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REPRODUCTION & GYNAECOLOGY > Breast Cancer Oncology and Palliative Care > Flashcards

Breast Cancer Oncology and Palliative Care Flashcards

1
Q

Other than oncologists, who has the ability to diagnose cancer?

A
  • GPs
  • Surgeons (breast, plastics, urologists, hepatobiliary, ENT, orthopaedic…)
  • Physicians (gastroenterologists, dermatologists, respiratory physicians, endocrinologists,…)
  • Interventional radiologists
  • Haematologists
  • Paediatricians
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2
Q

Why are patients usually referred to oncology?

A
  • This indicates the clinician thinks there is a need for radiotherapy or chemotherapy
  • This treatment is carried out by the oncology team
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3
Q

What treatments can oncologists offer?

A

Radiotherapy
Chemotherapy
Hormonal therapy (oestrogen blockade)
Antibodies (e.g. trastuzumab (Herceptin))

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4
Q

How does treatment intent and timing change if the cancer is deemed curable or non-curable?

A

if curable:

  • Neo-adjuvant (before main tx = surgery)
  • Adjuvant (with or after => radiotherapy)

If non-curable:
=> Palliative treatment

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5
Q

WHat therapies are offered as neo-adjuvant?

A
  • hormonal (e.g. ER receptor blockers)

- chemotherapy

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6
Q

What are the advantages and disadvantages of neoadjuvant chemotherapy?

A

Adv:

  • more cosmetic outcome (shrinks tumour so that wide local excision could be performed instead of mastectomy)
  • less extensive nodal clearance done if there is an excellent response to treatment

Disadv:

  • no overall survival benefit
  • no better than adjuvant treatment
  • complications may cause patients previously fit for surgery to then not be suitable
  • 6 extra imaging investigations
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7
Q

What treatment is usually used as adjuvant therapy?

A

Radiotherapy

  • Used routinely after wide local excision
  • given over 3 weeks (+ extra tx if young and positive margins)
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8
Q

By how much does adjuvant radiotherapy reduce risk of recurrence?

A

Reduces recurrence by about half

however remember relative risk indicates if patient is already at low risk then this doesn’t make much of a difference

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9
Q

HOw many years of Tamoxifen treatment is thought to reduce the rate of relapse?

A

5 years = most benefit

10 years max therapy (not as much benefit over the 2nd 5 years but still some)

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10
Q

What are the side effects of oestrogen receptor blockers?

A
  • Clots (DVTs)
  • Partial agonist => can stimulate endometrium
    => PV bleeding
    => polyp formation
    => endometrial cancer
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11
Q

What two drugs usually are combined in chemotherapy for breast cancer?

A

Anthracyclines (e.g. Idarubicin)

Taxanes (e.g. paclitaxel)

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12
Q

What side effects may occur due to chemotherapy?

A

Anthracyclines cause alopecia and nail changes (including nails falling off completely)

Taxanes cause mylagia aches

Other Side effects may include:
- anorexia, malaise, neutropenia, peripheral neuropathy, severe axial skeleton pain from marrow stimulation

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13
Q

What adjuvant therapy can be given in HER2 expressing breast cancers?

A

Trastuzumab (Herceptin)

  • by s/c injection (sometimes IV)
  • One year of 3-weekly treatment
  • Improves survival by 3% absolute
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14
Q

What are the potential side effects of Trastuzumab (Herceptin)?

A
  • Allergic reactions

- Reversible cardiac failure

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15
Q

How are patients reviewed after treatment?

A
  • Review at end of adjuvant treatment
  • Discharge from Oncology clinic
  • Surgical review on anniversary of surgery
  • No clinic follow up but ANNUAL mammograms for 3 years
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16
Q

WHat treatments against the cancer are still used even if patients are palliative?

A
  • Systemic treatment if widespread disease (e.g. ER-blockade or chemotherapy)
  • Radiotherapy for fungating breast disease or bone metastases
  • Bisphosphonates for bone metastases as prevention of crush fractures
17
Q

What techniques have developed when delivering radiotherapy in order to reduce the radiation dose on non-target tissues?

A
  • electron beam (more superficial) rather than photon beam which is more penetrative
    (Aim to reduce lung and heart irradiation)
  • breath-hold
18
Q

Why is irradiation of the heart a risk?

A
  • increased radiation delivered to heart causes ischaemic heart disease and increased risk of MI
19
Q

Trastuzumab has been combined with another drug emtansine to create a combination preparation. What is the aim of this new drug?

A

combining chemotherapy with trastuzumab

=> Delivers chemotherapy directly to the tumour

20
Q

A patient presents with new onset bone pain after being treated for breast cancer. What factors increase the likelihood that the pain is caused by bony metastases and the cancer has recurred?

A

If previous cancer was

  • high grade
  • large in size
  • nodal infiltration occurred

=> cancer is more likely to have recurred and this pain should be presumed as bony metastases until proven otherwise

21
Q

WHat imaging modalities can be used to investigate if bone pain after breast cancer is in fact bony metastases?

A
  • localized CT (or MRI) of the affected bone
  • Ribs = problematic in terms of diagnosis
  • Bone scan only helpful if it shows shower of metastases affecting axial skeleton
22
Q

Neutropenia is common in patients undergoing chemotherapy. What symptoms would indicate an urgent referral to oncology is needed?

A
  • septic (increased HR, RR and Temp, low BP, etc)
  • OR Well but with fever

=> admit to oncology urgently

23
Q

What can be used to treat the hot flushes that patients experience with Tamoxifen or Aromatase Inhibitors?

A
  • Clonidine (careful if pt suffers from depression or hypertension)
  • Phyto-oestrogens best avoided (don’t want to add EXTRA oestrogens)
  • Progestogens (safety unclear)
  • Stop the ER-blockade?
24
Q

The mirena coil is contraindicated after a diagnosis of breast cancer. TRUE/FALSE?

A

TRUE

- Contra-indicated by the company if breast cancer is diagnosed

25
Q

What tumour markers can be tested in metastatic disease, and what is the purpose in testing?

A

CEA or CA15-3

  • useful for monitoring
  • BUT poor for diagnosis
  • Don’t check unless metastatic disease known to be present
26
Q

When are bisphosphonates usually used and what should be considered before starting them?

A
  • used in metastatic disease in high dose
  • Used with AIs if DEXA scan is abnormal
    (i. e. osteopenia or worse)
  • Get dental work done before starting them (risk of jaw osteonecrosis)
27
Q

If a patient is experiencing oestrogenic side effects of tamoxifen, what can they be swapped onto?

A

Aromatase Inhibitor (if post-menopausal)

Goserelin [GnRH antag. inj.] (if pre-menopausal)

28
Q

What adverse reactions can occur due to radiotherapy of the breast?

A
  • Skin Reaction
  • Tends to come on at end of treatment/once treatment stopped
  • Lasts a few weeks, then spontaneously heals
29
Q

What is the main complication of axillary node surgery and what should be avoided if this occurs?

A
  • Lymphoedema of arm

- avoid instrumentation (BP monitoring, cannulation) etc. of the affected arm after axillary surgery

30
Q

What would cause a new lump to appear soon after treatment of breast cancer?

A
  • Unless cancer is extremely aggressive, local recurrence is unlikely so soon after treatment
  • Fat necrosis causing firm localized swelling is
    common after trauma, particularly after reconstructive surgery
  • if unsure, refer to One Stop clinic
31
Q

What symptoms and signs would indicate a patient may have bony metastases compressing their spinal cord?

A
  • severe back pain
  • radicular back (comes round to front of ribs)
  • non-specific difficulty walking with no signs of reduced power or abnormal reflexes
32
Q

If you suspect a patient has a bony metastases compressing their spinal cord, what is the first investigation to do?

A

Urgent MRI spine

33
Q

Antidepressants and Tamoxifen are known to interact. What is the best approach to treating both conditions?

A
  • Avoid paroxetine

- If pt has brittle depression, then risk of change of anti-depressant may be greater than any effect on tamoxifen

34
Q

What metastases are most likely to occur in HER2 positive breast cancer and what symptoms should be looked out for?

A
  • central nervous system => brain and meninges
  • Pleura

=> Be aware of:

  • Headaches
  • Blurred vision - (also consider retinal metastases)
35
Q

Lobular breast cancer is more difficult to see on mammography. TRUE/FALSE?

A

TRUE

36
Q

Where does lobular breast cancer commonly metastasize to and how does this present?

A

peritoneum and gut
=> may be invisible on scan

BUT often presents with sub-acute bowel obstruction

37
Q

HOw can women reduce their risk of breast cancer?

A
  • Normal BMI/exercise
  • Self-examination BUT NOT TOO OFTEN or else you will miss the changing area
  • Don’t consume excessive alcohol
38
Q

What other gynaecological side effects can occur with oestrogen receptor blockades?

A

vaginal dryness

  • treatments for this (e.g. vagifem) may not always be suitable
  • especially if high risk cancer and patient is on an aromatase inhibitor

REPRODUCTION & GYNAECOLOGY (58 decks)

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