breast cancer JH Flashcards
genetics and breast cancer
FHx strongest RF
first degree relative 2-3x higher risk
BRCA1 and BRCA2 major risk genes associated with BC
personal Hx RF of BC
age
previous BC
high breast density
previous exposure to radiation (chest)
inc exposure to oestrogen
- early menarche, late menopause
- combined oral contraceptives/HRT
- nulliparous
- never breast fed
higher social/economic status
white ethnicity
lifestyle RF with BC
lower incidence in those who exercise regularly
higher incidence in obese patients
inc risk when acohol consumed regularly (even small quantities)
screening for BC
mammogram
x-ray of the breast tissue to detect presence of cancer that is too small to see/feel
How is diagnosis of BC made?
self examination or screening
usually facilitated using TRIPLE ASSESSMENT:
- clinical exam (characteristics of the lump, size/texture/moves)
- breast imaging (mammogram, ultrasound, to diff between solid/fluid filled lump)
- pathological evaluation (biopsy, assessment of tissue from lump)
What is first line Tx?
surgery
aim of surgery as first line Tx
remove the primary breast tumour, sent to lab for assessment
4 types of surgery for BC
- wide local excision
- radical mastectomy surgery
- conventional mastectomy surgery
- axillary surgery
What is wide local excision?
breast conserving surgery/lumpectomy
tumuor removed with small margin (1cm) of uninvolved surrounding tissue
better cosmetic outcome
patients not suitable for wide local excision
proir radiotherapy
widespread disease
tumour >5cm
persistent pathological margin
What is radical mastectomy surgery?
removal of breast, pectoralis major and minor muscles and axillary contents
What is conventional mastectomy surgery?
removal of breast including skin and nipple
pectoral muscle maintained unless evidence of tumour invasion
What is axillary surgery?
used to get lymph nodes for pathological examination required for all bc cases
- sentinel lymph node biopsy
- axillary lymph node dissection
- axillary lymph node clearance
axilla frequent site of lymph node metastases
What is lymphoedema?
build up of lymphatic fluid in lymph nodes
caused by surgery/radiotherapy
they cut off some of the lymph nodes
lymph fluid normally flows along lymph vessels and drains through lymph nodes
arm can become stiff, uncomfortable, tight
Tx for lymphoedema
compression tockings
massage
exercises
consideration for patient with lymphoedema
take blood/BP/injections in other arm
When can radiotherapy be used?
after surgery for early bc
combined with systemic therapy and surgery for locally advanced cancer
combined with systemic therapy for Tx of metastatic disease
What patients should receive radiotherapy?
all patients who have undergone bresat conserving surgery
- LT survival equivalent to mastectomy
Should radiotherapy be given after axillary surgery?
not recommended
30-40% risk of significant lymphoedema
adverse effects of radiotherapy
EARLY
- skin Tx areas become more sensitive, red, swollen
- fatigue
- hair loss
LATE
- breast changes (smaller, harder, skin changes)
- bone damage (ribs, collar bone)
- cardiac, respiatoty toxicity (less comon now, more targeted)
adjuvant chemotherapy
started within 31 days of surgery or earliest clinically appropriate date
considerations for adjuvant chemotherapy
nodal involvement
oestrogen R status
HER2 status
When is neo-adjuvant chemotherapy considered?
for locally advanced disease and tumours where down staging may facilitate breast conserving surgery
What to determine before neo-adjuvant chemotherapy?
ER, PR, HER2 status
oestrogen receptor in breast cancer
oestrogen only effects cells with oestrongen receptors
oestrogen main effect in some tissues is to cause cells to grow/divide
ER overexpressed in up to 70% of BC
Tx for oestrogen R overexpression in BC
Tamoxifen
aromatase inhibitors
s/e of hormonal therapy
- bone loss - monitor bone density, BP if required
- menopausal Sx - hot flushes/sweats, abnormal vaginal bleeding, dec libido, vaginal dryness, mood changes
- inc risk of venothromboembolism (Tamoxifen)
What does HER2 stand for?
human epidermal growth factor receptor 2
What type of R is HER2?
tyrosine kinase receptor
HER2 in BC
overexpressed in 20-30% of BC
HER2 overexpression/amplification associated with
- accelerated cell growth and proliferation
- increased risk of disease recurrence
- shortened overall patient survival
Herceptin
MAB that blocks HER2 R
Herceptin (Trastuzumab)
MAB that blocks HER2 R
adverse effetcs of herceptin
neutropenia
amaenia
thrombocytopenia
hypersensitivity rxn
CVD
What does Tx for metastatic disease depend on?
R status
previous Tx
performance status
patient choice
What does Tx for metastatic disease depend on?
R status
previous Tx
performance status
patient choice
1st line Tx for hormone receptor positive (E+ve) patients for metastatic disease
endocrine therapy 1st line
- premenopause: tamoxifen + ovarian ablation
- postmenopause: aromatase inhibitor
1st line Tx for HER2 positive patients for metastatic disease
chemotherapy
most common sites for metastases in BC and Tx
bone
- ribs
- spine
- pelvis
- arms
- legs
liver
lungs
Tx = bisphosphoantes (zoledronic acid) or denosumab
problems metastatic disease can cause
pain
impaired mobility
pathological #
hyperglycaemia
Tx for brain metastases
surgery
whole brain radiotherapy
palliative care + steroids to reduce swelling
Tx for liver/lung metastases
systemic therapy
surgery
radiotherapy
What is ulcerating/fungating disease?
grows in shape of fungus
rare
devleops in untreated cancer
cancer grows upwards and breaks through skin
- painful, itchy, affects movement
wound mamagement/ABX
strongest RF for BC
FHx
