Breast Cancer ✅

Related Subjects: | Assessment of the Causes of Breast Tenderness/Pain (Mastalgia) | BRCA Genes (Familial Breast Cancer) | Breast Anatomy and Examination (OSCE) | Breast Cancer | Benign Breast Disease | Malignant Breast Disease | Breast Lumps: Clinical Approach | Mastitis and Breast Abscess | Malignant Breast Disease

🎗️ Breast cancer: big picture - Breast cancer is the most common cancer in women in the UK and may also occur in men. The key clinical tasks are to recognise suspicious features early, refer appropriately, confirm the diagnosis by triple assessment, and understand that definitive treatment depends on stage and tumour biology.

🧬 Breast anatomy relevant to cancer

• Site of origin: Most breast cancers arise from the terminal duct–lobular unit.
• Duct–lobule system: Lobules drain into ducts, which converge at the nipple; this is why malignancy may present as a lump, nipple change, or ductal abnormality on imaging.
• Lymphatic spread:
  • 🟦 Axillary nodes are the main drainage basin
  • 🟩 Internal mammary / parasternal nodes are another important route
  • 🟪 Smaller contributions come from other regional nodal groups

Why this matters: breast cancer can first present with an axillary lump, and nodal involvement is crucial for staging, prognosis, and adjuvant treatment decisions.

🧬 Risk factors for breast cancer

• Sex and age: risk rises with age; most cases occur in women, but men can also be affected.
• Family history: especially younger diagnoses, bilateral disease, male breast cancer, ovarian cancer, or multiple affected relatives.
• Genetic predisposition: BRCA-associated and other hereditary syndromes increase lifetime risk.
• Hormonal / reproductive factors: prolonged oestrogen exposure, nulliparity, and later menopause increase risk.
• Past history: previous breast cancer, chest irradiation, or high-risk breast pathology.
• Lifestyle: obesity and alcohol contribute to risk.

🧠 Exam pearl: Most breast cancers are sporadic, but a good family history can change surveillance, referral, and access to specialist genetics pathways.

🧪 Family history features suggesting increased inherited risk

• 👩‍👧 First-degree relative with breast cancer at a young age
• 👨 Male breast cancer in the family
• 👩‍👩 Bilateral breast cancer
• 👨‍👩‍👧‍👦 Multiple affected first- or second-degree relatives
• 🧬 Family history including ovarian, pancreatic, or prostate cancer in patterns suggestive of hereditary disease

⚠️ Clinical presentation of breast cancer

• Painless breast lump - classic presentation, but cancer may also be painful
• New unilateral nipple inversion or retraction
• Unilateral nipple discharge, especially bloody
• Skin tethering, dimpling, ulceration, or peau d’orange
• Change in breast size, contour, or symmetry
• Unexplained axillary lump
• Inflammatory change that does not settle as expected

🚦 NICE suspected cancer referral thresholds

📌 Suspect breast cancer and refer urgently when the pattern fits NICE criteria. A normal-feeling breast does not exclude malignancy if there is an axillary lump or suspicious nipple/skin change.

• 🚨 Suspected cancer pathway referral if:
  • Age ≥30 with an unexplained breast lump (with or without pain)
  • Age ≥50 with unilateral nipple discharge, retraction, or other concerning unilateral nipple change
• ⚠️ Consider suspected cancer pathway referral if:
  • Skin changes suggestive of breast cancer
  • Age ≥30 with an unexplained axillary lump
• 🟡 Consider non-urgent referral if:
  • Age <30 with an unexplained breast lump

📝 What to include in a breast cancer referral

• Breast symptoms: lump, nipple retraction, discharge, skin change, altered breast shape
• Axillary findings: lump or nodal enlargement
• Duration and progression of symptoms
• Systemic features: weight loss, bone pain, breathlessness, jaundice, fatigue
• Risk factors: family history, prior breast disease, previous irradiation, hormonal factors, alcohol, obesity

📬 Breast screening and cancer detection

• 📅 In England, people registered as female are usually first invited for NHS breast screening between 50 and 53.
• 🔁 Screening is then offered every 3 years until age 71.
• 📞 After 71, patients can self-refer for continued screening every 3 years.
• 🎯 High-risk patients may enter specialist surveillance pathways.

🏥 Triple assessment in suspected breast cancer

Breast cancer diagnosis is based on triple assessment:

• 🩺 Clinical assessment - history and examination of both breasts and axillae
• 🖼️ Imaging - ultrasound and/or mammography depending on age, breast density, and lesion type
• 🧫 Tissue diagnosis - usually core biopsy, sometimes FNAC

NICE quality standards support offering triple assessment in a single hospital visit where possible.

🧠 Why tissue matters: imaging may strongly suggest malignancy, but histology confirms the diagnosis and determines the receptor profile that drives treatment.

🧫 Histological types of breast cancer

• Invasive ductal carcinoma (no special type) - most common
• Invasive lobular carcinoma
• Ductal carcinoma in situ (DCIS) - non-invasive but premalignant / malignant precursor lesion
• Less common special types: tubular, mucinous, medullary-like, papillary and others

🧬 Tumour biology and receptor status

• ER / PR positive: hormone-driven disease; endocrine therapy is important
• HER2 positive: responsive to HER2-targeted therapy
• Triple negative: ER-, PR-, HER2-negative; often more aggressive and lacks endocrine/HER2 targets
• Grade 1–3: reflects how differentiated the tumour is

📈 Staging and prognostic assessment

• TNM staging is based on tumour size, nodal involvement, and distant metastases
• Nodal status is one of the strongest prognostic factors
• Metastatic sites commonly include bone, liver, lung, and brain
• Receptor status and grade also shape prognosis and treatment intensity

💊 Treatment of breast cancer

🎯 Core principle: treatment is individualised by stage, operability, and tumour biology. Think: local control + systemic control.

🔄 Neoadjuvant and adjuvant treatment

• Neoadjuvant treatment is given before surgery to shrink the tumour and improve operability or breast conservation.
• Adjuvant treatment is given after surgery to reduce recurrence risk.
• Modern treatment pathways are strongly influenced by receptor subtype and NICE technology appraisals.

🏥 Locally advanced and metastatic breast cancer

• Locally advanced disease may require multimodal treatment and sometimes neoadjuvant systemic therapy.
• Metastatic disease is treated with palliative intent: prolong survival, control symptoms, preserve quality of life.
• Options may include endocrine therapy, chemotherapy, HER2-targeted therapy, PARP inhibitors, CDK4/6 inhibitors, immunotherapy, and palliative radiotherapy depending on subtype and prior treatment.

🧠 OSCE / finals “do not miss” list

• 🍊 Peau d’orange
• ↩️ New unilateral nipple inversion/retraction
• 🩸 Unilateral bloody nipple discharge
• 🫧 Unexplained axillary lump
• 👨 Male breast lump or nipple change
• 🌍 Symptoms suggesting metastases: bone pain, breathlessness, weight loss, jaundice, neurological symptoms

📚 References (NICE / NHS)

• NICE NG12: Suspected cancer: recognition and referral - breast cancer section
• NICE NG101: Early and locally advanced breast cancer: diagnosis and management
• NICE NG101 recommendations
• NICE CG81: Advanced breast cancer: diagnosis and treatment
• NICE CG164: Familial breast cancer - assessment and referral
• NHS: Who breast screening is for
• NICE Quality Standard QS12: Triple diagnostic assessment