Who is affected by breast carcinoma?
- 1 in 8 ♀
- Rare in men (~1% of all breast cancers).
What are some of the Risk Factors for developing breast cancer?
- FMH
- Age (older)
- Uninterrupted oestrogen exposure, so nulliparity
- 1st pregnancy >30yrs old
- Early menarche
- Late menopause
- HRT
- Obesity
- BRCA genes
- Not breastfeeding
- Past breast cancer (metachronous rate ≈2%, synchronous rate ≈1%)
What types of breast cancer can you get?
- Non-invasive ductal carcinoma in situ (DCIS): premalignant; microcalcification on mammography (unifocal or widespread)
- Non-invasive lobular CIS - Rarer. Multifocal.
- Invasive ductal carcinoma - Most common (~70%)
- Lobular carcinoma: 10–15%
- Medullary cancers (~5%) - younger patients while
- Colloid/mucoid (~2%) - elderly.
- Others: papillary, tubular, adenoid-cystic and Paget’s (p[link]).
How does oestrogen receptor +ve/ HER over expression convey prognosis in breast cancer?
- Oestrogen receptor +ve: 60–70% of breast cancers - better prognosis
- HER2 over-expression: ~30% - aggressive disease / poorer prognosis
How is breast cancer investigated?
Triple assessment
- Clinical examination
- USS + Mammogram
- <35 - USS only - Breast tissue more dense
- >35 USS + Mammogram
- Histology/ Cytology: FNA, core biopsy, USS guided biopsy best for new lumps
What are USS or mammogram more accurate for picking up?
- USS: More accurate for invasive breast cancer
- Mammography: Most accurate at detecting ductal carcinoma DCIS
What do each of the stages 1-4 used for breast cancer represent?
- Stage 1: Confined to breast, mobile.
- Stage 2: Growth confined to breast, mobile, lymph nodes in ipsilateral axilla.
- Stage 3: Tumour fixed to muscle (not chest wall), ipsilateral lymph nodes matted/ fixed, skin involvement larger than tumour.
- Stage 4: Complete fixation of tumour to chest wall, distant mets.
What is the TNM staging and what does it indicate?
- T: T1<2cm, T2, 2–5cm, T3 >5cm, T4, fixity to chest wall or peau d’orange
- N1: Mobile ipsilateral nodes; N2: fixed nodes
- M1, distant metastases.
How is local disease (stages 1-2 treated)?
- Surgery: Wide local excision (WLE)/ mastectomy ± breast reconstruction + axillary node sampling/surgical clearance or sentinel node biopsy
- Radiotherapy:
- For invasive cancer after WLE.
- Axillary radiotherapy used if lymph node +ve on sampling and surgical clearance not performed
- SE: pneumonitis, pericarditis, and rib fractures.
- Chemotherapy:
- Adjuvant chemotherapy BEST.
- eg epirubicin + ‘CMF’ (cyclophosphamide + methotrexate + 5-fu).
- Neoadjuvant chemotherapy has shown no difference in survival but may facilitate breast-conserving surgery.
- Endocrine agents: ↓ oestrogen activity
- Used in ER or PR +ve disease.
- Tamoxifen - ER blocker is widely used - may rarely cause uterine cancer
- Anastrozole (Aromatase inhibitors) - Post-menopausal only. SE: osteoporosis
- Pre-menopausal + ER+ve tumour: ovarian ablation (via surgery or radiotherapy) OR gnrh analogues (eg goserelin) ↓ recurrence and ↑ survival.
What is a Sentinel Node Biopsy?
- Reduces needless axillary clearances in lymph node −ve pt
- Performed if pre-operative axillary ultrasound is positive
- Patent blue dye and/or radiocolloid injected into periareolar area or tumour.
- The nodes are identified by injecting a blue dye with associated radioisotope into the peri-areolar skin; radioactivity detection and / or visual assessment (as the nodes become blue) can then identify the sentinel nodes, which can be removed and sent for histological analysis.
- Sentinel node identified in 90%
- Offer to:
- To all people who are having a mastectomy for DCIS
- Those w/ invasive breast cancer
How is distant disease treated in breast cancer (stage 3-4) ?
- Long-term survival is possible and median survival is >2yrs
- Staging investigations: CXR, bone scan, liver USS, CT/MRI or PET-CT, + LFTs and Ca2+.
- Radiotherapy to painful bony lesions: bisphosphonates, ↓ pain and fracture risk.
- Neoadjuvant Chemotherapy: if relapse after initial success.
- Hormonal therapy
- Trastuzumab (Herceptin): for HER2 +ve tumours + chemotherapy.
- Tamoxifen: ER+ve;
- Anastrozole: post menopausal
- CNS surgery for solitary (or easily accessible) metastases may be possible; if not—radiotherapy
How are deaths prevented with breast cancer?
- Promote awareness.
- In the UK, the NHS breast cancer screening programme currently invites women aged 50-70yrs to have a mammogram every three years; any abnormalities identified will be referred to breast clinic for triple assessment.
What prognostic factors affect breast cancer?
- Tumour size, grade
- Lymph node status
- ER/PR status
- Presence of vascular invasion all help assess prognosis.
- Nottingham Prognostic Index (NPI) is widely used to predict survival and risk of relapse
What are the different types of benign breast disease?
- Fibroadenoma
- Breast cysts
- Infective mastitis/breast abscesses
- Duct ectasia
- Fat necrosis
What is a fibroadenoma and who does it affect?
- Usually <30yrs but can occur up to menopause
- Benign overgrowth of collagenous mesenchyme of one breast lobule
- Firm, smooth, mobile lump, the ‘breast mouse’. Painless.
- May be multiple.
- ⅓ regress, ⅓ stay the same, ⅓ get bigger.
- Treatment: observation and reassurance, but if in doubt refer for USS (usually conclusive) ± FNA.
- Surgical excision if large.
Who most commonly gets breast cysts?
- >35yrs, esp. perimenopausal
- Benign, fluid-filled rounded lump
- Not fixed to surrounding tissue. Occasionally painful.
- Treatment: diagnosis on aspiration (perform only if trained).
What is Infective mastitis/breast abscesses?
- Infection of mammary duct often associated with lactation (usually Staph. aureus)
- Abscess presents as painful, hot swelling of breast segment.
- Abx (flucloxacillin): Open incision or percutaneous drainage if abscess.
What is Duct ectasia?
- Menopause usually
- Ducts become blocked and secretions stagnate.
- Nipple discharge (green/brown/bloody) ± nipple retraction ± lump.
- Refer for confirmation of diagnosis. Advise to stop smoking.
What is Fat necrosis?
- Fibrosis and calcification after injury to breast tissue
- Scarring results in a firm lump
- Refer for triple assessment
What prognostic index is used for Breast Cancer?
The Nottingham Prognostic Index (NPI)* is a widely used clinicopathological staging system for primary breast cancer prognosis. It is calculated by:
(Size x 0.2) + Nodal Status + Grade
Size is the diameter of the lesion in cm, nodal status is number of axillary lymph nodes involved (0 nodes=1, 1-4 nodes=2, >4 nodes=3), and grade is based on Bloom-Richardson classification
When should women with a breast lump be referred under the 2WW?
Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if they are:
Aged 30 and over and have an unexplained breast lump with or without pain
