Breast Cancer

Question 1

What is the epidemiology of breast cancer?

Answer 1

• most common cancer in women, accounting for 15% of all new cases
• In the UK, 55000 new cases diagnosed each year
• 1 in 8 women will develop breast cancer
• rare in men

Question 2

What are some of the risk factors associated with breast cancer?

Answer 2

• Increasing age
• increased periods of oestrogen exposure e.g.
  
  • late childbearing
  • nulliparity
  • early menarche
  • late menopause
  • obesity
• Oral contracepive pill and some types of hormone replacement therapy
• Obesity
• Alcohol
• Ionising radiation
• Family Hx
• Genetics
  
  • mutations in the BRCA1 gene (breast and ovarian cancer)
  • mutations in BRCA2 gene =early onset breast cancer and male breast cancer

Question 3

What is the histology of breast cancer? Most commone type?

Answer 3

• Infiltrating or invasive ductal carcinoma most common cell type
  
  • 70-80% of all cases
• Lobular carcinoma, comprising 10% of cases =characterized by higher incidence of multicentric tumours within same or opposite breast
• other types: medullary, colloid, comedo and papillary

Question 4

How does breast cancer present?

Answer 4

• Typically presents with a breast mass
• Less common presentations:
  
  • nipple discharge
  • regional lymphadenopathy (axillary / supraclavicular nodes)
  • symptoms of metastatic disease

Question 5

A patient present to the GP with a unexplained breast lump. What happens next?

Answer 5

• GP refers as a 2 week wait through the NHS Breast screening programme

Question 6

In the breast clinic, patients with suspected cancer, what do they undergo? What does this consists of?

Answer 6

A “triple assessment”

• Clinical assessment -full history and examination
• Bilateral mammography (to detect multicentric tumours or synchronous primaries in opposite breast)
• Targeted ultrasound (+biopsy) of symptomatic breast area or area of mammographic abnormality
  
  • patients also have ultrasound of axillae +/- biopsy of suspicious nodes

Question 7

How is the diagnosis of breast cancer confirmed?

Answer 7

• Cytological diagnosis confirmed by fine needle aspiration cytology, needly biopsy, incisional or excisional biopsy

Question 8

What is furtehr imaging offered to patients after the biopsy confirms a diagnosis of breast cancer? What imaging is offered?

Answer 8

• CT scan and liver imaging with ultrasouns and isotopic bone scan
  
  • in aptients at high risk of disseminated disease
• MRI
  
  • if there is a discrepancy between clinical examination, mamograma nd ultrasound finding

Question 9

What system is used to definitively stage breast cancer? What does each stage mean:

• Stage 0
• Stage 1
• Stage 2
• STage 3
• Stage 4

Answer 9

• TNM system used
• Stage 0: Tis, N0, M0
• Stage 1: T1, N0, M0
• Stage 2: T2/3, N0, M0 or T0/1/2, N1, M0
• Stage 3: T or N > stage 2, M0
• Stage 4: Any T, Any N, M1

Question 10

What is the management of localized breast cancer?

Answer 10

• Standard treatment would be surgery first
• Some have neoadjuvante chemo (chemo before surgery) in specific cases:
  
  • due to size of tumour
  • allow breast conservation
  • Her2 positive or triple negative breast cancer (ER, PR and HER2 negative)

Question 11

What are the surgical options for breast cancer?

Answer 11

• Mastectomy
• Conservative surgery (e.g. wide local excision) with postoperative radiotherapy

Question 12

What does the selection of the appropriate therapeutic approach depend on?

Answer 12

• Location
• Size of the lesion and breast size
• Single or multifocal disease
• Extent of in-situ change
• Patient’s preference

Question 13

What is doe to check the lymph nodes in breast cancer? Subsequent management dependent on findings?

Answer 13

• Assessment of axillary lymph node should be performed in all patients
• Done at time of surgery
• Initial assessment shows evidence of metastatic involvement:
  
  • patients will have axillary clearnace
• If no evidence of metastatic involvement in lymph nodes:
  
  • patient has sentinel node biopsy
  • sentinel nodes are first few lymph nodes into which a tumour drains

Question 14

What is involved in a sentinel node biopsy?

Answer 14

• Injecting a tracer material that helps the surgeon locate the sentinel nodes
• Sentinel nodes are removed and analyzed in lab
• If positive then patients will go on to have axillary clearance or radiotherapy to axillae

Question 15

What factors are considered when selecting systemic treatment for breast cancer?

Answer 15

• Hormone receptor status [oestrogen receptor (ER) status]
• HER-2 receptor status
• Menopausal status
• Tumour size and grade
• Nodal involvement
• Performance status

Question 16

What adjuvant therapy can be used in the treatment of breast cancer?

Answer 16

• Chemotherapy
  
  • when advised it is based on the assessment of risk
• Trastuzamab
  
  • effective where the cancer over-expresses the target epithelial growth factor recepto (HER-2)
  • given for 12 months
  • can affect cardiac function so patient need regular cardiac monitoring
• Endocrine therapy
  
  • Tamoxifen prescribe for premenopausal women who have tumours that are ER/PR positive if no contraindication
  • Aromatase inhinbitors e.g. anastrazole. letrozole in post-menopausal women
• Radiotherapy
  
  • following conservative surgery, all patients require radiotherapy

Question 17

What is the standar radiotherapy treatment in breast cancer?

Answer 17

• Following conservative surgery all patients require radiotherapy
• Given daily, Monday to Friday
• For 3 weeks
• For younger patients or those wiht close surgical margins they will receive an additional week of radiotherapy

Question 18

What endocrine therapy is available for women with breast cancer? When is it given? Who to?

Answer 18

Tamoxifen

• premenopausal women
• Tumour that are ER/PR positive
• 20mg/day reduces annual risk of recurrence by 25% and death 17%
• Given along side chemo and for 5/10year post breast cancer

Aromatase Inhibitors e.g. anastrazole or letrozole

• postmenopausal women
• Can cause problems with osteoporosis so patients have:
  
  • baseline DEXA scan to assess bone mineral density
  • lifestyle changes
  • Vit D
  • Calcium supplementation or bisphosphonates

Question 19

What is meant by a HER2 positive breast cancer?

Answer 19

• HER2 (human epidermal growth factor receptor 2) is a gene
• The HER2 gene makes HER2 proteins
• HER2 proteins are receptors on breast cells.
• HER2 receptors help control how a healthy breast cell grows, divides, and repairs itself. But in about 10% to 20% of breast cancers, the HER2 gene doesn’t work correctly and makes too many copies of itself
• Breast cancers with HER2 gene amplification or HER2 protein overexpression are called HER2-positive
• Tend to grow faster and are more likely to spread and come back compared to HER2-negative breast cancers

Question 20

When would ovairan ablation be considered as a treatment for women with breast cancer? Why?

Answer 20

• In premenopausal women
• Endogenous ovarian oestrogen production may be stopped by ovarian ablation (surgical or radiotherapy) or by use of LH releasing hormone agonist

Question 21

What are the prognostic % for each stage of breast cancer?

Answer 21

Stage of tumour and 5 year survival rate

• Stage 1 95%
• Stage 2 80%
• Stage 3 60%
• Stage 4 25%

Histology is also dependent on histological grade, nuclear grade, HER2 and oestrogen receptor status