Breast Cancer: Intro & Clinical Case

Introduction to Breast Cancer

• Breast cancer is the most common cancer in women worldwide
• It is the second leading cause of cancer death in women; lung cancer is the first
• Risk factors include age, genetic predisposition (BRCA1/2), family history, hormonal factors
• Mammography plays a key role for screening of early detection

Clinical Case: Mrs. Jane Smith

• Mrs. Jane Smith is a 52-year-old female teacher
• She has a history of hypertension, which is controlled with medication
• She has no prior history of cancer and has regular mammograms
• She has no family history of breast cancer
• She is a non-smoker who occasionally consumes alcohol and is physically active
• Mrs. Smith presented to her GP with a lump in her right breast of three weeks duration
• The lump is painless and firm with no skin changes, nipple discharge, or retraction
• She reports no associated weight loss, fatigue, or other systemic symptoms
• A breast exam reveals a 2.5 cm, firm, non-tender mass in the upper outer quadrant of the right breast
• There are no skin changes, nipple retraction, or palpable axillary lymph nodes
• A cardiovascular, respiratory, and abdominal exam was unremarkable

History Taking & Examination

• It is important to identify the timeline of symptom onset
• Describe the lump in detail, including size, texture, associated symptoms and mobility
• Relevant negatives should be noted, such as the absence of nipple discharge or systemic symptoms
• Note any new asymmetry between breasts
• Axillary lymphadenopathy, which may suggest metastasis or infection
• Changes in breast contour or size, which might indicate underlying pathology

Risk Factors for Breast Cancer

• Non-modifiable risk factors: age, gender, family history, BRCA1/BRCA2 gene mutations
• Modifiable risk factors: hormone replacement therapy, alcohol consumption, obesity, physical inactivity
• Protective factors: early childbirth, breastfeeding, physical activity

Signs and Symptoms of Breast Disease

• Breast lumps can be painless, hard, and immobile if malignant
• Breast lumps can be soft and movable if benign (cysts, fibroadenomas)
• Breast pain, or mastalgia, can be cyclical, related to the menstrual cycle, or non-cyclical
• Nipple discharge can be serous or bloody, indicating an intraductal papilloma or carcinoma
• Nipple discharge that is milky can indicate galactorrhea, which is typically benign
• Nipple discharge that is purulent, indicates infection or abscess
• New onset nipple retraction/inversion may be indicative of underlying malignancy
• Skin changes that indicate underlying malignancy may include dimpling or puckering (peau d’orange)
• Erythema and swelling can indicate inflammatory breast cancer or infection
• Ulceration can be a late sign of advanced breast cancer
• Other systemic symptoms include weight loss and fatigue
• Fever is associated with infection, such as mastitis or an abscess

Differential Diagnosis of Benign Conditions

• Fibroadenoma: characterized as a firm, movable, well-defined lump, and common in young women (20s-30s)
• Breast cysts: Fluid-filled, smooth, tender, and mostly found in women 30s-50s
• Fat necrosis: Firm, irregular, often due to trauma, and can occur at any age
• Intraductal papilloma: small lump in the duct, may cause discharge, and affects women 35-55 years old

Differential Diagnosis of Malignant Conditions

• Invasive ductal carcinoma (IDC): presents as a hard, irregular, immobile mass, and is common in postmenopausal women
• Invasive lobular carcinoma (ILC): presents as a thickening or fullness that is less distinct, and is common in postmenopausal women
• Ductal carcinoma in situ (DCIS): often non-palpable, found on mammogram, and common in postmenopausal women
• Inflammatory breast cancer: presents as a red, swollen breast with skin changes (peau d'orange), and is aggressive irrespective of age.

Investigations

• Imaging types: mammography, ultrasound, MRI
• Biopsy techniques: fine-needle aspiration (FNA), core needle biopsy, excisional biopsy
• Histological subtypes include invasive ductal carcinoma, invasive lobular carcinoma
• Hormone receptor status and HER2 testing are important

Triple Assessment

• Triple assessment involved a clinical exam, imaging and pathology asessment
• Imaging studies include USS (ultrasound) and mammography
• Pathology is assessed with FNA (fine needle aspiration) and corecut biopsies
• This leads to a confident diagnosis in 99.9% of cases

Principles of Treating Benign Breast Disease

• Observation is indicated for small, asymptomatic, or stable lumps, and involves regular follow-up and monitoring/self-breast examination
• Surgical intervention is indicated for large, symptomatic lumps or patient preference, and involves surgical excision for diagnosis or symptom relief, with monitoring for any recurrence
• Individualisation of care: consider patient age, health status, and personal preferences, and monitor for new or recurring symptoms
• Management goals: Alleviate any discomfort or anxiety. Educate on factors that may influence breast health

Mrs. Smith's Mammogram, Ultrasound, and Biopsy

• Mammogram: a 2.5 cm spiculated mass in the right breast with microcalcifications
• Ultrasound: a solid mass with irregular borders
• Biopsy: invasive ductal carcinoma, ER/PR positive, HER2 negative

Staging Investigations

• MRI of the breast: used to evaluate the extent of the disease
• Chest X-ray/CT scan: used to rule out metastasis
• Bone scan: used to rule out metastasis

MDT Approach to Management

• The TNM staging system assesses tumour size (T), lymph node involvement (N), and metastasis (M)
• Staging investigations involve PET-CT, bone scan, and liver function tests
• Survival rates are based on stage at diagnosis

Subtypes of Breast Cancer

• Hormone receptor-positive (ER/PR+), HER2-positive, Triple-negative

Implications of Subtypes

• Differences in prognosis, treatment options, and recurrence rates
• Emerging biomarkers are utilized, such as gene expression profiling (e.g., Oncotype DX)

Treatment Modalities

• Surgery may involve lumpectomy vs. mastectomy, or sentinel lymph node biopsy vs. axillary dissection
• Radiation therapy is indicated post-surgery and includes whole-breast irradiation or partial-breast irradiation
• Systemic therapies include chemotherapy, endocrine therapy, targeted therapy

Surgical Management

• In Breast-conserving surgery (lumpectomy), only the cancer and some surrounding tissue is removed
• Mastectomy (simple, modified radical, skin-sparing): removes the entire breast. Skin-sparing mastectomy preserves the skin envelope of the breast for reconstruction
• Reconstruction options: immediate vs. delayed reconstruction, or autologous tissue vs. implant-based reconstruction

Radiation Therapy

• Post-lumpectomy, for locally advanced disease, palliative care
• Techniques: external beam radiation therapy (EBRT), brachytherapy
• Side effects: skin changes, fatigue, lymphedema, cardiac toxicity

Chemotherapy

• Indications: Adjuvant, neoadjuvant, metastatic disease
• Common regimens: AC-T (Adriamycin, Cyclophosphamide, Taxol), CMF (Cyclophosphamide, Methotrexate, Fluorouracil).
• Complications of chemotherapy include nausea, hair loss, immunosuppression and sepsis
• Tumor lysis syndrome, coagulopathy, anemia and cardiotoxicity

Hormonal Therapy

• ER/PR-positive tumours
• Agents: Tamoxifen, aromatase inhibitors (Anastrozole, Letrozole)
• Duration of therapy: Typically 5-10 years
• Side effects: include hot flashes, bone density loss, thromboembolic events

Targeted Therapy

• HER2-Positive Breast Cancer agents: Trastuzumab (Herceptin), Pertuzumab, T-DM1
• PARP Inhibitors are used for BRCA-mutated cancers
• Other Emerging Targets include CDK4/6 inhibitors, PI3K inhibitors

Clinical Case Continued: Mrs. Smith

• Multidisciplinary discussion involved surgical options and neoadjuvant chemotherapy
• Patients should understand options include lumpectomy vs mastectomy with sentinel lymph node biopsy
• Neoadjuvant Chemotherapy: Considered given the tumour size, to downstage the tumour before surgery via endocrine therapy
• Discussed as an option after surgery due to ER/PR positivity
• Radiation Therapy: Likely required post-lumpectomy
• Mrs. Smith opted for a lumpectomy followed by radiation

Mrs. Smith, Post-Op

• Intraoperative Course: The surgery proceeds as planned and is uneventful
• Sentinel lymph node biopsy shows a successful removal of the mass
• Postoperative Day 3: Mrs. Smith develops increased swelling and redness around the surgical site
• Fever of 38.5°C, and the surgical drain is draining a small amount of cloudy fluid

Surgical Site Infection

• Start broad-spectrum antibiotics covering skin flora (e.g., Flucloxacillin or Vancomycin if MRSA is suspected)
• Wound Care: Regular dressing changes and monitoring of the wound site
• Drain Management: Assess for drain patency; consider aspiration or surgical drainage if there is an abscess formation
• Blood Cultures: To rule out sepsis if there are systemic signs
• Ultrasound of the Breast to evaluate for abscess
• Wound Culture to send a sample for culture to guide treatment

Treatment Plan Adjustments

• Surgically debride an abscess is confirmed
• Review her chemotherapy timeline to delay the infection
• Adjust her postoperative pain management

Patient Education

• Instruct patients to watch for worsening infection
• Remind patients in the importance of completing her antibiotic course correctly
• Discuss the potential impact cancer treatment plans

Clinical Case Continued: Mrs. Smith Follow-Up

• Close monitoring in the postoperative period with frequent wound checks.
• Reassess her chemotherapy once the infection is controlled.
• Schedule a multidisciplinary team meeting to discuss further treatment options in light of the infection and its management.
• General Post-Op Follow-Up includes surveillance for recurrence of clinical exams, imaging, and tumour, and to improve long-term bone health, cardiovascular health, psychosocial support
• Lifestyle Modifications in post op care includes: Diet, exercise, smoking cessation must be adhered to
• Good Technique and Education should be emphasized

Patient Education and Advocacy

• It is important to be aware on the importance of early detection and understanding treatment options
• Patients should engage in self-checking with good technique and education for early detection
• Roles of Advocacy groups: Support, education, funding research
• Shared Decision-Making promotes empowering patients to be active in their care

Communication Task

• Scenario: You are discussing the treatment plan for a 60-year-old woman with ER-positive breast cancer post-lumpectomy
• She is about to start adjuvant therapy where the options include Tamoxifen and an Aromatase Inhibitor
• The menopause inhibits aromatase
• Aromatase inhibitors are less effective in premenopausal, side effects and patient preference

PSA Task

• A 40-year-old female patient with ER-positive breast cancer is being considered for adjuvant therapy following a lumpectomy
• Tamoxifen's Mechanism is an oestrogen receptor modulator
• It works by binding to oestrogen receptors on breast cancer cells, blocking oestrogen from binding to these receptors
• This inhibits the growth of oestrogen-dependent tumours
• Side effects of Tamoxifen include: Hot Flashes, Vaginal Dryness, or Discharge and Mood Changes
• As potential risks include: Endometrial Cancer, Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) and Osteoporosis