Management of Breast Cancer Flashcards
Epidemiology of breast cancer
1 in 9 women–> commonest cause of cancer death in women, 6% of all female deaths–>UK highest in developed world
Lifetime risk has increased from 1:20 to 1:8
Presentation of Breast cancer
Breast Lump Nipple discharge
Inversion of Nipple Skin Dimpling
Lump in axilla Lymphoedema
Diagnosis of Breast cancer
Triple assessment (clinical, imaging and biopsy)
Stage vs Grade of breast cancer
Stage is an indication of the size and spread of the cancer –> Time dependent
Grade is the cellular and histological character which doesn’t change over time
Stage 1 breast cancer
<2cm in diameter
Hasnt spread to lymph nodes or outside the breast
If treated at this stage 5yr survival is 100%
Stage 2 breast cancer
5cm but there is no lymph node involvement
If treated at this stage 5yr survival is 90%
Stage 3 breast cancer
> 5cm with axillary lymph node involvement but the nodes arent attached to each other
5yr survival is 50%
Inflammatory breast cancer
Caused by cancerous spread to lymphatic vessels in the skin
Causes swelling, redness, ridged or dimpled skin
Is classified as stage 3 breast cancer
10 and 20 year survival rates
Less commonly used than 5yr
10 year is usually about 20% lower than 5yr
20 year is not much lower than 10 except for stage 4
Stage 4 breast cancer
Defined by the presence of distant mets (bone, lung, liver or lymph nodes)
Treatment is symptomatic at this stage
5yr survival is 20%
Grading of breast cancers
Based on histological differentiation –> scored from 3-9 in tubule formation, pleomorphism and mitotic rate
Can be well, moderately or poorly differentiated (worst)
Treatments of invasive Breast Ca
Local –> Surgery or radio
Systemic –> Chemo, endocrine or targeted therapies (biologics etc)
Surgical Options for breast Ca
(1) Breast conserving surgery (BCS) with radiotherapy –> wide local excision, quadrantectomy or segmentectomy. (2) Simple or (3) Modified radical mastectomy
Immediate or delayed reconstruction can be performed after a mastectomy
Aims of breast cancer surgery
Maximise local control of Ca and chance of cure
Attempt to get the best cosmetic and prognostic outcome possible
Prevent the sequelae of local recurrence
Tumour types allowing for breast conservation
Aesthetically viable breast –> unifocal Ca <4cm. For suitable tumours there is no difference in outcome between BCS+radio and mastectomy. Large tumours can be reduced with chemo or endocrine therapy to make BCS possible
Radiotherapy for breast Ca
50 grays (5000 rads) over 6 weeks–> boost of 15-25grays may be given by beam or implant. If the axilla has been cleared surgically there is no need to irradiate that site. Causes sig. less reoccurrance
Sentinel Node biopsy (SNB)
Sentinel node is the first node from the breast, identified by isotope (Technetium colloid) + Dye
If SN clear, axilla clear (sensitivity 80-95%)
Types of Breast Ca surgery
Simple/total mastectomy +- SNB.cModified radical Mastectomy–> entire breast and axillary nodes removed.Skin sparing –> maximium skin envelope saved but NAC lost. Subcutaneous masectomy–> as SSM but NAC saved
NAC
Nipple and Areola complex
Axillary surgery in Breast Ca
30-40% of B Ca pts have nodal involvement and clinical or imaging evaluation is unreliable
Surgical evaluation is best –> sampling can miss nodes and understage cancer
Surgical clearance of the Axilla
surgical clearance of the axilla gives better prognostic information and outcomes–> 5% increased survival
BUT–> >50% are node negative, 5-30% of pt suffer lymphoedema or arm infections
Damage to nerves or frozen shoulders is possible
Prognosis of Breast Ca
3 factors–> axillary lymph node involvement (most important)
Tumour size
Tumour grade
Adjuvant Chemo therapy
Anthracycline regimes now routine–> used in several cancers although have Cardiotoxicity and neutropenia risks
In c-erbB2 positive cases Herceptin is better
Taxoids can also be used (Docetaxel)
Timing of Chemotherapy in Breast Cancer
Can be given before surgery (neoadjuvant) to downstage tumour
Adjuvant after surgery
Greatest benefit from combination therapy in pre-menopausal women
Neo-adjuvant chemotherapy
Used for large/locally advanced tumours–> 70% of people respond –>20-30% show complete response –> surgery always still required
Not yet been shown to improve survival compared to post-surgery chemo
Estrogen receptors and breast cancer
60% of cancers are estrogen or progesterone positive–> If estrogens are inhibited then this will prevent growth of cancer cells
Side effects of antagonising estrogens
Pharmacological estrogens–> nausea, IHD
Androgen therapy–> virilisation
Progestins–> weight gain, oedema, HTN
Prevent ovarian estrogen synthesis
Techniques for stopping ovarian estrogen synthesis
Surgical–> irreversible but painful
Irradiation–> irreversible but painless
GnRH analogues–> reversible but expensive
Adjuvant endocrine treatment
Blocking ovarian synthesis
Tamoxifen (antagonist of the estrogen receptor)(used are menopausal oestrogen receptor positive)
Aromatase inhibitors–> post-menopausal only
Risk factors for Cancer relapse
Aged under 40yrs (p=0.02) Symptomatic (p=0.008) Solid or cribiform archecture (p=0.01) Involved Margins (0.0008) Radiotherapy (0.009)
Local treatment alone or with adjuvant systemic treatment?
50% of women who receive local treatment alone will die from metastatic disease
systemic treatment is good
Chronological prognostic factors
Lymph nodes are the single most powerful factor. Age (younger women have poorer prognosis at equivalent stage). Tumour diameter correlates directly with survival. Distant metastasis worsens outcome
Grade–> III is worst, C-erbB2 negative is worse, presence of urokinase and cathepsin D is bad too
Lympho-vascular invasion
Occurs in 25% of operable cancers
Doubles the risk of local and short term systemic relapse
EGF receptors
Negatively correlated with ER and so worsen outcome
C-erbB2 positive tumours
Resistant to CMF chemo and hormonal therapy,
BUT
responsive to Anthracycline and Taxol chemotherapy and Tamoxifen
Stage 0 breast Cancer
DCIS or LCIS
Malignant but not yet invasive
Can be treated with Tamoxifen but not radio
May still require mastectomy if extensive
Breast reconstruction
Immediate gives better cosmetic outcomes but must be planned around adjuvant treatments
Use a combination of implants (silicone+-saline) and grafts (free flap or pedicle)
Goals of breast reconstruction
To make breast contour balanced and prevent pts requiring an external prosthesis
Use of trastuzumab (herceptin)
Monoclonal antibody for HER2/neu receptor (blocks EGF signalling)
