Breast Oncology and Palliative Care

Question 1

What are the oncological treatments available?

Answer 1

• Chemotherapy
• Radiotherapy
• Hormonal therapy
• Antibodies (TZ, Herceptin)

Question 2

Of cancer can be cured what treatment is provided

Answer 2

Adjuvant and neoadjuvant

Question 3

If cancer cannot be cured what treatment is provided

Answer 3

Palliation

Question 4

What treatments are given as neo-adjuvant therapies?

Answer 4

Radiotherapy- usually no

Hormonal therapy- yes

Question 5

Who is given hormonal therapy?

Answer 5

• ER-positive tumours
• less fit patients
• patients in whom it is not certain if surgery will be performed

Question 6

How long is neo-adjuvant hormonal treatment given?

Answer 6

Up to a year before sugery

Question 7

What are the advantages of neo-adjuvant chemotherapy

Answer 7

• cosmetic- WLE could be done instead of mastectomy
• less expensive nodal clearance post chemo

Question 8

What are the disadvantages of neo-adjuvant chemotherapy

Answer 8

Attendances for 6 extra imaging investigaitons compared with adjuvant treatment

Question 9

When is adjuvant radiotherapy used?

Answer 9

• routinely after WLE

Question 10

How is adjuvant radiotherapy delivered?

Answer 10

By external beam therapy using linac over 3 weeks

Extra treatment boost makes course longer

Question 11

What are the indications for boost adjuvant radiotherapy?

Answer 11

Young age

+ve margins

Question 12

adjuvant radiotherapy reduces recurrence risk by about ___; probably saves ___ life for every 4 recurrences prevented

Answer 12

adjuvant radiotherapy reduces recurrence risk by about half; probably saves one life for every 4 recurrences prevented

Question 13

Describe effect of tamoxifen adjuvant therapy?

Answer 13

5 years of tamoxifen- reduces risk of relapse by 15% at 10 years,

Improvement in survival is 5-10%

10 years of tamoxifen gives a further increase in survival of 3%

Question 14

How do tamoxifen and AI’s work?

Answer 14

Oestrogen receptor blockade

Question 15

Aromatase inhibitors – _______, ________ – ___ _________ in overall survival between tamoxifen and AIs

Answer 15

Aromatase inhibitors – letrozole, anastrozole – no difference in overall survival between tamoxifen and AIs

Question 16

Adjuvant chemotherapy is given to improve 10-year survival by _-__% absolute

Answer 16

Adjuvant chemotherapy is given to improve 10-year survival by 5-10% absolute

Question 17

What do the various adjuvant chemotherapy regimens involve?

Answer 17

Anthracycline and often a taxane

Question 18

What are the side effects of adjuvant chemotherapy?

Answer 18

• Anorexia
• malaise
• neutropenia
• alopecia
• taxanes induce myalgia
• peripheral neuropathy
• gCSF injections may produce severe axial skeleton pain from marrow stimulation

Question 19

Describe adjuvant hormonal therapy

Answer 19

Trastuzumab (herceptin)

given by s/c injection- sometimes IV

One year of 3-weekly treatment

Causes allergic reactions and reversible cardiac failure

Question 20

What is the survival advantage from adjuvant hormonal therapy

Answer 20

3%

Question 21

After treatment surgical review on …….. then discharge from clinic follow up but …… mammograms for …. ……

Answer 21

After treatment surgical review on the anniversary of surgery then discharge from clinic follow up but yearly mammograms for three years

Question 22

What can be given as palliative treatment for breast cancer?

Answer 22

• systemic blockade for widespread disease (e.g. ER blockade or chemotherapy)
• Radiotherapy for fungating breast disease or bone metastases
• bisphosphonates (e.g. oral ibandronic acid) for those with bone metastases as prevention

Question 23

What is trastuzamab-emtansine

Answer 23

New drug combining chemotherapy moiety with trastuzumab

Delivers chemotherapy moiety directly to the tumour

Question 24

What is the only way to be sure of bony mets?

Answer 24

localised CT or MRI

Bone scan often only helpful if it shows shower of mets on axial skeleton

Question 25

What should be done about neutropenia during chemotherapy?

Answer 25

If patient well and has no fever, ignore If they are septic, or well but with fever, admit to oncology urgently

Question 26

What should be done about hot flashes on tamoxifen?

Answer 26

* no good treatment * clonidine 50ug-75ug bd sometimes works, needs to be reduced and stopped slowly * phyto-oestrogens should be avoided * progestogens work, but safety unclear * stop the ER blockade

Question 27

What is the issue with merina coil in breast cancer?

Answer 27

Contraindicated by the company if breast cancer diagnosed depsite no obvious risk, may leave it in

Question 28

What tumour markers are there?

Answer 28

CEA CA15-3

Question 29

How should tumour markers be interpreted

Answer 29

OK for monitoring, poor for diagnosis Don't check them unless metastatic disease known to be present Don't check them unless it's clear how the result will change treatment

Question 30

When are bisphosphonates used?

Answer 30

In metastatic disease in high dose with AIs if DXA scan abnormal

Question 31

Why should dental work be done before starting bisphosphonates?

Answer 31

Can cause osteonecrosis of the jaw

Question 32

What is the risk with tamoxifen?

Answer 32

Vaginal bleeding Endometrial cancer (1:400) Endometrial hyperplasia/polyps

Question 33

What can be used as opposed to tamoxifen?

Answer 33

**Post-menopausal:** aromatase inhibitor **Pre-menopausal:** goserelin

Question 34

When does radiotherapy reaction come on?

Answer 34

When there is a greater volume of tissue the greater the reaction Tends to come on at end of treatment/once treatment stopped and lasts a few weeks

Question 35

What is a common cause of a new lump after treatment?

Answer 35

Fat necrosis causing a firm localized swelling

Question 36

What should be looked out for in back pain with bone mets

Answer 36

* severe back pain * radicular back * non-specific difficulty walking with no signs

Question 37

Which anti-depressants should be avoided if on tamoxifen?

Answer 37

Paroxetine

Question 38

Where does HER-2 +ve breast cancer preferentially metastasise to?

Answer 38

CNS and pleura

Question 39

What should be looked out for in HER-2 +ve breast cancer?

Answer 39

* headaches- seek head scan * blurred vision- consider retinal mets

Question 40

Where does lobular breast cancer metastasise to preferentially?

Answer 40

Peritoneum and gut Can present with sub-acute bowel obstruction

Question 41

How can risk of breast cancer be reduced?

Answer 41

* normal BMI * exercise * self-examination * don't drink to excess

Question 42

What can be done for vaginal dryness with ER blockade?

Answer 42

UNCERTAIN If cancer low risk (e.g. low grade, small, \<1cm, node-negative) then might consider vagifem NOT if high risk cancer and on AI