Breast Cancer GP PDF

Chapter 19 663 Breast disease Breast symptoms 664 Benign breast disease 668 Breast cancer screening 670 Risk factors for breast cancer 672 Breast cancer: diagnosis and care 674 0 7 6 670 CHAPTER 19 Breast disease Breast cancer screening...

Chapter 19 663 Breast disease Breast symptoms 664 Benign breast disease 668 Breast cancer screening 670 Risk factors for breast cancer 672 Breast cancer: diagnosis and care 674 0 7 6 670 CHAPTER 19 Breast disease Breast cancer screening In the UK there has been a national screening programme for breast cancer since 1988. The aim of the programme is to detect breast cancer at an early stage in order to i survival chances (stage I tumours—5y survival 84%; stage IV tumours—5y survival 18%). Breast awareness Trials of self-examination have not d mortality. Instead less formal ‘Breast Awareness’ is advocated—E p. 662. Screening test Low-risk women >47y 2-view mammographic screening is currently avail- able to women aged 50–70y throughout the UK (in some areas age 47–73y as part of an evaluation trial). Older women can also request screening every 3y via their local breast screening unit. Screening detects 85% of can- cers in women aged >50y (60% of which are impalpable) and 770–80% screening-detected cancers have good prognosis. Organization of breast cancer screening in the UK—Figure 19.2. High-risk women Women with family history of breast cancer may be at i risk of breast cancer themselves (Figure 19.3, E p. 673) and benefit from early/more frequent screening with either mammography or MRI—Table 19.2. Figure 19.2 Organization of breast cancer screening in the UK  BREAST CANCER SCREENING 671 Table 19.2 UK screening strategy for women at high risk of breast cancer Risk group Screening test 3-yearly Annual Annual MRI mammography mammography TP53 mutation 20–49y; consider if 50–69y BRCA1/2 mutation ≥70y 40–69y if not having 30–49y MRI screening High risk—lifetime ≥60y 40–59y if not having 20–49y if >30% risk of >30% MRI screening; chance of TP53 consider if 30–39y mutation; 30–49y and not having other if >30% chance of screening BRCA1/2 mutation Medium risk—lifetime ≥50y 40–49y; consider if risk of 17–30% 50–59y Interval cancers Cancer occurring in the interval between screens. Can occur through failure to detect a cancer at screening or as a result of a new event after screening took place. In the 1st year after screening, 20% of breast cancers are interval cancers. This i to ~60% in the 3rd year. Acceptability of screening See Table 19.3. ~81% women find mam- mography uncomfortable but 90% return for subsequent screens. Table 19.3 Pros and cons of breast cancer screening Benefits Adverse effects Earlier diagnosis Discomfort and inconvenience of screening Improved prognosis and Radiation risks of screening lower mortality False reassurance if false −ve results Less radical and invasive False reassurance if subsequent development of an treatment needed interval cancer; possibly later presentation Reassurance for those with Anxiety and adverse effects of further investigation −ve results for those with false +ves Overdiagnosis of minor abnormalities that would never develop into breast cancer Earlier knowledge of disease and over-treatment for those for whom prognosis is unchanged Further information NHS Breast screening: programme overview. M www.gov.uk/guidance/ breast-screening-programme-overview NICE (2013, updated 2017) Familial breast cancer. M www.nice.org.uk/ guidance/cg164 2 7 6 672 CHAPTER 19 Breast disease Risk factors for breast cancer Breast cancer is now the most common cancer in the UK with ~55,200 new diagnoses every year (including ~390 new cases/y affecting men). Women have a 1 in 8 lifetime risk of developing breast cancer. Virtually all breast cancers are adenocarcinoma (85% ductal; 15% lobular). Breast cancer screening E p. 670 Risk factors Geography More common in the developed world—migrants assume the risk of the host country within 2 generations. Personal characteristics Age i with age—~80% of breast cancers occur in women >50y Socioeconomic Higher incidence in more affluent social classes Lifestyle factors Obesity i risk post menopause Physical activity 30% d risk if taking regular physical activity High-fat diet Probably associated with i risk Alcohol i risk by 7%/unit consumed/d Reproductive history Early menarche or late menopause i risk Pregnancy i parity results in d risk (32% d risk in women reporting 3 births compared to women reporting 1); late age when first child is born and nulliparity i risk Breastfeeding d relative risk by 4.3% for each year of breastfeeding Combined hormonal contraception Slight i risk (relative risk 1.24 for current users)—excess risk disappears within 10y of stopping Combined HRT  Small i risk if >51y and taking combined HRT (1 extra case/1000 women taking combined HRT/year) but no i in breast cancer mortality. Excess risk disappears on stopping. Combined HRT i breast density and the risk of having an abnormal mammogram. Oestrogen-only HRT does not i breast cancer risk Other past medical history Past history of breast disease Ductal or lobular carcinoma in situ, florid hyperplasia, and papilloma with fibrovascular core all i risk Ionizing radiation Exposure i risk Family history Referral algorithm for people with family but no personal his- tory of breast cancer—Figure 19.3. Offer support (e.g. risk management advice, psychological counselling) for women with FH of breast cancer who are not eligible for referral and/or surveillance on the basis of age/risk level, but have ongoing concernsN. Further information NICE (2013, updated 2017) Familial breast cancer. M www.nice.org.uk/ guidance/cg164  RISK FACTORS FOR BREAST CANCER 673 Figure 19.3 Referral of women with a family history of breast cancerN 4 7 6 674 CHAPTER 19 Breast disease Breast cancer: diagnosis and care Breast cancer screening E p. 670 Prevention Consider referral to secondary/tertiary care if family history of breast cancer (E p. 673) Lifestyle measures—d alcohol intake; d weight; i exercise; avoid exogenous sex hormones (e.g. HRT); breastfeed Chemoprophylaxis—tamoxifen d risk of breast cancer by 40% in high- risk women but use is limited by side effects (thromboembolism and endometrial carcinoma)—other drug trials are in progress Prophylactic surgery—d risk by 90% in very high-risk women Presentation Most common site is upper-outer quadrant of the breast. Often found at breast screening (E p. 670). Clinical presentations: Breast lump (90%) Breast pain (21% present with painful lump; pain alone