Oncology Flashcards
1
Q
What two types of radiotherapy are used in the UK?
A
- Photons (External) (high energy x-rays)
■ Penetrate deep & spare overlying skin (produce secondary electrons & free radicals which cause DNA damage - Electrons
■ Deliver dose just below skin surface
2
Q
Name two types of internal radiotherapy and describe them
A
Brachytherapy
■ Radiation sources placed within or close to tumour
Radioisotopes
■ Most commonly radioactive iodine to treat thyroid cancer
n.b. with radioisotopes have to stay in a lead-lined room for about 4 days until radiation they’re emitting is low enough to be safe to others
3
Q
Describe two different methods of Brachytherapy
A
● Interstitial: material is put into the target (eg prostate)
● Intracavity: material is placed inside a body cavity near to the tumour (eg uterus/cervix, oesophagus
4
Q
Why does radiotherapy work, i.e. why do cancer cells respond differently to normal cells ?
n.b. what can it sometimes cause?
A
Radiotherapy causes DNA damage to ALL cells
○ Normal cells can repair damage done by radiotherapy
○ Cancer cells already have faulty dna replication so can’t repair
Nb can cause secondary cancers caused by the
5
Q
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x
6
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7
Q
What are the broad indications for radiotherapy? (4)
A
● Radical/Curative
○ often in combination with chemo (eg head and neck Ca)
● Adjuvant
○ Following surgery to reduce the risk of local recurrence (eg breast Ca)
● Palliative
○ To help symptom control (all cancer sites - especially bone for pain)
● Neo-adjuvant
○ Prior to surgery (eg rectal Ca)
8
Q
x
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x
9
Q
What is the expression/unit of the dose of radiation absorbed?
What is a series of small doses called?
A
● The number of fractions and the The absorbed dose of radiation is expressed as the unit “gray” (Gy)
● Radiotherapy (RT) is commonly delivered as a series of small doses called fractions rather than as a single dose
10
Q
x
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x
11
Q
List the 7 steps of a radiotherapy treatment pathway
A
- Consent
- Immobilisation - Must make sure you’re getting the same spot every time
- CT simulations - This is done by a clinical
oncologist to design the radiotherapy - Tattooing -Usually get three - one in the middle and two on either sides. This helps make sure the patient is not rotated
- Volume definition
- Radiotherapy
a. Given as outpatient on continuous weekdays - Follow up
12
Q
Describe three measurements (volumes) involved in the volume definition before radiotherapy?
A
a. Gross tumour volume (GTV) = area of the tumour according to CT scan
b. Clinical target volume (CTV) = margins added for microscopic tumour spread
c. Planning target volume (PTV) = an extra margin made to allow for minor daily variations in patient and tumour position - try and be accurate within 2mm.
n.b. This is particularly the case with lung tumours that move up and down as the patient breaths.
13
Q
x
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x
14
Q
What does SACT stand for?
A
Systemic Anti-Cancer Treatment
15
Q
Name 4 types of SACT
A
- Cytotoxic therapies
- Hormonal therapies
- Biological of targeted therapies
- Immunotherapy
16
Q
Give three examples of cytotoxic therapy drugs
How do you normally calculate the dose required?
Which of these requires a different calculation for dosage?
A
Docetaxel, Cisplatin, Carboplatin
Calculate body surface area using the DUBOIS formula
Carboplatin is only one which do by renal function
n.b. ii. The most aggressive tumours (ie with higher cell replication) respond to chemo the best - eg SCLC
17
Q
Cytotoxic therapies are normally given by IV, but how else can they be delivered? (3)
A
Can also be given regionally:
- Intravesical (into bladder)
- Intraperitoneal (eg for metastatic ovarian tumours)
- Intraarterial (if good blood supplies - eg liver mets)
18
Q
x
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x
19
Q
Describe 3 (broad objectives) types of hormonal therapy?
A
- Reduce production of hormone
i. In ‘sex-related’ tumours, try and suppress sex hormones
ii. In lymphatic malignancies, try to suppress corticosteroids - Inhibit hormone binding to receptor
i. Tamoxifen in all stages of breast cancer
ii.Cyproterone and bicalutamide used in prostate
cancer - Increasing hormones
i. Glucocorticoids in high concentration can cause apoptosis in some malignant lymphoid cells
ii. To induce negative feedback loops
20
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x
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x
21
Q
Give two types of Biological or targeted therapy. include an example drug name for each
A
a. Monoclonal antibodies
often end in ‘mab’, eg Herceptin, trastuzumab
b. Tyrosine kinase inhibitors
Often end in ‘ib’, Eg imatinib, sunitinib
22
Q
Describe Immunotherapy (broad/brief summary)
A
Activation of the immune system against the cancer
n.b. All end in ‘mab’ (but not all things that end in mab are immunotherapy agents)
Eg anti-PD1 Pembrolizumab
23
Q
X
A
x
24
Q
Give the definitions of the intentions of treatment for radiotherapy (often used incorrectly!)
- Radical / primary
- Adjuvant
- Neoadjuvant
- Palliative
A
○ Radical / primary = to cure (is sometimes used to mean ‘big’)
- Eg germ cell or hodgkin’s lymphoma
○ Adjuvant = after surgery or radiotherapy
○ Neoadjuvant = before surgery or radiotherapy
-Nb normally do adjuvant or neoadjuvant (rarely do both)
○ Palliative = symptom control
25
Give the definitions (in context of radiotherapy) of the following terms:
- Cycle
- Course
- Line
○ Cycle = repeating pattern of treatment & rest days (get side effects when not having treatment)
○ Course = complete pattern of cycles
○ Line = order of treatments (eg this is their 3rd line of therapy)
26
Give the definitions of WHO Performance status (context oncology) (0-5)
○ 0 = fully active, no change to normal
○ 1 = restricted in physically strenuous activity (but can do office / light house work)
○ 2 = unable to work, capable of all self care (up & about for >50% waking hours)
○ 3 = capable of only limited self care (in bed / chair for >50% of waking hours)
○ 4 = cannot carry out any self care, totally confined to bed / chair
○ 5 = dead
27
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28
Give 4 types of Oncological emergency
1. Neutropenic Sepsis
2. Metastatic Spinal Cord Compression
3. Hypercalcaemia
4. Superior Vena Cava Obstruction
29
What is Neutropenic Sepsis?
When does it typically occur?
○ Patients having cancer treatment whose neutrophil count is <0.5×10⁹/Litre
■ Who have either
● A temp >38degs
● OR other signs or symptoms consistent with neutropenic sepsis even if not febrile (eg hypotensive, tachycardic, other signs/symptoms of infection)
○ Typically occurs between 7-14 days post chemo (timing of chemo is key in Hx!)
30
List 6 things to ask in history of Neutrophenic Sepsis patient
1. chemo drugs & timing, line & access, stents etc
2. previous episodes
3. localising symptoms- what’s the source?
4. PMHx/other comorbidities
5. Medications
■ Incl any recent paracetamol or ibuprofen - as this could mask a fever
6. Allergies
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What should you do in physical examination of Neutrophenic Sepsis patient? (5)
What should you NOT do?
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1 Temp
2 circulatory status (ABC)
3 MEWS
4 Full systematic examination (cardiovascular, respiratory, abdominal)
5 focus on potential site of infection
■ remember lines & catheters
■ perianal area
■ Look in mouth - oral mucosa
■ Wound site
```
DO NOT do rectal or vaginal exam on someone who is neutropenic!
33
What investigations should you do if Neutrophenic Sepsis suspected? (Give the acronym. 6 letters)
What bloods should you do? (8)
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○ Do BUFALO
■ Blood cultures
■ Urine output (measure)
■ Fluids
■ Antibiotics
■ Lactate
■ Oxygen
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○ Bloods (ring down to get bloods done quickly)
1. FBC
2. LFTs
3. U&Es
4. CRP
5 Lactate (VBG)
6 glucose
7 Consider clotting
8 Blood culture - (PAIRED if have line in - 3 if have a line with double lumen - take from both lumens)
● x2 (aerobes, anaerobes)
● Line (all ports) & peripheral (or 2 peripheral sets if no line)
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35
Give 5 other types of analysis that can be done if Neutrophenic Sepsis suspected?
1.Swabs
■ If suspected site of infection, incl lines
2. Sputum culture
3. Urine analysis & culture
4. Stool analysis & culture (if diarrhoea)
5. CXR - if resp symptoms/signs
36
What percentage of fevers during neutropenia have no identifiable aetiology?
60% - 70% of fevers during neutropenia have no identifiable aetiology i.e. fever of unknown origin.
37
What is the main treatment option for neutrophenic Sepsis?
When should this be given and what do you need to check first?
What to do if not responding to treatment?
- Broad spectrum IV antibiotics (as per local guidelines)
- Given within 1 hour of admission to hospital in all suspected cases
- ALWAYS ASK ABOUT ALLERGIES
- Do cultures before give Abx!!
- If not improving after 48 hours, change to 2nd line broad spec
- If still not responding, consider fungal, viral or atypical cause
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39
What is another treatment for Neutrophenic Sepsis? (other than broad spec abx)
Can give colony stimulating factors (G-CSF) (filgrastim or lenograstim) which promote stem cell proliferation
■ Give if severe - not routinely given
40
What is a MASCC score, what is used for and what does it look at?
○ Assesses risk of complications during a febrile neutropenic episode
○ Looks at: burden of infection, comorbidities, BP, COPD, tumour type, haematological/ solid tumour, fluid status, age <60 yrs, in-patient vs outpatient
41
What red flag symptoms (general i.e. non cancer-specific) for back pain might indicate Metastatic Spinal Cord Compression (MSCC)? (4)
```
General:
■ Age <20 or >55
■ Trauma
■ Weight loss
■ Pyrexia
```
42
What Cancer-Specific red flag symptoms for back pain might indicate MSCC? (3 broad)
Specific for cancer
1. Pain - MSSC may not have pain! - may have just tripped dt neuropathy
● Thoracic back pain, constant at night and rest
2.Pelvic symptoms
● Change in bowel or bladder function (nb often occurs late)
● loss of anal tone
● Saddle anaesthesia
3. Neuromuscular
● Leg weakness (incl abnormal gait)
○ Can be unilateral or bilateral and often not complete
○ May be perceived changes (believe pt - you may not feel difference)
● Sensory loss
43
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44
What cancers commonly spread to bone (and thus increase risk of spinal cord compression)?
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Most common(3)
Less Common (2)
```
```
Most common
1. Gendered
● Prostate
● Breast
2. Smoking
● lung
3. Blood
● Lymphoma
● Myeloma
```
Less common
1. Renal
2. thyroid
45
What is the management for suspected MSCC? (4 steps)
1. Lay flat
2. Neurological exam (must do before request MRI)
● Including a PR (to assess perianal sensation & anal tone)
● Plantar reflex is the most useful part of the neuro exam in this instance
● They have UMN signs
3. 16mg dexamethasone (with PPI cover)
4. Urgent MRI spine
● Within 24hrs
46
If MRI is positive for MSCC, what treatment options should be considered? (2 broad)
■ Consider neurosurgical intervention
| ■ Radiotherapy
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48
What is a common differential diagnosis for suspected MSCC?
Proximal myopathy from steroids is a common DDx
n.b. Macmillan has a really good MSCC leaflet for patients - useful to use for safety-netting, give to pts who you think don’t have but just in case
49
If patients are treated within 24hrs, what percentage will be able to walk again?
How long untreated before recovery becomes unlikely?
57% will walk again if treated in <24hrs
Recovery unlikely if left untreated for > 48hrs
(therefore treat asap!)
50
Describe the pathophysiology of Hypercalcaemia?
Some tumours secrete parathyroid hormone (PTH) related peptides and other growth factors which increase bone reabsorption & increase renal calcium reabsorption -> increased plasma calcium
N.b. after primary hyperparathyroidism, Ca is most common cause of hypercalcaemia (be alert)
51
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52
List the most common cancers associated with hypercalcaemia ( 3 broad +2 specific for each)
1. Ones associated with smoking
■ Non-small cell lung cancer (squamous cell)
■ Renal cell carcinoma
2. Gendered ones
■ Breast cancer
■ Prostate cancer
3. Think neck
■ Multiple myeloma & lymphoma
■ Head & neck cancers
53
List the general symptoms in the clinical presntation of hypercalcaemia (4)
```
General
■ Dehydration
■ Weakness
■ Fatigue
■ Bone pain
```
54
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55
List the CNS symptoms in the clinical presntation of hypercalcaemia (5)
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CNS
■ Confusion
■ Seizures
■ Proximal neuropathy
■ Hyporeflexia
■ coma
```
56
List the Cardiac symptoms in the clinical presntation of hypercalcaemia (5)
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Cardiac
■ Bradycardia
■ BBB
■ Arrhythmia
■ arrest
■ On ECG
-Short QT interval
-Wide T wave
-Prolonged PR interval
```
57
List the GI symptoms in the clinical presntation of hypercalcaemia (8)
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GI tract
■ Weight loss
■ Nausea
■ Vomiting
■ Abdo pain
■ Constipation
■ Ileus
■ Dyspepsia
■ pancreatitis
```
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59
List the Genitourinary symptoms in the clinical presntation of hypercalcaemia (1)
Genitourinary
| ■ Polyuria
60
What is another phrase fro remembering the symptoms of hypercalcaemia?
■ STONES, BONES, GROANS, MOANS, THRONES, MUSCLE TONE, PSYCHIATRIC OVERTONES
● Stones
○ kidney or biliary calculus (less common if acute)
● Bones
○ bone pain
● Groans
○ abdominal pain, nausea and vomiting
● Moans
○ may complain about other non-specific symptoms
● Thrones
○ Polyuria
● Muscle tone
○ hypotonicity, muscle weakness, hyporeflexia
● Psychiatric overtones
○ Depression 30–40%, anxiety, cognitive dysfunction, insomnia, coma
61
List and describe 4 treatments for Hypercalcaemia
1. Normal saline (make sure includes adequate K+)
■ 1L 4 hourly for 24 hours
■ Then 1l 4 hourly for 48-72 hours
2. Consider giving furosemide if at risk of fluid overload
■ Forceful diuresis promotes calcium excretion
c. Bisphosphonates
3. IV pamidronate or zolendronic acid
4. Calcitonin and corticosteroids (if arrhythmias or seizures)
■ Used in combination to lower plasma calcium
■ Rapid acting and no toxicity in short term
■ calcitonin is given S/C or IM with oral prednisolone
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How does Superior Vena Cava Obtruction present?
| List 3 broad types of symptom
- Swelling
- Lack of Oxygen
- Symptoms involving the Head (headache, dizziness etc)
64
Describe the type of swelling caused by superior vena cava obstuction (2 signs)
Swelling
■ facial/ neck/ arm swelling
■ Distended neck & chest veins
65
What symptoms are caused by lack of oxygen in superior vena cava obstuction? (2)
■ SOB (worse when lying flat)
| ■ cyanosis
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What symptoms affect the head in superior vena cava obstuction? (4)
■ Headache - > worse on coughing
■ Visual disturbance
■ Dizziness
■ Confusion / reduced consciousness
68
List potential non-malignant causes of superior vena cava obstuction? (5)
■ Non-malignant tumours (goiter)
■ Mediastinal fibrosis
● Idiopathic
● Post-radiotherapy
■ Infection
● TB
■ Aortic aneurysm
■ Thrombus associated with indwelling catheter etc
69
List potential malignant causes (specific cancers) of superior vena cava obstuction? (5)
```
■ Specific cancers
Mediastinal
○ Lymphoma
○ Germ cell tumours
○ thymoma
Nearby organs
○ Lung cancer (70%)
○ Oesophageal cancer
```
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What are potential superior vena cava obstuction causes from any (non-specific) cancer/malignancy?
What is the most common malignant cause?
From any cancers
○ Mediastinal lymphadenopathy
○ Tumour associated thrombus (^risk clots)
Lung cancer (70%)
72
What is the intial treatment for all patients presenting with superior vena cava obstruction? (3steps)
■ 16mg dexamethasone (with PPI cover)
■ Do CTPA to identify cause
■ Consider diuretics to reduce fluid load (keep an eye on U+Es)
73
When the cause is determined what treatments should be considered for superior vena cava obstruction? (4)
■ Vascular stent (radiological guidance) - with IV heparin cover (see trust guidelines)
● 1st line management
■ Radiotherapy
■ Chemotherapy
■ LMWH (if thrombus confirmed)
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What are potential side effects from surgical cancer treatments? (11)
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● Ongoing pain
● Fatigue (dt anaesthesia, stress of surgery, metabolic requirements)
● Appetite loss (common after GA)
● Drainage from site of surgery
● bruising/inflammation
● Infection at the incision site
● Organ dysfunction (eg bowel ileus)
● Sexual side effects: impotence, fertility, libido
○ Always ask as people unlikely to offer
● Psychological distress/body image (eg following mastectomy)
● Lymphoedema (if lymph nodes cleared)
● Stoma - temporary or permanent
```
76
What are 2 common (generic) side effects from Radiotherapy?
Fatigue
■ Also just tiring having to travel to & from hospital every day for however many weeks!
Skin reaction (radiation dermatitis)
■ Can be painful
■ Continue for 2 weeks after treatment but will then get better
■ In long term skin will fibrose & fell firm & woody
■ Emollients & opioid analgesics can help!
77
What are common radiotherapy toxicity side effects that affect the head and neck? (4)
How can they be managed? (2)
■ Mucositis - Inflammation of mucous membranes (mouth & eyes) = Painful
■ Thick oral secretions
■ Loss of taste
■ Dry mouth
Management
■ Mugard, gelclair, saline mouthwash & aspirin gargles, mucaine & saline nebulisers
■ Nutritional support (eg supplements NGT, PEG)
78
What are common side effects specifically seen with prostate cancer radiotherapy? (6)
Give basic management for each
1. Cystitis like symptoms – dysuria, frequency, urgency
■ Exclude concurrent UTI
■ Ensure good fluid intake to dilute urine
2. Diarrhoea – rectal inflammation (proctitis)
■ Fybogel for loose stools – to bulk stools
3. Poor urine flow (prostatitis)
■ Alpha-blocker – Tamsulosin, to improve flow
4. Haematuria
5. Abdominal pain
■ analgesia
6. Nausea
■ antiemetics
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What are common side effects specifically seen with lung cancer radiotherapy? (6)
Give basic management for each
a. Ordynophagia/ oesophagitis – due to mucositis in the oesophagus
i. May get oesophageal stricture that needs stenting
ii. mucaine
b. Cough
i. Exclude infection
c. SOB
i. inhalers/nebulisers
d. Chest pain
i. analgesia
e. Rarely nausea
f. Pneumonitis – occurs 6-8 weeks after RT. Progressive SOB and cough.
i. Treated with high dose steroids and oxygen
ii. Can lead to long term pulmonary fibrosis
81
Describe the side effects Cytoxic Chemotherapy has on the hair/skin/nails (2)
Hair, skin & nails
1. Hair loss (alopecia)
● Nb not all chemo drugs have this effect
● Can reduce risk with a cold cap
2. Hand & foot syndrome (palmar plantar dysathesia)
● Skin on hands & feet start to flake away
● Emollients
■ Skin changes
■ Nail changes
● Nail splitting
● Bow’s lines - periods of no growth - coincide w chemo cycles
■ Can also get skin pigmentation or photosensitivity with some drugs
82
Describe the side effects (+management) Cytoxic Chemotherapy has on the GI tract (4)
1.Nausea & vomiting
● Antiemetics
○ often given IV during treatment (eg dexamethasone & ondansetron)
- Ondansetron is antiemetic of choice for chemo!!
○ And oral to take home (eg metoclopramide)
2. Loss of appetite
3. Mucositis
● Encouraging oral health is really important
● Also caused by radiotherapy (so occurs especially with chemoradiotherapy)
● Seems to be worse in older patients
○ They also tolerate less well & seem to stop eating sooner
● Diabetes (& Bechet’s) increase likelihood & severity
4.Diarrhoea
● Fybogel for loose stools – to bulk stools
83
Describe the side effects (+management) Cytoxic Chemotherapy with regards to Myelosupression (3)
Myelosuppression
1. Neutropenia (Neutrophil count of <1)
● Get a thermometer & go hospital if temp of 38+ or signs of infection
● Treat with broad spec Abx within an hour
2. Anaemia
● Blood transfusion or recombinant erythropoietin, if symptomatic
3. Thrombocytopenia -> clots or bleeding
● Assess VTE risk & give prophylaxis (norm SC to ensure absorption)
● Platelet transfusion if low
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Describe the Neurological and Genitourinary side effects (+management) Cytoxic Chemotherapy has (2 each)
Neurological
1. Peripheral neuropathies
● Especially occur with ‘platinum drugs’ (eg Cisplatin)
● Can also get autonomic neuropathies (and rarely CNS toxicity)
2. Ototoxicity (especially cisplatin)
```
Genitourinary
1. Nephrotoxicity
● Platinum agents, especially cisplatin
2. Bladder toxicity
● Cyclophosphamide and ifosfamide cause hemorrhagic cysts
○ Mesna is an antidote to this
```
86
Describe the Cardiac and Hepatic side effects (+management) Cytoxic Chemotherapy has (1 each)
Cardiac
■ Acute arrhythmias (& possibly coronary artery spasm)
● In some drugs
Hepatic
■ Transient rise in liver enzymes, returns to normal
● (rarely liver failure can occur)
87
Describe the Psychological & systematic side effects (+management) Cytoxic Chemotherapy has (5)
```
Psychological & systematic
■ fatigue
■ Insomnia
■ ‘Fuzzy head’ - memory & concentration problems
■ stress , anxiety & depression
■ Low libido
```
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89
Describe some Long Term side effects (+management) Cytoxic Chemotherapy has (5)
Long term
1. Due to method of excretion
■ Liver
■ Kidney
2. Due to slowly regenerating cells
■ Heart - cardiac fibrosis
■ Peripheral nerves
■ Ears (deafness)
3. Secondary malignancies
4. Reduced fertility or infertility
■ Make sure to counsel patients
5. Psychological & social
90
How do Immunotherapy side effects present?
```
Normally mimics of autoimmune diseases
○ Thyroiditis or pituatory failure
- Doesn’t respond to steroids, lifelong hormone replacement is usual
○ Nephritis
○ Arthralgia / arthritis
○ Fatigue
○ Skin rashes
○ Colitis (also oesophagitis)
- Really worry about diarrhoea or abdo pain in this group of pts
○ Pneumonitis
- Common - differentiate from chest infection
○ Vasculitis
○ Hepatitis (norm pick up on LFTs)
○ Encephalitis (rare!)
```
91
What is the management for Immunotherapy side effects?
When do symptoms usually occur?
Rule out infection then treat with high dose steroids
○ Peak 6-8 weeks after start of treatment
○ But can occur up to 6 months after drug
N.b. A broad range of potential symptoms with many other causes - remain vigilant!
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93
List the potential causes of breast cancer (4 broad categories + few examples of each)
1. Uninterrupted oestrogen exposure
i. Early menarche, late menopause
ii. Nulliparity / first child at an older age
iii. Use of HRT
iv. Prolonged use of COCP
v. Obesity, esp after menopause
2. Lifestyle
i. Alcohol >14 units/wk
ii. Smoking
iii. obesity
3. Genetics
i. Often a family history (1 in 8 women will have)
● Particularly relevant if relative was premenopausal
ii. BRCA 1 & 2, P53
4. Misc/Other
i. Increased age
ii. Chest wall / mediastinal radiotherapy
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95
Give 5 prognostic factors involved in breast cancer?
Poorer prognosis if
i. Larger size >5cm
ii. Higher grade (3>2>1)
iii. ER negative disease
iv. HER-2 positive disease
v. Lymph node involvement
96
What is the most common type of breast cancer?
● Invasive ductal carcinoma is the most common (70-80%)
Nb inflammatory breast cancer is particularly aggressive
Nb 10 year survival is 80% in UK (very treatable)
97
Questions to ask when patient present (normally with breast lump)
○ O + P = How long?
○ E = related to menstrual cycle?
○ R = (less relevant)
```
○ A =
Local
● Skin changes
● Nipple changes
● Nipple discharge
● Pain
● Heat
● Lumps under arms?
Systemic
● Weight loss
● Reduced appetite
● Fatigue
● pain
```
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PMHx Qs to ask for suspected breast cancer/lump? (4)
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PMHx
○ Any previous lumps?
○ Age at menarche
○ Any children? What age? Did breastfeed?
○ Age at menopause?
```
100
DMHx Qs to ask for suspected breast cancer/lump? (2)
DHx
- HRT?
- COCP?
101
FHx Qs to ask for suspected breast cancer/lump? (1)
SHx Qs to ask for suspected breast cancer/lump? (2)
FHx
○ Any FHx? Which relatives and what age?
SHx
- Alcohol?
- Smoking?
(though do full ASD OHA DOT)
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103
What two ways do patients get referred for breast cancer investigations?
What assessments are done? (3)
Referral
○ Via 2ww from GP
○ From breast screening
Triple assessment
○ Clinical = full Hx & exam by breast surgeon
○ Radiology = Bilateral mammography
○ Histology = targeted ultrasound + biopsy of lump
■ Also USS of axilla +/- biopsy of any suspicious nodes
● N.B. If discrepancy in triple assessment - MRI is done
104
Describe the pattern of spread from breast cancer?
```
● Axillary lymph nodes first
● Then through the lymph to
○ Bone
○ Brain
○ Liver
○ Lung
```
105
Describe how breast cancer staging is calculated (i.e. what is the acronym and what are the components of the acronym)
```
TNM
○ Primary tumour (T)
■ TX primary tumour can’t be evaluated
■ T0 No evidence of primary tumour
■ Tis Carcinoma in situ
■ T1, T2, T3, T4 size and/or extent of primary tumour
```
○ Regional lymph nodes (N)
■ NX regional lymph nodes can’t be evaluated
■ N0 no regional lymph node involvement
■ N1, N2, N3 Involvement of regional lymph nodes (number of lymph nodes and/or extent of spread
○ Distant metastasis (M)
■ MX distant metastasis can’t be evaluated
■ M0 no distant metastasis
■ M1 distant metastasis is present
106
Give summary descriptions of breast cancer stages 0-4 (don't worry about exact scores of (TNM)
○ Stage 0 = Tis, N0, M0
○ Stage 1 = T1, N0, M0
■ Invasive carcinoma <2cm
○ Stage II = T2/3, N0, M0 OR T0/1/2, N1, M0
■ Either tumour <5cm or some node involvement
○ Stage III = any T or N >stage II, M0
■ T & N above stage II, no metastasis
○ Stage IV = any T, any N, M1
■ Any tumour with metastasis
107
Describe Curative treatment for breast cancer?
| two surgical procedures
Curative treatment
○ Aim is to eradicate all disease (macroscopic & microscopic) and provide a cure
○ Curative local treatment = Surgery (removes macroscopic disease)
● Breast: wide local excision or mastectomy
○ Want margin of >2mm
● Axilla: sentinel node biopsy
○ axillary surgical clearance (or axillary radiotherapy) if positive
108
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109
When is adjuvant radiotherapy required in breast cancer patients?
What three types of adjuvant systemic treatments are used ? (give drug examples for each and when they can be used)
Adjuvant treatment (removes microscopic disease) - given AFTER surgery:
Adjuvant radiotherapy
● Required following all conservative surgery (ie wide local excision) & after high risk mastectomy!
Adjuvant systemic treatments
1. Chemotherapy
○ EC (epirubicin & cyclophosphamide) and Paclitaxel are most commonly used
2. Hormonal therapy (only works if ER or PR positive)
■ Tamoxifen - works for all
3. Targeted therapy (Her2)
○ Trastuzumab (herceptin)
■ Monoclonal antibodies against Her-2 protein
■ Only works if tumour is Her2 positive
110
Describe 3 specific types of hormonal therapy for breast cancer
Hormonal therapy (only works if ER or PR positive)
1. Block oestrogen fitting in the lock
■ Tamoxifen - works for all
○ Block oestrogen production in pre-menopausal women
2. Oophorectomy
○ Block extra-ovarian oestrogen production in post-menopausal women
3. Aromatase inhibitors
● Anastrozole (Arimidex), letrozole & emestane
111
When is neoajuvant treatment used for breast cancer patients? (3 reasons)
Neoadjuvant treatment - given BEFORE surgery
Given if:
● Initial surgery not possible dt size of tumour
● To allow for breast conservation
● Her2 positive or triple negative (as high response rates are possible)
■ Nb doesn’t seem to improve survival
112
x
x
113
Describe treatments available for symptom control during breast cancer palliative care? (3 medical + 1 possible referral)
What is likely prognosis when palliative care is started? (how long )
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Symptom control
■ Antiemetics
■ Analgesia
■ Steroids - dexamethasone short course
■ Consider referral to Macmillan team
=> Maximise QoL
=> Improve survival
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■ Prognosis likely to be 12-18 months
n.b Can have all forms of treatment in that time depending on patient suitability and responsiveness of tumour
