Green Book Ch 42 General Breast Cancer Flashcards
What are the 3 most commonly diagnosed cancers in women in decreasing order of incidence?
Most commonly diagnosed cancers in women: breast > lung > colorectal
What are the 3 most common cause of cancer death in women in decreasing order of incidence?
Most common causes of cancer death in women: lung > breast > colorectal
Appx how many women in the US are diagnosed with invasive and noninvasive breast cancer, and how many will die of breast cancer annually?
Incidence: ~ 253,000 invasive breast cancers and ~63,000 noninvasive breast cancers annually
Mortality: ~ 41,000
What is the median age of Dx for invasive breast cancer?
The median age for invasive breast cancer is 61 yrs.
What race has the highest rate of breast cancer Dx?
What race has the highest rate of breast cancer mortality?
Highest Dx: Whites
Highest mortality: Blacks
What percentage of women will be diagnosed with breast cancer in their lifetime?
~ 12% (1 in 8) of US women will be diagnosed with breast cancer
Between 2010 and 2020, is the incidence of breast cancer in the US expected to increase or decrease?
Increase
In the US in 2015, was the incidence of breast cancer mortality increasing or decreasing?
Decreasing
What % of breast cancers are due to known hereditary mutations in single genes?
=< 10%
What are the 2 most common hereditary mutations that predispose to breast cancer?
BRCA 1 and BRCA 2 are the most common mutations
In what ethnic population is the BRCA 1 and BRCA 2 mutations most common and what is the incidence?
Most common in the Ashkenazi Jewish population.
As many as 1 in 40.
Mutations in which gene, BRCA 1 or BRCA 2 confers a higher risk of ovarian cancer?
Both BRCA 1 and BRCA 2 are associated with increased risk of ovarian cancer, but risks are higher with BRCA 1 (45% lifetime risk) compared to BRCA 2 (15% lifetime risk).
What are 2 other hereditary syndromes associated with an increased risk of breast cancer and their related germline mutations?
Both are a result of mutations in tumor suppressor genes:
- Li-Fraumeni syndrome: TP53
- Cowden/Bannayan - Riley - Ruvalcaba syndrome: PTEN
Is HRT with estrogen and progestin associated with an increased or decreased risk of breast cancer?
HRT with estrogen and progestin is associated with an increased RR of 1.7.
Separate the following factors into those that increase or decrease the risk of breast cancer:
- younger age at menarche
- younger age at menopause
- nulliparity
- prolonged breastfeeding
- use of HRT
Increased risk:
- younger age at menarche
- nulliparity
- use of HRT
Decreased risk:
- younger age at menopause
- prolonged breastfeeding
Estimate the annual risk of a contralateral breast cancer in the 10 yrs following a primary Dx.
Premenopausal: 1%/yr
Postmenopausal: 0.5%/yr
What is the definition of natural menopause and what is the median age at which is occurs?
Definition: permanent cessation of menstrual periods (12 mos of amenorrhea) without other obvious pathologic or physiologic cause
Median age: 51 yrs
What are the United States Preventive Services Task Force (USPSTF) screening recommendations for normal-risk women age 40-49 yrs, age 50-74 yrs, and age > 74 yrs?
For normal risk women age 40 - 49 yrs: individualized decision based on potential benefits and potential harms
For normal risk women age 50 -74 yrs: biennial mammogram
For normal risk women age >= 74 yrs: insufficient evidence to assess balance of benefits and harms
What are the ACS screening recommendations for normal-risk women age 40 - 44 yrs, age 45 - 54 yrs, and women >= 55 yrs?
for normal-risk women age 40 - 44 yrs: opportunity for annual mammogram
for normal-risk women age 45 - 54 yrs: annual mammogram
for normal-risk women age >= 55 yrs: biennial mammogram, with opportunity to continue annual mammogram (no age cutoff, as long as life expectancy is >= 10 yrs, whereas the USPSTF recommends biennial screening mammography beginning at age 50 and discontinuation at age 74).
What is one of the major differences between USPSTF vs ACS screening recommendations?
for normal-risk women age >= 55 yrs: biennial mammogram, with opportunity to continue annual mammogram (no age cutoff, as long as life expectancy is >= 10 yrs, whereas the USPSTF recommends biennial screening mammography beginning at age 50 and discontinuation at age 74).
For women with prior thoracic RT between ages 10 and 30 yrs, when should screening begin for breast cancer and how?
According to 2018 NCCN guideline,
Age < 25: annual clinical breast exam (CBE) beginning 8-10 yrs after RT
Age >= 25: CBE every 6-12 months + annual mammogram and breast MRI beginning 8-10 yrs after RT
When should a woman be screened for breast cancer using MRI?
NCCN (2018) recommends MRI to be used as an adjunct to mammography for women with a BRCA mutation or women who are 1st degree relatives of a BRCA carrier (but are themselves untested) beginning at age 25, women with Li-Fraumeni (TP53) syndrome and their 1st degree relatives, women with Cowden/Bannayan-Riley-Ruvalcaba (PTEN) syndrome and their 1st degree relatives, women with mutations in ATM, CDH1, CHEK2, PALB2, PTEN, or STK11 with an expected >= 20% lifetime risk of breast cancer, women without known genetic mutations who have a lifetime risk of >= 20% as defined by models that are highly dependent on family Hx, and women who rcvd T or CW irradiation between the ages of 10 and 30.
According to NCCN 2018, what are the potential clinical indications and applications of dedicated breast MRI testing?
Breast MRIs should be performed only where there is a dedicated breast coil, an experienced radiologist, and capacity for MRI-guided Bx. Since false+ findings on MRI are common, surgical decisions should not be based solely on MRI; additional tissue sampling should be performed in areas of concern identified by MRI.
- Define extent of cancer, multifocal or multicentric Dz in the ipsi breast
- Screen for contralateral breast cancer in a newly diagnosed breast cancer pt
- Evaluate before and after neoadj therapy to define extent of Dz, response to Tx, and potential for breast conservation
- Detect additional Dz in women with mammographically dense breasts
- Detect primary Dz in pts with +axillary LNs or Paget Dz of the nipple when primary is not identified on mammogram, US, or physical exam
Name the 5 rare histologic types of breast cancer that have a more favorable overall prognosis than invasive ductal/lobular carcinoma
Rare types of breast cancer with a more favorable prognosis:
- Tubular
- Mucinous
- Medullary (not including atypical medullary)
- Cribriform
- Invasive papillary
Name the 1 rare histologic type of breast cancer that has a less favorable overall prognosis than invasive ductal/lobular carcinoma
Micropapillary carcinoma has a less favorable overall prognosis
What is the Oncotype DX, and which breast cancer pts are eligible for its use?
Oncotype DX is a 21-gene assay that quantifies the likelihood of distant recurrence in tamoxifen-treated ER+, node - breast cancer patients (Paik S et al., NEJM 2004).
Evaluation of Oncotype DX in pts from NSABP B20 suggests that the recurrence score also predicts the magnitude of chemo benefit (Paik S et al., JCO 2006).
NCCN currently recommends considering Oncotype DX in patients with > 0.5 cm, ER+, node-, and N1mic pts
What are the 4 major molecular subtypes of breast cancer? Which subtype is associated with the poorest prognosis?
Molecular subtypes:
- Luminal A (ER+/HER2-, low proliferation)
- Luminal B (ER+HER2+/-, high proliferation)
- HER2 overexpressing
- Basal-like (ER-/PgR-/HER2-)
The basal-like subtype carries the poorest prognosis
What are phyllodes tumors of the breast, and what is the most important factor that determines risk of recurrence?
Phyllode tumors (cystosarcoma phylloides) are rare tumors containing both stromal and epithelial elements. Although the subtypes range from benign to malignant, the most important prognostic factor for recurrence is a clear margin after resection.
What views comprise a screening mammogram?
- Mediolateral oblique: allows localization of tumor in sup-inf dimensions
- Craniocaudal: allows localization of tumor in medial-lat dimentions
What is the view of this mammogram image?
Mediolateral oblique
Demonstrate the mediolateral oblique projection position for breast mammogram.
What is the view of this mammogram image?
(A) Craniocaudal and (B) mediolateral oblique views of the right breast
Describe the station I, II, and II
Describe P. Major, P. Minor, and lymph node stations I, II, and III.
Describe the location of the Rotter’s nodes (Interpectoral nodes)
