Breast Cancer

Question 1

Signs and Symptoms of Breast Lump with Worrisome Features

Answer 1

• Asymmetry
• Fixed
• Non discrete
• Firm / Hard
• Does not change with cycle

Question 2

Non Breast Lump Signs and Symptoms (skin / nipple)

Answer 2

Skin Change:
•	Ecchymosis 
•	Erythema
•	Puckering / Pitting (Peau D’Orange)
Nipple / Areolar Change
•	Discharge: Milky vs. Brown / Green / Blood
•	Nipple Inversion
•	Lymphadenopathy
•	Constitutional Symptoms

Question 3

List 5 risk factors for Breast Cancer

Answer 3

• Female
• Age > 50
• PMHx: Prev. Breast CA, Benign Breast Dx (Atypical hyperplasia > Moderate / florid Hyperplasia > Sclerosing adenosis), Prev. Breast Bx, Radiation Exposure
• FHx: BRCA gene, 1st Degree relative with Breast CA, Colon CA, Ovarian CA; Ashkenazi Jewish
• Gyne Hx: Unopposed Estrogen (nulliparity, first pregnancy, >30 y/o, menarche <12, menopause >55 y/o, NOT breastfeeding, >5 yr HRT)
Radiation exposure
Alcohol
Sedentary lifestyle

Question 4

Low Risk Screening

Answer 4

• 50-69: Screen q2-3 years based on patient preferences

* 70-74: Screen q2-3 years based on patient preferences

Question 5

What screening modalities are used / not used

Answer 5

Mammography

Self Exam not recommended

Question 6

High Risk Screening frequency and indications

Answer 6

Screening Mammography / MRI:
• 30-69 q annual if:
o Personal hx BRCA ½
o 1st degree relative BRCA ½
o Chest Radiation <30 years old and > 8 years ago
o >25% lifetime risk using IBIS or BOADICEA

Question 7

BRCA ½ GENETIC SCREENING:

Answer 7

• Breast CA < 50 y/o
• Ovarian CA
• B/L Breast CA
• Personal hx of Breast and Ovarian CA
• Multiple breast CA on SAME side of family
• Male breast CA
• Ashkenazi Jewish

Question 8

INVESTIGATIONS for breast lump based on age

Answer 8

• < 30 = U/S

* >30 = U/S + Mammography

Question 9

Investigations if features suggestive of cancer

Answer 9

• Mammography, U/S, Core Bx

Question 10

Investigations if features NOT suggestive of cancer. Next steps if solid vs. cystic and bloody OR does not disappear vs. cystic AND non-bloody AND disappears

Answer 10

• Aspirate with FNA
• Solid: Send aspirate to pathology, send pt to mammography, U/S, refer for core biopsy
• Cystic AND bloody OR does not disappear: Send aspirate to pathology, send pt to mammography, U/S, refer for core biopsy
• Cystic AND non-bloody AND disappear: discard aspirate, f/u in 6-8 weeks. If 0 recurrence, resume screening. If recurrence send pt to mammography, U/S, refer for core biopsy.

Question 11

Investigations for metastasis

Answer 11

o Bone Scan
o Abdo U/S
o CXR
o Head CT

Question 12

Hypercalcemia prognosis, symptoms, treatment

Answer 12

• Prognosis: Median survival 3-4 months
• Sx: N/V, constipation, abdo pain, dehydration, confusion
• Txt: Hydration IVF NS, IV bisphosphonate (pamidronate or zoledronate), +/- corticosteroids, calcitonin

Question 13

List 4 Mets

Answer 13

• Bone > Lungs > Liver > Brain

Question 14

list 4 classes of medications

Answer 14

Estrogen antagonist (Tamoxifen) 
Aromatase inhibitors (Letrozole) 
Progestins

Question 15

List adverse effects of estrogen, estrogen antagonists, aromatase inhibitors, progestins

Answer 15

• Estrogen: VTE
• Estrogen Antagnists (Tamoxifen): VTE, Hot flash, Cataracts, Risk of endometrial cancer
• Aromatase Inhibitors (anastrozole, letrozole): Osteopaenia, Arthralgias / MSK pain, Vaginal Dryness
• Progestins: WG, Nausea, Fluid Retention

Question 16

Adverse effect of surgery

Answer 16

• Lyphadenopathy

Question 17

Adverse effect of radiation

Answer 17

• weakness / paresthesia, lung / vascular / valve fibrosis

Question 18

Adverse effect of chemo

Answer 18

• POF, Dilated Cardiomyopathy, Peripheral Neuropathy, CA, Cognitive Dysfunction

Question 19

Breast Cancer Follow up Frequency

Answer 19

• q 3-6 mo for year 1-3
• q 6-12 mo for year 4-5
• q yearly for year >5

Question 20

Breast Cancer Breast self exam frequency

Answer 20

• q monthly

Question 21

Breast Cancer Mammograph frequency

Answer 21

• q 1 yrs

* >6 mo post radiation