Breasts Flashcards
How common is breast cancer?
Commonest cancer in UK
11,500 deaths per year
1 woman in 8 will develop disease
90% women survive 5 years/more
5 year survival 82%
What can increase your risk of breast cancer?
Main risk factors - female, getting older, significant family history (BRCA1 or 2 or other genes)
Also…
Radiotherapy treatment < 35 years (Hodgkin’s)
Li Fraumeni syndrome
Late first childbirth (> 35)
Alcohol consumption
HRT for > 5 years
Oral contraceptive use
Obesity (post menopausal)
Not breast fed
Nulliparous
Lack of exercise
Extrogenous oestrogens
Late onset menarche
What genes are associated with increased breast cancer risk?
BRCA1 - female breast, ovarian - 40-80% lifetime risk
BRCA2 - female and male breast, ovarian, prostate, pancreatic - 20-80% lifetime risk
Li Faumeni - Tp53 - breast, sarcoma, leukaemia, brain, adrenocortical, lung - 56-90% lifetime risk
Cowdens - PTEN - breast, thyroid, endometrial - 25-50% lifetime risk
Peutz-Jeghers - STK11 - breast, ovarian, cervical, uterine, testicular, colon, small bowel - 32-54% lifetime risk
Hereditary diffuse gastric cancer - CDH1 - early onset diffuse gastric cancer, lobular breast cancer - 60%
What some modifiable lifestyle risk factors are there for breast cancer?
Weight
Exercise
Alcohol
Extrogenous oestrogens
What some non-modifiable lifestyle risk factors are there for breast cancer?
Age of menarche and menopause
Early parity and breast feeding
Breast density
Heredity
Who is the NHS breast screening programme offered to?
Women aged 47-73
What is the 5 year survival rate improvement from the breast cancer screening programme?
Rises from 80-95%
What is the triple assessment/fast track for breast cancer diagnosis?
Clinical score P1-5 (1 normal, 5 clearly malignant) (from physical examination)
Imaging score U1-5 or M1-5 (USS/mammogram)
Biopsy score B1-5
Need concordance on MDT review
What is MRI scanning useful for?
Useful for assessment of implants
Contrast enhanced high sensitivity for invasive breast carcinoma
High risk screening - inherited/iatrogenic
Evaluating response of chemotherapy
What are the presenting S&S for breast cancer?
Painless lump
- Irregular
- Hard
- Fixed
Nipple discharge (can be bloody)
Nipple in-drawing
Skin tethering
Bone pain/pathological fractures, jaundice, SOB - metastases
Pain not common
What surgery for operable breast cancers are available?
Breast conservation + radiotherapy
Mastectomy
Surgery to axilla
When would you do breast conservation + radiotherapy?
Small tumour relative to breast size < 25% volume or 25-50%
No previous radiotherapy to breast
Pre-operative chemotherapy may allow breast conservation
Patient choice
Older patient who can have GA
What can affect the outcome of the breast conservation surgery?
Tumour size relative to breast
Position of tumour in breast
Re-excision or not
Radiotherapy fibrosis
When would you do a mastectomy?
Large tumour relative to breast size
More than one cancer in same breast if in different quadrants
May have immediate or delayed reconstruction
Patient choice
BRCA genes
Inflammatory cancer
What options are there for breast cancer treatment?
Surgery
Chemotherapy - for high risk disease
Endocrine therapy
Adjuvant therapy
What are the risk factors for high risk breast cancer?
Young age
ER -ve
HER-2+ve
High grade
Node positive
Ki67 positive
Tumour size
High oncotype DX recurrence score
Complex algorithms
What endocrine therapy is there for breast cancer?
Tamoxifen
Aromatase inhibitors
How does tamoxifen work?
Inhibits oestrogen receptor on breast cancer cells
Increases survival 15-25% in women with ER+ cancer
What are the complications of tamoxifen treatment?
Hot flushes, nausea, vaginal bleeding, rarely thromboses and endometrial cancer
How do aromatase inhibitors work?
Inhibit aromatase enzyme responsible for conversion of androgens to oestrogens in post-menopausal females
Slightly better anticancer efficacy than tamoxifen
What are the S/E of aromatase inhibitors?
Hot flushes, reduced bone density and joint pains, no DVT/endometrial cancer risk
What is the adjuvant therapy available for breast cancer treatment?
Transtuzumab - 1 year, 3 weekly alongside chemotherapy
Radiotherapy
When should adjuvant radiotherapy be used?
Always after wide local excision, local recurrence rate 35% without, 10-12% with
Increased use of mastectomy wound radiotherapy for high risk cancers
May be used for axilla in low risk cases with positive SLNB where low axilla treated as part of breast irradiation or full formal axillary RT as good alternative to axillary clearance with lower rate of lymphoedema
Palliative/neoadjuvant uses
What is the TNM staging for breast cancer?
T0 no evidence primary
T1 < 2cm
T2 2-5cm
T3 > 5cm
T4 extends to chest wall or skin or inflammatory
N0 no nodes
N1 mobile nodes
N2 fixed/matted nodes
N3 internal mammary nodes
M0 no metastases
M1 metastases
What do HER-2, Neu, and EGFR-2 mean for breast cancer prognosis?
Marker of poor prognosis
HER-2 +ve has worst prognosis
15% of all breast cancers
Penchant for the brain, 50% have metastatic
What are the advantages of primary reconstruction of the breast?
Increased options for skin preservation and therefore better objective cosmesis
Reduced psychological trauma from disfigurement
What are the disadvantages of primary reconstruction of the breast?
May delay chemotherapy or radiotherapy if complications
Radiotherapy may spoil result
What are the advantages of delated breast reconstruction?
Minimal risk of delays in other adjuvant therapies from complications
Irradiated tissue may be excised when reconstructing and healthy tissue used to recreate breast
What are the disadvantages of delated breast reconstruction?
Loss of intra-mammary fold
Limited skin preservation options
Period without a breast - may never have reconstruction or face long delays as no longer urgent
When is radiotherapy needed for breast cancer treatment?
Difficult to predict before surgery
T3 and T4 cancers usually attract a recommendation for post-operative chest wall radiotherapy
High grade PLUS nodal disease may be offered radiotherapy
Close margin posteriorly, careful review of imaging
What are the problems with radiotherapy?
High rate of capsule formation with implants
Skin viability risk
Wound healing
Loss of elasticity
Fat necrosis
Fibrosis
Implant extrusion
How can you recreate a breast?
Implant based
Autologous (use of patient’s own tissues)
Latissimus dorsi flap
How can you treat locally advanced breast cancer?
Attempt to shrink with either radiotherapy, chemotherapy or hormone therapy
Stage for metastases - USS liver, CXR, bone scan, bloods
Very high risk recurrence/metastases
Salvage surgery may be possible
Where does breast cancer metastasise to?
Bone 70%
Soft tissue 25%
Pleura 48%
Lung 67%
Liver 50%
Brain 20%
How can you treat metastatic breast cancer?
Hormonal treatments - slow acting, only suitable for hormone sensitive cancers, longer lasting control
Bisphosphonates and denosumab
Radiotherapy - bone, brain, soft tissues, axillary nodes, palliative surgery
Chemotherapy - CMF, doxorubicin, taxanes, herceptin, rapid action, high toxicity
Newer agents - multiple trials
Symptoms control and social/financial support
What is the population risk of breast cancer?
12% lifetime risk
What is a moderate lifetime risk of breast cancer?
17-30%
What is a high lifetime risk of breast cancer?
> 30%
- Definite gene carriers lifetime risk up to 80%
What strategies are there to manage moderate risk of breast cancer?
Screening - annual mammograms 40-50
Consider prophylactic SERM
Lifestyle advice
What strategies are there to manage high risk of breast cancer?
Enhanced screening
Risk reducing mastectomy
Risk reducing salpingo-oophorectomy
Lifestyle advice
Prophylactic SERM