Breast cancer Flashcards
Incidence of breast cancer
Affects 1 in 7 women
Accounts for one quarter of malignancies in women
55,000 new cases per year in the UK;
>560 new cases annually in Grampian
>9,000 diagnosed each year are <50 years old
>12 000deaths annually
Around 300 new cases per year in men
risk factors for breast cancer
Age: Increased incidence
Previous breast cancer
Genetic: BRCA1 and BRCA2 (5%)
Early menarche and late menopause
Late or no pregnancy
HRT
Alcohol (>14 units per week)
Weight
Post Radiotherapy treatment for Hodgkin’s disease
when is breast screening offered
to 50-70 y olds - 3 yearly, australia 2 yearly
what are typical symptoms
Lump
Mastalgia (persistent unilateral pain)
Nipple discharge (blood-stained)
Nipple changes (Paget’s disease, retraction)
Change in the size or shape of the breast
Lymphoedema (Swelling of the arm)
Dimpling of the breast skin
patient clinic criteria to cover
1.CLINICAL:
History and Examination
2. RADIOLOGICAL:
Bilateral mammograms / USS
3. CYTO-PATHOLOGICAL:
FNA- cells only (cytology)
Core Biopsy- tissue (histo-pathology)
clinical assessment what to cover
History
Present Complaint
Previous Breast Problems
Family History
Hormonal Status
Drug History
Examination
BOTH Breasts, Axillae, SCF
breast imaging offered
The breast can be imaged with mammography, ultrasound or MRI
Mammography is the most sensitive in older women
Sensitivity is reduced in young women due to the presence of increased glandular tissue (<35yrs)
cytology and histology how to obtain
FNA
Fine Needle Aspiration
-> Cytology
Core Biopsy
-> Histo-Pathology
Invasive versus in-situ
ER, PR, HER2 receptor status
what are invasive pathological types of breast cancer
80% Ductal Carcinoma
10% Lobular Carcinoma
10% Others
what are non invasive types of breast cancer
DCIS
LCIS
(Ductal Carcinoma In Situ
17% screening detected)
(Lobular Carcinoma In Situ)
what makes up the MDT for breast cancer
Breast Surgeon
Radiologist
Cytologist
Pathologist
Clinical Oncologist
Medical Oncologist
Nurse counselor
Psychologist
Reconstructive surgeon
Patient and partner
Palliative care
how is breast cancer staged
FBC, U&Es, LFTs, Ca2+/PO2-
Chest x ray
Others as clinically indicated
No reliable tumour markers
T staging
Tx Primary tumour cannot be assessed
T0 Primary tumour not palpable
T1 Clinically palpable tumour -size < 2 cm
T2 Tumour size 2-5 cm
T3 Tumour size > 5 cm
T4a Tumour invading skin
T4b Tumour invading chest wall
T4c Tumour invading both
T4d Inflammatory breast cancer
N staging
N0 No Regional lymph nodes palpable
N1 Regional lymph node palpable- mobile
N2 Regional lymph node palpable- fixed
M staging
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Two main types of surgical procedure for treatment of breast cancer
Breast conservation surgery
Mastectomy
Patients suitable for
breast conservation surgery
Tumour size clinically<4cm – IN THE OLD DAYS
Breast/Tumour size ratio
Suitable for radiotherapy
Single tumours – IN THE OLD DAYS
Patient’s wish – most important!!
Sentinel lymph node biopsy
first node to receive lymphatic drainage
first node the tumour spreads to
if negative, rest of nodes in lymphatic basin are negative
Only performed when preoperative axillary USS normal/benign
treatment of the axilla
If SLN is negative
(= clear of tumour)
– no further treatment required
If SLN contains tumour
– either remove them all surgically (clearance= ANC) or give radiotherapy to all the axillary nodes
Complications of axillary treatment
Lymphoedema (10-17%)
sensory disturbance (intercostobrachial n.)
decrease ROM of the shoulder joint
nerve damage (long thoracic, thoracodorsal, brachial plexus)
vascular damage
radiation-induced sarcoma
Factors associated with increased risk of disease recurrence?
Lymph node involvement
Tumour grade
Tumour size
Steroid receptor status (negativity- ER/PR neg)
HER2 status (positivity- HER2 pos)
LVI- lymphovascular invasion
PREVENTION/ ADJUVANT TREATMENT
Radiotherapy
Hormone therapy
Chemotherapy
Targeted therapies
radiotherapy role in breast cancer treatment
(All) patients after WLE as adjuvant treatment
over (3 weeks)
Boosts reduce local recurrence
After Mx if there is local involv./signif LN involv.
Complications: immediate - longterm
Skin reaction- Skin telangiectasis
Radiation pneumonitis
Cutaneous Radionecrosis/ Osteonecrosis
Angiosarcoma
hormone therapy offered to breast cancer patients
oestrogen receptor positive
tamoxifen
aromastase inhibitors
Tamoxifen
20mg once daily over 5-10yrs
Blocks directly on ER receptor
Effective in all age groups
More effective given after chemotherapy
!Thromboembolic events
Aromatase Inhibitors
Arimidex (1mg) &
Letrozole (2.5mg)
Once daily for 5 years
Inhibiting ER synthesis
Should only be used in postmenopausal women
Improve disease free survivial (switch thx)
!Osteoporosis
chemotherapy role in breast cancer
Clinical Trials have shown:
Benefits greatest
in younger women (<50 years)
In patients with increasing adverse prognostic factor (grade 3, LN pos, ER neg, HER2 pos)
Traditional :
CMF Combinations (1st generation)
Anthracycline Combinations (Doxorubicin or Epirubicin- 2nd generation)
Taxane based Combinations (eg. Docetaxel- 3rd generation)
“Oncotype DX” – 21 gene assay to determine whether chemotherapy likely to be of benefit; RS= Recurrence Score
HER2 positivity and Anti-HER2 therapy
Trastuzumab (Herceptin®)/Pertuzamab
Monoclonal antibody against HER-2 receptor
Given to patients with over-expression of HER2 and chemotherapy
50% decrease risk of recurrence
33% increase in survival at 3 years!
local metastatic spread
Chestwall
Skin
Nipple
distant metastatic spread
Contralateral Breast
Bone
Lung
Liver
Brain
Bone Marrow
