Women's Health : Breast Cancer

Question 1

What is the most common cancer in the UK?

Answer 1

Breast cancer, accounting for 15% of new cancer cases annually.

Question 2

How many new cases of breast cancer are diagnosed annually in the UK?

Answer 2

Approximately 56,000.

Question 3

2 types of pre-invasive breast cancer

Answer 3

Ductal carcinoma in situ (DCIS) & Lobular carcinoma in situ (LCIS)

Question 4

Ductal carcinoma in situ (DCIS).

Answer 4

● Neoplastic proliferation of epithelial cells - confined to duct without invasion through basement membrane. ● Precursor to invasive breast cancer. ● Comedo and non-comedo subtypes

Question 5

Lobular carcinoma in situ (LCIS).

Answer 5

Neoplastic proliferation of epithelial cells, confined to TDLU.

Question 6

Name some types of Invasive breast cancer

Answer 6

Invasive ductal carcinoma, Invasive lobular carcinoma, Medullary carcinoma, Many others - including mucinous, tubular, papillary, inflammatory etc

Question 7

Which type of breast cancer is most common?

Answer 7

Invasive ductal carcinoma (commonest - 75%). ; Neoplastic proliferation of epithelial cells that invades through the ductal basement membrane

Question 8

medullary carcinoma

Answer 8

More prevalent in the younger population. ● Higher grade than IDC.

Question 9

Invasive carcinoma can be graded using the _________

Answer 9

Nottingham criteria

Question 10

Which 3 components make up the Nottingham criteria

Answer 10

○ Gland formation ○ Nuclear atypia / pleomorphism ○ Mitosis counts (indicates rate of cellular reproduction)

Question 11

A higher grade carcinoma is one that is markedly different from ___________ and is considered ________.

Answer 11

A higher grade carcinoma is one that is markedly different from normal breast tissue and is considered poorly differentiated.

Question 12

What genetic mutation is often linked to breast cancer?

Answer 12

BRCA1 mutation.

Question 13

What are the five steps of metastasis in breast cancer?

Answer 13

1. Invasion through basement membrane 2. Intravasation (entry into circulation) 3. Circulation 4. Extravasation 5. Colonisation

Question 14

What are the common sites of breast cancer metastasis?

Answer 14

bones, liver, lungs and brain.

Question 15

List key risk factors for breast cancer.

Answer 15

1. Increasing age 2. Female sex (100:1 F:M incidence) 3. Family history 4. Inherited genetic mutations e.g. BRCA1 5. Endogenous oestrogen exposure: a. Early menarche b. Nulliparity / absence of breastfeeding c. Late menopause 6. Exogenous oestrogen and progestin exposure: a. Systemic hormonal HRT b. Systemic hormonal contraception

Question 16

What are the common symptoms of breast cancer?

Answer 16

breast lump

Question 17

What are the common signs of breast cancer

Answer 17

nipple discharge, nipple retraction, skin changes e.g. peau d’orange, axillary lymphadenopathy

Question 18

Metatastic features of breast cancer

Answer 18

weight loss, bony pain, shortness of breath.

Question 19

What type of staging is used for breast cancer

Answer 19

TNM staging (tumour, node, metastasis) -

Question 20

Stage 1A

Answer 20

<2cm, isolated to breast

Question 21

Stage 1B

Answer 21

<2cm, minor axillary LN spread

Question 22

Stage 2A

Answer 22

<2cm, spread to 1-3 ipsilateral LNs.

Question 23

Stage 2B

Answer 23

2 - 5cm, minor axillary nodal spread or 2 - 5cm with 1-3 ipsilateral nodes or >5cm, no nodal spread

Question 24

Stage 3A

Answer 24

4-9 ipsilateral nodes or >5cm with 1-3 ipsilateral nodes

Question 25

Stage 3B

Answer 25

spread to skin / chest wall

Question 26

Stage 3C

Answer 26

> 10 axillary nodes or supraclavicular spread or parasternal + axillary spread

Question 27

Stage 4

Answer 27

distant metastatic spread to organs.

Question 28

What is the NHS breast cancer screening programme?

Answer 28

3-yearly mammogram for women aged 50-71.

Question 29

What are the “2-week wait” criteria for breast cancer referral?

Answer 29

○ Unexplained breast lump in a woman aged >30.
○ Unexplained axillary lump in a woman aged >30.
○ Unilateral nipple changes in a woman aged >50.
○ Skin changes suggestive of breast cancer, any age.

Question 30

First line Ix for breast cancer

Answer 30

○ >30 or highly suspicious for cancer: mammogram ○ <30: breast ultrasound ○ Plus: ultrasound of the axilla +/- needle biopsy

Question 31

Second line Ix for breast cancer

Answer 31

○ Fine needle aspiration and cytology ○ Plus: oestrogen / progesterone receptor testing, HER2 receptor testing

Question 32

Ix : If symptoms / signs suggestive of metastasis

Answer 32

CT scan (CT thorax-abdomen-pelvis, CT head).

Question 33

What are mammogram features of invasive carcinoma?

Answer 33

Pre-invasive: unifocal / widespread microcalcifications ● Invasive carcinoma: 1. Irregular spiculated mass 2. Clustered microcalcifications 3. Linear branching calcifications.

Question 34

What is the first-line surgical treatment for breast cancer?

Answer 34

Tumour excision or mastectomy +/- breast reconstruction ○ Plus sentinel lymph node biopsy (no evidence of nodal spread) or axillary node clearance

Question 35

When is radiotherapy used in breast cancer management?

Answer 35

After surgery, especially for invasive cancers. radiotherapy
○ Whole breast / partial-breast
○ If tumour is invasive (i.e. not DCIS, LCIS), systemic third line therapy is indicated

Question 36

What systemic therapies are used for breast cancer?

Answer 36

: systemic therapy (guided by the PREDICT tool); oestrogen-receptor positive, HER2, chemotherapy. - systemic therapies can be neoadjuvant i.e. used to reduce tumour size before attempting surgery.

Question 37

Oestrogen-receptor positive:

Answer 37

■ Pre-menopausal / male - tamoxifen (anti-oestrogen) ■ Post-menopausal - anastrozole / letrozole (aromatase inhibitor, prevents peripheral oestrogen synthesis) ■ Note - tamoxifen therapy can be continued long-term (5 years) before
switching to an aromatase inhibitor.

Question 38

HER2 (human epidermal growth factor receptor 2) positive:

Answer 38

Trastuzumab (Herceptin)

Question 39

Chemotherapy:

Answer 39

■ Including a taxane and an anthracycline ■ E.g. ACT: doxorubicin, cyclophosphamide and paclitaxel