Breast Cancer

Question 1

How many women are said to develop BC?

Answer 1

1 in 8

Question 2

What are RF

Answer 2

• Age
• FHx - 1st degree relative premenopausal w bc
• Nulliparity, having 1st child <30yrs
• BRCA genes
• Early menarche, late menopause
• HRT (combined oral)
• Obesity
• Alcohol - even a small amount causes a considerable risk increase

Question 3

When are women invited for breast screening?

Answer 3

50 -70 every 3 years but is being expanded to 47-73

Question 4

How Many women are invited back for further assessment after initial mammogram?

Answer 4

1 in 25

Question 5

How is a diagnosis made?

Answer 5

Triple assessment:

history + examination, imaging, and histology

Question 6

When are women referred for a triple assessment?

Answer 6

• by GP if signs or sx that meet the breast cancer “2 week wait” referral criteria, or
• if there has been a suspicious finding on their routine breast cancer screening mammography

Question 7

What are possible sx of breast cancer?

Answer 7

• Painless lump - irregular, hard, fixed
• Nipple discharge
• Nipple in-drawing
• Pain and tenderness not common
• Peau de l’orange
• Skin tethering
• Indrawn nipple

Question 8

How may metastatic cancer present?

Answer 8

back pain, pathological fracture etc.

Question 9

What indicates BC in mammogram

Answer 9

fluffy edge of mass - speculation

speckles of calcium - cancerous change

Question 10

when is MRI used?

Answer 10

assessment of implants

Question 11

when is US used?

Answer 11

to guide biopsies

Question 12

What are the surgical options for breast canceR?

Answer 12

1. breast conservation

2. Mastectomy

Question 13

when is breast conservation recommended?

Answer 13

small tumour relative to breast size
not underneath nipple
no prev radiotherapy
DCIS<4cm

Question 14

When is mastectomy recommended?

Answer 14

large tumour
tumour underneath or indrawn of the nipple
multi cancer in same nipple
BRCA carrier (double m)
DCIS >4cm

Question 15

When is full axillary clearance indicated?

Answer 15

if glands clinically involved

Question 16

What is a SE of axillary clearance?

Answer 16

can cause lymphoedema

Question 17

How can breast cancers be classified? which is the most common type?

Answer 17

Ductal (70%) or lobular
Further subdivided into:
i. In situ - hasn’t spread beyond local tissue
ii. invasive - has spread

Question 18

Explain the TNM staging for breast cancer

Answer 18

TNM = tumour, nodes, metastasis
T0 = no evidence 
T1 = <2cm
T2 = 2-5cm
T3 = >5cm
T4 = extends to chest wall, skin, inflammatory
N0 = no nodes 
N1 = mobile nodes
N2 = fixed/matted nodes
N3 = internal mammary nodes
M0 = no metastases 
M1 = metastases

Question 19

What criteria is used to give prognosis of bc?

Answer 19

Nottingham Prognostic Index

Grade + LN +0.2xsize

Question 20

When is radiotherapy recommended?

Answer 20

ALWAYS after wide local excision to reduce rate or recurrence
after mastectomy if T3-4 or 4 or more +ve axillary nodes

Question 21

When is hormonal therapy offered?

Answer 21

if tumours are positive fore oestrogen receptors

Question 22

Which hormone therapies are recommended for who? why?

Answer 22

Tamoxifen - pre/perimenopausal women, inhibits oestrogen receptor
Aromatase inhibitors (anastrozole) on post-menopausal women

Question 23

Why are aromatase inhibitors used in treatment?

Answer 23

aromatisation accounts for majority of oestrogen production in post-menopausal women

Question 24

What are important SE of tamoxifen?

Answer 24

increased risk of endometrial cancer, VTE and menopausal symptoms

Question 25

What biological therapy is offered to women? when is it indicated and contraindicated?

Answer 25

Trastuzumab (perception) - used in HER2 positive tumours CI: hx of heart disorders

Question 26

When is chemotherapy indicated?

Answer 26

if a tumour needs down staging or after surgery depending on stage of tumour

Question 27

What are the advantages of immediate reconstruction?

Answer 27

• options for skin preservation and better objective cosmesis
  reduced physiological trauma from disfigurement

Question 28

What are disadvantages of immediate breast reconstruction?

Answer 28

May delay chemo or radio if complications

Radio may spoil result

Question 29

What are advantages of delayed reconstruction?

Answer 29

Minimal risk of delays in other adjuvant therapies from complications
Can excise irradiated tissue

Question 30

What are disadvantages of delayed reconstruction?

Answer 30

• limited sin preservation options
• loss of inframammary fold
• period w/o breast, may never have reconstruction or face delays as no longer urgent

Question 31

What are complications of breast implants?

Answer 31

capsule formation
infection
rupture
shape changing w age 
hamper sensitivity of mammograms

Question 32

What is adjuvant therapy in metastatic disease?

Answer 32

Bisphosphonates and denosumab