Breast cancer

Question 1

Breast lump history

Answer 1

• site of lump
• size of lump
• mobility of lump
• tender or non-tender
• change with menstrual cycle
• smooth or irregular
• tethered to underlying tissue
• painful?
• ulceration
• skin changes
• nipple - discharge, inversion

Question 2

Other breast history

Answer 2

• family history - 1st degree, males
• parity and pregnancy
• early menarche, late menopause
• red flags including loss of weight, bone pain
• breast trauma

Question 3

Non-modifiable breast cancer risk factors

Answer 3

• age over 35 years
• female gender
• family or personal history
• BRCA1 and BRCA2
• early menarche, late menopause

Question 4

Modifiable breast cancer risk factors

Answer 4

• nulliparity, not breast feeding
• oral contraceptive pill
• hormone replacement therapy
• obesity, alcohol, smoking

Question 5

Breast cancer gene markers

Answer 5

• CA15-3 - monitor disease progression
• BRCA1 and BRCA2
• oestrogen positive
• progesterone positive
• HER2 positive

Question 6

Breast lump differentials

Answer 6

• benign fibroadenoma - smooth, mobile, non-tender
• fibrocystic changes - smooth, fluid filled, painful, cyclical
• breast abscess - smokers, lactating women - discharge +/- nipple inversion
• breast carcinoma - solid, irregular, non-tender

Question 7

Breast cancer metastases

Answer 7

• lungs
• liver
• bone
• brain

Question 8

Breast cancer triple assessment

Answer 8

• clinical history and examination
• imaging - ultrasound if under 40, mammogram if over 40
• biopsy - fine needle aspiration, core biopsy (higher diagnostic yield)

Question 9

Breast 2 week wait referral criteria

Answer 9

• aged 30 or over with an unexplained breast lump with or without pain
• aged 50 and over with:
• unilateral discharge
• unilateral retraction
• consider if skin changes suggestive of breast cancer
• consider if age 30+ with unexplained lump in axilla

Question 10

Breast cancer staging

Answer 10

• stage 1 - confined to breast
• stage 2 - lymph nodes in ipsilateral axilla
• stage 3 - fixed to muscle, local invasion
• stage 4 - metastatic spread

Question 11

Breast cancer surgical management

Answer 11

• surgical - wide local excision if solitary or peripheral tumour, DCIS <4cm
• multifocal, central or large tumour, DCIS >4cm - mastectomy
• palpable lymphadenopathy - axillary node clearance
• no palpable lymphadenopathy - SLNB

Question 12

Breast cancer other management

Answer 12

• adjuvant or neoadjuvant chemotherapy - Epirubicin (cardiotoxic) + CMF
• adjuvant radiotherapy after surgery (good for palliation, bony mets)
• hormonal therapy or biologics

Question 13

Breast cancer hormonal therapy

Answer 13

• pre-menopausal - Tamoxifen (oestrogen receptor blocker)
• side effects - teratogenic, endometrial cancer, osteoporosis, hot flushes
• post-menopausal - Anastrozole (aromatase inhibitor)
• side effects - hot flushes, osteoporosis, myalgia, bone pain

Question 14

Breast cancer biologics

Answer 14

• HER2 receptor positive
• Herceptin (Trastuzumab)
• side effects - cardiomyopathy, reduced LVEF (echocardiogram)