Breast Cancer

Question 1

What are non-modifiable risk factors for breast cancer?

Answer 1

• Female gender
• Older age
• Family history
• Personal history
• BRCA1 and BRCA2
• Breast changes on biopsy
• Ionizing radiation
• Breast density
• Early menarche/late menopause

Question 2

What are modifiable risk factors for breast cancer?

Answer 2

• Nulliparity or older age at first child birth
• Postmenopausal hormone therapy
• Postmenopausal obesity
• Physical inactivity
• Alcohol consumption

Question 3

Which type of breast cancer is identified by a “lump”?

Answer 3

Invasive ductal carcinoma

Question 4

Which type of breast cancer is seen as ill-defined thickening of the breast?

Answer 4

Invasive lobular carcinoma

Question 5

What are the NCCN screening recommendations?

Answer 5

Women ages 25-39: Clinical breast exam very 1-3 years
Women ages >40: Clinical breast exam and mammogram annually

Question 6

How is breast cancer diagnosed?

Answer 6

• History and physical exam
• Diagnostic bilateral mammogram
• Breast ultrasound
• Biopsy
• Bloodwork and additional imaging are directed by signs and symptoms

Question 7

What are prognostic factors of breast cancer?

Answer 7

• Tumor size
• Lymph node status
• Tumor grade (differentiation)
• Ki67 index
• Lympho-vascular invasion

Question 8

ER/PR/HER2 negative cancers are rapidly growing but are more sensitive to chemo

Answer 8

TRUE

Question 9

HER2/neu positive breast cancer is less aggressive and slower growing than ER/PR receptor positive breast cancer

Answer 9

FALSE: other way around

Question 10

How do we treat lobular carcinoma in situ?

Answer 10

Regular monitoring, no treatment

Question 11

How do we treat ductal carcinoma in situ?

Answer 11

Lumpectomy + radiation
Mastectomy

+/- endocrine therapy

Question 12

What is endocrine therapy for premenopausal patients?

Answer 12

Tamoxifen

Question 13

What is endocrine therapy for postmenopausal patients?

Answer 13

Aromatase inhibitors

Question 14

In which patients do we use the Oncotype diagnosis?

Answer 14

ER/PR+, HER2-
Tumor > 0.5 cm

Question 15

What are the preferred chemo treatments for ER/PR(-/+), HER2(-) diease?

Answer 15

• Dose-dense doxorubicin/cyclophosphamide x4 doses -> paclitaxel every 2 weeks x4-12 doses
• Docetaxel and cyclophosphamide (TC) every 3 weeks for 4-6 doses

Question 16

Which neoadjuvant treatment can only be used for triple negative patients?

Answer 16

Pembrolizumab every 3 weeks for 4 doses + weekly paclitaxel/carboplatin x12 doses -> pembrolizumab + doxorubicin/cyclophosphamide every 3 weeks x4 doses

Question 17

Which treatment should triple negative patients receive AFTER surgery?

Answer 17

Pembrolizumab every 3 weeks for 9 doses

Question 18

What treatment is preferred for HER2(+) disease?

Answer 18

Docetaxel/carboplatin/trastuzumab + pertuzumab every 3 weeks for 6 doses
Paclitaxel + trastuzumab every week for 12 doses

Question 19

What criteria must be met to use pertuzumab?

Answer 19

> T2 or >N1, HER2(+) tumor

Question 20

What are common chemotherapy toxicities?

Answer 20

• Myelosuppression
• N/V
• Mucositis
• Hair loss
• Fatigue
• Nail/skin toxicity
• Appetite/weight changes

Question 21

How do we combat peripheral edema with docetaxel?

Answer 21

Dexamethasone

Question 22

What are ADEs of doxorubicin?

Answer 22

• Cardiotoxic
• Red secretions/urine
• Cancer
• Vesicant (use central line)

Question 23

What should we avoid giving with tamoxifen?

Answer 23

CYP2D6 inhibitors (strong) - careful of SSRI/SNRI

Question 24

What must be given with tamoxifen for premenopausal patients?

Answer 24

Ovarian suppression

Question 25

What are considerations of tamoxifen?

Answer 25

- Cancer - VTE/stroke - Avoid in pregnancy

Question 26

What are considerations of aromatase inhibitors?

Answer 26

- Bone loss - HLD - CV risk

Question 27

When can we consider capecitabine for breast cancer?

Answer 27

Triple negative patients who have tried a neoadjuvant

Question 28

When can we consider ado-trastuzumab for breast cancer?

Answer 28

HER2(+) patients who tried a neoadjuvant

Question 29

When can we consider neratinib for breast cancer?

Answer 29

HER2(+) patients after completion of adjuvant trastuzumab for high recurrence risk (use prophylactic loperamide)

Question 30

When can we consider olaparib? (PARP)

Answer 30

High risk HER2(-) breast cancer with BRCA mutation

Question 31

When can we consider abemaciclib?

Answer 31

Adjuvant for ER/PR(+), HER(-) high0risk breast cancer

Question 32

When should we give zoledronic acid in breast cancer?

Answer 32

For postmenopausal patients whenever possible (2 years)

Question 33

When do we use palbociclib?

Answer 33

ER/PR(+), HER2(-) MBC in combo with aromatase inhibitor, fulvestratn

Question 34

Which other CDK 4/6 inhibitors can be considered for ER/PR(+), HER2(-) MBC?

Answer 34

Ribociclib (monitor LFT, QT) Abemaciclib (LFT, SCr)

Question 35

Which mTOR treatment can be used for ER/PR(+), HER2(-) MBC?

Answer 35

Everolimus

Question 36

When can we use Alpelisib?

Answer 36

PIK3CA-mutation

Question 37

When do we consider chemotherapy in MBC?

Answer 37

- Failure of multiple endocrine manipulations - Visceral crisis - Patient is symptomatic - Patient decision With good performance status

Question 38

What is the dose-limiting toxicity of taxanes?

Answer 38

Neuropathy