Dx and Rx Flashcards
When do you start mammography in the general population? Above what age does mammography have the greatest mortality benefit? At what age do you stop doing mammography?
Start mammography at age 40 to 50 (or, as soon as a lump is found) every 2 years. The reduction in mortality is greatest above age 50. Screening can stop at age 75.
What is the best initial test when breast CA is suspected?
The best initial and most accurate test is biopsy. More specifically:
- Fine needle aspiration is the best initial biopsy. It has a low false positive rate (2%; very sensitive) but a high false negative rate (10%; not very specific).
- Open biopsy is the most accurate diagnostic test. Frozen section is done while the pt is in the operating room; immediate resection of the cancer follows.
- Core needle biopsy takes a large sample of the breast. It enables you to test for estrogen receptors, progesterone receptors, and HER2/neu. Drawbacks include greater deformity to the breast and the possibility that the needle will miss the lesion.
If a lump is found in the breast and you’re planning a FNA, what else could you do that would be most likely to benefit the pt? Why?
Despite planning the biopsy, it would still benefit the pt to have a mammogram because 5-10% of pt’s have bilateral disease. In addition, there is a huge difference in management of the pt if there is a single lesion or multiple lesions within the same breast.
When is ultrasound used in breast lesion diagnosis?
US is used for clinically indeterminant mass lesions. It tells cystic versus solid lesions. US is the answer if the lesion:
- Is painful (breast CA lesions are typically painless)
- Varies in pain or size with menstruation
How are PET scan and bone scan used in breast CA diagnosis?
PET scan and bone scan are used to detect occult metastases after breast CA is already confirmed. Bone scan can be done on its own, but PET scan usually follows CT.
PET is used specifically to determine the content of abnormal lymph nodes that are not easily accessible to biopsy, e.g. an abnormal hilar lymph node on CT. Cancer increases uptake on PET scan.
How are CT and MRI used in breast cancer diagnosis?
CT is used only after diagnosis of breast CA is confirmed to detect possible metastases.
MRI does not have a role in breast CA as of yet.
Why is BRCA testing done? What is the next step if it is positive? What is the benefit of BRCA testing? What other disease is it associated with?
BRCA is definitely associated with increased risk of breast CA. However, it is unclear what to do when BRCA testing is positive because it has not yet been proven to add mortality benefit to usual management.
BRCA is also associated with ovarian cancer.
What is a sentinel lymph node? When do you biopsy one?
The first node identified near the operative field (after injection of contrast dye) of a definitively identified breast cancer is the sentinel node.
Sentinel node biopsy is done routinely in ALL pts at the time of lumpectomy or mastectomy. A negative sentinel node eliminates the need for axial lady node dissection.
When do you test for estrogen and progesterone receptors?
ER and PR testing is routine for ALL pts with breast CA so that hormone replacement therapy can be done if either test is positive.
In terms of breast CA surgery, what is the typical protocol?
Lumpectomy with radiation is the gold standard. It is equal in efficacy to modified radical mastectomy but is much less deforming. Radiation at the site of the cancer is indispensable in preventing recurrences at the breast.
Radical mastectomy is NEVER the right choice.
Which breast CA pts receive hormonal manipulation therapy? What are the different drugs used and what are there adverse effects?
All ER or PR positive pts should receive tamoxifen, raloxifene, or an aromatase inhibitor (anastrazole, letrozole, exemestane.
Aromatase inhibitors seem to have the best efficacy, but only slightly. Their major adverse effect is osteoporosis.
Tamoxifen and raloxifene both cause menopausal Sx, e.g. hot flashes. Tamoxifen also causes clotting and endometrial cancer.
Raloxifene has the benefit of helping prevent osteoporosis.
Which breast CA pts do you test for Her2/neu? What is the drug of choice for Her2/neu positive breast CA?
All breast CAs should be tested for Her2/neu, an abnormal estrogen receptor. Those who are positive should receive trastuzumab, an anti-Her2/neu antibody medication. Trastuzumab decreases the risk of recurrent disease.
What is adjuvant chemotherapy? When is it used in pts with breast CA?
Adjuvant chemotherapy is any additional chemotherapy used after primary treatments like surgery or radiation to clean up presumed microscopic cancer cells too small to be detected.
In breast CA, adjuvant chemotherapy is used when:
- lesions are larger than 1 cm
- positive axillary lymph nodes are found
What can be done for a woman who has multiple first-degree relatives that have breast cancer?
Prophylactic therapy with tamoxifen is used in these pts to lower their risk of breast CA.
Which of the following is superior in the management of prostate cancer: prostatectomy, external beam radiation, implantable radioactive pellets, or watchful waiting?
It is unknown at this time what the best management is. Even watchful waiting is an option because most prostate CAs are asymptomatic and half of men > age 80 have prostate CA on autopsy.
