Breast Cancer - Oncology

Question 1

What is the pathway for patients with metastatic disease?

Answer 1

Investigation undertaken by medical or surgical specialty

Biopsy obtained as appropriate, surgical/ oncological referral made by investigating team

Question 2

In terms of breast ca, what are the different type of oncological treatment?

Answer 2

Radiotherapy
Chemotherapy
Hormonal therapy (oestrogen blockade)
Antibodies (trastuzumab)

Question 3

In what subgroup of patients with breast ca is neo-adjuvant hormonal therapy recommended?

Answer 3

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

Question 4

What are the advantages to neo-adjuvant chemotherapy in patients with breast ca?

Answer 4

Cosmetic; wide local excision instead of mastectomy

In Tayside, less extensive nodal clearance if there is an excellent response to treatment

Question 5

What type of adjuvant therapy is offered in patients with breast ca?

Answer 5

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

Question 6

What are indications for boost radiotherapy treatment in breast cancer?

Answer 6

Young age

Positive margins

Question 7

For how long is ER blockage given as adjuvant therapy?

Answer 7

5 years; reduces risk of relapse by 15% at 10 years

Question 8

When are aromatase inhibitors given in place of ER blockade?

Answer 8

Post menopausal women for whom there is a high risk of clots or previous endometrial issues

Question 9

What are common side effects of tamoxifen?

Answer 9

DVT/ PE
Endometrial bleeding, polyps, endometrial ca
Hot flushes
Vaginal dryness

Question 10

Does chemotherapy play a large part in the adjuvant therapy in breast cancer?

Answer 10

No; mainly radio and hormonal therapy

Improves 10 year survival by 5-10% absolute risk

Question 11

What regimens are given for chemo in adjuvant breast ca?

Answer 11

Anthracycline - doxorubicin

Taxane - docetaxel

Question 12

Common side effects of chemo?

Answer 12

Anorexia
Malaise
Neutropenia
Alopecia
Taxanes; myalgia, peripheral neuropathy 
gCSF injections may produce severe axial pain

Question 13

What are gCSF injections?

Answer 13

Glycoprotein injection that stimulates bone marrow to produce granulocytes and stem cells with subsequent release into bloodstream

Question 14

How is trastuzumab given as adjuvant therapy in breast ca?

Answer 14

S/C or IV
One year of 3 weekly treatment
Can cause allergic reactions and reversible cardiac failure

Question 15

What is the absolute risk reduction from use of trastuzumab?

Answer 15

3%

Question 16

What is the follow up post treatment for breast cancer?

Answer 16

Review
Discharge from oncology
Surgical review on anniversary of surgery then discharge
Yearly mammograms for 3 years

Question 17

What is the palliative treatment for breast ca?

Answer 17

Systemic tx; ER blockade or chemo
Radio for fungating breast disease or bone mets
Bisphosphonates for bone mets to reduce rates of pathological #

Question 18

What type of radiotherapy is given in breast ca?

Answer 18

Electron therapy

More superficial than proton to protect lungs and heart from irradiation

Question 19

What is the only way to determine if there are bone mets?

Answer 19

Localised CT or MRI of affected bone
Unless rampant mets, bone scan not that helpful
Ribs can be really hard to diagnose

Question 20

What is the recommended treatment for hot flushes with tamoxifen?

Answer 20

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

Question 21

Can the mirena coil be inserted in women with breast cancer?

Answer 21

No; CI

Question 22

What tumour markers can be seen with breast ca?

Answer 22

CEA

Ca 15-3

Question 23

Are tumour markers good for diagnosis?

Answer 23

No; ok for monitoring metastatic disease

DON’T use for diagnosis

Question 24

When are bisphosphonates utilised in breast ca?

Answer 24

Metastatic disease
If a patient has osteopenia/porosis prior to AI treatment, give concurrently with bisphosphonates as AIs can induce osteoporosis

Question 25

What is the option for pre-menopausal women with vaginal bleeding with tamoxifen?

Answer 25

Stop and put on GnRH antagonist

Cannot put on AIs because ovaries will still produce oestrogen

Question 26

What should be avoided in women who have lymphoedema of an arm that has previously had an axillary node clearance?

Answer 26

BP measurements

Cannulation etc

Question 27

If a patient with previous breast cancer presents with a new lump during or shortly after treatment what is it likely to be?

Answer 27

Fat necrosis; firm localised swelling, common particularly after reconstructive surgery

Question 28

What investigation is warranted urgently in a patient with breast cancer with back pain?

Answer 28

Urgent MRI of spine

Looking for spinal cord compression

Question 29

Can you take antidepressants with tamoxifen?

Answer 29

Yes and no
Can interfere with tamoxifen
Avoid paroxetine

Question 30

Where will HER2 positive cancers commonly metastasize to?

Answer 30

Preferentally to CNS and pleura
If headache; get CT scan brain
Blurred vision; consider retinal mets

Question 31

Where will lobular breast ca metastasize to?

Answer 31

Preferentially to peritoneum and gut

Presents with sub-acute bowel obstruction

Question 32

What can be done to reduce risk of recurrence of breast cancer?

Answer 32

Normal BMI
Frequent exercise
Self-examine every month or so
Reduction in alcohol consumption

Question 33

Can topical oestrogens be used for vaginal dryness assoc with tamoxifen use in breast can tx?

Answer 33

Uncertain; depends on symptom severity and patient wishes
If on tamoxifen; risk is low
If high risk cancer and on AI; avoid