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Y4 Cancer Care: Oncology > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

What is the most common cancer in the UK?

A

Breast cancer is the most common form of cancer in the UK.

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2
Q

What are the risk factors for breast cancer?

A
  • Female (99% of breast cancers)
  • Increased oestrogen exposure
    • Early menarche or late menopause
    • Nulliparity or late first pregnancy
    • Oral contraceptives or Hormonal Replacement Therapy
  • More dense breast tissue (more glandular tissue)
  • Obesity
  • Smoking
  • Family history (first-degree relatives)
  • Past history of breast cancer
    *
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3
Q

Briefly describe breast cancer screening in the UK

A

Breast cancer screening is a nationwide programme within the UK aimed at reducing morbidity and mortality through early detection.

It involves a 3 yearly mammogram (x-ray) in the caudal-cranial and mediolateral oblique views for all women aged 50-70.

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4
Q

What are the benefits of breast cancer screening?

A
  • Early detection of cancers
  • Approximately 20% reduction in relative risk of death from breast cancer
  • Can provide peace-of-mind for some patients
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5
Q

What are the risks of breast cancer screening?

A
  • Mammograms are painful and felt to be undignified by some
  • Screening is not 100% sensitive and some cancers are missed (i.e. false negatives)
  • Some research suggests that for every 2000 women screened for 10 years, 1 life is saved and 10 healthy patients are treated unnecessarily
  • False positive results can be emotionally distressing for patients
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6
Q

What genetic mutations are associated with breast cancer?

A

The most common genes associated with familial breast cancer are BRCA1 and BRCA2.

Other rarer mutations include TP53 (Li-Fraumeni syndrome). PTEN, MLH1, MLH2, and STK11.

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7
Q

Briefly describe the risk of BRCA1 mutation

A

The BRCA1 gene is on chromosome 17. In patients with a faulty gene:

  • Around 70% will develop breast cancer by aged 80
  • Around 50% will develop ovarian cancer
  • Also increased risk of bowel and prostate cancer
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8
Q

Briefly describe the risk of BRCA2 mutation

A

The BRCA2 gene is on chromosome 13. In patients with a faulty gene:

  • Around 60% will develop breast cancer by aged 80
  • Around 20% will develop ovarian cancer
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9
Q

What genetic pattern does BRCA1 and BRCA2 follow?

A

Autosomal dominant.

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10
Q

What type of genes are BRCA genes?

A

BRCA refers to the BReast CAncer gene. The BRCA genes are tumour suppressor genes.

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11
Q

Give examples of the histological subtypes of breast cancer

A
  • 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
  • Rarer Types of Breast Cancer:
    • Medullary breast cancer
    • Mucinous breast cancer
    • Tubular breast cancer
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12
Q

What is the most common type of breast cancer?

A

Most common form of breast tumour (75%).

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13
Q

Briefly describe the features of Ductal Carcinoma In Situ (DCIS)

A

Ductal Carcinoma In Situ (DCIS):

  • Pre-cancerous or cancerous epithelial cells of the breast ducts
  • Localised to a single area
  • Often picked up by mammogram screening
  • Potential to spread locally over years
  • Potential to become an invasive breast cancer (around 30%)
  • Good prognosis if full excised and adjuvant treatment is used
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14
Q

Briefly describe the features of Lobular Carcinoma In Situ (LCIS)

A

Lobular Carcinoma In Situ (LCIS):

  • A pre-cancerous condition occurring typically in pre-menopausal women
  • Usually asymptomatic and undetectable on a mammogram
  • Usually diagnosed incidentally on a breast biopsy
  • Represents an increased risk of invasive breast cancer in the future (around 30%)
  • Often managed with close monitoring (e.g., 6 monthly examination and yearly mammograms)
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15
Q

Briefly describe the features of Invasive Ductal Carcinoma- NST

A

Invasive Ductal Carcinoma- NST

  • NST means no special/specific type, where it is not more specifically classified (e.g. medullary or mucinous)
  • Also known as invasive breast carcinoma of no special/specific type (NST)
  • Originate in cells from the breast ducts
  • 80% of invasive breast cancers fall into this category
  • Can be seen on mammograms
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16
Q

Briefly describe the features of Invasive Lobular Carcinomas (ILC)

A

Invasive Lobular Carcinomas (ILC):

  • Around 10% of invasive breast cancers
  • Originate in cells from the breast lobules
  • Not always visible on mammograms
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17
Q

Briefly describe the features of Inflammatory Breast Cancer

A

Inflammatory Breast Cancer:

  • 1-3% of breast cancers
  • Presents similarly to a breast abscess or mastitis
  • Swollen, warm, tender breast with pitting skin (peau d’orange)
  • Does not respond to antibiotics
  • Worse prognosis than other breast cancers
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18
Q

Briefly describe the features of Paget’s Disease of the Nipple

A

Paget’s Disease of the Nipple:

  • Looks like eczema of the nipple/areolar
  • Erythematous, scaly rash
  • Indicates breast cancer involving the nipple
  • May represent DCIS or invasive breast cancer
  • Requires biopsy, staging and treatment, as with any other invasive breast cancer
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19
Q

Who is classed as high risk patients with regards to breast cancer?

A

There are specific criteria for a referral from primary care for patients that may be at higher risk due to their family history. For example:

  • A first-degree relative with breast cancer under 40 years
  • A first-degree male relative with breast cancer
  • A first-degree relative with bilateral breast cancer, first diagnosed under 50 years
  • Two first-degree relatives with breast cancer
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20
Q

Briefly describe the investigations for those who are deemed at high risk of breast cancer

A

Depending on their risk factors, they may be seen in a secondary care breast clinic or a specialist genetic clinic.

Patients require genetic counselling and pre-test counselling before performing genetic tests. This is to discuss the benefits and drawbacks of genetic testing, such as the implications for family members and offspring.

Annual mammogram screening is offered to women with increased risk, between specific age ranges, depending on their level of risk (potentially starting from aged 30, if high risk).

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21
Q

What treatment can be offered to those at high risk of breast cancer?

A

Chemoprevention may be offered for women at high risk, with:

  • Tamoxifen if premenopausal
  • Anastrozole if postmenopausal (except with severe osteoporosis)

Risk-reducing bilateral mastectomy or bilateral oophorectomy (removing the ovaries) is an option for women at high risk. This is suitable for only a small number of women and requires significant counselling and weighing up risks and benefits.

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22
Q

What are the clinical features of breast cancer?

A

Clinical features that may suggest breast cancer are:

  • Lumps that are hard, irregular, painless or fixed in place
  • 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
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23
Q

What is the triple diagnostic assessment?

A

Once a patient has been referred for specialist services under a two week wait referral for suspected cancer, they should initially receive a triple diagnostic assessment comprising of:

  • Clinical assessment (history and examination)
  • Imaging (ultrasound or mammography)
  • Biopsy (fine needle aspiration or core biopsy)
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24
Q

Briefly describe the role of imaging of breast cancer

A

Younger women generally have more dense breasts with more glandular tissue. Ultrasound scans are typically used to assess lumps in younger women (e.g. under 30 years). They are helpful in distinguishing solid lumps (e.g. fibroadenoma or cancer) from cystic (fluid-filled) lumps.

Mammograms are generally more effective in older women. They can pick up calcifications missed by ultrasound.

MRI scans may be used:

  • For screening in women at higher risk of developing breast cancer (e.g., strong family history)
  • To further assess the size and features of a tumour
25
Q

Briefly describe the role of lymph node assessment in breast cancer

A

Women diagnosed with breast cancer require an assessment to see if cancer has spread to the lymph nodes. All women are offered an ultrasound of the axilla (armpit) and ultrasound-guided biopsy of any abnormal nodes.

A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.

26
Q

Briefly describe the role of sentinal lymph node biopsy in breast cancer

A

Sentinel node biopsy is performed during breast surgery for cancer. An isotope contrast and a blue dye are injected into the tumour area. The contrast and dye travel through the lymphatics to the first lymph node (the sentinel node). The first node in the drainage of the tumour area shows up blue and on the isotope scanner. A biopsy can be performed on this node, and if cancer cells are found, the lymph nodes can be removed.

27
Q

What hormonal receptors are tested for in breast cancer?

A

Breast cancer cells may have receptors that can be targeted with breast cancer treatments. These receptors are tested for on samples of the tumour and help guide treatment. There are three types of receptors:

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

Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors.

28
Q

What is the role of gene expression profiling in breast cancer?

A

Gene expression profiling involves assessing which genes are present within the breast cancer on a histology sample. This helps predict the probability that the breast cancer will reoccur as a distal metastasis (away from the original cancer site) within 10 years.

The NICE guidelines (2018) recommend this for women with early breast cancers that are ER positive but HER2 and lymph node negative. It helps guide whether to give additional chemotherapy.

29
Q

What is the treatment of ER positive tumours?

A

Treat with Tamoxifen (oestrogen receptor antagonist) if premenopausal or Anastrozole (aromatase inhibitor) if postmenopausal.

30
Q

What is the treatment of HER2 positive tumours?

A

Receive Trastuzumab (otherwise known as Herceptin) which is a monoclonal antibody against the extracellular domain of the HER2 receptor.

31
Q

Where does breast cancer commonly metastasise to?

A

You can remember the notable locations that breast cancer metastasis occur using 2 Ls and 2 Bs:

  • Lungs
  • Liver
  • Bones
  • Brain

It’s important to remember that breast cancer can spread to any region of the body.

32
Q

Briefly describe the staging of breast cancer

A

The first step in staging is with triple assessment (clinical assessment, imaging and biopsy). Additional investigations may be required to stage the breast cancer:

  • Lymph node assessment and biopsy
  • MRI of the breast and axilla
  • Liver ultrasound for liver metastasis
  • CT of the thorax, abdomen and pelvis for lung, abdominal or pelvic metastasis
  • Isotope bone scan for bony metastasis

The TNM system is used to stage breast cancer. This grades the tumour (T), nodes (N) and metastasis (M).

33
Q

How does hormonal receptors influence prognosis?

A

Absence of ER or PR is a poor prognostic factor

Being ‘triple negative’ (ER/PR/HER2) is associated with a younger age of diagnosis and worse overall survival.

34
Q

When is a core needle biopsy more appropriate than a fine needle biopsy?

A

If the lesion is large or there is suspicion of malignancy following mammography and/or ultrasound, the patient may be referred for a Core Needle Biopsy over a Fine Needle Aspirate, which is capable of providing histological information as well as cytological.

35
Q

Briefly describe the role of tumour removal (surgery) in breast cancer

A

The objective is to remove the cancer tissue along with a clear margin of normal breast tissue. The options are:

  • Breast-conserving surgery (e.g. wide local excision) usually coupled with radiotherapy
  • Mastectomy (removal of the whole breast) potentially with immediate or delayed breast reconstruction
36
Q

Briefly describe the role of axillary clearance (surgery) in breast cancer

A

Removal of the axillary lymph nodes is offered to patients where cancer cells are found in the nodes. Usually, the majority or all lymph nodes are removed from the axilla. This increases the risk of chronic lymphoedema in that arm.

37
Q

Briefly describe the role of radiotherapy in breast cancer

A

Radiotherapy is usually used in patients with breast-conserving surgery to reduce the risk of recurrence. High-dose radiation is delivered from multiple angles to concentrate radiation on a targeted area. Patients will have a course of radiotherapy after surgery, for example, with a session of radiotherapy every day for 3 weeks.

Almost all patients with wide local excision should be offered adjuvant radiotherapy and it should be offered to mastectomy patients with higher cancer stages (i.e. T3 or 4 or positive nodes).

38
Q

What are the common side effects of radiotherapy?

A

Common radiotherapy side effects include:

  • 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)
39
Q

Briefly describe the role of chemotherapy in breast cancer

A

Recommended for hormone receptor negative and HER2 over-expressing patients.

Sometimes neoadjuvant chemotherapy is given to downstage tumours before surgery.

40
Q

How is oestrogen receptor positive breast cancer treated?

A

Patients with oestrogen-receptor positive breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer.

There are two main first-line options for this:

  • Tamoxifen for premenopausal women
  • Aromatase inhibitors for postmenopausal women (e.g. letrozole, anastrozole or exemestane)

Other options for women with oestrogen-receptor positive breast cancer, used in different circumstances, are:

  • Fulvestrant (selective oestrogen receptor downregulator)
  • GnRH agonists (e.g., goserelin or leuprorelin)
  • Ovarian surgery
41
Q

Briefly describe the role and mechanism of action of tamoxifen

A

Tamoxifen is a selective oestrogen receptor modulator (SERM). It either blocks or stimulates oestrogen receptors, depending on the site of action. It blocks oestrogen receptors in breast tissue, and stimulates oestrogen receptors in the uterus and bones. This means it helps prevent osteoporosis, but it does increase the risk of endometrial cancer.

Tamoxifen or an aromatase inhibitor are given for 5 – 10 years to women with oestrogen-receptor positive breast cancer.

42
Q

What are the common side effects of tamoxifen?

A

Side effects:

  • Hot flushes
  • Nausea
  • Vaginal bleeding and discharge
  • Weight gain
  • Increased risk of DVT/PE
  • Increased risk of endometrial cancer
    • The drug is a weak agonist on endometrial tissue
43
Q

Briefly describe the role and mechanism of action of aromatase

A

Aromatase is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen. After menopause, the action of aromatase in fat tissue is the primary source of oestrogen. Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue.

Tamoxifen or an aromatase inhibitor are given for 5 – 10 years to women with oestrogen-receptor positive breast cancer.

44
Q

Briefly describe the role and mechanism of action of Herceptin

A

Trastuzumab (Herceptin) is a monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer.

45
Q

What needs to be monitored if using Herceptin?

A

Notably, it can affect heart function; therefore, initial and close monitoring of heart function is required.

46
Q

Briefly describe the role and mechanism of action of Pertuzumab (Perjeta)

A

Pertuzumab (Perjeta) is another monoclonal antibody that targets the HER2 receptor. It may be used in patients with HER2 positive breast cancer. This is used in combination with trastuzumab (Herceptin).

47
Q

Briefly describe the role and mechanism of action of Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.

A

Neratinib (Nerlynx) is a tyrosine kinase inhibitor, reducing the growth of breast cancers. It may be used in patients with HER2 positive breast cancer.

48
Q

Following treatment, how often are surveillance mammograms required?

A

The NICE guidelines (2018) recommend all patients treated for breast cancer have surveillance mammograms yearly for 5 years (longer if they are not yet old enough for the regular breast screening programme).

49
Q

What is involved in an indivualised care plan for those with breast cancer?

A

Patients treated for breast cancer are given an individual written care plan, including details on:

  • Designated contacts and details
  • Adjuvant treatment review dates
  • Surveillance dates
  • Advice on identifying recurrence
  • Support service details
50
Q

Why does chronic lymphodema occur following radiotherapy?

A

Lymphoedema is a chronic condition caused by impaired lymphatic drainage of an area. Lymphoedema can occur in an entire arm after breast cancer surgery on that side, with removal of the axillary lymph nodes in the armpit.

The lymphatic system is responsible for draining excess fluid from the tissues. The tissues in areas affected by an impaired lymphatic system become swollen with excess, protein-rich fluid (lymphoedema).

The lymphatic system also plays an important role in the immune system. Areas of lymphoedema are prone to infection.

51
Q

What are the non-surgical treatment options for chronic lymphoedema?

A

There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include:

  • Massage techniques to manually drain the lymphatic system (manual lymphatic drainage)
  • Compression bandages
  • Specific lymphoedema exercises to improve lymph drainage
  • Weight loss if overweight
  • Good skin care
52
Q

Briefly differentiate between immediate and delayed reconstruction

A

Immediate reconstruction is done at the time of the mastectomy.

Delayed reconstruction which can be delayed for months or years after the initial mastectomy.

53
Q

After breast-conserving surgery, what reconstruction may not offered?

A

After breast-conserving surgery, reconstruction may not be required. The standard options, if needed, are:

  • Partial reconstruction (using a flap or fat tissue to fill the gap)
  • Reduction and reshaping (removing tissue and reshaping both breasts to match)
54
Q

After mastectomy, what reconstruction may be offered?

A

After mastectomy, the options for reconstructing the breast(s) include:

  • Breast implants (inserting a synthetic implant)
  • Flap reconstruction (using tissue from another part of the body to reconstruct the breast)
55
Q

Briefly describe the role of implants following breast surgery

A

Inserting an implant is a relatively simple procedure (compared with a flap) with minimal scarring. It gives an acceptable appearance but can feel less natural (e.g. cold, less mobile and static size and shape). There can also be long-term problems, such as hardening, leakage and shape change.

56
Q

Briefly describe the role of latissimus dorsi flap after breast surgery

A

The breast can be reconstructed using a portion of the latissimus dorsi and the associated skin and fat tissue. The tissue is tunnelled under the skin to the breast area.

“Pedicled” refers to keeping the original blood supply and moving the tissue under the skin to a new location.

“Free flap” refers to cutting the tissue away completely and transplanting it to a new location.

57
Q

Briefly describe the role of Transverse Rectus Abdominis Flap (TRAM Flap) after breast surgery

A

The breast can be reconstructed using a portion of the rectus abdominis, blood supply and skin. This can be either as a pedicled flap (tunnelled under the skin) or a free flap(transplanted). It poses a risk of developing an abdominal hernia due to the weakened abdominal wall.

58
Q

Briefly describe the role of Deep Inferior Epigastric Perforator Flap (DIEP Flap) after breast surgery

A

The breast can be reconstructed using skin and subcutaneous fat from the abdomen (no muscle) as a free flap. The deep inferior epigastric artery, with the associated fat, skin and veins, is transplanted from the abdomen to the breast. The vessels are attached to branches of the internal mammary artery and vein. This is a complex procedure involving microsurgery. There is less risk of an abdominal wall hernia than with a TRAM flap, as the abdominal wall muscles are left intact.

Y4 Cancer Care: Oncology (7 decks)

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