Breast Cancer Flashcards
Risk factors for breast cancer?
Female (99% of breast cancers)
Increased oestrogen exposure (earlier onset of periods and later menopause)
More dense breast tissue (more glandular tissue)
Obesity and/ore high fat diet
Alcohol (More so than smoking)
Smoking
Family history (first-degree relatives)
The combined contraceptive pill gives a small increase in the risk of breast cancer, but the risk returns to normal ten years after stopping the pill.
Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).
First pregnancy > 30 years
Not-breast feeding
Radiation of the chest
Which type of HRT particularly increases the risk for breast cancer?
Hormone replacement therapy (HRT) increases the risk of breast cancer, particularly combined HRT (containing both oestrogen and progesterone).
How long after stopping the COCP does the risk of breast cancer return to normal?
10 years
Where is the BRACA1 gene found?
Chromosome 17
Where is the BRACA2 gene found?
Chromosome 13
What risks are higher in patients with the BRACA1 genes?
75% Breast cancer lifetime risk
Around 70% will develop breast cancer by aged 80
Around 50% will develop ovarian cancer
Also increased risk of bowel and prostate cancer
What risks are higher in patients with the BRACA2 gene?
Up to 85% lifetime risk of breast cancer?
Around 60% will develop breast cancer by aged 80
Around 25% will develop ovarian cancer
In men - 6% lifetime risk for breast cancer?
There are other rarer genetic abnormalities associated with breast cancer other than the BRACA genes, such as?
TP53 and PTEN genes
What are the types of breast cancer?
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 type: Medullary breast cancer, Mucinous breast cancer, Tubular breast cancer
The NHS breast cancer screening program offers a mammogram to whom and when?
every 3 years to women aged 50 – 70 years
Also available:
- Previous breast cancer
- First degree relative with cancer < 50 years
- Have known BRACA1, BRACA2, TP53 gene
Negatives of breast cancer screening?
Anxiety and stress
Exposure to radiation, with a very small risk of causing breast cancer
Missing cancer, leading to false reassurance
Unnecessary further tests or treatment where findings would not have otherwise caused harm
There are different recommendations for screening patients with a higher risk due to a family history of breast cancer. These are in the NICE guidelines (2013, updated 2019).
There are specific criteria for a referral from primary care for patients that may be at higher risk due to their family history, such as?
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
There are different recommendations for screening patients with a higher risk due to a family history of breast cancer. Depending on their risk factors, they may be seen in a secondary care breast clinic or a specialist genetic clinic. What may they be officered?
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).
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.
Breast cancer chemoprevention: premenopausal women
Tamoxifen
Breast cancer chemoprevention: postmenopausal women
Anastrozole
Presentation of breast cancer?
- Lumps that are hard, irregular, painless or fixed in place
- Lumps may be tethered to the skin or the chest wall or muscle
- Nipple retraction
- Skin dimpling or oedema (peau d’orange)
Lymphadenopathy, particularly in the axilla
Asymmetry, or swelling,
Abnormal nipple discharge
Paget’s-like nipple changes)
Mastalgia
Ulceration
NICE guidelines on breast lump referral
The NICE guidelines (updated January 2021) recommend a two week wait referral for suspected breast cancer for:
An unexplained breast lump in patients aged 30 or above
Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
The NICE guidelines recommend also considering a two week wait referral for:
An unexplained lump in the axilla in patients aged 30 or above
Skin changes suggestive of breast cancer
The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.
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 what?
Clinical assessment (history and examination)
Imaging (ultrasound or mammography)
Biopsy (fine needle aspiration or core biopsy)
Imaging choice in ?breast cancer
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
Below which age are women with a breast lumped offered an USS over a mammogram and why?
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.
At menopause, the breast tissue will involute - during this process, much of the glandular tissue undergoes apoptosis and is replaced by fat. The general density of the breast reduces in response to the lack of oestrogen .
What might mammograms detect that may be missed by USS?
Calcifications
Breast cancer - lymph node assessment
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.
When is a sentinel lymph node biopsy performed and what is involved?
A sentinel lymph node biopsy may be used during breast cancer surgery where the initial ultrasound does not show any abnormal nodes.
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.
What type of receptors are involved in breast cancer?
Oestrogen receptors (ER)
Progesterone receptors (PR)
Human epidermal growth factor (HER2)
What receptor status carries the worst prognosis?
Triple negative
Triple-negative breast cancer is where the breast cancer cells do not express any of these three receptors. This carries a worse prognosis, as it limits the treatment options for targeting the cancer.
What are the biopsy options at triple assessment clinic?
fine needle aspiration or core biopsy
Notable locations of metastasis secondary to breast cancer?
2 Ls and 2 Bs:
L – Lungs
L – Liver
B – Bones
B – Brain
What is gene expression profiling, when and why is it performed?
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) [DG34] 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.
What is Ductal Carcinoma In Situ (DCIS) and how does it present?
Pre-cancerous or cancerous epithelial cells of the breast ducts
Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast malignancy and currently comprises around 20% of all breast cancers diagnosed. It is a malignancy of the ductal tissue of the breast that is contained within the basement membrane
Localised to a single area
Often picked up on mammogram screening
Why is DCIS treated?
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
What is Lobular Carcinoma In Situ (LCIS) and how does it present?
A pre-cancerous condition occurring typically in pre-menopausal women
Usually asymptomatic and undetectable on a mammogram
Usually diagnosed incidentally on a breast biopsy
How is LCIS managed and why?
LCIS represents an increased risk of invasive breast cancer in the future (around 30%)
Low grade LCIS is usually treated by close monitoring (e.g., 6 monthly examination and yearly mammograms)rather than excision.
When an invasive component is identified, it is less likely to be associated with axillary nodal metastasis than with DCIS.
Bilateral prophylactic mastectomy can be potentially indicated if individuals possess the BRCA1 or BRCA2 genes.
What is meant by ‘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
Into which category do 80% of invasive breast cancers fall into?
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)
Where does invasive ductal carcinoma - NST originate from?
Cells in the breast ducts
What is Invasive Lobular Carcinomas (ILC) and how is it detected?
Around 10% of invasive breast cancers
Originate in cells from the breast lobules
Not always visible on mammograms
How does inflammatory breast cancer present?
Presents similarly to a breast abscess or mastitis
Swollen, warm, tender breast with pitting skin (peau d’orange)
Does not respond to antibiotics
Which breast cancer type makes up 1-3% of breast cancers and has the worst prognosis?
Inflammatory breast cancer
1-3% of breast cancers
Worse prognosis than other breast cancers
What does Paget’s Disease of the Nipple indicate?
Indicates breast cancer involving the nipple
May represent DCIS or invasive breast cancer
How does Paget’s disease of the nipple appear?
Looks like eczema of the nipple/areolar
Erythematous, scaly rash
Persistent roughening, scaling, ulcerating or eczematous change to the nipple.
What is done in order to stage breast cancer?
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).
MDT role in breast cancer management?
All patients are discussed with the multidisciplinary team (MDT) for treatment planning:
After the initial diagnosis
After abnormal staging tests
After further pathology and results
After recurrence of the disease
At any point where a treatment decision will be made
What is involved in the surgical management of breast cancer?
Tumour Removal
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
Axillary Clearance
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.
Patients may have adjuvant radiotherapy to the chest wall after mastectomy for tumours with a high risk of recurrence.
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. What risk does this incur?
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.
There are specialist lymphoedema services that can help manage patients. Non-surgical treatment options include what?
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
It is important to remember that you should avoid taking blood or putting a cannula in the arm on the side of previous breast cancer removal surgery. Why?
There is a higher risk of complications and infection due to the impaired lymphatic drainage on that side.
DCIS is often detected during screening - how?
Around 90% of patients with DCIS will have suspicious microcalcifications seen on mammography, with the diagnosis then subsequently confirmed via biopsy
Invasive ductal carcinoma (IDC) is the most common type of breast carcinoma, constituting 70-80% of all cases. Microscopically, IDC is composed of what?
nests and cords of tumour cells with associated gland formation
Invasive lobular carcinoma (ILC) is the second most common type of breast cancer, constituting 5-10% of all cases. Microscopically, ILC is composed of what?
It is characterised by a diffuse (stromal) pattern of spread that makes detection more difficult.
IDC or ILC?
IDC - invasive ductal carcinoma
nests and cords of tumour cells with associated gland formation
IDC or ILC
Invasive lobular carcinoma (ILC)
diffuse (stromal) pattern of spread that makes detection more difficult.
Fibroadenoma - presentation
highly mobile lesions (historically termed a “breast mouse’’)
well-defined and rubbery on palpation
most less than 5cm in diameter.
They can be multiple and bilateral.
What is a ductal adenoma
Benign glandular tumour
How do papilomas present and how/why are they managed?
They will often present with bloody or clear nipple discharge, yet larger papillomas can also present initially as a mass typically occurring in the subareolar region (usually less than 1cm away from the nipple).
They can appear similar to ductal carcinomas on imaging and therefore usually require biopsy. Some cases may be excised to ensure no atypical cells or neoplasia are present. Risk of breast cancer is only increased with multi-ductal papilloma and most are treated with microdochectomy.
What are phyllodes tumours? How should the be managed and why?
Phyllodes tumours are rare fibroepithelial tumours.
Phyllodes tumours are commonly larger, occur in an older age group, and are comprised of both epithelial and stromal tissue. They often grow rapidly.
They are difficult to clinically and microscopically differentiate from fibroadenomas, however around one third of Phyllodes tumours have malignant potential and 10% of benign tumours will recur after excision. Consequently, most Phyllodes tumours should be widely excised (or mastectomy if the lesion is large).
