breast cancer part II

what kind of team management is needed for most breast patients

multidisciplinary

what has been key in studying treatment options

clinical trials

what has research over the past 30 years indicate about breast cancer

it is systemic

what percent of breast cancers are early stage and does not need chemo

60%

what is the chemo treatment being used to increase

microscopic, lymphatic, and systemic disease

when is radiation usually delivered

postop

what does a radial mastectomy remove

the breast, its overlying skin, all axillary nodes, and the pectoral muscles

what are complications of a radical mastectomy

lymphedema of arm, shoulder stiffness, arm weakness, concave chest wall

why did radical mastectomy fall out of favor

high complication rate and it did not reduce incidence of mets disease

what were the benefits of the modified radical mastectomy

it preserved muscle, skin, lymphatics, and blood vessels

what does the modified radical mastectomy remove

removal of breast, some axillary nodes, and rarely the pectoralis minor muscle

what were the better results that the patient had when getting modified radical mastectomys

better cosmetic results, arm mobility, and arm edema

t/f: the survival rates similar in a RM and MRM

true

what can be done following a MRM

reconstruction

what is another name for a lumpectomy

tylectomy or tumorectomy

what does a lumpectomy remove

tumor with margin of normal appearing tissue

what is an axillary dissection

removal of a sample of axillary nodes on the side of the involved breast (ipsilater)

what is the purpose of an axillary dissection

for staging

why is staging important in an axillary dissection

guides in tx decisions and helps indicate prognosis

when is breast construction accomplished by

after mastectomy or lumpectomy

when will insurances pay for breast reconstruction

when it is a cancer diangosis

what are 7 factors considered by the surgeon for a breast reconstruction

cancer free, adjuvant tx completed, age, smoking, medical risk factor, skin laxity, compliance

what is skin laxity

how much skin is avaliable

what does smoking delay

healing

what age does better with breast reconstructions

younger

how long do all the reconstruction options take to completely recover

6 months

what are 4 different reconstruction options

tissue expansion, silicone implants, muscle skin flap, free tissue transfer

which reconstruction option is the most common technique

tissue expansion

what is another name for a muscle skin flap

TRAM: trans-rectus abdominis muscle

what is the result of a muscle skin flap

reconstruction and a tummy flap

which reconstruction option is less expensive than most options

tissue expansion

when is the balloon expander inserted for a tissue expansion

after mastectomy

what is the balloon expander do when inserted in a tissue expansion

filled to stretch skin over several weeks/months

how long do the tissue expansion need to be replaced

every 10 years

what is used when tissue expansion is unacceptable

muscle skin flap

where is the skin muscle flap pulled from in the muscle skin flap reconstruction

back (latissimus) or abdomen (TRAM)

what can systemic therapy be combined with

surgery or xrt

what is the goal of systemic therapy

destruction, prevention, or delay of tumor spread to distant sites

when systemic therapy is used with sx or xrt, what is referred to as

adjuvant therapy

what is the definition of adjuvant

given after surgery or radiation

what is the definition of neoadjuvant

as the first course of tx

what is the definition of concurrent

taking place at the same time as another form of therapy

what is the definition of sequential

one modality followed by another modality

what are common chemo agents commonly used alone or in combination

cyclophospamide, methotrexate, 5-FU, doxorubicin, vinblastine, mitoantrone

how are chemo drugs given

PO or via injection into vein or muscle

what can be the duration of chemo tx

months to years

what tx type is required for pts with Stage IV disease

combo of systemic and local tx

what percent of breast cancers require estrogen to grow and spread to other organs

50-70%

what are essential in order for cells to use estrogen to grow

estrogen receptors

what percent of breast cancer is in premenopausal women have ERs

30-50%

what percent of breast cancer in postmenopausal women have ERs

70-80%

what is endocrine therapy aimed at

removing the influence of estrogen on breast cancer cells

what will endocrine therapy prevent the cells to do

growing and spreading

why is endocrine therapy the initial treatment for women with mets breast cancer

because it is effective wherever cancer cells are located

what does endocrine therapy do to the cancer cells

deprive them of the hormones needed for growth

what is the most simples, but most invasive method of endocrine therapy

oophorectomy

what does it mean if you have no ovaries

little estrogen will be available to the tumor, that means better survival rates for women with ER+ cancer

what age is oophorectomy not considered for

younger pts

what are 4 factors that are considered in managing patients

stage of the disease, lymph node status, estrogen and progesteron receptor status, menopausal status

what are some permanent damage that can happen to pts on chemo

cardiac toxicity and increased risk of second malignancy

what are some side effects of chemo

nausea/vom, loss of appetite, fatigue, change in menstruation, mouth ulcers, hair loss, hot flashes

what are hot flashes a result of

lowered levels of estrogren

what two things has research proven have equal results for stage I and II disease

mastectomy and breast conservation tx

what is the main goal of conservative breast surgery

total gross removal of the tumor plus a margin while maintaining good cosmesis

how long is the surgical recovery of a conservation breast cancer management before XRT can begin

2-4 weeks

what two things are used to improve dose homogeneiety

lower energy beams and tissue compensation via planning

how much lung in a tangent field should present

1-2cm

what is the total dose of a breast pt

4500-5000cGy

what is the dose for a boost to tumor bed

6000-6600cGy

how is the chestwall treated

tangential fields with lower energy beams and compensators

what can be a challenge when abutting with tangential ports

treating IM nodes

what should be assessed at time of consultation

mobility

what do you want to avoid when setting up the patient

skin folds in their skin

what can be a limitation of an incline breast board

CT simulation

what things will effect skin changes

total dose, fraction size, bolus, wedge, beam type

when will side effects worsen

when combined with chemo

what is radiation recall

cause by some chemos that can increase reactions on skin, esophagus, lungs, and heart

what can be used to help eliminate skin folds

straws

what are to be avoided to the treatment area and why

lotions, creams, deodorant, or powder'; cannot contain perfumes, alcohol, and metals

what should also be avoided to the treatment area

shaving under arm

how long should the pt protect the area from the sun

one year after treatment

what dose will call dryness and redness (erythema)

3000cGy

how long can dryness/redness can occur

2-3 weeks

what dose can make dry desquamation occur

4000cGy

what should pts do with extreme temps to tx area

avoid them

what is moist desquamation supposed to be cleaned with

solution of hydrogen peroxide diluted with sterile water

what are long term side effects of tx

hyperpigmentation, epidermal thinning, telangectasia, and fibrosis of skin

list out the side effects of radiation

skin changes, fatigue, cardiac effects, pulmonary effects, lymphedema, brachial plexopathy, myelopathy, osteoradionecrosis

what is sometimes in the tangential field for left breast cancer

portions of the heart

what may be included if treating IM nodes

larger heart volume

t/f: myocardia is radioresistant

true

what dose can give a 5% risk of percarditis

small heart volume = 6000cGy; larger heart volume = 4000cGy

what are two ways to minimize dose to heart

respiratory gating for left breast and deep inspiration breath hold technique for left breast

what dose can cause pneumonitis and fibrosis of the lung

2500cGy

what are symptoms of pulmonary effects

coughing, dyspnea, sputum production, fever, and night sweats

why is incidence of chronic pulmonary effects rare

because the volume of lung included in treatment field is kept to a minimum

what side effect can result of breast surgery or axillary dissection

lymphedema

what percent of pts receiving XRT after level III axillary lymph node dissection experience arm edema

30%

what more commonly causes lymphedema

surgery, tumor infiltration, infection, or inflammation

what is the brachial plexus

network of nerves supplying the upper extremity