Imaging & screening

Question 1

Risk Factors for Breast Cancer

Answer 1

Exposure to steroid hormones (early menache, nulliparity/late age of first child, oral contraception/HRT)
Age (50% >65YRS) Weight/height FH
Carcinogens or radiation exposure

Question 2

Male Breast Cancer

Answer 2

<1% of all breast cancers
peak age 71
Many have unusual causative agent, particularly in africa

Question 3

Risk factors for male breast cancer

Answer 3

Work in hot environments (testicular failure). Men taking estrogens (transsexuals or prostate Ca). Undescended testis (relative risk 12)
Mumps over the age of 20 (relative risk 2.5). Obesity

Question 4

Is male gynaecomastia as risk factor for breast cancer?

Answer 4

No

was once treated with radiotherapy which is a risk factor

Question 5

Genetic risk factors for Male breast cancer

Answer 5

4-40% due to BRCA2 mutations–> only important risk gene in men
Men with Klinefelter’s have a similar risk of breast cancer to women

Question 6

Protective Factors for Breast Cancer

Answer 6

Pregnancy –> age of first pregnancy-> major determinant
Oophorectomy Lactation
Late menache or early menopause

Question 7

Oophorectomy as breast cancer protection

Answer 7

At age of 30 it reduces risk by 2/3 but by 50 there is no protective effect

Question 8

Oral contraception and Breast cancer risk

Answer 8

Current use increases risk by 25% (from 0.006 to 0.007%) –> this returns to normal between 5 and 10 years after

Question 9

HRT and Breast cancer risk

Answer 9

Increases risk by between 10% (1yr) and 50% (15yrs) –> still very low risk
But it slightly reduces the mortality of cancer and decreases the grade at detection

Question 10

Radiation and Breast cancer risk

Answer 10

Increases risk by 2-8 times depending on dose

Hiroshima and Nagasaki had a 2x increase in breast cancer after bombing

Question 11

Smoking and Breast cancer risk

Answer 11

Smoking has anti-estrogenic effects, inducing early menopause and gives lower risk of endometrial cancer but higher risk of osteoporosis
But any reduction in ER+ve breast cancers will be offset by increases in ER-ve cancers. Smokers may also have a worse prognosis

Question 12

Alcohol and Breast cancer risk

Answer 12

A solvent for carcinogens and modulates oestrogen metabolism which increases free estrogen (E2)
Can increase risk up to 50% depending on dose

Question 13

Fat intake and Breast cancer risk

Answer 13

Highly significant relationship between fat intake and breast cancer incidence across countries–> but at individual levels difficult to prove

Question 14

Obesity and Breast cancer risk

Answer 14

Obesity is protective in premenopausal women but increases risk for postmenopausal women, who also have worse prognosis if fat

Question 15

Height and Breast cancer risk

Answer 15

Much argument but probably explaining by other factors which effect both (calorie intake or genetics)
Some studies found taller women at more risk

Question 16

Gamma GT and Breast cancer risk

Answer 16

Elevated levels are associated with liver damage
GGT >72u/l increased risk 3-4x–> GGT is related to organic pollutants, lead and cadmium which are carcinogens–> argument to monitor these women more closely

Question 17

Family history and genetics in breast cancer

Answer 17

5% of breast cancers are genetic in basis–> only people with multiple relatives with early onset breast cancer should be worried

Question 18

BRCA genes and Breast cancer risk

Answer 18

BRCA1 –> 65% lifetime risk of breast Ca and 40% for ovarian Ca
BRCA2 –> 45% lifetime risk of Breast Ca and 20% for ovarian Ca
Also 14% of prostate, 6% of male breast cancer and 3% pancreatic

Question 19

Molecular classification of Breast cancer

Answer 19

Basal-like –> ER neg, HER2 neg, grade III 84%
Luminal A (high differentiation) –> ER pos, HER2 neg, grade III 19%
Luminal B (poor differentiation) –> ER pos, HER2 neg, grade III 53%
HER2-like —> ER 50/50, HER2 pos, grade III 74%

Question 20

DCIS

Answer 20

Was rare, now 20% of screening detected cancers because of microcalcification –> major RF for invasion

Question 21

Breast Imaging

Answer 21

Mammography–> X rays in two views converted into 3D only method valid for screening. USS–> Dynamic study which assess vascularity and elastography–> can be combined with MRI. good for young, dense breasts. MRI–>contrast to assess enhancement of lesions
PET/CT–> useful in staging

Question 22

BI-RAD grading system

Answer 22

A way of reporting breast imaging. 1- Normal. 2- Benign finding. 3- Probably benign. 4- suspicious of malignancy. 5- highly suggestive of malignancy. 6- Biopsy proven cancer

Question 23

Initial Screening of a breast lump

Answer 23

Under 35yrs–> USS, possibly a mammogram after,
Over 35yrs–> Mammogram, possibly an USS
If abnormality detected proceed to FNA or core biopsy

Question 24

Breast cysts on imaging

Answer 24

Well circumscribed –> smooth, round lumps on mammogram (will not tell you if solid or cystic) USS is diagnostic

Question 25

Fibroadenoma on imaging

Answer 25

A smooth, round or oval solid mass. Similar appearance on both mammogram and USS

Question 26

Calcification on mammograms

Answer 26

Clustered, linear or branching calcification is characteristic of DCIS, while coarse, generalised calcification is usually benign (‘popcorn’)

Question 27

Mammographic, but not palpable lesions

Answer 27

Stellate lesions –> starlike–> complex sclerosing lesion
Spiculated lesion–> sharp pointed body with irregular margins–> infiltrating carcinoma
Rounded lesions–> oval with smooth borders –> FA or lymph node

Question 28

Definition of Breast cancer screening

Answer 28

Evaluation of a population asymptomatic women who have no overt signs or symptoms in an effort to detect unsuspected disease at a time when cure is still possible

Question 29

Why screen for breast cancer?

Answer 29

1/3 of all female Ca–>most common female Ca,
Most common cause of Ca deaths worldwide
Incidence is 50-60 per 100,000–>41,000 cases/yr–>15,000 deaths/yr
RFs well known, but not cause–> Forrest report 1986 showed 30% mortality reduction

Question 30

NHS breast cancer screening programme (NHSBSP) – History

Answer 30

set up in 1988–> originally invited 50-64yos for a single view (MLO) every three years–> 2 view mammogram at first screen (1995)–> extended to 50-70 yos

Question 31

NHS breast cancer screening programme (NHSBSP) – stats

Answer 31

Each year–> 1.6m women screened–. 13,500 cancers detected, 1400 lives saved
1 life saved for every 8 women diagnosed
Costs 96million per year

Question 32

NHS breast cancer screening programme (NHSBSP) – Aims

Answer 32

To detect–> Grade I tumours <10mm and high or intermediate DCIS

Question 33

NHS breast cancer screening programme (NHSBSP) – Quality assuarance

Answer 33

Aim to detect 90% of cancers

Actually detect 80%

Question 34

Why use Mammography?

Answer 34

Because it is the only screening tool which has been shown to reduce mortality
Only 5% of mammograms are equivocal–> most benign lesions are clearly benign and most malignant lesions are clearly malignant

Question 35

NHS breast cancer screening programme (NHSBSP) — Impact

Answer 35

~35% reduction in breast cancer mortality among women involved
between the ages of 40-49 there is limited evidence of reduction in mortality due to false positives in this group –> cause of significant anxiety

Question 36

NHS breast cancer screening programme (NHSBSP) – stages

Answer 36

Invitation by letter–> basic screen (two views) of each breast –> Assessment (pt may be called back for further evaluation –> Treatment if abnormality is detected

Question 37

NHS breast cancer screening programme (NHSBSP) — secondary evaluation

Answer 37

If recalled the pt may undergo–> clinical examination, extramammographic views, ultrasounds of breasts and possibly an Xray or USS guided biopsy

Question 38

NHS breast cancer screening programme (NHSBSP) — Sensitivity

Answer 38

Some false negatives and positives are unavoidable
Mammograms over-diagnose grade I and low grade DCIS
Over 20yrs screening saves 5.7/1000, but puts 2.3/1000 through unnecessary treatment

Question 39

MRI screening of High-risk women

Answer 39

High-risk if–> BRCA1/2 carrier, related to 1 or strong other FH (or previously tx with radiotherapy)
MRI is able to detect smaller, earlier tumours ( combination of MRI & mammogram most sensitive
Only offered to high risk women under age of 50yrs

Question 40

Disadvantages of MRI screening

Answer 40

Expensive

High false positive rate and require MRI biopsy to investigate

Question 41

Use of Urgent Breast lump referrals

Answer 41

All lumps in over 30yr olds and any lump with worrying features in under 30yr olds.