Breast Oncology and Palliative Care Flashcards
What are the oncological treatments available?
- Chemotherapy
- Radiotherapy
- Hormonal therapy
- Antibodies (TZ, Herceptin)
Of cancer can be cured what treatment is provided
Adjuvant and neoadjuvant
If cancer cannot be cured what treatment is provided
Palliation
What treatments are given as neo-adjuvant therapies?
Radiotherapy- usually no
Hormonal therapy- yes
Who is given hormonal therapy?
- ER-positive tumours
- less fit patients
- patients in whom it is not certain if surgery will be performed
How long is neo-adjuvant hormonal treatment given?
Up to a year before sugery
What are the advantages of neo-adjuvant chemotherapy
- cosmetic- WLE could be done instead of mastectomy
- less expensive nodal clearance post chemo
What are the disadvantages of neo-adjuvant chemotherapy
Attendances for 6 extra imaging investigaitons compared with adjuvant treatment
When is adjuvant radiotherapy used?
- routinely after WLE
How is adjuvant radiotherapy delivered?
By external beam therapy using linac over 3 weeks
Extra treatment boost makes course longer
What are the indications for boost adjuvant radiotherapy?
Young age
+ve margins
adjuvant radiotherapy reduces recurrence risk by about ___; probably saves ___ life for every 4 recurrences prevented
adjuvant radiotherapy reduces recurrence risk by about half; probably saves one life for every 4 recurrences prevented
Describe effect of tamoxifen adjuvant therapy?
5 years of tamoxifen- reduces risk of relapse by 15% at 10 years,
Improvement in survival is 5-10%
10 years of tamoxifen gives a further increase in survival of 3%
How do tamoxifen and AI’s work?
Oestrogen receptor blockade
Aromatase inhibitors – _______, ________ – ___ _________ in overall survival between tamoxifen and AIs
Aromatase inhibitors – letrozole, anastrozole – no difference in overall survival between tamoxifen and AIs
Adjuvant chemotherapy is given to improve 10-year survival by _-__% absolute
Adjuvant chemotherapy is given to improve 10-year survival by 5-10% absolute
What do the various adjuvant chemotherapy regimens involve?
Anthracycline and often a taxane
What are the side effects of adjuvant chemotherapy?
- Anorexia
- malaise
- neutropenia
- alopecia
- taxanes induce myalgia
- peripheral neuropathy
- gCSF injections may produce severe axial skeleton pain from marrow stimulation
Describe adjuvant hormonal therapy
Trastuzumab (herceptin)
given by s/c injection- sometimes IV
One year of 3-weekly treatment
Causes allergic reactions and reversible cardiac failure
What is the survival advantage from adjuvant hormonal therapy
3%
After treatment surgical review on …….. then discharge from clinic follow up but …… mammograms for …. ……
After treatment surgical review on the anniversary of surgery then discharge from clinic follow up but yearly mammograms for three years
What can be given as palliative treatment for breast cancer?
- systemic blockade for widespread disease (e.g. ER blockade or chemotherapy)
- Radiotherapy for fungating breast disease or bone metastases
- bisphosphonates (e.g. oral ibandronic acid) for those with bone metastases as prevention
What is trastuzamab-emtansine
New drug combining chemotherapy moiety with trastuzumab
Delivers chemotherapy moiety directly to the tumour
What is the only way to be sure of bony mets?
localised CT or MRI
Bone scan often only helpful if it shows shower of mets on axial skeleton
What should be done about neutropenia during chemotherapy?
If patient well and has no fever, ignore
If they are septic, or well but with fever, admit to oncology urgently
What should be done about hot flashes on tamoxifen?
- no good treatment
- clonidine 50ug-75ug bd sometimes works, needs to be reduced and stopped slowly
- phyto-oestrogens should be avoided
- progestogens work, but safety unclear
- stop the ER blockade
What is the issue with merina coil in breast cancer?
Contraindicated by the company if breast cancer diagnosed depsite no obvious risk, may leave it in
What tumour markers are there?
CEA
CA15-3
How should tumour markers be interpreted
OK for monitoring, poor for diagnosis
Don’t check them unless metastatic disease known to be present
Don’t check them unless it’s clear how the result will change treatment
When are bisphosphonates used?
In metastatic disease in high dose with AIs if DXA scan abnormal
Why should dental work be done before starting bisphosphonates?
Can cause osteonecrosis of the jaw
What is the risk with tamoxifen?
Vaginal bleeding
Endometrial cancer (1:400)
Endometrial hyperplasia/polyps
What can be used as opposed to tamoxifen?
Post-menopausal: aromatase inhibitor
Pre-menopausal: goserelin
When does radiotherapy reaction come on?
When there is a greater volume of tissue the greater the reaction
Tends to come on at end of treatment/once treatment stopped and lasts a few weeks
What is a common cause of a new lump after treatment?
Fat necrosis causing a firm localized swelling
What should be looked out for in back pain with bone mets
- severe back pain
- radicular back
- non-specific difficulty walking with no signs
Which anti-depressants should be avoided if on tamoxifen?
Paroxetine
Where does HER-2 +ve breast cancer preferentially metastasise to?
CNS and pleura
What should be looked out for in HER-2 +ve breast cancer?
- headaches- seek head scan
- blurred vision- consider retinal mets
Where does lobular breast cancer metastasise to preferentially?
Peritoneum and gut
Can present with sub-acute bowel obstruction
How can risk of breast cancer be reduced?
- normal BMI
- exercise
- self-examination
- don’t drink to excess
What can be done for vaginal dryness with ER blockade?
UNCERTAIN
If cancer low risk (e.g. low grade, small, <1cm, node-negative) then might consider vagifem
NOT if high risk cancer and on AI
