Breast station Flashcards
How can a breast lump be assessed on examination?
4S- site, size, shape, symmetry
4Ts- Tranillumination, temperature, tethering, tenderness
3C-colour, consistency, compressability
What causes breast cancer?
90%sporadic 10% hereditary
What are the risk factors for breast Ca
Risk factors for breast carcinoma include:
Increased hormone exposure Early menarche or late menopause Nulliparity or late first pregnancy Oral contraceptives or Hormonal Replacement Therapy Susceptibility gene mutations Most commonly BRCA mutations (BRCA1/BRCA2) Advancing age Caucasian ethnicity Obesity and lack of physical activity Alcohol and tobacco use Past history of breast cancer Previous radiotherapy treatment
How common is male breast cancer?
1% of all breast cancers are male.loss os chest hair ,klinefletiers
What is the tumour marker for breast cancer
CA 15.3
What inherited syndromes can cause breast cancer
High pentrance
BRACA 1 &2,PLAB2
Li fraumeni(tp53)-brain tumours, leukemias and sarcomas
Cowden PTEN(microcephaly, autism,thyroid kidney caendometrial ca)
CDH1(diffuse gastric ca)
STK11(Peutz Jeghers)
What is the Nottingham criteria for breast cancer?
The most basic prognostic factors aregradeof tumour,sizeof tumour, and axillalymph nodestatus.
Grade: a measure of cellular differentiation, from grade 1 (well differentiated) to grade 3 (poorly differentiated). Essentially, a measure of how “aggressive” the individual cells are deemed to be.
Lymph nodes can be scored from 1-3, with 1 = 0 nodes affected and 3 = >3 nodes affected.
These basic prognostic factors can be combined to give a 5-year survival probability in theNottingham Prognostic Index (NPI):
(0.2*size) + grade + lymph node score
A score below 2.5 has a 93% 5-year survival, and a score of 5.5+ has a 50% 5-year survival.
Other prognostic factors includehistologyandstage.
What is oncotype dx?
PREDICTIVE AND PROGNOSTIC – ONCOTYPE DX:Oncotype Dxis a predictive test that gives the likeliness of a patientbenefitting from chemotherapy(and hormone therapy),and the likelihood ofcancer recurrence. It is carried out in some ER+ HER2- LN- patients.
Detailed explanation:
Oncotype DX is an assay carried out on a surgical specimen. Unlike the previous two tests, it does not look at the expression of one or two specific receptors. Instead, it looks at expression of 21 genes associated with breast cancer. The oncotype DX assay will output a score of 0-100, which predicts the likeliness of cancer recurrence, and who is likely to benefit from chemotherapy. Based on their score, patients are considered “low risk”, “intermediate risk”, or “high risk”. They will be subsequently directed towards or away from chemotherapy to avoid either under- or over-treatment.
What is the Manchester criteria for BRACA?when should testing be offered?
BRCA1/2 testing is indicated in an unaffected person where there is no living affected person available for testing. The Manchester score should be 20 or above
The individual should have a 1st degree relative affected with a relevant cancer
Ideally testing should be offered to an affected individual where there is a greater chance of identifying a mutation
Testing for the 3 Ashkenazi founder mutations offered to women with breast cancer and Ashkenazi ancestry. Full analysis of offered when Manchester Scoring is 20 and above
Testing of other genes e.g. PALB2, P53, Stk11, CDH1, PTEN can also be considered if appropriate
When is prophylactic mastectomy offered?
In women who have been assessed and deemed “high risk” for developing breast cancer, a bilateral mastectomy can be considered. High risk is defined by NICE as having a lifetime risk of ≥30%. The majority of patients that undergo risk reduction surgery have been diagnosed with a specific gene mutation (most commonly BRCA-1, BRCA-2 or p53).
Note that the procedure is referred to as risk reducing, not ‘prophylactic’. This is due to the fact that there is a residual risk of developing breast cancer, even after bilateral mastectomy surgery. Therelative riskreduction of a bilateral mastectomy is 95%. This means that the post-procedure lifetime risk is 5% of whatever the individual’s risk was considered to be pre-operatively. For example, if the patient was given a 9lifetime risk of approximately 80% (as might be the case with a BRCA-1 gene mutation), then the residual risk after bilateral mastectomy would be around 4%.
The decision to undergo a bilateral mastectomy for risk reduction can be difficult and is often associated with a significant psychological burden. As such, formal psychological assessment is a requirement during the counselling process and it is important to discuss all of the alternative options and ensure that the patient has all of the information to make an informed decision.
What is the referral criteria for breast cancer
- Refer people using a suspected cancer pathway referral(for an appointment within 2 weeks) for breast cancer if:
- They are aged 30 and over and have an unexplained breast lump with or without pain or
- They are aged 50 and over with any of the following symptoms in one nipple only:
- Discharge
- Retraction
- Other changes of concern (new NICE recommendation for 2015)
-
Consider a suspected cancer pathway referral(for an appointment within 2 weeks) people:
- With skin changes that suggest breast cancer or
- Aged 30 and over with an unexplained lump in the axilla (new NICE recommendation for 2015).
- Consider non-urgent referralin people aged under 30 with an unexplained breast lump with or without pain (new NICE recommendation for 2015).
What are the contraindications for radiotherapy?
Radiotherapy is carried out around 6 weeks after the end of chemotherapy (or after surgery, if the patient is not receiving chemotherapy). The patient will first have a planning CT scan to map out the area to focus. Small blue marks will be tattooed onto the skin to ensure the correct locations are used for all future sessions. Tangential beam radiotherapy will then be used in short sessions 5 days per week for 3 weeks, with an occasional “boost” week. Tangential beam therapy involves low dose radiotherapy at 40Gy from multiple directions. The intensity of the beams is low so as to minimise harm to surrounding structures, but will be high where the beams cross at the target location. There is still a risk of developing complications from radiotherapy usage, however.
If a patient is diagnosed with osteoporosis or has a fragility fracture further investigations may be warranted. NOGG recommend testing for the following reasons:
exclude diseases that mimic osteoporosis (e.g. osteomalacia, myeloma);
identify the cause of osteoporosis and contributory factors;
assess the risk of subsequent fractures;
select the most appropriate form of treatment
The following investigations are recommended by NOGG:
History and physical examination
Blood cell count, sedimentation rate or C-reactive protein, serum calcium,
albumin, creatinine, phosphate, alkaline phosphatase and liver transaminases
Thyroid function tests
Bone densitometry ( DXA)
Other procedures, if indicated
Lateral radiographs of lumbar and thoracic spine/DXA-based vertebral imaging
Protein immunoelectrophoresis and urinary Bence-Jones proteins
25OHD
PTH
Serum testosterone, SHBG, FSH, LH (in men),
Serum prolactin
24 hour urinary cortisol/dexamethasone suppression test
Endomysial and/or tissue transglutaminase antibodies (coeliac disease)
Isotope bone scan
Markers of bone turnover, when available
Urinary calcium excretion
So from the first list we should order the following bloods as a minimum for all patients: full blood count urea and electrolytes liver function tests bone profile CRP thyroid function tests
What are side effects of chemotherapy
Normally given as an adjuvant therapy to reduce recurrence and improve survival, chemotherapy can also be taken as a neo-adjuvant therapy to shrink a tumour prior to surgery. It is generally a combination of 2-3 cytotoxic medications taken IV in sessions lasting a few hours and followed by a break of a few weeks. This is considered one “cycle”, and treatment may involve up to 8 cycles. Historically, disease factors indicating need for chemotherapy were TNM staging based decisions. Now, disease factors indicating need for chemotherapy also include HER2+ subtype, triple negative subtype, having a high oncotype DX score, and otherwise having a poor prognosis.
Chemotherapy increases mortality and has a high morbidity. As such, molecular subtyping is important in determining whether chemotherapy will be beneficial and outweigh the risks.
Regime options includeFEC(fluorouracil, epirubicin, and cyclophosphamide) andEC(epirubicin and cyclophosphamide). These regimes may have other medications added on top of them.Taxanes(e.g. docetaxel) may be added in patients with poor prognoses, for example node positive patients (a common example of a taxane containing regime isFEC-T). Taxanes comes with the risk of additional side effects, such as neuropathy, but reduce recurrence risk.Platinum-basedmedications (e.g. carboplatin) may be added if the cancer is triple negative.
Side effects
Common side effects of chemotherapy include:
Nausea, appetite and weight loss, changes to taste, changes to skin and nails, severe fatigue, immunosuppression, easy bleeding and bruising, bowel disturbance, hair loss
Potentially serious complications include:
Deterioration in kidney function, thrombosis, changes in hearing
Severe complications include:
Cardiotoxicity,neutropenic sepsis (especially with taxanes),death
Possible late effects include:
peripheral neuropathy, early menopause,infertility,secondary malignancy(with certain chemotherapies)
It is important to discuss these risks with the patient prior to treatment.
When mastectomy be preferred over wide local excision
Surgery is the first line of treatment in the majority of patients that are diagnosed with breast cancer. Nowadays, most of these patients undergo a breast conserving procedure (see wide local excision [hyperlink])but in approximately 25% of cases, a mastectomy is still performed. The decision to perform mastectomy versus breast conserving surgery is multifactorial, including:
·Tumour size (in relation to the individual’s breast volume)
·Multifocal tumour
·Contraindication to chest wall radiotherapy (most patients who have breast conserving surgery also require radiotherapy to the remaining tissue whereas a mastectomy often permits the omission of radiotherapy). Example contraindications = previous radiotherapy to the same area, p53 gene mutation (Li-Fraumeni Syndrome).
·Patient choice
Common indications for mastectomy include
- Breast cancer
- “Risk reduction” surgery
- Symmetrising surgery (in patients with a contralateral mastectomy)
- Very rarely other reasons such as recurrent infections or necrotising fasciitis
After a mastectomy with no reconstruction (termed a simple mastectomy), most patients choose to wear an external prosthesis that sits in the cup of their bra. This is professionally fitted to match the contralateral breast. However, a minority of patients request a contralateral mastectomy simply to provide symmetry and remove the necessity to wear the prosthesis (which can be uncomfortable or heavy).
Most common side of metastasis
Increasingly, women present as a consequence of mammographic screening. Around 40% of patients will have axillary nodal disease, the likelihood of this rising with increasing size of the primary tumour. The involvement of axillary nodes by tumour is the strongest prognostic predictor. Distant metastases are infrequently present at diagnosis and the commonest sites of spread are: bone (70%), lung (60%), liver (55%), pleura (40%), adrenals (35%), skin (30%) and brain (10–20%).
What hormonal contraception methods are safe to use in patients who have a family history of breast cancer
- The copper-bearing intrauterine device (Cu-IUD).
- The levonorgestrel-releasing intrauterine system
- .Etonogestrel-only implant (Nexplanon®)
- Depot medroxyprogesterone acetate (Depo-Provera®, SAYANA PRESS®).
- Progestogen-only pill (POP).
- Combined hormonal contraceptives (CHC).
- Inform women aged over 35 years with a family history of breast cancer that there is an increased risk of breast cancer associated with taking the oral contraceptive pill, given that their absolute risk increases with age.
- Advice to women up to age 35 years with a family history of breast cancer should be in keeping with general health advice on the use of the oral contraceptive pill.
-
For women who are known carriers of a gene mutation associated with breast cancer (such as BRCA1 or BRCA2):
- TheCu-IUDmay be usedwithout restriction (UKMEC category 1).
- The following methods may be generally used (UKMEC category2):
- POP.
- Depot medroxyprogesterone acetate (Depot-Provera, SAYANA PRESS).®®
- Etonogestrel-only implant (Nexplanon).®
- LNG-IUS.
- If the CHC is being considered (UKMEC category 3), discusswith (or refer the woman to) a specialist genetics service, as views are conflicting on whether or not the protective effects of CHC against ovarian cancer outweigh the increased risk of breast cancer.
Breast anatomy
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What are the tanner staging of breast development
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