Breast Oncology Flashcards
is oncologist involved in cancer diagnosis?
no
4 types of oncological treatment?
radiotherapy
chemotherapy
hormonal therapy (oestrogen blockade)
antibodies (trastuzumab (herception))
types of medical treatment if intent to cure?
neo-adjuvant (before surgery)
adjuvant (after surgery)
types of treatment if non-curative intent?
palliative
what can be given as neo-adjuvant treatment?
not radiotherapy
hormonal therapy
chemotherapy
when is neo-adjuvant hormonal therapy used?
ER positive tumours
less fit patients
not sure if surgery can be done
advantages of neo-adjuvant chemo?
cosmetic (can do a wide local excision instead of mastectomy)
can result in less extensive nodal clearance being needed if good response
disadvantage of neo-adjuvant chemo?
attendances for 6 extra imaging investigations compared with adjuvant chemo
what is mainly used as adjuvant treatment?
radiotherapy
how is adjuvant radiotherapy used?
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
advantages of adjuvant radiotherapy?
reduces recurrence risk by around half
disadvantages of adjuvant radiotherapy?
general risks of radiotherapy
boosts can make treatment course longer if needed
how is adjuvant hormonal therapy delivered?
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
how is adjuvant chemo given?
given to improve 10 year survival by 5-10%
various regimes but usually includes anthracycline and often a taxane
side effects of adjuvant chemo?
anorexia malaise neutropenia alopecia taxanes induce myalgia peripheral neuropathy gCSF injections can cause severe axial skeleton pain from marrow stimulation
how is adjuvant herceptin given?
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
what happens after all treatment has finished?
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
what can be used for palliative treatment?
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
what is trastuzumab emtansine?
new drug combining chemotherapy with trastuzumab
delivers chemo directly to the tumour
problems with diagnosis of bone mets?
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
immune problems with chemotherapy?
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
common problems with hormonal therapy (tamoxifen/AI)
hot flushes
general menopause symtoms
how can side effects of tamoxifen/AIs be managed?
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?
problems with marina coil in breast cancer?
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
common problems with tumour markers (CEA and CA15-3)?
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
when are bisphosphonates used?
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
problems with tamoxifen?
vaginal bleeding
increased endometrial cancer risk
endometrial hyperplasia and/or polyps
how are tamoxifen risks managed?
seek gynae opinion
may need to change to AI (if post menopausal)
goserelin if premenopausal (GnRH agonist)
problems with breast radiotherapy?
lymphoedema of arm
greater volume of tissue = greater reaction
tends to come on at end of treatment
lasts a few weeks then spontaneously heals
how is arm lymphoedema due to radiotherapy managed?
seek advice from breast care nurses at an early stage
avoid instrumentation of the ipsilateral arm after axillary surgery
what can cause a new lump during or after cancer treatment?
unlikely to be local recurrence unless cancer is extremely aggressive
fat necrosis can cause a firm localized swelling after trauma, particularly after reconstructive surgery
how is a new lump during or shortly after treatment managed?
seek advice from local one stop surgical clinic for repeat triple assessment
important signs to look out for in people with potential bone mets?
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
how does tamoxifen interact with antidepressants?
unclear
should probably avoid paroxetine
risk of changing antidepressant might be worse than effects of interactions if brittle depression
problems with HER2 +ve breast cancer?
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
problems with lobular breast cancer?
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
how can vaginal dryness due to ER blockade be managed?
can use vagifem (oestrogen pessary) if low risk cancer and taking tamoxifen
avoid if taking AI and high risk cancer
