Treatment Of Breast Cancer Flashcards
All breast lumps should undergo …
Triple assessment procedure - hospital based assessment clinic that allows the early and rapid detection of breast cancer
Women and men can be referred by GP to this one stop clinic if they have signs or symptoms that meet the breast cancer 2 week wait or if suspicious findings on screening
What steps are involved in the triple assessment ?
Clinical assessment - history and examination
Imaging - mammography or USS
Histology - code biopsy or FNA
What does mammography involve?
Compression views of the breast across two views - oblique and craniocaudal
Allowing for detection of mass lesions or microcalcifications
Who is USS more useful for ?
Women <35 and in men
Due to the density of the breast tissue in identifying anomalies
Also used during core biopsy
Is MRI used in triple assessment?
Not routinely
Can be useful in assessment of lobular breast cancers and in assessing response to neoadjuvant therapy
High sensitivity but low specificity
What is the difference between core biopsy and FNA?
Core biopsy gives full histology - allowing differentiation between invasive and in situ carcinoma
FNA only provides cytology
What happens at each stage of the triple assessment?
The suspicion of malignancy is graded to create overall risk index - establish whether likely benign lesion or if patient should go onto have more definitive biopsy and further intervention
Describe the scoring that occurs at the triple assessment
Examination: P1 - normal P2 - benign P3 - uncertain/ likely benign P4 - suspicious of malignancy P5 - malignant
Imaging score
M1/U1 - normal
M2/U2 - benign
Etc
Histology score
B1- normal
B2 - benign
Etc
Where will the treatment plan be developed?
MDT
What does adjuvant mean?
After surgery
What does neo-adjuvant mean?
Before surgery
What does palliative mean?
Symptom control
Not curative
Surgical breast conserving treatment is only suitable for…
Localised, operable disease
No evidence of metastatic disease
What is the most common surgical breast conserving treatment?
Wide local excision (WLE)
Describe wide local excision
Excision of tumour typically ensuring a 1cm margin of macroscopically normal tissue is taken along with the malignancy
Chosen if:
- solitary lesion
- peripheral tumour
- small lesion in large breast
- DCIS <4cm
- patient choice
What is a mastectomy?
Removes all the tissue of the affected breast along with significant portion of overlying skin (muscles of chest wall left intact)
When are mastectomies indicated?
Multi focal disease High tumour:breast tissue ratio Disease recurrence Patient choice Risk reducing cases - strong FH of breast cancer/ ovarian cancer, positive gene mutations, previous history of breast cancer
When is axillary surgery performed?
Often alongside WLE and mastectomy to assess nodal status and remove any nodal disease
What is a sentinel node biopsy?
Removal first few lymph nodes into which tumour drains
The nodes are identified by injecting blue dye with associated radioisotope into peri-areolar skin
Radio activity detection/ visual assessment (as nodes become blue) can identify sentinel nodes - removed and sent for histological analysis
What is axillary node clearance?
Removing all nodes in axilla
Ensuring not to damage important structures in axilla
Send for histological analysis
What common complications can occur from axillary node clearance?
Paraesthesia
Seroma formation
Lymphoedema in upper limb and functional arm impairment
Outline the treatment for early stage disease
Early stage = localised tumours without metastatic spread
WLE or mastectomy
Axillary node sampling at least (e.g sentinel node biopsy) but usually axillary node clearance
Adjuvant radiotherapy to chest wall (recommended for all with invasive cancer after WLE)
RT to axilla if positive nodes on sampling and node clearance not performed
Adjuvant chemotherapy improves survival particularly in young with node positive disease (consider in all expect excellent prognosis patients)
Tamoxifen and herceptin also have a role
What are side effects of RT to chest wall or axilla?
Pneumonitis Rib fracture Pericarditis Lymphoedema Brachial plexus injury
Medical treatment is commenced usually after primary surgery, yet it can be the treatment of choice in…
Elderly patients
Those unfit for surgery
What medication treatment options are there (not surgery)?
Chemotherapy
Radiotherapy
Immunotherapy
Hormone therapy - biggest contributor to improved survival
What hormone treatments are there?
Tamoxifen
Aromatase inhibitors
Who is tamoxifen typically given to?
Pre-menopausal patients
How does tamoxifen work?
Blockade of oestrogen receptors - so lack of DNA synthesis inside cancer cells
Affected cell remains in G0/G1 phases of cell cycle
It is a selective oestrogen selective modulator (SERM)
What does tamoxifen increase the risk of?
Thromboembolism during and after surgery or periods of immobility
In bone and endometrial tissue = oestrogen agonist - improves bone density (positive) but increases risk of endometrial cancer
How do aromatase inhibitors work?
Bind to oestrogen receptors - prevent further malignant growth and prevent further oestrogen production
Block the conversion of androgens to oestrogen in peripheral tissue
Who are aromatase inhibitors typically given to?
Post menopause patients as adjuvant therapy
Pre menopausal women majority of oestrogen production occurs in ovary, but in post-menopausal women majority occurs in adrenals - from conversion of androgens
- aromatase inhibitors inhibit the conversion of androgens to oestrogen in adrenals, so only suitable in post-menopausal women
Immunotherapy is used in those whose…
Cancers express specific growth factor receptors
What is herceptin?
Also know as Trastuzumab
Monoclonal antibody that targets human epidermal growth factor receptor (HER2 positive malignancies)
How is herceptin used?
As adjuvant or monoclonal therapy in those who have had at least 2 chemotherapy regimes for metastatic breast cancer
What is a common side effect of herceptin?
Cardiotoxicity - need to monitor cardiac function before and during treatment
ECHO
What are some examples of aromatase inhibitors?
Anastrozole
Letrozole
Exemestane
What are the side effects of tamoxifen?
Fatigue Hot flushes Mood changes Cardiovascular- VTE risk increased Fatty liver Reduced libido
How is herceptin usually given?
IV every 3 weeks
What does a triple negative tumour mean?
Not oestrogen receptor, progesterone receptor or HER2 receptor positive
These tumours have worst prognosis - target therapies not effective
Outline the treatment plan for advanced disease
Advanced= locally advanced cancers that cannot be cured with surgery alone and metastatic breast cancer
Surgery
Chemotherapy plus specific treatment dependant on molecular type e.g hormone therapy or immunotherapy
Localised treatment options e.g RT for individual bony met pain
What percentage of breast cancers will express oestrogen receptors?
75%
The fact that a tumour is receptor positive, indicates a higher or lower level of cell differentiation?
Higher - hasn’t differentiated to an extent as to become unrecognisable
Where does breast cancer typically spread to?
Lungs Bones Liver Brain Adrenals
Radiotherapy after WLE reduces risk of disease reoccurrence from 30% to…
10%
Tamoxifen can cause uterine cancer in rare cases, so what symptom should you warn the patient of?
Vaginal bleeding - should report
Is radiotherapy offered to women who have had a mastectomy?
If T3 or T4 tumours and for those with 4 or more positive axillary nodes
Why might chemotherapy be used before surgery (neoadjuvant)?
To downstage a primary lesion before surgery - may allow breast conserving surgery rather than mastectomy
Axillary node clearance is associated with what percentage risk of lymphoedema and functional arm impairment?
14%
What is the most important side effect of aromatase inhibitors?
Osteoporosis
How are BRCA gene mutations inherited?
Autosomal dominant
Having one part with mutation results in 50% chance of that gene being passed onto child
There is 50% chance of sibling having the gene
What is a seroma?
A mass or lump caused by the build up of lymph fluid at the site of the surgery
