Breast cancer is the most common cancer in women

Classification

  • Non-invasive breast cancer - cancer cells have not invaded the basement membrane. They are commonly referred to as pre-malignant, and are at risk of progression into invasive breast cancer. 
    • Ductal carcinoma in situ (DCIS) - arise from the epithelial cells which line the breast ducts
    • Lobular carcinoma in situ (LCIS) - arise from the epithelial cells within the breast lobules
  • Invasive breast cancer
    • Invasive ductal carcinoma - most common
    • Invasive lobular carcinoma 

Other, rare types of breast cancer include

  • Paget’s disease of the nipple
    • Erythematous, dry, scaly ulceration of the skin around the nipple. Sore, itchy. 
    • Significance: Paget’s is usually associated with an underlying breast malignancy (in situ or invasive). 
  • Inflammatory breast cancer
    • Rare and aggressive breast malignancy which results from lymphatic obstruction by malignant cells. The breast becomes painful, erythematous and oedematous. 

 

Risk factors

  • Genetics -  BRCA1/2 = 40% lifetime risk of breast or ovarian carcinoma 
  • Family history
  • Menstrual risk - early menarche, late menopause
  • Pregnancy and breastfeeding are protective! So nulliparity/late 1st pregnancy (>30yrs) are RFs
  • Oestrogen containing medications: combined HRT, COCP

 

Clinical Features

Breast lump 

  • A painless breast lump is the most common presenting complaint
  • On examination, malignant lumps may feel hard or ‘gritty’, with irregular margins. Due to their invasive nature they may also be fixed to the chest wall or tethered to surrounding tissue. 

Axillary lymphadenopathy 

Nipple changes 

  • Paget’s disease - erythematous, ulcerated skin around nipple
  • Change in shape, colour
  • Irritation or bleeding
  • Discharge and retraction

Skin changes

  • Dimpling, puckering of skin
  • Peau d’orange 

 

Referral

Refer via a 2WW suspected cancer pathway if:

  • Unexplained axillary lump and age > 30
  • Age > 30 and Breast lump (regardless of painful/painless)
    • If age < 30 and breast lump, consider non-urgent referral
  • Age > 50 and unilateral nipple changes 
  • Skin changes suggestive of breast malignancy (Peau d’orange)

 

Assessment

Following referral, patients undergo a triple assessment

  1. History/Examination
  2. Imaging
    1. Ultrasound in younger patients (<40) due to denser breast tissue making mammography less sensitive
    2. Mamogram in women > 40 with two views
  3. Biopsy - core biopsy/FNA

 

Management

Patients may be managed with a combination of chemotherapy (neoadjuvant or adjuvant), radiotherapy, and surgery (wide local excision, mastectomy) with sentinel node sampling to identify lymph node involvement. 

Pharmacological treatments include

  • Anti-oestrogen therapy - to reduce oestrogen dependent tumour growth
    • Tamoxifen - ER blocker - used in premenopausal women with ER+ BC
      • SEs: Flushes, VTE risk, menstrual cycle disturbance
      • Typically continued for up to 5 years post-excision 
    • Aromatase inhibitors (anastrozole, letrozole etc) - used in postmenopausal women with ER+ BC (blocks the conversion of androgens into oestrogen). 
  • Biological treatments
    • Herceptin (trastuzumab) - monoclonal antibody used in HER2+ BC. 

 

Screening and Family History

Managing Family History of Breast Cancer

NICE advises that the following cohorts of patients should be offered referral for specialist assessment on the basis of family history:

  • One first-degree female relative with BC < 40 yrs
  • One first-degree male relative with BC at any age
  • One first-degree relative with bilateral breast cancer (where first BC was Dx at < 50 yrs)
  • One relative with BC and one with ovarian ca at any age
  • Three 1st/2nd degree relatives with BC at any age 

 

The NHS Breast Screening Program

  • Women aged 50-70 years 
  • 3-yearly routine breast screening which uses mammography to detect breast cancer 

  

Differential diagnosis

Breast cyst

  • Smooth, fluid-filled lump, may be painful
  • Size varies throughout menstrual cycle 

 

Fibroadenoma

  • Common in young patients (20-30)
  • Discrete, rubbery, firm and non tender
  • Highly mobile, so sometimes referred to as “breast mouse”

  

Fat necrosis

  • A fibrotic lump which occurs following trauma to the breast
  • More common in obese women 

 

Breast abscess

  • A painful, inflamed lump with systemic upset such as fever, malaise, SIRS
  • Commonly occurs during breastfeeding
  • Examination - erythematous, warm and tender to touch 

 

Cyclical breast pain

  • Hormone related breast pain - presents with pain which starts within 2 weeks of menstruation, gradually increases and then improves once period begins
  • Pain is usually bilateral 
  • Management - simple analgesia (paracetamol +/- ibuprofen) 

 
 

References & Further Reading

 

NICE CKS. Breast cancer - managing FH [2018]. Available at URL: https://cks.nice.org.uk/topics/breast-cancer-managing-fh/management/breast-cancer-managing-fh/