Cram The Pance - S1E50 Breast Cancer

Episode Date: April 9, 2023

High Yield Breast Cancer Review.Review for your PANCE, PANRE, Eor's and other Physician Assistant exams. Merchandise Link: https://cram-the-pance.creator-spring.com/►Paypal Donation Link: https://bit.ly/3dxmTql (Thank you!)Included in review: Breast cancer risk factors, clinical manifestations, physical exam findings, screening, diagnostic tools including mammogram, ultrasound, fna, core needle biopsy, surgical biopsy, Paget disease of the breast, Inflammatory breast cancer, In situ, Invasive, Infiltrating ductal carcinoma, HER2 positive, hormone receptor positive, Tamoxifen, Trastuzumab, targeted therapy, chemotherapy, radiation.Become a supporter of this podcast: https://www.spreaker.com/podcast/cram-the-pance--5520744/support.

All right. So today we're going to be talking about breast cancer. Thank you, as always, for the really nice comments, the support, everybody who's donated. I really just can't thank you enough. I really do appreciate the support. So thank you so much. Let's go ahead and get started with breast cancer. So even though breast cancer is just one single topic, there's a lot to know for it. So I've dedicated an entire podcast to all the details you need to know. As always, I'll be focusing on the high-eield stuff. So breast cancer is the most common cancer worldwide, surpassing lung cancer for the first time in 2020, accounting for over two. million cases each year. It's also the most frequent cause of cancer death in women worldwide, and the second leading cause of cancer death in women in the U.S. So breast cancer, you need to be familiar with this. There's a lot to know. The screening risk factors, treatment, clinical manifestations. Let's start with the risk factors for breast cancer. There is a lot of risk factors for breast cancer. Let's talk about some of the important ones, starting with family history. So this is a big one. The breast cancer risk increases almost twofold if a woman had a woman had one first-degree relative with breast cancer and three-fold if she had two affected first-degree

relatives. Next, increasing age, quite simply, the older you are, the higher the risk of breast cancer, really no need to go any deeper into it than that. Next, dense breast tissue. So women with mammographically dense breast tissue, generally defined as dense tissue comprising 75% or more of the breast, have a higher breast cancer risk compared with women of a similar age with less or no dense tissue. The reason behind this is not completely understood, but just remember, dense breast tissue, higher breast cancer risk. Next, hormonal factors. So when we're talking about hormonal risk factors, what we're mainly referring to is increased endogenous and exogenous sources of estrogen, primarily in progesterone to a lesser extent. So whether a woman with a higher endogenous

estrogen levels or women who are taking hormone replacement therapy, like those combined with estrogen and progesterone. Any increase in these hormones can increase the risk for breast cancer. Next, reproductive factors. When it comes to risk factors related to reproductive factors, what you need to be thinking of is anything that makes a woman have more menstrual cycles. The more times a woman menstruates in her life, the higher the risk of breast cancer. So what do menstrual cycles have to do with breast cancer? Well, going back to what we just discussed about increased exposure to estrogen as well as progesterone, during the menstrual cycle, there is a surge of both estrogen and progesterone at different stages. This leads to a longer lifetime

exposure to these hormones and more exposure to estrogen and progesterone due to more menstrual cycles, more risk of breast cancer. So what are some things that lead to an increased number of menstrual cycles? Well, one would be early menarche, meaning the earlier a woman starts menstruating in life, the higher the risk of breast cancer. And the later she starts menstruating, the opposite, the lower the risk. One study actually found that for every one, one-year delay in the onset of menarchie, breast cancer risk was reduced by 5%. And then, of course, at the opposite end of a woman's life, late menopause, a later age of menopause is associated with a higher breast cancer risk. Again, same idea here. Simply put,

more menstrual cycles due to menopause not occurring until later in life, higher lifetime exposure to estrogen and progesterone, higher risk of breast cancer. Next, Nola parity, nulliparity meaning a woman who hasn't given birth to a child. So while the relationship between noeloparity and increased risk of breast cancer isn't fully understood. One of the proposed theories is what we were just discussing, that these women don't ever have a break in that estrogen progesterone cycle. This is also why breastfeeding can actually have a protective effect and decrease the risk of breast cancer as it delays the reestablishment of the menstrual cycle. So again, main takeaway here is more menstrual cycles, more breast cancer, less menstrual cycles,

less breast cancer. And then finally, we have genetic mutations that can predispose a patient to breast cancer. And while there are a few different types, the ones you absolutely need to know are Broca 1 and Broca 2 mutations. It's estimated that 5 to 10% of breast cancers are linked to inherited genetic mutations with Broca 1 and Broca 2 mutations being the most common. So you need to know these. So Braca 1 and Brocka 2, they've gotten such a bad name that when you hear the name, Brocka 1 and Brocka 2, you automatically associated with cancer. But Bronca 1 and Brocka 2 are actually the good guys. They're tumor suppressor genes.

And it's only when these genes have mutations that we have issues. When these genes are not properly, when these genes, I'm sorry, when these genes are properly functioning, they actually have the opposite effect. They produce proteins and help repair damage DNA and protect you from getting certain cancers. But if you inherit a pathogenic mutation in the Broca 1 or Brocka 2 gene, the mutation prevent them from working properly, and that puts you at a higher risk to get breast, ovarian, as well as other types of cancers. So just a little side note, there's actually four main types of cancers associated with Broca 1 and Broca 2 mutations. Obviously, breast cancer, as we just discussed,

is a big one. Ovarian cancer is another. And then to a lesser extent, prostate and pancreatic cancer. It's important to know those four are associated with Broca 1 and Bracca 2 mutations. It may come up on an exam. So how can you remember that? Well, Braca sounds very much like Barack, Brahma, Barack, which made me think of our past president, Barack Obama. The first letters in past President Barack Obama are P-P-B-O. The PA in past, helped me remember pancreatic, because those are the first two letters in pancreatic, past, pancreatic, PA, PA, the PR and PR in PR and PR-P-R-N-B-R-B-R helped me remember breast, and the O-BOMA-O-VARIA. So again, remember Bracca as in Bracca 1 and Brock of two mutations, sound like Barack as in past President Barack Obama, pancreatic, prostate,

breast and ovarian cancer. That'll help you remember the four cancers that are associated with it. All right. So getting back on track, those are the risk factors you need to know. Now, there are, of course, other risk factors, smoking, alcohol use, obesity, exposure, diionizing radiation. But the ones I listed above, those are the ones you really need to remember, as those are often tested on. So remember, your older patient with dense breast tissue, a bunch of extra estrogen, lots of menstrual cycles, and a broca mutation. That's what you need to know. Let's move on to your clinical manifestations next.

So generally, what you're going to be looking for, the classic presentation in your clinical manifestations of a malignant breast tumor, the key terms are hard, immovable, irregular mass. So a hard, immovable, single dominant lesion with ill-defined or irregular borders. Now, of course, these features alone cannot reliably distinguish a benign tumor from a malignant tumor. And also keep in mind in real life, there may not always be a palpable mass, which is why screening is important. But for the exam, those are the key terms you're looking for when they describe a malignant mass, hard, immovable, unlike, say, a fibro idanoma that we know rolls all around, and irregular or ill-defined.

Those are the three key terms to look out for, hard, immovable, irregular. Now, on physical exam, there's a few important things to be aware of, and it all depends on the type of cancer involved. So, on physical exam, I want you to remember six key findings, which are, are all neatly packaged into a mnemonic that I came up with, and that mnemonic goes by the name of Aureola, very fitting for the current topic, and it should help you remember the key physical exam findings to look out for in a patient with breast cancer. So Ariola stands for axillary lymphadenopathy, retraction, erythema, orange peel, leaking, and atopic dermatitis. Let's break down what those means, starting with A, which stands for axillary lymphadenopathy. So this is very important.

Anytime you do a clinical breast examination, you need to check the axiolidom. lymph nodes. The axillary lymph nodes receive 85% of the lymphatic drainage from the breast, meaning if breast cancer is going to spread to a regional lymph node, it's likely going to be the axillary lymphadenopathy. So keep this in mind, axillary lymphadenopathy is one of the key findings in locally advanced breast cancer. So that's what A stands for. What about R? So the R stands for retraction, as in retraction or inversion of the nipple, which occurs in sub-aeriorolar or central malignancies of the breast. This can also be seen in inflammatory, breast cancer. So these structural changes occur beneath the breast from these malignancies, which can

cause the nipple to retract into the breast. So that's what the R stands for. Next, E stands for erythema. So skin changes like erythema, which is a reddening of the skin, can be a warning sign of locally advanced breast cancer, and more importantly, a specific subtype of breast cancer called inflammatory breast cancer, which causes this warm, red, thickened breast tissue combined with edema. and it can look very much like mastitis clinically. So if you have a woman who is being treated for mastitis with antibiotics, she's not getting any better. Make sure inflammatory breast cancer is on your list of differentials. So remember, E is for erythema.

Next, the O stands for orange peel, aka po de orange, which is a French term meaning orange peel or orange skin. So what does that have to do with breast cancer? Well, this is a super important finding that they love to mention in exam questions and another potential finding in inflammatory breast cancer, which we just, discussed. So due to the erythema thickening and dimpling of the overlying skin that we see in inflammatory breast cancer, the skin can take on the appearance of the appearance of an orange peel. And that's why they call it orange peel or poe to orange appearance. And just an interesting side note,

the term inflammatory, as in inflammatory breast cancer, is actually a misnomer since there is not actually true inflammation present. The clinical signs that suggest inflammation are not actually due to infiltration of inflammatory cells, Rather, it's caused from tumor cells invading the dermal lymphatics, causing the called quote-unquote inflammation. So that might be helpful for patho. Moving on to L. L stands for leakage as a nipple leakage. The L and ariola stands for leakage.

Nipple leakage or nipple discharge. The discharge can be cirrus, milky, or bloody. And although there's much more common causes for nipple discharge like a benign papilloma, cancer should always be on the list of differentials as it's found in 5 to 15% of patients with pathologic nipple discharge. And then the last letter A stands for atopic dermatitis, aka eczema. So let me explain this one. So do patients with breast cancer develop atopic dermatitis? They do not.

But similar skin changes that are often mistaken for atopic dermatitis, aka eczema, are seen in a condition called Pagis disease of the breast, which is a rare condition associated with an underlying breast malignancy. So the key physical exam findings in Pagis disease is an eczema-like eruption of the nipple in areola. So if you see them describing this persistent, scaling, eczemotose, or ulcerated lesion involving the nipple, ariola complex, very similar to the dermatologic findings in a patient with atopic dermatitis, make sure you think of padis disease of the breast.

All right. So again, on physical exam, be looking out for ariola, axillary lymphadenopathy, retraction, erythema, orange peel, leaky, and atopic dermatitis. Those are the main findings that will be on your exam question. Next, I want to quickly break down a few of the most important types. of breast cancer you should be familiar with and also explain a bit of the terminology you're going to hear. So there's a few terms that are used when we're talking about breast cancer in situ, infiltrating ductal lobular. Let's break this down to have a better understanding. So in the breast, you have lobules and you have ducks.

The lobules, they produce the milk and the ducks, they carry the milk from the lobules to the nipple. So breast cancer can be in either one of these locations, the lobules or the ducks. So if there's cancer in the lobule, you guessed it, it's called lobular carcinoma. and if the cancer is in the duct, it's called ductal carcinoma. That's step one, where it's located. Step two, does it stay put or is it spreading? So if it stays put, if it's combined to the lobule or it's combined to the duct, this is called incitue. The Latin translation of incitue is in its original place or location.

So if the lesion is in the duct and it's confined to the duct, that would be called ductal carcinoma in situ. If it breaches the structure, if it breaks through the basement membrane and spreads from the duct or the lobule to the surrounding structures, this is known as a lot of the infiltrating or invasive, so infiltrating lobular carcinoma or infiltrating ductal carcinoma. All right, so now that we have a basic understanding of the terminology, let's review a few specific types that you'll likely be asked about, starting with infiltrating ductal carcinoma. So infiltrating ductal carcinoma, we know, is a cancer that has spread from the duct of

the breast. It's breached the basement membrane. So why is infiltrating ductal carcinoma, aka invasive ductal carcinoma, so important? Well, it's the most common type of invasive breast cancer accounting for 70 to 80% of invasive lesions. So definitely commit this one to memory. Next, we have inflammatory breast cancer. So inflammatory breast cancer, we talked about this one a little bit before. This is an aggressive form of locally advanced breast cancer. It's a pretty rare disorder accounting for only about one to five percent of invasive breast cancers. So why should you bother knowing about a relatively rare type of breast cancer? Well, it has a unique presentation, and any time something is unique, it's often tested on. So patients with inflammatory breast cancer,

will often have this rapid onset of breast theretema, adema, along with the skin becoming warm, thickened and dimpled, which is often described as poe to orange or orange skin appearance. That's the key. The orange skin appearance, as we discussed before in physical exam findings,

very important to know that. And then finally, we have Padgett disease of the breast. So this is another rare one, accounting for only 1 to 3% of new cases of female breast cancer, but again, unique presentation. So as we discussed before, the classic appearance for Padgett disease is this scaly, itchy,

itchy, eczemotose ulcerated lesion that begins on the nipple and then spreads to the aureola. The pathologic hallmark for this disease is the present of malignant intraepathial adenal carcinoma cells, also known as Padgett cells within the epidermis of the nipple. So for Padgett's disease of the breast, the key is remembering that scaly, itchy, eczema-like eruption on the nipple and ariola. That's why in my mind, I changed its name from Padgett's disease, to Padgett's disease. Padge itch as an ITCH.

That helped me remember this is the one associated with the itchy eczema-like rash. So again, remember, instead of Padgett's disease, remember it as Padge-Ich disease. So there's many other histologic types of breast cancer, medullary, tubular, papillary, apocry, and we'll discuss some of the receptor positive subtypes when we go over treatment. But in general, for the exam, I would really suggest focusing on the ones I went over above, as those are the ones that often come up in exam questions. Next, let's talk about screening protocols. Now, screening protocols, they vary.

They vary from the medical society referencing the patient's risk factors. This is a big topic of discussion, and in many areas, there is no clear consensus. But for the exam, there's one age bracket that's widely agreed upon that you need to remember, which I'll go over in a second. Let's first break down each of the age brackets and discuss when you screen with mammography and when you don't. And this is going to be for patients at average risk for breast cancer. So starting in women under 40 with average risk.

risk, screening mammography is not recommended. So no screening guidelines currently recommend routine screening for average risk women who are under 40 years of age. So don't even worry about this one. Next, 40 to 49 years old, individualized. So the name of the game for this age bracket is shared decision making between the provider and the patient. It's going to be individualized for each patient. There's no clear consensus in this age bracket between the medical societies as the net benefit of breast cancer screening is less clear for women in their 40s. Some societies say yes, others know. So in this age bracket, the general approach is discuss this with your patient,

individualize the decision based on the benefits and harms of screening and their personal values and preferences. So overall, I wouldn't worry too much about this one. The next one, though, this is the one that you need to know. 50 to 74 years, mammography every one to two years. This is the age bracket that almost all organizations agree on, a woman that has an average risk of breast cancer between the ages of 50 to 74 years, should be screened with the mammography every one to two years. This is consistent with most major U.S. and international medical group recommendations,

including the U.S. Preventative Services Task Force. So this is the one you need to know. The other age brackets, it's going to be individualized decisions based on risk factors, etc. But for the exam, remember, 50 to 74 years, mammography every one to two years. That's the high-yield screening info you need to know. Moving on to diagnosis and your diagnostic tools. So for diagnostic evaluation of suspect,

breast cancer, there's basically three modalities you need to be aware of, ultrasound mammography and biopsy. Let's talk a bit about each when you use them and what you're looking for. Let's start with the most important and that, of course, is mammography. So mammography, this is really the best modality to not only detect breast cancer at an early stage through screening, but also for the diagnostic workup of patients after a tumor is detected. Mammography often detects a lesion before it is palpable by clinical breast examination and on average, one to two years, before you before noted by breast self-examination. So, MAMO is very important for you to know.

There's a few important things to commit to memory for the exam. Number one, 40 years or older. So first, this imaging modality is generally used in patients 40 years of age or older. Younger patients will usually have an ultrasound rather than a mammoth, at least initially, and I'll explain a bit more about that when we go over that modality next. Second thing, when it comes to mammographic feature suggestive of breast cancer, there's a couple key phrases you want to have in your head. Speculated and microcalcifications, which instead of the word microcalcifications, I used to call them small stones because it was easy to remember,

speculated small stones. It rhymes. They all start with an S. Anyways, let's start with speculated, as in speculated soft tissue mass. If you see this described on mammoth, very, very likely a malignancy. 90% of speculated soft tissue masses represent invasive cancer. This is the most specific mammographic feature of malignancy. Speculated just means the mass has these little spikes or projections coming out of it. So remember, if you see a speculated soft tissue mass on an exam question, it's cancer. Second, small stones, aka microcalculsifications. So microcalcifications are seen in approximately 60% of cancers on mammoth. These microcalcifications actually represent necrotic cells in the center of a cluster of tumor cells. So remember on mammo, if you see speculated small stones,

a.klaucosifications, it's very, very likely in malignancy. So just keep repeating that in your head. Spiculated small stones, speculated small stones. And then the last thing I think you should know for MAMO is your BIRAD score. So all mammograms are read by a radiologist and assigned a BIRAD score. ByRD stands for breast imaging, reporting, and data system. And it's not only used in MAMO, but also for ultrasound and even MRI of the breast to determine the relative likelihood of a malignant diagnosis based on the imaging findings. So the radiologist assigns a bi-rads score from one to five, technically zero to six, but I'll go over that in a minute. And the higher the number, the higher the chance of cancer. The bi-rat score also helps determine how soon the patient should follow up.

So let's break this down, starting with bi-rad 1 and 2. So if you get a bi-rad score of 1 or 2, the chance of malignancy is essentially 0. This patient should follow up annually as per screening guidelines. So bi-rad 1 and 2, I just used to remember, not cancer, see you next year. Byrad 3. So byrad 3 score means this is most likely benign. Likelihood of malignancy is less than 2%, but there were some areas that were a little suss, focal asymmetry, a group of round calcifications. So these patients, instead of the regular one to two year screening, generally you'll see these patients back in six months for repeat imaging. So for birat 3, I just used to remember, see ya in 6. Byrad 4 and 5. So by rad 4 and 5, you're getting

a biopsy. Byrads 4 is actually broken down into subc categories, A, B, and C, depending on the likelihood of malignancy. Don't memorize that, though. Just remember, Byrad 4 or 5, biopsy in most cases. And for those of you who like to get technical, there is Byrad 0 and Byrad 6, like I talked about before, but you don't need to know those. Byrad zero just means it was inconclusive and needs further imaging. Sometimes the mammoth was just sub-optimal, maybe there was improper positioning. And Byrat 6 just means the mass was already biopsyed and proven to be malignant. So remember, again, by rad 1 and 2, not cancer, see you next year. Byrad 3, Little Suss, CN6, birat 4 and 5, biopsy. All right, next diagnostic tool is ultrasound. The most important thing

you need to know for ultrasound is it's the imaging modality of choice in women under 30. So why do we use ultrasound in women under 30 and not mammography? It's a couple of reasons. First, most breast lesions in young women are not visualized on mammography due to the density of breast tissue and young women. This limits the sensitivity of mammoth. And then two, There is an increased radiation risk with mammography, so it's best to avoid any radiation exposure in young patients if possible. Ultrasound is also useful as an adjunct to Mammo to give some details about the mass. It can help differentiate between solid and cystic masses. It can be used to assess axillary lymph nodes, as well as provide guidance for interventional procedures like biopsy.

Main takeaway here, though, breast mass and a patient under 30, your initial imaging will be ultrasound. So you might be thinking to yourself. You said, Mamo 40 and older. ultrasound under 30. What about women in their 30s? In that in between age range, what about them? So that's one of the gray areas where there's not a specific guideline. In general, either ultrasound or mammal can be used in this age group. Up to date states it's reasonably acceptable to start with an ultrasound as the initial imaging modality, but with a low threshold for using mammography if clinical suspicion is high. So that's ultrasound. There are some other imaging modalities,

MRI, which can be utilized for a preoperative evaluation. There's also functional breast imaging techniques like positron and mission mammography. Those aren't used as often, but just be aware that they do exist. Nothing really to know for the exam with those. All right, finally, let's talk about your biopsies. So who's getting a biopsy? Well, any patient that has a suspicious mammographic abnormality, remember, this would be your birat four and five patients, or even with a patient that just has a very clinically suspicious palpable breast mass, they need to have a biopsy done. Let's talk about the different types of biopsies starting with your fine needle aspiration. So a fine needle aspiration or FNA, it's a quick, minimally invasive. Small needle is going to be placed in the

mass under ultrasound guidance. So those are the pros. It's quick and easy. The results normally come back quick. But what are the cons? Well, there's a high rate of false negatives. It also cannot reliably distinguish between in situ and invasive cancers. And oftentimes, due to the small tissue sample obtained with an FNA, you can't always check for receptor status, like your estrogen, progesterone, and HDR2 receptors, which I'll go over this in more detail when we talk about treatment. So FNA, it's quick and easy, but it can't always provide all of the necessary details, and because of its high rate of false negatives, it's not the best test.

The better test and the preferred initial biopsy procedure is a core needle biopsy. So a core needle biopsy is generally preferred as the initial biopsy procedure. It's a little bit more invasive compared to an FNA. as you're using a larger needle. An FNA uses a 23 to 27 gauge needle. A core needle biopsy uses a 9 to 14 gauge. In addition, it also requires a small incision to allow entry of the larger needle.

But this larger needle increases the amount of tissue obtained and allows for some improvements over an FNA. First, it's more sensitive at detecting a malignancy. A core needle biopsy has an 87% sensitivity compared to an FNA at only 74%. This larger sample also allows for more reliable determination of hormone receptor levels like estrogen, progesterone, and H.R2 receptors. And finally, it's able to distinguish

between inciteal lesions and invasive carcinoma, which as we talked about before, an invasive or an FNA could not determine the difference between those two. So corn needle biopsy, it's a bit more invasive, but it's more sensitive, allows for receptor testing and can distinguish between in situ and invasive cancer. And for those reasons, remember, it's generally the initial biopsy of choice. Finally, we have a surgical or open biopsy. So surgical or open biopsy, this is clearly the most invasive of all the procedures, and most of the time will not be the initial method of diagnosis. It's performed in fewer than 10% of cases.

Usually this is going to be performed when a needle biopsy, like with FNA or core needle, is not feasible, or if the core needle biopsy results were inconclusive. All right, so that was diagnosis. There's a lot to know. High-yield takeaways. Remember, mammo, women 40 and older. Look for your speculated small stones, aka microcosifications, ultrasound, under 30 or as an adjunct to mammal for more info.

For biopsy, FNA is quick and easy, but lacking in detail. Cornedle biopsy is your preferred method, gives you the most bang for your buck, distinguishing between in situ and invasive cancer, as well as providing info on receptor status. Finally, surgical biopsy only if all else fails. That's diagnosis. Let's move on to the last section and talk about some of the treatment options for breast cancer. Now, the treatment for breast cancer, it's complex, it's highly individualized. There's many factors to consider, including age, TNM stage, tumor type,

hormone receptor status, risk of recurrence, it can be really overwhelming and you really don't need to know all of the details for the exam. You really just need to know the basics. So let's break down each of the treatment options, focusing on just the need-to-know stuff. Let's start with your surgical options, starting with breast-conserving therapy. So breast-conserving therapy, this is usually going to be a lumpectomy plus radiation and a sentinel biopsy. So breast-conserving therapy, which is performed with a lumpectomy, is an alternative to mastectomy for certain patients with early stage breast cancer. This is not going to be appropriate for all patients,

patients that have inflammatory breast cancer, patients with diffuse malignant microcosifications, as well as a number of other contraindications, but if the patient is able to have a lumpectomy, a lumpectomy can remove the tumor, but not the breast itself. So the breast is conserved. A couple of things to know.

First, in most patients who have a lumpectomy, it will need to be followed by radiation therapy. This is going to eradicate any, microscopic residual disease. Then the second thing is these patients will always require evaluation of the axillary lymph nodes. If they have a clinically negative axillary examination, you can do something known as a sentinel node biopsy. So sentinel node biopsy helps guide the surgeon to know which lymph nodes need to be biopsy

rather than just biopsy all of them. The surgeon injects contrast near the tumor. They watch the contrast get absorbed by the surrounding lymph nodes. And whichever lymph nodes absorb the contrast first, those are the lymph nodes that the cancer would first spread to, so those are the ones that are going to be sent out to pathology. So lumpectomy, no, this is an option for patients with early stage breast cancer. Tumor can be removed without removing the breast, usually needs to be followed by radiation and evaluation of the axillary lymph nodes.

Next, let's talk about mastectomy. So mastectomy is a complete removal of the tissue of the breast, as we discussed before. Not all patients are going to be candidates for a lumpectomy. So patients who have inflammatory breast cancer, diffuse malignant microcosifications, multi-centric disease with two or more primary tumors prior radiation of the breast, don't memorize those. But these patients, they can't have a lumpectomy, so they're going to require a complete removal of the breast, a mastectomy. It's also in many cases decided by the patient to have a mastectomy. Some women prefer to avoid future post-operative radiation as required with a lumpectomy,

or maybe they want to avoid further screening and biopsies. Some women also are just at a higher risk due to genetic mutations and would prefer to have a mastectomy instead of a lumpectomy. So a number of reasons why a woman may have this procedure rather than a lumpectomy. And then finally, just as in lumpectomy, patients with a mastectomy need evaluation of the axillary lymph nodes. All right. Next, let's quickly talk about radiation. It's really not a lot to know here. There's many reasons a woman might require radiation. Of course, as we discussed before, most women who have a lumpectomy, the breast conserving therapy,

will require radiation to eradicate and. any tumor deposits remaining. Most patients, though, that have a mastectomy only will require radiation if they have a high risk for local recurrence. So most patients with lumpectomy need radiation, whereas mesectomy not as common, only specific high risk patients. All right. So the next part of treatment, it gets a little bit more complicated.

I'm going to try to simplify it as best I can. So with breast cancer, there's something known as positive receptors or receptor positive breast cancer. We touched on that a little bit before. So patients with breast cancer can have these positive. positive receptors that can be influenced by certain hormones and proteins, which can cause the cancers to grow and spread. Knowing which receptors are positive is really important because there's specific targeted treatments depending on which receptor is positive or negative. So again,

positive receptors, they're just like an on switch for the tumor to make it grow. There's basically three subgroups that you need to know. Patients with positive estrogen or progesterone receptors called hormone receptor positive, patients with positive H.E.R.2 receptors, aka human epidermal growth factor. And then finally, the last subgroup patients who are negative for all of them. So negative for estrogen, progesterone, and HER2, which is called being triple negative. And of course, you can have any variation of the above positive for all three, negative for all three, positive for just one, not the others, and so on. So let's start with your hormone receptor positive breast cancer. So hormone receptor positive breast cancer means the breast cancer cells have,

either estrogen or progesterone receptors, both, just one. These patients are in a more favorable position because this type of cancer in some cases can be treated with alternatives to chemotherapy. And obviously, if we can avoid chemo, that's ideal. So what options do we have in this type of cancer? Well, since these positive receptors allow estrogen and progesterone to promote the growth of cancer cells, the goal is obviously to block those hormones. And since estrogen plays a more significant role in the growth and development of breast cancer cells compared to progesterum. What we wind up doing is attempting to either deplete estrogen production or block it altogether. There's a number of ways to do this and don't memorize all of them, but aim to just have

a general understanding. So let's start with blocking estrogen receptors. So tamoxifen is a big one, tamoxifen as well as raloxifen, are selective estrogen receptor modulators, or also known as serms. They work by blocking those estrogen receptors in the breast, which prevent estrogen from binding and stimulating the growth of cancer cells. So that's one option. Next is your aromatase inhibitors, anastrozoz, letharzole. These are mainly utilized in postmenopausal women, and they work by blocking the enzyme aromatase.

And aromatase, if you're not familiar with it, its job in the body is to divert androgens like testosterone into estrogen. So by blocking aromatase, we in turn decrease estrogen in the body. And then finally, we have your targeted agents like a bemacoclib. These are CDK-4-6 inhibitors. You don't really need to memorize these, but just recognize that these meds are often combined with the other agents we discussed above as they enhance the benefit of those other estrogen-regulating medications. All right, so that's patients with hormone receptor positive breast cancer.

It's a lot, but just focus on shutting down or blocking estrogen with meds like tamoxifen or anastrozole, combining it with your targeted agents. Next, what about patients with positive HER2 receptors? How do we treat those patients? Well, from an exam standpoint, it's actually fairly easily. It's basically just one med you need to know. So HER2 positive breast cancer, this occurs when breast cancer cells have a higher than normal level of something known as HER2, human epidermal growth factor receptor 2. So normally, this HER2 protein helps breast cells grow, divide, and repair themselves, no big deal.

But in this case, something goes wrong with a gene that can. controls the H.R2 protein, and you have this over-expression of HER2. And this can obviously lead to the breast cells growing and dividing uncontrollably. So how do we treat this? Well, in this case, we have a specific targeted therapy, and this is with something known as Trastusimab. This is the treatment you need to know for H.E.R2 positive breast cancer. This is usually going to be combined with chemo, as this is a more aggressive form of breast cancer. It also may be combined with another targeted therapy called pertuzumab. But for the exam, just remember trastusumab because if you get a question on this, this is the med most commonly used

and it's the one the most likely ask you about. So trastusumab is a type of targeted therapy and it works by targeting and binding to the H.R2 protein on the surface of cancer cells and it prevents the cancer cells from receiving signals to grow and divide. So for HER2, you need to know Tras Taz2zumab. You remember that because HER2 has a two in it and so does Tras 2zumab. So if if you see an exam question and they ask you, they say the patient's H-E-R-2-positive, which men are you going to give them? Look for the med with a two in it. Her two gets Tras-2-Zumab. Two gets two. So again, remember, H-E-R-2 positive. Just remember Tras-2-Zumab. All right, I think I drilled that one home. Finally, we have chemotherapy. So with chemotherapy, you'll hear the terms

adjuvant chemotherapy and neo-adjuvant chemotherapy. Neoadjuvant chemo. Neo-adjuvent chemo just means it's given prior to the main intervention, which is usually surgery, to improve the outcome, shrink the tumor size, and then adjuvant chemo is just chemo that's given after surgery to lower the risk of recurrence by eradicating any microscopic foci of cancer cells remaining. So a number of reasons why chemotherapy will be utilized, patients with a high risk of recurrence, cancer that's spread to the lymph nodes or other parts of the body, patients with positive HGR2 status, patients with triple negative breast cancer and a tumor size over 0.5 centimeters. Nothing, I'd advise memorizing or waste to, more than a couple minutes on for the exam. Just be aware it's another treatment option utilized for

breast cancer. All right. So that is treatment. It's a lot to know. Let's do a triple distilled 30 second recap starting with lumpectomy. Lumpectomy is a breast conserving therapy. Removes the tumor, but not the breast. If a patient has something bad like inflammatory breast cancer, prior radiation of the breast, diffuse malignant microcosifications, got to do a mastectomy, which is complete removal of the breast. Next, radiation. Most patients with a lumpectomy will get this compared to only high risk mastectomy patients. If they're hormone positive, stop or block the estrogen, tamoxifen, letharzozol, plus targeted agents. If they're HER2 positive, hit them with Trasthusumab, treat two with two.

And then finally, chemo for your high-risk patients, cancer that is spread, etc. That's treatment, and that is breast cancer. Let's do five quick questions to wrap it up. Question one. A 52-year-old woman presents to her PCP complaining of a new lump in her breast. Mammography confirms the presence of a 2-centimeter speculated mass, and biopsy confirms H.E.R. 2 positive breast cancer, which therapy listed below would be most appropriate to treat H.E.R.2 positive breast cancer in this patient. Choice A, tamoxifen, choice B, trastusumab, choice B,

and phlixomab. Again, A, tamoxifen, B, trastusamab, C, letharzrazoam, D, and Fliximab. So that is going to be option B, trastusomab. So remember, with her H.E.R.2 positive breast cancer, look for the medication with a two in it. Her two is treated with tracetuzumab, the targeted therapy that binds to the H.R2 protein and stops the cancer cells from growing and dividing. Let's talk about why it's not the other options. Answer A and C are most utilized in hormone receptor positive breast cancer targeting your estrogen. Tamoxifen is a selected estrogen receptor modulator, and letharazole is an aromatase inhibitor. Then finally, answer D in Flixomab, that's a TNF inhibitor that's commonly used in ulcerated colitis.

not H.E.R2 positive breast cancer. Question two, a 57-year-old woman presents for a routine mammogram. The mammogram reveals a suspicious lump in her breast classified as a biarrads 4, and a biopsy confirms that it is malignant. Her doctor explains that the type of cancer found is the most common form of invasive breast cancer, counting for 80% of all invasive breast cancer cases. What type of cancer does this patient likely have? So that's going to be infiltrating ductal carcinoma. So infiltrating or invasive ductal carcinoma, it's the most common type of invasive breast cancer accounting for 70 to 80% of invasive lesions. Question three, a 51-year-old woman presents to the office today complaining of itching redness and flaking skin on and around her right nipple. The condition

was initially diagnosed as eczema, but she has found little to no improvement with the topical corticosteroids prescribed by her PCP. Biopsy is performed, which confirms the diagnosis of a rare form of breast cancer. What is the most likely diagnosis in this patient? Padgett disease of the breast. Remember, anytime you see a description of a scaly, raw, itchy, ulcerated lesion on the nipple and ariola, similar to the presentation of eczema, always have Padgett disease in your list of differentials, as this rare condition associated with breast cancer can cause eczema like changes to the skin of the nipple and ariola. Remember, instead of Padge it's disease, remember it as Padge itch disease, ITCH, to remember the itchy, scaly findings.

Question four, a 27-year-old woman notices some discomfort in her right breast and discovers a lump while performing a self-examination. She schedules an appointment with her primary care physician who conducts a physical exam and decides to order an imaging test to gather more information about the mass. Which screening test is her doctor likely to recommend? So that is going to be ultrasound. So remember, in women under 30, as the breast tissue, is more dense and the fact we're trying to avoid any unnecessary radiation to the breast in this age group, ultrasound is ideal to use as the initial screening test for a breast mass. Question 5. A 61-year-old woman was recently diagnosed with early stage breast cancer and underwent a lumpectomy

to remove the primary tumor. During the procedure, a sentinel biopsy was performed, which was negative. After the surgery, her medical team discussed additional treatment options to reduce the risk of cancer recurrence. Which additional form of treatment will the patient most likely need based on her diagnosis and the procedure she underwent. So that is going to be radiation therapy. So most women who get a lumpectomy, aka breast conserving surgery, will require whole breast radiation

to eradicate any tumor deposits remaining. This is the majority of patients. So remember, when a patient gets a lumpectomy, assume it will be combined with radiation therapy. All right, so that was your breast cancer review. I hope that was helpful. Thank you, as always, for listening to the podcast. And thank you so much for your support.