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Reproduction > Breast: Treatment of Disease > Flashcards

Breast: Treatment of Disease Flashcards

1
Q

What is the epidemiology of breast cancer?

A
  • 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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2
Q

How does breast cancer risk vary with age?

A
  • Risk increases with age

- Overall lifetime risk of 1:8

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3
Q

Who is involved in the MDT approach to breast cancer?

A
  • Breast surgeon
  • Radiologist
  • Cytologist
  • Pathologist
  • Clinical oncologist
  • Medical oncologist
  • Nurse counsellor
  • Psychologist
  • Reconstructive surgeon
  • Patient and partner
  • Palliative care
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4
Q

What are the 2 main divisions of breast cancer?

A
  • In situ carcinoma

- Invasive carcinoma

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5
Q

What are the types of invasive carcinoma?

A
  • Ductal
  • Lobular
  • Tubular
  • Cribriform
  • Medullary
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6
Q

What are the 2 types of in situ carcinoma?

A
  • Ductal carcinoma in situ

- Lobular carcinoma ain situ

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7
Q

What is cancer in situ?

A

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

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8
Q

How can ductal carcinoma in situ be picked up?

A
  • 3% symptomatic

- 17% screen detected

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9
Q

How can lobular carcinoma in situ be picked up?

A
  • 0.5% symptomatic

- 1% screen detected

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10
Q

What is the breakdown of invasive carcinoma?

A
  • 70% are ductal
  • 20% are lobular
  • Lobular and ductal classed as no special type
  • Special type have better prognosis
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11
Q

What are 2 ways of being diagnosed with breast cancer?

A
  • 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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12
Q

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

A
  • Establish the diagnosis
  • Assess the severity (“staging”)
  • Treat the underlying cause
  • General measures
  • Specific measures
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13
Q

How is the diagnosis of breast cancer established?

A
  • 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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14
Q

What are the risk factors for breast cancer?

A
  • 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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15
Q

What are some signs and symptoms of breast cancer?

A
  • 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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16
Q

What is the triple assessment used in breast cancer?

A
  • Clinical examination
  • Imaging
  • FNA or core biopsy
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17
Q

How sensitive are tests in breast cancer?

A
  • FNA cytology 94%
  • Mammography 93%
  • Clinical examination 88%
  • Ultrasound 88%
18
Q

How is breast cancer stages?

A

-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

19
Q

What system is used to stage breast cancer?

A

TNM

20
Q

How is T staged in breast cancer?

A
  • T1 – 0-2cm
  • T2 - 2-5cm
  • T3 - >5cm
  • T4 – fixed to skin or muscle
21
Q

How is N staged in breast cancer?

A
  • N0- none
  • N1 – nodes in axilla
  • N2 – large or fixed nodes in the axilla
22
Q

How is M staged in breast cancer?

A
  • M0- none

- M1- metastasis

23
Q

What approach is used for primary breast cancer?

A
  • Obtain local control

- Eradicate disease

24
Q

What approach is used for regional tumour draining nodes?

A
  • Obtain regional control
  • Staging
  • Eradicate disease
25
Q

What approach is used for micro metastasis?

A

Eradicate disease

26
Q

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

A
  • Breast conservation surgery (Wide local excision, quadrantectomy or segmentectomy)
  • Mastectomy
27
Q

What patients are suitable for breast conservation?

A
  • 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!!
28
Q

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

A

For a 2cm tumour there is a:

  • 60% chance 1 cm away
  • 40% chance 2cm away
  • 20% chance 3cm away
  • 10% chance 4cm away
29
Q

What are axillary nodes used for?

A
  • Obtaining regional control of disease in order to eradicate disease
  • Staging and prognostic information
30
Q

What is the sentinel node?

A

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

31
Q

Why is a negative sentinel node biopsy a good sign.

A

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

32
Q

When is the axilla treated?

A
  • 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
33
Q

When is axillary clearance carried out?

A
  • All patients with breast cancer have FNAC at clinic

- If it shows malignant cells then axillary clearance is carried out

34
Q

What is axillary clearance?

A
  • All nodes removed from the axilla
  • No radiotherapy is given, even if nodes involved with tumour
  • More morbidity than with other axillary surgery
35
Q

What are the possible complications of axillary treatment?

A
  • Lymphoedema
  • Sensory disturbance (intercostobrachial n.)
  • Decrease ROM of the shoulder joint
  • Nerve damage (long thoracic, thoracodorsal, brachial plexus)
  • Vascular damage
  • Radiation-induced sarcoma
36
Q

What factors are associated with increased risk of disease recurrence?

A
  • Lymph node involvement
  • Tumour size
  • Tumour grade
  • Absence of oestrogen receptors
  • Presence of Her2 receptors
  • Lymphovascular invasion in the tumour
37
Q

How is micrometastases treated?

A
  • Hormone therapy
  • Chemotherapy
  • Targeted therapies
38
Q

What hormonal therapies are used?

A
  • Zoladex blocks FSH and LH
  • Tamoxifen blocks oestrogens
  • Aromatase inhibitors block oestrogens and peripheral conversion
39
Q

What types of hormone therapy do we usually give?

A
  • 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
40
Q

When is chemotherapy given for micro metastasis?

A
  • 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
41
Q

What anti-Her2 therapy is there?

A

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!
42
Q

How is breast cancer followed up?

A
  • 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

Reproduction (34 decks)

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