ONCOLOGY

A CASE OF INVASIVE DUCTAL CARCINOMA (BREAST CANCER)

Lecturer: Ms. Siew Lian

TUAN NOOR KHAIZURA TUAN RAHIM 1008-1878 SHALINI SEGARAN 1008-1863

PATIENT DEMOGRAPHIC & BACKGROUND

Name: Mdm DG Age: 36 years old Gender: Female Race: Malay Weight: 50kg Height: BMI:-

Review of system CLINICAL MANIFESTATION

ER (estrogen receptor): +VE (10%, moderate intensity) PR (progesterone receptor): -VE C-erb-B2: -VE (score:0) E-cadherine: +VE

Clinical manifestation CLINICAL MANIFESTATION

RIGHT BREAST: large hypoechoic lesion, 1 cm from nipple. Microlobulated margin. 3.1cm (W)x 4.7cm (CC)
Peri and intralesional vascularity noted. Well define round cyst 8-9 oc clock region (1.1x1.1x1.1 cm) Multiple enlarge right axillary nodes with scanty fatty hillum (2.1cm in short axis diameter) LEFT BREAST: small cyst measuring (0.7x0.3x0.8 c m) normal left axillary nodes
.

impression IMPRESSION
Right breast mass suspicious of malignancy with right axillary nodes metastases. Category 5. Bilateral breast cyst.

impression DIAGNOSIS
CATEGORIES:

Right breast IDC cT4N1Mx

impression CHEMOTHERAPY MEDICATION

Neoadjuvant Chemotherapy FEC 6 cycle 500/75/500:
5-fluorouracil 500mg Epirubicin 75 mg Cyclophosphomide 500mg

DISCHARGE MEDICATION
T. Granisetron I/I OD (x 1/7) T. Maxalon(Metochlorpramide) I/I TDS (x3/7) T. Dexamethasone 4mg BD (x3/7) T. Multivitamin Therapy I/I OD (x3/52)

FULL BLOOD COUNT

Range 1/4 29/4 20/5 22/5 10/6 13/6 1/7 3/7 22/7 24/7

HGB
Neut

12-16 g/dL
>1.5 x109/L >100 x109 /L

13
5.3

11
6.2

11
1.2

12
4.02

11
1.49

11
2.83

11
0.8

11
1.7

11
0.86

11
3.6

PLAT

257

312

259

338

318

299

253

270

276

290

RBC
WBC

3.8-5.8 x1012L
> 3.0 x109/ L

4.4
8.1

3.9
8.7

4
2.9

4.4
4.9

3.9
3.6

3.8
4.9

3.7
2.7

3.7
4.2

3.7
3

3.8
4.5

FBC interpretation
FBC should be check prior to chemotherapy. Min baseline: WBC > 3.0 X 109/ L Neut > 1.5x109/L Plat: > 100x109 /L Chemotherapy should not be given until counts recover fully. Chemotherapy for this ptn was initiated on 20/3. There is no FBC result taken before the chemo date. Low blood cell counts, as patient is undergoing cancer treatment.

LIVER FUNCTION TEST

NR Albumin ALP ALT 35-50 g/L 42-98 U/L <31 U/L 1/4 39 69 9 29/4 36 71 12 20/5 38 62 9 10/6 37 59 7 1/7 38 53 9 22/7 39 47 9

AST
Globulin In. bili T. bili T. protein

<31 U/L
22-34 g/L <21 umol/ L <17 umol/L 66-87 g/L

15
41 5 8.7 80

15
38 3 7.6 74

14
35 4 7.2 73

16
35 10 11.5 72

16
33 5 6.8 71

20
28 9.5 11.3 67

LFT interpretation
Liver function test should be checked with every cycle of chemotherapy but usually not necessary to wait for results before administration except for drugs metabolised in the liver and raised bilirubin which may increase toxicity. Pt. is not under Doxorubicin. Indirect bilirubin and total bilirubin is normal in this pt. High consistent globulin indicates ptn having chronic inflammation.

ELECTROLYTE AND RENAL PROFILE

NR Cl Cr K Na Urea 96-108 mmol/L 44-80 umol/L 3.5-5 mmol/L 135-145 mmol/L 1.7-8.3 mmol/L 1/4 100 54 4.3 137 2.6 29/4 105 54 3.9 138 1.6 20/5 106 52 4.3 140 1.4 10/6 106 54 3.9 141 1.7 1/7 109 60 4.3 139 2.6 22/7 103 49 3.8 137 2.5

ELECTROLYTE AND RENAL management PROFILE interpretation

Special attention to renal function if patient is prior to administration of cisplatinum and ifosfamide. CrCl should be more than 50 ml/min. CrCl in this pt = 101 ml/min To monitor nephrotoxicity caused by chemotherapy.

Serum creatinine should not be more than 150 mic mol/L. Cr highest in this pt = 60 mic mol/L

PATHOPHYSIOLOGY
T4: Tumor is any size growing into the chest wall or skin. N1:Cancer has spread to 1 to 3 axillary lymph node. MX: presence of distant spread cannot be assessed. Stage: IIIb (High risk Breast cancer)
Abnormal cancer cells that began forming in the milk ducts

Spread beyond the ducts into other parts of the breast tissue via axillary lymph node

Metastasised to left breast

management MANAGEMENT
Chemotherapy reg. should be individualized according to risk factor co- morbidities and ptn wishes Ptn: high risk
Size:10x 9cm Multiple enlarge right axillary nodes with scanty fatty hillum (2.1cm in short axis diameter) ER (estrogen receptor): +VE (10%, moderate intensity) PR (progesterone receptor): -VE

MANAGEMENT

Operable Local advanced BC

Surgery

Inoperable

Chemother apy Inoperable Palliative care

Radiotherapy Hormone therapy

PCI Invasive Ductal Carcinoma (IDC)

Goal of therapy

Pharmacist intervention

Follow up

1. To Management: eradicate Neoadjuvant FEC 6 cycle 500/75/500 the 5-fluorouracil 500mg growth of Epirubicin 75 mg cancer Cyclophosphomide 500mg cells. Recommendation: Based on CPG, treatment of Breast Cancer, In Stage IIIa and IIIb inoperable cancer, the treatment of choice is neoadjuvant chemotherapy followed by surgery for those who respond to chemotherapy. (CPG M. Breast Cancer, 2002) In locally advanced breast cancer that is inoperable, neo-adjuvant chemotherapy should be given to downsize the tumour. (CPG Breast Cancer, 2010)

FEC 6 cycle is suitable to be given as management neoadjuvant for LABC. (Systemic Therapy of Cancer)

Goal of therapy

Pharmacist intervention Appropriate regiments: 1. FAC/FEC 2. CMF 3. AC 4. Taxane based

Follow up Monitor: Safety: FBC LFT RP Cardiac enzyme

No significant difference in the pretreatment characteristics of patients receiving FAC/CA, FEC/CE and CMF including age, disease stage, Efficacy: menopausal and estrogen/progesteron Self receptor (ER/PR) status. examination Mamogram (Source: Effect of different neoadjuvant MRI chemotherapy regimens on locally advanced Ultrasound breast cancer, Department of Medical biopsy Oncology, Gazi University Medical School, 2003) Comment: This chemotherapy is rational because ptns tumour is downsized. RB mass from 10x9cm to 2x2 cm after FEC.

FEC CYCLE
Cycle length (days) = 21 Drugs 5-fluorouracil Epirubicin Cyclophospha mide Dose (mg/m2) 500-600 60-75 500-600 route IV IV IV antiemetic =4 Infusion time Bolus Bolus Bolus days 1 1 1

Source: Systemic Therapy of Cancer,2007

PCI Invasive Ductal Carcinoma (IDC)

Goal of therapy 2. To prolong pts survival rate

Pharmacist intervention Suggestion: Tamoxifen 20mg OD + radiotherapy after surgery.

Follow up Educate ptn about s/e: - Hotflush - tiredness

1. Hormonal therapy (Tamoxifen) is indicated in all pt. with ER +ve tumours. For premenopausal women Tamoxifen is given 20 mg daily for 5 years to improve recurrent free survival and overall survival.
2. Breast cancer tumors that are ER/PR-positive are 60% likely to respond to endocrine therapy (WebMed) 3. Hormanal therapy should no be used concurrently with chemotherapy because can the risk of thromboembolic thus should be initiated after chemotherapy. (J. Clinical Oncology,1996)

PCI Chemother apyinduced nausea and vomiting (CINV)

Goal of therapy Prophylaxis of CINV.

Pharmacist intervention Management (AFTER 5TH CYCLE): 1. T. Granisetron 1/1 OD x 1/7 2. T. Metochlorpromide 1/1 TDS x 3/7 3. T. Dexamethasone 4mg BD x 3/7 Recommendation: Vomiting occurring in the first 24 hours of administering chemotherapy is labelled as acute CINV and in the absence of effective prophylaxis. (Management of Chemotherapy-Induced Nausea and Vomiting, Dewan et al, 2010) To determine the emetic risk category: Calculating the Emetogenicity of Multiple Agent Chemotherapy/Biotherapy Regimens: 1. List each agent contained within the multiple agent regimen. 2. Identify the agent with the highest emetogenic level .

Follow up

PCI

Goal of therapy

Pharmacist intervention

Follow up

3. Determine the contribution of the remaining agents using the following guidelines: a. Level 1 agents do not contribute to emetogenicity in combination regimens. Examples: Level 1+1=0 2+1=2 3+1=3 4+1=4

b. Adding one or more level 2 agents increases the highest level by 1 in combination regimens. Examples: Level 2+2=3 3+2=4 2+2+2=3 3+2+2=4

c. Adding level 3 or 4 agents increases the

highest level by 1 per each agent in combination regimens. Examples: Level 3+3=4 3+3+3=5 4+3=5

PCI

Goal of therapy

Pharmacist intervention

Follow up

Cyclophophamide oral: emetogenicity level =3 Epirubicin 90 mg/m2 : emetogenicity level = 3 Fluorouracil : emetogenicity level = 2 (3 + 1 + 1= 5) NCCN Levels of Emetogenicity: Level 5 High Emetic Risk: 90% frequency of emesis (Emetogenic Risk of Chemotherapy and Biotherapy Agents) For pt with High Emetic Risk (90% frequency of emesis ) Granisetron 2 mg (PO) OD and Dexamethasone 8 mg PO OD should be given with chemotherapy D1.

PCI

Goal of therapy

Pharmacist intervention

Follow up

Followed by Dexamethasone 8 mg PO OD and Metochlorpromide 10-20 mg PO TDS on D2 and D3 should be given to patient as prophylaxis for CINV. (Systemic therapy of cancer 2nd edition) Comment : Pt complaint had severe nausea and vomiting D1 & D2 after 5th cycle chemotherapy (Acute nausea & vomiting). Doctor prescribed Granisetron OD for 1 day, Metochlorpromide TDS for 3 days and Dexametasone 4 mg BD for 3 days. Metochlorpramide does not need to be given for 3 days from D1 chemotherapy. This is because on D1 patient is prescribed with Granisetron and Dexamethasone for the prophylaxis of CINV.

PCI

Goal of therapy

Pharmacist intervention

Follow up

Additional of Metochlorpramide will only cause polypharmacy to the pt. However, pt. still experience severe nausea and vomiting although the doctor prescribed the anti-emetic drugs to the pt.

Efficay: Monitor sign and symptom of nausea or vomiting after chemotherapy.

This indicates that the pt was not compliance to the medication given. Therefore, pt should be counseled on the importance of prophylaxis of CINV.

PCI Cyclophosph amideinduced hemorrhage

Goal of therapy

Pharmacist intervention

Follow up Educate ptn about side effect of cyclophospha mide. Monitor: FBC, WBC, urinalysis

Prevention of Suggestion: hemorragic Mesna cystitis Rationalization: Based on Medscape Adequate hydration to induce brisk diuresis, continuous bladder irrigation, and prophylactic dosing of mesna are important preventive measures.

Recommended dose by Drug Info. Handbook:

IV: 60% of cyclophosphamide dose in 4 divided dose, (0,4, 6 and 9 hours) IV/oral: 100% cyclophosphamide dose, given 20% cyclophosphamide dose, 40% of cyclophosphamide dose given orally 2 and 4 hrs after start cyclophosphamide. Thus: IV: 300mg (0, 4,6,9 hrly) Oral/IV: 100mg (iv) + 200 (2,4 hr)

management PATIENT EDUCATION

Side effect of chemotherapy :
Nausea, vomitting, hemorrhage, etc

Psycho-education programme: improving physical and emotional Palliative care: support from family (to enhance QoL) Follow up Lifestyle modification: high fiber, low fat, physical activity

management REFERENCES
CPG Management of Breast Cancer 2002, 2010. Systemic Therapy of Cancer 2nd Edition MOH. Effect of different neoadjuvant chemotherapy regimens on locally advanced breast cancer, Department of Medical Oncology, Gazi University Medical School, 2003 Webmed (retrieved from: http://www.webmd.com/breastcancer/breast-cancer-types-er-positive-her2-positive) Role of epirubicin in advanced breast cancer, Clin. Breast Cancer, 2000. Drug Information Handbook 18th Edition. J. Clinical Oncology (http://www.ncbi.nlm.nih.gov/pubmed/8874334)