Breast cancer Flashcards
Describe breast cancer screening in the UK.
- All women 47-73y offered screening
- screening with 2-view mammography at a screening centre
- normal screen:
(i) 3-year recall - abnormal screen:
(i) immediate recall for further investigation
(ii) either all clear, early recall in 6months or 1y, or diagnosis of breast cancer
What screening, if any, is available for high-risk women <50y?
- high-risk women aged 40-49: offered annual 2-view mammography
- women known to have a genetic mutation:
- annual MRI from 20y if TP53 mutation
- annual MRI from 30y if BRCA1/2 mutation - MRI surveillance offered for:
- women 30-39y with 10-year risk >8%
- women 40-49y with 10-year risk >20%
- at-risk women 40-49 with a dense pattern on mammography
What are the pros and cons of breast cancer screening?
Pros:
- earlier diagnosis
- improved prognosis and lower mortality
- less radical and invasive treatment needed
- reassurance for those with -ve results
Cons:
- discomfort and inconvenience of screening
- radiation risks of screening (v small)
- reassurance to those who have false -ve results
- reassurance to those who develop an interval cancer and possibly present later due to false sense of security
- anxiety + adverse effects of further investigations
- over diagnosis of minor abnormalities that would never develop into breast cancer
- earlier knowledge of disease and over treatment for who those, despite early diagnosis, ahve unchanged prognosis
What are the risk factors for breast cancer?
- Personal characteristics:
- increasing age (~81% of breast cancers occur in women >50y)
- taller women have icnreased risk
- women with denser breast have 2-6x increased risk - Lifestyle factors:
- obesity icnreases risk post-menopause
- 30% reduction in risk if exercising regularly
- high fat diet
- alcohol increases the risk by 7%/unit consumed/day - Reproductive history:
- early menarche or late menopause increases the risk
- pregnancy: increased parity reduced risk; first childbirth at late age increases risk
- breastfeeding reduces the relative risk by 4.3% for each year of breastfeeding
- COCP: slight increased risk; excess risk disappears 10ys after stopping
- HRT: increases risk and reduces sensitivity of mammography - Other PMH:
- past history of breast disease: ductal or lobular carcinoma in situ, papilloma with fibrovascular core
- ionising radiation exposure increases risk - Family history:
- One 1st degree relative with breast cancer (95% of women who develop breast cancer have no FHx)
- Several family members with early onset breast cancer (BRCA1/2 genes account for 2-5% of all breast cancers)
How does receptor status of a breast cancer impact prognosis?
oestrogen -ve tumours have poorest prognosis
How can breast cancer present?
- Breast lump (90%)
- Breast pain (21% present with painfullumo; breast pain alone <1%)
- Nipple skin change (10%) → any red, scaly lesions or eczema around the nipple Paget’s disease of the breast (intraepidermal, intraductal cancer)
- Family history (6%)
- Skin contour change (5%)
- Nipple discharge (3%)
- Rarely presents with distant metastases (e.g. bone pain)
How are potential breast cancers investigated?
- Specialist investigations:
- mammography
- USS
- ± fine needle aspiration (looks at cells) or core biopsy (looks at tissue) - if diagnosis confirmed, fiurther investigations include:
- tumour markers
- CT/MRI
- liver USS
- bone scan (to evaluate spread)
What are the features of breast cancer in situ? What is the TNM equivalent of in situ?
Features:
- non-invasive
TNM:
Tis N0 M0
What are the features of stage 1 breast cancer? What is the TNM equivalent of stage 1?
Features:
- ≤2cm diameter
- no lymph nodes affected
- no spread beyond breast
TNM:
- T1 N0 M0
What are the features of stage 2 breast cancer? What is the TNM equivalent of stage 2?
Features:
- 2-5cm diameter
- ± lymph nodes in axilla involved
- no spread beyond axilla
TNM:
- T0-2 N1 M0
- T2/3 N0 M0
What are the features of stage 3 breast cancer? What is the TNM equivalent of stage 3?
Features:
- > 5cm diameter
- lymph nodes in axilla involved
- no spread beyond axilla
TNM:
- T0-2 N2 M0
- T3 N1/2 M0
- T4 any N M0
- Any T N3 M0
What are the features of stage 4 breast cancer? What is the TNM equivalent of stage 4?
Features:
- any sized tumour
- lymph nodes in axilla may be affected
- distant metastases
TNM:
- Any T/N M1
What are the management options fo rbreast cancer?
- surgery (lumpectomy ± axillary clearance, mastectomy)
- endocrine therapy
- radiotherapy
- chemotherapy
What adjuvant endocrine therapies are available in the treatment of breast cancer?
- Tamoxifen
- Aromatase inhibitors
- Trastuzumab
What is the MOA of Tamoxifen? What type of breast cancer is it used for? How long should it be taken for?
- Oestrogen antagonist
- Used un oestrogen receptor +ve tumours (60% of breast cancers) in any age
- continue for ≥5 years
