Breast Cancer (AAG) Flashcards
1
Q
How common is breast cancer?
A
It is the second most frequent cancer in women, after non-melanotic skin cancer
2
Q
How does breast cancer compare to other diseases in terms of causing death?
A
It is the most common cause of death in women aged 35-54 years in England
3
Q
Describe the typical course of breast cancer
A
It follows an unpredictable cause, with metastases presenting up to 20 years after initial diagnosis
4
Q
What is the life time risk of breast cancer in the England?
A
1 in 9
5
Q
What has caused improvements in the 5 year survival of breast cancer?
A
- Earlier detection by screening
- Improved treatment
6
Q
What factors play a role in the aetiology of breast cancer?
A
- Genetic factors
- Hormonal factors
7
Q
In what % of breast cancer cases is hereditary predisposition implicated?
A
Around 10%
8
Q
Give 3 examples of hereditary disposition of breast cancer
A
- BRCA1 mutation
- BRCA2 mutation
- Li-Fraumeni syndrome
9
Q
What hormonal factors are important in the development of breast cancer?
A
Prolonged exposure to oestrogen
10
Q
What can cause a prolonged exposure to oestrogen?
A
- Early menarche
- Late menopause
- Late first pregnancy (over 35 years old)
- Nulliparity
11
Q
Does the OCP increase the relative risk of breast cancer?
A
Not significantly
12
Q
Does HRT increase the relative risk of breast cancer?
A
Yes, in long-term current users
13
Q
What is the most common histology of breast cancer?
A
Invasive ductal carcinoma, with or without ductal carcinoma in situ (DCIS)
14
Q
What % of cases of breast cancer are invasive ductal carcinoma?
A
70%
15
Q
What is the second most common type of breast cancer histology?
A
Invasive lobular carcinoma
16
Q
What % of screening-detected breast cancers are DCIS?
A
20%
17
Q
In what proportion of women is DCIS multi-focal?
A
1/3
18
Q
What is the risk of DCIS becoming invasive?
A
High - 10% at 5 years following excision only
19
Q
Does pure DCIS cause lymph node metastases?
A
No
20
Q
What is the clinical significance of lobular carcinoma in situ?
A
It is a predisposing risk factor for developing cancer in either breast
21
Q
What is the risk of developing breast cancer in a patient with lobular carcinoma in situ?
A
7% at 10 years
22
Q
How does breast cancer usually present?
A
As a mass that persists throughout the menstrual cycle
23
Q
What % of patients with breast cancer have nipple discharge?
A
10%
24
Q
What % of patients with breast cancer have pain?
A
7%
25
Give an example of a presentation that confers an adverse prognosis in breast cancer
Inflammatory carcinomas with diffuse induration of the skin
26
How are women with breast cancer increasingly presenting?
As a consequence of mammographic screening
27
What % of breast cancer patients will have axillary nodal disease?
40%
28
What increases the likelihood of breast cancer patients having axillary nodal disease?
Increasing size of the primary tumour
29
What is the strongest prognostic predictor in breast cancer?
The involvement of axillary nodes
30
Are distant metastases commonly present at time of diagnosis?
No, it is infrequent
31
What are the most common sites of spread of breast cancer?
- Bone
- Lung
- Liver
- Pleura
- Adrenals
- Skin
- Brain
32
What % of breast cancer cases does Paget's disease of the nipple account for?
1%
33
How does Paget's disease of the nipple present?
With a relatively long history of eczematous change in the nipple area, with itching, burning, oozing, or bleeding
34
Is there a palpable underlying lump in Paget's disease of the nipple?
There may be
35
What does the nipple contain in Paget's disease of the nipple?
Malignant cells, singularly or in nests
36
What is prognosis related to in Paget's disease of the nipple?
The underlying tumour
37
What should be looked for on the face in breast cancer?
- Conjunctival pallor
| - Jaundice
38
What lymph node areas may be involved in breast cancer?
- Neck
- Supraclavicular
- Axillary
39
What may be found on breast examination in breast cancer?
- Asymmetry
- Mass
- Overlying skin changes
- Peau d'orange
- Displacement of nipples
- Nipple inversion or retraction
- Nipple discharge
- Inflammatory changes
- Puckering
- Discolouration
- Change in temperature
40
What should be done with any mass on breast examination?
Measure it
41
What may be seen on observation in breast cancer
- Skin changes
- Ascites
- Cachexia
- Dehydration
- Previous radiotherapy marks
42
What should be looked for on the hands in breast cancer?
- Signs of smoking
- Pallor
- Lymphoedema
43
What should be looked for in the periphery in breast cancer?
Calf tenderness or DVT
44
What might be seen on fundoscopy in breast cancer?
Choroidal metastasis
45
What should be looked for on cardiovascular examination in breast cancer?
- Atrial fibrillation
| - Pericardial effusion
46
What should be looked for on respiratory examination in breast cancer?
- Consolidation
| - Pleural effusion
47
What should be looked for on abdominal examination in breast cancer?
- Abdominal distention
- Ascites
- Hepatomegaly
48
What should be looked for on neurological examination in breast cancer?
- Focal neurological signs
- Sensory deficit
- Spinal cord compression
- Memory deficit
- Personality change
- Cranial nerve changes
49
What features of hypercalcaemia may be seen in breast cancer?
- Confusion
- Nausea
- Polydipsia
50
What should be looked for on skeletal examination in breast cancer?
- Focal bone tenderness
| - Vertebral collapse
51
Where should be checked for focal bone tenderness in breast cancer?
- Pelvis
- Spine
- Humerus
- Femur
52
What is T0 in breast cancer?
No evidence of primary tumour
53
What is T1 in breast cancer?
Tumour of 2cm or less in its greatest dimension
54
What differentiates T1a and T1b in breast cancer?
T1a has no fixation to underlying pectoral muscle or fascia, whereas T1b does.
55
What is T2 in breast cancer?
Tumour more than 2cm, but not more than 5cm in its greatest dimension
56
What is T3 in breast cancer?
Tumour more than 5cm in its greatest dimension
57
What differentiates between T3a and T3b in breast cancer?
T3a has no fixation to underlying pectoral muscle and fascia, T3b does
58
What is T4 in breast cancer?
Tumour of any size fixed with direct extension to the chest wall and skin
59
What is meant by 'chest wall' when staging breast cancer?
- Ribs
- Intercostal muscles
- Serratus anterior muscle
Not pectoral muscle
60
What is N0 in breast cancer?
No ipsilateral lymph node metastasis
61
What is N1 in breast cancer?
Movable ipsilateral axillary nodes
62
What differentiates N1a and N1b in breast cancer?
In N1a, the nodes are not considered to contain growth. In N1b, they are considered to contain growth
63
What is N2 in breast cancer?
Ipsilateral axillary nodes containing growth, and fixed to one another or to other structures
64
What is N3 in breast cancer?
Ipsilateral supraclavicular or infraclavicular nodes containing growth or oedema of the arm
65
What is M0 in breast cancer?
No distant metastasis
66
What is M1 in breast cancer?
Distant metastasis, including skin involvement beyond the breast area
67
What are the treatment options for LCIS?
Span from observation with annual screening, to bilateral prophylactic mastectomy in selected patients
68
Is there a place for chemotherapy in LCIS or DCIS?
No
69
What is the treatment for patients with early breast cancer?
Wide local excision and axillary node surgery, followed by adjuvant breast radiotherapy
70
What axillary node surgery might be done in patients with early breast cancer?
- Dissection
- Sampling
- Sentinel lymph node biopsy
71
What is the advantage of wide local excision and radiotherapy over mastectomy in early breast cancer?
It achieves similar local control and survival rates to mastectomy, with less mutilating surgery
72
What is the purpose of adjuvant radiotherapy in early breast cancer?
It is given to reduce the risk of local recurrence
73
By how much does post-operative radiotherapy reduce the recurrence in early breast cancer?
Reduces rate from 40-60% to 4-6%
74
What drugs are used for adjuvant hormonal therapy in breast cancer?
- Tamoxifen
| - Aromatase inhibitors
75
What is the advantage of adjuvant hormonal therapy in breast cancer?
It can improve disease-free and overall survival in pre- and post-menopausal patients who have tumours that express oestrogen receptors
76
Who will only require adjuvant hormonal therapy?
Patients at low risk, with tumours that are small and ER +ve
77
What hormonal therapy should be given to ER +ve breast cancer patients that are pre-menopausal?
LHRH analogue
78
What hormonal therapy should be given to ER +ve breast cancer patients that are post-menopausal?
Tamoxifen and an aromatase inhibitor
79
Who should adjuvant chemotherapy be considered for?
Patients at higher risk of recurence
80
What factors increase the risk of recurrence in breast cancer?
- Tumour >1cm
- Tumour that is ER -ve
- Involvement of axillary lymph nodes
81
What is the advantage of adjuvant chemotherapy in breast cancer patients at higher risk of recurrence?
It improves disease-free and overall survival
82
What is trastuzumab?
A humanised monoclonal antibody to HER2
83
What is the use of trastuzumab?
It should be used alongside standard chemotherapy in women with early HER2+ breast cancer
84
What is the aim of breast cancer treatment, with respect to receptor status?
To personalise the treatment approach depending on the patients receptor status, including ER +, HER2+, and ER/PR/HER 'triple negative' patients
85
Why is important to personalise the breast cancer treatment approach based on receptor status?
Because the clinico-pathological behaviour of these groups of patients is distinct, and they require appropriate treatment strategies to optimise the survival benefit of adjuvant treatment
86
What endocrine therapy is used in metastatic breast cancer?
Second line endocrine therapy with aromatase inhibitors
87
What is the purpose of aromatase inhibitors in metastatic breast cancer?
They inhibit peripheral oestrogen production in adrenal and adipose tissues
88
How might advanced ER -ve breast cancer be traeted>
With combination chemotherapy
89
What might be considered for patients with relapsed HER2+ disease?
Trastuzumab
90
What is involved in the treatment of bone metastases in breast cancer?
- Radiotherapy
| - Bisphosphonates
91
What is the purpose of radiotherapy in bone metastases?
Pallitation to reduce pain
92
What is the purpose of bisphosphonates in bone metastases?
- Treat hypercalcaemia
| - Reduce skeletal morbidity
93
Is tamoxifen effective in the chemoprevention of breat cancer?
It has been shown to reduce the incidence of breast cancer in an American RCT in women with high risk of developing breast cancer, but the results have not been reproduced in similar European trials
