PA30326 workshops Breastcancer Flashcards
Mrs HB, a 49yr old female, presented to her GP with a small lump in her right breast. She was previously in good health and worked as a legal secretary. She was a keen cyclist and runner. She took the contraceptive pill from age 19-28, then had 3 children at ages 30, 32 & 35. She recently entered the menopause, experiencing hot flushes and her last menstrual period was 11 months ago. Her aunt died of breast cancer aged 43. She drinks 15 units of alcohol per week.
Q) What risk factors does Mrs HB have for developing breast cancer?
- Contraceptive Pill use
- less than 1% breast cancer caused by Oral contraceptives
- used OC for >4yrs before aged 25 and before 1st full term pregnancy. Risk goes back to normal 10 years after stopping taking the pill - Alcohol
- 8% breast cancers are caused by alcohol. Breast cancer risk 4% higher in women who consume 1.5 units alcohol/day.
- Risk increases as alcohol intake increases - Family history
- risk is twice as high in women with 1st degree relative with breast cancer.
- 1st degree = parent, sibling or chilid
- BRCA 1/2 mutation carriers have a 45-65% risk of developing breast cancer by age 70
- Risk is higher with relatives affected by breast cancer under 50yrs - Age
- biggest risk factor. Cell DNA damage accumulates over time - Age at which she had children
- (>25 yrs) breast cancer risk increased by 3% for each year older a women is when she first gives birth
- having children is itself a protective factor, breast cancer risk decreases by 7% with each live birth
Mrs HB’s GP referred her to the one-stop breast clinic at the local hospital, where a mammogram & FNA were performed. Histology confirmed a malignant tumour, 2 x 2cm, in her right breast. Physical examination revealed enlarged lymph nodes in her axilla on the right side. A chest x-ray showed no evidence of lung metastases, and a bone scan was negative for bony metastases. She was referred to the breast surgeons.
Mrs HB underwent a wide local excision of the tumour with removal of lymph nodes. It was found to be an invasive ductal carcinoma. Her tumour was found to be T2 N1 M0. 1 lymph node was positive for cancer. It was ER +ve and HER2 –ve.
Q) Does Mrs HB have metastatic breast cancer?
- No (M0)
As Mrs HB has nodal involvement she will benefit from adjuvant chemotherapy. The Consultant Oncologist decides that she will receive 6 cycles of FEC-T chemotherapy at 3 weekly intervals, followed by radiotherapy. He asks the Pharmacist Independent Prescriber to oversee the care of Mrs HB whilst she is receiving chemotherapy.
Q) What are the drugs involvedi n this chemotherapy regimen? Describe the sequencing of the drugs and how they are administered (i.e as a bolus/infusion. volume of infusion bag, time of infusion)
Cycle 1-3
- Fluorouracil IV bolus
- Epirubicin IV bolus
- Cyclophosphamide IV short infusion
Cycle 4-6
- Docetaxel IV infusion in 250m NaCl over 1hr
Imagine you are the pharmacist prescriber. What doses of chemotherapy drugs in the first cycle of FEC-T would you prescribe, given the following information:
Height 175cm
Weight 85kg
Surface area 2cm^2
Fluorouracil 1g
Epirubicin 200mg
Cyclophisphamide 1g
What are the main side effects of FEC-T chemotherapy?
- N&V
- Alopecia (hair loss)
- Anaemia, neutropenia
- Sepsis
- Mucositis
- Red urine 24 hrs post epirubicin
- Diarrhoea/Constipation
- Lethargy
- Cardiotoxicity
- Docetaxcel: nail changes
The FEC regimen is highly emetogenic and 3 antiemetics are usually given as prophylaxis for nausea & vomiting – dexamethasone, domperidone and ondansetron.
Consider the MHRA guidance on giving IV ondansetron – what are the potential risks and how should it be administered to patients of different ages?
Ondansetrone
- Prolongation of QTc interval and cardiac arrhythmia
- recommendation for maximum single IV dose in adults
Dilution and administration in patients age 65yrs or older
- all IV doses for prevention of CINV should be diluted in 50-100ml saline or other compatible fluid and infused over at least 15mins
Patient aged 75 or older
- single dose of IV ondansetron for prevention of CINV must not exceed 8mg (infused over at least 15mins)
Adults <75yrs
- a single dose of IV ondansetron for prevention of CINV must not exceed 16mg
If Mrs HB was diabetic, what advice would you give her about taking dexamethasone?
- Dexamethasone can increase blood glucose
- Monitor blood glucose more frequently when on dexamethasone
- Contact Chemo helpline if develops symptoms of hyperglycaemia
- Define the following terms related to chemotherapy-induced nausea & vomiting (CINV):
Acute CINV
Delayed CINV
Anticipatory CIN
Acute CINV
- N&V experienced during the first 24hr period immediately after chemo administration
Delayed CINV
- N&V experienced more than 24hrs after chemo administration and may continue for upto 7 days or more
Anticipatory CIN
- N&V that occurs prior to the beginning of a new cycle of chemotherapy
Mrs HB receives her 1st cycle of FEC-T with no immediate obvious complications. She attends the pharmacist’s clinic the day before she is due cycle 2 FEC-T. Her FBC & U&Es are checked and the results are as follows:
Hb 135 (115-165) Na 140 (135-145) Bilirubin 6 (1-17) WCC 2.3 (4-11) K 4.1 (3.5-5.2) ALP 55 (30-120) Neuts 0.8 (2-7.5) Ur 3.7 (2.5-7.8) ALT 22 (15-60) Plts 269 (150-400) Cr 75 (50-110) Albumin 40 (35-50)
Should she proceed with chemotherapy the next day, based on these results?
No, Neuts are too low,
Delay 1 week
Mrs HB tells the pharmacist that she vomited several times in the 2 days following the 1st cycle of chemotherapy. She had taken her antiemetics as prescribed, i.e. dexamethasone 8mg po od for 3 days starting day before chemo, domperidone 10mg po tds for 3 days, ondansetron 8mg po 1 hour before chemo + 8mg on night of chemo + 8mg bd on day after chemo.
Would you recommend any changes are made to her antiemetics? If so, what would you do?
- Give extra ondansetron for a few days
- Could add aprepitant (given day of chemo and for next 3 days) or Cyclizine or Prochlorperazine prn
- Advise her to keep taking domperidone for a few extra days
- Switch domperidone to metoclopramide
Mrs HB receives her 2nd cycle of FEC-T 1 week later, by which time her neutrophil count had recovered to 2.7. The pharmacist reinforces the information given to Mrs HB prior to chemotherapy about the risk of bone marrow suppression leading to lowered red cells, white cells and platelets
What would be the possible symptoms of:
a) A haemoglobin level reduced to 85 b) A platelet count reduced to 38
a)
- Lethargy
- Shortness of breath
- Dizziness
- Palpitation/angina
b)
- Bleeding
- Easy bruising
- Petechiae
If Mrs HB feels feverish and has a sore throat, what should she do?
- Take her temp & if above 38C, phone hospital chemo helpline for advice
Mrs HB receives her 3rd cycle of FEC-T with no complications.
What dose of docetaxel would you prescribe for cycle 4 of FEC-T? (assume height, weight & surface area are the same as previous, and no renal or hepatic impairment).
- 200mg
Mrs HB completes the remaining cycles of FEC-T with no particular problems. She has 4 weeks of radiotherapy and requires hormonal therapy.
Would tamoxifen or anastrozole be the best choice for Mrs HB? Why?
Anastrozole
- as post menopausal.
- Pre-menopause oestrogen is also produced by ovaries. Anastrozole only acts on oestrogen produced in skin, fat, muscles
Mrs HB completes the remaining cycles of FEC-T with no particular problems. She has 4 weeks of radiotherapy and requires hormonal therapy.
Anastrozole (aromatase inhibitor)
What side effects would you counsel her on if you were handing out this medicine?
Hot flushes Nausea Diarrhoea Vaginal dryness Rash Joint stiffness
