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Cancer Studies > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

Outline the normal anatomy of the breast.

A
  • Breast is a sebaceous gland.
  • Made of glandular and fatty tissue.
  • 4 quadrants:
    Upper outer quadrant (greatest bulk of mammary tissue). Benign and malignant tumours most common here.
  • Upper border is in 2nd IC space just below the clavicle.
  • Lower border is at 6th IC space but clearly breast tissue can lie below this posterior attachment.
  • Medial: inner sternum.
  • Outer: anterior axillary line.
  • Axillary tail (include in breast examination)
  • Breast tissue changes in month due to menstruation and with pregnancy.
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2
Q

Epidemiology: 1 in how many women are diagnosed with breast cancer?

A

1 in 9

1,000 new diagnoses a year in NI

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3
Q

Discuss the risk factors for developing breast cancer.

A
  • Increasing age
  • Environmental factors > genetic
  • Early first menarche (prolongs oestrogen exposure)
  • Late menopause (prolongs oestrogen exposure)
  • Age at first pregnancy (prolongs oestrogen exposure)
  • Obesity (aromatase in adipocytes –> increases oestrogen exposure)
  • Alcohol
  • Diet
  • Previous breast disease - CIS, atypical hyperplasia
  • Exogenous oestrogen: HRT, oral contraceptives
  • Genetics (BRCA-1, BRCA-2)
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4
Q

How does breast cancer normally present?

A

Typically: painless breast lump found on asymptomatic screening.

  • Lump (most often)
  • Through screening (mammography every 3 years 50-70 years)

Less often:

  • Nipple discharge
  • Nipple retraction
  • Skin changes - rash, scaling, puckering
  • RARELY, pain
  • Family history - genetic component
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5
Q

Outline breast clinic assessment.

A

Triple assessment (examination/imaging/biopsy):

+ History

  • Examination
  • Mammography/USS
  • MRI (if required)
  • FNA/core biopsy
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6
Q

Which tumour marker may be used to monitor response of breast cancer to treatment or to surveil for recurrence?

A
  • CA 15-3.
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7
Q

What are the classical characteristics of a palpable breast lump (cancer)?

A
  • Single lesion
  • Hard
  • Immobile
  • Irregular border
  • Skin dimpling
  • Skin > 2cm
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8
Q

Outline important characteristics of familial breast cancer (genetic).

A
  • 5% of total
  • Younger age of onset
  • Often bilateral
  • Autosomal dominant (maternal or paternal)
  • BRCA-1/BRCA-2 (tumour suppressor gene) - risk of ovarian cancer as well
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9
Q

Outline NICE’s Suspected Cancer Referrals Pathway for breast cancer.

A
  1. Refer via the “Suspected Cancer Pathway”
    – age >30 + unexplained breast lump +/- pain
    – age >50 + unilateral nipple symptom
  2. Consider referring via the “Suspected Cancer Pathway”
    – skin changes that suggest breast cancer
    – age >30 + axilla lump
  3. Consider a routine surgery referral
    – age <30 + unexplained lump +/- pain
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10
Q

List the differential diagnoses of a breast lump.

A

Most commonly:

  1. Fibroadenoma
  2. Fibrocystic change
  3. Intraductal papilloma
  4. Fat necrosis
  5. Breast abscess
  6. Invasive breast cancer
  7. Ductal carcinoma in-situ (DCIS)
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11
Q

Describe how the diagnosis of breast cancer is made (briefly).

A
  1. Clinical assessment (history + examination of both breasts)
  2. Imaging assessment (mammogram +/- USS)
  3. Tissue acquisition (FNA vs. core biopsy –> ductal vs. lobular)
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12
Q

Recall the TNM staging of breast cancer (give overview)

A 
TNM covers pattern of spread 
T = local spread 
Size of largest (if multiple)
Local extension (skin or chest wall)
N = lymphatic spread 
Number of positive axillary nodes
M = haematogenous spread 
Bone, lung, liver, brain
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13
Q

Recall the TNM staging of breast cancer (give specifics)

A 
pT Stage
T1 < 2cm
T2 2-5 cm
T3 ≥ 5 cm
T4a chest wall
T4b skin 
T4c both
T4d inflammatory
pN Stage
NX not assessable
N0 no nodes
N1 1–3 nodes
N2 4–9 nodes
N3 ≥10 nodes

M Stage
M0 no metastases
M1 metastases

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14
Q

Discuss tumour-related prognostic biomarkers.

A 
• De novo metastatic disease
• Nodal status
• Primary tumour size & grade
• T4 disease
• Lymphovascular invasion
• Receptor status:
– ER & PR: positive is good
– HER2: positive is poor
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15
Q

What is the surgical aim in the primary management of breast cancer?

A

Surgical Aim:
– Remove tumour: local control & possible cure
– obtain prognostic information (staging/node assessment)
- Restore anatomy

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16
Q

Outline the types of surgical intervention.

A

Types of Surgery

a. wide local excision
b. mastectomy +/- reconstruction

17
Q

Outline axillary surgery in breast cancer management.

A

Axillary surgery:

Sentinel Node Biopsy (SNB)
– radioactive colloid & blue dye to peri-areolar area
– sentinel node located (Geiger counter & visualisation)
– ANC avoided if ≤1 node involved

• Axillary Clearance (ANC)
– >1 node positive on SNB
– N1–3 on examination/imaging 
– most patients have shoulder pain/stiffness
– 15% get lymphoedema
18
Q

Discuss the rational selection of adjuvant radiotherapy approaches.

A
  • Whole breast radiotherapy = post-WLE. Reduces local relapse.
  • Additional dose ‘boost’ to tumour bed = reserved for age <50, grade III, close margins, or “triple negative”
  • Chest-wall radiotherapy = post-mastectomy for ≥T3 or ≥N2
  • Ipsilateral supraclavicular fossa radiotherapy = ≥N2 disease
19
Q

What is the rationale behind adjuvant systemic chemotherapy?

A
  • Surgery often not ‘curative’
  • Cancer may have spread prior to this intervention
  • Micro-metastases a source of future relapse
  • If these are eliminated, the patient has the potential for a cure
20
Q

Discuss adjuvant hormonal therapy in breast cancer.

A

• 2/3 breast cancers are ER or PR positive
• Cells from these tumours are usually oestrogen–dependent
• Tamoxifen blocks the oestrogen receptors
• Aromatase inhibitors block oestrogen production in fat
– oestrogens arise from peripheral tissues due to the aromatase enzyme
– ovarian pathway available for oestrogen production pre-menopause
– hence AIs are effective in post-menopausal women only

21
Q

What hormonal therapy regime is preferred in pre-menopausal women?

A

Tamoxifen 20 mg daily for 5-10 years

22
Q

What hormonal therapy regime is preferred in post-menopausal women?

A

Tamoxifen 20 mg daily for 2 years then switch to aromatase inhibitors for 3-8 years OR aromatase inhibitors for 5-10 years (anastrozole/letrozole)

23
Q

Outline some adverse effects of tamoxifen treatment.

A
  • Menopausal symptoms
  • VTE
  • Low-grade uterine cancers
24
Q

Outline some adverse effects of aromatase inhibitor treatment.

A
  • Menopausal symptoms
  • Osteoporosis (MCQs often have a stem where a post-menopausal woman falls and fractures her femur post-cancer treatment)
  • Arthralgia
25
Q

What is an important consideration when prescribing hormonal therapy?

A
  • Don’t Forget Bone Protection!
  • Adcal D3 ± Bisphosphonate
  • DEXA Scan at Baseline + 2 Years
26
Q

Discuss the rational selection of adjuvant chemotherapy approaches.

A 
• FEC-100
– fluorouracil, epirubicin, cyclophosphamide
– FEC x 6 cycles
• FEC-D
– FEC x 3 cycles, 
– docetaxel x 3 cycles (aka 3rd generation chemo)
– more effective than FEC-100
– more toxic than FEC-100

Important for MCQs:
• Node-positive patients FEC-D
• Node-negative patients FEC

27
Q

What is HER2?

A

HER2 is a transmembrane EGFR receptor over-expressed in 20% of breast cancers

28
Q

What does HER2 positivity mean for survival outcomes in breast cancer?

A

Median survival halved if HER2 positive.

29
Q

Which targeted therapy is administer in HER2 positive breast cancers?

A
  • Trastuzumab (Herceptin)
  • Humanised monoclonal antibody
  • Improves survival outcomes
30
Q

Where does breast cancer typically metastasise?

A
  • Bone
  • Brain
  • Liver
  • Lungs

Cancer Studies (14 decks)

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