Breast Disease

Question 1

Why is a holistic approach when investigating breast cancer important?

Answer 1

Breast cancer is a scary diagnosis, you want the patient to feel involved, cared for mentally and physically

Question 2

Which model do patients diagnosed with breast cancer often go through?

Answer 2

Kugler-Ross model of stages of grief - denial, anger, bargaining, acceptance

Question 3

What is the UK Breast Screening programme - who is the target population? How effective is it? What are the challenges of it?

Answer 3

Mammographic screening - X-ray

Women aged 47-73 years, every 3 years

Allows for earlier detection and better prognosis, saves 1 life from breast cancer for every 200 women screened

Lead time and length time bias, creates anxiety, can get false negatives

Question 4

What are the common clinical presentations of breast cancer?

Answer 4

• Lump - fixed, irregular, hard
• Nipple discharge
• Nipple retraction - bloody, unilateral
• Peau d’orange - skin dimpling
• Usually painless

Question 5

How is a diagnosis of breast cancer made?

Answer 5

Triple approach 
* Clinical - history, family history, examination
referral
* Radiographic imaging - mammogram, USS
* Pathology - core biopsy, FNAC

Question 6

What are the two key histological types of breast cancers?

Answer 6

Adenocarcinoma - ductal or lobule

Stromal

Question 7

What is the tumour grading system for breast cancer?

Answer 7

Grading - Bloom-Richardson

Staging - TNM

Question 8

What is DCIS (ductal carcinoma in situ)?

Answer 8

Neoplastic cells limited to ducts by the basement membrane

Presents as mammography calcifications or as a mass, histologically shows central necrosis with calcification

Could become metastatic, but can also spread throughout the ducts quite extensively

Question 9

Which metastatic sites are involved in breast cancer?

Answer 9

• axillary lymph nodes
• distant via blood vessels - bones, lungs, liver and brain
• invasive lobular carcinoma can spread to odd sites - peritoneum, retroperitoneum, leptomeninges, GI tract, ovaries and uterus

Question 10

Which gene can be seen in breast cancer that makes it genetically susceptible?

Answer 10

BRCA1/BRCA2 gene mutations

Question 11

What are the key therapeutic approaches to breast cancer treatment?

Answer 11

• Breast surgery - mastectomy, breast conserving surgery
• Axillary surgery
• Post-op radiotherapy
• Hormonal treatment - tamoxifen if ER+
• Herceptin if Her2+
• Chemotherapy

Question 12

What are the main risk factors for breast cancer?

Answer 12

• Early menarche
• Late menopause
• Nullparity
• BRCA1/2 gene mutation
• Female
• Obesity
• Breast density
• COCP
• Radiation e.g. treatment for cancer as a child
• Previous breast cancer
• Atypical changes/previous biopsy

Question 13

What are the common clinical presentations of benign breast disease?

Answer 13

• Movable, smooth lump
• Painful
• Nipple discharge - bilateral, green/yellow
• Nodularity

Question 14

What is a fibroadenoma?

Answer 14

Most common benign tumour
Occur at any age, but often under 30

Present as firm, non-tender, mobile (breast mouse) lump

Hormone aetiology

Question 15

Which benign conditions cause nipple discharge?

Answer 15

• Duct ectasia

* Mastitis

Question 16

What are the referral criteria for women with breast symptoms?

Answer 16

Urgent (within 2 weeks)

• 30 years or older and unexplained breast lump with or without pain or lump in axilla
• 50 years or older with discharge, retraction, other concerning changes in one nipple only
• skin changes suggesting cancer

Non-urgent
* under 30 with unexplained lump with or without pain