Treatment of Breast Cancer Flashcards by Chloe Mackle

How many women are affected by breast cancer?

1 in 8

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How many new cases per year are there of breast cancer in the UK?

46,000

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What number of malignancies in women does breast cancer account for?

1/4

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What percentage of deaths due to cancer are accounted for by breast cancer?

18%

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How many cases of breast cancer occur in men?

Up to 1/100

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What is the biggest risk factor for breast cancer?

Age

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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

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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

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What aerate two commonest types of breast cancer?

Ductal and lobular

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What percentage of ductal carcinoma in situ are symptomatic and what percentage are screen detected?

3% symptomatic

17% screen detected

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What percentage of lobular carcinoma in situ are symptomatic and what percentage are screen detected?

0.5% symptomatic

1% screen detected

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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

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How might breast cancer present?

Symptomatically or via NHS breast screening programme

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What is the current breast screening programme?

Women aged 50-70 invited through GP practice to attend 3 yearly mammogram

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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

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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

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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

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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

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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

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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&amp;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