Case 14- breast disease and SAP Flashcards
Gender identity
An individuals sense of having a particular gender
Gender expression
The ways we show our gender to the world around us
Gender dysphoria
The sense of unease or discomfort that a person may have because of a mismatch between their anatomical sex and their gender identity
Transgender
Someone whose gender identity does not correspond with the sex they were assigned at birth
Nonbinary
A person who identifies or expresses a gender identity that is neither male nor entirely female
Transphobia
Irrational fear or, aversion to or discrimination against transgender people
Cissexism
A system of attitudes, bias and discrimination in favour of a cisgender identity
What are transgender people more at risk of
Alcohol or substance abuse, violence, sexual assault, depression, stress, suicide and delayed cancer diagnosis.
How to make transgender people feel safe in a consultation
- Use correct name and pronouns
- Make the environment gender neutral and LGBT friendly (poster)
- Explain what you are doing
- Preferred term (chest, breast)
- Put the patient in the ward that matches their gender- or ask
- Discuss gender in a private room
How to increase cervical screening uptake
- Gender neutral material for trans men
- Education for healthcare providers on gender and sexuality
- Gender neutral spaces
- LGBT specific services
Differentiating between benign and Malignant breast lumps
Difficult to tell on examination. Benign breast lumps are normally mobile, smooth with regular borders. Malignant breast lumps are hard, have irregular borders and may be fixed to underlying structures. Usually requires specialist assessment for diagnosis.
Other features of Malignant breast disease
1) Skin or nipple changes
2) Symptoms of metastatic disease
Diagnosing malignant breast disease
Triple assessment
- Clinical assessment by specialist- decides if more tests are required
- Radiological assessment- by US or/and mammography, US is more common in younger patients because of increased density of breast tissue.
- Histological assessment- fine needle aspiration/core biopsy. Analysed under a microscope.
List of Benign breast conditions
1) Fibrocystic breast disease
2) Fibroadenoma
3) Fat necrosis
4) Lipoma
5) Breast cysts
Fibrocystic breast disease
Breast lumps, tenderness and pain can appear around your period (commonly the week before). Due to fibrous tissue in the breast, the lumps can be fluid filled i.e. breast cysts. When it is an issue its fibrocystic changes. 20-50 age group. It is a nodular or thickened area of the breast tissue separate from the rest of the breast
Fibroadenoma
Most common benign breast condition, seen in women in their 20s. Grow to 2-3cm. Soft, well circumscribed and painless. Highly mobile lumps. If the fibroadenomas are multiple or complex its associated with an increased risk of breast cancer.
Fat necrosis
Benign inflammation of fat cells causing palpable lumps. Occurs in larger breasts normally due to trauma (accidental or instrumental). On the breast tissue there may be bruising, erythema, dimpling or signs of trauma over the area of the lump. The lump is usually painless. Looks similar to breast cancer, may need biopsy.
Lipoma
Benign tumour of fat cells, found in the neck, abdomen and breast. Soft, well-circumscribed, smooth and non-tender. Found superficially just under the skin
Breast cysts
Develop from the terminal duct lobular unit. Common in pre-menopausal women in their 30s/40s. Difficult to distinguish from malignant lesions. They are fluid filled, round, palpable masses, which can become painful and may require aspiration. Similar to breast abscesses but without infective symptoms and tenderness.
Non-modifiable risk factors for breast cancer
- The sex hormones oestrogen, progesterone and testosterone. Any factor which increases these hormones can cause breast cancer.
- Female sex
- Long interval between menarche and menopause (early menarche <12, late menopause>55)
- Age >50, uncommon in under 40s
- Radiation (radiotherapy, CT scans)
- Family history, risk increases with number of family members and if they got it at a young age.
- Genetic mutations i.e. BRCA 1 or 2, p53 gene. Personal history of some cancers and hyperplasia in the breast.
- Geographic location i.e. Europe, north America, Australia
Modifiable risk factors for breast cancer
- Lack of physical activity
- Older age at first time of pregnancy (>30). Nulliparous (not having kids).
- OCP/ HRT- remains high even after stopping medication
- Obesity- fat tissue increases oestrogen levels
- Alcohol intake
Protective factors for breast cancer
Having lots of children and breast feeding, because they disrupt normal hormone levels
Two types of breast cancer
Carcinoma in situ and invasive carcinoma
Carcinoma in situ
Cancerous cells are found in the structure of the breast i.e. the ducts (DCIS) or lobules (LCIS). Have not breached the basement membrane or spread into the rest of the breast tissue. Not malignant.
Lobular carcinoma in situ (LCIS)
Abnormal cell growth confined to the lobules of the breast, diagnosed on biopsy. Increased risk of future invasive breast cancer. Dependent on type of LCIS increased monitoring or surgical removal may be required.
Ductal carcinoma in situ (DCIS)
Abnormal cell growth confined to the ducts of the breast. Can present with breast lump or nipple discharge or be found incidentally. Can become invasive if not removed, surgery is the main treatment.
Invasive Breast carcinoma
Have breached the underlying basement membrane. Can metastasize to other areas of the body. Most common breast invasive carcinomas arise from the epithelial lining of the ducts.
Paget’s disease of the breast
Cancer of the aerola/ nipple complex which is associated with an underlying carcinoma in situ or invasive breast cancer. It presents as an eczematous lesion of the nipple or areola, which may have an underlying palpable lump.
Inflammatory breast cancer
Rapidly developing breast cancer that blocks the lymphatic drainage of the breast. Breast swelling, redness which feels firm, hot to touch and possibly painful. Can cause skin changes like peau d’orange or skin thickening. There may be nipple changes or a palpable breast lump.
Route of spread of breast cancer
- Direct-locally into surrounding muscle and skin, causes tethering
- Via Lymphatics- axillary lymph nodes are the commonest lymphatic site involved. Can also involve intramammary, supraclavicular and tracheobronchial lymph nodes. Can feel hard and cause lymphadenopathy.
- Via blood (haematogenous)- usually causes metastasis in lungs, bone, brain and liver. Can cause dyspnoea, chest pain, chronic cough, headaches and bone pain.
Most common presentation of breast disease
Breast lump, can often by asymptomatic
Symptoms of breast disease
- Skin changes i.e. skin tethering, peau d’orange (skin is pitted and swollen due to lymphatic infiltration or inflammatory breast cancer). Or Eczematous changes i.e. Pagets disease.
- Nipple discharge or inversion
- Enlarged regional lymph nodes i.e. axillary.
- Symptoms of metastases or late presentation with fungating mass
- Change in size or shape of the breast, oedema or enlarged regional lymph nodes (lymphadenopathy)
Structural causes of female subfertility
1) Tubal patency i.e. previous ectopic pregnancy
2) Endometriosis
3) Fibroids
4) Previous surgery
Other causes of subfertility in females
1) Medications- Chemotherapy, Contraception, NSAID
2) Age >35
3) Smoking, obesity, alcohol, drugs
4) Adrenal problems- Crushing’s, Congenital adrenal hyperplasia
5) Hyperthyroidism/Hypothyroidism
Structural causes of subfertility in males
1) Vas deferens/ejaculatory duct obstruction
2) Erectile dysfunction
3) Undescended testes
4) Post inflammatory i.e. Mumps
Other causes of subfertility in males
1) Medication- anabolic steroids, chemotherapy, herbal remedies
2) Smoking, obesity, alcohol, drugs
3) Cystic fibrosis, renal failure, liver cirrhosis
4) Klinefelters 47XXY
Definition of infertility
A couple who have not conceived after 1 year of regular (every 2-3 days) of unprotected sexual intercourse
Initial infertility investigations in women
Measure mid-luteal phase progesterone, to confirm ovulation
In some…measure serum progesterone, with weekly measurements after first test and measure FSH and LH if cycles are irregular
Measure TFTs if symptoms of thyroid disease (only with women with symptoms of thyroid dysfunction) and measure prolactin if necessary
Initial infertility investigations in men
Semen analysis- after 2 days of sexual abstinence but no more then 7 after. Repeat at 3 months, earlier if grossly abnormal.
The semen sample needs to be complete and if not the man should report this, should be delivered to lab within an hour
Initial infertility investigations in mean
Semen analysis- repeat at 3 months
Secondary infertility investigations in women
1) Hysterosalpingography, x-ray examination of a woman’s uterus, using fluoroscopy and contrast imaging
3) Hysterosalpingo-contrast ultrasonography, which is a technique to assess tubal patency
3) Diagnostic laparoscopy and dye
Secondary infertility investigations in men
1) Microbiology tests
2) Sperm culture
3) Endocrine tests
4) Imaging of the urogenital tract
5) Testicular biopsy
The Emotional issues associated with assisted conception
The process of pregnancy itself is highly emotionally and physically demanding and has risks associated
Only one cycle of IVF is offered over 40 years old (some trusts say 35)
Some trusts state you cannot have IVF if either partner already has children
Techniques can, and regularly do, fail
Fertility medications involve injections and have side effects (especially emotional side effects
IVF is sometimes only offered after 12 failed cycles of artificial insemination
You can pay to undergo assisted conception privately, but one cycle of IVF can cost £5000
Infertility investigations to offer both makes and females
1) Full medical, sexual and social history
2) Examination
3) Screen for chylamidia
Female infertility- things to check for if there are symptoms
1) Check thyroid function tests
2) Check Prolactin if signs or symptoms of Polystistic ovarian syndrome, galactorrhoea or a pituitary gland. There increased Prolactin in infertility
Fertility- when the refer women to secondary care
1) Age 36 and older (refer after 6 months)
2) Amenorrhoea or oligomenorrhoea
3) Previous STI
4) Abnormal pelvic examination
5) Previous abdominal or pelvic surgery
Infertility- when to refer men to secondary care
1) Previous genital pathology
2) Previous urogenital surgery
3) Previous STI
4) Significant systemic illness
5) Abnormal genital examination
How do you engineer a 3 person baby
1) In the donors egg the nucleus is removed and destroyed
2) The mothers healthy nucleus is transferred to the donors healthy egg
3) IVF using the fathers sperm
4) The embryo is placed in the mothers uterus
How do you engineer a 3 person baby
1) In the donors egg the nucleus is removed and destroyed
2) The mothers healthy nucleus is transferred to the donors healthy egg
3) IVF using the fathers sperm
4) The embryo is placed in the mothers uterus
Why do you engineer 3 person babies
So that both parents can be related to the child and the child wont suffer from mitochondrial disease
Conditions for someone to have a 3 parent baby
Women have to suffer from a mitcichindrial disease; pregnancy will be dangerous, test eggs to see whether that will have mitochondrial disease
BMI <30, non-smoker, normal HbA1c, heart scan clear
Alternatives to a 3 parent baby
Voluntary childlessness, adoption, IVF techniques
Pro-nuclear transfer
The procedure used to generate 3 parent babies
Assisted pregnancy techniques
1) IUI- intrauterine insemination
2) In vitro fertilisation
3) ICSI= Intra-cytoplasmic sperm injection
4) In females Gonadotrophins or Clomiphene citrate to induce ovulation
Health economics
Evaluates the clinical effectiveness and cost effectiveness of health care provisions, aims to produce the maximum benefit for patients whilst reducing costs
Costs to consider in healthcare economics
- The direct costs i.e. staff, drugs, equipment. Costs for patient
- The indirect costs i.e. productivity losses for staff, knock on effect on society
- Intangible costs i.e. pain, suffering, stigma
QALY (quality adjusted life years)
A way of comparing mere survival without vitality to survival with good health. A full year of health is a full QALY; people with less than full health have a fraction of QALY each year. Thus, their total QALY is less than the total years they live.
NICE QALY spending limit
There is a £20,000-£30,000 budget for every QALY for treatments and drug options
What needs to be considered when treating patients with expensive therapies?
Dependents Societal contribution Ability to pay Age Cost of treatment Patient's responsibility for illness Rule of rescue
What does NICE make recommendations on?
- New and existing medicines, treatments and procedures
- Treating and caring for specific diseases and conditions
- How to improve people’s health and prevent illness and disease
What does QALY consider
1) Side effects
2) Clinical effectiveness
3) Cost
4) Quality of life- pain, mobility and general mood
Calculating cost per QALY
Cost per QALY= Cost/QALY
The incremental cost effectiveness ration (ICER)
Difference in price between the two treatments / Difference in QALY i.e. 700 / 0.35= £2000 per 1 QALY.
Importance of Policy
If you make decisions about treatment without referring to policy, you risk introducing unfair discrimination. Discuss with your team recourse allocation decisions and be honest with patients when recourse constraints affect treatment options.
Helps provide consistency across the NHS and uses evidence based knowledge
How should decisions about allocating recourses be made?
Accountability of reasonableness:
1) Promoting transparency on how decisions are made
2) Provide reasons that are relevant to that stakeholder
3) Be open to changing descisions
Ethical principals related to recourse allocation
1) Does the patient have dependents?
2) Does the patient depend on others?
3) Did or does the patient contribute to society
4) Can the patient pay for treatment?
5) How old is the patient?
6) How costly is the treatment?
7) Is the patient personally responsible for the illness?
8) Is the patient in dire need?
9) Is the patient related, either personally or culturally?
Criticisms of QALY
- Prognosis may be uncertain.
- Hard to measure quality of life
- What if QALY is the same between several patients and one
- Costs are unfair i.e. rare diseases are most expensive to treat then common ones
Cost minimisation
Application- where evidence shows that competing therapies are equivalent
Measure- use the cheapest therapy
Cost effectiveness
Application- where there are competing therapies or different treatments for a common therapeutic goal
Outcome- use the drug with the best QALY
Cost utility
Application- where you want to measure the cost of something for a given outcome i.e. life years or reduction in pain
Outcome- How much does X cost per utility unit i.e. life year gained
Cost benefit
Application- where the costs and benefits of a particular treatment are compared
Outcome- how much does X cost and what are its benefits
Methods used to decide between options in a healthcare setting
1) Cost-minimisation
2) Cost-effectiveness
3) Cost-utility
4) Cost-benefit
