Breast Cancer

Question 1

What are risk factors for developing breast cancer?

Answer 1

1. Increased hormone exposure
   - Early menarche or late menopause
   - Nulliparity or late first pregnancy
   - Oral contraceptives or Hormonal Replacement Therapy
2. Susceptibility gene mutations
   - Most commonly BRCA mutations (BRCA1/BRCA2)
3. Advancing age
4. Caucasian ethnicity
5. Obesity and lack of physical activity
6. Alcohol and tobacco use
7. Past history of breast cancer
8. Previous radiotherapy treatment

Question 2

How does the UK screening programme work?

Answer 2

A 3 yearly mammogram for all women aged 50-70

Question 3

What are the benefits of a breast cancer screening programme?

Answer 3

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

Question 4

What are the risks of a breast cancer screening programme?

Answer 4

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

Question 5

What are the indications for a two week urgent breast cancer referral?

Answer 5

1. They are >30 with an unexplained breast mass (regardless of whether there is pain present or not)
2. They are >50 or older presenting with nipple discharge, retraction or other concerning symptoms.

Question 6

What are the histological types of breast cancer?

Answer 6

1. Ductal carcinoma
2. Lobular carcinoma
3. Medullary carcinoma
4. Phyllodes tumour

Question 7

What is the most common type of breast cancer?

Answer 7

Ductal carcinoma (75%)

Question 8

What is a ductal carcinoma in situ?

Answer 8

If the basement membrane is NOT BREACHED then it is considered ductal carcinoma in situ (DCIS).

Question 9

What is ductal carcinoma?

Answer 9

Abnormal proliferation of ductal cells

The grade is considered higher as the ductal cells lose their acinar structure and their nuclei become abnormally large.

Question 10

What is the second most common type of breast cancer?

Answer 10

Lobular Carcinoma (15%)

Question 11

What are key facts about lobular breast carcinoma?

Answer 11

More likely to be bilateral and multi-centric

Abnormal proliferation of lobular cells which arrange themselves in single rows. The cells are often small, bland and uniform

Due to the sparse distribution of the tumour cells they are frequently impalpable or not appreciable as a discrete lump.

Question 12

What are key facts about medullary carcinoma?

Answer 12

More common in younger patients and with BRCA1 mutations.

Question 13

What are key facts about BRCA1 mutation?

Answer 13

Autosomal dominant on chromosome 17

Lifetime breast cancer risk: 65-85%

Associated with a 40% risk of ovarian cancer as well as increased pancreatic, colon and prostate cancer.

More likely to give rise to high grade triple negative cancers.

Question 14

What are key facts about BRCA2 mutation?

Answer 14

Autosomal dominant on chromosome 13

Lifetime breast cancer risk: 40-85%

Has a 15% lifetime risk of ovarian cancer

More likely to give rise to oestrogen and progesterone receptor positive tumours.

Question 15

What are the criteria to refer someone with a family history of breast cancer?

Answer 15

One first degree relative with breast cancer diagnosed before 40 years old

Any male first degree relative with breast cancer (any age)

One first degree relative with bilateral breast cancer the first of which was diagnosed <50 years old

Two first degree, or one first and one second degree relative with breast cancer at any age

Question 16

What do you know about the significance of hormone receptors in breast cancer?

Answer 16

Oestrogen (ER)
Progesterone (PR)
HER2 (human epidermal growth factor receptor type 2)

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

Question 17

How would you manage ER positive breast tumours?

Answer 17

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

Question 18

How would you manage HER2 positive breast tumours?

Answer 18

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

Question 19

What is part of the triple assessment in breast cancer?

Answer 19

Clinical examination (of the breast and surrounding lymph nodes)
Radiological examination (most commonly mammography but can also involve breast ultrasound and MRI scanning)
Biopsy (typically Core Needle Biopsy or Fine Needle Aspirate)

Question 20

What are the side effects of tamoxifen?

Answer 20

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

Question 21

What is most common treatment for breast cancer?

Answer 21

Wide local excision with adjuvant radiotherapy

Question 22

What are the risks of breast cancer surgery?

Answer 22

1. Anaesthetic (stroke, venothromboembolism, MI, aspiration)
2. Surgical (pain, bleeding, infection, serum)
3. Axillary node clearance (Lymphoedema, damage to brachial plexus, axillary artery or vein injury)