SACDALAN, D.B., SALES, M.C., SALONGA, A.E., SALVADOR, D.S., SAQUITAN, A.T., SARANZA, G.R., SEÑA, L.C., SEÑGA, I.R.,

SERRANO, G.K., SESE, D.G., SIMBULAN, J.C., SOBRIO, M.C., SUAREZ, F.L., SUGUITAN, A., SUMALAPAO, D.E., SY, P.L., SY.

S.M., TALADUA, K.M., TAN, C.S.

G r a n d R o u n d s

GENERAL DATA

JG 42 years oldFemalechief complaint : low back pain

Previously diagnosed with invasive ductal carcinoma stage 3B

2 yrs. PTA 6 mo. PTA 5 mo. PTA 1 wk. PTA

low back pain

-mostly in the evening

-temporarily relieved by Mefenamic Acid

Pain increased in intensity and was no longer relieved by Mefenamic Acid

-prescribed with unrecalled pain medications which offered slight relief

Consulted at PGH-OPD and a metastatic work-up (CXR, UTZ and Bone Scan) was done

HISTORY OF PRESENT ILLNESS

Diagnosed with Invasive Ductal

Carcinoma Stage III-B

PATIENT HISTORY PROFILE

Review of Systems

Past Medical History

Family History

Personal Social History

Obstetrics History

(+) weight loss(+) anorexia(+) dyspnea on exertion

(-) bowel changes

(-) urination changes(-) cough(-) headache

(-) seizure (-)

headache

• Diagnosed with Invasive Ductal Carcinoma Stage III-B 2 years PTC

• Underwent MRM, radiation therapy and 6 cycles of chemotherapy

• No hormal treatment• (-) HTN, (-)DM, (-)asthma,

(-)allergy

history of breast cancer: maternal aunt

• Nonsmoker• Nonalcoholic• Worked as a bank

teller

• Menarche at 14 y/o• G2P2 with regular

menses

PHYSICAL EXAMINATION

ORGAN SYSTEM

FINDINGS

General Survey

conscious, coherent, non-ambulatory, not in cardiorespiratory distress

HEENTpale palpebral conjunctivae, anicteric sclerae,

HeartDistinct heart sounds, (-) murmurs, (-) heaves, (-) thrills

Chest and

Lungs

Symmetrical chest expansion, (-) crackles, (-) wheezes;Healed surgical scar on the right breast area, normal left breast, no masses / LAD

PHYSICAL EXAMINATION

ORGAN SYSTEM

FINDINGS

AbdomenNormoactive bowel sounds; soft palpable liver with a liver span of 10 cm

Skin, ExtremitiesNails

Extremities are grossly normal(-) edmeaFull pulses

Neurologic Exam

unremarkable

I. Symptom: Low back pain, 42 y/o

Consider: • Metabolic x• Infection• Autoimmune/Inflammatory• Neoplasm• Degenerative• Trauma• Congenital x• Vascular x

Infection

1. UTI- ask for other GU symptoms, dysuria, discharge

2. Pelvic Inflammatory Disease- ask for sexual history, other GU symptoms, vaginal discharge

3. Endometriosis - ask for timing of pain, history of heavy menstrual bleeding, other symptoms fatigue, pain with intercourse, diarrhea, constipation, painful bowel movements during the menstrual period, rectal bleeding or blood in urine only during the menstrual period, and irregular bleeding or spotting between periods

4. Osteomyelitis - ask for tenderness, swelling and warmth in the affected area; avoidance of use in the affected part; malaise, loss of appetite, fever, nausea, fatigue, irritability

5. spinal infection- ask for fever, night sweats, and recent weight loss; check for elevated erythrocyte sedimentation rate and, spinous tenderness on percussion.

Degenerative

1. Osteoporosis- patient its over 40 years of age; ask thoroughly focusing on risk factors

2. Lumbar disc herniation- a slowly progressive degenerative process; ask for distribution of pain in the body

3. Acquired spinal stenosis- a consequence of degenerative joint disease that has been present for many years; ask for insidious pain at lower back and buttocks radiating to the legs; burning sensation in the buttocks and posterior thighs; pain typically increases with walking and

is relieved by rest. The patient may also feel better when he or she bends at the waist, because the diameter of the spinal canal is increased with flexion and decreased with extension; patient with spinal stenosis feels worse with hyperextension.

4. Spondylolisthesis- ask for progressive neurological deficit, cauda equina syndrome, or unremitting leg pain; affects women more than men

Inflammatory

1. Ankylosing Spondylitis- ask for pattern of pain (usually worse in the morning and improving through the day) and stiffness experienced over 3 months; ask for pain in sacrum, lumbar spine and thoracic spine and other peripheral joints; family history

2. Rheumatoid Arthritis- consider the criteria (presence of four of the following):

(1) morning stiffness in and around joints that lasts for longer than one hour

(2) arthritis (pain and inflammation) with swelling of three or more joints simultaneously

(3) at least one of the joints referred to in (2) must be in the hand

(4) symmetric arthritis with simultaneous involvement of the same joint bilaterally

(5) rheumatoid nodules over bony prominences or near joints

(6) positive serum rheumatoid factor (RF)

(7) x-ray changes typical of RA.

Neoplasm

1. spinal tumor (Primary)- severe and progressive pain, which commonly occurs during the night; slow and progressive neurological loss

2. Osteoid Osteoma- back pain that becomes worse at night, but is relieved by taking aspirin; look for visible bone loss on x-ray studies.

3. Metastatic spinal tumors- history of breast ca; unexplained weight loss; ask for other non- spinal symptom; ask for relief of pain: Degenerative Joint Disease is typically relieved by rest while metastatic bone pain is not

4. Multiple Myeloma

Trauma

1. Spinal Fracture- ask for any history of major and minor trauma e.g. falls; ask for neurologic deficits and paralysis

2. Cauda Equina syndrome- ask for bilateral leg pain, numbness, and/or weakness, as well as bowel and bladder incontinence, saddle anesthesia around the anus and buttocks; may be due to spinal stenosis, a spinal cord lesion, a very large posterior disc herniation, an inflammatory reaction, or a combination of all of these pathologies

II. Signs and Symptoms : low back pain mostly in the evening for 6 mos., temporarily relieved by Mefenamic acid; progression of pain slightly relieved by another pain killer (unrecalled); weight loss; previously

diagnosed to have Invasive Ductal Carcinoma Stage III-B

(-) hx of trauma

(-) signs of infection, fever

(-) asthma, allergy

(-) Cardiorespiratory symptoms except for dyspnea on exertion

(-) GU symptoms

(-) Abdominal symptoms

(-) Neurologic problems

II. Symptoms: low back pain mostly in the evening for 6 mos., temporarily relieved by Mefenamic acid; progression of pain

slightly relieved by another pain killer (unrecalled); weight loss; previously diagnosed to have Invasive Ductal Carcinoma Stage III-

B

Consider:

Neoplastic

1. Spinal tumor (Primary)- (+) severe and progressive pain, which commonly occurs during the night; ask if there is slow and progressive neurological loss

2. Osteoid Osteoma- (+) back pain that becomes worse at night, but should be relieved by taking aspirin; look for visible bone loss on x-ray studies.

3. Metastatic spinal tumors- (+) history of breast cancer, weight loss; soft palpable liver, 10 cm liver span which may indicate metastasis to the liver;

ask for relief of pain: Degenerative Joint Disease is typically relieved by rest while metastatic bone pain is not

Parameter Px Results Normal Values Interpretation

Hgb 100 g/L 120-180 g/L Low (Anemic)

Hct .35 0.370-0.540 Low (Anemia and Bone Marrow

problems)

WBC 15 x 109/L 4.0-11.0 x 109/L High (leukocytosis probably due to

an infection)

Neut 80% 50-70% High ( due to an infection)

Platelet 400 x 109/L 150-450 x 109/L Normal

AST 20 U/L 15-37 U/L Normal

ALT 30 U/L 30-65 U/L Normal

BUN 3 mmol/L 2.8-6.4 mmol/L Normal

Crea 72 mmol/L 53-115 mmol/L Normal

Alk phos 300 U/L 50-136 U/L High ( may indicate liver or bone

mets)

Ca 2.9 mmol/L 2.2-2.62 mmol/L High ( may indicate bone mets)

Alb 35 g/L 34-50 g/L Normal

LABORATORY FINDINGS

III. Symptoms: above signs and symptoms plus labs

Hypercalcemia- may indicate cancer especially in the ff cases:

• Multiple myeloma• Breast cancer• Squamous Cell Lung cancer• Renal cancer

These have high propensity to spread to the bones and release calcium into the blood. Some tumors secrete parathyroid-related peptide which acts like PTH.

 

III. Symptoms, PE + labs

Consider:

Neoplasm- Metastatic spinal tumor

D i a g n o s t i c s

Chest X-ray• Straight PA position with

clavicle equidistant with each other.

• There is a veil of haziness on the right lower lung with the right lateral sulcus, not defined.

– Veil of haziness in the RLL may suggest a pneumonic process with associated pleural effusion.

• The right hemi-diaphragm is slightly elevated laterally and the lateral elevation of the right hemi-diaphragm may suggest the presence of a sub-pulmonic effusion.

– A right lateral decubitus may be indicated for confirmation.

• The delineated osseus structures of the chest appears unremarkable.

Radionuclide Bone Scanning

Utilizes a radioactive tracer, a radionuclide to visualize various bone conditions on a scanner

Radionuclide emits γ radiation which accumulates at regions called “hot spots”

“Hot spots” correspond to areas of interest as these could point towards a tumor or focus of inflammation

INTERPRETATIONNormal: A scan result

is normal if bone uptake is equal throughout the body that is, there are no “hot” or “cold” spots seen

It is important to note the symmetric nature of traceruptake here

Radionuclide Bone Scanning

Radionuclide Bone Scanning

Abnormal: A scan result is abnormal by virtue of the presence of areas of increased or decreased uptake in the bone imaged.o Increased uptake may indicate

inflammation, bone infection, a malignant process, or a metabolic bone dyscrasia such as Paget’s disease

o Decreased uptake may indicate bone ischemia/infarction or malignancies such as multiple myeloma

Sample Bone Scan: J.G.

Sample Bone Scan: J.G.

Bone scan of J.G. presents hot spots at various sites: ribs, skull, femur, and lumbar spine

However taken alone this image is suggestive but not diagnostic of metastasis Sources estimate that bone scanning has an

excellent sensitivity of about 95% but a specificity of only 70% for malignancy; and only a 64% positive predictive value for metastasis in patients with a known extra osseous malignancy

Good as a screening but not as a diagnostic tool

Correlation with clinical findings and other laboratories may be beneficial

Abdominal UTZ

No significant findings

Other DiagnosticsCT Scan

Optimal for the visualization of bone over soft tissue

Higher sensitivity than X-ray

12000 php (VRPMC) and 9000 (The Medical City)

MRIOptimal for the visualization of soft tissue pathologies

Some sources note Sensitivity and Specificity to be as high as 95%

Capable of detecting bone marrow involvement which precedes cortical or trabecular bone changes seen in RBS and CT

17,261 php (St. Luke’s) 19,000 php (The Medical City)

PET ScanUsing a radioactive glucose analog, PET scanning can detect areas of increased

metabolic demand such as malignant tumors

Low sensitivity for malignancy, negative result of limited value in work-up

Lower sensitivity and specificity than MRI

3000-700 USD in the US and 890 USD in S.Kor.

C a n c e r S t a g i n g

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PRIMARY TUMOR (T)

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REGIONAL LYMPH NODES (N)

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DISTANT METASTASIS (M)

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STAGE GROUPING

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STAGE GROUPING

Ethnicity Females w/ breast CA per 100,000 women

All races 123.8

White 127.8

Black 117.7

Asian/Pacific Islander 89.5

American indian 74.4

Hispanic 88.3

Epidemiology: Global Burden

Source: US National Cancer Institute, Surveillance Epidemiology and End Result(SEER, 2009)

• Breast cancer is the 3rd most common tumor in the world

• Incidence Rates among races:

Breast CA in the Philippines

One of the top 10 leading cancers in both sexes

It is also one of the top 10 leading causes of cancer deaths in both sexes

#1 site of cancer and cancer deaths in Filipino women

Risk Factors

Genetic• Tumor

suppressor genes• Li-Fraumeni

syndrome (p53 mutation)

• PTEN gene

• DNA Repair genes• BRCA-1 and

BRCA-2 genes

Hormonal• Estrogen

exposure

HER2• also called HER2/neu, and HER-2 or human epidermal growth factor receptor 2• a gene that sends control signals to cells telling them to grow, divide, and make repairs. • A healthy breast cell has 2 copies of the HER2 gene. Breast cancer gets started when a breast cell has more than 2 copies of that gene due to overproduction of HER2 protein. This causes the cells to grow and divide much too quickly. This problem is not genetic but is more likely caused by aging, and wear and tear of the body.

HER2• Breast cancer gets started when a breast cell has more than 2 copies of that gene due to overproduction of HER2 protein. This causes the cells to grow and divide much too quickly. This problem is not genetic but is more likely caused by aging, and wear and tear of the body.

HER2• If breast cancer’s HER2 status is positive then the HER2 genes are over producing and creating the cancer.

–HER2 positive type of breast cancer is associated with more aggressive disease, greater likelihood of recurrence, poorer prognosis, and decreased survival.

• If it is negative, HER2 protein is not causing the cancer.

HER2• Immunohistochemistry or IHC measures the production of the HER2 protein by the tumor. Fluorescence In Situ Hybridization or FISH uses fluorescent probes to look at the number of HER2 gene copies in a tumor cell. If there are more than 2 copies of the HER2 gene, then the cancer is HER2 positive.

Other Risk Factors

Sex

Age

Early age at menarche

Later age at first full-term pregnancy

Late age at Menopause

No/short duration of Breastfeeding

First-degree relatives w/ breast CA

Radiation exposure

Endometrial carcinoma

Geographic influence

Diet

Classification of Breast CA

Almost all breast malignancies are adenocarcinomas, with other types (squamous cell, phyloodes, sarcomas, and lymphomas) making up <5%

Classified as either carcinoma in situ, or invasive carcinoma

Source: Geneva Foundation for Medical Research and Education

Invasive Ductal Carcinoma

Also called invasive carcinoma of no special type (NST)

Accounts for about 70-80% of breast CA

Carcinomas that cannot be classified as any other subtype

Histologically display a wide spectrum of appearances

Breast Cancer Metastasis Prognostic Factors

Breast Cancer Metastasis

The most common areas of breast cancer metastasis are: soft tissues, lung/liver and bone (1/3 of cases each)

5 leading site of metastatic breast CA are: lung, bone, lymph nodes, liver and pleura.

Spread of breast cancer to bone primarily involves the hematogenous route

HPIM

Kang, Y. New tricks agains an old foe: Molecular dissection of metastasis tissue tropism in breast cancer. Breast Disease 26 (2006,2007) 129–138 129.

Why bone?• Seed and Soil Hypothesis• Some proposed mechanisms:

– RANK (receptors) are abundant in the breast cancer cells, they preferentially migrate to bone where RANKL (ligand) is abundant

– Chemokine receptor CXCR-4 is abundant in breast cancer cells, goes to bone marrow, lungs and liver abundant in SDF-1/CXCL-12, its natural ligand.

– Involvement of VEGFR-1+ HPC in areas of metastasis– Breast cancer cell signals, including osteoblast-mediated signals acting

on osteoclasts, promote the formation of bone metastases.

Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101Psailaa, B, Kaplana, RN, Port, ER, Lydena, D. (2006-2007). Priming the ‘soil’ for breast cancer metastasis: The pre-metastatic niche. Breast Disease 26, 65-74, 65.Rose AA, Siegel PM. Breast cancer-derived factors facilitate osteolytic bone metastasis. Bull Cancer. 2006;93:931-943.

Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101Psailaa, B, Kaplana, RN, Port, ER, Lydena, D. (2006-2007). Priming the ‘soil’ for breast cancer metastasis: The pre-metastatic niche. Breast Disease 26, 65-74, 65.Rose AA, Siegel PM. Breast cancer-derived factors facilitate osteolytic bone metastasis. Bull Cancer. 2006;93:931-943.

Seed and Soil HypothesisRANK (receptor)

RANK (ligand)

CXCR-4 (receptor)

SDF-1/CXCL-12(ligand)

VEGDR-1+HPC

Bone Metastasis

Primary sites: vertebrae, proximal femur, pelvis, ribs,

sternum, proximal humerus, skull

Clinical manifestation: PAIN!PAIN is the most frequent complaint, it is

present over weeks, localized, more severe at night

Other manifestations include swelling, nerve root/ spinal cord compression, pathologic fracture, myelophthisis

Can also be asymptomatic

Bone metastasis

Can be either osteolytic, osteoblastic or both.

In most metastasis, there are stages where osteolytic or osteoblastic tendency predominates.

HPIM,Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101

Osteolytic Bone Metastasis

Tumor produces substances that can lead to resorption (ex. Vit D-like steroid, prostaglanding, PTH-related peptide) or the tumor produces cytokines that induce osteoclast formation (ex. IL-1, TNF, receptor activator of NF-êB ligand (RANKL) )

Bone destruction

Hypercalcemia, excretion of hydroxyprobe-containing peptide

Release of parathyroid hormone-related peptide, IL-6, TGF

Serve as tumor survival factors

Tumor produces cytokines that activate osteoblasts

Increased alkaline phosphatase, hypocalcemia

Osteoblastic Bone metastasis

Patient’s problem list

Low back painWeight loss and anorexiaDyspnea on exertionPallorAnemiaLeukocytosis, neutrophiliaHypercalcemiaIncreased alkaline phosphatase

BREAST CA BONE METASTASIS

LOW BACK PAIN

+ ANOREXIA= WEIGHT LOSS

IMMUNOCOMPROMISE

INFECTION (PNEUMONIA)

LEUKOCYTOSIS

DYSPNEA ON EXERTION

OSTEOLYTIC OSTEOBLASTIC

HIGH ALKALINE PHOSPHATASE

HYPERCALCEMIA

ANEMIA OF CHRONIC DISEASE

ANEMIAPALLOR

Complications

Liver Metastasis

Lung Metastasis

Early detection: Ultrasound / CT scan:

liver metastasis

Chest X-ray / sputum cytology: lung metastasis

Systemic therapy:-chemotherapy, radiotherapy, hormone therapy

Complications

Thromboembolic complicationstumor cells can directly

activate the blood-clotting cascade

Tumor cells can induce procoagulant properties of vascular endothelial cells, platelets, monocytes and macrophages.

Early detection of symptoms through patient education (edema, warmth, tenderness)

Low molecular weight heparin

Complications

Bone loss and fractureso From bone

metastasiso From hormonal

changes due to primary tumor

Screening by DEXASystemic TherapyBisphosphonate drugs

MoA: inhibit osteoclasts and induce apoptosis

prevent loss of bone, reduce the risk of fractures, decrease pain

calcium and vitamin D,weight-bearing exercisescessation of smokingreduction in alcohol intake

Tr e a t m e n t

Stage IV Invasive Ductal Carcinoma with systemic disease

4 Goals of Therapy in Cancer

1 Prevention

2 Curative

3 Control

4 Palliation

Curative

1 Hormone/Endocrine Therapy

2 Chemotherapy

Bone metastasis

Ovarian Ablation+ Biphosphonate

Endocrine Therapy

Visceral symptoms or

Completed 3 cycles of consecutive endocrine therapy

Yes

No

ChemotherapyECOG performance status >= 3

No further improvement/clinical benefit

Completed 3 cycles of consecutive endocrine therapy

Biphosphonate

Bone metastasis complications:

pathologic fractures

nerve root compression

hypercalcemia

Pain

bone marrow infiltration

MOA: inhibits bone resorption and disrupt the metabolism and adhesive abilities of tumor cells

Bone metastasis

Ovarian Ablation

+ Biphosphonate

Endocrine Therapy

Visceral symptoms or

Completed 3 cycles of consecutive endocrine therapy

Yes

No

ChemotherapyECOG performance status >= 3

No further improvement/clinical benefit

Completed 3 cycles of consecutive endocrine therapy

Bone metastasis

Ovarian Ablation

+ Biphosphonate

Endocrine Therapy

Visceral symptoms or

Completed 3 cycles of consecutive endocrine therapy

Yes

No

Chemotherapy

ECOG performance status >= 3

No further improvement/clinical benefit

Completed 3 cycles of consecutive endocrine therapy

Endocrine/Hormone therapy

Bone Metastasis

Anastrazole

Tamoxifen

+ BiphosphonateNon steroidal

aromatase inhibitor(anastrozol

e or lestrozole)

Steroidal aromatase inactivator

Tamoxifen

currently used for the treatment of both early and advanced ER+ (estrogen receptor positive) breast cancer in pre- and post-menopausal women

binds to estrogen receptors on tumors and other tissue targets, producing a nuclear complex that decreases DNA synthesis and inhibits estrogen effects.

SIDE EFFECTS:BoneEndometrial cancerLipid profileCNSlibido

Tamoxifen

SIDE EFFECTS:BoneEndometrial cancerLipid profileCNSlibido

HERCEPTIN• (a.k.a. trastuzumab) is a monoclonal antibody drug that is used to treat HER2 positive breast cancer.• It is a targeted therapy and is referred to as an immune treatment. It is given intravenously, once every 2-3 weeks. • It targets HER2 protein production to stop the growth of HER2 positive cancer cells.• It shrinks positive tumors before surgery, it gets rid of HER2 positive cancer cells that have spread beyond the original tumor and it helps prevent recurrence of the HER2 positive cancer if it was a 2cm or larger tumor or if the cancer had spread to the lymph nodes.

HERCEPTIN• This treatment is most helpful with combination with chemotherapy. • Caution should be observed in using this drug as it may cause cardiac failure manifesting as congestive heart failure (CHF) and decreased left ventricular ejection fraction (LVEF). • Infusion should be interrupted for patients experiencing dyspnea or clinically significant hypotension. • should be discontinued for infusion reactions manifesting as anaphylaxis, angioedema, interstitial pneumonitis, or acute respiratory distress syndrome

Control

Bone metastasis

Ovarian Ablation

+ Biphosphonate

Endocrine Therapy

Visceral symptoms or

Completed 3 cycles of consecutive endocrine therapy

Yes

No

Chemotherapy

ECOG performance status >= 3

No further improvement/clinical benefit

Completed 3 cycles of consecutive endocrine therapy

Treatment ComplicationsChemotherapy

• Aches or pains from time to time in the treated breast or the muscles around the breast even years after treatment

• Nausea and vomiting

• Pain control

• Pre-medication with anti-emetics (ondansetron, serotonin receptor antagonists, dopamine agonists)

Treatment ComplicationsChemotherapy

• Diarrhea

• Oral mucositis

• Fluid intake, diet, drugs: Loperaamide, Atropine, Octreotide

• Soft bland diet, comprehensive dental examination, drugs: sucralfate, vitamins, antibiotics and antifungals

Treatment ComplicationsChemotherapy

• Myelosuppression resullting in infection, bleeding, anemia

• Primary ovarian failure resulting in sterility and low estrogen levels leading to osteopenia

• Erythropoietin or blood transfusion, G-CSF

• Counseling • Screening and prevention of bone loss

Treatment ComplicationsChemotherapy

• Pulmonary toxicity– Pulmonary fibrosis– Pulmonary edema– Acute

hypersensitivity pneumonitis

• Cardiotoxicity, nephrotoxicity, hepatotoxicity, neurotoxicity

• Supportive therapy (O2)

• Monitoring cumulative dose of drugs• Frequent monitoring for signs of organ

damage

Treatment ComplicationsRadiotherapy

• mild fatigue that builds up gradually over the course of therapy

• reddening, dryness and itching of the skin

• slowly goes away 1-2 months following the radiation therapy

• usually heal completely within a few weeks • Skin moisturizers may be applied

Treatment ComplicationsRadiotherapy

• Slight swelling of the breast

• radiation pneumonitis– cough, shortness of

breath and fevers three to nine months after

• goes away within 6-12 months

• usually mild so no specific treatment is needed• goes away within two to four weeks with no long-term

complications

Treatment ComplicationsEndocrine Therapy

Tamoxifen

Hot flashes (80%)

Vaginal discharge (50%)

Water retention (32%)

Nausea (26%)

Irregular menstrual periods (25%)

Weight loss (23%)

Vaginal bleeding (23%)

Patient counseling

Aromatase Inhibitors

joint stiffness and joint pain

bone problems

Pain management

Regular exercise

Screening and preventive measures for bone complications

ECOG PERFORMANCE STATUS*

Grade ECOG

0 Fully active, able to carry on all pre-disease performance without restriction

1 Restricted in physically strenuous activity but ambulatory and able to carry out work of a light or sedentary nature, e.g., light house work, office work

2 Ambulatory and capable of all selfcare but unable to carry out any work activities. Up and about more than 50% of waking hours

3 Capable of only limited selfcare, confined to bed or chair more than 50% of waking hours

4 Completely disabled. Cannot carry on any selfcare. Totally confined to bed or chair

5 Dead

• As published in Am. J. Clin. Oncol.:Oken, M.M., Creech, R.H., Tormey, D.C., Horton, J., Davis, T.E., McFadden, E.T., Carbone, P.P.: Toxicity And

• Response Criteria Of The Eastern Cooperative Oncology Group. Am J Clin Oncol 5:649-655, 1982. The ECOG Performance Status is in the public domain therefore available for public use. To duplicate the scale, please cite the reference above and credit the Eastern Cooperative Oncology Group, Robert Comis M.D., Group Chair.

Palliation

Physical

Emotional

Spiritual

Physical support

PainTreatment of InfectionsDifficulty breathingNutritional SupportLoss of appetiteFatigue, WeaknessSleeping disorders

Psychiatric consultDepression anxiety Confusion

Family counseling/Group TherapyEnd of life managementGenetic couselingFinancial counseling

Emotional

Community support

Cancer support groups/network

Visualization techniques and meditation

Spiritual

Alternative Therapy (CAM)

Relaxation techniques

Acupunture

Yoga and tai chi

Herbal medications for pain and relaxation

Prognosis: 5-year Survival Rate for Breast Cancer by Stage

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Prognostic Variables

Tumor Staging-tumor size -status of axillary lymph nodes-involvement of microvessels (capillary or lymphatic channels)

Detection of breast cancer cells -in the circulation/bone marrow-use of gene expression arrays

Prognostic VariablesEstrogen and Progesterone Receptor

Status- tumors that lack either or both has greater chances for relapse.

Measures of Tumor Growth Rate-tumors with high proportion (more than the median) of cells in S-phase pose greater risk of relapse.

DNA content/form- (+) nondiploid tumors have somewhat worse prognosis

Prognostic VariablesHistologic of Classification

-Elston Score: tumors with poor nuclear grade have higher risk recurrence than those with good nuclear grade.

Molecular Changes in the Tumor-tumor overexpresses erbB2 (HER -2/neu) or have a mutated p53 gene- worse prognosis

Presence of microvessels-worse prognosis

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Follow-Up

Survival is not influenced by early diagnosis of relapse.

Follow-Up Survival is not influenced by early diagnosis

of relapse.TEST FREQUENCY

History; eliciting symptoms; physical examination

Q3-6 months x 3 years; q6-12 months x 2 years; then

annually

Breast self-exam monthly

mammography annually

Pelvic exam annually

Patients education about symptoms of recurrence

ongoing

Coordination of care ongoing

Source HPIM 17th ed

Reference

http://www.radiologyinfo.org/en/info.cfm?pg=breastcancer&bhcp=1#4

http://www.thelancet.com/journals/lanonc/article/PIIS1470-2045(09)70029-4/fulltext

http://clincancerres.aacrjournals.org/cgi/content/full/12/20/6309s

http://www.biomedexperts.com/Abstract.bme/14534872/Coagulopathic_complications_in_breast_cancer

references• P53 pathway in breast cancer http://breast-cancer-research.com/content/4/2/70• Tp53 website http://p53.free.fr/our_work/breast.html• Mayoclinic risk factors http://www.mayoclinic.com/health/breast-cancer/DS00328/DSECTION=risk-factors• Ngelangel, Wang. 2002. Cancer and the philippines http://jjco.oxfordjournals.org/cgi/reprint/32/suppl_1/S52• Fauci et. al. Harrison’s Principles of Internal Medicine 17 th ed.• Robbins and Cotran Pathological Basis of Disease 7 th ed.• Geneva Foundation for Medical Research and Education •

http://images.google.com.ph/imgres?imgurl=http://tgmouse.compmed.ucdavis.edu/JENSEN-MAMM2000/BRCA-1/slide160.jpg&imgrefurl=http://www.gfmer.ch/selected_images_v2/detail_list.php%3Foffset%3D45%26cat1%3D2%26cat3%3D32%26stype%3Dd&usg=__W9Ntx_VhEgdcgh7e7Ldk84kks8A=&h=1205&w=1800&sz=813&hl=tl&start=13&tbnid=FzCM-bQKO6gVaM:&tbnh=100&tbnw=150&prev=/images%3Fq%3Dinvasive%2Bductal%2Bcarcinoma%26gbv%3D2%26hl%3Dtl

HPIM,

Hofbauer, LC, Rachner, T, Singh, SK. (2008). Fatal attraction: why breast cancer cells home to bone. Breast Cancer Research 2008, 10:101 Retrieved online at http://breast-cancer-research.com/content/10/1/101

Psailaa, B, Kaplana, RN, Port, ER, Lydena, D. (2006-2007). Priming the ‘soil’ for breast cancer metastasis: The pre-metastatic niche. Breast Disease 26, 65-74, 65.

Rose AA, Siegel PM. Breast cancer-derived factors facilitate osteolytic bone metastasis. Bull Cancer. 2006;93:931-943.

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