Asymptomatic: Breast Screening (50-70 yrs) OR Symptomatic: Outpatient Clinic Lump Mastalgia(persistent unilateral pain) Nipple discharge (blood-stained) Nipple changes (Paget’s disease, retraction) Change in the size or shape of the breast Lymphoedema (Swelling of the arm) – spread to lymph nodes Dimpling of the breast skin (peau d'orange)

Breast Cancer Flashcards by Chloe Lee

How many people does breast cancer effect?

1 in 8 women

46 000 new cases per year in UK

8000 diagnosed each year <50yrs

300 new cases per year in men

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What are the risk factors?

Age: Increasedincidence
Previous breast cancer
Genetic: BRCA1 and BRCA2 (5%)
Early menarche and late menopause
Late or no pregnancy
HRT
Alcohol (>14 units per week)
Weight
Exposure to radiation - post Radiotherapy treatment for Hodgkin’s disease

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What type of people recieve screening?

Screening for 50-70yrs every 3 years

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How does it present?

Asymptomatic: Breast Screening (50-70 yrs)

Symptomatic: Outpatient Clinic

Lump
Mastalgia(persistent unilateral pain)
Nipple discharge (blood-stained)
Nipple changes (Paget’s disease, retraction)
Change in the size or shape of the breast
Lymphoedema (Swelling of the arm) – spread to lymph nodes
Dimpling of the breast skin (peau d’orange)

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What is the triple assessment for diagnosing breast cancer?

CLINICAL:

History and Examination

RADIOLOGICAL:

Bilateral mammograms / USS

CYTO-PATHOLOGICAL:

FNA- cells only (cytology)

Core Biopsy- tissue (histo-pathology)

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What do you look for in history and examination?

History:

Present Complaint
Previous Breast Problems
Family History
Hormonal Status
DrugHistory – are they on blood thinners?

Examination: BOTH breasts, axillae, SCF

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Describe the signs and symptoms

Lump or thickening in breast - often painless
Discharge or bleeding
Change in size or contours of breast
Change in colour or appearance of areola
Redness or pitting of skin over the breast, like the skin of an orange

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Why is eczema of nipple and of the nipple areola complex different?

Of nipple – Pagets disease –> tissue sampling to test
Of areola – dermatological problem

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What tests are used for breast imaging?

Mammography, USS or MRI

Mammography is the most sensitive
Sensitivity is reduced in young women due to the presence of increased glandular tissue (<35yrs)

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What cytology/histology investigations are used?

Fine Needle Aspiration -> Cytology (cells)
Core Biopsy -> Histo-Pathology
- Need to do before surgery to see if invasive
- Evaluate of oestrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor- 2 (HER2) positive

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What does oestrogen + progesteron positive mean in core biopsy?

ER positive and PR positive means that cancer cells grows in response to oestrogen and progesterone –> considered hormone-receptor positive

More likely to respond to hormone therapy

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What are the two pathological types of breast cancer?

Invasive and non-invasive

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What are the invasive pathological types of breast cancer?

80% Ductal Carcinoma
10% Lobular Carcinoma
10% Others

(Mucinous, Tubular, Papillary, Medullary, Sarcoma, Lymphoma)

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What are the non-invasive pathological types of breast cancer?

DCIS (Ductal Carcinoma In Situ - 17% screening detected)
LCIS (Lobular Carcinoma In Situ)

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What are the three stages of managing breast cancer?

Diagnose the disease
Staging of the disease
Definitive treatment

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What investigations are used to assess the severity (staging)?

FBC, U&Es, LFTs, Ca2+/PO2- (bone marker)
Chest x ray
Others as clinically indicated
No reliable tumour markers

What investigation is indicated if CaPO₂and LFTs are abnormal?

CT chest/abdo/pelvis as invades bone, liver and lung

Describe the different grading on T (primary tumour)

Tx Primary tumour cannot be assessed

T0 Primary tumour not palpable

T1 Clinically palpable tumour -size < 2 cm

T2 Tumour size 2-5 cm

T3 Tumour size > 5 cm

T4a Tumour invading skin

T4b Tumour invading chest wall

T4c Tumour invading both

T4d Inflammatory breast cancer

Describe the different grading on N (regional lymph nodes)

N0 No Regional lymph nodes palpable

N1 Regional lymph node palpable- mobile

N2 Regional lymph node palpable- fixed

Describe the grading of M (distant metastasis)

Mx Distant metastasis cannot be assessed

M0 No distant metastasis

M1 Distant metastasis

What are the management options of breast cancer?

Surgery

+/- Radiotherapy

+/- Chemotherapy

+/- Hormonal Therapy

Neo-Adjuvant versus Adjuvant

Describe the use of hormal therapy in the management of breast cancer?

Some breast cancers are stimulated by the hormone oestrogen. This means that oestrogen in the body ‘helps’ the cancer to grow. This type of breast cancer is called oestrogen receptor positive (ER+).

Hormone therapy, also called endocrine therapy, is a treatment that blocks the effect of oestrogen on breast cancer cells.

What are the two main types of surgical procedures used in the management of breast cancer?

Breast conservation surgery – remove tumourwhilst preserving breast
Mastectomy
- Reconstruction options (i.e. implant, skin sparing mastectomy and use tissue from stomach or thighs)

What type of patients are suitable for breast conservation surgery?

* Tumoursize clinically \< 4cm – IN THE OLD DAYS * Breast/Tumour size ratio * Suitable for radiotherapy * Single tumours – IN THE OLD DAYS * Patient’s wish – most important!!

What is the purpose of AXILLA surgery?

* Prognostic information/staging * Regional control of disease/eradication in the axilla

What is the purpose of taking a sentinel lymph node biopsy?

As its the first node the tumour spreads to, if it's negative, rest of nodes in lymphatic basin are negative * Only performed when preoperative axillary USS normal/benign

What is the axilla treatment for breast Ca?

If Sentinel Lymph Node (SLN) is negative: * (= clear of tumour) --\> no further treatment required If SLN contains tumour: * Either remove them all surgically (clearance= ANC) or give radiotherapy to all the axillary nodes

Name possible complications of axillary treatments

* Lymphoedema (10-17%) * Sensory disturbance (intercostobrachial n.) * Decrease ROM of the shoulder joint * Nerve damage (long thoracic, thoracodorsal, brachial plexus) * Vascular damage * Radiation-induced sarcoma

Name factors associated with increase risk of disease recurrence

* Nottingham prognostic Index: * Lymph node involvement * Tumour grade * Tumour size * Steroid receptor status (negativity- ER/PR neg) * HER2 status (positivity- HER2 pos) * LVI- lymphovascular invasion

Name local and systemic prevention/adjuvant treatments

Local: * Radiotherapy Systemic: * Hormone therapy * Chemotherapy * Targeted therapies

When are people treated with radiotherapy?

* All patients after Wide Local Excision (WLE)as adjuvant treatment * 40–50yrs over 3 weeks * Boosts reduce local recurrence * After Mx if there is local involvement/signif LN involvement

Name possible complications of radiotherapy

* Immediate - longterm * Skin reaction- Skin telangiectasis * Radiation pneumonitis * Cutaneous Radionecrosis/ Osteonecrosis * Angiosarcoma

What are the two drugs that can be given for hormone therapy?

Tamoxifen or Aromatase Inhibitors

What is the action of tamoxifen and when is it used?

Blocks directly on ER receptor * 20mg once daily over 5-10yrs * Effective in all age groups * More effective given after chemotherapy * Risk of Thromboembolic events

What is the action of aromatase inhibitors and when is it used?

Arimidex(1mg) and Letrozole (2.5mg) Inhibiting ER synthesis * Once daily for 5 years * Should only be used in postmenopausal women * Improve disease free survivial(switch thx) * Risk: Osteoporosis

In what groups of people is chemo most effective in?

* In younger women (\<50 years) * In patients with increasing adverse prognostic factor (grade3, LN pos, ERneg, HER2 pos)

Describe HER2 positivity and Anti-Her2 therapy

Monoclonal antibody against Her-2 receptor * Given to patients with over-expression of Her2 and chemotherapy * 50% decrease risk of recurrence * 33% increase in survival at 3 years!

Describe the follow up

* Many different protocols – poor evidence base * Clinical examination for 1-5 years * Mammogram of breast(s) at yearly intervals for 3-10 years * Best person to keep an eye on it- PATIENT itself * Open Access to service