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• Seen at all ages in adults. Commonest in women over age 70.

Increased Risks

• Age: most breast cancers are diagnosed after age 50.
• Genetic mutations. Inherited mutations to BRCA1 and BRCA2. Women who have inherited these genetic changes are at higher risk of breast and ovarian cancer.
• Early menstrual period. Menarche < age 12 are exposed to hormones longer, raising the risk for breast cancer by a small amount.
• Late or no pregnancy. Having the first pregnancy after age 30 and never having a full-term pregnancy can raise breast cancer risk.
• Menopause after age 55. Longer exposure to oestrogen hormones
• Physically inactive. Women who are not physically active have a higher risk of getting breast cancer.
• Being overweight or obese after menopause.
• Dense breasts have more connective tissue than fatty tissue, which can sometimes make it hard to see tumours on a mammogram. Women with dense breasts are more likely to get breast cancer.
• HRT combination hormone therapy for more than five years raises the risk for breast cancer.
• Oral contraceptives (birth control pills).
• Personal history of breast cancer.
• Personal history of atypical hyperplasia or lobular carcinoma in situ are associated with a higher risk of getting breast cancer.
• Family history of breast cancer: mother, sister, or daughter (first-degree relative) or multiple family members on either her mother's or father's side of the family who have had breast cancer. Having a first-degree male relative with breast cancer also raises a woman's risk.
• Radiation therapy to the chest or breasts (like for treatment of Hodgkin's lymphoma) before age 30 have a higher risk of getting breast cancer later in life.
• Diethylstilbestrol (DES), which was given to some pregnant women in the United States between 1940 and 1971 to prevent miscarriage, have a higher risk. Women whose mothers took DES while pregnant with them are also at risk.
• Drinking alcohol. Studies show that a woman's risk for breast cancer increases with the more alcohol she drinks.

Clinical

Decreased risks

• Breastfeeding

Non Invasive forms

• Ductal carcinoma in situ
• Lobular carcinoma in situ

Invasive Cancer

• Invasive Ductal cancer: most common also called No Special Type or NST.
• Invasive lobular breast cancer
• Sarcomas, Metastases, lymphoma
• Inflammatory breast cancer: lymph channels blocked. The breast can appear red and inflamed.
• Triple negative breast cancers: no receptors for oestrogen and progesterone or Her2 protein
• Male breast cancer: men between the ages of 60 and 70. Overweight, excess oestrogens. Kleinfelter's syndrome, Radiation or Genetic.

Clinical

• Breast lump, dimpling of the skin, bleeding and fluid from the nipple
• Red hard tender breast
• Bone pain, lymphadenopathy, breathlessness
• Darkening skin around the nipple - Paget's disease of the breast

Differentials

• Fibroadenoma: mobile small benign lesion
• Fibrocystic disease a benign breast condition
• Breast abscess: settles with antibiotics. If fails to settle then escalate.

Investigations

• FBC, U&E, LFTs
• CXR: Effusion, Lymphangitis carcinomatosis
• Mammogram
• Biopsy from the breast, HER2 and oestrogen receptor status
• MRI scan
• lymph node ultrasound scan
• USS liver scan
• Bone scan

Multidisciplinary Triple Diagnostic Method:

• A. Clinical assessment
• B. Imaging assessment: x-ray mammography and high frequency ultrasound with probes suitable for breast imaging (12 MHz or more). Digital mammography is preferred to film-screen mammography particularly for women below 50 years and for those with dense breast tissue. Breast MRI does not form part of the initial imaging assessment of patients in the symptomatic breast clinic.
• C. Needle biopsy: The results of Triple Assessment should be discussed at a multidisciplinary meeting for all women who undergo needle biopsy. The results of each element of the Triple Assessment should be considered in order to ensure a correct diagnosis and appropriate further management. If there is discordance between the results, further assessment, if necessary including repeat biopsy, should be considered

Management

• Surgery: Surgical removal is the standard of care and is well tolerated. Smaller tumours can consider breast conservation with wide local excision or lumpectomy. Larger tumours need Mastectomy. Axillary nodes are removed for therapeutic and staging - a sentinel node which is a main draining node.
• Radiotherapy: adjuvant radiotherapy is also a standard of care
• Hormonal therapy: Tamoxifen and aromatase inhibitors started after chemotherapy
• Chemotherapy: individualised chemotherapy. usually Fluorouracil or anthracycline. Other drugs include doxorubicin or epirubicin. And a taxane drug, such as paclitaxel or docetaxel.
• Biological agents : Trastuzumab may be offered to HER2 positive patients.

References