Onc and Pallative Care Flashcards
Screening for Breast Cancer
“Average risk” guidelines (CTFPHC)1
Pertains to the General population
o Applies to women ages 40 to 74 who are NOT “High risk” (see next slide)
Age-based recommendations
o 40-49 yrs – Recommend AGAINST screening
o 50-74 yrs – Recommend FOR screening mammogram q2-3 yrs
o ≥ 75 yrs – No evidence of benefits/harms to make formal recommendation
Screen with mammogram only
o Recommend AGAINST self-breast exam, clinical breast exam, or US/CT/MRI
Screening for Lung cancer (CTFPHC)2
Criteria (need all 3)
1. Age 55-74 years
2. ≥ 30 pack-year* smoking history
3. Current smoker or quit within the past 15 years
Screen with annual low dose CT every year up to 3 consecutive years
o Recommend against screening CXR or sputum cytology
- After 3 years
o Canadian guideline doesn’t address
o US guideline suggests screening annually until quit smoking > 15
years, or develops other life-limiting illness
Screening for Colorectal Cancer (CRC)
“Average risk3,4 & Increased risk5”
General population.
No previous CRC or polyps, no IBD, no FHx CRC
- Age 50-74
- Not recommended over age 75
- Whichever youngest
- Age 40-50 yrs OR
- 10 yrs before earliest age of
relative’s diagnosis
Method of
Screening
- 2 Options
- FIT q2 yrs
- Flex sigmoidoscopy q10 yrs
- DO NOT USE colonoscopy
Increased Risk
≥ 1 First-degree relative with colon cancer OR advanced adenoma
- Whichever youngest
- Age 40-50 yrs OR
- 10 yrs before earliest age of
relative’s diagnosis - Colonoscopy q5-10 yrs
- FIT q1-2 yrs can be considered as
2nd-line/ alternative
Screening for Hepatocellular Carcinoma
(CASL 2018, AASLD new 2023)6,7
High risk populations (either of…)
o All patients with cirrhosis, regardless of age/etiology (Hep B/ C, NAFLD, EtOH, α-1
antitrypsin deficiency, NASH, AIH, HH, PBC, Wilson’s disease)
o AASLD 2023 recommends against screening Childs-Pugh C cirrhosis unless transplant candidate, or patients
with life limiting comorbidity as 1 year mortality from liver disease negates any benefit HCC screening
o Hep B carrier (sAg +) AND…
§ Endemic country (Hep BsAg prevalence >2%) (Asia): males ≥40, females ≥50
§ African or North American blacks ≥20 yrs
§ FHx of HCC in 1st degree relative (start at age 40)
§ CASL = All HIV co-infected patients (start at age 40)
§ AASLD= All Hep D co-infected patients
- Screening test – Ultrasound q6 months (CASL) / Ultrasound + AFP q6 months (AASLD 2023)
o Per AASLD 2023: Sensitivity of US alone 53%, but US+AFP sensitivity 63%
o CASL 2018 does not recommend AFP where US is available – at that time insufficient evidence to
recommend screening with both US and AFP
Screening for Cervical Cancer (CTFPHC 2013)8
Screening population
o Anyone with a cervix ages 25-69 – Screen with cervical cytology q3 years
§ Includes HPV-vaccinated women, transmen & women who have sex with
women
§ Cancer Care Ontario suggests start at 21 yrs
- Screen with pap test cervical cytology q3 yrs
- STOP screening at age ≥70 AND ≥ 3 negative tests in the last 10 yrs
- These guidelines DO NOT apply to: Never sexually active, Previous abnormal Pap tests,
Immunocompromised (eg. HIV, organ transplant, chemo, chronic corticosteroid use),
Symptomatic of cervical cancer (eg. abnormal vaginal bleeding), limited life expectancy
DO NOT SCREEN for These Cancers
- Melanoma (CTFPHC 2008) – Recommend AGAINST population-based skin
screening - Testicular (USPSTF 2011) – US guidelines recommend AGAINST screening
- Ovarian (CTFPHC 2013) – Do NOT screen in average risk women
- Prostate (CTFPHC 2014) – Do NOT screen with PSA
- Esophageal (CTFPHC 2020)9
- Do NOT screen for cancer or dysplasia/ Barrett’s in chronic GERD without alarm symptoms
– Does not apply to patients with alarm symptoms (dysphagia, odynophagia, weight loss, anemia, bleed, loss of appetite)
– Does not apply to patients with previously diagnosed Barrett’s
Breast Cancer: Diagnostic Workup
Relevant Biology
* ESTROGEN (Hormone-driven) vs HER2
Diagnosis
* Imaging
* Diagnostic bilateral mammogram & ultrasound of breast AND axilla*
* Biopsy/Markers
* Core needle biopsy (US-guided) + Receptor status testing: ER (estrogen hormone receptor), PR (progesterone
hormone receptor), HER-2 (human epidermal growth factor receptor)
RC EXAM TIP: Mastitis not responding to antibiotics à BIOPSY to rule out Paget’s/ Inflammatory Breast CA)
(In Clinical Practice: U/S + Mammogram with Biopsy)
Once Confirmed Localized Breast Cancer- Move on to Surgery! (Before completion of staging)
Breast Cancer: Initial Localized Management
Primary treatment
* Surgery
* Primary Tumor- 2 options
* Mastectomy
* Lumpectomy (Breast Conserving Surgery) + Whole Breast Radiation
- Regional lymph node Management
- They need it (Choosing Wisely Caveat for age 70, ER+, clinically node negative- NoE)
- Sentinel Lymph Node Biopsy or Axillary Lymph Node Dissection
Bottom Line for early stage Breast CA: Mastectomy or Lumpectomy + Lymph Node Sampling/ Dissection.
Based on Surgical Path-> Complete Staging -> Decide on further treatment
Breast Cancer: Staging
Staging Post Surgery- Do they need imaging?
* Stage I (LN negative)à No further tests
* Stage II (LN+ up to 3)à No further tests unless symptoms
* Stage III (T4 or ≥ 4 LN positive)à STAGE - Bone scan, CT C/A/P
Breast Cancer: Adjuvant Therapy
see chart
*Endocrine therapies: TAM = Tamoxifen. Aromatase Inhibitor = Letrozole, Exemestane, Anastrozole
**Chemotherapies: Anthracycline (doxorubicin, epirubicin) + Cyclophosphamide+ Taxane (docetaxel, paclitaxel)
~Anti-HER2 drug: Trastuzumab
Post-menopause: TAM or AI
Pre-menopause : TAM
± Anti-resorptive therapy
Breast Cancer: Metastatic Therapy
HR+
1. Endocrine therapy AND
2. CDK 4/6 inhibitor
HER2 +
1. Double HER-2
blockade AND
2. Chemo (Taxane)
Triple positive
- Double HER-2 blockade AND
- Chemotherapy (Taxane) AND
- Endocrine therapy
Triple negative
- Immunotherapy (for
PD-L1+ disease) - Chemotherapy
CDK 4/6 inhibitor: “ciclibs”- Palbociclib, Ribociclib
Double HER2 blockade: Trastuzumab + Pertuzumab
Chemotherapy examples: Taxanes (Docetaxel, paclitaxel) + Cyclophosphamide
Immunotherapy: Pembrolizumab
Breast Cancer Treatment Side Effects
Trastuzumab (Herceptin®)/ Pertuzumab
* REVERSIBLE cardiomyopathy
Anthracyclines (i.e. Doxorubicin, Epirubicin)
* IRREVERSIBLE cardiomyopathy
* Secondary leukemia
Taxanes (i.e. Paclitaxel, Docetaxel)
* Peripheral neuropathy
AI- increase OA
TAM - increase endometrial cancer and thrombosis
Breast Cancer: Antiresorptive therapy
Bisphosphonates (Zoledronic Acid, Clodronate, Ibandronate) or Denosumab
o Purposes
1. Decreases spread to bones (altered bone microenvironment, esp. for ER/PR +)
2. Protect against AI-induced osteoporosis
3. Decreased risk of skeletal related events (SRE - i.e. fracture, need for radiation,
cord compression)
Breast Cancer: Surveillance
Annual mammogram, history, physical & breast exam
Lifestyle modifications after breast cancer (CMAJ 2017)
o Bottom line- Live healthy- same recommendations as cardiac guidelines
o Prevent weight gain
o Exercise (150 mins/wk = reduced breast cancer mortality)
o Quit smoking
o Minimize alcohol
o Limit saturated fats and high-fat dairy products
o No need to avoid soy (purported “phytoestrogens”)
o Vitamin C/D/E – questionable benefit
Lung Cancer: Biology
Non-Small Cell
Squamous Cell
* Central lesions
* Strong link with smoking
* Unlikely EGFR/ALK mutated
Adenocarcinoma
* Peripheral lesions
* Most common
* Has driver mutations (EGFR)
Rare(ish) tumor types
* Neuroendocrine
* Adenosquamous
* Sarcomatoid
* Large cell
Small Cell
* Central lesions
* Strong link with smoking
* Non-EGFR/ALK mutated
* Rapidly growing
High Yield
* The 4 S’s of Lung Ca: Smokers get Squamous and the Speedy Small cell
* Adeno: “I Don’t Know why I got cancer…” – Lots of targetable mutation
* Neuroendocrine tumor of lung (RARE- know workup for carcinoid):
* PREOP do an Echo if suspicious
* Serum Chromogranin A
* Urine 24-HR Urine 5-HIAA.
* Gallium-PET scan (NOT Regular PET)
Lung Cancer:
Note on Radiation Pneumonitis
Typically 4-12 weeks (1-3 months post radiation)
• Corresponds to radiation field, depends on dose of radiation and presence of concurrent chemotherapy
• Mimics pneumonia in radiographic and clinical presentation
– Groundglass
– Interstitialchanges
• Typically by the time patients present, no longer immunosuppressed by chemo (beyond day 7 to 14 post-chemo)
• Treat with steroids.
Lung Cancer: Workup
Biopsy: Need both Histology + Markers
• Commonly done via CT guided or EBUS of primary.
• Molecular (NSCLC only)
• Adeno:PDL-1+MolecularTargets(EGFR,ALK,ROS1,NTRK,KRAS,BRAF,HER2)
• “Typical” EGFR+ profile – Elderly, Female, Asian, Non-smoker, Adenocarcinoma
• Squamous:PD-L1
Diagnostic Imaging + Staging (DONE PRIOR TO SURGERY- unlike Breast)
1. ALL patients –Rule out metastatic disease: CT C/A/P + MRI brain , ± Bone scan if symptomatic
2. If no obvious metastases- May be able to get cured (surgery or radiation/ chemoradiation)
o PET scan – look for occult metastases (to stage resectable disease/curative intent)
o Mediastinal staging (mediastinoscopy or endobronchial ultrasound [EBUS])
Non-Small Cell Lung Cancer: Early Stage Management
See chart in notes
Neoadjuvant Chemo+ Immuno becoming standard of care for resectable lung cancer
• For resectable stage 2 and 3 lung cancer with EGFR mutation- Adjuvant Osimertinib x 3 years
• For resectable stage 2 and 3 lung cancer withOUT EGFR mutation- Adjuvant Atezolizumab x 1 year
