Breast Oncology

Question 1

what oncological treatments exist

Answer 1

radiotherapy
chemotherapy
hormonal therapy (oestrogen blockade)
antibodies (e.g. trastuzumab (herceptin))

Question 2

what are the treatment options for a curative cancer

Answer 2

neo-adjuvant
adjuvant
radical (treating cancer with oncological tx alone)

Question 3

what is the role of adjuvant therapy

Answer 3

acts as back up to oncological Tx, wont cure it on its own but improves survival

Question 4

what neoadjuvant therapies are given for breast cancer

Answer 4

hormonal therapy- for ER +ve tumours (can be given up to a year before surgery)
chemotherapy- can allow WLE instead of mastectomy

Question 5

what is the disadvantage of neo aduvant chemo

Answer 5

need to attend for 6 extra imaging investigations compared with adjuvant therapy

Question 6

what adjuvant therapies are used in breast cancer

Answer 6

radiotherapy (used after WLE)

ER blockade (5 years of tamoxifen or aromatase inhibitors (letrozole, anastrozole)

chemotherapy (usually anthracycline and taxane)

trastuzumab (herceptin - antibody against HER2)

Question 7

how is adjuvant radiotherapy given

Answer 7

external beam therapy using linac over 3 weeks

extra boost sometimes makes tx longer- indicated if young age or positive margins

Question 8

whar are the SEs of ER blockade

Answer 8

tamoxifen- DVT, PE, (is a partial agonist, paritally oestrogenic=will cause endometrium to proliferate) bleeding, polyps, endometrial cancer, endometrial hyperplasia
(may need to switch to goserelin)
AIs- heart problems, osteoporosis

Question 9

why are AIs given to postmenopausal women

Answer 9

cant stop ovaries making oestrogen so given to post menopausal
are more effective in post menopausal
cause less clots and endometrial cancer

Question 10

what are the side effects of chemotherapy

Answer 10

anorexia
malaise
neutropenia
alopecia
myalgia
peripheral neuropathy 
gCSF infections- these can cause severe axial skeletal pain from marrow stimulation

Question 11

how is trastuzumab given

Answer 11

sc injection
one year of 3 weekly treatments
only for cancers that overexpress HER2

Question 12

what are the risks of trastuzumab

Answer 12

allergic reactions

reversible cardiac failure

Question 13

what happens at the end of adjuvant treatment

Answer 13

review at end
discharge
surgical review on anniversary of surgery
yearly mammograms for 3 years

Question 14

what are the palliative options for breast cancer

Answer 14

systemic Tx for widespread disease- ER blockage or chemotherapy

radiotherapy for fungating breast disease/ bone mets

bisphosphonates for bone mets to prevent risk of #

Question 15

how is radiotherapy delivered

Answer 15

cancer localised
beams targeted to area, avoiding heart (exposure increases risk of ischaemic heart disease)
proton or electron (better for more superficial lesions)

Question 16

what is trastucumab-emtansine

Answer 16

combo of herceptin with chemo- delivers chemo to the tumour

used palliatively and as an adjuvant

Question 17

what increases the change of breast cancer recurrence

Answer 17

its size
its grade
the involvement of axillary lymph nodes

Question 18

is bone pain after cancer always mets

Answer 18

no - assess risk of the cancer to determine likelyhood

Question 19

what is the best way to diagnose bone mets

Answer 19

localised CT or MRI of affected bone
bone scans only helpful if there is a shower of mets affected the axial skeleton (other things can make it appear hot eg #’s)

Question 20

when should you worry about neutropenia during chemo

Answer 20

if patient septic, or well with fever admit to oncology urgently
if patient well and no fever ignore

Question 21

what treatments for hot flushes caused by tamoxifen/ AI

Answer 21

clonidine
avoid plant oestrogens
progesterones work but safety unclear
stop ER blockage if cancer not risky

Question 22

can you use the marina coil when have breast cancer

Answer 22

CI by companies
risk unclear
may be cases where it is left in

Question 23

what tumour markers for breast cancer

Answer 23

CEA

CA125

Question 24

what is the role of tumour markers in breast cancer

Answer 24

ok for monitoring, poor for diagnosis
dont check unless mets disease known to be present
dont check unless its clear of how the result will change the treatment

Question 25

when are bisphosphonates used in breast cancer

Answer 25

in metastatic disease in high dose with AIs if DXA scan abnormal (osteopenia or worse) do dental work needed before starting them- risk of jaw osteonecrosis if lack of oral tolerance try IV

Question 26

what are the risks of radiotherapy

Answer 26

skin reactions chornic swollen breast (greater the volume of tissue, greater the reaction) tends to come on at end of treatment, lasts a few weeks then heals lymphoodema of arm - rare, refer to breast care nurses if starting, avoid instrumentation (CP, cannulation, venopuction)= of ipsilateral arm after axillary surgery

Question 27

what is a new lump after breast cancer treatment likely to be

Answer 27

unless cancer very aggressive unlikely to be local recurrence if shortly after Tx finishing -fat necrosis common after surgery if uncertain do refer for triple assessment

Question 28

what should you be worried about in patients who have bone mets and back pain

Answer 28

spinal cord compression look out for : -severe back pain -radicular back -non specific difficulty walking with no signs URGENT MRI of spine by time classic signs have developed too late to treat

Question 29

what is the guidance for antidepressants and tamoxifen

Answer 29

``` avoid paroxetine (SSRI) antidepressents inhibit cytochrome P450 liver enzymes which are needed to convert tamoxifen to its active form ``` if someone has brittle depression then risk of change of anti depressant may be greater than any effect on tamoxifen

Question 30

what are the risks of a HER-2 positive breast cancer

Answer 30

high risk of recurrence similar distribution of mets, but esp to CNS, meninges and pleura if headache in this group do head scan if blurred vision condsider retinal mets

Question 31

what are the risks of lobular breast cancer

Answer 31

Similar distribution of mets, but preferential metastases to peritoneum and gut may be invisible on scan- Often more difficult to see on mammography too often presents with sub-acute bowel obstruction

Question 32

how can you reduce your risk of breast cancer

Answer 32

normal BMI exercise dont smoke or consume excessive alcohol self examine but not too often as may miss changing area

Question 33

can use topical oestrogen (vagifen) for vaginal dryness caused by ER blockade

Answer 33

uncertain decide on symptom severity and patient wishes risk on tamoxifen or if low risk cancer probably less avoid if high risk cancer and on AI

Question 34

when is back pain after breast cancer tx likely/possible to be mets

Answer 34

if high risk cancer

Question 35

when should you do a head scan after breast cancer treatment

Answer 35

if headaches or visual disturbance or inco-ordination (particularly fleeting peripheral disturbance) especially in patients who have had HER-2-positive cancer removed