Management of Breast Cancer

Question 1

Epidemiology of breast cancer

Answer 1

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

Question 2

Presentation of Breast cancer

Answer 2

Breast Lump Nipple discharge
Inversion of Nipple Skin Dimpling
Lump in axilla Lymphoedema

Question 3

Diagnosis of Breast cancer

Answer 3

Triple assessment (clinical, imaging and biopsy)

Question 4

Stage vs Grade of breast cancer

Answer 4

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

Question 5

Stage 1 breast cancer

Answer 5

<2cm in diameter
Hasnt spread to lymph nodes or outside the breast
If treated at this stage 5yr survival is 100%

Question 6

Stage 2 breast cancer

Answer 6

5cm but there is no lymph node involvement

If treated at this stage 5yr survival is 90%

Question 7

Stage 3 breast cancer

Answer 7

> 5cm with axillary lymph node involvement but the nodes arent attached to each other
5yr survival is 50%

Question 8

Inflammatory breast cancer

Answer 8

Caused by cancerous spread to lymphatic vessels in the skin
Causes swelling, redness, ridged or dimpled skin
Is classified as stage 3 breast cancer

Question 9

10 and 20 year survival rates

Answer 9

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

Question 10

Stage 4 breast cancer

Answer 10

Defined by the presence of distant mets (bone, lung, liver or lymph nodes)
Treatment is symptomatic at this stage
5yr survival is 20%

Question 11

Grading of breast cancers

Answer 11

Based on histological differentiation –> scored from 3-9 in tubule formation, pleomorphism and mitotic rate
Can be well, moderately or poorly differentiated (worst)

Question 12

Treatments of invasive Breast Ca

Answer 12

Local –> Surgery or radio

Systemic –> Chemo, endocrine or targeted therapies (biologics etc)

Question 13

Surgical Options for breast Ca

Answer 13

(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

Question 14

Aims of breast cancer surgery

Answer 14

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

Question 15

Tumour types allowing for breast conservation

Answer 15

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

Question 16

Radiotherapy for breast Ca

Answer 16

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

Question 17

Sentinel Node biopsy (SNB)

Answer 17

Sentinel node is the first node from the breast, identified by isotope (Technetium colloid) + Dye
If SN clear, axilla clear (sensitivity 80-95%)

Question 18

Types of Breast Ca surgery

Answer 18

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

Question 19

NAC

Answer 19

Nipple and Areola complex

Question 20

Axillary surgery in Breast Ca

Answer 20

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

Question 21

Surgical clearance of the Axilla

Answer 21

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

Question 22

Prognosis of Breast Ca

Answer 22

3 factors–> axillary lymph node involvement (most important)
Tumour size
Tumour grade

Question 23

Adjuvant Chemo therapy

Answer 23

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)

Question 24

Timing of Chemotherapy in Breast Cancer

Answer 24

Can be given before surgery (neoadjuvant) to downstage tumour
Adjuvant after surgery
Greatest benefit from combination therapy in pre-menopausal women

Question 25

Neo-adjuvant chemotherapy

Answer 25

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

Question 26

Estrogen receptors and breast cancer

Answer 26

60% of cancers are estrogen or progesterone positive–> If estrogens are inhibited then this will prevent growth of cancer cells

Question 27

Side effects of antagonising estrogens

Answer 27

Pharmacological estrogens–> nausea, IHD
Androgen therapy–> virilisation
Progestins–> weight gain, oedema, HTN
Prevent ovarian estrogen synthesis

Question 28

Techniques for stopping ovarian estrogen synthesis

Answer 28

Surgical–> irreversible but painful
Irradiation–> irreversible but painless
GnRH analogues–> reversible but expensive

Question 29

Adjuvant endocrine treatment

Answer 29

Blocking ovarian synthesis
Tamoxifen (antagonist of the estrogen receptor)(used are menopausal oestrogen receptor positive)
Aromatase inhibitors–> post-menopausal only

Question 30

Risk factors for Cancer relapse

Answer 30

Aged under 40yrs (p=0.02)
Symptomatic (p=0.008)
Solid or cribiform archecture (p=0.01)
Involved Margins (0.0008)
Radiotherapy (0.009)

Question 31

Local treatment alone or with adjuvant systemic treatment?

Answer 31

50% of women who receive local treatment alone will die from metastatic disease
systemic treatment is good

Question 32

Chronological prognostic factors

Answer 32

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

Question 33

Lympho-vascular invasion

Answer 33

Occurs in 25% of operable cancers

Doubles the risk of local and short term systemic relapse

Question 34

EGF receptors

Answer 34

Negatively correlated with ER and so worsen outcome

Question 35

C-erbB2 positive tumours

Answer 35

Resistant to CMF chemo and hormonal therapy,
BUT
responsive to Anthracycline and Taxol chemotherapy and Tamoxifen

Question 36

Stage 0 breast Cancer

Answer 36

DCIS or LCIS
Malignant but not yet invasive
Can be treated with Tamoxifen but not radio
May still require mastectomy if extensive

Question 37

Breast reconstruction

Answer 37

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)

Question 38

Goals of breast reconstruction

Answer 38

To make breast contour balanced and prevent pts requiring an external prosthesis

Question 39

Use of trastuzumab (herceptin)

Answer 39

Monoclonal antibody for HER2/neu receptor (blocks EGF signalling)