WEBVTT 1 00:00:00.640 --> 00:00:03.680 All right, so today we're gonna be talking about breast cancer. Thank you, 2 00:00:03.720 --> 00:00:07.440 as always for the really nice comments to support everybody who's donated. I 3 00:00:07.480 --> 00:00:10.400 really just can't thank you enough. I really do appreciate the support, so 4 00:00:10.480 --> 00:00:13.080 thank you so much. Let's go ahead and get started with breast cancer. 5 00:00:13.160 --> 00:00:16.800 So even though breast cancer is just one single topic, there's a lot to 6 00:00:16.800 --> 00:00:20.120 know for it. So I've dedicated an entire podcast to all the details you 7 00:00:20.160 --> 00:00:23.199 need to know. As always, I'll be focusing on the high old stuff. 8 00:00:23.320 --> 00:00:27.879 So, breast cancer is the most common cancer worldwide, surpassing lung cancer 9 00:00:27.920 --> 00:00:31.760 for the first time in twenty twenty, counting for over two million cases each 10 00:00:31.879 --> 00:00:36.200 year. It's also the most frequent cause of cancer death in women worldwide and 11 00:00:36.240 --> 00:00:39.920 the second leading cause of cancer death in women in the US. So breast 12 00:00:39.920 --> 00:00:42.240 cancer you need to be familiar with this. There's a lot to know, 13 00:00:42.359 --> 00:00:45.840 the screening, risk factors, treatment, clinical manifestations. Let's start with the 14 00:00:45.880 --> 00:00:49.600 risk factors for breast cancer. There is a lot of risk factors for breast 15 00:00:49.600 --> 00:00:53.200 cancer. Let's talk about some of the important ones, starting with family history. 16 00:00:53.840 --> 00:00:57.799 So this is a big one. The breast cancer. Breast cancer risk 17 00:00:58.000 --> 00:01:02.880 increases almost twofold if woman had one first degree relative with breast cancer, and 18 00:01:03.119 --> 00:01:07.680 threefold if she had two effected first degree relatives. Next, increasing age. 19 00:01:07.760 --> 00:01:11.280 Quite simply, the older you are, the higher the risk of breast cancer. 20 00:01:11.400 --> 00:01:14.200 Really no need to go any deeper into it than that. Next, 21 00:01:14.400 --> 00:01:19.200 dense breast tissue. So women with mammographically dense breast tissue generally defined as dense 22 00:01:19.239 --> 00:01:25.159 tissue comprising seventy five percent or more of the breast have a higher breast cancer 23 00:01:25.239 --> 00:01:29.200 risk compared with women of a similar age with less or no dense tissue. 24 00:01:29.480 --> 00:01:33.359 The reason behind this is not completely understood, but just remember, dense breast 25 00:01:33.400 --> 00:01:37.719 tissue, higher breast cancer risk. Next, hormonal factors. So, when 26 00:01:37.719 --> 00:01:42.680 we're talking about hormonal risk factors, what we're mainly referring to is increased endogenous 27 00:01:42.760 --> 00:01:47.920 and exogenous sources of estrogen, primarily in progesterone to a lesser extent, So 28 00:01:48.239 --> 00:01:53.640 whether a woman with a higher endogenous estrogen levels or women who are taking hormone 29 00:01:53.680 --> 00:01:59.000 replacement therapy like those combined with estrogen progesterone, any increase in these hormones can 30 00:01:59.040 --> 00:02:02.560 increase the risk for breast cancer. Next, reproductive factors. When it comes 31 00:02:02.560 --> 00:02:07.280 to risk factors related to reproductive factors, what you need to be thinking of 32 00:02:07.480 --> 00:02:10.719 is anything that makes a woman have more menstrual cycles. The more times a 33 00:02:10.840 --> 00:02:15.840 woman menstruates in her life, the higher the risk of breast cancer. So 34 00:02:15.879 --> 00:02:19.240 what do menstrual cycles have to do with breast cancer? While going back to 35 00:02:19.240 --> 00:02:23.080 what we just discussed about increased exposure to estrogen as well as progesterone. During 36 00:02:23.120 --> 00:02:29.000 the menstrual cycle, there is a surge of both estrogen and progesterone at different 37 00:02:29.080 --> 00:02:34.960 stages. This leads to a longer lifetime exposure to these hormones and more exposure 38 00:02:35.000 --> 00:02:38.879 to estrogen and progester own due to more menstrual cycles, more risk of breast 39 00:02:38.879 --> 00:02:42.360 cancer. So what are some things that lead to an increased number of menstrual 40 00:02:42.400 --> 00:02:46.080 cycles. While one would be early menarchy, meaning the earlier a woman starts 41 00:02:46.080 --> 00:02:50.680 menstruating in life, the higher the risk of breast cancer, and the later 42 00:02:50.759 --> 00:02:53.879 she starts menstruating the opposite, the lower the risk. One study actually found 43 00:02:53.919 --> 00:02:59.319 that for every one year delay in the onset of menarchy, breast cancer risk 44 00:02:59.400 --> 00:03:01.560 was reduced by five percent. And then, of course, at the opposite 45 00:03:01.639 --> 00:03:07.240 end of a woman's life late menopause. A later age of menopause is associated 46 00:03:07.240 --> 00:03:10.360 with a higher breast cancer risk. Again, same idea here. Simply put, 47 00:03:10.479 --> 00:03:15.560 more menstrual cycles due to menopause not occurring until later in life, higher 48 00:03:15.560 --> 00:03:19.879 lifetime exposure to estrogen and progesterone, higher risk of breast cancer. Next, 49 00:03:20.159 --> 00:03:23.080 nollaparity. Nollaparity meaning a woman who hasn't given birth to a child. So 50 00:03:23.120 --> 00:03:28.520 while the relationship between nollaparity and increased risk of breast cancer isn't fully understood, 51 00:03:28.800 --> 00:03:31.680 one of the proposed theories is what we were just discussing, that these women 52 00:03:31.719 --> 00:03:37.520 don't ever have a break in that estrogen progesterone cycle. This is also why 53 00:03:37.840 --> 00:03:42.639 breastfeeding can actually have a protective effect and decrease the risk of breast cancer as 54 00:03:42.639 --> 00:03:46.039 it delays the re establishment of the menstrual cycles. So again, main takeaway 55 00:03:46.120 --> 00:03:52.080 here is more menstrual cycles, more breast cancer, less menstrual cycles, less 56 00:03:52.120 --> 00:03:55.599 breast cancer. And then finally, we have genetic mutations that can predispose a 57 00:03:55.639 --> 00:04:00.479 patient to breast cancer. And while there are a few different types, the 58 00:04:00.520 --> 00:04:03.919 ones you absolutely need to know are Brocca one and Braccato mutations. It's estimated 59 00:04:03.960 --> 00:04:09.199 that five to ten percent of breast cancers are linked to inherited genetic mutations, 60 00:04:09.360 --> 00:04:14.240 with Brocca one and Braccato mutations being the most common, So you need to 61 00:04:14.280 --> 00:04:16.360 know these. So Brocca one and Bracca two, they've gotten such a bad 62 00:04:16.439 --> 00:04:20.360 name that when you hear the name Brocca one and Broca two automatically associated with 63 00:04:20.399 --> 00:04:25.160 cancer. But Brocco one and Brocca two are actually the good guys, their 64 00:04:25.160 --> 00:04:29.160 tumor suppressor genes, and it's only when these genes have mutations that we have 65 00:04:29.240 --> 00:04:32.600 issues. When these genes are not properly. When these genes, I'm sorry, 66 00:04:32.639 --> 00:04:35.480 When these gens are properly functioning, they actually have the opposite effect. 67 00:04:35.480 --> 00:04:41.639 They produce proteins and help prepare damage DNA and protect you from getting certain cancers. 68 00:04:41.639 --> 00:04:46.199 But if you inherit a pathogenic mutation in the Brocca one or Broca two 69 00:04:46.240 --> 00:04:49.000 gene, the mutation prevent them from working properly, and that puts you at 70 00:04:49.000 --> 00:04:54.040 a higher risk to get breast ovariant as well as other types of cancers. 71 00:04:54.319 --> 00:04:58.480 So just a little side note, there's actually four main types of cancers associated 72 00:04:58.480 --> 00:05:00.959 with Brocca one and braccato mute, pas. Obviously, breast cancer, as 73 00:05:00.959 --> 00:05:04.480 we just discussed, is a big one, ovarian cancer as another, and 74 00:05:04.519 --> 00:05:09.560 then to a lesser extent prostate and pancreatic cancer. It's important to know those 75 00:05:09.600 --> 00:05:13.360 four are associated with Brocca one and Broca two mutations may come up on an 76 00:05:13.360 --> 00:05:16.120 exam. So how can you remember that? Well, Bracca sounds very much 77 00:05:16.199 --> 00:05:21.000 like Barack Bracca Barack, which made me think of our past president Barack Obama. 78 00:05:21.120 --> 00:05:26.639 The first letters in past President Barack Obama are PPBO, the PA in 79 00:05:26.759 --> 00:05:30.439 past. Help me remember pancreatic because those are the first two letters in pancreatic 80 00:05:30.480 --> 00:05:34.920 past pancreatic, PAPA, the PR and president help me remember prostate president PR, 81 00:05:35.120 --> 00:05:40.040 prostate PR. The B in Barack helped me remember breast and the O 82 00:05:40.279 --> 00:05:44.560 in Obama ovarian. So again, remember Broca as in Brocca one and Broca 83 00:05:44.560 --> 00:05:49.160 two mutations sound like Barack as in past President Barack Obama, pancreatic, prostate, 84 00:05:49.600 --> 00:05:53.519 breast, and ovarian cancer. That will help you remember the four cancers 85 00:05:53.519 --> 00:05:56.040 that are associated with it. All right, So getting back on track, 86 00:05:56.160 --> 00:05:59.199 those are the risk factors you need to know. Now there are, of 87 00:05:59.240 --> 00:06:02.759 course, other risk factor is smoking alcohol use. So BCD exposured ionizing radiation. 88 00:06:03.040 --> 00:06:05.160 But the ones I listed above, those are the ones you really need 89 00:06:05.199 --> 00:06:09.920 to remember as those are often tested on. So remember your older patient with 90 00:06:10.040 --> 00:06:14.360 dense breast tissue, bunch of extra estrogen, lots of ventstral cycles, and 91 00:06:14.399 --> 00:06:16.319 a Brocka mutation. That's what you need to know. Let's move on to 92 00:06:16.399 --> 00:06:20.439 your clinical manifestations next. So generally, what you're going to be looking for 93 00:06:20.560 --> 00:06:27.120 the classic presentation in your clinical manifestations of a malignant breast tumor. The key 94 00:06:27.279 --> 00:06:32.079 terms are hard, immovable, irregular mass, so a hard immovable, single 95 00:06:32.160 --> 00:06:36.360 dominant lesion with ill defined or irregular borders. Now, of course these features 96 00:06:36.399 --> 00:06:41.959 alone cannot reliably distinguish a benign tumor from a malignant tumor, and also keep 97 00:06:42.000 --> 00:06:45.000 in mind in real life there may not always be a palpable mass, which 98 00:06:45.040 --> 00:06:47.000 is why screening is important. But for the exam, those are the key 99 00:06:47.079 --> 00:06:51.600 terms you're looking for when they describe a malignant mass. Hard immovable, unlike 100 00:06:51.639 --> 00:06:56.279 say a fibride anoma that we know, roles all around, and irregular or 101 00:06:56.319 --> 00:06:59.279 ill define. Those are the key three key terms to look out for. 102 00:06:59.439 --> 00:07:02.600 Hardle irregular, Now on physical exam, there's a few important things to be 103 00:07:02.639 --> 00:07:06.519 aware of and it all depends on the type of cancer involved. So a 104 00:07:06.560 --> 00:07:11.759 physical exam, I want you to remember six key findings which are all neatly 105 00:07:11.800 --> 00:07:15.240 packaged into a mnemonic that I came up with. And that mnemonic goes by 106 00:07:15.240 --> 00:07:17.600 the name of ariola, very fitting for the current topic and it should help 107 00:07:17.600 --> 00:07:21.079 you remember the key physical exam findings to look out for in a patient with 108 00:07:21.199 --> 00:07:28.839 breast cancer. So ARIOLA stands for axillary lymphadoopathy, retraction, rithema, orange 109 00:07:28.839 --> 00:07:32.480 peel leaking, and atopic dermatitis. Let's break down what those means, starting 110 00:07:32.519 --> 00:07:36.839 with A, which stands for axillary lymphad andopathy. So this is very important. 111 00:07:36.879 --> 00:07:41.160 Anytime you do a clinical breast examination, you need to check the axillary 112 00:07:41.240 --> 00:07:45.600 lymph nodes. The axillary lymph nodes receive eighty five percent of the lymphatic drainage 113 00:07:45.600 --> 00:07:48.319 from the breast, meaning if breast cancer is going to spread to a regional 114 00:07:48.399 --> 00:07:51.759 lymph node, it's likely going to be the axillary lymph nodes. So keep 115 00:07:51.759 --> 00:07:56.560 this in mind. Axillary lymphat andopathy is one of the key findings in locally 116 00:07:56.600 --> 00:07:59.879 advanced breast cancer, so that's what A stands for. What about are? 117 00:08:00.360 --> 00:08:05.079 So the R stands for retraction, as in retraction or inversion of the nipple, 118 00:08:05.360 --> 00:08:09.519 which occurs in sub aeriolar or central malignancies of the breast. This can 119 00:08:09.560 --> 00:08:13.199 also be seen in inflammatory breast cancer. So these structural changes occur beneath the 120 00:08:13.240 --> 00:08:18.519 breast from these malignancies, which can cause the nipple to retract into the breast. 121 00:08:18.519 --> 00:08:22.040 So that's what the R stands for. Next E stands for arethema. 122 00:08:22.319 --> 00:08:24.879 So skin changes like rathema, which is a reddening of the skin, can 123 00:08:24.920 --> 00:08:30.639 be a warning sign of locally advanced breast cancer and more importantly, a specific 124 00:08:30.759 --> 00:08:35.679 subtype of breast cancer called inflammatory breast cancer which causes it this warm, red, 125 00:08:35.840 --> 00:08:39.879 thickened breast tissue combined with edema, and it can look very much like 126 00:08:39.000 --> 00:08:43.639 mastitis clinically. So if you have a woman who is being treated for mastitis 127 00:08:43.679 --> 00:08:48.039 with antibiotics, she's not getting any better. Make sure inflammatory breast cancer is 128 00:08:48.039 --> 00:08:52.000 on your list of differentials. So remember E is for rathema. Next, 129 00:08:52.120 --> 00:08:56.639 the O stands for orange peel aka poe to orange, which is a French 130 00:08:56.759 --> 00:08:58.759 term meaning orange peel or orange skin. So what does that have to do 131 00:08:58.799 --> 00:09:01.960 with breast cancer. Well, this is a super important finding that they love 132 00:09:03.000 --> 00:09:07.799 to mention in exam questions. And another potential finding an inflammatory breast cancer, 133 00:09:07.840 --> 00:09:11.080 which we just discussed. So due to the eurethema thickening and dimpling of the 134 00:09:11.159 --> 00:09:16.080 overlying skin that we see an inflammatory breast cancer. The skin can take on 135 00:09:16.120 --> 00:09:20.000 the appearance the appearance of an orange peel, and that's why they call it 136 00:09:20.039 --> 00:09:24.440 orange peel or poe orange appearance. And just an interesting side note, the 137 00:09:24.559 --> 00:09:28.840 term inflammatory as an inflammatory breast cancer is actually a misnomer since there is not 138 00:09:28.960 --> 00:09:35.879 actually true inflammation present. The clinical signs that suggest inflammation are not actually due 139 00:09:35.919 --> 00:09:39.639 to infiltration of inflammatory cells. Rather, it's caused from tumor cells invading the 140 00:09:39.720 --> 00:09:45.840 dermal lymphatics, causing the called quote unquote inflammation. So that might be helpful 141 00:09:45.879 --> 00:09:48.960 for patho. Moving onto, l L stands for a leakage as a nipple 142 00:09:50.039 --> 00:09:52.799 leakage, the L and areola stands for leakage, nipple leakage, or nipple 143 00:09:52.919 --> 00:09:56.799 discharge. The discharge can be serious, milky or bloody, and although there's 144 00:09:56.879 --> 00:10:01.600 much more common causes for nipple discharge like a benign papoloma cancer should always be 145 00:10:01.639 --> 00:10:05.879 on the list of differentials, as it's found in five to fifteen percent of 146 00:10:05.879 --> 00:10:09.879 patients with pathologic nipple discharge. And then the last letter A stands for atopic 147 00:10:09.919 --> 00:10:15.360 dermatitis aka eggzema. So let me explain this one. So do patients with 148 00:10:15.440 --> 00:10:20.679 breast cancer develop atopic dermatitis? They do not, but similar skin changes that 149 00:10:20.720 --> 00:10:26.320 are often mistaken for atopic dermatitis aka egzema are seen in a condition called Pagets 150 00:10:26.360 --> 00:10:30.519 disease of the breast, which is a rare condition associated with an underlying breast 151 00:10:30.559 --> 00:10:35.320 malignancy. So the key physical exam findings and pages disease is an egzema like 152 00:10:35.600 --> 00:10:39.759 eruption of the nipple and areola. So if you see them describing this persistent 153 00:10:39.960 --> 00:10:46.279 scaling egzematose or ulcerated lesion involving the nipple, aerial or complex very similar to 154 00:10:46.360 --> 00:10:50.320 the dermatologic findings and a patient with atopic dermatitis, make sure you think of 155 00:10:50.399 --> 00:10:52.720 pagt disease of the breast all right. So again on physical exam, be 156 00:10:52.840 --> 00:10:58.799 looking out for areola, axillary lymphatinopathy, retraction, rithema, orange peel, 157 00:10:58.960 --> 00:11:01.720 leaky and atopic dermatitis. Those are the main findings that will be on your 158 00:11:01.759 --> 00:11:05.200 exam question. Next, I want to quickly break down a few of the 159 00:11:05.240 --> 00:11:09.039 most important types of breast cancer you should be familiar with, and also explain 160 00:11:09.080 --> 00:11:13.559 a bit of the terminology you're going to hear. So there's a few terms 161 00:11:13.600 --> 00:11:18.600 that are used when we're talking about breast cancer. Incite to infiltrating, ductal, 162 00:11:18.679 --> 00:11:20.519 lobular. Let's break this down to have a better understanding. So in 163 00:11:20.559 --> 00:11:24.360 the breast, you have lobules and you have ducks. The lobules they produce 164 00:11:24.399 --> 00:11:28.360 the milk, and the ducts they carry the milk from the lobules to the 165 00:11:28.440 --> 00:11:31.879 nipple. So breast cancer can be in either one of these locations, the 166 00:11:31.960 --> 00:11:35.519 lobules or the ducks. So if there's cancer in the lobule, you guessed 167 00:11:35.559 --> 00:11:37.759 it, it's called lobular carcinoma. And if the cancer is in the duct, 168 00:11:37.799 --> 00:11:43.039 it's called ductal carcinoma. That's step one where it's located. Step two, 169 00:11:43.200 --> 00:11:46.120 does it stay put or is it spreading? So if it stays put, 170 00:11:46.200 --> 00:11:48.120 if it's combined to the lobule or it's combined to the duct, this 171 00:11:48.240 --> 00:11:52.240 is called incite. To the Latin translation of incite too, is in its 172 00:11:52.240 --> 00:11:56.600 original place or location. So if the lesion is in the duct and it's 173 00:11:56.639 --> 00:12:00.639 confined to the duct, that would be called ductal carcinoma in site. If 174 00:12:00.639 --> 00:12:03.200 it breaches the structure, if it breaks through the basement membrane and spreads from 175 00:12:03.240 --> 00:12:07.919 the duct or the lobule to the surrounding structures, this is known as infiltrating 176 00:12:07.000 --> 00:12:13.200 or invasive, So infiltrating lobular carcinoma or infiltrating ductal carcinoma. All right, 177 00:12:13.240 --> 00:12:16.200 So now that we have a basic understanding of the terminology, let's review a 178 00:12:16.200 --> 00:12:20.720 few specific types that you'll likely be asked about, starting with infiltrating ductal carcinoma. 179 00:12:20.840 --> 00:12:26.240 So, infiltrating ductal carcinoma, we know is a cancer that has spread 180 00:12:26.279 --> 00:12:30.120 from the duct of the breast. It's breached the basement membrane. So why 181 00:12:30.240 --> 00:12:35.559 is infiltrating ductal carcinoma aka invasive ductal carcinoma so important? While it's the most 182 00:12:35.600 --> 00:12:39.080 common type of invasive breast cancer, accounting for seventy to eighty percent of invasive 183 00:12:39.159 --> 00:12:43.360 lesions, so definitely commit this one to memory. Next, we have inflammatory 184 00:12:43.360 --> 00:12:46.759 breast cancer. So inflammatory breast cancer we talked about this one a little bit 185 00:12:46.759 --> 00:12:52.039 before. This is an aggressive form of locally advanced breast cancer. It's pretty 186 00:12:52.120 --> 00:12:56.360 rare disorder, accounting for only about one to five percent of invasive breast cancers. 187 00:12:56.559 --> 00:13:00.000 So why should you bother knowing about a relatively rare type of breast cancer. 188 00:13:00.320 --> 00:13:03.879 Well, it has a unique presentation, and anytime something is unique, 189 00:13:03.879 --> 00:13:07.840 it's often tested on. So patients with inflammatory breast cancer will often have this 190 00:13:07.039 --> 00:13:11.720 rapid onset of breast stathema edema along with the skin becoming warm, thickened, 191 00:13:11.720 --> 00:13:16.759 and dimpled, which is often described as poe to orange or orange skin appearance. 192 00:13:16.120 --> 00:13:20.120 That's the key, the orange skin appearance, as we discussed before in 193 00:13:20.120 --> 00:13:22.440 physical exam finding is very important to know that. And then finally, we 194 00:13:22.519 --> 00:13:26.080 have Paget disease of the breast. So this is another rare one, counting 195 00:13:26.080 --> 00:13:30.399 for only one to three percent of new cases of female breast cancer. But 196 00:13:30.440 --> 00:13:33.879 again unique presentation. So as we discussed before, the classic appearance for Paget 197 00:13:33.960 --> 00:13:39.200 disease is the scally itchy exzematos ulstrated lesion that begins on the nipple and then 198 00:13:39.240 --> 00:13:43.360 spreads to the areola. The pathologic hallmark for this disease is the present of 199 00:13:43.440 --> 00:13:50.240 malignant intra epithelial adeno carcinoma cells also known as Paget cells within the epidermis of 200 00:13:50.279 --> 00:13:52.799 the nipple. So for Paget disease of the breast, the key is remembering 201 00:13:52.840 --> 00:13:58.519 that scally itchy eggma like eruption on the nipple and areola. That's why in 202 00:13:58.559 --> 00:14:03.759 my mind I changed its name from Paget's disease Paget's disease to patch Itch disease. 203 00:14:03.840 --> 00:14:09.519 Patch Itch as an itch that helps me remember this is the one associated 204 00:14:09.519 --> 00:14:13.480 with the itchy eggima like rash. So again remember instead of Paget's disease, 205 00:14:13.559 --> 00:14:18.240 remember it as patch Itch disease. So there's many other histologic types of breast 206 00:14:18.240 --> 00:14:24.000 cancer medullary, tubular, papillary, apocrine, secretary, and we'll discuss some 207 00:14:24.039 --> 00:14:26.559 of the receptor positive subtypes when we go over treatment, But in general, 208 00:14:26.559 --> 00:14:30.519 for the exam, I would really suggest focusing on the ones I went over 209 00:14:30.559 --> 00:14:33.120 above, as those are the ones that often come up in exam questions. 210 00:14:33.559 --> 00:14:37.440 Next, let's talk about screening protocols. Now screening protocols, they vary they 211 00:14:37.519 --> 00:14:41.519 vary from the medical society referencing the patient's risk factors. This is a big 212 00:14:41.559 --> 00:14:46.639 topic of discussion and in many areas there is no clear consensus. But for 213 00:14:46.679 --> 00:14:50.360 the exam, there's one age bracket that's widely agreed upon that you need to 214 00:14:50.360 --> 00:14:52.279 remember, which I'll go over in a second. Let's first break down each 215 00:14:52.320 --> 00:14:56.279 of the age brackets and discuss when you screen with mommography and when you don't. 216 00:14:56.600 --> 00:15:01.080 And this is going to be for patients at average risk for breast cancer. 217 00:15:01.440 --> 00:15:05.960 So starting in women under forty with average risk, screen momography is not 218 00:15:05.120 --> 00:15:11.919 recommended, so no screening guidelines currently recommend routine screening for average risk women who 219 00:15:11.919 --> 00:15:15.440 are under forty years of age. So don't even worry about this one next 220 00:15:15.759 --> 00:15:18.320 forty to forty nine years old individualized. So the name of the game for 221 00:15:18.360 --> 00:15:22.360 this age bracket is shared decision making between the provider and the patient. It's 222 00:15:22.360 --> 00:15:26.240 going to be individualized for each patient. There's no clear consensus in this age 223 00:15:26.240 --> 00:15:31.720 bracket between the medical societies, as the net benefit of breast cancer screening is 224 00:15:31.799 --> 00:15:35.799 less clear for women in their forties. Some societies say yes, others no. 225 00:15:35.240 --> 00:15:39.279 So in this age bracket, the general approaches. Discuss this with your 226 00:15:39.320 --> 00:15:43.519 patient, individualize the decision based on the benefits and harms of screening and their 227 00:15:43.519 --> 00:15:46.919 personal values and preferences. So overall, I wouldn't worry too much about this 228 00:15:46.960 --> 00:15:48.519 one. The next one, though, this is the one that you need 229 00:15:48.559 --> 00:15:54.200 to know. Fifty to seventy four years, mammography every one to two years. 230 00:15:54.200 --> 00:15:58.399 This is the age bracket that almost all organizations agree on. A woman 231 00:15:58.399 --> 00:16:02.679 that has an average risk of cancer between the ages of fifty to seventy four 232 00:16:02.759 --> 00:16:07.759 years should be screened with momography every one to two years. This is consistent 233 00:16:07.759 --> 00:16:12.559 with most major US and international medical group recommendations, including the US Preventative Services 234 00:16:12.639 --> 00:16:15.360 Task Force. So this is the one you need to know. Of the 235 00:16:15.440 --> 00:16:19.279 other age brackets, it's going to be individualized decisions based on risk factors, 236 00:16:19.279 --> 00:16:23.559 etc. But for the exam, remember fifty to seventy four years, momography 237 00:16:23.639 --> 00:16:26.759 every one to two years. That's the high old screen info you need to 238 00:16:26.799 --> 00:16:32.440 know. Moving on to diagnosis and your diagnostic tools. So for diagnostic evaluation 239 00:16:32.519 --> 00:16:36.639 of suspected breast cancer, there's basically three modalities you need to be aware of. 240 00:16:36.960 --> 00:16:41.039 Ultrasound, momography and BIOPSYED let's talk a bit about each when you use 241 00:16:41.080 --> 00:16:44.240 them and what you're looking for. Let's start with the most important, and 242 00:16:44.320 --> 00:16:48.639 that of course is momography. So momography this is really the best modality to 243 00:16:48.799 --> 00:16:52.440 not only detect breast cancer at an early stage through screening, but also for 244 00:16:52.480 --> 00:16:56.519 the diagnostic workup of patients after a tumor is detected. Momography often detects a 245 00:16:56.639 --> 00:17:02.559 lesion before it is palpable by clinical breast examination and on average one to two 246 00:17:02.639 --> 00:17:06.839 years before noted by breast self examination. So MAMMO is very important for you 247 00:17:06.880 --> 00:17:10.119 to know. There's a few important things to commit to memory for the exam 248 00:17:10.640 --> 00:17:15.559 number one forty years or older. So first, this imaging modality is generally 249 00:17:15.680 --> 00:17:19.079 used in patients forty years of age or older. Younger patients will usually have 250 00:17:19.160 --> 00:17:23.079 an ultrasound rather than a MAMMO at least initially, and I'll explain a bit 251 00:17:23.119 --> 00:17:26.160 more about that when we go over at that modality. Next second thing, 252 00:17:26.279 --> 00:17:30.839 when it comes to mammographic features suggestive of breast cancer, there's a couple key 253 00:17:30.880 --> 00:17:37.000 phrases you want to have in your head speculated and microcalcifications, which instead of 254 00:17:37.000 --> 00:17:40.599 the word microcalcifications I used to call them small stones because it was easy to 255 00:17:40.640 --> 00:17:44.920 remember speculated small stones. At rhymes, they'll start with an S. Anyways, 256 00:17:45.119 --> 00:17:48.680 let's start with spiculated, as in spiculated soft tissue mass. If you 257 00:17:48.720 --> 00:17:52.720 see this described on MAMMO, very very likely a malignancy. Ninety percent of 258 00:17:52.759 --> 00:18:00.279 speculated soft tissue masses represent invasive cancer. This is the most specific mammographic of 259 00:18:00.359 --> 00:18:04.480 malignancy. Speculated just means the mass has these little spikes or projections coming out 260 00:18:04.519 --> 00:18:08.200 of it. So remember if you see spiculated soft tissue mass on an exam 261 00:18:08.279 --> 00:18:15.759 question, it's cancer. Second, small stones aka microcalcifications, So microcostifications are 262 00:18:15.759 --> 00:18:21.599 seen in approximately sixty percent of cancers on MAMMO. These microcostifications actually represent necrotic 263 00:18:21.680 --> 00:18:25.359 cells in the center of a cluster of tumor cells. So remember on MAMMO, 264 00:18:25.599 --> 00:18:30.960 if you see spicculated small stones aka microcostifications, it's very very likely in 265 00:18:30.960 --> 00:18:36.359 malignancy. So just keep repeating that in your head speculated small stones, spirculated 266 00:18:36.440 --> 00:18:38.079 small stones. And then the last thing I think you should know for MAMMO 267 00:18:38.480 --> 00:18:44.440 is your BIRAD score. So all mammograms are read by a radiologist and assigned 268 00:18:44.480 --> 00:18:48.680 a BIRAD score by RED stands for Breast Imaging Reporting and Data System and its 269 00:18:48.720 --> 00:18:52.839 own. It's not only used in MAMMO, but also for ultrasound and even 270 00:18:52.920 --> 00:18:56.519 MRI of the breasts to determine the relative likelihood of a malignant diagnosis based on 271 00:18:56.519 --> 00:19:00.440 the imaging findings. So the radiologist as signs a BYRAD score from one to 272 00:19:00.599 --> 00:19:03.880 five technically zero to six, but I'll go over that in a minute, 273 00:19:04.039 --> 00:19:07.200 and the higher the number, the higher the chance of cancer. The BYRAD 274 00:19:07.279 --> 00:19:11.160 score also helps determine how soon the patient should follow up. So let's break 275 00:19:11.160 --> 00:19:15.079 this down starting with BYRAD one and two. So if you get a BYRAD 276 00:19:15.160 --> 00:19:19.599 score of one or two, the chance of malignancy is essentially zero and this 277 00:19:19.680 --> 00:19:25.000 patient should follow up annually as per screening guidelines. So BYRAD one and two, 278 00:19:25.119 --> 00:19:29.319 I just used to remember not cancer CIA next year by RAD three, 279 00:19:29.359 --> 00:19:33.759 So BYRAD three score means this is most likely benign. Likelihood of malignancy is 280 00:19:33.799 --> 00:19:37.279 less than two percent. But there were some areas that were a little suss 281 00:19:37.359 --> 00:19:41.279 focal asymmetry a group of round calcifications, So these patients instead of the regular 282 00:19:41.319 --> 00:19:45.759 one to two year screening, generally you'll see these patients back in six months 283 00:19:45.759 --> 00:19:48.920 for repeat imaging. So for BYRAD three, I just used to remember C 284 00:19:48.200 --> 00:19:52.480 and six by RAD four and five. So BYRAD four and five you're getting 285 00:19:52.480 --> 00:19:56.839 a biopsy. Byrad's four is actually broken down into subcategories A, B and 286 00:19:56.960 --> 00:20:00.599 C depending on the likelihood of malignancy. Don't memorize that though, Just remember 287 00:20:00.640 --> 00:20:04.599 by ROD four or five biopsy in most cases. And for those of you 288 00:20:04.680 --> 00:20:07.920 who like to get technical, there is BYRAD zero and by RAD six like 289 00:20:07.920 --> 00:20:11.759 I talked about before, but you don't need to know those. BYRAD zero 290 00:20:11.839 --> 00:20:15.160 just means it was inconclusive and needs further imaging. Sometimes the MAMMO was just 291 00:20:15.359 --> 00:20:19.880 suboptimal, maybe there was improper positioning, and BYRAD six just means the mass 292 00:20:19.960 --> 00:20:23.759 was already biopsed improven to be malignant. So remember again by RAD one and 293 00:20:23.799 --> 00:20:27.799 two, not cancer CEA. Next year BYRAD three little sus C and six 294 00:20:29.039 --> 00:20:33.160 by RAD four and five biopsy. All right, next diagnostic tool is ultrasound. 295 00:20:33.200 --> 00:20:36.319 The most important thing you need to know for ultrasound is it's the imaging 296 00:20:36.319 --> 00:20:40.079 modality of choice in women under thirty, So why don't we use ultrasound in 297 00:20:40.079 --> 00:20:44.720 women under thirty and not momography a couple of reasons. First, most breast 298 00:20:44.799 --> 00:20:48.279 lesions in young women are not visualized on momography due to the density of breast 299 00:20:48.319 --> 00:20:52.240 tissue in young women. This limits the sensitivity of MAMMO. And then two, 300 00:20:52.440 --> 00:20:56.000 there's an increased radiation risk with momography, so it's best to avoid any 301 00:20:56.079 --> 00:21:02.119 radiation exposure in young patients if possible. Utrasound is also useful as an adjunct 302 00:21:02.119 --> 00:21:06.000 to MAMMO to give some details about the mass. It can help differentiate between 303 00:21:06.039 --> 00:21:10.000 solid and cystic masses. It can be used to assess axillary lymph nodes, 304 00:21:10.039 --> 00:21:14.599 as well as provide guidance for interventional procedures like biopsy. Main takeaway here though, 305 00:21:14.799 --> 00:21:18.839 breast mass and a patient under thirty, your initial imaging will be ultrasound. 306 00:21:18.279 --> 00:21:22.640 So you might be thinking to yourself, you said MAMMO forty and older, 307 00:21:22.880 --> 00:21:26.759 ultrasound under thirty. What about women in their thirties and that in between 308 00:21:26.799 --> 00:21:29.720 age range? What about them? So that's one of the gray areas where 309 00:21:29.720 --> 00:21:33.920 there's not a specific guideline. In general, either ultrasound or MAMMO can be 310 00:21:33.039 --> 00:21:37.640 used in this age group. Up to date states it's reasonably acceptable to start 311 00:21:37.680 --> 00:21:42.599 with an ultrasound as the initial imaging modality, but with a low thresholding with 312 00:21:42.640 --> 00:21:48.119 a low threshold for using momography if clinical suspicion is high, so that's ultrasound. 313 00:21:48.160 --> 00:21:51.960 There are some other imaging modalities MRI which can be utilized for a preoperative 314 00:21:51.960 --> 00:21:56.359 evaluation. There's also functional breast imaging techniques like positron emission momography. Those aren't 315 00:21:56.400 --> 00:22:00.640 used as often, but just be aware that they do exist. Nothing really 316 00:22:00.640 --> 00:22:03.119 didn't know for the exam with those. All right, Finally, let's talk 317 00:22:03.119 --> 00:22:07.119 about your biopses. So who's getting a biopsy? Won't any patient that has 318 00:22:07.160 --> 00:22:11.400 a suspicious mammographic abnormality. Remember this would be your by RED four in five 319 00:22:11.480 --> 00:22:15.960 patients, or even with a patient that just has a very clinically suspicious palpable 320 00:22:15.000 --> 00:22:18.000 breast mass, they need to have a biopsy done. Talk about the different 321 00:22:18.000 --> 00:22:22.759 types of biopsies, starting with your fine needle aspiration, so a fine needle 322 00:22:22.799 --> 00:22:26.559 aspiration or FNA. It's a quick, minimally invasive small needle is going to 323 00:22:26.559 --> 00:22:30.960 be placed in the mass under ultrasound guidance. So those are the pros. 324 00:22:30.960 --> 00:22:33.119 It's quick and easy. The results fromly come back quick, but what are 325 00:22:33.160 --> 00:22:37.960 the cons Well, there's a high rate of false negatives. It also cannot 326 00:22:37.000 --> 00:22:42.640 reliably distinguish between insight you and invasive cancers. And often times, due to 327 00:22:42.640 --> 00:22:48.079 the small tissue sample obtained within FNA, you can't always check for a receptor 328 00:22:48.160 --> 00:22:52.000 status like your estrogen, progesterone and HR two receptors, which I'll go over 329 00:22:52.079 --> 00:22:55.079 this in more detail when we talk about treatment. So f ANDA it's quick 330 00:22:55.079 --> 00:22:57.680 and easy, but it can't always provide all of the necessary details, and 331 00:22:57.799 --> 00:23:02.000 because of its high rate of as negatives, it's not the best test. 332 00:23:02.240 --> 00:23:06.720 The better test and the preferred initial biopsy procedure is a core needle biopsed. 333 00:23:07.000 --> 00:23:11.119 So a core needle biopsy is generally preferred as the initial biopsy procedure. It's 334 00:23:11.119 --> 00:23:15.319 a little bit more invasive compared to an FNA, as you're using a larger 335 00:23:15.359 --> 00:23:18.920 needle. An FNA uses a twenty three to twenty seven gage needle, a 336 00:23:18.960 --> 00:23:22.640 core needle biopsy uses a nine to fourteen gage. In addition, it also 337 00:23:22.759 --> 00:23:26.720 requires a small incision to allow entry of the larger needle. But this larger 338 00:23:26.759 --> 00:23:30.319 needle increases the amount of tissue obtained and allows for some improvements over an FNA. 339 00:23:30.440 --> 00:23:34.319 First, it's more sensitive at detecting a malignancy. A core needle biopsy 340 00:23:34.400 --> 00:23:40.400 has an eighty seven percent sensitivity compared to an FNA at only seventy four percent. 341 00:23:40.680 --> 00:23:45.440 This larger sample also allows for more reliable determination of hormone receptor levels like 342 00:23:45.599 --> 00:23:48.680 estrogen, progesterone, and HR two receptors. And finally, it's able to 343 00:23:48.680 --> 00:23:53.839 distinguish between insight to lesions and invasive carcinoma, which as we talked about before, 344 00:23:53.880 --> 00:23:59.160 and or an FNA could not determine the difference between those two. So 345 00:23:59.240 --> 00:24:02.240 core needle biops see it's a bit more invasive, but it's more sensitive, 346 00:24:02.319 --> 00:24:06.960 allows for receptor testing, and can distinguish between insight to and invasive cancer. 347 00:24:07.200 --> 00:24:11.839 And for those reasons, remember it's generally the initial biopsy of choice. Finally, 348 00:24:11.920 --> 00:24:15.119 we have a surgical or open biopsy. So surgical or open biopsy this 349 00:24:15.200 --> 00:24:18.759 is clearly the most invasive of all the procedures, and most of the time 350 00:24:18.799 --> 00:24:22.880 will not be the initial method of diagnosis. It's performed in fewer than ten 351 00:24:22.960 --> 00:24:26.720 percent of cases. Usually this is going to be performed when a needle biopsy, 352 00:24:26.799 --> 00:24:30.279 like with FNA or core needle is not feasible or if the core needle 353 00:24:30.279 --> 00:24:34.200 biopsy results were inconclusive. All right, so that was diagnosis. There's a 354 00:24:34.240 --> 00:24:40.240 lot to know, hi you'll takeaways remember MAMMO women forty and older, look 355 00:24:40.279 --> 00:24:45.920 for your spiculated small stones aka microcossifications ultrasound under thirty or as an adjunct to 356 00:24:45.960 --> 00:24:48.200 MAMMO for more info. For biopsy, FNA is quick and easy, but 357 00:24:48.279 --> 00:24:52.559 lacking in detail. Core needle biopsy is your preferred method. Gives you the 358 00:24:52.599 --> 00:24:56.680 most bang for your buck, distinguishing between insight to and invasive cancer, as 359 00:24:56.680 --> 00:25:00.680 well as providing info on receptor status. Finally, surgical b ape only if 360 00:25:00.720 --> 00:25:03.240 all else fails. That's diagnosis. Let's move on to the last section and 361 00:25:03.279 --> 00:25:07.400 talk about some of the treatment options for breast cancer. Now, the treatment 362 00:25:07.440 --> 00:25:11.440 for breast cancer, it's complex, it's highly individualized. There's many factors to 363 00:25:11.480 --> 00:25:14.640 consider, including age, TNM, stage, tumor, type, hormone, 364 00:25:14.680 --> 00:25:18.920 receptor status, risk of recurrence. It can be really overwhelming, and you 365 00:25:18.960 --> 00:25:21.559 really don't need to know all of the details for the exam. You really 366 00:25:21.599 --> 00:25:23.319 just need to know the basics. So let's break down each of the treatment 367 00:25:23.319 --> 00:25:26.279 options, focusing on just the need to know stuff. Let's start with your 368 00:25:26.279 --> 00:25:30.920 surgical options, starting with breast conserving therapy, so breast conserving therapy. This 369 00:25:30.960 --> 00:25:36.359 is usually going to be a lumpectomy plus radiation and a centralal biopsy. So 370 00:25:36.440 --> 00:25:40.559 breast conserving therapy, which is performed with a lumpectomy, is an alternative to 371 00:25:40.759 --> 00:25:45.160 mass stectomy for certain patients with early stage breast cancer. This is not going 372 00:25:45.200 --> 00:25:48.559 to be appropriate for all patients, patients that have inflammatory breast cancer, patients 373 00:25:48.559 --> 00:25:53.880 with diffused malignant microcassifications, as well as a number of other contraindications. But 374 00:25:55.240 --> 00:25:57.640 if the patient is able to have a lumpectomy, a lumpectomy can remove the 375 00:25:57.720 --> 00:26:02.720 tumor but not the rest itself, so the breast is conserved. A couple 376 00:26:02.799 --> 00:26:06.960 things to know first, and most patients who have a lumpectomy, it will 377 00:26:07.000 --> 00:26:11.680 need to be followed by radiation therapy. This is going to eradicate any microscopic 378 00:26:11.799 --> 00:26:17.319 residual disease. And then the second thing is these patients will always require evaluation 379 00:26:17.359 --> 00:26:21.480 of the axillary lymph nodes. If they have a clinically negative axillary examination, 380 00:26:21.559 --> 00:26:25.440 you can do something known as a sentinel node biopsy, so sentinel node biopsy 381 00:26:25.480 --> 00:26:29.319 helps guide the surgeon to know which lymph nodes need to be biopsy rather than 382 00:26:29.359 --> 00:26:33.559 just biopsying all of them. The surgeon injects contrast near the tumor. They 383 00:26:33.559 --> 00:26:37.920 watch the contrast get absorbed by the surrounding lymph nodes and whichever lymph nodes absorb 384 00:26:37.000 --> 00:26:41.559 the contrast first. Those are the lymph nodes that the cancer would first spread 385 00:26:41.559 --> 00:26:42.640 to, so those are the ones that are going to be sent out to 386 00:26:44.000 --> 00:26:48.039 pathology. So lumpectomy no. This is an option for patients with early stage 387 00:26:48.079 --> 00:26:52.240 breast cancer. Tumor can be removed without removing the breast usually needs to be 388 00:26:52.240 --> 00:26:56.279 followed by radiation and evaluation of the axillary lymph nodes. Next, let's talk 389 00:26:56.319 --> 00:27:00.640 about massectomy. So massetectomy is a complete removal of the tissue of the breast. 390 00:27:00.759 --> 00:27:03.400 As we discuss before, not all patients are going to be candidates for 391 00:27:03.519 --> 00:27:10.640 a lumpectomy. So patients who have inflammatory breast cancer diffuse malignant microcossifications, multicentric 392 00:27:10.680 --> 00:27:14.519 disease with two or more primary tumorous prior radiation of the breast. Don't memorize 393 00:27:14.559 --> 00:27:18.000 those. But these patients, they can't have a lumpectomy, so they're going 394 00:27:18.039 --> 00:27:22.319 to require a complete removal of the breast a mastectomy. It's also in many 395 00:27:22.359 --> 00:27:26.000 cases decided by the patient to have a mastectomy. Some women prefer to avoid 396 00:27:26.079 --> 00:27:30.400 future post operative radiation as required with a lumpectomy, or maybe they want to 397 00:27:30.400 --> 00:27:36.039 avoid further screening and biopsies. Some women also just at a higher risk due 398 00:27:36.079 --> 00:27:40.599 to genetic mutations and would prefer to have a mastectomy instead of a lumpectomy. 399 00:27:40.799 --> 00:27:44.440 So a number of reasons why a woman may have this procedure rather than a 400 00:27:44.559 --> 00:27:48.039 lumpectomy. And then, finally, just as a lumpectomy, patients with a 401 00:27:48.119 --> 00:27:51.880 mast stectomy need evaluation of the axillary lymph nodes. All right, next, 402 00:27:52.599 --> 00:27:56.000 let's quickly talk about radiation. It's really not a lot to know here. 403 00:27:56.000 --> 00:28:00.200 There's many reasons a woman might require radiation. Of course, as we discuss 404 00:28:00.200 --> 00:28:04.079 before, most women who have a lumpectomy the breast conserving therapy will require radiation 405 00:28:04.119 --> 00:28:07.759 to eradicate any tumor deposits remaining. Most patients, though, that have a 406 00:28:07.880 --> 00:28:14.279 mestectomy, only will require radiation if they have a high risk for local recurrence. 407 00:28:15.119 --> 00:28:18.240 So most patients with lumpectomy need radiation, whereas mess ectomy not as common, 408 00:28:18.279 --> 00:28:22.359 only specific high risk patients. All right, so the next part of 409 00:28:22.400 --> 00:28:23.759 treatment, it gets a little bit more complicated. I'm going to try to 410 00:28:23.759 --> 00:28:26.920 simplify it as best as I can. So with breast cancer, there's something 411 00:28:26.960 --> 00:28:32.720 known as positive receptors or receptor positive breast cancer. We touched on that a 412 00:28:32.720 --> 00:28:37.039 little bit before. So patients with breast cancer can have these positive receptors that 413 00:28:37.079 --> 00:28:41.480 can be influenced by certain hormones and proteins, which can cause the cancers to 414 00:28:41.519 --> 00:28:45.759 grow and spread. Knowing which receptors are positive is really important because there's specific 415 00:28:45.799 --> 00:28:51.799 targeted treatments depending on which receptor is positive or negative. So again, positive 416 00:28:51.839 --> 00:28:53.799 receptors, they're just like an on switch for the tumor to make it grow. 417 00:28:55.319 --> 00:28:59.960 There's basically three subgroups that you need to know. Patients with positive estrogen 418 00:29:00.200 --> 00:29:06.599 or progesterone receptors called hormone receptor positive, patients with positive HR two receptors aka 419 00:29:06.759 --> 00:29:11.359 human epidermal growth factor. And then finally the last subgroup patients who are negative 420 00:29:11.559 --> 00:29:14.519 for all of them, so negative for estrogen progesterone in h R two, 421 00:29:14.720 --> 00:29:18.279 which is called being triple negative, and of course you can have any variation 422 00:29:18.319 --> 00:29:21.559 of the above positive for all three, negative for all three, positive for 423 00:29:21.680 --> 00:29:23.599 just one, not the others, and so on. So let's start with 424 00:29:23.599 --> 00:29:30.359 your hormone receptor positive breast cancer. So hormone receptor positive breast cancer means the 425 00:29:30.400 --> 00:29:37.160 breast cancer cells have either estrogen or progesterone receptors both just one. These patients 426 00:29:37.200 --> 00:29:41.240 are in a more favorable position because this type of cancer in some cases can 427 00:29:41.279 --> 00:29:45.279 be treated with alternatives to chemotherapy, and obviously, if we can avoid chemo, 428 00:29:45.359 --> 00:29:48.559 that's ideal. So what options do we have in this type of cancer. 429 00:29:48.880 --> 00:29:52.640 Well, since these positive receptors allow estrogen and progesterone to promote the growth 430 00:29:52.680 --> 00:29:57.079 of cancer cells, the goals obviously to block those hormones. And since estrogen 431 00:29:57.119 --> 00:30:00.799 plays a more significant role in the grow both in development of breast cancer cells 432 00:30:00.799 --> 00:30:06.880 compared to progesterone, what we wind up doing is attempting to either deplete estrogen 433 00:30:06.960 --> 00:30:10.640 production or block it all together. There's a number of ways to do this, 434 00:30:10.680 --> 00:30:12.400 and don't memorize all of them, but aim to just have a general 435 00:30:12.440 --> 00:30:18.559 understanding. So let's start with blocking estrogen receptors. So to moxifin is a 436 00:30:18.599 --> 00:30:22.920 big one. To moxifin as well as roloxifen are selective estrogen receptor modulators, 437 00:30:22.920 --> 00:30:27.400 are also known as SERMs. They work by blocking those estrogen receptors in the 438 00:30:27.400 --> 00:30:32.960 breast, which prevent estrogen from binding and stimulating the growth of cancer cells. 439 00:30:33.000 --> 00:30:37.039 So that's one option. Next is your aromatase inhibitors and nostrosol lectrozol. These 440 00:30:37.039 --> 00:30:41.920 are mainly utilized in post metopausal women and they work by blocking the enzyme aromatase 441 00:30:42.279 --> 00:30:45.200 and a romatase. If you're not familiar with it, Its job in the 442 00:30:45.200 --> 00:30:51.359 body is to convert androgens like testosterone into estrogen. So by blocking aromatase, 443 00:30:51.400 --> 00:30:55.160 we in turn decrease estrogen in the body. And then finally we have your 444 00:30:55.200 --> 00:31:00.680 targeted agents like a beamacoclib. These are CDK for six inhibitors. You don't 445 00:31:00.680 --> 00:31:04.440 really need to memorize these, but just recognize that these meds are often combined 446 00:31:06.079 --> 00:31:08.839 with the other agents we discussed above as they enhance the benefit of those other 447 00:31:08.960 --> 00:31:14.559 estrogen regulating medications. All right, so that's patients with hormone receptor positive breast 448 00:31:14.599 --> 00:31:18.319 cancer. It's a lot, but just focus on shutting down or blocking estrogen 449 00:31:18.359 --> 00:31:22.000 with meds like tomoxifen or anast resolve, combining it with your targeted agents. 450 00:31:22.039 --> 00:31:26.039 Next, what about patients with positive HR two receptors? How do we treat 451 00:31:26.079 --> 00:31:30.319 those patients well? From an exam standpoint, it's actually fairly easily. It's 452 00:31:30.400 --> 00:31:34.400 basically just one med you need to know. So HR two positive breast cancer. 453 00:31:34.519 --> 00:31:38.960 This occurs when breast cancer cells have a higher than normal level level of 454 00:31:40.000 --> 00:31:45.440 something known as HR two human epidermal growth factor receptor two. So normally this 455 00:31:45.680 --> 00:31:48.559 HR two protein helps breast cells grow, divide, and repair themselves, no 456 00:31:48.640 --> 00:31:52.440 big deal. But in this case, something goes wrong with a gene that 457 00:31:52.480 --> 00:31:56.559 controls the HR two protein and you have this over expression of HR two and 458 00:31:56.559 --> 00:32:01.279 this can obviously lead to the breast cells growing and dividing uncontrollably. So how 459 00:32:01.279 --> 00:32:05.359 do we treat this well? In this case, we have a specific targeted 460 00:32:05.359 --> 00:32:08.319 therapy and this is with something known as trast two zomap. This is the 461 00:32:08.400 --> 00:32:13.079 treatment you need to know for HR two positive breast cancer. This is usually 462 00:32:13.119 --> 00:32:15.759 going to be combined with chemo as this is a more aggressive form of breast 463 00:32:15.759 --> 00:32:21.319 cancer. It also may be combined with another targeted therapy called pertozumap. But 464 00:32:21.400 --> 00:32:24.240 for the exam, just remember TRASTS two zomap because if you get a question 465 00:32:24.240 --> 00:32:28.559 on this, this is the med most commonly used and it's the one they'll 466 00:32:28.599 --> 00:32:31.640 most likely ask you about. So TRST two zomap is a type of targeted 467 00:32:31.680 --> 00:32:36.720 therapy and it works by targeting and binding to the HR two protein on the 468 00:32:36.759 --> 00:32:40.079 surface of cancer cells, and it prevents the cancer cells from receiving signals to 469 00:32:40.079 --> 00:32:45.359 grow and divide. So for HR two you need to know TRST two zoomab. 470 00:32:45.559 --> 00:32:47.799 You remember that because HR two has a two in it, and so 471 00:32:47.960 --> 00:32:52.480 does T two zoomap TRST two zoomab. So if you see an exam question 472 00:32:52.480 --> 00:32:57.640 and they ask you, they say, the patients HR two positive, which 473 00:32:57.640 --> 00:33:00.440 matter you're going to give them, look for the med with a two in 474 00:33:00.519 --> 00:33:05.440 it. Her two gets TRAS two zoomab two gets two. So again remember 475 00:33:05.720 --> 00:33:08.799 h R two positive to remembers two zoomab. All right, I think I 476 00:33:08.880 --> 00:33:14.599 drilled that one home. Finally, we have chemotherapy. So with chemotherapy you'll 477 00:33:14.680 --> 00:33:21.680 hear the terms adjuvent chemotherapy and neoadjuvent chemotherapy neoadjuvent chemo just means it's given prior 478 00:33:21.720 --> 00:33:23.759 to the main intervention, which is usually surgery, to improve the outcome, 479 00:33:23.799 --> 00:33:29.079 shrink the tumor size, and then adjuvent chemo is just chemo that's given after 480 00:33:29.200 --> 00:33:32.640 surgery to lower the risk of recurrence by eradicating any microscopic folk i of cancer 481 00:33:32.680 --> 00:33:37.039 cells remaining. So a number of reasons why chemotherapy will be utilized. Patients 482 00:33:37.200 --> 00:33:40.920 with a high risk of recurrence cancer that's spread to the lymph nodes or other 483 00:33:42.000 --> 00:33:45.160 parts of the body, patients with positive HR two status, patients with triple 484 00:33:45.240 --> 00:33:50.680 negative breast cancer and a tumor size over point five centimeters. Nothing I'd advise 485 00:33:50.799 --> 00:33:52.559 memorizing or wasting more than a couple of minutes on for the exam. Just 486 00:33:52.680 --> 00:33:57.079 be aware it's another treatment option utilized for breast cancer, all right, So 487 00:33:57.240 --> 00:34:00.279 that is treatment. It's a lot to know. Let's do a triple still 488 00:34:00.319 --> 00:34:05.319 thirty second recap, starting with lumpectomy. Lumpectomy is a breast conserving therapy removes 489 00:34:05.359 --> 00:34:07.880 the tumor but not the breast. If the patient has something bad like inflammatory 490 00:34:07.920 --> 00:34:13.199 breast cancer, primary adiation, or the breast diffuse malignant microcostifications. Got to 491 00:34:13.239 --> 00:34:15.880 do a mess stectomy, which is complete removal of the breast next radiation. 492 00:34:16.079 --> 00:34:21.159 Most patients with the lumpectomy will get this compared to only high risk mass stectomy 493 00:34:21.199 --> 00:34:24.280 patients. If their hormone positive, stop or block the estrogen to moxifin, 494 00:34:24.400 --> 00:34:29.800 letterzol plus targeted agents. If their h are two positive hidden with TRESS two 495 00:34:29.920 --> 00:34:32.639 zamap, treat two with two and then finally chemo for your high risk patients. 496 00:34:32.760 --> 00:34:37.000 Cancer that is spread, etc. That's treatment, and that is breast 497 00:34:37.039 --> 00:34:39.639 cancer. Let's do five quick questions to wrap it up. Question one, 498 00:34:39.800 --> 00:34:44.440 A fifty two year old woman presents her PCP complaining of a new lump in 499 00:34:44.519 --> 00:34:49.159 her breast. Momography confirms the presence of a two centimeter spiculated mass, and 500 00:34:49.320 --> 00:34:53.360 biopsy confirms HR two positive breast cancer. Which therapy listed below would be most 501 00:34:53.400 --> 00:34:59.239 appropriate to treat HR two positive breast cancer in this patient? Choice A to 502 00:34:59.360 --> 00:35:06.159 moxifin, choice B, transtuzumab, choice c letrozol choice D, and fliximab. 503 00:35:06.239 --> 00:35:10.360 Again A to moxifin, B, trastuzumab, c letrozol, d infliximab. 504 00:35:10.800 --> 00:35:15.719 So that is going to be option B trastwozomaps. Remember with her HR 505 00:35:15.760 --> 00:35:19.880 two positive breast cancer, look for the medication with A two in it. 506 00:35:20.199 --> 00:35:23.239 Her two is treated with tras two zomab, the targeted therapy that binds to 507 00:35:23.320 --> 00:35:28.400 the HR two protein and stops the cancer cells from growing and dividing. Talk 508 00:35:28.400 --> 00:35:31.199 about why it's not the other options. Answer A and C are most most 509 00:35:31.360 --> 00:35:37.199 utilized in hormone receptor positive breast cancer. Targeting your estrogen to moxifen is a 510 00:35:37.280 --> 00:35:42.360 selected estrogen receptor modulator, and letrozol is an a romatase inhibitor. And then 511 00:35:42.400 --> 00:35:46.360 finally answer D infliximab, that's a TNF inhibitor that's commonly used in ulcerated colitis, 512 00:35:46.599 --> 00:35:51.480 not HR two positive breast cancer. Question two. A fifty seven year 513 00:35:51.480 --> 00:35:55.239 old woman presents for a routine mammogram. Mamogram reveals a suspicious lump in her 514 00:35:55.239 --> 00:35:59.960 breast classified as a bi rad's four, and a BioC confirms that it is 515 00:36:00.159 --> 00:36:04.920 malignant. Her doctor explains that the type of cancer found is the most common 516 00:36:05.000 --> 00:36:08.920 form of invasive breast cancer, counting for eighty percent of all invasive breast cancer 517 00:36:09.039 --> 00:36:14.199 cases. What type of cancer does this patient likely have? So that's going 518 00:36:14.280 --> 00:36:19.400 to be infiltrating ductal carcinoma. So infiltrating or invasive ductal carcinoma. It's the 519 00:36:19.480 --> 00:36:22.519 most common type of invasive breast cancer, accounting for seventy to eighty percent of 520 00:36:22.599 --> 00:36:27.920 invasive lesions. Question three. A fifty one year old woman presents to the 521 00:36:28.000 --> 00:36:31.360 office today complaining of itching, redness, and flaking skin on and around her 522 00:36:31.440 --> 00:36:36.519 right nipple. The condition was initially diagnosed as eggema, but she has found 523 00:36:36.559 --> 00:36:40.079 little to no improvement with the topical cortico steroids prescribed by her PCP. Biopsy 524 00:36:40.239 --> 00:36:44.880 is performed, which confirms the diagnosis of a rare form of breast cancer. 525 00:36:45.280 --> 00:36:49.760 What is a most likely diagnosis in this patient? Paget disease of the breast. 526 00:36:49.880 --> 00:36:52.880 Remember anytime you see a description of a scaly, raw, itchy ulcerate, 527 00:36:52.920 --> 00:36:57.400 a lesion on the nipple and areola similar to the presentation of eggzema, 528 00:36:57.719 --> 00:37:01.480 always have Paget disease in your list of differentials, as this rare condition associated 529 00:37:01.519 --> 00:37:06.679 with breast cancer can cause ezema like changes to the skin of the nipple and 530 00:37:06.719 --> 00:37:10.199 areola. And remember, instead of page Its disease, remember it as page 531 00:37:10.280 --> 00:37:15.800 itch disease, I to remember the itchy scaly findings. Question four. A 532 00:37:16.000 --> 00:37:21.320 twenty seven year old woman notices some discomfort in her right breast and discovers a 533 00:37:21.480 --> 00:37:24.719 lump while performing a self examination. She schedules an appointment with her primary care 534 00:37:24.800 --> 00:37:29.719 physician, who conducts a physical exam and decides to order an imaging test to 535 00:37:29.760 --> 00:37:34.159 gather more information about the mass. Which screening test is her doctor likely to 536 00:37:34.239 --> 00:37:37.360 recommend, So that is going to be ultrasounds. So remember in women under 537 00:37:37.480 --> 00:37:40.440 thirty, as the breast tissue is more dense, and the fact that we're 538 00:37:40.480 --> 00:37:45.400 trying to avoid any unnecessary radiation to the breast in this age group, ultrasound 539 00:37:45.519 --> 00:37:49.320 is ideal to use as the initial screening test for a breast mass. Question 540 00:37:49.480 --> 00:37:52.400 five. A sixty one year old woman was recently diagnosed with early stage breast 541 00:37:52.480 --> 00:37:58.000 cancer and underwent a lumpectomy to remove the primary tumor. During the procedure, 542 00:37:58.039 --> 00:38:00.960 a sentinelal biopsy was performed, which was negative. After the surgery, her 543 00:38:01.000 --> 00:38:06.519 medical team discussed additional treatment options to reduce the risk of cancer recurrence. Which 544 00:38:06.559 --> 00:38:10.519 additional form of treatment will the patient most likely need based on her diagnosis and 545 00:38:10.599 --> 00:38:15.519 the procedure she underwent, so that is going to be radiation therapy. So 546 00:38:15.800 --> 00:38:21.360 most women who get a lumpectomy aka breast conserving surgery will require whole breast radiation 547 00:38:21.440 --> 00:38:24.280 to eradicate any tumored deposits remaining. This is the majority of patients. To 548 00:38:24.360 --> 00:38:28.920 remember, when a patient gets a lumpectomy, assume it will be combined with 549 00:38:29.079 --> 00:38:31.320 radiation therapy. All right, So that was your breast cancer review. I 550 00:38:31.440 --> 00:38:35.239 hope that was helpful. Thank you as always for listening to the podcast, 551 00:38:35.440 --> 00:38:36.920 and thank you so much for your support.