Breast Oncology and Palliative Care Flashcards
Are oncologists involved pre-diagnosis?
No
What is the diagnostic process for suspected metastatic disease in someone with no previous diagnosis?
Investigation undertaken by medical and surgical specialty and biopsy taken = surgical/oncological referral then made
How are most breast lumps diagnosed?
More are diagnosed by CT than by physical examination
What oncological treatment options are available?
Radiotherapy and chemotherapy
Hormonal therapy = oestrogen blockade
Antibodies = herceptin
What is the oncological management of cancer?
Curable = neo-adjuvant and adjuvant Non-curative = palliative therapy
Is radiotherapy commonly offered as neo-adjuvant therapy?
No = not usually used
What patients receive hormonal neo-adjuvant therapy?
Oestrogen-positive tumours, less fit patients, patients in whom it isn’t certain if surgery will be performed
How long can neo-adjuvant hormonal therapy be given for?
Can be given for up to 1 year before surgery
What are some advantages of neo-adjuvant therapy?
Cosmetic = sometimes wide local excision can be done instead of mastectomy
Less extensive nodal clearance done if excellent treatment response (Tayside only)
What is a disadvantage of neo-adjuvant therapy?
Attendance for 6 extra imaging investigations compared to adjuvant treatment
What are some options for adjuvant therapy?
Radiotherapy, oestrogen blockade, chemotherapy, herceptin
What are some indications for using radiotherapy as adjuvant treatment?
Used routinely after wide local excision = reduces recurrence risk by about half
Used in young patients and those with positive margins
How can an oestrogen blockade be achieved?
5 years tamoxifen or use aromatase inhibitors
How effective is adjuvant treatment by tamoxifen oestrogen blockade for 5 years?
Reduces relapse risk by 15% at 10 years and improves 5 year survival by 10%
What are some features of aromatase inhibitors?
Examples = letrozole and anastrozole
Offer no difference in overall survival when compared to tamoxifen
How is chemotherapy given as adjuvant therapy?
Given to improve 10 year survival by 5-10%
Usually includes anthracycline and a taxane
What are some side effects of chemotherapy?
Anorexia, malaise, neutropenia, alopecia, myalgia (taxane), peripheral neuropathy
What is a side effect of gCSF chemotherapy injections?
Severe axial skeleton pain = due to marrow stimulation
How is herceptin therapy given?
Subcutaneous injection = sometimes given by IV
One year of three weekly treatment
What is herceptin?
Antibody against HER2 receptor = HER-2 receptor overexpression seen in about 15% of breast cancers
How effective is herceptin?
Improves overall survival by a further 3%
Side effects = allergic reactions, reversible cardiac failure
What happens to patients after their treatment?
Review at end of adjuvant treatment and discharge from oncology clinic = surgical review on anniversary of surgery then discharge from clinic follow up
How long do patients have to present for yearly mammograms following adjuvant treatment completion?
Have yearly mammograms for 3 years
What are some palliative systemic treatment options for widespread disease?
Oestrogen blockade or chemotherapy
When is radiotherapy used palliatively?
To treat fungating breast disease or bone metastases
What is used to palliatively treat bone metastases as prevention?
Bisphosphonates = oral ibandronic acid
How has chemotherapy developed?
Multiple therapies for metastatic disease
Benefits often minimal or non-existent
Can distract from good palliation in terminal phase
How has radiotherapy developed?
Treatment set up more complicated and time consuming
Techniques to reduce lung/heart treatment becoming more common
What imaging modality is routinely used for image acquisition before radiotherapy treatment?
CT scans
What is intra-operative radiotherapy (IORT)?
Radiotherapy that is delivered in one fraction during surgery
What is trastuzumab-emtansine?
New drug combining chemotherapy moiety with trastuzumab = delivers chemotherapy moiety directly to tumour
What are some features of bone pain following breast cancer?
Recurrence depends on grade, tumour size and amount of axillary lymph nodes involved
Usually request localised CT of affected bone
Ribs are especially problematic to diagnose
What are some features of bone scans for bone pain following breast cancer?
Bone scan may appear positive = only helpful if it shows shower of metastases affecting axial skeleton
How should neutropenia following chemotherapy be managed?
Ignore if patient is well and has no fever
Urgent admittance to oncology if fever or sepsis
How are hot flushes caused by tamoxifen managed?
No good treatment = clonidine 50-70ug 2x daily sometimes works (needs to be reduced/stopped slow)
Phyto-oestrogens best avoided
Progestogens work but their safety is unclear
Can the Mirena coil be used in patients with breast cancer?
No = contraindicated in breast cancer
What are some tumour markers for breast cancer?
CEA and CA15-3
How are tumour markers used to monitor disease?
Okay for monitoring but poor for diagnosis
Don’t check unless known metastatic disease
When are bisphosphonates indicated?
Metastatic disease in high dose and with aromatase inhibitors if DEXA scan abnormal
What are some issues with bisphosphonates?
Lack of oral tolerance = may try IV
Risk of osteonecrosis of jaw = issue if dental work required
What are the risk associated with vaginal bleeding due to tamoxifen?
Risk of endometrial cancer = common to induce endometrial hyperplasia and/or polyps
What can tamoxifen be switched to if it’s causing vaginal bleeding?
Aromatase inhibitor if postmenopausal
Goserelin if premenopausal
When can lymphoedema of the arm occur?
Associated with greater volumes of radiotherapy
Tends to occur at the end of treatment
What are some features of lymphoedema of the arm?
Rare = lasts few weeks then spontaneously heals
Avoid instrumentation of ipsilateral arm after axillary surgery
Is it likely that local recurrence will happen shortly after or during treatment?
No = not unless the cancer is extremely aggressive
What is a cause of a new breast lump following treatment for cancer?
Fat necrosis = causes firm localised swelling and can occur after reconstructive surgery
Why do patients suffering from back pain with bone metastases need urgent MRI of spine?
There is risk of spinal cord compression
What are the signs of spinal cord compression due to bone metastases?
Too late to treat by time symptoms develop = severe and radicular back pain, non-specific difficulty walking with no signs
What antidepressant should you avoid using when taking tamoxifen?
Paroxetine
What are some features of HER-2 positive breast cancers?
Higher risk of recurrence
Preferential metastases to CNS and pleura
Consider retinal metastases if blurred vision
What are some investigations that may need to be done in a patient with HER-2 positive breast cancer?
Head scan if suffering headaches
Why are lobular breast cancers hard to detect?
May be invisible on scan and more difficult to see on mammography
Often presents with sub-acute bowel obstruction
Where do lobular breast cancer metastases tend to occur?
The peritoneum and gut
How can you reduce the risk of developing breast cancer?
Normal BMI and regular exercise
Avoid excessive alcohol intake
Self examination helps awareness
What treatment can cause vaginal dryness?
Oestrogen blockade
Can vagifem be used to treat vaginal dryness caused by oestrogen blockade?
Depends on symptom severity = lower risk if low risk cancer or if on tamoxifen
Avoid if high risk cancer and taking aromatase inhibitor
What would make back pain after treatment more likely to be due to metastases?
If the cancer was high risk
In what patients should you consider doing a head scan?
Especially if HER-2 positive = headaches, visual disturbances or uncoordination (especially fleeting peripheral disturbances)
