Breast cancer

Question 1

What does management depend on?

Answer 1

staging, tumour type and patient background

Question 2

What management options are there?

Answer 2

surgery
radiotherapy
hormone therapy
biological therapy
chemotherapy

Question 3

What is the management for the vast majority of patients and what is the contraindication?

Answer 3

surgery

frailty with metastatic disease who may be better manageed with hormonal therapy

Question 4

What is relevant prior to surgery and what determines management?

Answer 4

the presence/absence of axillary lymphadenopathy

Question 5

Prior to surgery what should women with no palpable axillary lymphadenopathy at presentation have?

Answer 5

a pre-operative axillary ultrasound before their primary surgery

Question 6

Prior to surgery what should women with no palpable axillary lymphadenopathy at presentation have if axillary US picks up on lymph nodes?

Answer 6

sentinel node biopsy to assess node burden

Question 7

what should be done prior to surgery inpatients who present with clinically palpable lymphadenopathy and what may this lead to?

Answer 7

axillary node clearance is indicated at primary surgery

lead to arm lymphedema and functional arm impairment

Question 8

What meets the criteria for mastectomy?

Answer 8

multifocal tumour

central tour

large lesion in small breast

DCIS > 4cm

Question 9

What meets the criteria for wide local excision?

Answer 9

solitary lesion

peripheral lesion

small lesion in large breast

DCIS < 4cm

Question 10

When is whole breast radiotherapy offered and by how much may it reduce the risk of recurrence?

Answer 10

Whole breast radiotherapy is recommended after a woman has had a wide-local excision as

this may reduce the risk of recurrence by around two-thirds

Question 11

For women who have had a mastectomy when is radiotherapy offered?

Answer 11

for T3-T4 tumours and for those with four

or more positive axillary nodes

Question 12

When is hormonal therapy offered?

Answer 12

if tumours are positive for hormone receptors

Question 13

What hormonal therapy is used in pre-menopausal women?

Answer 13

tamoxifen

Question 14

what hormonal therapy is used in post-menopausal women?

Answer 14

aromatase inhibitors

Question 15

risks of tamoxifen

Answer 15

increased risk of endometrial cancer

venous thromboembolism

menopausal symptoms.

Question 16

What is the most common type of biological therapy and when is it used?

Answer 16

trastuzumab (Herceptin)

HER2 positive patients

Question 17

when is Herceptin contraindicated?

Answer 17

heart disorders

Question 18

When is chemotherapy used?

Answer 18

prior to surgery (‘neoadjuvanant’ chemotherapy) to downstage a primary lesion or after surgery depending on the stage of the tumour

Question 19

When should people be referred on the 2ww cancer referral pathway?

Answer 19

aged 30 and over and have an unexplained breast lump with or without pain

or

aged 50 and over with any of the following symptoms in one nipple only: discharge, retraction or other changes of concern

Question 20

When should referral to 2ww cancer pathway be considered?

Answer 20

with skin changes that suggest breast cancer
or

aged 30 and over with an unexplained lump in the axilla

Question 21

When should non-urgent referrals be suspected?

Answer 21

under 30 with an unexplained breast lump with or without pain.

Question 22

Risk factors for breast cancer

Answer 22

BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer

1st degree relative premenopausal relative with breast cancer (e.g. mother)

nulliparity, 1st pregnancy > 30 yrs (twice risk of women having 1st child < 25 yrs)

early menarche, late menopause

combined hormone replacement therapy
(relative risk increase * 1.023/year of use),

combined oral contraceptive use

past breast cancer

not breastfeeding

ionising radiation

p53 gene mutations

obesity

previous surgery for benign disease (?more follow-up, scar hides lump)

Question 23

What are ductal or lobular carcinoma?

Answer 23

Most breast cancers arise from duct tissue followed by lobular tissue

Question 24

What is the most common type of breast cancer?

Answer 24

invasive ductal carcinoma or ‘No Special Type (NST)

Question 25

Other types of breast cancer

Answer 25

Invasive lobular carcinoma Ductal carcinoma-in-situ (DCIS) Lobular carcinoma-in-situ (LCIS)

Question 26

What is pagets disease of the nipple?

Answer 26

an eczematoid change of the nipple associated with an underlying breast malignancy .

Question 27

What is inflammatory breast cancer?

Answer 27

where cancerous cells block the lymph drainage resulting in an inflamed appearance of the breast.

Question 28

what age ranges breast cancer screening process offered?

Answer 28

50-70 years every 3 years mammograms after 70 encouraged to make own appointments

Question 29

if the person has 1st degree or second degree relative when do they need to be urgently referred?

Answer 29

age of diagnosis < 40 years 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

Question 30

when can women with an increased risk of breast ca due to FH be offered screening earlier?

Answer 30

one first-degree female relative diagnosed with breast cancer at younger than age 40 years, or one first-degree male relative diagnosed with breast cancer at any age, or one first-degree relative with bilateral breast cancer where the first primary was diagnosed at younger than age 50 years, or two first-degree relatives, or one first-degree and one second-degree relative, diagnosed with breast cancer at any age, or 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), or three first-degree or second-degree relatives diagnosed with breast cancer at any age