Back Pain after Cancer Treatment Flashcards
What are red flag back symptoms?
- Difficulty walking or reduced power in any limbs
- Pain in thoracic region (benign pain tends to be lower down, thoracic more likely to be serious)
- Loss of sensation, particularly in legs or perineum
- Changes in bladder or bowel function, particularly retention of urine
What is the link between breast cancer and back pain?
Patients with breast cancer can be put on letrozole (hormone therapy) but this is an aromatase inhibitor and acts to reduce oestrogen levels (can lead to osteoporosis). This can accelerate bone loss and patients are monitored with DEXA scans whilst they’re on this treatment. This osteoporosis can cause osteoporotic collapse, which unlike cancer, tends to cause severe pain at onset, but improves over time. Do spine MRI if suspecting serious back pathology.
What are the symptoms of MSCC?
- Mid-thoracic spine pain
- Progressive pain in spine
- Severe unremitting spinal pain
- Spinal pain aggravated by straining e.g. when passing stools, coughing, sneezing or moving
- Pain described as ‘band-like’
- Localised spinal tenderness
- Nocturnal spinal pain preventing sleep
- Neurological symptoms: radicular pain, any limb weakness, difficulty in walking, sensory loss or bladder/bowel dysfunction
- PMH of cancer
What are the features of osteoporotic collapse?
Tends to be most severe at onset and then gradually improves over time. Considered when patient:
- Oestrogen drug treatment in past
- PMH of breast cancer > hormones
- Female
- Thoracic and lumbar spine pain
What is the process if a cancer patient has red flag back pain?
- All cancer networks have access to an MSCC coordinator. Patient needs urgent i.e. within 24-48 hours.
- MR scan of whole spine
- Might be referred to neurosurgical unit or Emergency admissions unit for assessment
- Inform patient of further red flag symptoms while they wait
What is done in early detection of MSCC?
- Inform patients at high risk of developing bone metastases, patients with diagnosed bone metastases, or patients with cancer who present with spinal pain about symptoms of MSCC. Offer info e.g. leaflet to patients/families/carers which explains the symptoms of MSCC and advises them what to do if they develop.
- Contact MSCC coordinator urgently (within 24 hours) to discuss care of patients with cancer and any symptoms suggestive of spinal metastases
What are symptoms suggestive of spinal metastases?
- Pain in middle (thoracic) or upper (cervical) spine
- Progressive lower (lumbar) spinal pain
- Severe unremitting lower spinal pain
- Spinal pain aggravated by straining e.g. cough, sneeze, stool
- Localised spinal tenderness
- Nocturnal spine pain preventing sleep
What is the treatment for MSCC?
- Radiotherapy: likely to be offered either after/instead of surgery
- Neurosurgical stabilisation: all patients with cord compression, actual or imminent, or vertebral instability should be discussed with neurosurgeons. There is evidence that neurosurgical intervention with decompression and stabilisation improves chance of patient retaining mobility.
- Analgesia
- Corticosteroids: high dose dexamethasone, to reduce any inflammation around metastatic deposit and can improve neurological function if cord compression is identified (Dexamethasone PO 8mg BD)
What can metastases in the spine cause?
Can cause osteoporosis which will lead to excess calcium being released into the blood. Can give 0.9% saline to rehydrate the patient. If that doesn’t work then give IV bisphosphonate e.g. zolendronic acid (~16mg/day - 2x8mg) and PPI.
- Saline infusion if urea is high (results from diuresis due to hypercalcaemia)
- RANK ligand inhibitor denosumab - also now given to patients with bone metastases, inhibits osteoclasts and promotes BMD
What tests need to be done in spinal tumours?
- FBC: bone marrow infiltration can cause bone marrow suppression with anaemia and thrombocytopenia
- Bone profile: hypercalcaemia can occur with bone metastases and may be asymptomatic
- U+Es: especially important if hypercalcaemia is found
- LFTs: as a marker for other sites of metastatic disease
- CT of chest/abdo and pelvis: check for metastases/tumour progress
- Isotope bone scan: needed at some stage to assess rest of the bones but not needed before treating MSCC
What is a vertebroplasty?
Kyphoplasty
Inject cement into collapsed vertebral body which can help with pain control
What is endocrine (or hormone) therapy for breast cancer?
- Breast cancers are checked for ER and PR which determines if hormone treatments will help stop the tumour from growing/spreading
- Tamoxifen = Selective Oestrogen Receptor Modulator (SERM) > blocks oestrogen receptors
- Fulvestrant is a SERM that’s licensed in post-menopausal women with metastatic breast cancer but isn’t 1st line - given IM once month
- Aromatase inhibitors: prevent conversion of androgens to oestrogen > reduced oestrogen levels to undetectable levels, only effect in post-menopausal women
How is chemotherapy involved in treatment for breast cancer?
- If patient’s cancer isn’t ER positive then chemotherapy would be offered instead of hormone therapy
- Usual recommendation for metastatic disease is to use 1 chemotherapy drug at a time (referred to as a silent agent) > check for response and change new drug if tumour continues growing
- Chemotherapy can be combined with targeted therapies as well
What is HER2 targeted therapy for breast cancer?
- Several drugs that target HER2 receptors
- Only ~15% of breast cancers are HER2 positive but if they are, the combo of chemotherapy and HER2 targeted therapy can be very effective > sometimes leads to complete response (tumour becomes undetectable on scans, will relapse at later date but may be some years)
- Transtuzumab (Herceptin) was 1st line
- Now 1st line for metastatic HER2 positive breast cancer > pertuzumab and trastuzumab and chemotherapy (specifically Docetaxel)
- Trastuzumab prevents HER2 receptor stimulation by growth factors
- Pertuzumab prevents dimerisation of HER2 receptors with other receptors in the group
What tests need to be done before trastuzumab and pertuzumab are started?
Both affect cardiac function so patients must have an assessment of their LVEF prior to starting these drugs and at regular intervals while they continue to receive them. This can be done either with an echo or a MUGA (Multi-Gated Acquisition) scan which is a nuclear medicine scan.
