Breast Cancer

Question 1

What lifetime risk of breast cancer does the BRCA1 mutation confer?

Answer 1

80%

Question 2

BRCA1 mutations are thought to be responsible for what percentage of breast cancers?

Answer 2

5%

Question 3

What is the breast cancer screening programme?

Answer 3

A national screening programme in which every woman in the UK registered to a GP is invited for a mammogram, every 3 years, starting at the age of 50 and stopping at age 70.

Question 4

Histiologically, what type are 70-80% of breast cancers?

Answer 4

Infiltrating or invasive ductal carcinoma

Question 5

In breast cancer, if there is a lump present, is it normally painful or painless?

Answer 5

Painless

Question 6

What is involved in the triple assessment in breast clinic?

Answer 6

Clinical assessment - full history and examination
Bilateral mammography - to detect any tumours
Targeted USS and biopsy - cytological diagnosis confirmed with fine needle aspirate/needle biopsy/incisional/excisional biopsy

Question 7

If breast tissue density (typically in younger patients) precludes accurate mammogram assessment, what scan should be performed?

Answer 7

MRI

Question 8

What staging system is used in breast cancer?

Answer 8

TNM
T - from in situ to 4 (skin involvement)
N - from 0 (no lymph nodes) to 3 (internal mammary nodes)
M - from 0 (no mets) to 1 (distant mets)

Question 9

What is the first line treatment of choice for localized disease?

Answer 9

Surgery - either mastectomy or more conservative wide local excision with postoperative radiotherapy.
Lymph node disease is also typically assessed during the surgery (with axillary clearance if lymph node involvement evident, or sentinal node biopsy if not)

Question 10

What factors are taken into account when deciding whether to offer adjuvant chemotherapy to breast cancer patients?

Answer 10

• Hormone receptor status [oestrogen receptor (ER) status]
• HER-2 receptor status
• Menopausal status
• Tumour size and grade
• Nodal involvement
• Performance status

Question 11

In what patient group is chemotherapy more effective for breast cancer?

Answer 11

Under 50s

Question 12

What treatment can be offered for HER-2 positive breast cancers, whether they are metastatic or local?

Answer 12

Trastuzamab (Herceptin®) for 12 months. Affects cardiac function so regular monitoring with MUGA scan required

Question 13

Which patient group (with which cancers) will benefit from Tamoxifen treatment?

Answer 13

Premenopausal women who have tumours that are ER/PR positive if there are no contraindications.

Question 14

What is the normal length of tamoxifen treatment?

Answer 14

5-10 years

Question 15

What are the risks of Tamoxifen therapy?

Answer 15

Increased thrombotic complications and increased risk of endometrial cancer

Question 16

What type of drug is more beneficial for post-menopausal patients with breast cancer that is ER/PR positive?

Answer 16

Aromatase Inhibitors. e.g. Anastrazole and Letrozole.

Different S/E profile to tamoxifen - lower rates of vascular and malignant events but higher risk of osteoporosis.

Question 17

Which patients should receive radiotherapy after surgery for breast cancer?

Answer 17

All patients who have had conservative surgery (i.e. wide local excision rather than mastectomy)

Question 18

What proportion of patients with metastatic disease respond to endocrine therapy?

Answer 18

1/3

Question 19

What options are available for endocrine therapy for patients with metastatic disease?

Answer 19

Tamoxifen 20mg OD
Aromatase inhibitors (e.g Anastrazole, Letrozole)
Ovarian ablation (surgical/radiological/LHRH agonists) - to stop endogenous oestrogen production