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Breast Cancer Treatment Options for a 74-Year-Old Woman

This case study follows a 74-year-old woman with a lump in her left breast. The patient's medical history, examination results, and recommended treatment options are discussed. The study also explores the Nottingham Prognostic Index, reasons for mastectomy, and post-operative therapies.

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Breast Cancer Treatment Options for a 74-Year-Old Woman

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  1. Case 3 • Jane McNicholas • Consultant Oncoplastic Breast Surgeon • East Lancashire Hospitals

  2. Case 3 • 74 year old woman presents with lump in left breast she noticed 2 weeks ago • In past, was on HRT for 7 years • No FH of breast cancer • Otherwise fit and well

  3. Case 3 • On examination - 2cm mass in left breast, hard, discrete, feels malignant. No axillary nodes to feel - P5 • Mammogram - 2cm mass in left breast - M5 • Ultrasound - 22mm lesion in breast - U5 • Ultrasound of axilla - normal • FNA - malignant cells - M5 • Core Biopsy - Invasive Ductal Cancer, Grade 2 - B5b

  4. Case 3 • What do you offer the patient?

  5. Case 3 • WLE + SLNB • Mastectomy + SLNB • Axillary node clearance only if SLNB shows metastatic disease • Post-op radiotherapy? • Post-op chemotherapy? • Endocrine therapy?

  6. Case 3 • Patient chooses WLE and SLNB • Post op histology - 19mm Grade 2 Invasive Ductal Cancer, fully excised. No evidence of lymphovascular invasion. 0/4 lymph nodes • ER - 8/8, PR - 7/8, Her2 - -ve • What is her NPI?

  7. Nottingham Prognostic Index • NPI = Grade + Lymph Nodes + (Size (cm) x0.2)

  8. Nottingham Prognostic Index

  9. Case 3 • NPI = 2 + 1 + (1.9 x 0.2) = 3.38 • Puts patient into a good prognosis group • Post-operative MDT recommended radiotherapy and endocrine therapy (Aromatase inhibitor)

  10. Reasons for Mastectomy • Patient choice • Large tumour in relation to breast size • Previous breast conserving surgery with radiotherapy • Multi-focal disease • Unable to have radiotherapy (unable to lie flat, unable to raise arm, pacemaker with left sided tumour • Patients with collagen vascular diseases • Central breast tumour - No longer a valid reason

  11. Post-op Radiotherapy • Always given after WLE - local recurrence rate unacceptably high if not given (i.e 25% in 10 years) • Given after mastectomy in patients thought to be at higher risk of local recurrence (i.e. close to chest wall, large tumour, vascular invasion, etc

  12. Post-op Chemotherapy • Given to patients at high risk of disease recurrence/progression • Usually node positive, large tumour, adverse histological features, oestrogen receptor negative, herceptin positive • Traditionally given up to 70, but this is changing - over 70 given in many more cases if fit enough

  13. Endocrine Therapy • Given to patients who are Oestrogen Receptor positive • First used was Tamoxifen. Side effects include hot flushes (50%), increased thrombo-embolic risk, increased risk of endometrial cancer • Newer agents more widely used now - Anastrozole (Arimidex), Letrozole (Femara) and Exemestane (Aromasin). Side effects are hot flushes (30%) and reduced bone mineral density

  14. HRT and Breast Cancer • The Million Women Study is the largest study looking at HRT usage and breast cancer risk • It found that taking HRT for 5 years increased the risk of breast cancer • This increased risk was for Oestrogen only and Combined Preparations but Combined preparations had a greater risk

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