P03.004 Breast cancer

Breast cancer is the most common malignancy affecting women globally. Understanding its presentation, diagnosis, and management is crucial for the PLAB exam and future clinical practice.

Epidemiology:

• Most common cancer in females.
• Lifetime risk in the UK: 1 in 8 women.
• Increasing incidence with age, but rising concerns about younger women diagnosed.
• Risk factors include:
  • Age (increasing risk)
  • Family history (stronger risk with first-degree relatives)
  • Genetic predisposition (mutations in BRCA1 and BRCA2 genes)
  • Hormonal factors (early menarche, late menopause, lifetime exposure to estrogen)
  • Lifestyle factors (obesity, alcohol consumption, lack of physical activity)

Clinical Presentation:

• Breast lump (most common)
• Skin changes (dimpling, redness, thickening)
• Nipple changes (retraction, inversion, discharge)
• Axillary lymphadenopathy (enlarged lymph nodes in the armpit)
• Less common: bone pain, weight changes

Diagnosis:

• History and Physical Examination: A thorough history focusing on risk factors and a detailed breast examination are essential.
• Triple Assessment: This standard approach combines:
  • Mammography: X-ray imaging of the breast to detect abnormalities.
  • Ultrasound: Used to differentiate cysts (fluid-filled sacs) from solid masses.
  • Core biopsy or fine-needle aspiration: Tissue sampling for definitive diagnosis.
• Further Investigations: Depending on the case, additional investigations may be needed like:
  • MRI scan: Provides detailed anatomical information for complex cases.
  • PET scan: This may be used for staging advanced disease.

Management:

Breast cancer management is multidisciplinary, involving surgeons, oncologists, radiologists, and other specialists. Treatment plans are tailored to the individual based on:

• Stage of cancer (extent of spread)
• Tumor characteristics (receptor status – ER, PR, HER2)
• Patient’s overall health and preferences

Main Treatment Modalities:

• Surgery:
  • Lumpectomy (removal of the tumor only) with clear margins.
  • Mastectomy (removal of the entire breast) may be necessary depending on the stage and patient preference.
  • Axillary lymph node surgery is often performed to assess lymph node involvement.
• Adjuvant Therapy: Additional treatment after surgery to reduce the risk of recurrence. Options include:
  • Endocrine therapy (hormone therapy): For hormone-receptor-positive tumors to block estrogen signaling.
  • Chemotherapy: May be used depending on tumor characteristics and stage.
  • Radiotherapy: Targeted radiation to the breast or chest wall to destroy residual cancer cells.
• Targeted Therapy: Drugs targeting specific HER2-positive tumors may be used.

Points to Remember for PLAB:

• Early diagnosis and prompt treatment are crucial for improving survival rates.
• A thorough history, physical examination, and triple assessment are essential for diagnosis.
• Management is multidisciplinary and tailored to the individual.
• Be familiar with different surgical options and adjuvant therapy choices.
• Understand the role of hormone receptor status in guiding treatment decisions.

Additional Resources:

• National Institute for Health and Care Excellence (NICE) guidelines on breast cancer: [Insert hyperlink to NICE guidance when possible]
• Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on breast cancer: [Insert hyperlink to RCOG guidance when possible]