BREAST CANCER Flashcards by

What is the most common type of breast cancer?

Invasive ductal carcinomas

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What are commonly found as precursors to invasive ductal carcinomas of the breast?

Ductal carcinoma in situ (DCIS)

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What are the main histopathological types of breast cancer?

Invasive ductal carcinomas

Invasive lobular carcinoma

Tubular carcinoma

Medullary carcinoma

Lymphoma

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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

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What is the lifetime risk of developing breast or ovarian cancer is you inherit a BRCA gene?

40%

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Who is invited to the breast screening programme in the UK?

Women aged between 47 and 73

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How often are women between the age of 47 and 73 screened apart of the National Breast Screening programme?

Every 3 years

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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

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What tests are offered as part of the National Breast Cancer screening programme?

Mammogram

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How long after a mammogram screening test should the patient and her GP receive the results?

Within 2 weeks

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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

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Where in the breast are most cancers found?

In the upper lateral quadrant

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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

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What are the components of the breast lump triple assessment?

Clinical examination

Imaging - USS, mammogram

Biopsy

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Having identified and confirmed breast cancer through triple assessment, what further investigation would a woman warrant?

PET

To stage cancer looking for lymph node and distant involvement

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What are the two views given as part of mammogram imaging?

CC view - from above

MLO view - from the side

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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?

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