Studied by 1 personHow many women will develop breast cancer?
1 in 8
What percentage of breast cancer is familial?
5-10%
surveillance & more intensive screening may be appropriate at a younger age
What genetic alterations exist in cases of Breast cancer?
BRCA 1, BRCA 2, over expression of HER2
What is BRCA1 and BRCA2?
tumor suppressor genes; mutations are associated w/ increased risks of breast, ovarian, and prostate cancer
What is HER2?
oncogene associated w/ breast cancer hat results from increase in gene number not gene mutation (breast cells grow and divide in an uncontrolled manner)
often recur and are more aggressive and harder to cure
What type of gene alteration results in a breast cancer that often recur and is more aggressive?
HER2
How many women who develop breast cancer will have a BRCA1 or BRCA2 mutation?
only 5 to 10 out of 100
(most cases are not the resul
How many women who develop ovarian cancer will have a BRCA1 or BRCA2 mutation?
15 out of 100
(most cases are not the result of inherited mutation in BRCA)
What are the WHI findings on estrogen plus progestin?
resulted in inc risk of MI, CVA, blood clots, and breast cancer
dec risk of colorectal cancer
fewer fractures
no protection against cognitive impairment or dementia
What were the WHI findings on estrogen alone?
no change in MI risk
inc risk of CVA, blood clots, questionable breast cancer
dec risk of fractures
no effect on risk of colorectal cancer
What are the WHI findings on hormone replacement therapy (HRT)?
should not be taken to prevent CV disease
use the lowest dose possible for the shortest duration to achieve tx goals
can be used for relief of hot flashes and sx of vaginal atrophy
only for women at significant risk of osteoporosis
For average risk women, how often should women between the ages 45-54 get mammograms?
yearly
How often should women older than 55 get mammograms?
every 2 years
per the ACS for an average risk individual, when should a woman begin getting mammograms?
age 45 (their choice if they want to start between 40-44)
continue yearly until 54
What percentage of cancers does mammography fail to detect?
10-20%
According to ACS guidelines, how often should high risk patients who meet the criteria get an MRI and a mammogram to screen for breast cancer?
every year
What is the ACS criteria for high risk individuals to get a yearly MRI and mammogram for breast caner screening?
lifetime risk of breast cancer 20-25% or more
known BRCA1 or BRCA2 gene mutation
first degree relative w/ BRCA mutation
had radiation therapy to the chest b/t ages 10-30
have / have first degree relatives w/ lifraumeni syndrome, cowden syndrome, or Riley-ruvalcaba syndrome
What are the most common findings on a physical exam in a breast cancer patient?
single, non-tender, firm, immobile mass most commonly in the upper outer quadrant
What are PE findings in breast cancer patients that are less common?
nipple discharge or retraction, breast enlargement or shrinkage, peau d’orange, palable axillary or supraclavicular lymph nodes
When performing a PE, what finding is indicative of breast cancer and requires an immediate referral to surgical oncology?
peau d’orange (skin thickening or changes)
How do you dx breast cancer?
ultrasound and/or mammogram to confirm suspicious PE findings —> fine needle aspirate (FNA) or stereotactic core needle bx of nodule/mass (excisional bx preferred if possible)
What tumor markers are seen in breast cancer?
CA 15-3, CA 27-29, CEA
What should you do after any positive or suspicious findings on a mammogram?
surgical oncology referral
What is ductal carcinoma in situ (DCIS)?
noninvasive tumor in the breast ducts that can progress to invasive cancer
What is the most common type of invasive breast cancer?
infiltrating ductal carcinomas
How are invasive breast cancers classified?
operable, locally advanced, or metastatic
What do some Breast cancers rely on for growth?
estrogen (meaning they have receptors for estrogen)
Do ER positive breast cancers or ER negative breast cancers carry a better prognosis? why?
ER positive because they allow for target specific treatment
What is tamoxifen?
selective estrogen receptor modulator (SERM) that inhibits the growth of great cancer cells by competitive antagonism; taken as a 20mg pill QD
How is breast cancer staged?
TNM system
Ipsilateral axilla often staged w/ sentinel node bx to evaluate node involvement
What dictates the treatment and prognosis of breast cancer?
staging and molecular testing of tumor
When evaluating for biomarkers for breast cancer, what is ER?
estrogen-receptor; associated w/ more indolent course and treated w. hormone therapy (Tamoxifen)
When evaluating for biomarkers for breast cancer, what is PR?
progesterone-receptor
what is HER2 breast cancer treated with?
trastuzumab (Herceptin)
What is the “triple negative” in regard to breast cancer?
presence of ER, PR, and HER2 (worst kind of breast cancer)
worse survival, higher likelihood of metastatic disease, limited tx options
What are selective estrogen receptor modulators (SREM)?
breast cancer tx that blocks the effect of estrogen in the breast tissue; can be used to treat women pre and post menopause
ex: raloxifene (evista), tamoxifen (soltamox), toremifene (fareston)
What is an aromatasae inhibitor?
breast cancer tx that stops the production of estrogen; best for postmenopausal women
ex: exemastane (aromasin), anastrozole (amrimidex), letrozone (femara)
Which type hormone therapy drugs can be used before and after menopause?
SERM
What is the best type of hormonal therapy to start with for postmenopausal women?
aromatase inhibitors
What is associated with a higher risk of recurrence in breast cnacer?
larger tumor, with lymph node involvement or with more invasive behavior
What is the cure for metastatic breast cancer?
none- there is no known cure
What replaced cervical cancer as the leading cause of death from genital cancer?
ovarian cancer
How many women will get ovarian cancer by age 70?
1 in 72 (most commonly in women over 50)
What are risk factors associated with ovarian cancer?
family history, age, hereditary (BRCA1, BRCA2, lynch syndrome), nulliparity, hormonal therapy
What factors offer protection against ovarian cancer?
pregnancy, oral contraceptives containing both estrogen and progesterone x5 years, breast feeding x 1 year, tubal ligation, salpingo-oophorectomy, hysterectomy
Where does ovarian cancer usually remain?
abdominal cavity (metastasis to bone, lung or brain uncommon)
What is ovarian cancer frequently misdiagnosed as?
IBS, stress, depression
What is the clinical presentation of ovarian cancer?
abdominal fullness, bloating, wt loss, dec appetite, early satiety, vague abdominal discomfort, dysuria or urinary frequency, dyspareunia, low back pain
Who is at a high risk of ovarian cancer?
women w/ FHx ovarian/breast cancer
BRCA1 AND BRCA2 gene mutations
what is recommended for women who are high risk for ovarian cancer?
prophylactic oophorectomy or salpingo-oophorectomy b/t 35-40 and once childbearing is complete
How do you dx ovarian cancer?
tumor marker- Ca-125 (95% predictive of recurrence)
genetic testing- BRCA gene
transvaginal ultrasound
abdominal/pelvic CT scan
what is the tx for ovarian cancer?
surgery (TAH w/ BSO w/ omentectomy), chemotherapy, radiation
What accounts for 95% of testicular cancers?
germ cell tumors (GCT)
How does testicular cancer present?
nodule or painless swelling in 1 testicle noted incidentally ; dull ache or heavy sensation in lower abdomen or scrotum or perianal area
(10% have acute pain and 5% have gynecomastia)
What are risk factors for testicular cancer?
personal or fhx, infertility or subferitlity, HIV, hypospadias, extragonadal GCT
What reduces the likelihood of malignancy in testicular cancer?
cryptorchidism and orchiopexy
What precedes both seminomas and nonseminoma GCTs in adults?
premalignant condition GCNIS (germ cell neoplasia in situ)
In any man with a solid, firm mass w/in the testis, what must be the considered diagnosis until proven otherwise?
testicular cancer
Why do you NOT perform biopsies for testicular cancer/germ cell tumors?
may result in tumor seeding into scrotal sac or metastatic spread of tumor into inguinal nodes
(it can spread)
How do you dx testicular cancer?
scrotal ultrasound followed by CT scan of abdomen/pelvis/chest
measurement of serum tumor markers
radical inguinal orchiectomy
restroperitoneal lymph node dissection (RPLND)
What tumor markers are seen in testicular cancer?
alpha fetoprotein (AFP), beta-hCG, lactate dehydrogenase (LDH)
What staging system does testicular cancer use?
TNM
What should you perform BEFORE chemotherapy in men with clinically advanced testicular cancer?
radical orchiectomy (whenever possible)
How do seminomas differ from nonseminomas?
more likely to present w/ localized disease
rarely spread via blood stream to other areas
very sensitive to radiation therapy
usually not marked by inc serum to markers
indolent growth
How do nonseminomas (NSGCT) differ from seminomas?
spread via bloodstream to other areas
radiresistant
serum markers are elevated
What is the most common non-skin cancer in men AND the 2nd most common cause of cancer death in men?
prostate cancer
What is a man’s lifetime risk of prostate cancer?
1 in 7
How does prostate cancer usually present?
asymptomatic until obstructive voiding issues
What are risk factors for prostate cancer?
older age, fhx, inherited gene changes (BRCA1, BRCA2, lynch syndrome), african american race, high saturated fat diet
Describe the FHx risk factors associated w/ prostate cancer?
first degree - inc 2 fold
2 first degree - inc 9 fold
higher risk w/ affected brother than affected father
high risk if relatives were young at dx
What form of prostate cancer develops earlier (< age 50)?
hereditary
Per ACS, PCP should discuss the uncertanties, risks, and potential benefits associated w/ prostate screening, and the OFFER testing. What does this testing include?
PSA and DRE
When should discussion for prostate cancer screening take place for men with an average risk?
age 50 (and expected to live atleast 10 years)
When should discussion for prostate cancer screening take place for men with a high risk?
age 45 or 40
When should average risk men have a DRE and PSA?
54-69 (greatest benefit is in this age range)
When should high risk men have a DRE and PSA?
(african americans or those w/ FHX in first degree relative dx under age 65)
age 40-54
When is DRE and PSA testing NOT recommended?
over 70 or any man w/ less than 10-15 year life expectancy
What are the PSA reference ranges?
Balls said to just know that different age ranges have different target PSA levels and to not memorize the specific numbers
What is the tumor marker for prostate cancer?
PSA
What is the PSA level required for a dx of prostate cancer?
> 4.0 ng/ml
What level of increase per year in PSA requires a referral?
> 0.75 ng/ml
What not cancerous conditions raise PSA?
ejaculation w/in past 48 hours, bacterial prostatitis, acute urinary retention
Which test do you perform first- PSA or DRE? Why?
PSA bc there is a possibility of raising PSA if recent DRE
What is the gold standard for prostate cancer dx?
biopsy, 12-14 cores
How is prostate cancer graded?
gleason score- evaluate the 2 largest centers of disease
correlates w/ tumor volume, pathologic stage, and prognosis
How is prostate cancer staged?
TNM staging system
What is the tx for prostate cancer?
watchful waiting (not harmful w/ mild sx)
can consider bisphosphonate therapy for bone metastases
What are possible side effects of tx for prostate cancer?
incontinence and impotence
When is tx required for prostate cancer?
urethral and outflow obstruction, renal failure, recurrent UTI, hematuria, bladder stones
What is used for hormone therapy in prostate cancer?
leutinizing hormone releasing hormone (LHRH)
lower amount of testosterone is made by testicles and can cause a flare initially, but this can be prevented by giving anti-androgens a few weeks prior
What are possible preventative measures for prostate cancer?
yearly PSA & DRE, low fat diet, lycopene, increased soy diet, selenium, vitamin E
what accounts for 8—85% of all primary renal neoplasms?
RCC- renal cell carcinoma (originates in renal cell cortex)
What is the 2nd most common kidney cancer?
transitional cell carcinoma of the renal pelvis
What kidney cancer is common in children?
nephroblastoma (wilm’s tumor)
What rare form of RCC is seen in sickle cell?
renal medullary carcinoma
Who is RCC 50% more common in?
men
When does RCC predominantly occur?
6th-8th decade (64 is median age of dx)
What subtype of RCC accounts for 75-85% of tumors?
clear cell
What is the classic triad of sx for RCC?
flank pain, hematuria, and palpable abdominal renal mass
What are the most common sites of metastases with RCC?
lung, lymph nodes, bone, liver, brain
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