Gp-Mksap-Onco-01

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=== BREAST CANCER ===

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=== BREAST CANCER ===

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Risk factors for breast cancer include

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- nulliparity, first childbirth > 30 years, early menarche, late menopause,
- older age, postmenopausal obesity, lack of physical activity, alcohol
- family history of breast cancer.

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BRCA Testing is indicated for women of Ashkenazi Jewish descent who have

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a family history of breast or ovarian cancer in

- any first-degree relative

- two second-degree relatives on the same side of the family

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BRCA Testing in NON-A'Nazi Jews, indications?

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- 2 first-degree relatives with breast cancer, one at < 50
- 3+ first- or second-degree relatives with breast cancer
- both breast and ovarian cancer among first- or second-degree relatives
- first-degree relative with bilateral breast cancer
- 2+ first- or second-degree relatives with ovarian cancer
- A first- or second-degree relative with both breast and ovarian cancer
- A male relative with breast cancer

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Chemoprevention in Breast Ca?

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- tamoxifen / raloxifene reduce incidence of hormone receptor +ve breast Ca but NO survival advantage

- ralox: fewer endometrial cancers, vaginal side effects, thromboembolic events, and cataracts

SERM benefits unclear in BRCA, ppx removal of breast / ovaries reduce risk > 90%

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DCIS tx?

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- lumpectomy + RXT or mastectomy

- tamoxifen (10 y) in estrogen receptor–positive cases.

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Invasive breast Ca tx

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Mastectomy + sentinel lymph node evaluation OR

lumpectomy and sentinel lymph node evaluation followed by whole-breast RXT

- tamox/AI if ER +

- adj chemo if LN+

- Staging with CT / Bone DX if obviously advanced, large or inflammatory

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Breast Ca,

i. Favorable prognostic variables

ii. poor px?

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i. expression of estrogen or progesterone receptors, small tumor size, and low pathologic grade.

ii. tumor size, lymph node involvement, overexpression of HER2/neu, and hormone receptor negativity

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Breast Ca, stages?

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I: < 2 cm in diameter + 0 LN

II: 2-5 cm + 3 LN OR > 5 cm + 0 LN

III: 4+ axillary lymph nodes, tumors >5 cm with one to three positive lymph nodes, or tumors that extend into the chest wall or skin.

IV: distant mets

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Breast Ca, adjuvant endocrine tx?

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Pre-menopause: tamoxifen 10 yrs or ovarian ablation if hx DVT

Post: Aromatase Inh 5 yrs

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Patients with triple-negative breast tumors, prognosis and options.

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- poor prognosis

seem to derive significant benefit from adjuvant chemotherapy

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trastuzumab? Give to? AE?

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monoclonal antibody targeting the HER2 receptor

- treat patients with tumors that overexpress HER2/neu

- can impair systolic ventricular function and cause heart failure (check EF q3mo, usu reversible)

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Locally advanced breast cancer?

Management?

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generally have large, potentially inoperable, tumors with skin or chest wall involvement (T4), or extensive lymph node involvement

- Do pre-op chemo

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inflammatory breast cancer?

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erythema, skin thickening, and a peau d’orange (dimpling of the skin typically due to obstruction of dermal lymphatics) appearance of the breast

- poor px

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Follow-up for survivors of early-stage breast cancer?

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- H&P q 6 months for at least 5 years, monthly breast self-examination, and annual mammography.

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Management of post-breast-Ca sx?

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vasomotor sx: venlafaxine (Avoid bupropion, fluoxetine, and paroxetine d/t interaction with tamox)

- use non-OCP birth control

- topical estrogen ok

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Blood per vag after tamoxifen use, mammo and pap neg. wtd

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Endometrial bx

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Metastatic breast cancer and management?

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- poor px ~2yrs

- local therapy such as surgery or radiation therapy is used for symptom palliation

- HER2: trastuzumab or lapatinib

- bone dzpamidronate or zoledronic acid

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First recurrance of breast ca, tx?

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Sample new mets to check for hormone status to guide treatment.

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=== OVARIAN CANCER ===

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=== OVARIAN CANCER ===

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Risk / protect factors for ovarian?

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Risk: BRCA, HNPCC
Protect: OCP, Breat feeding, tubal ligation

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In women at high risk for developing ovarian cancer, management?

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prophylactic bilateral salpingo–oophorectomy before age 40 years reduces the risk of developing cancer by 95%.

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Ovarian Ca tx?

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Optimal tumor debulking (no residual tumor mass >1 cm) is associated with increased survival

- low grade: NO chemo
Chemotherapy is indicated for patients with high–risk, early–stage disease and those with advanced disease (cis/carbo or paclitax)

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Management of Recurrent Ovarian Cancer

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Surgical resection is appropriate for patients with a recurrent solitary ovarian tumor or with limited relapse of cancer at sites favorable for surgical removal
– Bevacizumab (VEGF inh)

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Ovarian Ca, Monitoring and Follow–Up

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H&P, measurement of serum CA–125 levels, should be performed every 2 to 4 months for the first 2 years, then every 3 to 6 months for 3 years, and then annually

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has helped improve the quality of life and decrease complication rates in patients with ovarian cancer who are receiving chemotherapy.

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Use of hematopoietic growth factors

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=== CERVICAL CANCER ===

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=== CERVICAL CANCER ===

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Cervical Ca, Treatment

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IA: can observe if feritility desired
I/II: Surgery + Rads +/– cisplatin
large stage IB – IV: Rads + chemo

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Cervical Ca, f/u?

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– a pelvic examination and Pap smear every 3 to 6 months for 2 years, then every 6 months for the next 3 years, and then annually

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===GI CANCER ==

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===GI CANCER ==

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Colon Ca, tx

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– resection
– adjuvant chemo stage III+ (FOLFOX 6 mo)
– adjuvant optional in stage II
NO RADIATION (toxic to small bowel, cannot shield)

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Rectal Ca, tx

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– Resection
I: post–op RXT/chemo if LN+
Stage II/III: RXT + chemo before surgery and chemo alone after surgery
– chemo = FOLFOX

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Metastatic Colorectal Cancer, tx?

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– resect for cure if limited mets
– palliative chemo: Bevacizumab (VEGF) XOR cetuximab (EGFR)

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Adverse effects of

Bevacizumab

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Bevacizumab can cause hypertension, poor wound healing, and vascular catastrophes, including bleeding / perforation or thromboses

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Postoperative Colorectal Cancer Surveillance

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– PE + CEA levels every 3 to 6 months for the first 3 years and every 6 months during years 4 and 5. – CT C/A/P q yr x 3
– Colonoscopy 1 year after resection, then in 3 years, and then every 5 years

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Anal cancer tx

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Mitomycin + 5–FU + RXTSurgery not indicated unless invasive –> permanent colostomy

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Pancreatic Ca tx?

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– surgery if resectable + post–op gemcitabine
– metastatic: gemcitabine (+/– platin or FOLFIRNOX)

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Local and locoregional esophageal cancers, tx

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first: stage with CT/PET/ EUS

chemotherapy plus radiation therapy then surgery

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Gastric cancer, tx?

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surgery + post op 5–FU, leucovorin, RXT


HER2 positive: trastuzumab +cisplatin + 5–FU or capecitabine

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Gastric Carcinoid tumor, management?

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- Smaller (< 2cm) - Endoscopic resection - Larger: surgical resectionq 6-12 mo EGD for 3 yrs after- Sporadic, NORMAL gastrin level: gastrectomy- Unresectable: octreotide

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Gastrointestinal Neuroendocrine Tumors (NET), tx?

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–expectant observation and serial imaging (slow–growing)
– if in appendix do appy or hemicolectomy
– chemo minimally effective, best for pancreatic NET

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== LUNG CANCER ==

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== LUNG CANCER ==

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Diagnosis of central vs peripheral lesions?

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Centrally located lesions can be assessed by sputum cytology or bronchoscopy.


Peripheral masses often require CT–guided needle biopsy for diagnosis.

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Treatment of Stage I, II, and III Non–Small Cell Lung Cancer

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I/II: Surgery
IIIa: chemo + RXT +/– surgery (depending on LN) IIIb: chemo + RXT

Chemo: usu cisplatin

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Treatment of Stage IV Non–Small Cell Lung Cancer

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– incurable= > systemic chemo
– 1st line: 2 drug platinum–based combination +/– Bevacizumab

– RXT for SVC
– RXT + surgery for brain / spinal cord


– erlotinib if EFGR +

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Treatment of –Stage Small Cell Lung Cancer, limited and extensive

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Limited:Cis/Carbo + Etopside + RXT
– consider prophylactic Cranial RXT


Extensive: cisplatin /carboplatin + etoposide or irinotecan, palliative RXT

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Limited Small Cell Ca, 6 cycles chemo completed, residual mass on CXR. wtd?

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Cranial irradiation

- no benefit to > 6 cycles of chemo

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Metastatic Adeno Ca found in non-smoking Asian woman, wtd?

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Check for EGFR mutation.

Can potenially tx with erlotinib and gefitinib

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Lung Cancer Screening?

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-persons aged 55 to 80 years,

> 30-pack-year smoking history

- currently smoke or quit within the past 15 years

should undergo low-dose CT screening for lung cancer.