Instructions: Listen to the podcast episode available below, and then submit your answers to the multiple choice questions. You will review the answers and the material covered during your next Continuity Clinic Session.
Breast Cancers and Treatment
1. In patients with early breast cancer, risk-prediction models can help oncologists determine the risk of recurrence and the need for adjuvant therapy. The models can be based on clinical prognosticators or biomolecular features of the tumor. In addition to age, the prognostic factor common to most clinical models is:
1 in 8 women will be diagnosed with breast cancer during their lifetime
The greatest risk factor is age
Other risk factors: Genetic predisposition, early menarche (before 12), late menopause (after 55), multiparity and family history
Use of prognosticator models are meant to provide adjuvant therapy to those patients who would receive survival benefit and to limit toxicity
HER2/neu status is recommended in workup of breast cancer and those who are positive are treated with monoclonal antibodies to HER2/neu, but this is not part of risk prediction models
Most prediction modes include age, nodal status and tumor size (and many include comorbidities)
2. A 35 yo woman palpates a 1 cm solid breast mass. A needle biopsy is performed showing an invasive ductal carcinoma. The best treatment for this patient is:
Infiltrating ductal carcinoma accounts for 70-80% of invasive breast cancer. The rest are either infiltrating lobular or mixed-type ductal/lobular carcinomas.
Patients with suspicious axillary lymph nodes should undergo pre-op eval with fine-needle aspiration or core biopsy of the node
If lymph node is positive pre-op, axillary lymph node dissection is needed at surgery
If lymph node is negative pre-op, sentinel lymph node biopsy should be performed
Lumpectomy followed by radiation therapy is a common strategy
Breast-conserving surgery (lumpectomy) should be avoided in those with multifocal disease, large tumor size in relation to breast, diffuse malignant-appearing calcifications on imaging, history of chest wall radiation and persistent positive margins after re-excision (these patients usually require mastectomy)
The risk of microscopic axillary nodal metastases is about 5% in patients with microinvasive breast cancer. The risk is higher in tumors that have stromal invasion by clusters of cells (as compared to single cells)
3. A 40 yo woman is diagnosed with cancer of the right breast. She is otherwise healthy. She undergoes breast-conserving surgery with lumpectomy and axillary node dissection. She is found to have stage I breast cancer less than 1 cm in size with negative nodes. Her cancer is estrogen receptor positive and progesterone receptor positive. It is considered low risk. She menstruates monthly. After radiation therapy of the breast, what is the best next step in management?
About 25% of breast cancer cases are in premenopausal women; about 60% of these will be hormone receptor positive
Tamoxifen is the standard adjuvant endocrine therapy for premenopausal women with hormone receptor positive breast cancer.
Based on recent trials, Tamoxifen is continued for 10 years
Tamoxifen halves the recurrence risk and significantly decreases the risk of breast cancer mortality
Side effects in premenopausal women include menorrhagia and ovarian cysts