All right, so today we're gonna be talking about breast cancer. Thank you,
as always for the really nice comments to support everybody who's donated. I
really just can't thank you enough. I really do appreciate the support, so
thank you so much. Let's go ahead and get started with breast cancer.
So even though breast cancer is just one single topic, there's a lot to
know for it. So I've dedicated an entire podcast to all the details you
need to know. As always, I'll be focusing on the high old stuff.
So, breast cancer is the most common cancer worldwide, surpassing lung cancer
for the first time in twenty twenty, counting for over two million cases each
year. It's also the most frequent cause of cancer death in women worldwide and
the second leading cause of cancer death in women in the US. So breast
cancer you need to be familiar with this. There's a lot to know,
the screening, risk factors, treatment, clinical manifestations. Let's start with the
risk factors for breast cancer. There is a lot of risk factors for breast
cancer. Let's talk about some of the important ones, starting with family history.
So this is a big one. The breast cancer. Breast cancer risk
increases almost twofold if woman had one first degree relative with breast cancer, and
threefold if she had two effected first degree relatives. Next, increasing age.
Quite simply, the older you are, the higher the risk of breast cancer.
Really no need to go any deeper into it than that. Next,
dense breast tissue. So women with mammographically dense breast tissue generally defined as dense
tissue comprising seventy five percent or more of the breast have a higher breast cancer
risk compared with women of a similar age with less or no dense tissue.
The reason behind this is not completely understood, but just remember, dense breast
tissue, higher breast cancer risk. Next, hormonal factors. So, when
we're talking about hormonal risk factors, what we're mainly referring to is increased endogenous
and exogenous sources of estrogen, primarily in progesterone to a lesser extent, So
whether a woman with a higher endogenous estrogen levels or women who are taking hormone
replacement therapy like those combined with estrogen progesterone, any increase in these hormones can
increase the risk for breast cancer. Next, reproductive factors. When it comes
to risk factors related to reproductive factors, what you need to be thinking of
is anything that makes a woman have more menstrual cycles. The more times a
woman menstruates in her life, the higher the risk of breast cancer. So
what do menstrual cycles have to do with breast cancer? While going back to
what we just discussed about increased exposure to estrogen as well as progesterone. During
the menstrual cycle, there is a surge of both estrogen and progesterone at different
stages. This leads to a longer lifetime exposure to these hormones and more exposure
to estrogen and progester own due to more menstrual cycles, more risk of breast
cancer. So what are some things that lead to an increased number of menstrual
cycles. While one would be early menarchy, meaning the earlier a woman starts
menstruating in life, the higher the risk of breast cancer, and the later
she starts menstruating the opposite, the lower the risk. One study actually found
that for every one year delay in the onset of menarchy, breast cancer risk
was reduced by five percent. And then, of course, at the opposite
end of a woman's life late menopause. A later age of menopause is associated
with a higher breast cancer risk. Again, same idea here. Simply put,
more menstrual cycles due to menopause not occurring until later in life, higher
lifetime exposure to estrogen and progesterone, higher risk of breast cancer. Next,
nollaparity. Nollaparity meaning a woman who hasn't given birth to a child. So
while the relationship between nollaparity and increased risk of breast cancer isn't fully understood,
one of the proposed theories is what we were just discussing, that these women
don't ever have a break in that estrogen progesterone cycle. This is also why
breastfeeding can actually have a protective effect and decrease the risk of breast cancer as
it delays the re establishment of the menstrual cycles. So again, main takeaway
here is more menstrual cycles, more breast cancer, less menstrual cycles, less
breast cancer. And then finally, we have genetic mutations that can predispose a
patient to breast cancer. And while there are a few different types, the
ones you absolutely need to know are Brocca one and Braccato mutations. It's estimated
that five to ten percent of breast cancers are linked to inherited genetic mutations,
with Brocca one and Braccato mutations being the most common, So you need to
know these. So Brocca one and Bracca two, they've gotten such a bad
name that when you hear the name Brocca one and Broca two automatically associated with
cancer. But Brocco one and Brocca two are actually the good guys, their
tumor suppressor genes, and it's only when these genes have mutations that we have
issues. When these genes are not properly. When these genes, I'm sorry,
When these gens are properly functioning, they actually have the opposite effect.
They produce proteins and help prepare damage DNA and protect you from getting certain cancers.
But if you inherit a pathogenic mutation in the Brocca one or Broca two
gene, the mutation prevent them from working properly, and that puts you at
a higher risk to get breast ovariant as well as other types of cancers.
So just a little side note, there's actually four main types of cancers associated
with Brocca one and braccato mute, pas. Obviously, breast cancer, as
we just discussed, is a big one, ovarian cancer as another, and
then to a lesser extent prostate and pancreatic cancer. It's important to know those
four are associated with Brocca one and Broca two mutations may come up on an
exam. So how can you remember that? Well, Bracca sounds very much
like Barack Bracca Barack, which made me think of our past president Barack Obama.
The first letters in past President Barack Obama are PPBO, the PA in
past. Help me remember pancreatic because those are the first two letters in pancreatic
past pancreatic, PAPA, the PR and president help me remember prostate president PR,
prostate PR. The B in Barack helped me remember breast and the O
in Obama ovarian. So again, remember Broca as in Brocca one and Broca
two mutations sound like Barack as in past President Barack Obama, pancreatic, prostate,
breast, and ovarian cancer. That will help you remember the four cancers
that are associated with it. All right, So getting back on track,
those are the risk factors you need to know. Now there are, of
course, other risk factor is smoking alcohol use. So BCD exposured ionizing radiation.
But the ones I listed above, those are the ones you really need
to remember as those are often tested on. So remember your older patient with
dense breast tissue, bunch of extra estrogen, lots of ventstral cycles, and
a Brocka mutation. That's what you need to know. Let's move on to
your clinical manifestations next. So generally, what you're going to be looking for
the classic presentation in your clinical manifestations of a malignant breast tumor. The key
terms are hard, immovable, irregular mass, so a hard immovable, single
dominant lesion with ill defined or irregular borders. Now, of course these features
alone cannot reliably distinguish a benign tumor from a malignant tumor, and also keep
in mind in real life there may not always be a palpable mass, which
is why screening is important. But for the exam, those are the key
terms you're looking for when they describe a malignant mass. Hard immovable, unlike
say a fibride anoma that we know, roles all around, and irregular or
ill define. Those are the key three key terms to look out for.
Hardle irregular, Now on physical exam, there's a few important things to be
aware of and it all depends on the type of cancer involved. So a
physical exam, I want you to remember six key findings which are all neatly
packaged into a mnemonic that I came up with. And that mnemonic goes by
the name of ariola, very fitting for the current topic and it should help
you remember the key physical exam findings to look out for in a patient with
breast cancer. So ARIOLA stands for axillary lymphadoopathy, retraction, rithema, orange
peel leaking, and atopic dermatitis. Let's break down what those means, starting
with A, which stands for axillary lymphad andopathy. So this is very important.
Anytime you do a clinical breast examination, you need to check the axillary
lymph nodes. The axillary lymph nodes receive eighty five percent of the lymphatic drainage
from the breast, meaning if breast cancer is going to spread to a regional
lymph node, it's likely going to be the axillary lymph nodes. So keep
this in mind. Axillary lymphat andopathy is one of the key findings in locally
advanced breast cancer, so that's what A stands for. What about are?
So the R stands for retraction, as in retraction or inversion of the nipple,
which occurs in sub aeriolar or central malignancies of the breast. This can
also be seen in inflammatory breast cancer. So these structural changes occur beneath the
breast from these malignancies, which can cause the nipple to retract into the breast.
So that's what the R stands for. Next E stands for arethema.
So skin changes like rathema, which is a reddening of the skin, can
be a warning sign of locally advanced breast cancer and more importantly, a specific
subtype of breast cancer called inflammatory breast cancer which causes it this warm, red,
thickened breast tissue combined with edema, and it can look very much like
mastitis clinically. So if you have a woman who is being treated for mastitis
with antibiotics, she's not getting any better. Make sure inflammatory breast cancer is
on your list of differentials. So remember E is for rathema. Next,
the O stands for orange peel aka poe to orange, which is a French
term meaning orange peel or orange skin. So what does that have to do
with breast cancer. Well, this is a super important finding that they love
to mention in exam questions. And another potential finding an inflammatory breast cancer,
which we just discussed. So due to the eurethema thickening and dimpling of the
overlying skin that we see an inflammatory breast cancer. The skin can take on
the appearance the appearance of an orange peel, and that's why they call it
orange peel or poe orange appearance. And just an interesting side note, the
term inflammatory as an inflammatory breast cancer is actually a misnomer since there is not
actually true inflammation present. The clinical signs that suggest inflammation are not actually due
to infiltration of inflammatory cells. Rather, it's caused from tumor cells invading the
dermal lymphatics, causing the called quote unquote inflammation. So that might be helpful
for patho. Moving onto, l L stands for a leakage as a nipple
leakage, the L and areola stands for leakage, nipple leakage, or nipple
discharge. The discharge can be serious, milky or bloody, and although there's
much more common causes for nipple discharge like a benign papoloma cancer should always be
on the list of differentials, as it's found in five to fifteen percent of
patients with pathologic nipple discharge. And then the last letter A stands for atopic
dermatitis aka eggzema. So let me explain this one. So do patients with
breast cancer develop atopic dermatitis? They do not, but similar skin changes that
are often mistaken for atopic dermatitis aka egzema are seen in a condition called Pagets
disease of the breast, which is a rare condition associated with an underlying breast
malignancy. So the key physical exam findings and pages disease is an egzema like
eruption of the nipple and areola. So if you see them describing this persistent
scaling egzematose or ulcerated lesion involving the nipple, aerial or complex very similar to
the dermatologic findings and a patient with atopic dermatitis, make sure you think of
pagt disease of the breast all right. So again on physical exam, be
looking out for areola, axillary lymphatinopathy, retraction, rithema, orange peel,
leaky and atopic dermatitis. Those are the main findings that will be on your
exam question. Next, I want to quickly break down a few of the
most important types of breast cancer you should be familiar with, and also explain
a bit of the terminology you're going to hear. So there's a few terms
that are used when we're talking about breast cancer. Incite to infiltrating, ductal,
lobular. Let's break this down to have a better understanding. So in
the breast, you have lobules and you have ducks. The lobules they produce
the milk, and the ducts they carry the milk from the lobules to the
nipple. So breast cancer can be in either one of these locations, the
lobules or the ducks. So if there's cancer in the lobule, you guessed
it, it's called lobular carcinoma. And if the cancer is in the duct,
it's called ductal carcinoma. That's step one where it's located. Step two,
does it stay put or is it spreading? So if it stays put,
if it's combined to the lobule or it's combined to the duct, this
is called incite. To the Latin translation of incite too, is in its
original place or location. So if the lesion is in the duct and it's
confined to the duct, that would be called ductal carcinoma in site. If
it breaches the structure, if it breaks through the basement membrane and spreads from
the duct or the lobule to the surrounding structures, this is known as infiltrating
or invasive, So infiltrating lobular carcinoma or infiltrating ductal carcinoma. All right,
So now that we have a basic understanding of the terminology, let's review a
few specific types that you'll likely be asked about, starting with infiltrating ductal carcinoma.
So, infiltrating ductal carcinoma, we know is a cancer that has spread
from the duct of the breast. It's breached the basement membrane. So why
is infiltrating ductal carcinoma aka invasive ductal carcinoma so important? While it's the most
common type of invasive breast cancer, accounting for seventy to eighty percent of invasive
lesions, so definitely commit this one to memory. Next, we have inflammatory
breast cancer. So inflammatory breast cancer we talked about this one a little bit
before. This is an aggressive form of locally advanced breast cancer. It's pretty
rare disorder, accounting for only about one to five percent of invasive breast cancers.
So why should you bother knowing about a relatively rare type of breast cancer.
Well, it has a unique presentation, and anytime something is unique,
it's often tested on. So patients with inflammatory breast cancer will often have this
rapid onset of breast stathema edema along with the skin becoming warm, thickened,
and dimpled, which is often described as poe to orange or orange skin appearance.
That's the key, the orange skin appearance, as we discussed before in
physical exam finding is very important to know that. And then finally, we
have Paget disease of the breast. So this is another rare one, counting
for only one to three percent of new cases of female breast cancer. But
again unique presentation. So as we discussed before, the classic appearance for Paget
disease is the scally itchy exzematos ulstrated lesion that begins on the nipple and then
spreads to the areola. The pathologic hallmark for this disease is the present of
malignant intra epithelial adeno carcinoma cells also known as Paget cells within the epidermis of
the nipple. So for Paget disease of the breast, the key is remembering
that scally itchy eggma like eruption on the nipple and areola. That's why in
my mind I changed its name from Paget's disease Paget's disease to patch Itch disease.
Patch Itch as an itch that helps me remember this is the one associated
with the itchy eggima like rash. So again remember instead of Paget's disease,
remember it as patch Itch disease. So there's many other histologic types of breast
cancer medullary, tubular, papillary, apocrine, secretary, and we'll discuss some
of the receptor positive subtypes when we go over treatment, But in general,
for the exam, I would really suggest focusing on the ones I went over
above, as those are the ones that often come up in exam questions.
Next, let's talk about screening protocols. Now screening protocols, they vary they
vary from the medical society referencing the patient's risk factors. This is a big
topic of discussion and in many areas there is no clear consensus. But for
the exam, there's one age bracket that's widely agreed upon that you need to
remember, which I'll go over in a second. Let's first break down each
of the age brackets and discuss when you screen with mommography and when you don't.
And this is going to be for patients at average risk for breast cancer.
So starting in women under forty with average risk, screen momography is not
recommended, so no screening guidelines currently recommend routine screening for average risk women who
are under forty years of age. So don't even worry about this one next
forty to forty nine years old individualized. So the name of the game for
this age bracket is shared decision making between the provider and the patient. It's
going to be individualized for each patient. There's no clear consensus in this age
bracket between the medical societies, as the net benefit of breast cancer screening is
less clear for women in their forties. Some societies say yes, others no.
So in this age bracket, the general approaches. Discuss this with your
patient, individualize the decision based on the benefits and harms of screening and their
personal values and preferences. So overall, I wouldn't worry too much about this
one. The next one, though, this is the one that you need
to know. Fifty to seventy four years, mammography every one to two years.
This is the age bracket that almost all organizations agree on. A woman
that has an average risk of cancer between the ages of fifty to seventy four
years should be screened with momography every one to two years. This is consistent
with most major US and international medical group recommendations, including the US Preventative Services
Task Force. So this is the one you need to know. Of the
other age brackets, it's going to be individualized decisions based on risk factors,
etc. But for the exam, remember fifty to seventy four years, momography
every one to two years. That's the high old screen info you need to
know. Moving on to diagnosis and your diagnostic tools. So for diagnostic evaluation
of suspected breast cancer, there's basically three modalities you need to be aware of.
Ultrasound, momography and BIOPSYED let's talk a bit about each when you use
them and what you're looking for. Let's start with the most important, and
that of course is momography. So momography this is really the best modality to
not only detect breast cancer at an early stage through screening, but also for
the diagnostic workup of patients after a tumor is detected. Momography often detects a
lesion before it is palpable by clinical breast examination and on average one to two
years before noted by breast self examination. So MAMMO is very important for you
to know. There's a few important things to commit to memory for the exam
number one forty years or older. So first, this imaging modality is generally
used in patients forty years of age or older. Younger patients will usually have
an ultrasound rather than a MAMMO at least initially, and I'll explain a bit
more about that when we go over at that modality. Next second thing,
when it comes to mammographic features suggestive of breast cancer, there's a couple key
phrases you want to have in your head speculated and microcalcifications, which instead of
the word microcalcifications I used to call them small stones because it was easy to
remember speculated small stones. At rhymes, they'll start with an S. Anyways,
let's start with spiculated, as in spiculated soft tissue mass. If you
see this described on MAMMO, very very likely a malignancy. Ninety percent of
speculated soft tissue masses represent invasive cancer. This is the most specific mammographic of
malignancy. Speculated just means the mass has these little spikes or projections coming out
of it. So remember if you see spiculated soft tissue mass on an exam
question, it's cancer. Second, small stones aka microcalcifications, So microcostifications are
seen in approximately sixty percent of cancers on MAMMO. These microcostifications actually represent necrotic
cells in the center of a cluster of tumor cells. So remember on MAMMO,
if you see spicculated small stones aka microcostifications, it's very very likely in
malignancy. So just keep repeating that in your head speculated small stones, spirculated
small stones. And then the last thing I think you should know for MAMMO
is your BIRAD score. So all mammograms are read by a radiologist and assigned
a BIRAD score by RED stands for Breast Imaging Reporting and Data System and its
own. It's not only used in MAMMO, but also for ultrasound and even
MRI of the breasts to determine the relative likelihood of a malignant diagnosis based on
the imaging findings. So the radiologist as signs a BYRAD score from one to
five technically zero to six, but I'll go over that in a minute,
and the higher the number, the higher the chance of cancer. The BYRAD
score also helps determine how soon the patient should follow up. So let's break
this down starting with BYRAD one and two. So if you get a BYRAD
score of one or two, the chance of malignancy is essentially zero and this
patient should follow up annually as per screening guidelines. So BYRAD one and two,
I just used to remember not cancer CIA next year by RAD three,
So BYRAD three score means this is most likely benign. Likelihood of malignancy is
less than two percent. But there were some areas that were a little suss
focal asymmetry a group of round calcifications, So these patients instead of the regular
one to two year screening, generally you'll see these patients back in six months
for repeat imaging. So for BYRAD three, I just used to remember C
and six by RAD four and five. So BYRAD four and five you're getting
a biopsy. Byrad's four is actually broken down into subcategories A, B and
C depending on the likelihood of malignancy. Don't memorize that though, Just remember
by ROD four or five biopsy in most cases. And for those of you
who like to get technical, there is BYRAD zero and by RAD six like
I talked about before, but you don't need to know those. BYRAD zero
just means it was inconclusive and needs further imaging. Sometimes the MAMMO was just
suboptimal, maybe there was improper positioning, and BYRAD six just means the mass
was already biopsed improven to be malignant. So remember again by RAD one and
two, not cancer CEA. Next year BYRAD three little sus C and six
by RAD four and five biopsy. All right, next diagnostic tool is ultrasound.
The most important thing you need to know for ultrasound is it's the imaging
modality of choice in women under thirty, So why don't we use ultrasound in
women under thirty and not momography a couple of reasons. First, most breast
lesions in young women are not visualized on momography due to the density of breast
tissue in young women. This limits the sensitivity of MAMMO. And then two,
there's an increased radiation risk with momography, so it's best to avoid any
radiation exposure in young patients if possible. Utrasound is also useful as an adjunct
to MAMMO to give some details about the mass. It can help differentiate between
solid and cystic masses. It can be used to assess axillary lymph nodes,
as well as provide guidance for interventional procedures like biopsy. Main takeaway here though,
breast mass and a patient under thirty, your initial imaging will be ultrasound.
So you might be thinking to yourself, you said MAMMO forty and older,
ultrasound under thirty. What about women in their thirties and that in between
age range? What about them? So that's one of the gray areas where
there's not a specific guideline. In general, either ultrasound or MAMMO can be
used in this age group. Up to date states it's reasonably acceptable to start
with an ultrasound as the initial imaging modality, but with a low thresholding with
a low threshold for using momography if clinical suspicion is high, so that's ultrasound.
There are some other imaging modalities MRI which can be utilized for a preoperative
evaluation. There's also functional breast imaging techniques like positron emission momography. Those aren't
used as often, but just be aware that they do exist. Nothing really
didn't know for the exam with those. All right, Finally, let's talk
about your biopses. So who's getting a biopsy? Won't any patient that has
a suspicious mammographic abnormality. Remember this would be your by RED four in five
patients, or even with a patient that just has a very clinically suspicious palpable
breast mass, they need to have a biopsy done. Talk about the different
types of biopsies, starting with your fine needle aspiration, so a fine needle
aspiration or FNA. It's a quick, minimally invasive small needle is going to
be placed in the mass under ultrasound guidance. So those are the pros.
It's quick and easy. The results fromly come back quick, but what are
the cons Well, there's a high rate of false negatives. It also cannot
reliably distinguish between insight you and invasive cancers. And often times, due to
the small tissue sample obtained within FNA, you can't always check for a receptor
status like your estrogen, progesterone and HR two receptors, which I'll go over
this in more detail when we talk about treatment. So f ANDA it's quick
and easy, but it can't always provide all of the necessary details, and
because of its high rate of as negatives, it's not the best test.
The better test and the preferred initial biopsy procedure is a core needle biopsed.
So a core needle biopsy is generally preferred as the initial biopsy procedure. It's
a little bit more invasive compared to an FNA, as you're using a larger
needle. An FNA uses a twenty three to twenty seven gage needle, a
core needle biopsy uses a nine to fourteen gage. In addition, it also
requires a small incision to allow entry of the larger needle. But this larger
needle increases the amount of tissue obtained and allows for some improvements over an FNA.
First, it's more sensitive at detecting a malignancy. A core needle biopsy
has an eighty seven percent sensitivity compared to an FNA at only seventy four percent.
This larger sample also allows for more reliable determination of hormone receptor levels like
estrogen, progesterone, and HR two receptors. And finally, it's able to
distinguish between insight to lesions and invasive carcinoma, which as we talked about before,
and or an FNA could not determine the difference between those two. So
core needle biops see it's a bit more invasive, but it's more sensitive,
allows for receptor testing, and can distinguish between insight to and invasive cancer.
And for those reasons, remember it's generally the initial biopsy of choice. Finally,
we have a surgical or open biopsy. So surgical or open biopsy this
is clearly the most invasive of all the procedures, and most of the time
will not be the initial method of diagnosis. It's performed in fewer than ten
percent of cases. Usually this is going to be performed when a needle biopsy,
like with FNA or core needle is not feasible or if the core needle
biopsy results were inconclusive. All right, so that was diagnosis. There's a
lot to know, hi you'll takeaways remember MAMMO women forty and older, look
for your spiculated small stones aka microcossifications ultrasound under thirty or as an adjunct to
MAMMO for more info. For biopsy, FNA is quick and easy, but
lacking in detail. Core needle biopsy is your preferred method. Gives you the
most bang for your buck, distinguishing between insight to and invasive cancer, as
well as providing info on receptor status. Finally, surgical b ape only if
all else fails. That's diagnosis. Let's move on to the last section and
talk about some of the treatment options for breast cancer. Now, the treatment
for breast cancer, it's complex, it's highly individualized. There's many factors to
consider, including age, TNM, stage, tumor, type, hormone,
receptor status, risk of recurrence. It can be really overwhelming, and you
really don't need to know all of the details for the exam. You really
just need to know the basics. So let's break down each of the treatment
options, focusing on just the need to know stuff. Let's start with your
surgical options, starting with breast conserving therapy, so breast conserving therapy. This
is usually going to be a lumpectomy plus radiation and a centralal biopsy. So
breast conserving therapy, which is performed with a lumpectomy, is an alternative to
mass stectomy for certain patients with early stage breast cancer. This is not going
to be appropriate for all patients, patients that have inflammatory breast cancer, patients
with diffused malignant microcassifications, as well as a number of other contraindications. But
if the patient is able to have a lumpectomy, a lumpectomy can remove the
tumor but not the rest itself, so the breast is conserved. A couple
things to know first, and most patients who have a lumpectomy, it will
need to be followed by radiation therapy. This is going to eradicate any microscopic
residual disease. And then the second thing is these patients will always require evaluation
of the axillary lymph nodes. If they have a clinically negative axillary examination,
you can do something known as a sentinel node biopsy, so sentinel node biopsy
helps guide the surgeon to know which lymph nodes need to be biopsy rather than
just biopsying all of them. The surgeon injects contrast near the tumor. They
watch the contrast get absorbed by the surrounding lymph nodes and whichever lymph nodes absorb
the contrast first. Those are the lymph nodes that the cancer would first spread
to, so those are the ones that are going to be sent out to
pathology. So lumpectomy no. This is an option for patients with early stage
breast cancer. Tumor can be removed without removing the breast usually needs to be
followed by radiation and evaluation of the axillary lymph nodes. Next, let's talk
about massectomy. So massetectomy is a complete removal of the tissue of the breast.
As we discuss before, not all patients are going to be candidates for
a lumpectomy. So patients who have inflammatory breast cancer diffuse malignant microcossifications, multicentric
disease with two or more primary tumorous prior radiation of the breast. Don't memorize
those. But these patients, they can't have a lumpectomy, so they're going
to require a complete removal of the breast a mastectomy. It's also in many
cases decided by the patient to have a mastectomy. Some women prefer to avoid
future post operative radiation as required with a lumpectomy, or maybe they want to
avoid further screening and biopsies. Some women also just at a higher risk due
to genetic mutations and would prefer to have a mastectomy instead of a lumpectomy.
So a number of reasons why a woman may have this procedure rather than a
lumpectomy. And then, finally, just as a lumpectomy, patients with a
mast stectomy need evaluation of the axillary lymph nodes. All right, next,
let's quickly talk about radiation. It's really not a lot to know here.
There's many reasons a woman might require radiation. Of course, as we discuss
before, most women who have a lumpectomy the breast conserving therapy will require radiation
to eradicate any tumor deposits remaining. Most patients, though, that have a
mestectomy, only will require radiation if they have a high risk for local recurrence.
So most patients with lumpectomy need radiation, whereas mess ectomy not as common,
only specific high risk patients. All right, so the next part of
treatment, it gets a little bit more complicated. I'm going to try to
simplify it as best as I can. So with breast cancer, there's something
known as positive receptors or receptor positive breast cancer. We touched on that a
little bit before. So patients with breast cancer can have these positive receptors that
can be influenced by certain hormones and proteins, which can cause the cancers to
grow and spread. Knowing which receptors are positive is really important because there's specific
targeted treatments depending on which receptor is positive or negative. So again, positive
receptors, they're just like an on switch for the tumor to make it grow.
There's basically three subgroups that you need to know. Patients with positive estrogen
or progesterone receptors called hormone receptor positive, patients with positive HR two receptors aka
human epidermal growth factor. And then finally the last subgroup patients who are negative
for all of them, so negative for estrogen progesterone in h R two,
which is called being triple negative, and of course you can have any variation
of the above positive for all three, negative for all three, positive for
just one, not the others, and so on. So let's start with
your hormone receptor positive breast cancer. So hormone receptor positive breast cancer means the
breast cancer cells have either estrogen or progesterone receptors both just one. These patients
are in a more favorable position because this type of cancer in some cases can
be treated with alternatives to chemotherapy, and obviously, if we can avoid chemo,
that's ideal. So what options do we have in this type of cancer.
Well, since these positive receptors allow estrogen and progesterone to promote the growth
of cancer cells, the goals obviously to block those hormones. And since estrogen
plays a more significant role in the grow both in development of breast cancer cells
compared to progesterone, what we wind up doing is attempting to either deplete estrogen
production or block it all together. There's a number of ways to do this,
and don't memorize all of them, but aim to just have a general
understanding. So let's start with blocking estrogen receptors. So to moxifin is a
big one. To moxifin as well as roloxifen are selective estrogen receptor modulators,
are also known as SERMs. They work by blocking those estrogen receptors in the
breast, which prevent estrogen from binding and stimulating the growth of cancer cells.
So that's one option. Next is your aromatase inhibitors and nostrosol lectrozol. These
are mainly utilized in post metopausal women and they work by blocking the enzyme aromatase
and a romatase. If you're not familiar with it, Its job in the
body is to convert androgens like testosterone into estrogen. So by blocking aromatase,
we in turn decrease estrogen in the body. And then finally we have your
targeted agents like a beamacoclib. These are CDK for six inhibitors. You don't
really need to memorize these, but just recognize that these meds are often combined
with the other agents we discussed above as they enhance the benefit of those other
estrogen regulating medications. All right, so that's patients with hormone receptor positive breast
cancer. It's a lot, but just focus on shutting down or blocking estrogen
with meds like tomoxifen or anast resolve, combining it with your targeted agents.
Next, what about patients with positive HR two receptors? How do we treat
those patients well? From an exam standpoint, it's actually fairly easily. It's
basically just one med you need to know. So HR two positive breast cancer.
This occurs when breast cancer cells have a higher than normal level level of
something known as HR two human epidermal growth factor receptor two. So normally this
HR two protein helps breast cells grow, divide, and repair themselves, no
big deal. But in this case, something goes wrong with a gene that
controls the HR two protein and you have this over expression of HR two and
this can obviously lead to the breast cells growing and dividing uncontrollably. So how
do we treat this well? In this case, we have a specific targeted
therapy and this is with something known as trast two zomap. This is the
treatment you need to know for HR two positive breast cancer. This is usually
going to be combined with chemo as this is a more aggressive form of breast
cancer. It also may be combined with another targeted therapy called pertozumap. But
for the exam, just remember TRASTS two zomap because if you get a question
on this, this is the med most commonly used and it's the one they'll
most likely ask you about. So TRST two zomap is a type of targeted
therapy and it works by targeting and binding to the HR two protein on the
surface of cancer cells, and it prevents the cancer cells from receiving signals to
grow and divide. So for HR two you need to know TRST two zoomab.
You remember that because HR two has a two in it, and so
does T two zoomap TRST two zoomab. So if you see an exam question
and they ask you, they say, the patients HR two positive, which
matter you're going to give them, look for the med with a two in
it. Her two gets TRAS two zoomab two gets two. So again remember
h R two positive to remembers two zoomab. All right, I think I
drilled that one home. Finally, we have chemotherapy. So with chemotherapy you'll
hear the terms adjuvent chemotherapy and neoadjuvent chemotherapy neoadjuvent chemo just means it's given prior
to the main intervention, which is usually surgery, to improve the outcome,
shrink the tumor size, and then adjuvent chemo is just chemo that's given after
surgery to lower the risk of recurrence by eradicating any microscopic folk i of cancer
cells remaining. So a number of reasons why chemotherapy will be utilized. Patients
with a high risk of recurrence cancer that's spread to the lymph nodes or other
parts of the body, patients with positive HR two status, patients with triple
negative breast cancer and a tumor size over point five centimeters. Nothing I'd advise
memorizing or wasting more than a couple of minutes on for the exam. Just
be aware it's another treatment option utilized for breast cancer, all right, So
that is treatment. It's a lot to know. Let's do a triple still
thirty second recap, starting with lumpectomy. Lumpectomy is a breast conserving therapy removes
the tumor but not the breast. If the patient has something bad like inflammatory
breast cancer, primary adiation, or the breast diffuse malignant microcostifications. Got to
do a mess stectomy, which is complete removal of the breast next radiation.
Most patients with the lumpectomy will get this compared to only high risk mass stectomy
patients. If their hormone positive, stop or block the estrogen to moxifin,
letterzol plus targeted agents. If their h are two positive hidden with TRESS two
zamap, treat two with two and then finally chemo for your high risk patients.
Cancer that is spread, etc. That's treatment, and that is breast
cancer. Let's do five quick questions to wrap it up. Question one,
A fifty two year old woman presents her PCP complaining of a new lump in
her breast. Momography confirms the presence of a two centimeter spiculated mass, and
biopsy confirms HR two positive breast cancer. Which therapy listed below would be most
appropriate to treat HR two positive breast cancer in this patient? Choice A to
moxifin, choice B, transtuzumab, choice c letrozol choice D, and fliximab.
Again A to moxifin, B, trastuzumab, c letrozol, d infliximab.
So that is going to be option B trastwozomaps. Remember with her HR
two positive breast cancer, look for the medication with A two in it.
Her two is treated with tras two zomab, the targeted therapy that binds to
the HR two protein and stops the cancer cells from growing and dividing. Talk
about why it's not the other options. Answer A and C are most most
utilized in hormone receptor positive breast cancer. Targeting your estrogen to moxifen is a
selected estrogen receptor modulator, and letrozol is an a romatase inhibitor. And then
finally answer D infliximab, that's a TNF inhibitor that's commonly used in ulcerated colitis,
not HR two positive breast cancer. Question two. A fifty seven year
old woman presents for a routine mammogram. Mamogram reveals a suspicious lump in her
breast classified as a bi rad's four, and a BioC confirms that it is
malignant. Her doctor explains that the type of cancer found is the most common
form of invasive breast cancer, counting for eighty percent of all invasive breast cancer
cases. What type of cancer does this patient likely have? So that's going
to be infiltrating ductal carcinoma. So infiltrating or invasive ductal carcinoma. It's the
most common type of invasive breast cancer, accounting for seventy to eighty percent of
invasive lesions. Question three. A fifty one year old woman presents to the
office today complaining of itching, redness, and flaking skin on and around her
right nipple. The condition was initially diagnosed as eggema, but she has found
little to no improvement with the topical cortico steroids prescribed by her PCP. Biopsy
is performed, which confirms the diagnosis of a rare form of breast cancer.
What is a most likely diagnosis in this patient? Paget disease of the breast.
Remember anytime you see a description of a scaly, raw, itchy ulcerate,
a lesion on the nipple and areola similar to the presentation of eggzema,
always have Paget disease in your list of differentials, as this rare condition associated
with breast cancer can cause ezema like changes to the skin of the nipple and
areola. And remember, instead of page Its disease, remember it as page
itch disease, I to remember the itchy scaly findings. Question four. A
twenty seven year old woman notices some discomfort in her right breast and discovers a
lump while performing a self examination. She schedules an appointment with her primary care
physician, who conducts a physical exam and decides to order an imaging test to
gather more information about the mass. Which screening test is her doctor likely to
recommend, So that is going to be ultrasounds. So remember in women under
thirty, as the breast tissue is more dense, and the fact that we're
trying to avoid any unnecessary radiation to the breast in this age group, ultrasound
is ideal to use as the initial screening test for a breast mass. Question
five. A sixty one year old woman was recently diagnosed with early stage breast
cancer and underwent a lumpectomy to remove the primary tumor. During the procedure,
a sentinelal biopsy was performed, which was negative. After the surgery, her
medical team discussed additional treatment options to reduce the risk of cancer recurrence. Which
additional form of treatment will the patient most likely need based on her diagnosis and
the procedure she underwent, so that is going to be radiation therapy. So
most women who get a lumpectomy aka breast conserving surgery will require whole breast radiation
to eradicate any tumored deposits remaining. This is the majority of patients. To
remember, when a patient gets a lumpectomy, assume it will be combined with
radiation therapy. All right, So that was your breast cancer review. I
hope that was helpful. Thank you as always for listening to the podcast,
and thank you so much for your support.