Breast Cancer Flashcards
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
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
What type of people recieve screening?
Screening for 50-70yrs every 3 years
How does it present?
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)
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)
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
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
Why is eczema of nipple and of the nipple areola complex different?
- Of nipple – Pagets disease –> tissue sampling to test
- Of areola – dermatological problem
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)
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
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
What are the two pathological types of breast cancer?
Invasive and non-invasive
What are the invasive pathological types of breast cancer?
- 80% Ductal Carcinoma
- 10% Lobular Carcinoma
- 10% Others
(Mucinous, Tubular, Papillary, Medullary, Sarcoma, Lymphoma)
What are the non-invasive pathological types of breast cancer?
- DCIS (Ductal Carcinoma In Situ - 17% screening detected)
- LCIS (Lobular Carcinoma In Situ)
What are the three stages of managing breast cancer?
- Diagnose the disease
- Staging of the disease
- Definitive treatment
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 CaPO2 and 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
