Breast Cancer - Oncology Flashcards
What is the pathway for patients with metastatic disease?
Investigation undertaken by medical or surgical specialty
Biopsy obtained as appropriate, surgical/ oncological referral made by investigating team
In terms of breast ca, what are the different type of oncological treatment?
Radiotherapy
Chemotherapy
Hormonal therapy (oestrogen blockade)
Antibodies (trastuzumab)
In what subgroup of patients with breast ca is neo-adjuvant hormonal therapy recommended?
ER positive tumours; less fit patients; patients in whom it is not certain if surgery will be performed, may be given for months prior to surgery
What are the advantages to neo-adjuvant chemotherapy in patients with breast ca?
Cosmetic; wide local excision instead of mastectomy
In Tayside, less extensive nodal clearance if there is an excellent response to treatment
What type of adjuvant therapy is offered in patients with breast ca?
Radiotherapy
Used routinely after wide local excision; reduces recurrence risk by half; saves one life for every 4 recurrences
Given by external beam therapy using linac over 3 weeks
What are indications for boost radiotherapy treatment in breast cancer?
Young age
Positive margins
For how long is ER blockage given as adjuvant therapy?
5 years; reduces risk of relapse by 15% at 10 years
When are aromatase inhibitors given in place of ER blockade?
Post menopausal women for whom there is a high risk of clots or previous endometrial issues
What are common side effects of tamoxifen?
DVT/ PE
Endometrial bleeding, polyps, endometrial ca
Hot flushes
Vaginal dryness
Does chemotherapy play a large part in the adjuvant therapy in breast cancer?
No; mainly radio and hormonal therapy
Improves 10 year survival by 5-10% absolute risk
What regimens are given for chemo in adjuvant breast ca?
Anthracycline - doxorubicin
Taxane - docetaxel
Common side effects of chemo?
Anorexia Malaise Neutropenia Alopecia Taxanes; myalgia, peripheral neuropathy gCSF injections may produce severe axial pain
What are gCSF injections?
Glycoprotein injection that stimulates bone marrow to produce granulocytes and stem cells with subsequent release into bloodstream
How is trastuzumab given as adjuvant therapy in breast ca?
S/C or IV
One year of 3 weekly treatment
Can cause allergic reactions and reversible cardiac failure
What is the absolute risk reduction from use of trastuzumab?
3%
What is the follow up post treatment for breast cancer?
Review
Discharge from oncology
Surgical review on anniversary of surgery then discharge
Yearly mammograms for 3 years
What is the palliative treatment for breast ca?
Systemic tx; ER blockade or chemo
Radio for fungating breast disease or bone mets
Bisphosphonates for bone mets to reduce rates of pathological #
What type of radiotherapy is given in breast ca?
Electron therapy
More superficial than proton to protect lungs and heart from irradiation
What is the only way to determine if there are bone mets?
Localised CT or MRI of affected bone
Unless rampant mets, bone scan not that helpful
Ribs can be really hard to diagnose
What is the recommended treatment for hot flushes with tamoxifen?
Clonidine 50-75 micrograms (watch out for depression or hypertension)
Avoid phytoestrogens (soya milk)
PRogestogens work but safety unclear
If very severe with a low grade cancer with a very low risk of recurrence; stop tamoxifen
Can the mirena coil be inserted in women with breast cancer?
No; CI
What tumour markers can be seen with breast ca?
CEA
Ca 15-3
Are tumour markers good for diagnosis?
No; ok for monitoring metastatic disease
DON’T use for diagnosis
When are bisphosphonates utilised in breast ca?
Metastatic disease
If a patient has osteopenia/porosis prior to AI treatment, give concurrently with bisphosphonates as AIs can induce osteoporosis
What is the option for pre-menopausal women with vaginal bleeding with tamoxifen?
Stop and put on GnRH antagonist
Cannot put on AIs because ovaries will still produce oestrogen
What should be avoided in women who have lymphoedema of an arm that has previously had an axillary node clearance?
BP measurements
Cannulation etc
If a patient with previous breast cancer presents with a new lump during or shortly after treatment what is it likely to be?
Fat necrosis; firm localised swelling, common particularly after reconstructive surgery
What investigation is warranted urgently in a patient with breast cancer with back pain?
Urgent MRI of spine
Looking for spinal cord compression
Can you take antidepressants with tamoxifen?
Yes and no
Can interfere with tamoxifen
Avoid paroxetine
Where will HER2 positive cancers commonly metastasize to?
Preferentally to CNS and pleura
If headache; get CT scan brain
Blurred vision; consider retinal mets
Where will lobular breast ca metastasize to?
Preferentially to peritoneum and gut
Presents with sub-acute bowel obstruction
What can be done to reduce risk of recurrence of breast cancer?
Normal BMI
Frequent exercise
Self-examine every month or so
Reduction in alcohol consumption
Can topical oestrogens be used for vaginal dryness assoc with tamoxifen use in breast can tx?
Uncertain; depends on symptom severity and patient wishes
If on tamoxifen; risk is low
If high risk cancer and on AI; avoid
