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Terms in this set (71)

Age (roughly 1/4 occur before 50yo, roughly <5% before 35yo, average age 65yo)

Previous history of breast cancer

FMH in 1st degree relative, especially premenopausal 1st degree relative (take note of any FMH of early onset breast cancer, multiple cases in family, ovarian cancer, male breast cancer)

Genetic factors:
- BRCA1 mutation on chromosome 17: 65-85% lifetime risk of breast cancer, 40-50% lifetime risk of ovarian cancer, 40-60% risk of developing a 2nd breast cancer, increased risk of breast cancer in men, also increases risk of colon and prostate cancer
- BRCA2 mutation on chromosome 13: 40-85% lifetime risk of breast cancer, 10-25% lifetime risk of ovarian cancer, 6% lifetime risk of breast cancer in men
- TP53 mutation on chromosome 17: most women with this mutation develop breast cancer by 50yo
- PTEN gene: Cowden's syndrome (predisposes to breast cancer, thyroid cancer, uterine cancer and hamartomatous lesions of the skin)
- ATM, CHEK2, BRIP1, and PALB2 genes: moderate risk of breast cancer

Nulliparity or first child after 30yo

Not breast-feeding (breast-feeding protective)

Early menarche, late menopause

Radiation to chest (even small doses) - e.g. treatment of lymphomas in 80s

Previous surgery for benign disease

Western-style diet, obesity (especially post-menopause), alcohol

Socioeconomic status

Hormone-replacement therapy:
- oestrogen only = no increased risk
- oestrogen + progesterone = increased risk
- Related to duration and reduces after stopping HRT

Combined oral contraceptive pill

Specific "benign" abnormalities: radial scar, papilloma, florid hyperplasia, atypical lobular or ductal hyperplasia (NOT breast cyst, ductal ectasia or fibroadenoma)

Men: clinical disorders carrying hormonal imbalances (especially gynaecomastia and cirrhosis), radiation exposure, +ve family history, genetic predisposition
At least the following female breast cancers in the family:
- 2 first-degree or second-degree relatives diagnosed with breast cancer at younger than an average age of 50 years (at least 1 must be a first-degree relative)
- OR 3 first-degree or second-degree relatives diagnosed with breast cancer at younger than an average age of 60 years (at least 1 must be a first-degree relative)
- OR 4 relatives diagnosed with breast cancer at any age (at least 1 must be a first-degree relative)

Families containing 1 relative with ovarian cancer at any age and, on the same side of the family:
- 1 first-degree relative (including the relative with ovarian cancer)
- OR 1 second-degree relative diagnosed with breast cancer at younger than age 50 years
- OR 2 first-degree or second-degree relatives diagnosed with breast cancer at younger than an average age of 60 years
- OR another ovarian cancer at any age

Families affected by bilateral cancer (each breast cancer has the same count value as one relative):
- 1 first-degree relative with cancer diagnosed in both breasts at younger than an average age 50 years
- OR 1 first-degree or second-degree relative diagnosed with bilateral cancer and one first-degree or second-degree relative diagnosed with breast cancer at younger than an average age of 60 years

Families containing male breast cancer at any age and, on the same side of the family, at least:
- 1 first-degree or second-degree relative diagnosed with breast cancer at younger than age 50 years
- OR 2 first-degree or second-degree relatives diagnosed with breast cancer at younger than an average age of 60 years

A formal risk assessment has given risk estimates of:
- >=10% chance of a gene mutation being harboured in the family
- OR > 8% risk of developing breast cancer in the following 10 years
- OR >=30% lifetime risk of developing breast cancer
2/3 cases suitable for breast conservation (solitary lesion, peripheral tumour, small lesion in large breast, DCIS, <4cm, Paget's disease)
- wide-local excision(WLE)/lumpectomy with >1mm rim of healthy tissue excised + adjuvant whole-breast radiotherapy
- if impalpable lesion = localise with wires before surgery

Tumour >=4cm diameter, multifocal, central, large lesion in small breast = neoadjuvant chemo/HER2/endocrine therapy to shrink tumour + mastectomy (+ adjuvant radiotherapy if >=4 +ve axillary nodes or T3-4 tumours independent of nodal status) + breast reconstruction

+ve for hormonal receptors = adjuvant hormonal treatment with tamoxifen for 5 yrs if pre- or peri-menopausal or aromatase inhibitor hormone antagonist (anastrozole) if postmenopausal
- For premenopausal women, if after 5 yrs they are still premenopausal = continue tamoxifen for 5 yrs (but switch to letrozole for 5 yrs if postmenopausal, but stay on tamoxifen if intolerant to aromatase inhibitors)
- Offer adjuvant ovarian ablation/suppression in addition to tamoxifen to premenopausal women with ER-positive early invasive breast cancer who have been offered chemotherapy but have chosen not to have it

Advanced hormone-receptor -ve tumours or aggressive disease i.e. mets involving liver = adjuvant chemo (an anthracycline (e.g. doxorubicin or epirubicin) + CMF (cyclophosphamide + methotrexate + fluorouracil) OR CMF alone

HER2 over-expressing tumours = surgery + trastuzumab (Herceptin)

BRCA1/2 carriers = prophylactic bilateral mastectomy offered (risk reduction of about 95% - small amount of breast tissue left behind)