Breast Cancer Flashcards
Epidemiology of breast cancer:
Most common form of cancer in females (along with lung and bowel)
1 in 8 women affected
Incidence is increasing
1% of cancers in men
What is a Ductal Carcinoma in situ? (DCIs)
Pre-cancerous and non-invasive lesion of the breast tissue
Usually detected through screening mammography
Abnormal cluster of cells lining the lactiferous ducts
Lobular carcinoma in situ are rarer and tend to be multifocal
Do oestrogen positive cancers have a better prognosis than HER2 amplified cancers?
Large proportion of breast cancers are oestrogen positive and have a better prognosis
More efficient hormone treatment can be given like Tamoxifen
Cancers over-expressing Human Epidermal growth factor 2 are more aggressive with poorer prognosis
Risk factors for Breast cancer
Age (80% of breast cancers occur after menopause)
Extensive family history
BRAC1/2 or HER2 tumour suppressor gene positive
Past medical history of breast cancer
Hormone replacement therapy
Early menarche or late menopause (prolonged increased levels of oestrogen),
DCIS or CIS,
Contraceptive pill,
Nulliparity
What are protective factors for breast cancer?
Regular physical activity
Breastfeeding
Healthy diet
Aspirin and NSAID medications.
Principals of screening:
Cost-effective,
The condition must be an important health problem
There should be a recognisable latent phase
The natural history of the condition should be adequately understood
There should be an accepted and effective treatment for patients
The screening technique must have a high level of accuracy, be acceptable and have facilities
present.
How is screening performed for breast cancer?
Every 3 years for ages 47-72 via mammogram
Positive predictive value is low so several false negatives - more common in younger women due to denser breast tissue
Mammograms also detect DCIs
Organisation of breast cancer services in the NHS:
Mammogram: uses low-energy x rays
Results given in 2 weeks and around 4-7% women recalled to assessment clinic
Ultrasound, wine bore needle biopsy and examination performed here
Screening offered to younger women if there is a high risk.
Will have predictive genetic testing for BRAC1/2 tumour suppressor gene mutation which is hereditary (first degree relative with a diagnosis is tested for gene, then the patient at risk)
Strengths and limitations of mammography in screening:
Strengths:
Cost-effective,
Acceptable procedure,
Relatively quick.
Limitations:
Low sensitivity and specificity,
Several false negatives and false positives
Cannot distinguish between DCIS and breast tumour
Patients report that the procedure can be painful; potential deterrent.
Why do we use ultrasound and biopsy to finally diagnose breast cancer?
Ultrasound is a more specific imaging technique
Higher specificity and sensitivity
Can distinguish between DCIs and cancer
Not uncomfortable or painful and can be used in anxious patients
Biopsy (fine needle aspiration cytology) performed at increased suspicion of cancer. Fulfils the triple assessment (avoids misdiagnosis). Definitive test and can distinguish between benign and malignant.
What is the triple assessment and how do we rate each modality?
Triple assessment combining clinical examination, radiology and biopsy.
Each modality rated from 1-5 with an increased score meaning increased suspicion of cancer
Multimodality investigations are essential as they cover all aspects of breast cancer presentation.
With the three modalities hoping to reduce the chance of over diagnosis and overtreatment when
not necessary.
Types of biopsy that can be done:
Fine needle aspiration - Most reliable and good to differentiate cancer from lumps
Large-bore Core biopsy - histological confirmation and predictive factors e.g. grade, oestrogen positivity. Can bruise, be costly and cause discomfort
Sentinel node biopsy - to see if cancer has spread into lympathic system. Needed to stage cancer and help decide treatment. TNM tumour staging
Mammotome biopsy (vaccum)- large volumes of biopsy in case of diagnostic doubt. Can remove small benign lesions. Time consuming
What are the common clinical features of breast cancer?
- Lump - painless, hard, irregular and are fixed to the skin or muscle. Can enlarge over a short period of time. with distortion of breast shape.
- Nipple discharge - clear, dark or blood. May arise from duct ectasia
- Nipple retraction or ingrowth of skin - When cancer infiltrates suspensory ligaments of Cooper causing ptosis of the breast and inward pull of skin. Both breasts should be compared
- Pain - Rare. Normally with mastitis.
- Systemic symptoms - anorexia, nausea, vomiting, weight loss, fatigue
What is a fibroadenoma?
Benign and second most common benign breast lesion.
Mixture of stromal and epithelial cell growth mass in lobule.
Hormone related and usually regress after menopause.
Smooth, firm, mobile and painless lumps
Women aged 15-35
Core biopsy taken
Excise if more than 3 cms, rapidly increasing in size and patient’s wish
What is duct ectasia and how does it lead to nipple discharge?
Dilatation of the lactiferous ducts. They become blocked and the secretions become
stagnant, which would leak out the nipple as a dark brown fluid. There
will be nipple retraction and a lump.
This is a differential diagnosis as well.
What are the potential differentials for a patients with a lump?
Potential differentials - fibroadenoma, lipoma, papilloma and
hamartoma.
What is a lipoma?
Benign tumour composed of adipose tissue.
Soft to touch, mobile and generally painless.
Most commonly found in adults between the age of 40 and 60, although they may occur in people younger.
What factors cause a delayed presentation of symptoms in primary care?
Patient delay (interval between patient first noticing the symptom and first consulting) causes:
- Older age,
- Socio-economic status and education,
- Non-white ethnic origin,
- Awareness and interpretation of symptoms,
- :Wait and see approach” with denial, self-diagnosis and self-medicating,
- Fear of diagnosis, investigations and treatment,
- Lack of social support
Practitioner delay - Young ages and male patients not referred as quickly. Symptoms other than lump cause delay due to non-specificity
System delay - Misdiagnosis, treating symptomatically, failure to adequately exam, inappropriate tests
What is lymphoedema?
Localised fluid retention and tissue swelling caused by a
compromised lymphatic system.
Seen secondary to axillary lymph node dissection, breast surgery and/or radiation therapy
Why is their a risk of lymphoedema with breast cancer?
Lymph nodes and vessels that are damaged or removed cannot be replaced. This can affect the lymphatic system’s ability to drain fluid in this area, and lymph fluid can build up in the surrounding tissues.
Lymphoedema may develop soon after treatment but it can also occur many years later and may be triggered by a skin infection (cellulitis) or possibly injury.
Sometimes lymphoedema can be due to cancer cells blocking the lymphatic system.
What are the stages of lymphoedema
- Latent - lymph vessels have some damage but not yet apparent. transport capacity is sufficient.
- Spontaneously reversible - tissue is still at pitting stage but is reversed with pressure and elevation. Limb is normal size in the morning
- Spontaneously irreversible - tissue has a spongy consistency when pressed, bounces without indentation and some fibrosis. hardening of limbs and increasing size
- Lymphostatic elephantiasis - swelling is irreversible, limb markedly larger, tissue hard, fibrotic, heavy and unresponsive
Management of lymphoedema:
- Complete decongestive therapy - manual manipulation of lymphatic ducts, short-stretch compression bandaging, exercise and skin care
- Intermittent pneumatic compression - multi chambered pneumatic sleeve with overlapping cells to promote lymph movement. Home treatment and simple
- Surgery: suction assisted lipectomy, vascularised lymph node transfer (lymph from groin is harvested with their supporting artery into axilla), Lymphaticovenous anastomosis (circulation between blood and lymph being reconnected)
