Breast cancer and screening

Question 1

Who is offered screening?

Answer 1

Women aged 47-73 every 3 years. Mammogram.
After 73 you have to book your own appointments.

Fact: for every 1 life saved from screening, 3 go through pointless treatment.

Question 2

When should you consider genetics?

Answer 2

95% of breast cancers are non-hereditary.
Consider testing if:
1st degree relative diagnosed < 40 yrs
1st degree relative with bilateral breast cancer, one < 50 years
Any male breast cancers
2 1st degree relatives or 1 1st and 1 2nd degree relative diagnosed at any age.

Question 3

Risk factors

Answer 3

Increasing age
BRCA1/BRCA2 mutations
Nulliparity
Early menarche and late menopause
HRT and COCP use 
History of breast cancer
p53 gene mutation
Obesity

Question 4

Anatomy

1) What does the breast lie on?
2) Nerve supply?
3) Arterial supply?
4) Venous drainage?
5) Lymphatic drainage?

Answer 4

1) Pectoral fascia, pec major, serratus anterior and external oblique muscles
2) Intercostal nerves T4-T6
3) Internal and external mammary artery
4) Superficial venous plexus to subclavian, axillary and intercostal veins.
5) 70% to axillary nodes and internal mammary chain

Question 5

Referral for symptomatic women?

Answer 5

USC pathway if >30 with a lump or > 50 with anything -> triple assessment. History and examination, radiology and biopsy all at one clinic visit.
Biopsy- immunohistochemistry to look for oestrogen (ER) and Herceptin (HER2) status.

Question 6

Most common location and type?

Answer 6

Superior lateral quadrant, invasive ductal carcinoma.
Other types:
Invasive lobular carcinoma- mass is diffuse, less obvious on USS, perform MRI. Multifocal and can metastasise to other breast.
DCIS, LCIS, Special type, Paget’s, Inflammatory breast cancer.
1/3 are ER+ and PR+. 1/5 are also HER2+ and can be treated with Herceptin.

Question 7

Treatment options

Answer 7

Usually surgery (wide local excision or mastectomy), hormone therapy, radiotherapy (after a WLE and to chest wall after mastectomy), chemotherapy.
Do a WLE if solitary peripheral tumour, small lesion in large breast, DCIS < 4cm.
DO mastectomy if multifocal central tumour, large in small breast and DCIS >4cm.
Offer breast reconstruction at the time or later on.
Do sentinel node biopsy +/- clearance using radioactive tracer injection.

Unless very elderly/frail, then opt for hormone therapy only.

Question 8

Hormone therpay

Answer 8

Pre menopausal women:
Selective oestrogen receptor modulators e.g. TAMOXIFEN, FLUVESTRANT. Oestrogen receptor antagonist and partial agonist. Used in ER + breast cancers.
Side effects: menstrual disturbances, endometrial cancer, hot flushes, VTE.
For 5 years post surgery.

Post menopausal women:
Androgens in the peripheral tissue turn to oestrogens via aromatase. Aromatase inhibitors e.g. LETROZOLE, ANASTRAZOLE. Used in ER + cancers.
Reduces peripheral oestrogen synthesis.
Side effects: osteoporosis - do a DEXA scan, hot flushes, myalgia, insomnia.