Breast - Breast Cancer

Question 1

Breast Cancer - what re the RFs?

Answer 1

Increased exposure to oestrogen
Obesity
Smoking
Family History

HRT - increases risk, especially combined HRT (both oestrogen and progesterone)

Combined contraceptive pill - small increase in risk

Question 2

Breast Cancer - what is BRCA?

Answer 2

BRCA refers to BReast CAncer gene

BRCA genes are tumour suppressor genes

Mutations in these genes lead to an increased risk of breast cancer

Question 3

Breast Cancer - where is BRCA1 located?

Answer 3

Chromosome 17

Question 4

Breast Cancer - where is BRCA2 located

Answer 4

Chromosome 13

Question 5

Breast Cancer - what are the different types of breast cancer?

Answer 5

1. Ductal Carcinoma In Situ (DCIS)
2. Lobular Carcinoma In Situ (LCIS)
3. Invasive Ductal Carcinoma (NST, No Special Type)
4. Invasive Lobular Carcinomas (ILC)
5. Inflammatory Breast Cancer
6. Paget’s Disease of the Nipple

Question 6

Breast Cancer - what is DCIS?

Answer 6

Localised in a single area

Potential to become an invasive breast cancer (around 30%)

Basement membrane not breached

Good prognosis if full excised

Question 7

Breast Cancer - what is LCIS?

Answer 7

• Pre-cancerous condition occurring typically in pre-menopausal women
• Usually asymptomatic and undetectable on a mammogram
• Increased risk of invasive BC in future (30%)
• Managed with close monitoring (6 monthly examination and yearly mammograms)

Question 7

Breast Cancer - what is LCIS?

Answer 7

• Pre-cancerous condition occurring typically in pre-menopausal women
• Usually asymptomatic and undetectable on a mammogram
• Increased risk of invasive BC in future (30%)
• Managed with close monitoring (6 monthly examination and yearly mammograms)

Question 8

Breast Cancer - what is Invasive Ductal Carcinoma (NST)?

Answer 8

NST means no special/specific type, where it is not more specifically classified

• Originate in cells from the breast ducts
• 80% of invasive breast cancers fall into this category
• Can be seen on mammograms

Question 9

Breast Cancer - what is Invasive Lobular Carcinoma?

Answer 9

Invasive Lobular Carcinomas (ILC)

• Invasive → vast majority are oestrogen receptor-positive
• Originate in cells from the breast lobules
• Not always visible on mammograms
• In situ → incidentally found on biopsy (often managed
  with close monitoring, 6 month checks)

Question 10

Breast Cancer - what is Paget’s Disease of the nipple?

Answer 10

Commonly associated with ductal carcinoma in situ.

• Erythematous eczema-like rash
• Unilateral
• Itchy, inflamed nipple
• Ulceration that can cause blood-stained
• *discharge**
• Burning sensation

Indicates breast cancer involving the nipple

Question 11

Breast Cancer - how often is breast cancer screening and what age is it for?

Answer 11

Mammogram

Aged 50 to 70

Every 3 years

Question 12

Breast Cancer - what are the clinical features?

Answer 12

Lumps that are hard, irregular, painless or fixed in place

Lumps may be tethered to the skin or the chest wall

Nipple retraction

Skin dimpling or oedema (peau d’orange)

Lymphadenopathy, particularly in the axilla

Question 13

Breast Cancer - what is the criteria for the two week wait referral for BC?

Answer 13

An unexplained breast lump in patients aged 30 or above

Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)

An unexplained lump in the axilla in patients aged 30 or above

Skin changes suggestive of breast cancer

Question 14

Breast Cancer - what are the different types of imaging used and on who are they used?

Answer 14

Ultrasound - younger women as they have more dense breasts, hep distinguish solid from cystic lumps

Mammograms - used in older women, better at picking up calcifications missed from US

MRI Scans

Question 15

Breast cancer - what investigations are done on the lymph nodes?

Answer 15

If a women has been diagnosed with BC, they are offered:

• US of the axilla and ultrasound-guided biopsy of any abnormal nodes
• Sentinel lymph node biopsy - used during BC surgery where initial US does not show abnormal nodes

Question 16

Breast Cancer - what are the receptors, and why are they important in management?

Answer 16

Breast cancer cells may have receptors that can be targeted with breast cancer treatments:

Oestrogen receptors (ER)

Progesterone receptors (PR)

Human epidermal growth factor (HER2)

Question 17

Breast Cancer - what is Triple-negative breast cancer?

Answer 17

Triple-negative breast cancer is where the breast cancer cells do not express any of the three receptors

Worse prognosis, as limits treatment options for targeting cancer

Question 18

Breast Cancer - where will it most likely metastasise?

Answer 18

2 Ls and 2 Bs:

• L – Lungs
• L – Liver
• B – Bones
  
  • B – Brain

Question 19

Breast Cancer - where will it most likely metastasise?

Answer 19

2 Ls and 2 Bs:

• L – Lungs
• L – Liver
• B – Bones
  
  • B – Brain

Question 20

Breast Cancer - what is the staging system called?

Answer 20

The TNM system is used to stage breast cancer

This grades the tumour (T), nodes (N) and metastasis (M)

Question 21

Breast Cancer - what are the 5 different types of management options?

Answer 21

• surgery
• radiotherapy
• hormone therapy
• biological therapy
  
  • chemotherapy

Question 22

Breast Cancer - Management, Surgery

Answer 22

Majority of patients with breast cancer diagnosed offered surgery

Prior to surgery, presence/absence of axillary lymphadenopathy determines management

Question 23

Breast Cancer - which surgical option do you choose?

Answer 23

Depending on the characteristics of the tumour women either have a wide-local excision or a mastectomy

Question 24

Breast Cancer - radiotherapy

Answer 24

Whole breast radiotherapy recommended after a woman has had a wide-local excision Reduce risk of recurrence by around two-thirds

Question 25

Breast Cancer - Hormone Treatment

Answer 25

Patients with ***oestrogen-receptor positive*** breast cancer are given treatment that disrupts the oestrogen stimulating the breast cancer. **1st line:** * ***Tamoxifen*** for ***premenopausal women*** * ***Aromatase inhibitors*** for ***postmenopausal women*** (e.g., letrozole, anastrozole or exemestane)

Question 26

Breast Cancer - how does tamoxifen work?

Answer 26

Tamoxifen is a selective oestrogen receptor modulator (SERM) It blocks oestrogen receptors in breast tissue and stimulates oestogren receptors in the uterus and bones Helps prevent osteoporosis Increases risk of endometrial cancer

Question 27

Breast Cancer - how does aromatase inhbitors work?

Answer 27

***Aromatase*** is an enzyme found in fat (adipose) tissue that converts androgens to oestrogen Aromatase inhibitors work by blocking the creation of oestrogen in fat tissue After menopause, the action of aromatase in fat tissue is the primary source of oestrogen

Question 28

Breast Cancer - what are the biological therapies that you can use if they are HER2 receptor positive?

Answer 28

HER2 Positive **Trastuzumab -** monoclonal antibody targets HER2 receptor Can affect heart function, **cannot** be used in patients with a **history of heart disorders** **Pertuzumab** is another monoclonal antibody that targets the HER2 receptor, used in combination with trastuzumab **Neratinib** is a tyrosine kinase inhibitor, reducing the growth

Question 29

Breast Cancer - what does *Neoadjuvant therapy mean?*

Answer 29

***Neoadjuvant therapy*** – intended to shrink the tumour before surgery

Question 30

Breast Cancer - what does *Adjuvant chemotherapy mean?*

Answer 30

***Adjuvant chemotherapy*** – given after surgery to reduce recurrence