Breast: Treatment of Disease Flashcards by Dua Khan

What is the epidemiology of breast cancer?

Affects 1 in 8 women
46,000 new cases per year in the UK; >440 annually in Grampian
Accounts for one quarter of malignancies in women
18% of deaths due to cancer
Up to 1 in 100 cases occur in men

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How does breast cancer risk vary with age?

Risk increases with age

- Overall lifetime risk of 1:8

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Who is involved in the MDT approach to breast cancer?

Breast surgeon
Radiologist
Cytologist
Pathologist
Clinical oncologist
Medical oncologist
Nurse counsellor
Psychologist
Reconstructive surgeon
Patient and partner
Palliative care

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What are the 2 main divisions of breast cancer?

In situ carcinoma

- Invasive carcinoma

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What are the types of invasive carcinoma?

Ductal
Lobular
Tubular
Cribriform
Medullary

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What are the 2 types of in situ carcinoma?

Ductal carcinoma in situ

- Lobular carcinoma ain situ

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What is cancer in situ?

Cells have a malignant appearance but are contained within the basemen4t membrane. Has the ability to become invasive

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How can ductal carcinoma in situ be picked up?

3% symptomatic

- 17% screen detected

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How can lobular carcinoma in situ be picked up?

0.5% symptomatic

- 1% screen detected

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What is the breakdown of invasive carcinoma?

70% are ductal
20% are lobular
Lobular and ductal classed as no special type
Special type have better prognosis

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What are 2 ways of being diagnosed with breast cancer?

Present with a symptom

- NHS breast screening programme (women aged 50-70 invited, through GP practice, to attend for a 3 yearly mammogram)

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What are the 5 principles for the management of a patient with cancer?

Establish the diagnosis
Assess the severity (“staging”)
Treat the underlying cause
General measures
Specific measures

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How is the diagnosis of breast cancer established?

History and Clinical examination
Mammography
Ultrasonography
Magnetic resonance mammography
Cytology (FNAC)
Core biopsy
Image guided cytology or core biopsy
Open (surgical) biopsy

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What are the risk factors for breast cancer?

Increasing age
Western world location
Age at menarche and menopause
Age at first pregnancy
Family history
Previous benign breast disease
Cancer in the other breast
Radiation
Lifestyle factors
Oral contraceptive
HRT

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What are some signs and symptoms of breast cancer?

Most common lump or thickening, often painless
Discharge or bleeding
Change in size or contours of breast
Change in colour or appearance of the areola
Redness or pitting of skin (like an orange)

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What is the triple assessment used in breast cancer?

Clinical examination
Imaging
FNA or core biopsy

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How sensitive are tests in breast cancer?

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FNA cytology 94%
Mammography 93%
Clinical examination 88%
Ultrasound 88%

How is breast cancer stages?

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-Hb FBC, U&Es, LFTs
-Chest x ray
Isotope bone scan (if has spread to lymph nodes)
-Others as clinically indicated (symptom specific)
-No reliable tumour markers

What system is used to stage breast cancer?

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TNM

How is T staged in breast cancer?

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T1 – 0-2cm
T2 - 2-5cm
T3 - >5cm
T4 – fixed to skin or muscle

How is N staged in breast cancer?

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N0- none
N1 – nodes in axilla
N2 – large or fixed nodes in the axilla

How is M staged in breast cancer?

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M0- none

- M1- metastasis

What approach is used for primary breast cancer?

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Obtain local control

- Eradicate disease

What approach is used for regional tumour draining nodes?

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Obtain regional control
Staging
Eradicate disease

What approach is used for micro metastasis?

Eradicate disease

What are the 2 main types of surgery fro breast cancer?

- Breast conservation surgery (Wide local excision, quadrantectomy or segmentectomy) - Mastectomy

What patients are suitable for breast conservation?

- Tumour size <4cm (clinically) - Breast/Tumour size ratio - Suitable for radiotherapy - Single tumours – but now we do sometimes offer multiple tumours - Patient’s wish – most important!!

How does risk of other invasive or in situ cancer change with distance?

For a 2cm tumour there is a: - 60% chance 1 cm away - 40% chance 2cm away - 20% chance 3cm away - 10% chance 4cm away

What are axillary nodes used for?

- Obtaining regional control of disease in order to eradicate disease - Staging and prognostic information

What is the sentinel node?

First node to receive lymphatic drainage and therefore the first node to which tumour spreads

Why is a negative sentinel node biopsy a good sign.

-If negative, then the rest of the nodes will be negative as no skip metastasis occurs

When is the axilla treated?

- If SLN is clear of tumour – no further treatment required - If SLN contains tumour – either remove them all surgically (clearance) or give radiotherapy to all the nodes in the axilla

When is axillary clearance carried out?

- All patients with breast cancer have FNAC at clinic | - If it shows malignant cells then axillary clearance is carried out

What is axillary clearance?

- All nodes removed from the axilla - No radiotherapy is given, even if nodes involved with tumour - More morbidity than with other axillary surgery

What are the possible complications of axillary treatment?

- Lymphoedema - Sensory disturbance (intercostobrachial n.) - Decrease ROM of the shoulder joint - Nerve damage (long thoracic, thoracodorsal, brachial plexus) - Vascular damage - Radiation-induced sarcoma

What factors are associated with increased risk of disease recurrence?

- Lymph node involvement - Tumour size - Tumour grade - Absence of oestrogen receptors - Presence of Her2 receptors - Lymphovascular invasion in the tumour

How is micrometastases treated?

- Hormone therapy - Chemotherapy - Targeted therapies

What hormonal therapies are used?

- Zoladex blocks FSH and LH - Tamoxifen blocks oestrogens - Aromatase inhibitors block oestrogens and peripheral conversion

What types of hormone therapy do we usually give?

- If premenopausal – tamoxifen for 5 years - If postmenopausal – tamoxifen for 5 years if excellent prognosis. - BUT others get an aromatase inhibitor, eg ANASTROZOLE for 5-10 years

When is chemotherapy given for micro metastasis?

- Better effects if age<50 - Node positive or grade 3 – usually give - For others – balancing benefits versus toxicities, eg hasn’t spread to lymph nodes - “Oncotype DX” – 21 gene assay to determine whether chemotherapy likely to be of benefit

What anti-Her2 therapy is there?

Trastuzumab (Herceptin) - Monoclonal antibody against her-2 receptor - Given to patients with over-expression of Her2 and chemotherapy - 50% decrease risk of recurrence - 33% increase in survival at 3 years!

How is breast cancer followed up?

- Many different protocols – poor evidence base - Clinical examination 6 monthly for 3- 5 years - Discharge after 3- 5 years, or even sooner! - Mammogram of breast(s) at yearly intervals for 10 years

Breast: Treatment of Disease Flashcards

(42 cards)