Breast Cancer

Many breast conditions can present with a lump, which can be malignant or benign. When this happens, the standard procedure is to conduct a triple assessment, which involves three types of tests:

i) Clinical examination – should involve a chaperone (not a family member)

ii) Radiology – Ultrasound for <35years; mammography and ultrasound for >35 years old

iii) Histology – Fine needle aspiration (FNA) or core biopsy for new lumps

Risk Factors

The risk factors are related to oestrogen exposure as well as to specific genes:

– Age (most breast cancers occur in women >50yrs)

– Early menarche/lase menopause

– Obesity

– Not breastfeeding

– Combined oral contraceptive pill/combined HRT

– First degree relative with breast cancer

– BRCA1 and 2 gene mutations

–  Li-Fraumeni syndrome

Types of Breast Cancer

i) Ductal carcinoma in situ (DCIS)

This is due to a proliferation of duct cells with no invasion of the basement membrane

ii) Invasive ductal carcinoma

This is a malignant proliferation of ductal cells

– This is the most common invasive carcinoma in the breast, called non-special type with tumour marker CA 15-3- Tends to occur in older women (70 years) with a better prognosis

iii) Lobular carcinoma in situ

This is a proliferation of cells in lobules with no invasion of the basement membrane

– This does not produce a mass or calcification and is discovered incidentally

iv) Invasive lobular carcinoma

This is a a malignant proliferation of lobule cells associated with e-cadherin mutations

v) Hereditary breast cancer

This is associated with BRCA1 and BRCA2 mutations which are autosomal dominant

– This gives 40% lifetime risk of breast + ovarian cancer (BRCA2 also gives prostate cancer in men) so women undergo bilateral mastectomy to reduce risk of getting cancer

vi) Inflammatory breast cancer

Here, cancer cells block lymph drainage giving inflamed “orange-peel” breast appearance

vii) Paget disease of the breast

This is an eczematous change of the nipple associated with breast cancer

– It presents as nipple ulceration and erythema (looking like eczema) that can give bloody discharge

Diagnosis and Management

Breast cancers can be diagnosed both via the screening program (used to detect asymptomatic cases) as well as in patients who present with a breast lump. 

Screening:

Women aged 43-73 are offered a mammogram every 3 years to screen for breast cancer

Investigation:

All lumps undergo triple assessment

Management:

This usually involves curative surgery with neoadjuvant and adjuvant chemoradiotherapy

i) Surgery:  

This is the definitive curative treatment which is given to most women with breast cancer. The two most common types of surgery are:

– Wide local excision (a.k.a. ‘lumpectomy) = removal of the cancer + a margin of normal breast tissue

– Mastectomy = removal of the entire breast

Decision is based on size, location and number of cancerous lesions as well as patient preference

– All women who have wide local excision are offered radiotherapy to reduce recurrence risk

ii) Medical therapy:

This includes chemotherapy, hormone therapy and biological therapy

– It is used before surgery to reduce the size of the cancer –> this is called neoadjuvant therapy

– It can also be used after surgery to reduce the risk of recurrence –> this is called adjuvant therapy

To determine which drug treatment will be most effective, breast cancers are tested for the presence of oestrogen receptors (ER), progesterone receptors (PR) and human epidermal growth receptors (HER2).