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Our Patient Pathway

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PPCC Project

on 4 February 2013

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Transcript of Our Patient Pathway

Lets meet her... Our Patient Pathway Lesson Aims and Objectives A Difficult Decision - Breast Cancer Screening in Ireland
- Signs and Symptoms of Breast Cancer
- Diagnosing Breast Cancer
- Staging and Grading of Breast Cancer
- Treatment of Breast Cancer and Side Effects of Treatment
- Symptoms of Brain Metastases
- Diagnosing Brain Metastases
- How the Cancer Spread
- The Brain
- Palliative Treatment for Brain Metastases and Side Effects
- Incidence and Prevalence Rates
- Palliative Care and Services
- The BIG decision Screening Breast Cancer Diagnosis Palliative Care Diagnosis Age?
Smoking?
Breast injury (Bruising)?
Caffeine?
Birth control?
Alcohol?
Pregnancy?
Breast feeding? Risk Factors Julie's Risk Factors Blood Tests

Full Blood Count (FBC)
Can indicate if there is another condition.

White Blood Cell (WBC) Count
If she is treated with chemotherapy in the future it is important to keep an eye on WBC count Haematological Examination Imaging Negatives Safe
Cheap
Accurate
Can be read immediately by doctor and radiologist Positives www.uwhealth.org Used to evaluate stage and grade

Incisional Biopsy: Only a sample of the suspicious tissue is cut from a mass and removed for diagnosing.

Fine Needle Aspiration (FNA) or Core Needle Biopsy: If lesion cannot be felt through the skin, imaging such as ultrasound-guided biopsy or stereotactic needle biopsy can be used to guide surgeon Biopsy FNA Biopsy Staging and Grading Type of Cancer The cancer is normally named according to it’s primary site:

Common types of breast cancer:
DCIS
LCIS
Invasive ductal breast cancer
Invasive lobular breast cancer Possible Types 70 – 80 % of diagnosed breast cancers are this type. (www.cancerresearchuk.org)

Cancer has started in the cells that line the ducts of the breast and have begun to spread to the surrounding tissue.

Signs: change in the size of a breast, a lump or thickening of the skin, changes to the nipple, puckering or dimpling of the skin and swelling under the arm.

Diagnosis: clinical examination, mammogram, biopsy
Triple Assessment. Invasive Ductal Breast Cancer


Julie was diagnosed with invasive ductal breast cancer A standardized way to summarize the anatomic extent of the disease. Stage The stage of the cancer is based on four main factors:
Where the primary tumour is located
Tumour size
Lymph node involvement
Presence or absence of metastases

The most common system used to describe the stages of breast cancer is the American Joint Committee on Cancer (AJCC) TNM system Tumour size and spread to chest wall

TX
T0
Tis
T1
T2
T3
T4 T Lymph node involvement

NX
N0 - N0i+
N1 - N1mi, N1a, N1b, N1c
N2 – N2a, N2b
N3 – N3a, N3b, N3c N Metastases

MX = presence of metastases cannot be determined
M0 = No distant spread found. M0(i+) means that spread less than 0.2mm are found.
M1 = Spread to distant organs present. Most common sites are bone, lung, brain, liver M Stage 0: Tis, N0, M0
Stage IA: T1, N0, M0
Stage IB: T0/T1, N1mi, M0
Stage IIA: T0/T1, N1, M0 or T1, N0, M0
Stage IIB: T2, N1, M0 or T3, N0, M0
Stage IIIA: T0-T2, N2, M0 or T3, N1/N2, M0
Stage IIIB: T4, N0-N2, M0
Stage IIIC: Any T, N3, M0
Stage IV: Any T, Any M, M1 Stage Grouping Julie was first diagnosed with stage IIIA. T2, N2, M0

This means that her tumour was between 2cm and 5cm, it had spread to 4-9 axillary lymph nodes and had no metastases.

After two years the cancer then spread and she progressed to stage IV Describes the extent to which the tumour cells resemble the normal tissue. (differentiation) Grade Used commonly to grade breast cancers
Takes a variety of criteria into account including:
nuclear differentiation,
degree of gland or tubule formations and
mitotic activity Bloom-Richardson System Bloom – Richardson System


Julie was diagnosed with grade 3 cancer Treatment Surgery,
Radiation Therapy,
Chemotherapy,
Endocrine Therapy,
Biological Therapy. Treatment Personal preferences.
Overall health.
Stage and type of breast cancer.
Whether patient has gone through menopause.
Whether the cancer is dependent on female hormones to grow.
The presence of other markers suggestive of aggressive cancer, such as the HER2 oncogene. Treatment will depend on: Mastectomy
Lumpectomy
Lymph node removal
Prophylactic mastectomy Surgery Removal of all the breast tissue.
Can have breast reconstruction a few months later.

There are a few different types:
Simple or total mastectomy
Modified Radical Mastectomy
Radical Mastectomy Mastectomy












Cancer.gov The removal of only the tumour and a small amount of surrounding tissue.
Less invasive
Shorter recovery time
Effective if the cancer is less than 4cm and is only in one site in the breast. Lumpectomy The preventative removal of the breast to lower the risk of breast cancer in high-risk people. Prophylactic Mastectomy Infection
Bleeding
Reactions to medication
Numbness of breast skin
Necrosis of breast skin
If axillary lymph nodes are removed:
Lymphedema of the arm
Injury to nerves in the axilla Risks Chemotherapy

Usually after recovery from surgery and before radiation therapy.
Can be given to:
get rid of any remaining cancer cells from surgery
reduce the risk of the cancer coming back
treat metastases
Can be given if cancer seems to be confined to the breast or lymph nodes Chemotherapy Radiation Therapy Usually given after lumpectomy or mastectomy, either alone or in combination with chemotherapy and/or hormone therapy.
Would usually start several weeks after surgery.
Can be used:
to reduce the risk of cancer returning in the breast.
As the main treatment
To treat metastases Radiation Therapy Endocrine Therapy Endocrine therapy blocks, adds or removes hormones that affect cancer cells ability to divide
Oestrogen and progesterone can promote the growth of some breast cancer cells
Test called an immunohistochemical staining assay (IHC) can determine if cancer cells have estrogen or progesterone receptors (ER/PR positive) Endocrine Therapy


Selective estrogen-receptor response modulators (SERMs): tamoxifin, Fareston
Aromatase inhibitors: Arimidex, Aromasin, Femara
Estrogen-receptor down regulators (ERDs): Faslodex
Luteinizing hormone-releasing hormone agents (LHRHs): Zoladex, Lupron Types of Endocrine Therapy
Gene that makes protein HER2
Controls how breast cells grow, divide, repair
Gene amplification
Protein overexpression
Treatment = Herceptin
Blocks HER2 receptors on breast cancer cells
Alerts immune system HER2 Biological Therapy


Biological therapies use substances that occur naturally
in the body to destroy cancer cells.
The main types of biological therapies are:
Monoclonal antibodies
Cancer growth inhibitors
Angiogenesis inhibitors
Gene therapy
Vaccines
Interferon Biological Therapy


She was given treatment in order to prevent her cancer from metastasizing to other parts of her body and to allow her a full recovery.

Her treatment:
surgery →
chemotherapy →
radiation → therapy
hormonal therapy Julie’s Treatment


Julie had a modified radical mastectomy
After surgery the pathologist examined the removed tissue and declared the surgical margins to be close. This means that the cancer cells are close to the edge of the removed tissue. Surgery She then had adjuvant chemotherapy (after surgery).
This was done because there was a risk of metastases and there were cancer cells in the axillary lymph nodes.
Received CMF: combination of cyclophosphamide, methotrexate and Fluorouracil (5FU).
Given as a number of treatments with a break of 21 days in order to allow the body to recover from side effects.
Given intravenously. Chemotherapy Because the surgical margins are close Julie was given radiation therapy in order to kill any of the remaining cells.

Her chest wall and axilla were treated.

Many women are given a dose of approximately 40-50 Gy in 1.8-2 Gy fractions over 3-5 weeks though it varies from patient to patient. Radiation Therapy Julie was estrogen and progesterone receptor cell negative.
However she was HER2 positive
She took Herceptin to block the effects of the HER2 gene Endocrine Therapy Brain Metastases Symptoms How it spread The Brain Treatment Symptoms of Brain Metastases Psychological: What are the main psychological symptoms ?

Changes in mood

Personality changes (strange)

Mental Capacity

Lack of concentration Nausea & Vomiting

Loss of appetite Gastrointestinal Symptoms What are the main neurological symptoms ? Neurological Symptoms Headaches Frequency

Severity

In conjunction with vomiting

Increased pressure Most common symptom (1 in 4)

Jerking,twitching of the arm, leg and entire body

How to control it ? Seizures Decreased Vision

Double Vision Vision Poor Judgement

Memory loss

Tingling/Loss of sensation

Speech changes

Drowsiness Others Similarity with many other illnesses/disorder

Abscesses
Arteriovenious Malformations
Infarction's
Etc. Problems associated with these symptoms are: Julie experienced headaches that lasted longer than normal and occurred more frequently than usual.

It was when she started to get seizures that she got worried and consulted with her doctor. What symptoms did Julie present with? CT - Ionizing radiation
- Records of x-ray history
- Contrast agent-Iodine-Allergic reactions Difficulties in relation to these scans/examinations This test is similar to a PET scan

It looks at blood flow through the brain

An injection of a very mild radioactive substance is administered

An imaging technique using gamma rays Single Photon Emission Computerised Tomography
(PET Scan) MRI
CT
PET
SPECT
Biopsy
Blood tests Diagnostic tests A pathology report contains the analysis of brain tissue taken at the time of a craniotomy or needle biopsy.

A report is written , which provides the information needed to make a diagnosis of the tumour type.

Type of tumour determines course of treatment Pathology Report MRI - Sensitive to metal
- Uncomfortable for patient
- Open MRI/Sedative
- Contrast agents - Gadolinium
temporary headaches, NSF to patients with chronic renal disease Difficulties in relation to these scans/examinations A biopsy is a surgical procedure in which a sample of tissue is taken from the tumour site and examined under a microscope.

provide information on types of abnormal cells present
to discover the type and grade of a tumour
most accurate method of obtaining a diagnosis.
Craniotomy/stereotactic biopsy
Pathology report Biopsy A PET scan provides a picture of the brains activity, rather than its structure, by measuring the rate at which a tumour absorbs glucose.
Injection of deoxyglucose (labeled with radioactive markers)
Used to differentiate between scar tissue, recurring tumour cells, and necrosis Positron Emission Tomography
(PET Scan) Used to give a picture of the internal structure of the brain


Contrast Agents/Dyes Brain Scans A series of tests to measure the function of the patients nervous system and physical and mental alertness.

Abnormal results = brain scan or referral Neurological Examinations Mental exercises
Eye Examinations
Hearing tests
Facial Tests
Oral
Balance & Co-ordination
Neurological Examinations Initial Examinations Diagnosis A combination of both sophisticated x-ray and computer technology

Soft tissue, bone and blood vessels are visible
CT images can determine some types of tumours
Other functions
Contrast Dye Computed Tomography
(CT or CAT Scan) MRI is a scanning device that uses magnetic fields and computers to capture images of the brain on film.

X-rays aren't used
It provides pictures
from various planes Magnetic Resonance Imaging (MRI) What is it all about? Brain Metastasis When cells spread to another part of the body, they are called secondaries or metastasis What is it all about? Some types of cancers are more likely to spread to the brain.

The most likely are lung, breast, bowel, kidney (renal) and skin (malignant melanoma).

In our case the breast cancer metastasised into the brain Which cancers? In order to spread , some cells from the primary cancer must break away , travel to another part of the body and start growing there

It can happen in 3 different ways:
Local spread
Through the lymphatic system
Through the blood Stream Spread of tumour cells This is where the cancer grows directly into nearby tissues Local spread Becomes detached from the primary tumour
Travels to circulating lymph fluid
Gets stuck in the small channels inside a lymph node
Grows into a secondary cancer Lymphatic System Becomes detached from primary cancer
Moves to the wall of a blood vessel to get into the bloodstream
While in the bloodstream it is swept along by the circulating blood until it gets stuck somewhere, usually a capilllary
Tumour cells move out through the wall of the capillary and into the tissue of the nearby organ Blood Circulation In our case the breast cancer has spread up through the blood stream and into the brain through a series of complicated steps.
- Tumour cells have to gain access to the circulation,
- Survive while circulating
- Pass through the microvasculature
- Extravasate into the organ parenchyma
-Reestablish themselves at the secondary site. How does this happen? During the journey they have to avoid immune surveillance and survive intravascular circulation.

Tumour cells coat themselves with a shield made out of the coagulating elements such as fibrin and platlets in the blood

By doing this they can survive in environments of low oxygen tension How the tumour cells survive Centre of the nervous system

Largest and most complex organs in the body

Focus on the section of the cerebral hemisphere as the cancer metastasised to the right temporal lobe. Anatomy The tumor developed into the right temporal lobe

General functions:
Auditory perception
Memory
Speech
Emotional Responses
Visual perception Temporal Lobe An overview Chemotherapy The use of chemicals to treat disease, more specifically; the destruction of cancer cells.

There are more than 70 different types of drugs available for use in chemotherapy What is it? Chemotherapy effects both healthy cells and cancer cells
Because of this there are many extreme side effects such as alopecia & nausea
Side effects depend on both the individual and the type of drug used. Unfortunately chemotherapy does not have a very strong success rate.

This is because the brain is protected from many harmful substances that can get into the blood by what is know as the blood-brain barrier. Using it to treat brain metastasis Blood vessels in the brain are lined with cells that make a tighter seal than in the blood vessels in the rest of the body
Cancer cells can penetrate through the blood-brain barrier
Once the cancer cells cross this barrier they immediately multiply to form a tumor
Hence chemotherapy given orally or by injection is often prevented from reaching the brain. Blood brain barrier Possibly in the future chemotherapy will be able to be used.

As of now new ways are being developed in order to deliver the drug directly to the tumor. Future surgery Surgery is the preferred method of treating a brain tumour if there is only one site and if it is easily accessed.

Things such as:
Size
Location
Type of tumour
Overall health
History
are considered. Surgery Can relieve symptoms
Cure tumour by removing it.
Remove as much as possible to help with radiation therapy and chemotherapy
Allows biopsy on the tumour
Slow tumour growth Benefits Brain damage.
There may be risks with a general anaesthetic in patients with other significant medical conditions
Blood clot/ bleeding
Seizures
Coma
Infection
Swelling Risks Guided Biopsy
Craniotomy
Microsurgery
Shunts
Nueroendoscopy
Ultrasonic aspiration
Transphenoidal Surgery Types of Surgery Under anaesthetic, the surgeon drills a small hole in the skull - burr hole.

The surgeon puts a very thin needle into the hole and down into the tumour.

They remove a small piece of the brain tumour and send it to lab to be tested. Biopsy A biopsy guided by a CT or MRI
Done so that surgeon can put tip of needle in the exact right place.
Often done with tumours deep inside the brain.
Two methods:
1) Stereotactic biopsy
2) Neuronavigation Guided Biopsy Given a general anaesthetic as may need to be awake during part of the surgery.

The surgeon makes an incision in scalp and uses a special type of saw to remove a piece of bone from the skull.

After the tumour is removed,
the surgeon covers the opening
in the skull with the piece of bone
or with a piece of metal or fabric.
The surgeon then closes the
incision in the scalp. Craniotomy If during the operation the surgeon will uses a powerful microscope to look at the brain tissue it is called microsurgery.

This helps them to distinguish
between cancer tissue
and normal brain tissue. Microsurgery Brain tumours can cause raised intracranial pressure.One cause is hydrocephalus.

A shunt is a long, thin tube that’s placed in the brain and then threaded under the skin to another part of the body, usually into the lining of the tummy (abdominal cavity).

The tube allows excess fluid from the brain to drain into the abdominal cavity, where the body reabsorbs it. Shunts/ Ventricular catheter Treatment

Radiation Therapy The treatment of the brain tumour depends on ?
Size
Location
Type

In general, treatment consists of surgery, radiation therapy, and chemotherapy Throughout the treatment MRI's will be used to
assess the effectiveness of the ongoing treatment

The aim of treatment is to alleviate symptoms and to control the growth of any remaining tumour for as long as possible with the fewest possible side effects Why is it used ?

It is used when surgery alone cannot remove all the microscopic tumour cells .

Following surgery, radiation therapy is the single most effective treatment for tumours, and it is used as the primary treatment for cases in which surgery would involve too great a risk to the patient Radiation therapy Having diagnosed the brain tumor, CT scans are taken in order to find out:

The exact shape of the tumour

Where important structures are in relation to the tumour (for example, your eyes)

The direction to aim the radiation beams so that they avoid all the important structures CT Scans CT scan of a Julies brain tumour The plastic mask is sometimes called a shell or mould. It covers the whole of your face, the front of your head and your neck.

Keeps head still

Marks needed to line up beams of radiation The treatment Mask Mask is made before starting the treatment

Many radiation departments use plastic mesh called thermoplastic to make the masks

Soft when warm, hardens when it cools

The warmed plastic is shaped to the patients head and neck

It doesn't cover the nose or mouth and thus allows for easy breathing. Mould Room When the plastic cools it gives an exact impression of your face and head.

Plaster of Paris and perspex

Visit the Mould room again to get plastic legs made to fix the mask to the couch of the treatment unit.-it prevents movement

It is during the treatment planning when the mask is marked Mould Room
Curative/radical

Palliative Two Methods of Treatment A definite treatment used to cure

Curative/radical care refers to treatment and therapies provided to a patient with an intent to improve symptoms and cure the patient's medical problem

Curative/radical defined as treatment given with the intention to improve survival substantially, which will/ may amount to a cure. Curative Palliative care is medical care that provides relief, but does not cure a patient's medical problem.

A palliative therapy does not alter the course of a disease but can improve the patients Quality of Life (QoL)

Palliative treatment is used to relieve symptoms such as headaches or nausea that often occur with brain tumors. Palliative Care Treatment is given with the intention to improve QoL and may include prolonging the length of life as a secondary benefit

Goals/Aims of Palliative treatment :

-to control and reduce tumour bulk,
-to relieve symptoms,
-to prevent and treat tumour related complications. Palliative Care Used for external beam radiation treatments

It delivers high-energy x-rays

x-ray treatments can be designed in such a way that they destroy the cancer cells while sparing the surrounding normal tissue

The LINAC is used to treat all body sites, using conventional techniques, IMRT, IGRT, SRS, SBRT Linear Accelerator Cobalt units provide low-energy treatment using cobalt-60 as a radiation source

Adjustable collimator's are used to define the treatment field, and special filters or beam modifiers are also available for individual therapy needs.

Because cobalt radiation reaches its maximum dose at 0.5 cm below the skin surface, it is especially suited for radiotherapy of the head, neck

The beams reach the tumour while limiting further damage to other structures Cobalt 60
Poor dose penetration to deep tumours

Decreased accuracy and precision in comparison to the linac (large penumbra)

Cobalt 60 has a half-life of 5.26 years and thus the source needs to be changed approximately every 5 years because continuous use leads to prolonged treatment times. Disadvantages (CO-60) Stereotactic radiotherapy is a way of targeting radiotherapy very precisely at the tumour. You have the treatment aimed at the tumour from many different points around your head

The radiotherapy beam is targeted very accurately with this type of treatment. So it is vitally important that your head is in exactly the same position each time and does not move while you are being treated. Stereotactic Radiotherapy What stereotactic radiotherapy is used for ?

Secondary brain tumours
Gliomas that have come back since they were first treated Brain weight at birth?
Brain weight as an adult?
Percent of brain made up of water?
How many neurons in the brain?
How many ml’s of blood flow through the brain every minute?
How long will the brain stay alive for without oxygen?
What percentage of your energy does your brain use up?
How many thoughts do you think a day?
By what percent has the brain size shrunk since archaeological times? What do you think? The surface of the brain is convoluted by deep fissures, smaller grooves called sulci and ridges called gyri.

This surface is called the cerebral cortex and is home to about 100 billion neurons.

Parts of the brain;
Cerebrum
Cerebellum
Hypothalamus
Pituitary gland
Medulla Oblongata Anatomy At birth about 400grams
As an adult about 1.4Kg
78% of the brain is made up of water
100 billion neurons in the brain, same number of stars in our galaxy
Almost 1000ml’s of blood flows through the the brain every minute
The brain will survive for 4-6 minutes without oxygen, after that the cells will begin to die
The brain uses up 20% of our energy usage for the day
We think on average 70,000 thoughts a day
The brain has shrunk by 10% in size Answers! We need a Volunteer .. http://www.bbc.co.uk/science/humanbody/body/interactives/senseschallenge/senses.swf? Quality of Life QOL is a multidimensional construct encompassing patient perception of overall well-being.
Data may serve to increase the awareness on variables that affect patient well-being, inform treatment decision, and identify targets for intervention. Treatment? Should she go ahead with treatment? http://goanimate.com/videos/05mu3CaOR7nI?utm_source=linkshare The aim of BreastCheck is to reduce deaths from breast cancer by finding and treating the disease at an early stage The Screening Process 1. Consent and Invitation
2. The Screening Appointment
3. Mammogram
4. The Results
5. Further Investigation
6. Routine Re-Call Mammogram Be Breast Aware - Know what is normal for your body
- Know what changes you should look for: Any lumps or thickening in your breast
Skin – dimpling, puckering, or redness
Nipple – pulled in or flattened
Around the nipple – rash, flaky or crusted skin
A change in the shape or size of your breast
Swelling in your armpit or around your collarbone
Constant pain in one part of your breast or armpit Effectiveness of Breast Screening Effect of Screening Mammography on Breast-Cancer Mortality in Norway
Mette Kalager, M.D., Marvin Zelen, Ph.D., Frøydis Langmark, M.D., and Hans-Olov Adami, M.D., Ph.D.
N Engl J Med 2010; 363:1203-1210September 23, 2010 Signs and Symptoms • A change in size or shape such as one breast becoming larger than the other
• A change in the skin such as puckering or dimpling(like orange peel)
• A change in the direction or shape of your nipple, especially if it sinks into your breast or becomes irregular in shape Can't tell if tumor is malignant or benign
More tests needed
Uncomfortable Incidence and Prevalence The incidence of a disease is the rate at which new cases occur in a population during a specified period. Incidence Complete prevalence: the number of people ever diagnosed with cancer who are still alive at a specific date. Prevalence Estimated overall survival rate for infiltrating ductal carcinoma is 84% (www.breastcancer.ca)

The overall survival for women with HER-2 expression is estimated at below 40% (www.breastcancer.ca)

Breast cancer was the second leading cause of cancer death in women during the period 2007-2009, and accounted for 16% of female cancer deaths. (www.ncri.ie) Survival Rates Approximately 6% of breast cancers are metastatic at diagnosis with a 5 year survival rate of 21% (article: Locally recurrent or Metastatic Breast Cancer: ESMO Clinical Practice Guidelines for Diagnosis, Treatment and Follow-up. F. Cardoso) Medscape

Brain metastases are diagnosed in 10-16% of patients with metastatic breast cancer (Article: Management of brain metastases in breast cancer. Author: Nancy U Lin MD)

Brain metastases account for 20% of cancer deaths. (Article: Brain Metastases. Author: Victor Tse, MD, PhD)

Breast tumour is the main source of metastatic disease in women (Article: Brain Metastases. Author: Victor Tse, MD, PhD Metastases Breast cancer was 32.3% of female invasive cancers diagnosed in 2011 (excluding non-melanoma skin cancer)

An annual average of 2,800 women were diagnosed with invasive breast cancer in 2008 and 2009

Between 1995 and 2007 21% of all new female cancer cases in Ireland were breast cancer. Julie's Surgery Positron Electron Tomography www.breastcancer.ca www.webmd.com Ultrasound Globalsoin.com Mammogram Mammogram Breast MRI Stage This video shows a modified radical mastectomy A standard way of measuring the ability of cancer patients to perform ordinary tasks.

The Karnofsky Performance scores range from 0 to 100.

A higher score means the patient is better able to carry out daily activities.

KPS may be used to determine a patient's prognosis or to measure changes in a patient’s ability to function KPS
Karnofsky Performance Status Julies aged 60, had a KSP of >70, her primary cancer was controlled and she had no extracranial metastases.

Julie fell under the class 1 category according to the RTOG recursive partitioning analysis.

The Characteristics of class 1 include a KPS of >70, aged <65 and primary cancer controlled as well as no extracranial mets. Julie's KPS ? Frequency

For how long ?

Dosage ? Julie's Treatment plan
The MS (median survival) of class 1 is 7.2 months

Julie was treated using WBRT, the most standard dose is of WBRT is 30Gy/10.

This was the dosage Julie recieved.

WBRT is given using the linear accelerator Julie Whole brain radiation therapy (WBRT) is effective and the treatment of choice if there are many brain mets or if there is undefined margins.

About 80% of patients have more than one lesion.

For patients with only a single brain lesion, SRS would be the preferred option, as it reduces the risk of damaging other parts of the brain as well as side effects WBRT vs. Srs As Julie had undefined margins on her tumour SRS was not the preferred option and WBRT was the course of treatment to be given. Associated with Radiation treatment for Brain Metastases Side Effects Acute/Late

Acute effects occur during treatment

Late effects occur after treatment
(months and even years after the treatment has finished)

Specific/non specific Side Effects Fatigue

Short term memory loss

Temporary hair loss


Generally, you lose hair from the point where the beams enter your head and also where they leave (the exit beam).

Scalp Irritation/ muffled hearing Side Effects Skin tingling/rash What to do if side effects occur ? EORTC / RTOG

LENT / SOMA

WHO-CTC Scoring Systems European Organization for Research and Treatment of Cancer (EORTC)

Radiation Therapy Oncology Group (RTOG)

This system can be used for both late and acute side effects.
Despite this there is a tendency to move towards using the LENT / SOMA and the CTC Aev4 systems for evaluating late side effects EORTC / RTOG This is a scale of 0-5,
0 = no symptoms
5 = death directly in connection with side effects of radiation

The advantages include :
Quick
Easy EORTC / RTOG Julie experienced some hair loss . She also felt tired and lethargic. Thankfully she didn't experience any severe skin conditions as she avoided irritants as advised by her radiation therapist. What symptoms did Julie Experience She had a craniotomy in order to remove as much of the tumour as possible. This relieved her symptoms. The neurosurgeon was unable to remove all of the tumour because there were many lesions. Called partial resection or debulking.

The removed tumour was sent to be analyzed and it was confirmed that the tumour was a metastasis of the breast. www.ncri.ie Female breast cancer: 15 year prevalence = 20827
10 year prevalence = 17041
5 year prevalence = 10403
3 year prevalence = 6915
1 year prevalence = 2674 www.ncri.ie Fact or Fiction? Gender?
Underarm antiperspirants?
Genes?
Underwire bra?
Breast implants?
Race?
Breast Size?
Overweight/Obese? Performance Status Gender: Woman
Age: Julie was aged 58 when she was first diagnosed with breast cancer
Pregnancy: She started her family late and was after 30 when she had her first child of two.
Breast Feeding: Julie didn't breast feed.
Weight: Julie is overweight Ventricular Catheter References www.ncri.ie
www.breastcancer.ca
Article: Locally recurrent or Metastatic Breast Cancer: ESMO Clinical Practice Guidelines for Diagnosis, Treatment and Follow-up. F. Cardoso. Medscape
Article: Management of brain metastases in breast cancer. Author: Nancy U Lin MD
Article: Brain Metastases. Author: Victor Tse, MD, PhD
www.breastcancer.org www.cancerresearchuk.org
www.cancerstaging.org
www.breastcancercare.org.uk
www.emedicinehealth.com
www.webmed.com
www.macmillan.org.uk
Paper: Maximizing the Impact of the California Breast Cancer Research Program: Studying Environmental Influences and Breast Cancer by Robert Millikan Ph.D.
Article: Factors the modify breast cancer risk in women by Mary E Costanza, MD and Wendy Y Chen, MD, MPH
www.medterms.com
www.medicinenet.com
neurosurgery.ucsf.edu
www.braintumoursurgery.co.uk
www.sd.neurosurgeon.com
www.neuroskills.com
www.mayfieldclinic.com
www.northwestneurosurgery.com
www.rcr.ac.uk
www.hospicefoundation.ie - Palliative-Care-For-All.pdf
www.hse.ie
http://ministryhealth.org/MinistryHealth/Services/PalliativeCare/WhenisittimeforPalliativeCare.nws
www.cancer.ie
World Health Organisation
www.braintumour.org
www.cancerjournal.net
www.cancer.org
www.nhs.uk
www.livescience.com
www.bbc.co.uk
www.cancerresearchuk.org/cancer-help/type/brain-tumour/about/brain-tumour-symptoms
www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/brain_tumors_85,P00775/
Radiation Oncology: A Question-Based Review By Boris Hristov, John P. Christodouleas, Steven H. Lin After the Surgery Julie will be on many drips after her surgery for:
Fluids
Painkillers
Taking blood sample
Preventing her from getting sick (nasogastric tube)
She will have either a CT or MRI to show how much tumour is present and how much swelling there is.
She will be closely monitored to ensure her brain is working properly.
She was given steroids to reduce swelling. ophthalmoscope Blood Tests There is no specific blood test to detect a brain tumour

To check for specific chemical markers in the blood

Pineal region tumours or Germ cell tumours • An unusual discharge (liquid) from one or both of your nipples
• A change on or around the nipple such as a rash or flaky or crusted skin
• Swelling in your armpit or around your collarbone
• A lump or thickening in your breast
• Constant pain in one part of your breast or armpit “An approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” 
- World Health Organisation (WHO) What is Palliative Care 1. To provide the best quality of life possible for a terminally ill patient and their family
2. To respond to physical, psychological, social and spiritual needs and to support in bereavement
3. To keep the patient free from pain as far as is possible
4. Offers a support system to help the family cope during the patients illness and in their own bereavement Palliative Care Aims General Hospitals
In hospices
In people’s own homes
In community hospitals and nursing homes Where is Palliative Care Provided? General Hospitals Hospice In Peoples own Homes In community hospitals and nursing homes The decision Quiz What does the drug Herceptin do?
What is the most common type of diagnosed breast cancers?
What is the name of the system most commonly used to grade breast cancer?
What do cancer cells coat themselves in, in order to survive?
What are the functions of the right temporal lobe?
Name the 3 ways in which cancer can spread.
What is a small hole drilled into the skull called?
Why would a patient be given steroids after surgery?
Whats the ratio of patients who present to their doctor with a headache ?
What does KPS stand for ? what is it ?
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