Breast Oncology and Palliative Care

Question 1

what therapies are offered as neo-adjuvant (before main treatment such as surgery)?

Answer 1

hormonal eg ER receptor blockers

chemotherapy

Question 2

what therapy is often used as adjuvant (with or after main treatment)?

Answer 2

radiotherapy - used routinely after wide local excision

given over 3 weeks (+ extra tx if young and positive margins)

Question 3

by how much does adjuvant radiotherapy reduce risk of recurrence?

Answer 3

by about half

*remember if relative risk indicates if patient is already at low risk then this doesnt make much of a difference

Question 4

how many years of tamoxifen treatment is thought to reduce the rate of relapse?

Answer 4

5 years

Question 5

what are the side effects of oestrogen receptor blockers?

Answer 5

clots (DVTs)
partial agonist - can stimulate endometrium 
PV bleeding 
polyp formation 
endometrial cancer

Question 6

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

Answer 6

anthracyclines (eg idarubicin)

taxanes (eg paclitaxel)

Question 7

what side effects may occur due to chemotherapy?

Answer 7

anthracyclines cause alopecia and nail changes

taxanes cause mylagia aches

others = anorexia, malaise, neutropenis, peripheral neuropathy, severe axial skeletal pain from marrow stimulation

Question 8

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

Answer 8

trastuzumab (herceptin)

• by sc injection (sometimes IV)
• one year of 3-weekly treatment
• improves survival by 3%

Question 9

what are the potential side effects of trastuzumab (herceptin)?

Answer 9

allergic reactions

reversible cardiac failure

Question 10

what treatments against cancer are still used even if patients are palliative?

Answer 10

systemic treatment if widespread disease (eg ER blockade or chemotherapy)

radiotherapy for fungating breast disease or bone mets

biphosphonates for bone mets as prevention of crush fractures

Question 11

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

Answer 11

electron beam (more superficial) rather than photon beam which is more penetrative

breath-hold

Question 12

what is irradiation of the heart a risk?

Answer 12

increased radiation delivered to heart causes ischaemic heart disease and increased risk of MI

Question 13

trastuzumab has been combined with other drug emtasine to create a combination preparation - what is aim of this new drug?

Answer 13

delivers chemo directly to tumour

Question 14

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

Answer 14

localised CT (or MRI) of the affected bone

ribs = problematic in terms of diagnosis

bone scan only helpful if it shows shower of mets affecting axial skeleton

Question 15

neutropenia is common in those undergoing chemo, what symptoms would indicate a urgent referral to oncology is needed?

Answer 15

septic (increased HR, RR and temp, low BP etc)
or well with fever

admit to oncology urgently

Question 16

what can be used to treat the hot flushes that patients experience with tamoxifen or aromatase inhibitors?

Answer 16

clonidine (careful if pt suffers from depression or hypertension)

phyto-oestrogens best avoided (dont want extra oestrogens)

progesterones (safety unclear)

Question 17

the mirena coil is contraindicated after diagnosis of breast cancer - true or false?

Answer 17

true

Question 18

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

Answer 18

CEA or CA15-3

useful for monitoring but poor for diagnosis, dont check unless metastatic disease known

Question 19

when are biphosphonates usually used and what should be considered before starting them?

Answer 19

used in metastatic disease in high dose

consider getting dental work done before starting them (risk of jaw osteonecrosis)

Question 20

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

Answer 20

aromatase inhibitor (if post menopausal)

goserelin (GnRH anatoginist injection - if pre menopausal)

Question 21

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

Answer 21

skin reaction
tends to come on at end of treatment
lasts for few weeks then heals

Question 22

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

Answer 22

lymphoedema of arm

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

Question 23

what is a common cause of a lump in breast soon after treatment of breast cancer?

Answer 23

fat necrosis

Question 24

if you suspect a patient has bony mets compressing spinal cord, what is first investigation?

Answer 24

urgent MRI

Question 25

antidepressants and tamoxifen are known to interact - what is best approach to treating both conditions?

Answer 25

avoid paroxetine

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

Question 26

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

Answer 26

central NS - brain and meninges
pleura

be aware of headache, blurred vision

Question 27

lobular breast cancer is more difficult to see on mammography - true or false?

Answer 27

true

Question 28

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

Answer 28

peritoneum and gut - may be invisible on scan

but often presents with sub-acute bowel obstruction

Question 29

how can a women reduce their risk of breast cancer?

Answer 29

normal BMI / exercise

self examination but not too often

dont consume excessive alcohol

Question 30

what other gynaecological side effects can occur with oestrogen receptor blocker?

Answer 30

vaginal dryness

• tx for this (eg vagifem) may not always be suitable
• especially if high risk cancer and patient is on an aromatase inhibitor