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51 Cards in this Set

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  • Back
What are the progresses in breast cancer a result of ?
screening mammography
chemoprevention
adjuvant systematic chemotherapy and hormonal therapy
surgical techniques
partial breat irrad
New agents
BRCA 1/2 gene mutations
biological subtypes of breast cancer
What are the new agents that are helping with breast cancer treatment?
aromastase inhibitors
monoclonal antibodies
What are the major risk factors for breast cancer?
gender
age (60s- for breast cancer)
atypcial hyperplasia/ LCIS
Personal Family History
What are other risk factors for breat cancer?
estrogen replacement therapy
OC pill
lifetime estrogen exposure
nulliparity or older age 1st childbirth (.30)
alcohol intake
high fat diet
obesity
prior radiation (10-15 yrs latency)
What are types of lifetime estrogen exposure that make one at higher risk for breast cancer?
early age of menarche (before 12)
late age of menopause (afte 54)
What is the breat cancer cell progression?
normal
atypical hyerplasia
in situ
local invasion
primary tumor
What are the cell structures at the time of non invasive carcinoma?
atypical hyperplalsia
and in situ
What are the cell structures at the time of local invasive ?
in situ
local invasion
What are the cell structures at the time of onset of metastatic dissemination?
ocal invasion
primary tumor
What are the characteristics of hereditary cancer?
multiple relatives affected
young age at diagnosis
multiple primary cancers
autosomal dominant pattern
If you have the BRCA1, what are your chances of having breast and ovarian cancer...
50-80 breast
ovarian 40-60
colon
males
prostate
colon
If you have the BRCA2, what are your chances of having breast and ovarian cancer...
breast 50-80
ovary
pancreatic
melanoma
males
breast cancer
Gene Posiitve Patient
prpphylactic mastectomy
prophylactic oophorectomy
chemoprecention
close surveillance
What aare two drugs that can lower the risk of breast cancer?
raloxifene
tamoxifen
What are the benefits of raloxifene versus tamoifen?
fewer thromboembolic events
fewer cataracts
fewer endometrial cancers
What are methods of screeening and detection?
self exam every monthly
clinical exam
mammogram and ultrasound
calcifcations, mass/density, architectural distortion
What are you looking for in a clinical exam?
lump
skin retraction or fixation
skin edema/ dimplin g
nipple discharge (often benign)
more likely carcinoma if bloody or accompaning mass
THE ACS should screening guide lines are ...
20 or older Basic Self Exam
20-39 breast exam by physicians every three years
40 or older every year
Mammography at age 40 and annually thereafter
What are the limitations of mammography
none designed to evaluate the 40-49 age group separetly
failes to detect 20% that can become palpable within 1 year
sensitivity less in denser younger breats
Digital Mammography
= film mammograms with accuracy
better accuracy in <50 yrs
increased mammographic density
pre/peri menopause
MRI
2-6 percent cancers seen only on MRI alone
sensitivity for MRI higher than mammo
specificity for MRI lower than mammo
more false +, more biopsies
promising techniques need longer follow up and survival data
What are the breast lump facts?
90% found by a woman
80% of lumps biopsied are not cancers
breast cysts
invasive cancers
Facts about breast cysts
most common breast lumps
benign
usually bilateral
feels soft
moveable
fluid filled lump, blocked duct
occurs in 35-50 years
Facts about invasive cancers
occur in one breast
are singular lumps
very firm to hard
feels uneven with irregular borders
no pain
What are the types of biopsy?
FNA
Core needle/stereotactic
excisional
microcalcifications
small microscopic CA deposits found by mammography
caused by death of tissues
normal causes- cyst, injury, mastitis, aging
potential for cancer
four to five clusteed
radiologists check closely
What is the most common breat cancer
infiltrating invasice ductal
What are the types of pathology?
in situ carcinoma
infiltratinf ductal
infiltrating lobular
specific types: tubular, medullary, papillary, mucinous
may become bulky
metastases less common
Inflammartoy carcinoma
clinicopathologic entity
diagnosed on clinical or pathologic grounds
diffuse brawny induration of skin with an erysipeoid edge, usually w/o underlying palpable mass
radiographically there may be mass with characteristic skin thickening
What are the prognostic factors?
size
nodal status
grade
estrogen adn progesterone receptor
histology
her2/neu
lymphatic/vascular invasion
Where are you especially concerned about in the lymph nodes?
auxillary presences
What does it mean if there are estrogen receptors?
- more liekly that antiestrogens will work
- less aggresive cancers
- predictive marker
What is the staging system?
stage 0- in situ
What is stage 1?
tumor < 2cm, LN negative
What is statge 2 ?
tumor >2cm with LN negative or 1-3 LN+
What is stage 3?
.4 LN + or supraclav LN, tumor inv skin, chest
What is stage 4?
Metastatic
Treatment in early stage
local therapy
systemic therapy
Local therapy
surgery +/- reconstruction +/- radiation
MRM vs LE +ALND + XRT
equivalent OS
LE+ SLN + XRT
systemic therapy
chemotherapy
hormonal therapy
biological therapies (Herceptin)
none
What are the contraindication to breast conservation? (absolute)
2 or more primary tumors in separate quadrants
diffuse malignant appearing clacs on mammo
previous breast irradiation
pregnancy
presistent positive margins
What are the contraindication to breast conservation? (relative)
collagen vascular disease
multiple gross tumor in one quadrant
indeterminant calcs
large tumor in small breast, or tumor 4-5 cm
very large pendulous breasts (XRT technically difficult, more complications)
Partial Breast Irradiation
current breast irradiation techniques
whole breast external beam
multiple catheter interstitial
3d-crt
mammosite
Rationale for PBI
up to 40% of patients who are cadidates for breast conservation therapy do not receive it -- why?
physicians boas
patient choice
more complex and porlonged treatmetn course
6 weeks daily treatment monday to friday can be inconvient or prohibitive for those with poor access to a radiation facility, the elderly or working women
systemaic therapy: adjuvant
chemo, hormonal and or biological therpaties after primary curative intent surgery
treat micrometastases already present at time of DX
w/o adjuvant rx, recurrence in approx 30% of lymph node - patients
chemo
-proportional in risk of relapse about 25-30 %
hormonal
proportional reduction in risk of relapse almost 50% for ER and or PR positive patients
tamoxifen as adjuvant therapy
EBCTCG tamoxifen meta analysis
55 randomized trials of adjunctive tamosifen versus none
37,000 women
tamosifen has saved more lives from cancer than any other single cancer drug
*** aromatase inhibitor may be even better for post menopausal women
choice of adjucant therapy
most er/pr+ pts should get hormonal therapy
addition of chemo is opt if added absolute risk reduction felt to be worthwhile
if er/pr -, chemo +/-
hercetion is only option
three breast cancer studies used to select 21 gene panel
best rt-pcr performance and most robust predictions
metastatic breast cancer
hormonal therapy
chemotherapy
site specific radiotherapy
surgery
targeted biological therapies
metastatic breast cancer
MBC is incurable but treatable
treatment is palliative
median survival is 2-3 years
wide range in survival
exhaust endocrine therapy first if possible
use tempo of disease, not response rate to guide treatment
no rush to get to chemotherapy
commonly used drugs in metastatic breast cancer
hormonal therapies for ER/PR+
herceptin for her2+
avastin
chemotherapies
anthracylines
taxanes
alkylating agents
5 FU
vinorelbine
gemcitabine
methotrexate