Decision making- case 10: breast cancer
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12 Terms
1
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Based on your assessment of Mrs. Walters, you note that she has dyspnea, dry cough, and chest pain, which are all symptoms of radiation pneumonitis. You realize these symptoms may require pharmacological treatment. What should you do to advocate for proper treatment for Mrs. Walters?
Notify Mrs. Walters’ provider that Mrs. Walters may need steroids to treat her symptoms.
rationale:
Mrs. Walters’ symptoms indicate that she may be suffering from radiation pneumonitis, which is typically treated with steroids.
rationale:
Mrs. Walters’ symptoms indicate that she may be suffering from radiation pneumonitis, which is typically treated with steroids.
2
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As you begin preparing Mrs. Walters for her last radiation treatment, she tells you that her oncologist has prescribed tamoxifen for her. She hands you the prescription. What notation on the prescription would require you to notify the oncologist of an error?
Take 40 mg once per day by mouth
rationale:
Tamoxifen is usually prescribed at a total dose of 20-40 mg daily, given once or twice per day, with a max of 40 mg daily. Any total dose over 20 mg should be split into two doses, taken once in the morning and once in the evening. A prescription for 40 mg once per day by mouth is outside these prescribing guidelines. If a dose of 40 mg per day is given, the dose should be split into two 20 mg doses.
rationale:
Tamoxifen is usually prescribed at a total dose of 20-40 mg daily, given once or twice per day, with a max of 40 mg daily. Any total dose over 20 mg should be split into two doses, taken once in the morning and once in the evening. A prescription for 40 mg once per day by mouth is outside these prescribing guidelines. If a dose of 40 mg per day is given, the dose should be split into two 20 mg doses.
3
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What is the mechanism of action of tamoxifen?
Inhibits binding of estradiol to estrogen receptors, resulting in decreased cellular responses to estrogen
rationale:
Tamoxifen inhibits binding of estradiol to estrogen receptors in the breast. Therefore, it is frequently used to treat estrogen receptor-positive breast cancers.
rationale:
Tamoxifen inhibits binding of estradiol to estrogen receptors in the breast. Therefore, it is frequently used to treat estrogen receptor-positive breast cancers.
4
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You note from Mrs. Walters’ pathology report that her tumor is ER-positive and HER2-negative. How might her treatment change if her tumor was HER2-positive?
**She would likely be prescribed a drug such as trastuzumab (Herceptin).**
rationale:
Trastuzumab inhibits the activation of HER2 receptors. Therefore, it is often prescribed for patients with HER2-positive breast cancers.
rationale:
Trastuzumab inhibits the activation of HER2 receptors. Therefore, it is often prescribed for patients with HER2-positive breast cancers.
5
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Mrs. Walters states that her oncologist didn’t give her much information about tamoxifen, so she isn’t sure what to expect. You agree to answering several of Mrs. Walters’ questions.
Mrs. Walters says, “I’ve always heard that cancer treatments make you lose your hair. Will tamoxifen make me lose my hair?”
How would you respond?
Mrs. Walters says, “I’ve always heard that cancer treatments make you lose your hair. Will tamoxifen make me lose my hair?”
How would you respond?
“Some people lose their hair after taking tamoxifen, but only a small percentage. It is not a common side effect of tamoxifen.”
rationale:
Although hair loss is not a common side effect of tamoxifen treatment, it does occur in a small percentage of the population.
rationale:
Although hair loss is not a common side effect of tamoxifen treatment, it does occur in a small percentage of the population.
6
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Mrs. Walters responds, “If hair loss isn’t a common side effect of tamoxifen, what are common side effects?”
What side effects should you include in your answer? Select all that apply.
SELECT ALL THAT APPLY
What side effects should you include in your answer? Select all that apply.
SELECT ALL THAT APPLY
* nausea and vomiting
* hot flashes
* vaginal dryness, discharge, or bleeding
rationale:
* Nausea and vomiting occur in about 25% of patients who take tamoxifen.
* Because tamoxifen inhibits the estrogen receptor, it has similar side effects as menopause, including hot flashes.
* Because tamoxifen inhibits the estrogen receptor, it has similar side effects as menopause, including changes in vaginal discharge and dryness.
* hot flashes
* vaginal dryness, discharge, or bleeding
rationale:
* Nausea and vomiting occur in about 25% of patients who take tamoxifen.
* Because tamoxifen inhibits the estrogen receptor, it has similar side effects as menopause, including hot flashes.
* Because tamoxifen inhibits the estrogen receptor, it has similar side effects as menopause, including changes in vaginal discharge and dryness.
7
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Mrs. Walters tells you that she will definitely notify her oncologist if she has vaginal bleeding, because she is post-menopausal and hasn’t had her period in years. How might Mrs. Walters’ treatment for breast cancer differ if she was pre-menopausal?
The oncologist would likely add ovarian ablation by surgery, radiation, or drugs like goserelin (Zoladex) to her treatment regimen.
rationale:
Since pre-menopausal ovaries produce estrogen, ovarian ablation by surgery, radiation, or drugs such as goserelin may be needed in addition to tamoxifen treatment for pre-menopausal patients with estrogen receptor-positive breast cancer.
rationale:
Since pre-menopausal ovaries produce estrogen, ovarian ablation by surgery, radiation, or drugs such as goserelin may be needed in addition to tamoxifen treatment for pre-menopausal patients with estrogen receptor-positive breast cancer.
8
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Mrs. Walters tells you that she had horrible hot flashes and night sweats when she was going through menopause. She asks, “What can I do to reduce hot flashes if I get them from tamoxifen?”
What non-pharmacological measures would you include in your reply?
What non-pharmacological measures would you include in your reply?
* **Use relaxation exercises such as deep breathing**
rationale: Hot flashes are often accompanied by feelings of discomfort and panic. Relaxation techniques can help control the anxiety that accompanies hot flashes, thus reducing the perceived severity of the hot flash.
* **Wear loose-fitting, light-weight cotton clothing**
rationale: Loose-fitting, lightweight cotton clothing allows air to flow through the clothing, keeping the body cooler. This helps reduce the frequency and intensity of hot flashes.
* **Use a fan and open windows to keep air circulating in the house**
rationale: Air circulation is essential for reducing the frequency and intensity of hot flashes.
rationale: Hot flashes are often accompanied by feelings of discomfort and panic. Relaxation techniques can help control the anxiety that accompanies hot flashes, thus reducing the perceived severity of the hot flash.
* **Wear loose-fitting, light-weight cotton clothing**
rationale: Loose-fitting, lightweight cotton clothing allows air to flow through the clothing, keeping the body cooler. This helps reduce the frequency and intensity of hot flashes.
* **Use a fan and open windows to keep air circulating in the house**
rationale: Air circulation is essential for reducing the frequency and intensity of hot flashes.
9
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Next, Mrs. Walters asks you how long she will have to take tamoxifen. Her prescription has refills for 6 months, but she isn’t sure if she’ll need to take more than that.
How many years do you tell her she may need to take tamoxifen?
How many years do you tell her she may need to take tamoxifen?
**2, 3, 5, or 10 years**
rationale:
For post-menopausal women, tamoxifen is usually given 2, 3, 5, or 10 years, depending on the regimen chosen by the oncologist.
rationale:
For post-menopausal women, tamoxifen is usually given 2, 3, 5, or 10 years, depending on the regimen chosen by the oncologist.
10
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Mrs. Walters states that she understands she may need to take tamoxifen for up to 10 years depending on her oncologist’s orders. She then asks, “So after the tamoxifen, I’m done with treatment?”
How should you respond?
How should you respond?
**“If you take tamoxifen for only 2 to 5 years, you may need to take another drug called an aromatase inhibitor for another 5 years.”**
rationale:
In post-menopausal women, 2, 3, or 5 years of therapy with tamoxifen is often followed by 5 years of treatment with aromatase inhibitors.
rationale:
In post-menopausal women, 2, 3, or 5 years of therapy with tamoxifen is often followed by 5 years of treatment with aromatase inhibitors.
11
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Mrs. Walters states that she is worried about taking such an important medication for so long, because she occasionally forgets to take her current medications when she is supposed to.
How would you respond?
How would you respond?
**“Take your dose as soon as you remember, but if it is almost time for your next dose, then skip that dose and wait for the next dose.”**
rationale:
If a patient misses a dose, she should take the missed dose as soon as she remembers. However, if it is almost time for her next dose, she should skip the dose and take her next pill at the normally scheduled time.
rationale:
If a patient misses a dose, she should take the missed dose as soon as she remembers. However, if it is almost time for her next dose, she should skip the dose and take her next pill at the normally scheduled time.
12
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Before she leaves, Mrs. Walters asks you if there’s any medication that would help heal her radiation burn, as evidenced by her red, itchy skin with dry desquamation. What drug class do you identify that would help relieve Mrs. Walters’ symptoms?
**Topical Corticosteroids**
rationale:
You tell Mrs. Walters that topical corticosteroids might help reduce inflammation, and you will talk to her provider about a prescription.
Normally, severe radiation burn with dry desquamation can be treated by topical application of a corticosteroid such as hydrocortisone (e.g., Cortaid, Synacort) or betamethasone (e.g., Diprolene, Maxivate).
rationale:
You tell Mrs. Walters that topical corticosteroids might help reduce inflammation, and you will talk to her provider about a prescription.
Normally, severe radiation burn with dry desquamation can be treated by topical application of a corticosteroid such as hydrocortisone (e.g., Cortaid, Synacort) or betamethasone (e.g., Diprolene, Maxivate).