inferior epigastric perforator flap: deep inferior epigastric artery with associated fat, skin & veins is transplanted from abdo to the breast. Example of a free flap
  • Pedicled: keep original blood supply and move tissue under skin to new location
  • Free flap: cut tissue away and transplant to new location
48
Q

What is the main risk of a transverse rectus abdominis (TRAM) flap?

A

Abdominal hernia due to weakened abdominal wall

49
Q

State some potential complications of breast cancer

A
  • Metastases
  • Treatment related complications (chronic lymphaoedema, loss of breast tissue etc…)
50
Q

What is the 5yr survival for breast cancer?

A

85%

51
Q

State some prognostic factors for breast cancer

A
  • Tumour size
  • Type
  • Grade
  • Receptor status
  • Lymph node status
  • Vascular/lymphatic invasions
52
Q

See Yr3 Surgery: Breast to revise benign breast conditions as these are common differentials

A

Yr4: Cancer Care (19 decks)

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