The Big 4 - Breast

Question 1

What is the lifetime prevalence of breast cancer?

Answer 1

1 in 8 women
1 in 870 men

Question 2

What risk factors are there for breast cancer?

Answer 2

-Increasing age
-Increased periods of oestrogen exposure (late childbearing, early menarche, late menopause, obesity)
-OCP and some HRTs
-Obesity
-Alcohol
-Exposure to ionising radiation
-FHx (especially if premenopausal)
-Genetics (BRCA1 = breast and ovarian, BRCA2 = early and male breast, P53)

Question 3

What types of breast cancer are there and what is their histological appearance?

Answer 3

-70-80% of all cases consist of INVASIVE DUCTAL CARCINOMA cells
-10% of cases involve LOBULAR CARCINOMA - higher incidence of multi centric tumours
-Medullary, colloid, comedo and papillary are less common types

Question 4

What is a common presentation of breast cancer?

Answer 4

-Most present with a breast or axillary mass
-Less commonly present with nipple discharge, regional lymphadenopathy or mets symptoms eg back pain, leg weakness
-Inflammatory breast cancer = red, inflamed breast, commonly mistaken for mastitis

Question 5

What does the triple assessment of patients with suspected breast cancer involve?

Answer 5

-CLINICAL - full H+E
IMAGING
-MAMMOGRAPHY - bilateral to detect multi centric tumours or primaries in the opposite breast
-ULTRASOUND+BIOPSY - of the symptomatic /abnormal breast and axillae
(MRI done if discrepancy found between any of these assessments)
PATHOLOGY
-FNA or core biopsy done and assessed

Question 6

What further investigations would a patient with risk of disseminated disease have?

Answer 6

-Isotopic bone scan
-CT / US liver

Question 7

What do the T stages denote in breast cancer?

Answer 7

T0 = no primary tumour
Tis = in situ disease, no invasion
T1 = invasive tumour <2cm
T2 = invasive tumour 2-5cm
T3 = invasive tumour >5cm
T4 = skin involvement

Question 8

What do the N stages denote in breast cancer?

Answer 8

N0 = no lymph node involvement
N1 = mobile axillary lymph nodes
N2 = fixed axillae lymph nodes
N3 = internal mammary nodes

Question 9

What do Stages 0-IV denote in breast cancer?

Answer 9

Stage 0 = Tis, N0, M0
Stage I = T1, N0, M0
–95% 5YSR
Stage II = T2/3, N0, M0 OR T0/1/2, N1, M0
–80% 5YSR
Stage III = T or N >Stage II, M0
–60% 5YSR
Stage IV = any T, any N, M1
–25% 5YSR

Question 10

How is localised breast cancer managed?

Answer 10

-Most patients will have surgery first (sometimes followed by adjuvant systemic chemo)
-Some will have neoadjuvant chemotherapy eg if tumour is too large initially for surgery, to allow for breast conservation, in HER2+ / triple- breast cancer cases

Question 11

What surgical options are offered in the treatment of localised breast cancer?

Answer 11

-Mastectomy
-Conservative surgery eg wide local excision + post-op RT
-Choice depends on:
–Location
–Size of lesion vs breast size
–Single or multifocal disease
–Extent of in situ change
–Patient preference

Question 12

What else is done during breast surgery?

Answer 12

-Assessment of axillary lymph nodes
-Metastatic involvement of axillary lymph nodes? –> clearance
-If no metastatic involvement –> sentinel node biopsy
-If sentinel nodes are positive –> clearance / RT

Question 13

What does a sentinel node biopsy involve?

Answer 13

-Sentinel nodes = first nodes that tumour drains into
-Biopsy during assessment involves injecting the patient with a tracer so they can be located easily during surgery
-They are then removed and analysed

Question 14

What factors help decide what adjuvant systemic therapy should be chosen?

Answer 14

-ER receptor status (ER+ are less responsive to chemo)
-HER2 receptor status (HER2+ are more responsive to chemo)
-Menopause status
-Tumour size and grade
-Nodal involvement
-Performance status

Question 15

How successful is combination chemotherapy?

Answer 15

-Reduces annual risk of recurrence by 28%
-Reduces annual risk of mortality by 16%
-Less effective in women <60

Question 16

When is Trastuzamab (Herceptin) used?

Answer 16

-Effective against metastatic and localised disease where the cancer over-expressed HER2
-Given for 12 months in the adjuvant setting
-NB can affect cardiac function so should be monitored

Question 17

What endocrine therapy is offered to women with breast cancer?

Answer 17

PREMENOPAUSAL WOMEN:
-Tamoxifen offered if cancer is ER/PR positive
-20mg/day for 5 years
-Reduces risk of recurrence by 25% and death by 17%
-Increases risk of thrombosis and endometrial cancer
POSTMENOPAUSAL WOMEN
-Aromatase inhibitors offered eg letrozole, anastrozole
-Fewer vascular / malignant SEs, but increased osteoporosis problems (DEXA scan)

Question 18

How is radiotherapy administered for women with breast cancer?

Answer 18

-Required following conservative surgery
-Chest wall RT may be required following mastectomy
-Normally Mon-Fri for 3 weeks

Question 19

How is metastatic breast cancer managed differently to localised disease?

Answer 19

-Depends on extent of spread, symptoms etc
-Surgery only offered if <Stage IV or for palliative reasons
-Endocrine therapy offered if progression is slow and symptoms are minimal - reduced efficacy
-Chemotherapy offered palliatively
-RT offered palliatively in recurrent cases

Question 20

What molecular markers are important to be aware of in breast cancer?

Answer 20

-ER (oestrogen receptor)
–treat by blocking oestrogen from binding with receptor (tamoxifen)
–treat by blocking oestrogen production (oophorectomy in premenopausal women, aromatase inhibitors in postmenopausal women)
-HER-2 (growth promoting protein)
–mAbs agonists can inhibit (trastuzamab)
-PR (progesterone receptor

Question 21

What cases of breast cancer receive immunotherapy?

Answer 21

Triple negative

Question 22

When are women invited for breast cancer screening?

Answer 22

-Every 3 years from ages 50-70