Treatment of Breast Cancer Flashcards
How many women are affected by breast cancer?
1 in 8
How many new cases per year are there of breast cancer in the UK?
46,000
What number of malignancies in women does breast cancer account for?
1/4
What percentage of deaths due to cancer are accounted for by breast cancer?
18%
How many cases of breast cancer occur in men?
Up to 1/100
What is the biggest risk factor for breast cancer?
Age
What members of the MDT team are involved in treatment of breast cancer?
Breast surgeon Radiologist Cytologist Pathologist Clinical oncologist Medical oncologist Nurse counsellor Psychologist Reconstructive surgeon Patient and partner Palliative care
What are the pathological types of breast cancer?
In situ carcinoma
- ductal carcinoma in situ
- lobular carcinoma in situ
Invasive carcinoma
- ductal (70)
- lobular (25%)
- tubular
- cribriform
- medullary
What aerate two commonest types of breast cancer?
Ductal and lobular
What percentage of ductal carcinoma in situ are symptomatic and what percentage are screen detected?
3% symptomatic
17% screen detected
What percentage of lobular carcinoma in situ are symptomatic and what percentage are screen detected?
0.5% symptomatic
1% screen detected
Tubular, cribriform and medullary type breast cancers are cancers of special types, how common are they and what is their prognosis in comparison to breast cancers of no special type?
Less common
Better prognosis
How might breast cancer present?
Symptomatically or via NHS breast screening programme
What is the current breast screening programme?
Women aged 50-70 invited through GP practice to attend 3 yearly mammogram
What are the principles for management of a patient with breast cancer?
Establish diagnosis Assess severity - staging Treat underlying cause if possible General measures Specific measures
How do you establish the diagnosis of breast cancer?
History and examination Ask about risk factors for breast cancer Age at first pregnancy Breastfeeding Radiation exposure Weight Alcohol consumption OCP Mammography Ultrasound Magnetic resonance mammography Cytology Core biopsy Image guided cytology or core biopsy
Why is mammography more useful in older women?
Breast is denser in younger women, as age increases dense tissue is replaced with fatty tissue which is easier to see
What should you ask about in FH of a woman with suspected breast cancer?
Gene mutations in BRCA1 and BRCA2
Other genes - PTEN, TP53, Li Fraumeni syndrome, Lynch syndrome
Previous cancer in patient or first degree relatives
Ovarian cancer or male breast cancer
What are the risk factors for breast cancer?
Age Age at menarche and menopause Age at first pregnancy FH Previous benign breast disease Cancer in other breast Radiation exposure Lifestyle OCP/HRT
What do you look for when suspecting breast cancer?
Lump or thickening int he breast, often painless
Discharge or bleeding from nipple
Change in size or contours of breast
Change in colour or appearance of areola
Redness or pitting of skin over the breast (like the skin of an orange)
Paget’s disease of the nipple - can look like eczema or dermatitis
What is redness and inflammation with breast cancer known as?
Inflammatory cancer
What is the sensitivity of; clinical examination mammography ultrasound FNA cytology
for breast cancer?
Clinical examination 88%
Mammography 93%
Ultrasound 88%
FNA cytology 94%
What is the sensitivity?
The ability of a test to detect the disease if it is there
How do you assess the severity of breast cancer?
Look for metastases Hb, FBC, U&Es, LFTs CXR Isotope bone scan Others as clinically indicated No reliable tumour markers
What is the TNM staging?
T - Tumour T1 - 2cm or less T2 - 2-5cm T3 - > 5cm T4 - fixed to skin or muscle
N - Nodes
N0 - none
N1 - nodes in axilla
N2 - large or fixed nodes in axilla
M - Metastases
M0 - none
M1 - metastases
What are the specific measures in breast cancer management?
Primary breast cancer - local control, eradicate disease
Regional tumour-draining nodes - regional control, staging, eradicate disease
Micro-metastases - eradicated disease
What are the two main types of surgical procedure done for breast cancer?
Breast conservation - wide local excision, quadrantectomy or segmentectomy
Mastectomy
Randomised control trials show that tumours measuring 4cm or less can be treated with
breast conservation surgery, if > 4cm then mastectomy offered
How do you determine what patients are suitable for breast conservation surgery?
Tumour size < 4cm
Breast/tumour size ratio - 4cm tumour in small breast would not be suitable as there wouldn’t be breast shape/size left after
Suitable for radiotherapy - always given after breast conservation
Single tumour
Minimal in situ cancer component present
Patient’s wish
In a breast containing a 2cm invasive cancer, what is the risk of other invasive or in situ cancer at a distance of; 1cm 2cm 3cm 4cm
from the tumour that was removed
1cm - 60%
2cm - 40%
3cm - 20%
4cm - 10%
Why are axillary nodes relevant in breast cancer treatment?
Regional control of disease
Staging and prognostic information
Eradicate disease
What are the levels of the surgical anatomy of the axilla?
Level 1 - below and lateral to pectoralis minor
Level 2 - behind pectoralis minor
Level 3 - above and medial to pectoralis major
Why is the sentinel lymph node relevant in breast cancer?
First node to receive lymphatic drainage from breast
First node to which tumour spreads
If negative, the rest of the nodes in the lymphatic basin are negative
Skip metastases do not occur
What is the treatment of the axilla in breast cancer?
If SLN is clear of tumour no further treatment is required
If SLN contains tumour either remove all axillary nodes surgically (axillary clearance) or give radiotherapy to all the nodes in the axilla
What is axillary clearance?
If sentinel node is involved or patients have FNAC at clinical which shows malignant cells - all nodes removed from axilla
No radiotherapy given, even if nodes are involved with tumour
More morbidity than other types of axillary surgery
What are the complications of treatment to the axilla?
Lymphoedema
Sensory disturbance
Decreased range of movement of the shoulder joint
Nerve damage - long thoracic, thoracodorsal, brachial plexus
Vascular damage
Radiation-induced sarcoma
Who is most likely to have micrometastases and what factors of the disease are associated with increased risk of disease recurrence?
Lymph node involvement Tumour grade 3 most aggressive and likely to have micrometastases Tumour size > 4cm Absence of oestrogen receptors Presence of HER2 receptors Lymphovascular invasion in the tumour
What are the treatment choices for micrometastases?
Hormone therapy
Chemotherapy
Targeted therapies
When is hormone therapy given for micrometastases?
Only given if oestrogen receptors are present - oestrogen stimulates tumour growth
How do aromatase inhibitors work?
Convert androgens into oestrogen - not as useful in younger women
What is the hormone therapy for pre-menopausal women with micrometastases?
Tamoxifen for 5 years
What is the hormone therapy for post-menopausal women with micrometastases?
Tamoxifen for 5 years if very good prognosis
If poorer prognosis or more aggressive tumour then use aromatase inhibitor for 5 years
What is the hormone therapy in Scotland if the prognosis if intermediate?
Tamoxifen for 2 years plus aromatase inhibitor for 3 years
When is chemotherapy used in breast cancer?
Better effects if age < 50 but older patients still benefit
Given for node positive and grade 3 cancers
What are the chemotherapy agents used for breast cancer?
Anthracyclines and taxanes
What are the risks of chemotherapy for breast cancer?
Toxicity
Morbidity and mortality
Describe Anti-HER2 therapy
Trastuzumab (Herceptin)
Monoclonal antibody against HER-2 receptor given if receptor is present
Given to patients with over-expression of HER2 and chemotherapy
50% decreased risk of recurrence
33% increase in survival at 3 years
What is the follow up of breast cancer?
Many different protocols, poor evidence base
Clinical examination 6 monthly for 5 years
Yearly clinical examination after this
Discharge after 5 or 10 years
Mammogram of breasts annually for 10 years
