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Cancer Care > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

What is the most common cancer in women?

A

Breast cancer. 1 in 8 lifetime risk, accounts for 31% of malignancies in women.

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2
Q

What are the risk factors for breast cancer?

A
  1. Age (incidence doubles every 10 years until the menopause)
  2. Family history
  3. Hereditary syndromes
    • BRCA 1 & 2 mutations
  4. Exposure to oestrogen
    • early menarche
    • late menopause
    • nulliparity or late age of first pregnancy
    • exogenous oestrogens e.g. oestrogen use in HRT, use of COCP for >5 years
  5. Radiation - e.g. radiotherapy for Hodgkin’s lymphoma
  6. Breast density >75% on mammogram
  7. Diet - high dietary fat, obesity, alcohol
  8. Previous breast cancer
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3
Q

What percentage of women with either a BRCA 1 or BRCA 2 mutation will get breast cancer

A

45-65% develop breast cancer by the age of 70. There is a particular risk of pre-menopausal cancer in these women, with many cases occurring before the age of 40.

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4
Q

What other cancers are associated with BRCA 1 &2?

A

ovarian (particularly BRCA 1)

prostate cancer

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5
Q

What are the management options offered to women identified as moderate-high risk of breast cancer?

A
  1. Referral to medical genetics clinic for testing for BRCA 1/2, counselling and appropriate management.
  2. Annual screening and review in breast clinic between the ages of 40 and 50 years. Any screening under 40 years carried out using MRI.
  3. Prophylactic surgery - bilateral mastectomy (usually with immediate reconstruction) - reduces risk by 95% (not 100%). may be offered in conjunction with bilateral oophorectomy.
  4. Prophylactic tamoxifen - reduces incidence of ER positive breast cancer
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6
Q

What family history will mean a woman is classed as high risk for breast cancer?

A
  • two first degree relatives with breast cancer diagnosed <50y, or
  • three first or second degree relatives <60y, or
  • one relative with bilateral breast cancer <50y,
  • two relatives with ovarian cancer
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7
Q

What screening for breast cancer is offered in the UK?

A

Mammography offered every 3 years to women between the ages of 47-73 years.
Older women can self-refer and high risk women can access screening from a younger age.

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8
Q

Breast cancer most commonly arises in which quadrant of the breast?

A

Upper outer quadrant

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9
Q

What are the two main histological types of breast cancer?

A 
Ductal carcinoma (can be in-situ or invasive)
Lobular carcinoma (can be in-situ or invasive)
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10
Q

What are the possible subtypes of invasive ductal carcinoma?

A 
Medullary carcinoma (5-10%)
Mucinous carcinoma (2%)
Tubular carcinoma (2-3%)
Papillary carcinoma (1-2%)
Mixed
Not otherwise specified (70-80%)
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11
Q

What other types of cancer might occur in the breast?

A 
Lymphoma
Metastases 
Sarcoma - e.g. Phyllodes tumor
Paget's disease of the nipple
Inflammatory breast carcinoma
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12
Q

Where does breast cancer most commonly metastasize to?

A 
Lymph nodes
Lung and pleura
Bone
Brain
Liver
Skin
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13
Q

What percentage of breast carcinomas are ductal?

A

90%

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14
Q

When does DCIS become classed as invasive?

A

DCIS = tumour that remain within the confines of the ductal basement membrane

Invasive = spreads beyond the ductal basement membrane.

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15
Q

How do the majority of DCIS present?

A

Localized DCIS is often impalpable but visible on mammography as an area of microcalcification, therefore the majority of DCIS presents through the breast screening programme.

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16
Q

What percentage of DCIS progresses to invasive ductal carcinoma?

A

30-50%

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17
Q

How might breast cancer present?

A
  1. A lump of thickening in the breast, usually painless
  2. Discharge or bleeding from the nipple
  3. Change in size or contours of the breast
  4. Change in colour or contours of the breast - dimpling, puckering
  5. Erythema of the skin
  6. pitting of the skin - (p eau d’orange)
  7. Nipple inversion
  8. Rash (paget’s)
  9. Occasionally persistent breast pain or tenderness
  10. Symptoms from metastatic disease e.g. bone pain, spinal cord compression
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18
Q

What are the three histological features are used to grade invasive ductal carcinoma (grade I-III)?

A

Tubule formation
Nuclear pleomorphism
Mitotic frequency

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19
Q

What is the pattern of inheritance for BRCA1/2 mutations?

A

Autosomal dominant

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20
Q

What is Li-Fraumeni syndrome?

A

A loss-of-function mutation in the p53 tumour suppressor gene results in Li-Fraumeni Syndrome. this syndrome is associated with an increased risk of the following cancers:

  • breast
  • prostate
  • colorectal
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21
Q

What is Cowden Syndrome?

A

A loss-of-function mutation in the PTEN suppressor gener results in Cowden Syndrome. This syndrome is associated with an increased risk of the following cancers:

  • breast
  • endometrial
  • thyroid
  • brain
22
Q

What are the risk factors for breast cancer in men?

A
  1. Family history
  2. BRCA mutations
  3. Klinefelter syndrome
  4. Exposure to chest radiation
23
Q

What are the two views taken of the breast in a mammogram?

A

Medial-lateral

Cranio-caudal

24
Q

What are the advantages and disadvantages of mammographic screening for breast cancer?

A

Advantages:

  • can detect breast cancers that are clinically asymptomatic
  • shown to reduce breast cancer mortality
  • relatively good sensitivity and specificity

Disadvantages:

  • does not detect all breast cancers (especially in younger women who’s denser breast tissue makes it more difficult to interpret)
  • false positives result in costly and invasive follow up tests and distress for patients
25
Q

What molecular classifications can be given to breast cancers?

A

1) Hormone receptor status
- ER positive/negative
- PR positive/negative
2) HER2 status
- (human epidermal growth factor receptor 2)
- HER2 is present in all normal breast epithelial cells, but is overexpressed in 20-25% of breast cancers
- HER2 positive is a poor prognostic factor

26
Q

Which receptor statuses are considered poor prognostic indicators?

A

ER negative
PR negative
HER2 positive

27
Q

What does the term triple negative breast cancer mean?

A

ER negative, PR negative, HER2 negative.

accounts for 15% of breast cancers, is most common in pre-menopausal women and is associated with BRCA 1.

28
Q

What is involved in the Triple Assessment?

A
  1. Clinical examination - inspection and palpation
  2. Imaging - mammogram/USS/MRI
  3. Biopsy - fine needle aspiration (FNA) (usually for lymph nodes) or core needle biopsy (usually for breast lump) (can be guided by ultrasound)
29
Q

What features of breast cancer can be seen on a mammogram?

A

Radiopaque mass

Microcalcifications

30
Q

Other than the breast, what other areas of the body should be palpated during clinical examination?

A

Axilla

Supra-clavicular lymph nodes

31
Q

What are the advantages of core biopsy over fine needle aspiration?

A

Core biopsy takes a larger sample of tissue, allows for differentiation between carcinoma in situ and invasive carcinoma. Can also be used to determine tumour grade and receptor status.

FNA can only give cytological assessment, so core biopsy would then be indicated anyway.

32
Q

What further investigations are performed in breast cancer that is found to be invasive?

A

Chest XR or CT chest - if spread to lungs suspected
Liver imaging - CT or US
Bone scan (if bone pain, elevated alkaline phosphatase, positive axillary lymph nodes, or tumour size >5 cm).

33
Q

Which symptoms are considered red flags for breast cancer?

A

Breast lump
Ulceration or retraction of the skin
Eczema or retraction of the nipple

34
Q

What are the treatment modalities for breast cancer?

A
  1. Surgery
  2. Radiotherapy
  3. Hormone therapy (tamoxifen, AI, oopherectomy)
  4. Chemotherapy
  5. Immunotherapy (Herceptin)
35
Q

What are the management options for DCIS and LCIS?

A
  1. Wide local excision alone.
  2. Simple mastectomy - used for large in situ cancers or multifocal cancers. Can be offered with breast reconstruction if desired.
  3. Wide local excision and post-operative radiotherapy. Irradiation of the breast decreases the chance of recurrence. Majority of patients with DCIS are given radiotherapy following breast conserving surgery.
  4. Adjuvant chemotherapy. Tamoxifen 20mg daily, taken for 5 years, reduceds the frequency of recurrence of DCIS.
36
Q

Give the possible causes for a benign breast lump.

A 
Fibroadenomas
Fibrocystic changes
Cysts
Lipomas
Papillomas
37
Q

In what age group are fibroadenomas most commonly found?

A

20s

38
Q

What are the potential complications of axillary clearance?

A

Lymphoedema
Brachial plexus injury
Stiff/frozen shoulder
Anaesthesia/paraesthesia of the armpit/inner arm

39
Q

What are the possible early complictions (within 24hrs) of breast surgery?

A

Haematoma (will require evacuation).
Necrosis/breakdown of wound edges or skin flaps
Infection
Myocutaneous flap failure following reconstructive surgery (i.e. a cold flap with white arterial insufficiency or purple venous congestion)

40
Q

What are the possible long term complications of breast surgery?

A 
Seroma
Infection 
Arm lymphoedema 
Breast lymphoedema 
Poor cosmetic result
41
Q

What are the possible systemic side effects of breast radiotherapy?

A

Loss of appetite
Fatigue
Nausea

42
Q

What are the possible local effects of breast radiotherapy?

A

Short term

  • skin thinning, occasionally progressing to moist desquamation
  • erythema
  • puritis
  • aches and pains within the breast
  • shoulder restriction
  • oesophagitis

Long-term

  • telangiectasia
  • hyperpigmentation
  • cutaneous radionecrosis
  • fibrosis of the breast (producing a smaller, harder breast that does not alter with time like the contralateral breast)
  • arm lymphoedema
  • breast lymphoedema
  • rib pain, occasional rib fracture, osteoradionecrosis is now very rare
  • radiation pneumonitis
  • sarcomas (rare)
43
Q

What adverse effects are common to all hormonal treatments?

A
  • hot flushes and night sweats
  • fatigue and mood disturbance
  • fluid retention, weight gain, bloating
  • vaginal discharge, itching, dryness
  • irregular periods or amenorrhoea in pre-menopausal women
  • flare reaction and possible hypercalcaemia if bony mets present
  • headache, athralgia, rash, nausea
44
Q

What adverse effects are associated specifically with tamoxifen?

A
  • increased risk of endometrial cancer
  • increased risk of thromboembolic events (DVT, PE, CVA)
  • visual disturbances due to cataracts, corneal changes or retinopathy (rare)
  • thrombocytopenia, leucopenia, liver enzyme disregulation
  • contraindicated of pregnant or breast feeding.
45
Q

What adverse effects are specifically associated with aromatase inhibitors?

A
  • Osteoporosis (all women starting AI need baseline DEXA to assess need for adjuvant bisphosphonates)
  • diarrhoea or constipation
  • anastrozole can increase cholesterol levels
46
Q

What is the brand name for Trastuzumab?

A

Herceptin

47
Q

What is the mode of action of herceptin (trastuzumab)?

A

Monoclonal antibody against the HER-2 protein. Inhibits growth of HER2 positive breast cancers.

48
Q

What parameters are used in the Nottingham Prognostic Index (NPI) to predict 5-year survival?

A
  1. Tumour size
  2. Lymph node involvement
  3. Histological grade
49
Q

What class of drug is tamoxifen?

A

Selective Eostrogen Receptor Modulator (SERM)

antagonistic properties at ER in breast tissue, but acts as oestrogen elsewhere e.g. bones, endometrium

50
Q

What class of drug is letrozole and what is its mode of action?

A

Aromatase inhibitor (AI). Aromatase is an enzyme involved in the production of oestrogen from peripheral fat. Letrozol inhibits this enzyme therefore reducing the production of oestrogen.

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