Lowell E. Schnipper, M.D. Beth Israel Deaconess Medical Center Harvard Medical School
Oncology Review 1. A 56 year man with metastatic carcinoma of the colon has just completed a course of chemotherapy for progressive hepatic metastatic disease. The tumor has regressed, his appetite and energy are improved. The patient asks to see you because he has right sided pleuritic pain and cough. You find him to have swelling of the RLE, and a palpable cord. A doppler reveals a DVT in the right femoral vein and you order a pulmonary angiogram.
The appropriate management for this patient is: A. Insert an IVC filter and administer LMW heparin B. LMW heparin C. LMW heparin and transition to warfarin D. Start warfarin as outpatient and gradually adjust dose to INR of 2-5-3.5 E. Start a direct oral anti-coagulant
Oncology Review 2. A 54 year old post-menopausal woman with osteolytic metastases in ribs and vertebrae is receiving an aromatase inhibitor as systemic anti-cancer treatment. In addition to the endocrine therapy she should: A. Start a course of radiation therapy to the sites of metastatic disease B. Start a regimen of calcium plus vitamin D C. Start therapy with a bisphosphonate D. Start therapy with a RANK ligand inhibitor
Oncology Review 3. The oncologist caring for a 42 y.o. woman with a T2N0M0, ER+/PR+/Her-2 non-amplified breast cancer told her on the basis of his experience she does not need chemotherapy, just endocrine treatment. She asks for your opinion. Your best advice is to: Obtain the opinion of another oncologist Perform a gene expression assay Consult adjuvantonline! Assume all tumors greater than 2.0 cm in a premenopausal woman merit chemotherapy a.,
Kaplan-Meier plots for distant recurrence comparing treatment with tamoxifen (Tam) alone versus treatment with tamoxifen plus chemotherapy (Tam + chemo) All Pts Low RS Int RS High RS Paik, S. et al. J Clin Oncol; 24:3726-3734 2006
Take Home Message for Internists Genomics can be used to predict responsiveness to hormonal therapy and the need for chemotherapy The test is expensive, although many insurers cover it since it can lead to the avoidance of chemotherapy Lymphoma, colorectal cancer, NSCLC-analogous approaches
4. On your initial visit with a 42 year old man, he describes an extensive multi-generational family history for cancer.
Oncology Review 4. Which of the following is most likely to be mutated in this family: A. Retinoblastoma gene B. p53 gene C. BRCA2 gene D. MLH 1 gene E. Ataxia-telangiectasia gene
Oncology Review 5. A 57-year-old man underwent surgery for an acute obstruction of the ascending colon. He was found to have a adenocarcinoma of the colon that had perforated into the peritoneal cavity. All lymph nodes in the resection specimen were negative for metastatic cancer. His postoperative course was unremarkable and he was discharged from the hospital without evidence of symptoms. The appropriate management for this patient is for this patient is:
Oncology Review 5 The most appropriate management for this patient is: A. abdominal radiation to the area of the perforation B. systemic chemotherapy in conjunction with radiation C. intra-peritoneal chemotherapy D. intra-peritoneal chemotherapy and external beam radiation E. systemic chemotherapy
Oncology Review 6 6. Three years later the CEA was elevated and CT scan revealed to lesions in the right lobe of liver that were proven to be metastatic colon carcinoma. The optimal treatment is: A) Cryoablation of the metastases B) Chemoembolization of right lobe of liver C) Chemotherapy and hepatic resection D) Liver transplantation
Surveillance after Primary Therapy Indicated Colonoscopy perioperatively, 1 year, every 3-5 years CEA screening: if resection of met or suture line recurrence CT scans at MD discretion Not recommended Regular LFTs Routine chest xrays PET scans
7. The patient s father, father s sister had colon cancer, and the patient s sister was recently found to have endometrial cancer. This is the pedigree:
Oncology Review 7. You should refer him to a genetics clinic because of high suspicion for: A. Loss of p53 B. Loss of PTEN C. Loss of MLH1 D. Loss of BRCA 2
The Lynch Syndrome: Hereditary Non-polyposis Colon Cancer (HNPCC) Mutations in one of several mismatch repair genes are the basis of this cancer-prone syndrome, e.g., MLH1, MSH 2, etc. Path labs now routinely testing for this Women with the Lynch syndrome are at high risk for endometrial cancer, increased risk for ovarian cancer as well as other cancers in the GI tract Consider prophylactic TAHBSO
Oncology Review 8.* A 38 year old nulliparous woman has had 2 breast biopsies in the past (all benign), and her mother had breast cancer at age 55. Although she is BRCA 1 and 2 negative, she proves to be at higher than standard risk for developing breast cancer when employing the Gail model. She seeks your advice for the most clinically appropriate approach to preventing breast cancer.
Gail Model for Br CA Risk 1. Does the woman have a medical history of any breast cancer or of ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)? 2. What is the woman's age? The tool only calculates risk for women 35 years of age or older. 3. What was the woman's age at the time of her first menstrual period? 4. What was the woman's age at the time of her first live birth of a child? 5. How many of the woman's first-degree relatives - mother, sisters, daughters - have had breast cancer? 6. Has the woman ever had a breast biopsy? 6a. How many breast biopsies (positive or negative) has the woman had? 6b. Has the woman had at least one breast biopsy with atypical hyperplasia? 7. What is the woman's race/ethnicity?
8. Your advice to her is: a. perform bilateral mastectomies b. Perform bilateral oopherectomy c. Screen regularly with MRI and mammography d. Start raloxifen 60 mg per day for 5 years e. Start tamoxifen20 mg per day for 5 years
Effects of Tamoxifen vs Raloxifene on the Risk of Developing Invasive Breast Cancer and Other Disease Outcomes TheNSABP Study of Tamoxifen and Raloxifene (STAR) P-2 Trial Vogel, V. G. et al. JAMA 2006;295:2727-2741
Breast Cancer: Early Detection Mammography Highly controversial Ambiguous data <50 yrs (RR 0.92; NNS 3,125/1 life saved Improves survival in those women 50-70 (RR 0.77) NNS 1 life/543 women screened Tomosynthesis: more sensitive MRI Very sensitive Not very specific although interpretation is improving Clinical trials suggest useful in those carrying BrCa susceptibility genes
Oncology Review 9. This patient was interested in risk reduction therapy with Tamoxifen. After 3 months she reports having hot flashes, and difficulty sleeping at night. She awakens early and has repetitive dreams about death. She cries easily and complains of lassitude. You interpret this as clinical depression and recommend an anti-depressant.
Oncology Review #9 The most appropriate anti-depressant to prescribe is: A. Sertraline B. Paroxetine C. Amytryptylline D. Venlafaxine E. Nortryptylline
10. Cancers evade the immune system by invoking which one of the following mechanisms? a. Establishing a fibrin cocoon around the tumor mass b. Overwhelming the immune system by the large tumor burden c. Paralyzing B cells so no/or inadequate antibody production is developed d. Promoting apoptosis of cytotoxic T cells
Oncology Review 11. A 63 year old man was diagnosed by multiple myeloma three year earlier. Because of intense skeletal pain and a rising level of serum IgA, he was placed on chemotherapy. After a two year period of remission he presents with dizziness, somnolence, bruising, the peripheral smear on the left and his monoclonal IgA was measured at 5.0 gm/dl.
Oncology Review 11. Which diagnostic test is likely to be most helpful?: A) Check the serum viscosity B) MRI of the brain C) Bone marrow aspiration and biopsy D) PET/CT scan
Oncology Review #12* 53 yo African American male Initial annual visit Father died of prostate cancer (states that they got it late ); paternal uncle has prostate cancer Married, sexually active; no significant comorbidities No urinary or urological symptoms PE: mild hypertension; negative DRE WHAT ARE YOUR RECOMMENDATIONS REGARDING PSA BASED TESTING? Courtesy, M. Garnick
Oncology Review #12 A. Order a PSA test as part of the routine annual bloods, along with lipid panel, glucose, and CBC (patient not informed) B. Given the lack of symptoms and PE, do not bring PSA issue up, but document your decision in the medical record C. Briefly discuss controversies about PSA testing and have patient make decision (and document) D. Briefly discuss controversies about PSA testing and recommend the test (and document) E. Briefly discuss controversies about PSA testing and do NOT recommend the test (and document)
Oncology Review 13. A 40 year old woman is now 5 years from completing adjuvant endocrine therapy for ER+, Stage II adenocarcinoma of the right breast. Her menses have returned and she asks you if it is safe for her to become pregnant. Your assessment is that: a. She should avoid pregnancy and continue to take Tamoxifen b. She should proceed with a pregnancy but anticipate an enhanced risk of recurrence c. She should avoid pregnancy due to enhanced risk of a second breast cancer d. She should proceed with pregnancy assuming no increased risk of recurrence
Oncology Review 14. A 55 year old Chinese woman has a 2 month history of cough and blood streaked sputum. She has a left upper lobe mass on CT chest, biopsy of which demonstrates adenocarcinoma. The genetic abnormality that is most likely to be driving her cancer is: a. A mutation in the epidermal growth factor receptor b. A translocation involving EML4/ALK c. A mutation of k-ras d. A mutation of c-kit
15. A 39 year old woman with a strong family history and proven BRCA 1 mutation recent was recently found to have stage IIB estrogen receptor negative adenocarcinoma of the right breast and completed treatment with partial mastectomy, 4 cycles of adjuvant chemotherapy followed by radiation therapy to the involved breast. Optimal follow up care for this patient includes: a. Mammography alternating at 6 months with MR exams b. Mammography alternating at 6 months with MR exams plus semi-annual measurement of tumor markers and CA27.29 c. Mammography alternating at 6 months with MR exams, semiannual measurement of tumor markers CA27.29 and yearly CT scans d. Mammography alternating at 6 months with MR exams, semiannual measurement of tumor markers CA27.29 and yearly CT scans and bilateral mastectomy
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