Breast Cancer Flashcards
Breast cancer Stage 3A prognostic factors that make things favorable or unfavorable
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
Triple negative breast cancers are
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.
current guidelines for treatment of triple negative breast cancer
lumpectomy and surgical lymph node staging and chemotherapy and radiation. Adjuvant chemo and radiation helps to reduce risk of reoccurrence.
intraductal papilloma
common cause of serosanguinous nipple discharge. no skin changes or pruritis or ulcerations
pagets dx of breast will have
unilateral erythematous intensely pruritic ulcerative lesions confined to the nipple and areola.
diagnosis of paget’s disease of the breast is
biopsy
BRCA1 gene mutation means
pt is significant risk for developing ovarian cancer and breast cancer.
management of BRCA1
offer risk reducing salpingo-oophorectomy
hereditary breast and ovarian cancer syndrome genes
what cancers do they see?
BRCA1 and BRCA2
ovarian and breast cancer
can also see melanoma, prostate, and pancreatic cancer.
lifetime risk of breast cancer and ovarian cancer if BRCA1 or BRCA2
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.
what are some preventative measures for BRCA mutations:
close surveillance, chemoprevention, and risk reducing surgery.
Prophylactic mastectomy can be offered (reduces risk for breast cancer by 90-95%)
If BRCA positive patient declines prophylactic breast cancer screening, what do they do instead?
aggressive breast screening with breast self examination beginning at age 18.
At age 25, clinical breast exam annually with annual mammogram and breast MRI
what are BRCA screening procedures for ovarian cancer?
transvaginal U/S and Ca125
but these are not great as they have limited sensitivity in early dx
when should risk reducing salpingo oophrectomy be offered?
offer to pts age >35-40 or have completed their childbearing plans.
when and who to screen for BRCA or hereditary breast ovarian cancer syndromes?
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.
tamoxifene benefit in breast cancer
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.
skin changes concerning for cancer
redness, ulceration, scaling and flaking of the nipple
clinical manifestations of breast cancer
skin changes (peau'd orange) nipple discharge axillary LAD palpable breast mass abnormal mammogram
diagnosis of breast cancer
clinical breast exam
mammogram with or without U/S
biopsy (FNA or core needle biopsy)
staging (lymph node biopsy and MRI)
management of breast cancer
surgery (lumpectomy or mastectomy)
radiation
chemotherapy (neoadjuvant or endocrine)
in women who are >30 yrs with palpable mass, first step is
mammogram and U/S to characterize the mass and determine the need for biopsy.
if young female with palpable breast mass gets U/S and mammogram and only shows a benign radiographic features, what to do?
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.
when to get breast MRI?
after biopsy confirmed malginancy. This is done to help evaluate for metastasis.
high risk family history of breast cancer is:
- 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
women with less than 10 year life expectancy should not
undergo routine breast cancer screening or colonoscopy
this also includes those with limited life expectance due to comorbid diagnoses due to overdiagnosis
what medications can you not take with tamoxifene?
bupropion or fluoxetine (prozac)
decrease tamoxifene activation
tx of premenopausal women with LOW RISK breast cancer who don’t require adjuvant chemotherapy you will treat with
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
premenopausal women who receive adjuvant chemotherapy for high risk hormone positive breast cancer who remain pre menopausal need to get:
ovarian suppression with surgical oophorectomy OR pelvic radiation
need also either tamoxifene or an aromatase inhibitor which is superior to tamoxifene alone.
tamoxifene side effects:
endometrial cancer in women older >55 yrs hot flashes sexual dysfunction VTE stroke
aromatase inhibitor side effects:
arthralgias, vaginal dryness sexual dysfunction fractures cardiovascular events hyperlipidemia osteoporosis
Do we need imaging after surgery for stage 1 and II breast cancer?
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.
