Medical Oncology Flashcards
What is the incidence of breast cancer among Australian women?
1/8
What percentage of breast cancer is gene-related?
5-10%
Which gene is most common one to be associated with hereditary breast cancer?
BRCA1 (20-40%)
BRCA2 (10-30%)
Which BRCA gene is associated with prostate cancer in men?
BRCA2
What is the mode of transmission of BRCA genes?
Autosomal dominant
For breast cancer, which imaging modality is most sensitive in pre-menopausal women?
MRI breast
What is the best chemoprevention option for breast cancer in BRCA positive premenopausal women?
Tamoxifen
What age group receive screening mammography?
Age 50-74
Still free for women over 40
Which palpable breast masses need to be biopsied?
All of them!
What is the general purpose of adjuvant chemotherapy?
To eliminate micro-metastatic disease, to prevent relapse
What effect does HER2 positivity status have on breast cancer prognosis?
Confers poorer prognosis
In early stage breast cancer, what type of adjuvant chemotherapy is generally used?
Anthracycline and/or taxane based
In early stage breast cancer, what is the indication for axillary node dissection?
A clinically positive node pre-op
Consider if sentinel node biopsy positive
As adjuvant therapy in breast cancer, how long should Tamoxifen be given?
5 years for lower risk
10 years for high risk
What is the most effective adjuvant chemotherapy for breast cancer in postmenopausal women?
Aromatase inhibitors.
Block conversion of DHEA to oestrogen
What are the indications for adjuvant radiotherapy in early stage breast cancer? (2)
After breast conserving surgery
Post mastectomy in breast cancer >5cm per lymph node positive
What is the treatment of choice for metastatic breast cancer which is ER+/HER2- ?
Endocrine therapy =
Aromatase inhibitors
Tamoxifen
Fulvestrant
What is the treatment of choice for metastatic breast cancer that is HER2+ ?
Trastuzumab + pertuzumab + taxane chemo
What is the treatment of choice for metastatic breast cancer that is triple negative?
Chemotherapy =
Sequential single agent, many different options
What are the 4 main histological subtypes of lung cancer, in order of frequency?
Adenocarcinoma -40%
SCC - 20%
Small cell - 13%
Large cell - 7%
What defines ‘limited stage’ in small cell lung cancer?
All disease is within one radiation field
What size do lung tumours have to be to be classed as stage 1 NSCLC?
Less than 5cm
At what stage NSCLC are contralateral hilar nodes present?
Stage IIIb (N3)
What form of chemotherapy is favoured in metastatic NSCLC that is driver mutation negative?
Platinum containing doublet - cisplatin or carboplatin plus another
What is the classic phenotype of those with EGFR mutation negative NSCLC?
Non-smokers
Female
Asian
Adenocarcinoma
Which lung cancer type is most closely associated with smoking?
Small cell
For patients with unresectable, stage III NSCLC whose disease has not progressed following concurrent platinum-based chemotherapy and RT, what agent may improve survival?
PD-L1 antibody Durvalumab, irrespective of PD-L1 expression
As per PACIFIC trial
Which lung cancer type is most associated with hypercalcaemia?
What is the common mechanism?
Squamous cell carcinoma
PTHrP release by cancer
Which paraneoplastic syndromes are most common with SCLC?
SIADH
Neurological e.g. Lambert-Eaton, peripheral neuropathy
Which type of cancer is most common in Australia (aside from non-melanomatous skin cancers)?
Breast cancer
What is the strongest prognostic factor in breast cancer?
Lymph node involvement
What does “grade” refer to in cancer?
The degree of cellular atypia
What is the prognostic relevance of age in breast cancer?
Younger age confers poorer prognosis
What is the risk factor most associated with chemotherapy-induced amenorrhea?
Increasing age
Which form of metastatic breast cancer has the worst prognosis?
Triple negative
In what kind of cancers are CDK4/6 inhibitors used?
Hormone receptor positive, HER2 negative metastatic breast cancers
Which BRCA gene is more associated with pancreatic cancer?
BRCA 2
Which BRCA gene is more associated with prostate cancer?
BRCA 2
What is the deal with tamoxifen and CYP2D6?
Requires the enzyme to be converted to active form
Thus antidepressants that inhibit enzyme result in less efficacy of tamoxifen
Which electrolyte is decreased in TLS?
Calcium
What is the option for adjuvant treatment in Stage 2 CRC with high risk features?
Single agent 5FU or capecitabine
What is the usual adjuvant Rx for Stage 3 CRC?
Single or double agent chemo for 3-6 months depending on risk
- FOLFOX
- CAPOX
Best option for widely metastatic CRC that is R) sided?
Chemo - FOLFOX/FOLFIRI/CAPOX
Can do triplet of FOLFOXIRI if good performance status
+ Bevacizumab
When can EGFR inhibitors be used in CRC?
Metastatic disease, L) sided primary
KRAS / BRAF wild-type
**If KRAS wild-type, EGFR mutant in advanced disease ->
can consider BRAF/MEK/EGFR blockade
When are PD-1 inhibitors used in CRC?
Metastatic CRC that is MSI high or MMR deficient, that have progressed on chemotx
What is the difference between Goserelin and Degarelix?
Goserelin -> GnRH agonist
- can initially stimulate sudden surge in T = “flare response, need to cover with testosterone antagonist for first week e.g. Bicalutamide
Degarelix -> GnRH antagonist (avoids flare response)
What is done to the ADT in prostate cancer that has become castrate-resistant?
Generally continued, as it may slow progression
What is the ideal 1st line treatment for metastatic castrate-sensitive prostate cancer?
Aggressive upfront treatment ->
ADT + chemotherapy with docetaxel + abiraterone
What is the general treatment for metastatic castrate-resistant prostate cancer?
Continue ADT
Many options:
- chemo with taxane if fit enough
- unfit or progressed on chemo -> Abiraterone or Enzalutamide
How does abiraterone work?
AEs?
Androgen biosynthesis inhibitor -> inhibits CYP17 gene products, including 17-alpha-hydroxylase
AE: HTN + Hypokalaemia (overproduction of aldosterone)
Should be co-administered with prednisolone (as cortisol synthesis also blocked)
LFT derangement
How does enzalutamide work?
AEs?
AR antagonist. Inhibits binding of androgens to receptor
AEs: HTN, fatigue, may increase risk of seizures (contraindication in hx seizures), cognitive impairment
How does tamoxifen work?
Selective oestrogen receptor modulator, may act as agonist or antagonist depending on target organ
- antagonistic in breast cancer and breast tissue, as well as brain
- agonistic effects in bone, liver, and uterus
- Improves BMD and cholesterol
AEs: Headache, hot flushes (Rx venlafaxine), fluid retention, genitourinary Sx, small ↑ risk of thromboembolic events
Small ↑ risk endometrial cancer (in postmenopausal women)
How do aromatase inhibitors work?
Inhibits peripheral conversion of androgens to oestrogens
- More effective than tamoxifen in post-menopausal women where oestrogen production occurs outside of ovaries in peripheral tissues
- Can only be used in premenopausal women in combination with ovarian suppression, as it does only works peripherally
AEs: MENOPAUSE -> N&V, headaches, hot flushes, fluid retention, genitourinary Sx, hyperlipidaemia
- Joint pain and stiffness, vaginal dryness, accelerated BMD loss
- More CVD / increased chol / DM compared with tamoxifen
How do CDK4/6 inhibitors e.g. ribociclib work?
AEs?
Prevents progression through the cell cycle, resulting in arrest at the G1 phase. Inhibit progression of cell cycle from G to S phase.
AEs: neutropaenia (managed with cyclical dosing), QT prolongation, LFT derangement
Metastatic melanoma Rx - 1st line for..
- BRAF mutant?
- BRAF wild-type?
BRAF mutant -
- BRAF + MEK inhibition
- dabrafenib + trametinib
AEs: fever, rash, GI upset
BRAF wild-type -
- FIT -> Ipi (CTLA-4) + Nivo (PD1)
- not fit for combo ->
1. Nivolumab
2. Pembro
3. Ipi
