Breast Cancer

Question 1

How common is breast cancer

Answer 1

Most common cancer in U.K.

Women have 1/8 lifetime risk

Question 2

Risk factors for breast cancer

Answer 2

Increasing age 
Previous history
Family history
HRT
Early menarche
Late menopause
Low parity
Obesity
High alcohol consumption

Question 3

Differential for nipple discharge

Answer 3

Duct ectasia
DCIS
Papilloma
Infection/abscess
Physiological

Question 4

Differential for areolar change

Answer 4

Eczema

Paget’s disease

Question 5

Differential for breast lump

Answer 5

Cancer
Cyst
Fibroadenoma
Fibrocystic change

Question 6

Differential for breast redness

Answer 6

Mastitis
Abscess
Cancer - peau d’orange

Question 7

What is the triple assessment of breast referrals

Answer 7

Clinical examination
Imaging - USS or mammogram
Pathology - biopsy histology or fine needle aspiration cytology

Question 8

Views of a mammogram

Answer 8

Caudio-cranial

Oblique

Question 9

What determines which form of imaging used

Answer 9

<40 use USS
>40 use mammogram
MRI for investigating breast implants, for high risk patient screening and to exclude multifocal disease

Question 10

Benefits of core biopsy histology

Answer 10

Can determine receptor status (ER and HER-2)

Can determine grade

Question 11

What USS features suggest benign disease

Answer 11

Well circumscribed

Hyper-echoic shadow

Question 12

What features of mammography suggest malignant disease

Answer 12

Lots of microcalcification

Irregular

Question 13

What proportion of breast cancers are ER+

Answer 13

2/3

Question 14

What proportion of breast cancers are HER-2+

Answer 14

1/3

Question 15

What proportion of breast cancers are ER+ and HER-2+

Answer 15

20%

Question 16

What proportion of breast cancers are not receptor positive

Answer 16

15-20%

Question 17

Stepwise treatment for breast cancer

Answer 17

1. Neoadjuvant chemo
2. Surgery
3. Chemo and/or radiotherapy (if both, chemo first)
4. Biological and/or hormonal treatment

Question 18

What is the chemotherapy for breast cancer

Answer 18

FEC +/- taxanes

Question 19

What is the biological treatment and how long do you take it for

Answer 19

Herceptin for 1 year

Question 20

What is the hormonal treatment and how long do you take it for

Answer 20

Oestrogen antagonists e.g tamoxifen
Aromatase antagonists e.g anastrozole
5-10 years

Question 21

Surgical options for breast cancer

Answer 21

Mastectomy
Wide local excision
Sentinel lymph node biopsy
Axillary clearance

Question 22

When is a mastectomy preferred over WLE

Answer 22

Multifocal disease
Locally advanced: invading muscle/fascia, >5cm diameter (limit smaller for smaller breasts), skin ulceration
Patient choice
BRCA mutation

Question 23

Describe SLNB

Answer 23

Sentinel node is the first draining lymph node of the tumour found by injecting a dye or radioisotope

Question 24

Examples of breast reconstruction surgery

Answer 24

Implants only
Lat dorsi flap
Plastics - TRAM and DIEP

Question 25

Side effects of breast/chest wall radiotherapy

Answer 25

Acute: skin reaction, pain Chronic: fibrosis, atrophy, telangiectasia

Question 26

Disadvantages of oestrogen antagonists

Answer 26

Increased DVT risk Increased endometrial cancer risk Increased stroke/MI risk

Question 27

Disadvantages of aromatase inhibitors

Answer 27

Increased osteoporosis risk Reduced oestrogen production in post menopausal women Can only be used in post menopausal women

Question 28

How to calculate prognosis

Answer 28

Nottingham prognostic index: (Cancer size in mm x 0.2) + grade + node stage Gives a number which can be converted to a 10 year survival rate prediction

Question 29

What determines prognosis

Answer 29

Better prognosis with: Lower NPI (smaller tumour, lower grade, lower node stage) Younger age

Question 30

Median survival with metastatic breast cancer

Answer 30

18-24 months

Question 31

Lifetime risk of breast and ovarian cancer with BRCA 1/2 mutation

Answer 31

BRCA1: 75% breast cancer, 50% ovarian cancer BRCA2: 50% breast cancer, 30% ovarian cancer

Question 32

Why do you need to determine lobular or ductal

Answer 32

Lobular requires MRI before surgery because need accurate sizing, more likely to be multifocal and more likely to be bilateral

Question 33

When can you do an oncogene assay

Answer 33

ER positive HER2 negative Intermediate prognostic score

Question 34

Outcome of oncogene assay test

Answer 34

Gives score of 0-100 of risk of recurrence >35 need adjuvant chemo <25 adjuvant chemo has no benefit