Breast: Treatment of Disease Flashcards
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
How does breast cancer risk vary with age?
- Risk increases with age
- Overall lifetime risk of 1:8
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
What are the 2 main divisions of breast cancer?
- In situ carcinoma
- Invasive carcinoma
What are the types of invasive carcinoma?
- Ductal
- Lobular
- Tubular
- Cribriform
- Medullary
What are the 2 types of in situ carcinoma?
- Ductal carcinoma in situ
- Lobular carcinoma ain situ
What is cancer in situ?
Cells have a malignant appearance but are contained within the basemen4t membrane. Has the ability to become invasive
How can ductal carcinoma in situ be picked up?
- 3% symptomatic
- 17% screen detected
How can lobular carcinoma in situ be picked up?
- 0.5% symptomatic
- 1% screen detected
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
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)
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
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
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
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)
What is the triple assessment used in breast cancer?
- Clinical examination
- Imaging
- FNA or core biopsy
How sensitive are tests in breast cancer?
- FNA cytology 94%
- Mammography 93%
- Clinical examination 88%
- Ultrasound 88%
How is breast cancer stages?
-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?
TNM
How is T staged in breast cancer?
- T1 – 0-2cm
- T2 - 2-5cm
- T3 - >5cm
- T4 – fixed to skin or muscle
How is N staged in breast cancer?
- N0- none
- N1 – nodes in axilla
- N2 – large or fixed nodes in the axilla
How is M staged in breast cancer?
- M0- none
- M1- metastasis
What approach is used for primary breast cancer?
- Obtain local control
- Eradicate disease
What approach is used for regional tumour draining nodes?
- 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
