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Kirsty - Y3S2 > CPT: Endocrine therapy > Flashcards

CPT: Endocrine therapy Flashcards

1
Q

Naturally occurring hormones can stimulate the growth and proliferation of some cancers. What are examples of these?

A

There is a long duration of treatment:

  • Adjuvant (after surgery) to prevent recurrence
    • Breast cancer ~ 10 years
    • Prostate cancer ~ 3 years
  • For advanced cancers until disease progression
    • In advanced and metastatic cancer, hormone therapy is often given until it is no longer effective which is usually referred to as disease progression
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2
Q

How do Hormone therapies work to treat these types of cancers?

A

Reducing the level of hormones reaching cancer cells or Blocking the action of these hormones on cancer cells

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3
Q

What is the length of treatment for these cancers? When can be treatment be given and how long typically for?

A

There is a long duration of treatment: Adjuvant (after surgery) to prevent recurrence For advanced cancers until disease progression

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4
Q

Hormones are also used in neuroendocrine cancer tumours which are rarer than prostate and breast cancer but you may still come across in practice.

What is an example of hormones/ analogues used - how does it work and why?

A

Somatostatin analogues such as octreotide and lanreotide are used to relieve the symptoms of neuroendocrine tumours, including hormone-secreting tumours of the gastrointestinal tract.

These tumours express somatostatin receptors, Somatostatin is a naturally occurring inhibitory hormone activation of which inhibits cell proliferation as well as hormone secretion

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5
Q

75% of breast cancer tumours are ?

What does this mean?

A

75% of breast cancer tumours are (oEstrogen Receptor) ER+

This mean when oestrogen attaches to ER on surface of the tumour it stimulates growth an proliferation

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6
Q

Where pre and post menopause is the main producer of oestrogen?

A
  • Pre-menopause, ovaries main producer of oestrogen
  • Post-menopause, adipose tissue main source
    • Determines choice of therapy
    • Opportunity for lifestyle intervention
      • Explains link between obesity & breast cancer – help encourage lifestyle advice & referral to dietricain
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7
Q

Apart from life-style what treatment option can be used?

A

Ovarian Suppression can also be used

  • Chemotherapy (induces temporary or permanent ovarian suppression)
  • Gonadotrophin-releasing hormone analogues e.g. goserelin, leuprorelin, triptorelin used in premenopausal breast cancer
  • Surgery (Oophorectomy)
    • Not routinely considered – but might be for preventing women with BRCA gene at high risk
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8
Q

Tamoxifen is a drug used for treatment in breast-cancer

What is its mechanism of action?

A

Complex mechanism of action, acts primarily as an oestrogen antagonist therefore prevents oestrogen binding to the oestrogen receptors in tumour

  • …and in normal tissue leading to symptoms associated with menopause
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9
Q

When is tamoxifen used?

When is it most effective?

A
  • Used pre and post-menopause
  • When used for 10 years after surgery to reduce risk of recurrence
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10
Q

What interactions does tamoxifen have?

A
  • Interactions - cytochrome P450
    • SSRI’s
    • Important role for pharmacists

Tamoxifen is metabolised by cytochrome P450 system of enzymes and therefore carries a risk of interacting with other drugs metabolised by this group.

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11
Q

What is the mechanism of action of

A
  • Fulvestrant is a competitive oestrogen receptor (ER) antagonist and leads to the downregulation of oestrogen receptor protein levels.
  • Unlike tamoxifen does not have agonist activity
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12
Q

When is Fluvestrant used?

A
  • Second line endocrine therapy for relapsed disease on first-line endocrine therapy
  • It is also recommended in combination therapy with CDK4/6 inhibitors
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13
Q

What route, dose and frequency is fluvestrant taken?

A

•2 x 250mg slow IM injections each month – one delivered into each buttock

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14
Q

How do aromatase inhibitors work?

When can they be used?

What are examples?

A
  • In post-menopausal women oestrogen is primarily produced by adipose and muscle tissue
  • Aromatase inhibitors block the aromatisation process in adipose tissue responsible for conversion of androgens into oestrogens. This therefore reduces level of oestrogen available to stimulate cancer cells
  • Letrozole, Exemestane, Anastrozole
    • Check local formulary for choice
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15
Q

Side effects and maangement - read

A
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16
Q

What are common side effects of endocrine therpay/ menopausal symptoms?

A
  • Hot flushes and night sweats
  • Vaginal dryness, changes to libido
  • Heart palpitations
  • Mood changes, difficulty sleeping, anxiety, irritability
  • Memory and concentration problems
  • Joint pain
  • Changes to skin, thinning hair
  • Weight gain, particularly around the waist
  • Breast Cancer Now Discussing Menopausal Symptoms
  • https://youtu.be/GyMpbiaM_Os
17
Q

What are treatments for menopausal side effects?

A
  • Aimed at the individual symptoms
    • Pharmacological and non-pharmacological interventions (CBT)
  • Low dose SSRI, SNRI, gabapentin, clonidine
    • Used for vasomotor symptoms (hot flushes)
    • Off label, refer to NICE CKS for guidance
    • Also affective disorders due to diagnosis – may also have depression & anxiety
  • Vaginal moisturisers – for vaginal dyness
  • Complementary therapy and lifestyle interventions
    • Breast Cancer Now, Maggie’s and Macmillan
    • Herbal medicines (Black Cohosh) should be avoided
18
Q

What stimulates prostate cancer cells to grow and divide?

A

Testosterone

19
Q

What is cancer treatment for prostate cancer called?

What does it aim to do?

A

•Hormone therapy aka Androgen Depletion Therapy aims to:

  • •Lower the risk of recurrence with early prostate cancer
  • •Shrink or slow advanced cancer
20
Q

What are the 2 mechanisms by which andorgen depletion therapy can work?

A
  • Blocking androgen receptors (anti-androgens)
    • Bicalutamide
    • Enzalutimide
  • Lower testosterone levels
    • Luteinising hormone releasing hormone (LHRH) agonists
    • Gonadotrophin releasing hormone (GnRH) antagonsits
    • Abiraterone
21
Q

Prostate cancer divided into 2 different categories which helps influence which therapy used.

What are these?

A

Castrate sensitive disease or Castrate – resistant prostate cancer

  • Prostate Cancer which responds to hormone therapy is considered castrate sensitive disease.
  • Castrate-resistant prostate cancer (CRPC) is defined by disease progression despite androgen depletion therapy (ADT) and may present as either a continuous rise in serum prostate-specific antigen (PSA) levels, the progression of pre-existing disease, and/or the appearance of new metastases.
22
Q

Describe the normal hypothalamic–pituitary–adrenal axis.

A

Normal Hormonal feed-back In men/women:

WOMEN:

Hypothalamus produces Gonadotrophin releasing hormone (GnR). This stimulates anterior pituitary to release LH and FSH. These stimulate the development of the follicles in the ovaries. Follicles release ostrogen – which has a negative feed-back effect on the hypothalamus & anterior pituitary gland.

MEN:

Hypothalamus produces Gonadotrophin releasing hormone (GnR). This stimulates anterior pituitary to release LH. This acts on the testicals to produce testosterone which has a negative feed-back effect on the hypothalamus & anterior pituitary gland.

23
Q

How do GnRH analogues work?

A
  • These are agonists of GnRH receptors on the anteioir pituitary gland.
  • Activation of the GnRH receptors stimulates LSH and FSH to have a very large release.
  • This stimulates ovaries/testicles to release a lot of ostrogen/ testosterone for a few days (worsens symptoms of cancer).
  • Given as SC/IM which has a slow release over 1-3 months
  • After continuous stimulatous – these receptors become densisitised. This prevents these receptors action therefore lowers Testosterone/ oestrogen levels.
  • Over time they will become sensitized again therefore dose needs to be given regularly to prevent this.
24
Q

What are examples of GnRH analogues?

What is there route of admin and duration?

What can also be used along side to reduce effects of flare?

A
  • GnRH analogues: Goserelin, leuprorelin and triptorelin
    • Differ in method of administration (IM, SC)
    • Duration of action (1 – 6 months)
    • Check local formulary and guidelines
  • Transient increase in testosterone levels (“flare”) for 7-10 days
    • Usually start an anti-androgen 3 days before LHRH (bicalutamide, cyproterone) to minimise effects
25
Q

What is an example of Gonadotrophin release hormone antagonist?

How does it work?

Routem dose, frequency?

A
  • Degarelix
  • Competitively and reversibly binds to the pituitary GnRH receptors
  • Reduces release of gonadotrophins (LH/FSH) which halts the secretion of testosterone by the testes
    • No tumour flare
  • 2 x 120mg SC injections then 80mg each month
26
Q

Side effects of prostate cancer treatment

A
27
Q

What is the mechanism of action of Abiraterone?

Side effects?

Monitoring requirement?

A
  • Inhibits CYP17 to block androgen synthesis in testicular, adrenal and prostatic tumour tissues
  • CYP17 catalyses the conversion of pregnenolone and progesterone into testosterone precursors by 17α-hydroxylation and cleavage of the C17,20 bond
  • CYP17 inhibition also results in increased mineralocorticoid production by the adrenals leading to side effects:
  • Hypertension, hypokalaemia, oedema
  • Requires concurrent prednisolone (10mg daily)
  • Baseline blood pressure and cardiac function then monthly BP
  • FBC, U&Es, LFTs & PSA prior to each cycle
28
Q

Abiraterone counselling points

A
  • •Swallow 2 x 500mg tablets whole, with water one hour before and at least two hours after eating
    • •Consumption with food increase absorption by up to 10 times
  • •Patients with increased stress (e.g. admission to hospital) require additional steroid supplementation

•Interactions:

  • •CYP2D6: propranolol, venlafaxine, haloperidol, risperidone, flecainide, codeine, oxycodone, tramadol
  • •Inhibits CYP2C8 (pioglitazone) - switch antiepileptic drug
  • •Strong CYP3A4 inducers (such as phenytoin, carbamazepine, rifampicin, St John’s wort) may reduce abiraterone effectiveness. - stop taking these?
29
Q

How does enzalutimide work?

Dose, frequency, route?

Side effects?

Interactions?

Monitoring?

A
30
Q

What is a major side effect of treatment for both breast and prostate cancer?

Treatment?

A
  • Hormone therapy for breast and prostate cancer increase the risk of osteoporosis
  • Follow current guidelines for the condition being treated
  • Assess individual patients risk of falls and fracture
  • Consider:
    • Calcium and vitamin D supplementation
    • Bisphosphonates
    • Denosumab

Kirsty - Y3S2 (40 decks)

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