Breast Cancer

Question 1

Where are majority of breast cancers derived?

Answer 1

• epithelial tissue of lactiferous ducts and lobules

Question 2

Drainage of breast

Answer 2

• axillary lymph nodes

- or alternative -> internal mammary chain in sternum (minor route)

Question 3

Risk Factors

Answer 3

• age
• FH
• prior personal history of it
• increase oestrogen exposure = early menarche, late menopause, HRT
• nulliparity
• 1st pregnancy after 30
• diet and lifestyle (obesity, excessive alcohol consumption)
• radiation exposure before 40
• prior benign or premalignant breast changes = in situ cancer, atypical hyperplasia, radial scar

Question 4

Familial and Hereditary Breast Cancer

Answer 4

• genetic factor
• minority linked with BRCA1 and 2 inherited mutation
• high risk families = 4 or more relatives with breast/ovary c, 3 under age of 60, 2 under age of 40, 1 with both or bilateral breast cancer

Question 5

Lifestyle Risk Reduction

Answer 5

• early childbirth before 30
• exercise 3-5 hrs per week
• maintain normal weight
• avoid smoking/alcohol
• avoid LT HRT (especially combined oestrogen and progesterone)

Question 6

Early Detection

Answer 6

• national breast screening programme
• mammography every 3 years from menopause at 50-70
• only after menopause mammography is specific and sensitive
• otherwise on request
• investigation of MRI in premenopausal

Question 7

Types of Breast Cancer

Answer 7

NON INVASE CARCINOMA IN SITU
- ductal carcinoma in situ
- lobular carcinoma in situ
INVASIVE CARCINOMA
- infiltrating ductal or lobular carcinoma
- medullary, mucinous and tubular carcinomas
UNCOMMON TUMORS
- inflammatory carcinoma
- paget's disease

Question 8

General Breast Cancer Management

Answer 8

1 stop diagnosis
- history and exam
- mammography and US
- fine needle aspirate cytology and core biopsy
MDT Discussion
Patient agreed treatment plan
Personalised treatment

Question 9

Signs and symptoms at presentation

Answer 9

• mass or pain in axilla
• palpable mass
• thickening
• pain
• nipple discharge
• nipple retraction
• oedema or erythema of the skin

Question 10

Breast Cancer Staging

Answer 10

TX = primary tumor cannot be assessed
T0 = no evidence of primary tumor
Tis Carcinoma in situ = intraductal carcinoma, lobular carcinoma in situ or Paget's disease of nipple with no tumor
T1 = tumour 2cm<
T1a = 0.1-0.5cm
T1b = 0.5-1cm
Tc = 1-2cm
T2 = 2-5cm
T3 = >5cm
T4a = any size with direct extension to chest wall
T4b = any size with direct extension to skin (edema inc. peau d'orange or ulceration of skin or satellite skin nodules)
T4c = T4a and b
T4d = inflammatory carcinoma

Question 11

Early breast cancer treatment

Answer 11

LOCAL 
- surgery and radiotherapy
- aesthetics and reconstruction
SYSTEMIC TREATMENT FOR MCIROMETASTASES
- endocrine
- chemotherapy
- targeted biologicals
- bisphosphonates
REHAB AND SURVEILLANCE

Question 12

Sites of distant metastases

Answer 12

• lymph nodes
• brain
• pleura
• lung
• skin
• liver
• bone

Question 13

Prognostic factors

Answer 13

• tumor size
• no. of positive axillary nodes
• lymphatic and vascular invasion
• histologic tumor type
• histologic grade
• oestrogen/progesterone receptors ER/PR
• HER2 overexpression

Question 14

Molecular prognostic factors

Answer 14

• proliferation index
• oncotype DX21 gene profile
• Amsterdam 70 gene profile
• blueprint 80 gene profile

Question 15

Early endocrine treatment

Answer 15

• before menopause

- tamoxifen for 5 years 25% relative reduction in risk of death

Question 16

Chemotherapy for early breast cancer

Answer 16

• cyclophosphamide, methotrexate, fluorouracil (CMF)
• fluorouracil, epirubicin, cyclophosphamide (FEC)
• docetaxel, doxorubicin, cyclophosphamide (TAC)
• docetaxel or AC and paclitaxel weekly (FEC-T)

Question 17

Targeted therapy for early breast cancer

Answer 17

• trastuzumab

Question 18

Adjuvant therapy Risk Reduction

Answer 18

• reduction in relative risk of death from breast cancer
• tamoxifen or anastrozole (25% reduction)
• chemo (20-35%)
• trastuzumab (33%)
• radiotherapy (5%)
• personalised treatment combined 50-80% reduction depending on grade and prognostic factors

Question 19

Purpose of treatment of metastatic breast cancer

Answer 19

• palliative
• serial treatments to induce remission and maintain QoL
• first endocrine response 20 m
• chemotherapy response 10m
• overall survival 24m
• to maximise quality and duration of life
• chronic illness relapsing and remitting over a number of years

Question 20

Advanced Breast Cancer Treatment

Answer 20

• endocrine anti-oestrogen
• chemo with 1 or 2 drug regimens
• targeted biologicals (trastuzumab, pertuzumab, lapatinib)
• radiotherapy
• surgery to chest wall
• supportive care (bisphosphonates)
• psychological support (art therapy)

Question 21

ECOG Grading Performance Status

Answer 21

0 = normal activity
1 = symptoms but ambulatory
2 = in bed <50% of time
3 = in bed >50% of time
4 = 100% bedridden

Question 22

KARNOFSKY Performance status

Answer 22

80-100% = can carry on normal activity, no special care needed
50-70% = unable to work, able to live at home, cares for most personal needs, varying amount of assistance
10-40% = unable to care for self, require equivalent of institutional or hospital care, disease may be progressing

Question 23

Breast Cancer endocrine treatment premenopausal examples

Answer 23

• oophorectomy
• GnRH analogues (goserlin, leuproprelin)
• SERMS (tamoxifen, fuvestrant)
• medroxy progesterone acetate

Question 24

Breast cancer endocrine treatment postmenopausal examples

Answer 24

• aromatas inhibitors (anastrozole, letrozole, exemestane)

- all of premenopausal treatments

Question 25

Supportive and Palliative Care Examples

Answer 25

• anxiety = communication
• pain = analgesic ladder
• anorexia = diet and antiemetics
• constipation = laxatives for analgesics
• metabolic = bisphosphonates
• psychologic = counselling and coping