What are the risk factors for breast cancer?
Age Previous breast cancer Genetic Early menarche and late menopause Late or no pregnancy HRT Alcohol Weight Post radiotherapy treatment for Hodgkin's
What are the genes most associated with breast cancer?
BRCA 1 and 2
How do assymptomatic breast cancers usually present?
Breast screening (50-70yrs)
What are the symptoms of breast cancer?
Lump Mastalgia Nipple discharge (blood) Nipple changes Change in size or shape of breast Lymphoedema (swelling of arm) Dimpling of breast skin
What are some of the nipple changes that can occur in breast cancer?
Paget’s disease
Retraction
What is Paget’s disease of the nipple?
Red, scaly rash on skin of nipple and areola
Sore and inflammed
Ulceration
Itchiness, bleeding
What are the stages that occur in a new patient clinic for breast cancer?
- Clinical: history and exam
- Radiological: mammograms/US
- Cyto-pathological: FNA, core biopsy
What is the difference between FNA and core biopsy investigations for breast cancer?
FNA - cells only -> cytology
Core biopsy - tissue -> histo-pathology
What should you ask about that is different in a history for breast cancer?
Previous breast problems
Hormonal status
What are signs/symptoms of breast cancer on examination?
Lump or thickening in breast - often painless Discharge or bleeding Change in size or contours of breast Change in colour or appearance of areola Redness or pitting of skin over breast
What are the imaging techniques used for the breasts?
Mammography
US
MRI
What is the most sensitive imaging investigation for looking at the breasts?
Mammography
Why is the sensitivity of mammography reduced in young women?
Presence of increased glandular tissue
What are the two main groups of pathological types of breast cancer?
Invasive
Non-invasive
What are the two main types of invasive breast cancer?
Ductal carcinoma
Lobular carcinoma
What are the main types of non-invasive breast cancer?
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS)
What are the three steps (triple assessment) in management of breast cancer?
- Diagnose
- Staging
- Treatment
What are the investigations done to try and stage breast cancer?
FBC, U&Es, LFTs, Ca2+/PO2-
CXR
Others as clinically indicated
What are the tumour markers for breast cancer?
No reliable tumour markers
What staging system is used for breast cancer?
TMN
What does a T4 breast cancer stage automatically mean?
Involves other structures
What is T0 stage in breast cancer?
Primary tumour not palpable
*What is T1 stage in breast cancer?
Clinically palpable tumour <2cm
What is T2 stage in breast cancer?
Tumour size 2-5cm
*What is T3 stage in breast cancer?
Tumour size >5cm
What is N0 stage in breast cancer?
No regional lymph nodes palpable
What is N1 stage in breast cancer?
Regional lymph nodes palpable and mobile
What is N2 stage in breast cancer?
Regional lymph node palpable and fixed
What is Mx stage in breast cancer?
Distant metastasis cannot be assessed
What is M0 stage in breast cancer?
No distant metastasis
What is M1 stage in breast cancer?
Distant metastasis
What is the management for breast cancer?
Surgery
+/- radiotherapy/chemotherapy/hormonal therapy
What are the two main types of surgical procedure for breast cancer?
Breast conservation surgery
Mastectomy
Which patients are suitable for breast conservation surgery?
Depends on breast/tumour size ratio
Suitability for radiotherapy
Patient’s wishes
What is a sentinel lymph node?
First node to receive lymphatic drainage and so first node tumour spreads to
What is a sentinel lymph node (SLN) biopsy?
Biopsy first node tumour has spread to
What does it mean if a sentinel lymph node (SLN) biopsy is negative?
Rest of nodes in lymphatic basin are negative
When is a sentinel lymph node (SLN) biopsy performed?
When preoperative axillary USS normal/benign
What is the treatment for the axilla if the SLN is negative?
No further treatment required
What is the treatment for the axilla if the SLN contains tumour?
Remove them all surgically
OR
Give radiotherapy to all the axillary nodes
What are the complications of axillary treatment in breast cancer?
Lymphoedema Sensory disturbance Decrease ROM shoulder joint Nerve damage Vascular damage Radiation-induced sarcoma
What nerves can be damaged during axillary treatment for breast cancer?
Long thoracic
Thoracodorsal
Brachial plexus
What factors are associated within increased risk of disease recurrence in breast cancer?
Lymph node involvement Tumour grade Tumour size Steroid receptor status HER2 status LVI - lymphovascular invasion
What is the NPI in breast cancer?
Nottingham Prognostic Index (NPI)
Determines prognosis following surgery for breast cancer
What three pathological criteria does the NPI look at in breast cancer?
Size of the tumour No of involved lymph nodes Grade of the tumour
What is the local adjuvant treatment for breast cancer?
Radiotherapy
What is the systemic adjuvant treatment for breast cancer?
Hormone therapy
Chemotherapy
Targeted therapy
Which type of surgery for breast cancer receives radiotherapy as an adjuvant treatment?
Wide local excision (WLE)
What are some complications of radiotherapy following breast cancer surgery?
Skin reaction - telangiectasis
Radiation pneumonitis
Cutaneous radionecrosis/osteonecrosis
Angiosarcoma
What type of breast cancer responds to hormone therapy?
Oestrogen receptor positive (ER+)
What does hormone therapy in oestrogen receptor positive breast cancer do?
Blocks stimulation of cell growth by oestrogen
What are two types of hormone therapy used in breast cancer?
Tamoxifen
Aromatase inhibitors
What are two examples of aromatase inhibitors used in hormone therapy?
Arimidex
Letrozole
How does tamoxifen work?
Blocks directly on ER receptor
When is tamoxifen more effect?
After chemotherapy
What are the risks of tamoxifen?
Thromboembolic events
How is tamoxifen taken?
20mg once daily 5-10yrs
Which hormone therapy should only be used in postmenopausal women?
Aromatase inhibitors
Which hormone therapy is suitable in all age groups?
Tamoxifen
How do aromatase inhibitors work?
Inhibit ER synthesis
What are the risks of using aromatase inhibitors?
Osteoporosis
How long are aromatase inhibitors usually taken for?
Once daily for 5yrs
Who does chemotherapy benefit most in breast cancer?
Young women (<50) Patients with increasing adverse prognostic factor
What are the options for chemotherapy in breast cancer?
CMF combinations
Anthracycline combinations
Taxana based combinations
What is an example of a targeted therapy for breast cancer?
Trastuzumab
What is Trastuzumab a drug against?
Monoclonal antibody against Her2 receptor
Who is Trastuzumab given to in breast cancer?
Patients with over-expression of Her2 and chemotherapy
What is Her2?
Some breast cancer cells have a higher than normal level of a protein called HER2 (human epidermal growth factor receptor 2) on their surface, which stimulates them to grow
What is the follow up for breast cancer?
Mammograms yearly intervals 3-10yrs
Clinical exam 1-5yrs
Patient exam