BREAST CANCER Flashcards
What is the most common type of breast cancer?
Invasive ductal carcinomas
What are commonly found as precursors to invasive ductal carcinomas of the breast?
Ductal carcinoma in situ (DCIS)
What are the main histopathological types of breast cancer?
Invasive ductal carcinomas
Invasive lobular carcinoma
Tubular carcinoma
Medullary carcinoma
Lymphoma
What are the risk factors for developing breast cancer?
BRCA genes
p53 gene mutations
Family history - especially pre-menopausal history
Nulliparity
1st pregnancy is over the age of 30
Obesity
Early menarche
Late menopause
HRT
COCP use (debated)
Not breast feeding
Ionising radiation
Previous breast surgery - more to do with hiding disease than increasing risk
What is the lifetime risk of developing breast or ovarian cancer is you inherit a BRCA gene?
40%
Who is invited to the breast screening programme in the UK?
Women aged between 47 and 73
How often are women between the age of 47 and 73 screened apart of the National Breast Screening programme?
Every 3 years
According to NICE guidelines in 2013, certain people should be referred from breast screening if they have a first degree relative who develops breast cancer. What are the factors that would indicate referral in this situation?
Age of diagnosis was under 40
Bilateral breast cancer
Male breast cancer
Ovarian cancer also in family history
Jewish ancestry
Sarcoma (under 45) also in family history
Glioma or childhood adrenal cortical carcinomas also in family history
Complicated patterns of multiple cancers at a young age
Two or more relatives of any age with breast cancer on paternal side of the family
What tests are offered as part of the National Breast Cancer screening programme?
Mammogram
How long after a mammogram screening test should the patient and her GP receive the results?
Within 2 weeks
What are the clinical features of breast cancer?
Lump
Bloody discharge from nipple
Skin changes such as puckering, peau d’orange, dimpling,
Nipple retraction or indentation
Erythema
Scaling of nipple - particularly associated with Paget’s disease of the breast
Axillary lymphadenopathy
Where in the breast are most cancers found?
In the upper lateral quadrant
A woman presents to the breast clinic with a lump. How is she likely to be managed?
Triple assessment:
Clinical examination
Imaging - USS, mammogram
Biopsy
What are the components of the breast lump triple assessment?
Clinical examination
Imaging - USS, mammogram
Biopsy
Having identified and confirmed breast cancer through triple assessment, what further investigation would a woman warrant?
CT
PET
To stage cancer looking for lymph node and distant involvement
What are the two views given as part of mammogram imaging?
CC view - from above
MLO view - from the side
When viewing a CC-view mammogram how do we know which is the lateral edge of the breast and which is the medial edge?
The lateral edge is always the top part and hence the medial edge is always at the bottom
When describing a mammogram how should you start?
Patient details and then talk about density of the breast to get an idea of patient’s age.
What are the different ways of describing the shape of a lesion seen on mammogram?
Circumscribed
Macro-lobulated
Micro-lobulated
Obscured
Indistinct
Spiculated
What percentage of well circumscribed lesions seen on mammogram will be cancerous?
2%
What percentage of micro-lobulated lesions seen on mammogram will be cancerous?
48-52%
What percentage of spiculated lesions seen on mammogram will be cancerous?
75-95%
How do we describe density of a lesion seen on mammogram?
Relative to density of the rest of the breast
High
Equal
Low
Fat containing
Why do we not really bother with mammograms in the under 40 population who present with a lump?
They still have so much glandular tissue which is dense on film and therefore makes tumours impossible to see.
Therefore they will only have an USS
On a mammogram, what might a normal lymph node look like?
Like an ear pinna - if pathological the cortex will the thickened.
If you see multiple circumscribed masses on a mammogram are they likely to be malignant or benign?
Benign - most likely to be cysts
In an OSCE having presented a mammogram, what should you say you would like to do?
Perform an examination of the breast
See the other view - so if viewing a CC view say you want to see a MLO view
Do an USS
Take a biopsy
Take the case to MDT
With reference to breast cancer, what do we mean by PMU assessment?
This is the grading given to each modality of examination and investigation. They should all agree.
P - palpation
M - mammogram
U- Ultrasound
Each letter is given a score between 1 and 5.
1 - Nothing found
2 - Benign
3 - Unsure
4 - Highly suspicious
5 - Malignant
How do we initially manage a lady with breast cancer?
MDT
Surgery
What are the two surgical options for the management of breast cancer?
Wide local excision
Mastectomy
What are the factors that would make you confident that wide local excision would be suitable for treating breast cancer, rather than mastectomy?
Solitary lesion
Peripheral tumour
Large breasts
DCIS of less than 4 cm
Patient choice is always a factor
What are the factors that would make you feel that mastectomy would be more suitable for treating breast cancer, rather than wide local excision?
Multifocal tumour
Central tumour*
Small breasts
DCIS of more than 4 cm
Patient choice is always a factor
*Central lesions may be managed using breast conserving surgery where an acceptable cosmetic result may be obtained, this is rarely the case in small breasts
As well as surgery, what type of treatment options are available for breast cancer?
Radiotherapy
Hormonal therapy
Biological therapy
Chemotherapy
Which women are recommended to have radiotherapy as well as surgery for the management of breast cancer?
Those who have had wide local excision surgery rather than mastectomy
Those who have had mastectomy to treat T3-T4 graded tumours or those with 4 or more positive axillary nodes
What is the hormonal medication used as adjunctive therapy in the treatment of hormone sensitive breast cancer?
Pre or peri-menopausal women are given tamoxifen for 5 years.
Post-menopausal women are given aromatase inhibitors such as anastrozole.
How does tamoxifen work to prevent the return of hormone sensitive breast cancer?
It is a ‘selective estrogen receptor modulator’ (SERM). Its metabolite is a potent competitive partial agonist to the oestrogen receptor.
What are the adverse effects of tamoxifen?
Menstrual disturbance
Hot flushes
Venous thromboembolism
Increased risk of endometrial cancer
What is the alternative to tamoxifen which has a lower risk of endometrial cancer associated with it?
Raloxifene
What is the most common biological therapy used in the treatment of breast cancer?
Trastuzumab also called Herceptin. Used to treat HER2 positive tumours.
What proportion of breast cancers are HER2 positive and therefore treatable with Herceptin?
20-25%
What are the contraindications for Herceptin?
History of heart disease
