Breast Oncology

Question 1

is oncologist involved in cancer diagnosis?

Answer 1

no

Question 2

4 types of oncological treatment?

Answer 2

radiotherapy
chemotherapy
hormonal therapy (oestrogen blockade)
antibodies (trastuzumab (herception))

Question 3

types of medical treatment if intent to cure?

Answer 3

neo-adjuvant (before surgery)

adjuvant (after surgery)

Question 4

types of treatment if non-curative intent?

Answer 4

palliative

Question 5

what can be given as neo-adjuvant treatment?

Answer 5

not radiotherapy
hormonal therapy
chemotherapy

Question 6

when is neo-adjuvant hormonal therapy used?

Answer 6

ER positive tumours
less fit patients
not sure if surgery can be done

Question 7

advantages of neo-adjuvant chemo?

Answer 7

cosmetic (can do a wide local excision instead of mastectomy)
can result in less extensive nodal clearance being needed if good response

Question 8

disadvantage of neo-adjuvant chemo?

Answer 8

attendances for 6 extra imaging investigations compared with adjuvant chemo

Question 9

what is mainly used as adjuvant treatment?

Answer 9

radiotherapy

Question 10

how is adjuvant radiotherapy used?

Answer 10

used routinely after wide local excision
usually given by external beam therapy using linac over 3 weeks
extra treatment (boost) sometimes needed in young people or in cases with positive margins

Question 11

advantages of adjuvant radiotherapy?

Answer 11

reduces recurrence risk by around half

Question 12

disadvantages of adjuvant radiotherapy?

Answer 12

general risks of radiotherapy

boosts can make treatment course longer if needed

Question 13

how is adjuvant hormonal therapy delivered?

Answer 13

ER (oestrogen) blockade

• 5 years of tamoxifen reduces risk of relapse and improves survival
• 10 years tamoxifen gives a further 3% survival
• aromatase inhibitors (letrozole/anastrozole) has same effect

Question 14

how is adjuvant chemo given?

Answer 14

given to improve 10 year survival by 5-10%

various regimes but usually includes anthracycline and often a taxane

Question 15

side effects of adjuvant chemo?

Answer 15

anorexia
malaise
neutropenia 
alopecia
taxanes induce myalgia
peripheral neuropathy
gCSF injections can cause severe axial skeleton pain from marrow stimulation

Question 16

how is adjuvant herceptin given?

Answer 16

given by s/c injection (sometimes IV)
one year of 3 weekly treatment
improves overall survival
can only be used in cancers which overexpress HER2 receptor

Question 17

what happens after all treatment has finished?

Answer 17

review at end of adjuvant treatment
discharge from oncology
surgical review on anniversary of surgery then discharge from clinic follow up
yearly mammograms for 3 years

Question 18

what can be used for palliative treatment?

Answer 18

systemic treatment for widespread disease (oestrogen blockade or chemo)
radiotherapy for fungating breast disease or bone metastases
bisphosphonates (eg oral ibandronic acid) for those with bone mets

Question 19

what is trastuzumab emtansine?

Answer 19

new drug combining chemotherapy with trastuzumab

delivers chemo directly to the tumour

Question 20

problems with diagnosis of bone mets?

Answer 20

ribe are difficult
often the only way to be sure is to request a localized CT (or MRI) of the affected bone
- bone scan often only helpful if it shows a shower of mets affecting the axial skeleton

Question 21

immune problems with chemotherapy?

Answer 21

causes neutropaenia
if the patient is well with no fever = ignore
if they are septic or well but with a fever = admit to oncology urgently

Question 22

common problems with hormonal therapy (tamoxifen/AI)

Answer 22

hot flushes

general menopause symtoms

Question 23

how can side effects of tamoxifen/AIs be managed?

Answer 23

clonidine 50-70ug bd sometimes works (must reduce and stop slowly)
avoid phyto-oestrogens
progesterones work but safety is unclear
can stop the treatment if needed?

Question 24

problems with marina coil in breast cancer?

Answer 24

contra-indicated by the company if breast cancer has been diagnosed
risk is inclear (if any)
there may be cases where you want to leave it in after discussion

Question 25

common problems with tumour markers (CEA and CA15-3)?

Answer 25

Ok for monitoring but poor for diagnosis
dont check them unless metastatic disease is known to be present
dont check them unless its clear how the result will change treatment

Question 26

when are bisphosphonates used?

Answer 26

used in high doses when bone mets are present
used alongside aromatase inhibitors (AIs) if DEXA scan is abnormal (osteopenia/osteoporosis)
usually oral but can be IV if oral not tolerated

Question 27

problems with tamoxifen?

Answer 27

vaginal bleeding
increased endometrial cancer risk
endometrial hyperplasia and/or polyps

Question 28

how are tamoxifen risks managed?

Answer 28

seek gynae opinion
may need to change to AI (if post menopausal)
goserelin if premenopausal (GnRH agonist)

Question 29

problems with breast radiotherapy?

Answer 29

lymphoedema of arm
greater volume of tissue = greater reaction
tends to come on at end of treatment
lasts a few weeks then spontaneously heals

Question 30

how is arm lymphoedema due to radiotherapy managed?

Answer 30

seek advice from breast care nurses at an early stage

avoid instrumentation of the ipsilateral arm after axillary surgery

Question 31

what can cause a new lump during or after cancer treatment?

Answer 31

unlikely to be local recurrence unless cancer is extremely aggressive
fat necrosis can cause a firm localized swelling after trauma, particularly after reconstructive surgery

Question 32

how is a new lump during or shortly after treatment managed?

Answer 32

seek advice from local one stop surgical clinic for repeat triple assessment

Question 33

important signs to look out for in people with potential bone mets?

Answer 33

severe back pain (red flag pain)
radicular back
non-specific difficulty walking with no signs
risk of spinal cord compression so anyone with these signs should have urgent MRI

Question 34

how does tamoxifen interact with antidepressants?

Answer 34

unclear
should probably avoid paroxetine
risk of changing antidepressant might be worse than effects of interactions if brittle depression

Question 35

problems with HER2 +ve breast cancer?

Answer 35

higher risk of recurrence
similar distribution of mets tend to metastasise to CNS and pleura in particular
- should seek head scan if headaches or blurred vision occurs

Question 36

problems with lobular breast cancer?

Answer 36

similar distribution of mets but preferential metastases to peritoneum and gut
- may not be seen on scan but can cause sub-acute bowel obstruction
often more difficult to see on mammography

Question 37

how can vaginal dryness due to ER blockade be managed?

Answer 37

can use vagifem (oestrogen pessary) if low risk cancer and taking tamoxifen
avoid if taking AI and high risk cancer