Breast Cancer

Question 1

Breast cancer is the most common form of malignancy in women, especially in those aged over ____ years

Answer 1

50

Question 2

What are the risk factors for developing breast cancer? (8)

Answer 2

1. Age over 50
2. Early onset of menstruation
3. Late menopause
4. Older age at first completed pregnancy
5. Family history of breast cancer
6. Use of OCP and/or HRT
7. Obesity
8. Alcohol consumption

*factors that increase estrogen exposure

Question 3

Breast cancer in men is rare. Although risk factors are not fully understood, it may be associated with abnormalities of sex hormone metabolism, including those caused by ____________ or _____________, genetic predisposition, and environmental risk factors such as industrial exposure to _______________

Answer 3

liver diseas

testicular trauma

chronic heat

Question 4

What factors protect against breast cancer? (2)

Answer 4

1. Physical activity

2. Breast feeding

Question 5

Non-invasive breast cancer, also known as ____________, is when the cancer remains localised in the ducts

Answer 5

ductal carcinoma in situ

*However, in most cases, the cancer is invasive at the time of diagnosis, which means that malignant cells are liable to spread beyond the immediate area of the tumor

Question 6

What is the staging of breast cancer?

Answer 6

1. Early (stage I/II)
2. Locally advanced (stage III)
3. Advanced (stage IV)

Question 7

At what age does breast cancer screening begin in the UK?

Answer 7

50 until 71 yo every 3 years

https://www.nhs.uk/conditions/breast-screening-mammogram/when-youll-be-invited-and-who-should-go/

Question 8

Surgery and radiotherapy aim to _______________, whilst adjuvant drug therapy (drug treatment following surgery) aims to _________________

Answer 8

remove the tumour mass

reduce the risk of disease recurrence and the risk of developing invasive disease

Question 9

What is the aim of neoadjuvant drug therapy?

Answer 9

Neoadjuvant drug therapy (drug treatment before surgery) aims to reduce the size of the tumour to allow breast-conserving surgery to be possible and to reduce axillary lymph node involvement

Question 10

Is advanced breast cancer curable?

Answer 10

No; aim of treatment is to prolong survival, relieve symptoms of disease and improve QoL

Question 11

The management of patients with breast cancer involves ______________, _____________, ____________, or a combination of these

Answer 11

surgery

radiotherapy

drug therapy

Question 12

What factors determine the extent and aggressiveness of breast cancer? (5)

Answer 12

1. Patient age
2. Menopausal status
3. Tumor size and grade
4. Involvement of axillary LNs or skin
5. Presence of hormone receptors within the tumor

Question 13

What is the treatment of early or locally advanced breast cancer?

Answer 13

These cancers are considered operable; therefore the treatment involves:

• surgery to the breast (breast-conserving surgery or mastectomy) and to the axillary lymph nodes

+/- radiotherapy to reduce local recurrence rates

+/- often followed by adjuvant drug therapy to eradicate micro-mets that cause relapses

Question 14

In women with ____________ breast cancer, radiotherapy is recommended after breast-conserving surgery with clear margins (no cancer cells are found at the edges of the removed tissue), as it reduces local recurrence rates

Answer 14

invasive

Question 15

In women with invasive breast cancer, ______________ is recommended after breast-conserving surgery with clear margins (no cancer cells are found at the edges of the removed tissue), as it reduces local recurrence rates

Answer 15

radiotherapy

*However, the use of radiotherapy may be omitted if risk of local recurrence is very low and the woman is willing to take adjuvant endocrine therapy for a minimum of 5 years

Question 16

______________ is also recommended after mastectomy in patients with node-positive invasive breast cancer or involved resection margins (cancer cells are found at the edges of the removed tissue)

Answer 16

Radiotherapy

Question 17

In which cases of early and locally advanced breast cancer is post-operative radiotherapy recommended? (3)

Answer 17

1. Invasive breast cancer treated with breast-conserving surgery with clears margins
2. After mastectomy in patients with node-positive invasive breast cancer OR with involved resection margins
3. Patients with node-negative T3 or T4 invasive breast cancer

Question 18

Adjuvant drug therapy following treatment of breast cancer includes… (4)

Answer 18

1. Chemotherapy
2. Endocrine therapy
3. Biological therapy
4. Bisphosphonate therapy

Question 19

What factors affect the decision to use adjuvant drug therapy? (3)

Answer 19

1. Risks and benefits of treatment
2. Disease prognosis
3. Predictive factors such as ER/PR/HER2 status of the primary tumor

Question 20

Adjuvant ____________________ combination chemotherapy is recommended in patients with invasive breast cancer who are at sufficient risk of disease recurrence to require chemotherapy

Answer 20

anthracycline–taxane

Question 21

Which biological therapy is typically offered in the adjuvant treatment of invasive breast cancer?

Answer 21

Trastuzumab (aka Herceptin); monoclonal antibody that binds to HER2 receptors leading to preferential cell death

Question 22

Herceptin is also called ______________

Answer 22

Traztuzumab (monoclonal ab against HER2)

Question 23

_____________ function should be regularly assessed in patients receiving trastuzumab, and particular caution should be taken in patients with underlying _____________ disease (consult product literature for further details)

Answer 23

Cardiac

cardiac

Question 24

What hormonal therapies are used in the treatment of breast cancer?

Answer 24

Tamoxifen (men and pre- and perimenopausal women)

Anostrazole (post-menopausal women)

Question 25

Trastuzumab cannot be used in patients with a history of ___________ disorders

Answer 25

heart

Question 26

What is the objective of hormonal therapy in the treatment of breast cancer?

Answer 26

Antagonism of estrogen in ER+ cancers through: - blockage of estradiol receptor sites (tamoxifen, a SERM with antagonist and agonist activity) OR - suppression of estrogen production (anostrazole, an aromatase inhibitor)

Question 27

Why is anastrozole preferentially used in the treatment of breast cancer in post-menopausal women?

Answer 27

Aromatisation or adrenal androgens accounts for the majority of estrogen production in post-menopausal women (vs ovarian production in premenopausal women) *vs tamoxifen which has partial estrogen agonist properties and therefore does not suppress it as effectively

Question 28

Hormonal therapy is only used in _________+ breast cancers

Answer 28

Estrogen (ER+)

Question 29

In addition to tamoxifen therapy, ovarian function suppression with a _______________ should be considered in premenopausal women, taking into account the risk of temporary menopause.

Answer 29

gonadotropin-releasing hormone (GnRH) * Ovarian function suppression aims to stop the production of circulating oestrogen, which can stimulate breast cancer progression

Question 30

In postmenopausal women with oestrogen-receptor positive invasive breast cancer who are at medium or high-risk of disease recurrence, a(n) _______________ should be given as first-line therapy. Alternatively, ______________ should be given if a(n) _________________ is not tolerated or is contra-indicated, or if the risk of disease recurrence is low.

Answer 30

aromatase inhibitor tamoxifen aromatase inhibitor

Question 31

Endocrine therapy for ER+ breast cancer typically lasts up to _____ years; endocrine therapy beyond this is considered ____________ and is unlicensed

Answer 31

5 Extended *still, NICE recommends that anastrozole should be offered to postmenopausal women with oestrogen-receptor-positive invasive breast cancer at medium or high-risk of disease recurrence who have been taking tamoxifen for 2 to 5 years. Extended therapy should also be considered in postmenopausal women at low risk of disease recurrence

Question 32

Following breast-conserving surgery, endocrine therapy should be offered to women with oestrogen-positive ductal carcinoma in situ, if ________________ is recommended but not given. If radiotherapy is not recommended, the use of endocrine therapy should also be considered

Answer 32

radiotherapy

Question 33

Following breast-conserving surgery, ___________ therapy should be offered to women with oestrogen-positive ductal carcinoma in situ, if radiotherapy is recommended but not given. If radiotherapy is not recommended, the use of endocrine therapy should also be considered

Answer 33

endocrine

Question 34

________________ and ______________ have been shown to improve disease-free survival and overall survival in postmenopausal women with node-positive invasive breast cancer

Answer 34

Zoledronic acid sodium clodronate * However, there is insufficient evidence to recommend their use in premenopausal women

Question 35

Is bisphosphonate therapy recommended as part of adjuvant therapy in premenopausal women with breast cancer?

Answer 35

Insufficient evidence to recommend its use

Question 36

Intravenous zoledronic acid [unlicensed indication] or oral sodium clodronate [unlicensed indication] should be offered to postmenopausal women with ________________ breast cancer.

Answer 36

lymph-node-positive invasive * Treatment should also be considered in those with lymph-node-negative invasive breast cancer who are at high-risk of recurrence

Question 37

Bisphosphonate therapy is also recommended in women at high-risk of osteoporosis due to the use of ________________ in postmenopausal women, or in women with _________________

Answer 37

aromatase inhibitors treatment-induced premature menopause

Question 38

Neoadjuvant drug therapy may involve the use of ______________ or _____________ therapy

Answer 38

chemotherapy endocrine

Question 39

Neoadjuvant chemotherapy should be offered to reduce tumour size in patients with ________________ invasive breast cancer

Answer 39

oestrogen-receptor-negative In patients with oestrogen-receptor-positive invasive breast cancer, chemotherapy should be considered. In patients with HER2-positive invasive breast cancer, neoadjuvant chemotherapy should be offered in combination with trastuzumab and pertuzumab

Question 40

A chemotherapy regimen containing both a ______________ and an ______________ should be considered in patients with triple-negative invasive breast cancer (oestrogen-receptor-negative, progesterone-receptor negative and HER2-negative)

Answer 40

platinum [unlicensed indication] anthracycline

Question 41

If chemotherapy is not indicated, neoadjuvant _____________ therapy should be considered as an alternative in postmenopausal women with oestrogen-receptor-positive invasive breast cancer

Answer 41

endocrine

Question 42

Chemotherapy and endocrine therapy are equally effective in postmenopausal women in terms of _____________ and ____________

Answer 42

breast-conservation shrinking of the tumour

Question 43

Although chemotherapy is more effective than endocrine therapy at shrinking the tumour in _____________ women, some tumours may respond to endocrine treatment

Answer 43

premenopausal

Question 44

Although ______________ is more effective than ______________ therapy at shrinking the tumour in premenopausal women, some tumours may respond to endocrine treatment

Answer 44

chemotherapy endocrine

Question 45

What is the first line treatment of ER+ advanced breast cancer?

Answer 45

Endocrine therapy

Question 46

____________ should be offered to pre- and perimenopausal women who have had disease progression despite treatment with tamoxifen

Answer 46

Ovarian function suppression

Question 47

Ovarian function suppression should be offered to pre- and perimenopausal women who have had disease progression despite treatment with _____________

Answer 47

tamoxifen

Question 48

What is the first line treatment of ER+ advanced breast cancer in men?

Answer 48

Tamoxifen

Question 49

______________ should be offered as first-line treatment in patients with oestrogen-receptor-positive advanced breast cancer that is imminently life-threatening or requires early relief of symptoms because of significant visceral organ involvement

Answer 49

Chemotherapy * Once chemotherapy treatment is completed, endocrine therapy should be offered

Question 50

Chemotherapy should be offered as first-line treatment in patients with oestrogen-receptor-positive advanced breast cancer that is imminently life-threatening or requires early relief of symptoms because of significant visceral organ involvement. Once chemotherapy treatment is completed, _____________ therapy should be offered

Answer 50

endocrine

Question 51

Trastuzumab is recommended for the treatment of HER2-positive advanced breast cancer. It is used in combination with ____________ in those who have not received chemotherapy for metastatic breast cancer, and as monotherapy for patients who have received at least two chemotherapy regimens for metastatic breast cancer

Answer 51

paclitaxel

Question 52

The use of bisphosphonates should be considered in patients with metastatic breast cancer to ____________ and ____________ of bone metastases

Answer 52

reduce pain prevent skeletal complications

Question 53

_____________ should be offered to all women who have been identified as being at high- and moderate-risk of developing breast cancer

Answer 53

Chemoprevention eg familial breast cancer

Question 54

Other strategies to reduce breast cancer risk should also be considered, for example ___________ or ___________

Answer 54

bilateral mastectomy bilateral oophorectomy

Question 55

Should women who are at high risk of breast cancer who have undergone bilateral mastectomy receive chemoprevention?

Answer 55

No

Question 56

Chemoprevention should only be continued for ____ years

Answer 56

5

Question 57

_____________ is recommended as chemoprevention for premenopausal women who do not have a history of, or increased risk of thromboembolic disease or endometrial cancer

Answer 57

Tamoxifen

Question 58

In women who have severe osteoporosis, or who do not wish to take anastrozole, treatment with _________________ can be given, provided there is no history, or increased risk of thromboembolic disease or endometrial cancer

Answer 58

tamoxifen

Question 59

In women who have severe osteoporosis, or who do not wish to take anastrozole, treatment with tamoxifen can be given, provided there is no history, or increased risk of __________________ or _________________

Answer 59

thromboembolic disease endometrial cancer

Question 60

Alternatively, _________________ is an option [unlicensed indication] in postmenopausal women with a uterus who do not wish to take tamoxifen, unless there is a history or increased risk of thromboembolic disease

Answer 60

raloxifene hydrochloride

Question 61

Alternatively, raloxifene hydrochloride is an option [unlicensed indication] in postmenopausal women with a uterus who do not wish to take tamoxifen, unless there is a history or increased risk of __________________

Answer 61

thromboembolic disease

Question 62

Some treatments used in the management of breast cancer, such as tamoxifen or ovarian function suppression may lead to _______________, and women should be counselled about these side-effects prior to starting any of these treatments

Answer 62

menopausal symptoms or early menopause

Question 63

Some treatments used in the management of breast cancer, such as ________________ or __________________ may lead to menopausal symptoms or early menopause, and women should be counselled about these side-effects prior to starting any of these treatments

Answer 63

tamoxifen ovarian function suppression

Question 64

Women diagnosed with breast cancer should discontinue their ________________ because of possible tumour stimulation and interference with adjuvant endocrine therapy

Answer 64

hormone replacement therapy (HRT)

Question 65

____________ should not be offered routinely to women with menopausal symptoms if they have a history of breast cancer

Answer 65

HRT; however, in exceptional circumstances, HRT can be offered to women with severe menopausal symptoms once the associated risks have been discussed

Question 66

_____________ may be offered to relieve menopausal symptoms such as hot flushes in women with breast cancer who are not taking tamoxifen

Answer 66

Selective serotonin re-uptake inhibitor (SSRIs) antidepressants

Question 67

_______________, _______________ [unlicensed indication] and _______________ [unlicensed indication] are sometimes used for the treatment of hot flushes in women with breast cancer after discussion with the patient and information given about side effects

Answer 67

Clonidine hydrochloride venlafaxine gabapentin (However, SSRIs are preferred)

Question 68

________________ is an anti estrogen which induces gonadotrophins release by occupying estrogen receptors in the hypothalamus, thereby interfering with feedback mechanisms

Answer 68

Tamoxifen

Question 69

Tamoxifen is contraindicated in patients with a history of _________________ or genetic predisposition to ______________

Answer 69

VTE Thromboembolism

Question 70

What are the common or very common side effects of tamoxifen? (17)

Answer 70

1. Alopecia 2. Anemia 3. Cataracts, retinopathy 4. Cerebral ischemia 5. Constipation, diarrhea, nausea 6. Dizziness, fatigue 7. Embolism and thrombosis 8. Fluid retention 9. Headache 10. Hepatic disorders 11. Hot flushes 12. Hypersensitivity, skin reactions 13. Hypertriglyceridemia 14. Muscle complaints 15. Neoplasms 16. Uterine disorders, vaginal hemorrhage, vulvovaginal disorders 17. Altered taste, abnormal sensation

Question 71

What are the main 2 side effects that must be considered when prescribing tamoxifen?

Answer 71

1. Endometrial changes including hyperplasia, polyps, and cancer 2. Thromboembolism, particularly when used during or immediately after major surgery or periods of immobilization

Question 72

Unless being used in the treatment of female infertility, effective contraception must be used during treatment with tamoxifen and for ____ months after stopping

Answer 72

2

Question 73

Is tamoxifen safe to use during pregnancy and breastfeeding?

Answer 73

Avoid during pregnancy due to possible effects on fetal development Avoid during breastfeeding due to suppression of lactation

Question 74

Traztuzumab therapy is contraindicated in patients with _____________

Answer 74

Severe dyspnea at rest

Question 75

Manufacturer advises effective contraception in women of childbearing potential during and for _____ months after treatment with traztuzumab

Answer 75

7

Question 76

Is trastuzumab safe to use during pregnancy and breastfeeding?

Answer 76

Avoid in both - Oligohydramnios reported Avoid during breastfeeding and for 7 months afterward

Question 77

What are the monitoring requirements for patients taking trastuzumab?

Answer 77

Monitor cardiac function before and during treatment

Question 78

Is trastuzumab interchangeable with trastuzumab emtansine or trastuzumab deruxtecan?

Answer 78

NO; Biological medicines must be prescribed and dispensed by brand name

Question 79

What is the main contraindication of anastrozole?

Answer 79

Premenopausal women

Question 80

Anastrozole should be prescribed with caution in which patients?

Answer 80

Patients with susceptibility to osteoporosis

Question 81

What are the common or very common side effects of anastrozole? (12)

Answer 81

1. Alopecia 2. Decreased appetite, diarrhea, N/V 3. Arthritis, bone pain, carpal tunnel syndrome, joint disorders, myalgia 4. Asthenia 5. Drowsiness 6. Headache 7. Hot flushes 8. Hypercholesterolemia 9. Hypersensitivity 10. Osteoporosis 11. Abnormal sensation, taste altered 12. Vulvovaginal dryness, vaginal hemorrhage

Question 82

Is anastrozole safe to prescribe in patients with hepatic and/or renal impairment?

Answer 82

Caution in moderate to severe impairment Caution if eGFR is less than 30

Question 83

What pre-treatment screening should be performed before prescribing anastrozole?

Answer 83

Lab test for menopause if in doubt

Question 84

What are the monitoring requirements for patients taking anastrozole?

Answer 84

Assess bone mineral density before treatment and at regular intervals

Question 85

What advice should be given to patients and carers regarding anastrozole?

Answer 85

Asthenia and drowsiness may affect ability to drive or operate machinery

Question 86

What is the mechanism of action of raloxifene?

Answer 86

A SERM: agonist at bone, antagonist at breast tissue Prevents and treats osteoporosis by mimicking the effects of estrogen to increase bone density Also decreases the risk of developing invasive breast cancer by blocking the effects of estrogen on breast tissue

Question 87

What are the contraindications for raloxifene use? (4)

Answer 87

1. Cholestasis 2. Endometrial cancer 3. History of VTE 4. Undiagnosed uterine bleeding

Question 88

What are the common or very common side effects of raloxifene? (4)

Answer 88

1. Influenza 2. Leg cramps 3. Peripheral edema 4. Vasodilation (Less commonly embolism and thrombosis)

Question 89

Can raloxifene be used in hepatic and/or renal impairment?

Answer 89

Avoid in hepatic impairment and severe renal impairment Caution in mild to moderate renal impairment