Medically Fit For Exams
Medically Fit For Exams

Breast Cancer

Definition

  • Malignant neoplastic growth of breast tissue
    • Ductal
    • Lobar
    • Connective

 

Risk factors

  • High (unopposed) oestrogen
    • Early onset menarche
    • Late menopause
    • Fewer/later children, no breastfeeding
    • COC
    • HRT
    • Endogenous hormone levels (oestrogen dominance)
  • Age
  • High alcohol intake
  • ?Smoking
  • Family history
  • BRCA1/2

 

Differential diagnosis

  • Cyst
  • Benign hyperplasia
  • Fat necrosis
  • Mastitis

 

Epidemiology

  • Is the most common cancer
  • 99% of cases are in women
  • Lifetime risk about 1 in 11
  • More common in Caucasian than Black or Asian women

 

Aetiology

  • DNA damage/mutations/inherited defects
    • Tumour suppressor genes (need double hit)
      • p53
    • (Proto)oncogenes (only need single hit)
  • Unregulated growth
  • Further mutations lead to invasion and metastasis

 

Clinical features

  • Specific breast cancer features
    • Discrete, non-motile lump
    • Skin pitting
    • Peau d’orange
    • Nipple discharge
    • Nipple inversion
    • Lymphadenopathy (axillary)
    • Paget’s disease – eczema like rash over nipple, more common in elderly
    • Pain is generally not indicative of BC, although may be present in addition to other features
  • General cancer features
    • Anorexia
    • Weight loss/cachexia
    • Tiredness/fatigue

 

Pathophysiology

  • 6 steps of cancer
    • Can stimulate their own growth
    • Insensitivity to anti-growth signals
    • Evade apoptosis
    • Can multiply indefinitely
    • Can stimulate growth of blood vessels (angiogenesis)
    • Can invade and spread
  • Enlarged cells (benign and malignant neoplasms)
    • Enlarged nuclei & nucleoli
    • Increased nuclear-cytoplasmic ratio
    • Hyperchromasia – darkened and abnormal pattern
    • Irregular nuclei

 

Investigations

  • Screening
    • Mammograms offered every three years age 43-73
    • Genetic screening for those at high risk
  • Triple test
    • Examination/clinical
    • Imaging
      • Ultrasound
      • Xray/mammogram
    • Biopsy

 

 

Management

  • Depends on stage of cancer – stage 4 is likely to be palliative
  • Depends on type of tumour – eg HER2+
  • Surgery
    • Mastectomy is common, lumpectomy also offered in low stage cancer
    • For early stage cancer, breast-conserving surgery + radiotherapy has equal outcomes to mastectomy
    • Lymph node surgery – biopsy sentinel node first
  • Chemotherapy
    • Targets dividing cells
    • Adjuvant – after surgery
    • Neo-adjuvant – shrinks tumour before surgery
    • Palliative – usually only for stage 4, may decrease tumour size and lengthen life/improve symtpoms
  • Radiotherapy
    • Usually adjuvant after surgery
    • Can target breast tissue, chest wall or lymph nodes depending on tumour
  • Hormone therapy
    • Oestrogen receptor positive (ER+) cancers use oestrogen signals to help them grow, blocking oestrogen can slow/prevent growth
    • Tamoxifen for pre-menopausal women (prevents binding of oestrogen to oestrogen receptors on cancer cells)
    • Aromatase-inhibitors for post-menopausal women (stops production of oestrogen by aromatase)
  • Immunotherapy
    • Cancers that are HER2+ (human epidermal growth factor receptor 2)
    • Antibodies against HER2 can prevent signalling to cancer cells
    • Antibodies may mediate antibody mediated cytotoxicity
    • Eg Herceptin

 

Prognosis

  • About 85% 5-year survival
  • This is slightly higher in middle age, and lower over the age of 70
  • Depends on stage at diagnosis
    • Stage 1 – about 97%
    • Stage 2 – about 85%
    • Stage 3 – about 55%
    • Stage 4 – about 15%
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