Breast Cancer

Question 1

Breast cancer Stage 3A prognostic factors that make things favorable or unfavorable

Answer 1

two important prognostic factors for breast cancer is histopathological subtype (favorable: tubular mucinous versus unfavorable: ductal, lobar, mixed metaplastic)

Estrogen/progesterone receptor positivity
HER2 receptor status

Question 2

Triple negative breast cancers are

Answer 2

seen in 20% of all breast cancers
more aggressive clinical course and unique relapse pattern.

Tend to recur and peak at 3 years post diagnosis and higher incidence of visceral or brain metastasis.

Do not give hormonal therapy for these.

Question 3

current guidelines for treatment of triple negative breast cancer

Answer 3

lumpectomy and surgical lymph node staging and chemotherapy and radiation. Adjuvant chemo and radiation helps to reduce risk of reoccurrence.

Question 4

intraductal papilloma

Answer 4

common cause of serosanguinous nipple discharge. no skin changes or pruritis or ulcerations

Question 5

pagets dx of breast will have

Answer 5

unilateral erythematous intensely pruritic ulcerative lesions confined to the nipple and areola.

Question 6

diagnosis of paget’s disease of the breast is

Answer 6

biopsy

Question 7

BRCA1 gene mutation means

Answer 7

pt is significant risk for developing ovarian cancer and breast cancer.

Question 8

management of BRCA1

Answer 8

offer risk reducing salpingo-oophorectomy

Question 9

hereditary breast and ovarian cancer syndrome genes

what cancers do they see?

Answer 9

BRCA1 and BRCA2
ovarian and breast cancer

can also see melanoma, prostate, and pancreatic cancer.

Question 10

lifetime risk of breast cancer and ovarian cancer if BRCA1 or BRCA2

Answer 10

75% for breast cancer
20-46% for ovarian cancer

if have breast cancer on side have substantial risk for developing contralateral breast cancer as well.

Question 11

what are some preventative measures for BRCA mutations:

Answer 11

close surveillance, chemoprevention, and risk reducing surgery.

Prophylactic mastectomy can be offered (reduces risk for breast cancer by 90-95%)

Question 12

If BRCA positive patient declines prophylactic breast cancer screening, what do they do instead?

Answer 12

aggressive breast screening with breast self examination beginning at age 18.

At age 25, clinical breast exam annually with annual mammogram and breast MRI

Question 13

what are BRCA screening procedures for ovarian cancer?

Answer 13

transvaginal U/S and Ca125

but these are not great as they have limited sensitivity in early dx

Question 14

when should risk reducing salpingo oophrectomy be offered?

Answer 14

offer to pts age >35-40 or have completed their childbearing plans.

Question 15

when and who to screen for BRCA or hereditary breast ovarian cancer syndromes?

Answer 15

personal history of ovarian cancer, breast cancer before age of 40, bilateral breast cancer
Family history of breast cancer at young age, bilateral breast cancer, breast and ovarian cancer, or male breast cancer
Estrogen receptor neg/progesterone receptor neg/HER2 negative breast cancer (triple negative breast cancer)
Ashkenazi Jewish ancestry.

Question 16

tamoxifene benefit in breast cancer

Answer 16

used as an adjuvant therapy in pts with hormone receptor positive breast cancer and reduces risk for contralateral breast cancer in women who are carrier for BRCA.

Question 17

skin changes concerning for cancer

Answer 17

redness, ulceration, scaling and flaking of the nipple

Question 18

clinical manifestations of breast cancer

Answer 18

skin changes (peau'd orange)
nipple discharge
axillary LAD
palpable breast mass
abnormal mammogram

Question 19

diagnosis of breast cancer

Answer 19

clinical breast exam
mammogram with or without U/S
biopsy (FNA or core needle biopsy)
staging (lymph node biopsy and MRI)

Question 20

management of breast cancer

Answer 20

surgery (lumpectomy or mastectomy)
radiation
chemotherapy (neoadjuvant or endocrine)

Question 21

in women who are >30 yrs with palpable mass, first step is

Answer 21

mammogram and U/S to characterize the mass and determine the need for biopsy.

Question 22

if young female with palpable breast mass gets U/S and mammogram and only shows a benign radiographic features, what to do?

Answer 22

still need core needle biopsy.

In young people there can be false negatives on mammogram and U/S (occult malignancy with false negative rate as high as 30%) due to dense breasts.

Question 23

when to get breast MRI?

Answer 23

after biopsy confirmed malginancy. This is done to help evaluate for metastasis.

Question 24

high risk family history of breast cancer is:

Answer 24

• two or more 1st degree relatives with breast cancer, including 1 relative <50 yrs
• three or more 1st or 2nd degree relatives with breast cancer
• 1st or 2nd degree relative with breast and ovarian cancer
• 1st degree relative with bilateral breast cancer
• breast cancer in a male relative
• Ashkenazi Jewish women with any 1st or 2nd degree relatives with breast or ovarian cancer

Question 25

women with less than 10 year life expectancy should not

Answer 25

undergo routine breast cancer screening or colonoscopy

this also includes those with limited life expectance due to comorbid diagnoses due to overdiagnosis

Question 26

what medications can you not take with tamoxifene?

Answer 26

bupropion or fluoxetine (prozac)

decrease tamoxifene activation

Question 27

tx of premenopausal women with LOW RISK breast cancer who don’t require adjuvant chemotherapy you will treat with

Answer 27

tamoxifene for at least 5 years
preferably 10 years

extending tamoxifene use to 10 years decreases the absolute risk of recurrences between 5 to 14 years after diagnosis from 25% to pts who become post menopausal while taking tamoxifene can switch to an aromatase inhibitor

Question 28

premenopausal women who receive adjuvant chemotherapy for high risk hormone positive breast cancer who remain pre menopausal need to get:

Answer 28

ovarian suppression with surgical oophorectomy OR pelvic radiation

need also either tamoxifene or an aromatase inhibitor which is superior to tamoxifene alone.

Question 29

tamoxifene side effects:

Answer 29

endometrial cancer in women older >55 yrs
hot flashes
sexual dysfunction
VTE
stroke

Question 30

aromatase inhibitor side effects:

Answer 30

arthralgias, 
vaginal dryness
sexual dysfunction
fractures
cardiovascular events 
hyperlipidemia
osteoporosis

Question 31

Do we need imaging after surgery for stage 1 and II breast cancer?

Answer 31

no.

clinical staging based on history, PE, serum liver chemistry and alkaline phosphatase measurements is the standard to confirm early stage breast cancer.

only get imaging if there’s signs of metastatic cancer.