Wk 14: Breast cancer in practice Flashcards
What is the strongest risk factor for breast cancer?
Family history - 1st degree = 2-3x higher risk
What are the risk factors of breast cancer?
- Age
- Previous breast cancer
- High breast density
- Exposure to radiation
- Inc estrogen exposure: Late meo, COC/HRT, nulliparous, never breastfed
- Higher social status
- White
- Low physical activity
- Obesity
- Alcohol
How is breast cancer diagnosed?
Triple assessment:
- Clinical examination: characteristics of lump, skin changes, fluid leaking, nipple inversion
- Breast imaging: mammography + ultrasound
- Pathological evaluation: biopsy
What is the first line treatment for breast cancer?
Surgery - removes primary breast tumour
- Breast conserving surgery/lumpectomy
- Mastectomy
Which patients are not suitable for surgery?
- Prior radiotherapy
- Widespread disease
- Tumours >5cm
- Persistent pathological margin
What is involved in radical mastectomy?
Removal of breast, pectoralis major + minor muscles + axillary contents
What is involved in conventional mastectomy?
Removal of breast (skin + nipple), pectoral muscle maintained unless tumour invasion
What is a frequent site of lymph node metastases?
Axilla
What is an axillary procedure?
Obtain lymph nodes for examination
How does lymphoedema occur?
- Surgery/radiotherapy cut off lymph nodes causing fluid build up
- Metastatic disease in axilla
What are the symptoms of lymphoedema?
Arms stiff, uncomfortable + tight
How do you treat lymphoedema?
Compression stocking + massages
What readings do you take in a patient with lymphoedema?
Blood + BP
When do you use radiotherapy?
- Patients undergone breast conserving surgery
- After surgery for early BC
- Combined w/ systemic therapy + surgery for locally advanced cancer
- Combined w/ systemic therapy for metastatic disease
- Post mastectomy
What are the early adverse effects of radiotherapy?
- Skin in treatment area: sensitive, red + swollen
- Fatigue
- Hairloss
What are the late adverse effects of radiotherapy?
- Breast changes: smaller + harder
- Bone damage
- Cardiac + respiratory toxicity
When do you start adjuvant chemotherapy?
W/in 31 days of surgery or earliest date
What needs to be considered before starting adjuvant chemo?
- Nodal involvement
- Oestrogen receptor status
- HER 2 status
What is the regime for node negative patients?
Anthracycline containing regime:
- EC (Epirubicin / Cyclophosphamide) x 6
- FEC (5FU/Epirubicin/Cyclophosphamide) x6
Alt:
- Classical CMF (Cyclophosphamide/Methotrexate/5FU
What is the regime for node positive patients?
Taxane containing regime:
- FEC-T (5FU/ Epirubicin/ Cyclophosphamide – Docetaxel)
Alternative:
- TC (Docetaxel+Cyclophosphamide)
When is neoadjuvant chemo used?
Locally advanced disease:
- ER, PR + HER2 determined prior
- FEC/EC 4-6 cycles
- FEC-T if node involvement
What is used for hormonal regulation and estrogen receptor overexpression?
- Tamoxifen
- Aromatase inhibitors
What are the side effects of hormonal therapy?
- Bone loss: bisphosphonates
- Menopausal symptoms: hot flushes, vag bleed, red libido, mood changes
- Inc venous thromboembolism (tamoxifen)
What is HER2?
Human Epidermal Growth Factor Receptor 2
HER2 amplification is associated with what?
- Accelerated cell growth + proliferation
- Inc risk of recurrence
- Shortened survival
What is used to block HER2 receptors?
Trastuzumab - herceptin (monoclonal antibody)
What are the adverse effects lf trastuzumab?
- Neutropenia
- Anaemia
- Thrombocytopenia
- Hypersensitivity reaction
- Cardiovascular disease
What is given for metastatic disease patients who are hormone receptor positive?
Endocrine 1st line:
- Premenopausal – tamoxifen + ovarian ablation
- Postmenopausal – aromatase inhibitor
What is given for metastatic disease patients who are HER2 positive?
Targeted therapy w/ chemo:
- Herceptin + pertuzumab + taxane
- Herceptin + taxane
- Herceptin monotherapy
What is given to metastatic disease patients who are HER2 negative + hormone receptor negative?
Chemo
What is the common site for metastatic disease?
- Bones: ribs, spine, pelvis, arms + legs
- Cause: pain, impaired mobility, pathological fractures + hypercalcaemia
What is the treatment for bone metastasis?
Bisphosphonates or denosumab
What is the treatment for brain metastases?
- Surgery
- Whole brain radiotherapy
- Palliative: steroids red swelling
What are other common sites of metastatic disease + what are the treatments?
- Liver + lungs
- Systemic therapy, surgery + radiotherapy
What is ulcerating/fungating disease?
- Cancer grows upwards + breaks skin, in shape of fungus
- Develops if cancer untreated
- Painful, itchy + affect movement
- Treatment: wound management + antibiotics
