Breast Cancer Flashcards
Brief epidemiology of breast cancer.
- Affects 1 in 8 women
- 46,000 new cases per year in the UK; >440 annually in Grampian
- Accounts for 1/4 malignancies for women
- 18% deaths due to cancer
How does risk increase/decrease with age?
Risk increases with age
- 30-40, 1:252
- 40-50, 1:68
- 50-60, 1:35
- 60-70, 1:27
- lifetime-110, 1:8
Which members of the multidisciplinary team are involved in the treatment of breast cancer?
- Breast surgeon
- GP
- Radiology
- Nurses
- Cytology
- Pathologist
- Clinical Oncology
- Nurse councellor
- Physcologist
- Reconstructive surgeon
- Patient and partner
- Palliative
What are the two types of breast cancer?
- In situ carcinoma
- Invasice carcinoma
What are the subtypes of in situ carcinoma?
- Ductal carcinoma in situ
- 3% symptomatic
- 17% screen detected
- Lobular carcinoma in situ
- 0.5% symptomatic
- 1% screen tested
What are the subtypes of invasive carcinoma?
- Ductal
- Lobular
- Tubular
- Cribriform
- Medullary
In what two ways are people found to have breast cancer?
- Via presenting with a symptom
- Or breast screen symposium
5 principles of management with breast cancer?
- Establish diagnosis
- Stage (assess the severity)
- Treat the underlying cause
- General measures
- Specific measures
In what ways can we establish a diagnosis?
- History and Clinical examination
- Mammography
- Ultrasonography
- Magnetic resonance mammography
- Cytology (FNAC)
- Core biopsy
- Image guided cytology or core biopsy
- Open (surgical) biopsy
What are the main RF for breast cancer?
- Family history
- Age
- Age and menarche/menopause
- Previous benign breast disease
- Cancer in other breast
- Radiation
- COCP
- HRT
- Lifestyle: obese/alcohol
Signs and symptoms of breast cancer?
- Lump or thickening in breast (most common)
- Discharge or bleeding
- Change in size/contours of breast
- Change in colour/appearance of areola
- Redness or pitting in the breast, like skin of an orange
What are the investigations and how sensitive are they?
- Clinical examination: 88% sensitive
- Mammography: 93%
- USS: 88%
- FNA cytology: 94%
What investigations are used for staging?
- Hb, Us+Es, LFTs
- Chest xray
- Isotope bone scan
- Others as clinically indicated
Explain TNM staging.
Tumour (T)
- T1: 0-2cm
- T2: 2-5cm
- T3: >5cm
- T4: fixed to skin
Nodes (N)
- N0: none
- N1: nodes in axilla
- N2: large or fixed nodes in axilla
Metastases (M)
- M0: none
- M1: mets
Specific measures for:
Primary breast cancer
Regional tumour draining nodes
Micrometastases
- Primary breast cancer: (local control, eradicate disease)
- Regional tumour-draining nodes: (regional control, staging, eradicate disease)
- Micrometastases (eradicate disease)
What are the two main types of breast surgery?
- Breast conservation surgery (Wide local excision, quadrantectomy or segmentectomy)
- Mastectomy
Which patients are suitable for breast conservation?
- Tumour size <4cm (clinically)
- Breast/Tumour size ratio
- Suitable for radiotherapy
- Single tumours – but now we do sometimes offer multiple tumours
- Patient’s wish – most important!!
What is interesting to node about tumour size and risk of other invasive/in situ cancer?
- The bigger the tumour the lower the risk of other invasive/in situ cancer…
Why do we carry out a sentinal node biopsy?
- First node to recieve lymphatic drainage
- First node to which tumour spreads
- If negative, rest of nodes in lymphatic basin are negative
- “skip” metastases do not occur
How do we treat the lymph nodes of the axilla?
- If SLN is clear of tumour – no further treatment required
- If SLN contains tumour – either remove them all surgically (clearance) or give radiotherapy to all the nodes in the axilla
What are the steps of axillary clearance?
- All patients with breast cancer have FNAC at clinic – if shows malignant cells
- All nodes removed from axilla
- No radiotherapy given, even if nodes involved with tumour
- More morbidity than other types of axillary surgery
What are some complications when treating the axilla?
- lymphoedema
- sensory disturbance (intercostobrachial n.)
- decrease ROM of the shoulder joint
- nerve damage (long thoracic, thoracodorsal, brachial plexus)
- vascular damage
- radiation-induced sarcoma
What are RF for metastatic disease?
- age >50 years
- family history of breast and/or ovarian cancer
- BRCA1 (breast cancer type 1, early onset) or BRCA2 (breast cancer type 2 susceptibility protein) mutation present in either parent
Main types of treatment for micrometastases?
- Hormone therapy
- Chemotherapy
- Targeted therapy
Explain the hormonal therapy used to treat micromestasteses?
- Effects the oestrogen receptors
- Only given if hormone receptors are present
- Blocks stimulation of cell growth by oestrogen
- If premenopausal – tamoxifen for 5 years
- If postmenopausal – tamoxifen for 5 years if excellent prognosis.
- BUT others get an aromatase inhibitor, eg ANASTROZOLE for 5-10 years
Explain the use of chemotherapy in treatment of micromestastases?
- Better effects if age<50
- Node positive or grade 3 – usually give
- For others – balancing benefits versus toxicities, eg hasn’t spead to lymph nodes
- “Oncotype DX” – 21 gene assay to determine whether chemotherapy likely to be of benefit
What is the specific treatment for HER2 receptor?
- 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!
What is the follow up for breast cancer treatment?
- Many different protocols – poor evidence base
- Clinical examination 6 monthly for 3- 5 years
- Discharge after 3- 5 years, or even sooner!
- Mammogram of breast(s) at yearly intervals for 10 years
