Breast Oncology Flashcards
what oncological treatments exist
radiotherapy
chemotherapy
hormonal therapy (oestrogen blockade)
antibodies (e.g. trastuzumab (herceptin))
what are the treatment options for a curative cancer
neo-adjuvant
adjuvant
radical (treating cancer with oncological tx alone)
what is the role of adjuvant therapy
acts as back up to oncological Tx, wont cure it on its own but improves survival
what neoadjuvant therapies are given for breast cancer
hormonal therapy- for ER +ve tumours (can be given up to a year before surgery)
chemotherapy- can allow WLE instead of mastectomy
what is the disadvantage of neo aduvant chemo
need to attend for 6 extra imaging investigations compared with adjuvant therapy
what adjuvant therapies are used in breast cancer
radiotherapy (used after WLE)
ER blockade (5 years of tamoxifen or aromatase inhibitors (letrozole, anastrozole)
chemotherapy (usually anthracycline and taxane)
trastuzumab (herceptin - antibody against HER2)
how is adjuvant radiotherapy given
external beam therapy using linac over 3 weeks
extra boost sometimes makes tx longer- indicated if young age or positive margins
whar are the SEs of ER blockade
tamoxifen- DVT, PE, (is a partial agonist, paritally oestrogenic=will cause endometrium to proliferate) bleeding, polyps, endometrial cancer, endometrial hyperplasia
(may need to switch to goserelin)
AIs- heart problems, osteoporosis
why are AIs given to postmenopausal women
cant stop ovaries making oestrogen so given to post menopausal
are more effective in post menopausal
cause less clots and endometrial cancer
what are the side effects of chemotherapy
anorexia malaise neutropenia alopecia myalgia peripheral neuropathy gCSF infections- these can cause severe axial skeletal pain from marrow stimulation
how is trastuzumab given
sc injection
one year of 3 weekly treatments
only for cancers that overexpress HER2
what are the risks of trastuzumab
allergic reactions
reversible cardiac failure
what happens at the end of adjuvant treatment
review at end
discharge
surgical review on anniversary of surgery
yearly mammograms for 3 years
what are the palliative options for breast cancer
systemic Tx for widespread disease- ER blockage or chemotherapy
radiotherapy for fungating breast disease/ bone mets
bisphosphonates for bone mets to prevent risk of #
how is radiotherapy delivered
cancer localised
beams targeted to area, avoiding heart (exposure increases risk of ischaemic heart disease)
proton or electron (better for more superficial lesions)
what is trastucumab-emtansine
combo of herceptin with chemo- delivers chemo to the tumour
used palliatively and as an adjuvant
what increases the change of breast cancer recurrence
its size
its grade
the involvement of axillary lymph nodes
is bone pain after cancer always mets
no - assess risk of the cancer to determine likelyhood
what is the best way to diagnose bone mets
localised CT or MRI of affected bone
bone scans only helpful if there is a shower of mets affected the axial skeleton (other things can make it appear hot eg #’s)
when should you worry about neutropenia during chemo
if patient septic, or well with fever admit to oncology urgently
if patient well and no fever ignore
what treatments for hot flushes caused by tamoxifen/ AI
clonidine
avoid plant oestrogens
progesterones work but safety unclear
stop ER blockage if cancer not risky
can you use the marina coil when have breast cancer
CI by companies
risk unclear
may be cases where it is left in
what tumour markers for breast cancer
CEA
CA125
what is the role of tumour markers in breast cancer
ok for monitoring, poor for diagnosis
dont check unless mets disease known to be present
dont check unless its clear of how the result will change the treatment
when are bisphosphonates used in breast cancer
in metastatic disease in high dose
with AIs if DXA scan abnormal (osteopenia or worse)
do dental work needed before starting them- risk of jaw osteonecrosis
if lack of oral tolerance try IV
what are the risks of radiotherapy
skin reactions
chornic swollen breast
(greater the volume of tissue, greater the reaction)
tends to come on at end of treatment, lasts a few weeks then heals
lymphoodema of arm - rare, refer to breast care nurses if starting, avoid instrumentation (CP, cannulation, venopuction)= of ipsilateral arm after axillary surgery
what is a new lump after breast cancer treatment likely to be
unless cancer very aggressive unlikely to be local recurrence if shortly after Tx finishing
-fat necrosis common after surgery
if uncertain do refer for triple assessment
what should you be worried about in patients who have bone mets and back pain
spinal cord compression
look out for :
-severe back pain
-radicular back
-non specific difficulty walking with no signs
URGENT MRI of spine
by time classic signs have developed too late to treat
what is the guidance for antidepressants and tamoxifen
avoid paroxetine (SSRI) antidepressents inhibit cytochrome P450 liver enzymes which are needed to convert tamoxifen to its active form
if someone has brittle depression then risk of change of anti depressant may be greater than any effect on tamoxifen
what are the risks of a HER-2 positive breast cancer
high risk of recurrence
similar distribution of mets, but esp to CNS, meninges and pleura
if headache in this group do head scan
if blurred vision condsider retinal mets
what are the risks of lobular breast cancer
Similar distribution of mets, but preferential metastases to peritoneum and gut
may be invisible on scan- Often more difficult to see on mammography too
often presents with sub-acute bowel obstruction
how can you reduce your risk of breast cancer
normal BMI
exercise
dont smoke or consume excessive alcohol
self examine but not too often as may miss changing area
can use topical oestrogen (vagifen) for vaginal dryness caused by ER blockade
uncertain
decide on symptom severity and patient wishes
risk on tamoxifen or if low risk cancer probably less
avoid if high risk cancer and on AI
when is back pain after breast cancer tx likely/possible to be mets
if high risk cancer
when should you do a head scan after breast cancer treatment
if headaches or visual disturbance or inco-ordination (particularly fleeting peripheral disturbance)
especially in patients who have had HER-2-positive cancer removed
