Breast Cancer

Definition | Aetiology | Risk Factors | Clinical Presentation | Investigations | Management | When to Refer | References

Definition

Breast cancer is a malignant tumour that originates in the cells of the breast. It is the most common cancer in women in the UK, though it can also affect men. Early detection and treatment significantly improve prognosis.

Aetiology

Breast cancer arises from the uncontrolled growth of cells in the breast. The exact cause is not fully understood, but it is likely due to a combination of genetic, hormonal, and environmental factors. Key types of breast cancer include:

• Ductal Carcinoma In Situ (DCIS): A non-invasive cancer where abnormal cells are found in the lining of a breast duct but have not spread.
• Invasive Ductal Carcinoma (IDC): The most common type, where cancer cells spread beyond the ducts into other parts of the breast tissue.
• Lobular Carcinoma In Situ (LCIS): Abnormal cells found in the lobules, which may increase the risk of developing invasive cancer.
• Invasive Lobular Carcinoma (ILC): Cancer that starts in the lobules and spreads to surrounding breast tissue.

Risk Factors

Several factors can increase the risk of developing breast cancer:

• Age: Risk increases with age, particularly after 50.
• Family History: A history of breast cancer in close relatives, especially if diagnosed at a young age.
• Genetic Mutations: BRCA1 and BRCA2 gene mutations significantly increase the risk.
• Hormonal Factors: Early menarche, late menopause, and hormone replacement therapy (HRT) can increase risk.
• Obesity: Higher body fat, particularly after menopause, is associated with increased risk.
• Alcohol Consumption: Regular alcohol intake is linked to a higher risk.

Clinical Presentation

Breast cancer can present in various ways, and it is important to be vigilant for the following signs and symptoms:

• Lump or Thickening: The most common symptom, often painless and hard, with irregular edges.
• Changes in Breast Shape or Size: Any noticeable difference in the contour of the breast.
• Nipple Changes: Inversion, discharge (especially if bloody), or scaling.
• Skin Changes: Dimpling, puckering, or redness of the breast skin.
• Axillary Lump: Swelling or lumps in the armpit, indicating potential lymph node involvement.
• Pain: Although not usually painful, any persistent breast pain should be evaluated.

Investigations

Key investigations for suspected breast cancer include:

• Triple Assessment: This includes clinical examination, imaging (mammography or ultrasound), and needle biopsy. It is the gold standard for diagnosing breast cancer.
• Mammography: The primary imaging method, particularly effective in women over 40. It can detect tumours that are too small to feel.
• Ultrasound: Used alongside mammography, especially in younger women or when investigating a specific lump.
• Magnetic Resonance Imaging (MRI): May be used for high-risk patients or where mammography is inconclusive.
• Biopsy: A core needle biopsy is typically performed to obtain tissue samples for histological examination.
• Genetic Testing: For patients with a strong family history or diagnosed at a young age, BRCA1/2 gene testing may be offered.

Management

Breast cancer management depends on the stage and type of cancer, as well as the patient’s overall health and preferences:

Primary Care Management

As a Physician Associate, your role involves early detection, patient education, and timely referral. Ensure that any patient with suspicious symptoms is referred urgently for further assessment.

Secondary Care Management

Treatment options in secondary care include:

• Surgery:
  • Breast-Conserving Surgery (Lumpectomy): Removal of the tumour with a margin of normal tissue.
  • Mastectomy: Removal of the entire breast, sometimes with reconstruction.
  • Sentinel Lymph Node Biopsy: To check if cancer has spread to the lymph nodes.
• Radiotherapy: Often used after surgery to destroy any remaining cancer cells in the breast or lymph nodes.
• Chemotherapy: Systemic treatment to destroy cancer cells, usually recommended for higher-stage cancers or specific subtypes.
• Hormone Therapy: For hormone receptor-positive cancers, medications like tamoxifen or aromatase inhibitors are used to block the effects of oestrogen.
• Targeted Therapy: Such as trastuzumab for HER2-positive breast cancers, which specifically targets cancer cells with fewer side effects on normal cells.
• Immunotherapy: Emerging treatments that use the body’s immune system to fight cancer, typically used in advanced cases.

When to Refer

Urgent referral to a breast clinic is warranted in the following situations:

• Any new breast lump, especially if hard, fixed, or associated with other symptoms like nipple discharge or skin changes.
• Unexplained axillary lump.
• Persistent breast pain that is unexplained by other causes.
• In patients with a strong family history of breast or ovarian cancer, consider genetic counselling and testing referrals.

References

1. NHS (2024) Breast Cancer. Available at: https://www.nhs.uk/conditions/breast-cancer/ (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Early and Locally Advanced Breast Cancer: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng101 (Accessed: 26 August 2024).
3. British Medical Journal (2024) Diagnosis and Management of Breast Cancer in Primary Care. Available at: https://www.bmj.com/content/345/bmj.e8379 (Accessed: 26 August 2024).
4. Royal College of General Practitioners (2024) Breast Cancer: A Guide for Primary Care. Available at: https://www.rcgp.org.uk/clinical-and-research/resources/a-to-z-clinical-resources/breast-cancer.aspx (Accessed: 26 August 2024).

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