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CCC > Oncology - Breast > Flashcards

Oncology - Breast Flashcards

1
Q

What is the incidence of breast cancer?

A
  • Most common cancer in women

- 1 in 8 women and 1 in 870 men will develop breast cancer

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2
Q

What are the 2 main types of breast carcinoma?

A

Beast cancers are typically adenocarcinomas

  • Ductal carcinoma (85%) = epithelial lining of ducts
  • Lobular carcinoma (15%) = epithelium of terminal ducts of lobule

Others: medullary, colloid, comedo and papillary.

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3
Q

Which breast carcinoma is more infiltrative?

A

Lobular carcinoma - it can present similarly to gynaecological cancers

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4
Q

What genes are associated with increased risk of breast cancer and what chromosomes are they found on?

A

BRCA1 - Chr17 (breast and ovarian cancer)

BRCA2 - Chr13 (early onset breast cancer and male breast cancer)

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5
Q

What risk factors associated with oestrogen exposure increase the risk of breast cancer?

A 
Early menarche
Late menopause
HRT use
Prolonged use of OCP?
Obesity (especially post-menopause) 
Nullparity
First child after 30
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6
Q

Where is oestrogen produced?

A

Premenopausal women – oestrogen produced in ovaries

Postmenopausal women – synthesis in fat cells (adipose tissue), skin, liver, muscle, breast

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7
Q

What is the most common presentation of breast cancer?

A

Breast lump

Hard, painless lump with irregular margins
Fixed to skin/chest wall

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8
Q

What are other common presentations of breast cancer aside from breast lump?

A 
Breast pain
Skin changes - peau d'orange, skin dimpling
Nipple discharge
Nipple changes - paget's disease
Axillary lymphadenopathy
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9
Q

What causes peau d’orange?

A

Oedema due to lymphatic invasion from tumour

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10
Q

What questions are important to ask in a breast cancer history?

A
  • How long?
  • Change with cycle?
  • Skin/nipple changes?
  • Associated symptoms – discharge/pain?
  • Related to menstrual cycle?
  • Previous breast lumps? Previous cancer?
  • Lumps under arm?
  • Family history inc men
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11
Q

How do you investigate a suspected breast cancer?

A

Triple assessment

1) Examination - breast, axilla, supraclavicular fossa
2) Imaging
- bilateral mammogram
- targeted USS of the worrying area and axilla
3) Biopsy of the lump, and suspicious nodes (core biopsy done by USS)

  • The biopsy will state if it is cancer, what type of cancer, grade of cancer, tumour markers
  • Bone scan and full CT can be done if concerned about metastatic disease
  • MRI instead of mammogram if a lot of breast tissue, or suspected lobular
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12
Q

What is the treatment of choice for LOCALISED disease in breast cancer?

A

Surgery
Either:
- Wide local excision/lumpectomy to remove lump with postoperative radiotherapy (always chemo after)
- Mastectomy to remove breast (chemo if high recurrence risk)

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13
Q

In breast cancer surgery, when would we clear the axilla?

A

Axilla clearance

  • if the USS/biopsy show +LN involvement then clear axilla
  • if the USS/biopsy show no LN involvement then do sentinel node biopsy day before surgery to check> if +ve then clear axilla
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14
Q

What is required in ALL breast cancer patients after CONSERVATIVE surgery (wide local excision/lumpectomy)?

A
  • Adjuvant radiotherapy to residual breast tissue +/- lymph node areas
  • Reduces risk of local relapse by HALF
  • Monday-Friday for 3 WEEKS
  • (40 Grey in 15 fractions over 3 weeks)
  • Boost to tumour bed (10Gy in 5 fractions) in high risk disease
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15
Q

What adjuvant therapy is given to patients with breast cancer?

A

Adjuvant therapy for breast cancer depends on patient:

  • Adjuvant chemotherapy-especially <50 years (Oncotype DX is a genomic test designed to predict benefit from chemotherapy)
  • Targetted therapy (Herceptin/Trastuzamab) if HER2+
  • Endocrine Therapy (Tamoxifen or Aromatase Inhibitors-postmenapausal) if ER/PR+

-Adjuvant radiotherapy
•all patients after CONSERVATIVE surgery
• some patients after mastectomy in those who have high risk occurrence (multiple lymph nodes, large tumours)

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16
Q

What endocrine therapy is only useful in post-menopausal women?

Why?

A

Aromatase inhibitors (Anastrozole, Letrozole, Exemestane )

They stop oestrogen production outside the ovaries by blocking the action of aromatase enzyme (prevents conversion of cholesterol to oestrogen in fat cells)

17
Q

What are some side effects of aromatase inhibitors?

A

Aromatase inhibitors side effects (Anastrozole, Letrozole, Exemestane )

  • Mood changes
  • Vaginal dryness
  • Loss of libido
  • Muscle and joint pain (Myalgia, Arthralgia)

-Decreased bone density-osteoporosis- do a DEXA bone scan as a baseline before starting and monitor bone health (consider VitD, Ca supplements and bisphosphonates)

18
Q

What endocrine therapy is ONLY useful in pre-menopausal women?

A

Ovarian ablation. This stops the ovaries from producing oestrogen. Can also use luteinizing hormone releasing hormone (LHRH) agonists.

19
Q

What endocrine therapy can be used in pre- and post-menopausal breast cancer patients?

A

Oral Tamoxifen (give for 5 years)

20
Q

What risk should you council patients about tamoxifen? (2)

A

Come back in if:
-Episode of post menopausal bleeding/abnormal bleeding (ENDOMETRIAL CANCER)

-Sudden onset leg pain/breathlessness (DVT/PE)
(although it has antioestrogenic activity, it also produces oestrogen-like effects at some receptors)

21
Q

What is HER-2?

What is its relation to breast cancer?

A

HER-2 is an endothelial factor receptor oncoprotein that allow rapid multiplication of the cell

20% breast cancers overexpress HER-2

22
Q

What drug can be used in HER2 positive breast cancers?

How does it work?

How is its given?/how long for?

A

Herceptin = transtazumab (monoclonal antibody)

what: Monoclonal Ab against Her-2 protein, blocks cell signalling pathways (not chemo)
how: Give IV or S/C every 3 weeks for 12 months

23
Q

What is a risk of herceptin treatment?

How do we prevent this?

A

Cardiotoxicity
i.e. it makes the heart baggy
It is reversible

monitor cardiac function with MUGA scan

24
Q

Which breast cancers are most responsive to chemotherapy?

A

ER-negative (EaRN)

HER2-positive (HERP)

25
Q

What chemotherapy drugs are typically used in breast cancer?

How does the therapy change if no lymph nodes involved?

A

EC (epirubicin + cyclophosphamide) for 3 cycles
Docetaxel for 3 cycles

(if no lymph nodes involved, only EC for 6 cycles)

26
Q

What chemotherapy agents can be given for breast cancer that is ER positive and HER2 negative?

A

CDK4/6 inhibitors (end in lib) (used alongside hormone therapy)

27
Q

What are some poor prognostic indicators in breast cancer?

A 
Triple negative (nothing to act on) 
HER2 positive (give chemo) 
ER/PR negative (give chemo) 
High TNM stage
Lymph node involvement
>5cm mass
Higher grade (3>2>1)
28
Q

What is TNM staging for breast cancer?

A 
T0	No primary tumour
Tis	In situ disease, non invasive
T1	Invasive tumour less than 2 cm
T2	Tumour between 2 and 5 cm
T3	Primary tumour greater than 5 cm
T4	Skin involvement
N0	
No lymph nodes
N1	Mobile axillary nodes
N2	Fixed axillary nodes
N3	Internal mammary nodes

M0
No metastases
M1 Distant metastases

29
Q

When would we give neo-adjuvant chemo (chemo before surgery) to patients with breast cancer?

A

Neoadjuvant chemotherapy is considered when:

○ The SIZE of the tumour makes initial surgery impossible - or it is the woman’s preference so that she might have a lumpectomy and not a mastectomy

○ Deemed the best way to preserve breast tissue

○HER2 positive or triple negative breast cancer (ER, PR and HER2 negative)

30
Q

Side effects of tamoxifen?

A

tamoxifen causes post manopausal symptoms

  • hot flushes
  • mood changes
  • loss of libido
  • changes in vaginal discharge
  • weight change
31
Q

When are women screened for breast cancer?

A

Screening

  • Women aged 50 - 70 years
  • EVERY 3 YEARS
  • MAMMOGRAM
  • Screening is the route with the highest proportion of breast cancers diagnosed at an early stage
32
Q

How is metastatic breast cancer managed?

A

If the patient presents with metastases or is placed in stage 4 after assessment, surgery is not part of the treatment unless to palliate some particular site of disease

Endocrine (tamoxifen, aromatase)
○ If ER/PR positive and the disease is slowly progressing
○ Best responce in soft tissue>bone mets>visceral mets
○Median duration of response is 1-2 years

Chemotherapy
○ Palliate symptoms to help improve quality/duration of life.

Radiotherapy
○Palliation of locally recurrent disease and controlling symptoms such as pain from bony mets

33
Q

What is the predict tool?

A

Predicts how breast cancer will respond to therapies- 5 year survival

34
Q

What is Paget’s disease of the breast?

A

Infiltrating carcinoma of nipple epithelium

35
Q

Does the presence of HER2 mean it is a more/less aggressive disease?

A

More aggressive disease if HER2 (causes rapid multiplication of the cell)

CCC (15 decks)

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