Breast cancer Flashcards
(150 cards)
1
Q
What is the keynote-522 regimen?
A
carbo/taxol (TC) + pembrolizumab, followed by doxorubicin/cyclophosphamide (AC)
1
Q
Adjuvant treatment of DCIS
A
- None if mastectomy
- ET after BCT is a risk/benefit discussion given no proven OS benefit.
IF ER+ (PR doesn’t matter) AND premenopausal → tamoxifen 20 mg daily for 5 years
IF ER+ and postmenopausal –> AI for 5 years
2
Q
Class effects of CDK4/6 inhibitors
A
- Fatigue
- Myelosuppression
- Pneumonitis (2%)
3
Q
Abemaciclib SE to know
A
- GI toxicity (nausea, diarrhea)
4
Q
Schedule of CDK4/6 inhibitors
A
Abemaciclib is continuous, others are given 3 weeks on 3 weeks off
5
Q
CDK4/6 inhibitor with good CNS penetration
A
abemaciclib
6
Q
CDK4/6 inhibitor with demonstrated OS benefit
A
ribociclib
7
Q
Clinical significance of RB1 gene mutation
A
Confers resistance to CDK4/6
8
Q
Second line for ER PR + breast cancer patient with PI3k gene mutation
A
alpelisib + fulvestrant
9
Q
Second line for ER PR + breast cancer patient with ESR1 gene mutation
A
elacestrant
10
Q
Second line for ER PR + breast cancer patient with AKT1 or PTEN
A
fulvestrant + capivasertib
11
Q
First line for HER2 positive breast cancer
A
Trastuzumab + pertuzumab + taxane (THP or DHP)
12
Q
Second line for HER2 positive
A
T-Dxd
13
Q
What is T-Dxd conjugated to?
A
Topoisomerase I
14
Q
Third line for HER2 positive
A
IF no brain mets, T-DM1 (Preferred – Well tolerated. Used to be standard second line) (TH3ERESA – PFS 6.2, OS 22.7)
Given brain mets, tucatinib/capecitabine/trastuzumab (HER2CLIMB - median OS 21.9 months, Preferred if CNS disease because only Phase II data for T-DxD and proven OS benefit)
15
Q
margetuximab mechanism
A
HER2 ADC
16
Q
First line for metastatic TNBC
A
- Given PD-L1 CPS>10% AND absence of rapidly progressive visceral disease, pembrolizumab for up to 2 years + chemotherapy (taxol vs. abraxane vs. gem/carbo) – (KEYNOTE-355 – mOS 23, mPFS 9.7 months)
- Given PD-L1 negative AND absence of rapidly progressive visceral disease, single agent chemotherapy
***Given extensive and rapidly progressive visceral disease (diffuse, aggressive disease), combination chemotherapy (taxane vs carbo/gem preferred - but no proven OS benefit w/ combination)
17
Q
Second line for metastatic TNBC
A
- sacituzumab
- IF HER2 low, T-DxD also an option
18
Q
Third line for metastatic TNBC
A
Given BRCA+, olaparib (OlympiAD)
Single agent chemo
IF no neuropathy, Abraxane
Doxil
Gemcitabine
19
Q
CPS threshold for TNBC first line addition of immunotherapy
A
10
20
Q
most common localized breast cancer in terms of receptor phenotype
A
ER PR +
21
Q
When it is ok to defer radiation
A
- Over age 65 + less than 3 cm + node negative + ER positive (can just have adjuvant endocrine)
22
Q
Other indications for adjuvant radiation to chest wall (if undergoing mastectomy)
A
*greater than 5 cm
*close margins (less than 1 mm)
- positive lymph nodes
- positive margins
23
Q
Indications for neoadjuvant systemic therapy in node negative breast cancer
A
1) Inoperable (Need to shrink tumor to permit BCT or better cosmetic outcome with BCT)
2) Desires BCT but is not a candidate for BCT (Conversion chemotherapy (make operable))
3) Unlikely to have a good cosmetic outcome with BCT (Due to tumor location or size relative to patient’s breast)
Eg. high tumor: breast size ratio
4) Delay in definitive surgery
5) Downstage from limited N1 to N0 (could be candidate for sentinel lymph node biopsy if converted to node-negative with neoadjuvant)
6) Inflammatory breast cancer
7) Select operable breast cancer:
HER2 and TNBC if >cT2
24
What is ACT
Doxorubicin
Cyclophosphamide
Taxol
25
Sequencing of chemo vs. radiation adjuvantly for localized breast cancer
Adjuvant chemo is completed before starting XRT (IF no neoadjuvant received) (but institution dependent. decrease risk of radiation recall).
26
neoadjuvant regimens for TNBC
ACT
TC
CMF
27
What is CMF
cyclophosphamide
Methotrexate
5-Fu
27
When you can give TC rather than ACT
small node negative
(low risk (<1cm AND node negative OR cardiac RF’s))
28
TC?
Taxol
Cyclophosphamide
*but seems also used to refer to taxol carboplatin in breast cancer
29
Indication for neoadjuvant for TNBC based on size (confirm)
Greater than 0.5 cm
30
Endocrine therapy for men with breast cancer
tamoxifen
31
When you can omit adjuvant chemo in ER/PR + breast based on oncotype
- oncotype less than 26 + over the age of 50
- less than 50 (premenopausal)
IF node positive, chemo regardless of score (there was a subset analysis showing benefit but thought to be from ovarian suppression from chemo)
IF node negative, no chemo if <16 (some benefit for intermediate risk)
*just think of as premenopausal only if node negative and <16
32
Tamoxifen SE's
- increased risk of endometrial cancer
- increased arterial and VTE risk
- *cataracts
- menopausal symptoms
- weight gain
- hepatic steatosis
*photosensitivity
*bone strengthening but has been shown to cause bone density loss in some women
33
AI SE's
- vaginal dryness
- osteoporosis
34
management of AI induced arthralgias (aside from medication switch)
- duloxetine
- exercise
- acupuncture
35
Tamoxifen contraindicated with what medication?
- certain SSRI's - duloxetine or paroxetine
36
How can you reduce risk of infertility in women after chemo?
GNRH agonists - triptorelin, goserelin
37
Size cutoff for withholding systemic therapy for HER2
0.5 cm
38
Size threshold in HER2 disease for which you can use TH (taxol herceptin)
Less than 2 cm
39
Herceptin contraindication
pregnancy
40
Management of residual disease after neoadjuvant for HER2+ breast cancer
T-DM1
41
Management of localized inflammatory breast cancer
Neoadjuvant systemic therapy
Mastectomy w/ axillary nodal dissection
42
Contraindications in management of breast cancer during pregnancy 1) chemo? 2) endocrine therapy?
- herceptin
- CT scans and nuclear imaging
- chemo can be used in second trimester but ideally postpartum
- XRT
- endocrine therapy
*no axillary nodal dissection since can't get XRT
43
locoregional recurrence management in breast cancer
- mastectomy w/ axillary nodal dissection
- radiation if not previously done
- if TNBC adjuvant chemo per CALOR trial (not indicated if HR+)
44
Genetic syndromes associated with increased risk of breast cancer
BRCA1-2
PALB2
PTEN
ATM
CHEK2
P53
STK11
SDH1
45
Other
- Thoracic XRT
- ALH/ADH (atypical lobular and atypical ductal hyperplasia)
- Older age
- *early menarchy
- late menopause
46
When to start screening for breast cancer in patients with history of thoracic breast radiation
30 or 8 years after completion of radiation
47
Breast cancer screening age now
40
48
When to start screening BRCA patients
MRI + mammo starting at age 25
*high yield
49
LCIS management
- surgery +/- endocrine therapy depending on menopausal status (similar to DCIS)
*No XRT
50
Margin required in DCIS
2 mm
51
When endocrine therapy is indicated in DCIS
lumpectomy, NOT with mastectomy
52
Clinical benefit of ET for DCIS
- reduces risk of ipsilateral and contralateral breast cancer recurrence
*no effect on OS
53
phylodes tumor management + margin size requirement
- surgery alone
*with larger margins (>1 cm)
*hormone therapy is not effective
54
metastatic phylodes tumor management
taxane based chemo
55
Contraindications to BCT
- diffuse calcifications
- multifocal disease
- grossly positive margins
*homozygous ATM
56
Positive lymph node in breast cancer
0.2 mm or greater or >200 cells
57
Axillary lymph node dissection indications
1) More than 2 positive sentinel lymph nodes on SLNB
2) Clinically palpable axillary lymph node
3) Positive FNA
4) inflammatory breast cancer
5) pregnancy
58
What is the HER2 climb regimen?
tucatinib/capecitabine/trastuzumab
59
Management of clinically node positive ER+ breast cancer?
- Neoadjuvant downstaging chemo (eg ACT) w/ goal of downstaging axilla to prevent axillary nodal dissection
- surgery
- adjuvant endocrine therapy
60
CDK4/6 inhibitor mechanism
- Cause cell cycle arrest in G1 phase (not cytotoxic)
61
When abemaciclib is indicated in addition to endocrine therapy adjuvantly
4 or more positive axillary lymph nodes
or 1-3 nodes with tumor > 5cm, G3, or Ki-67 > or equal to 20%
62
aromatase inhibitors
anastrozole
letrozole
exemestane
63
First line for metastatic ER positive breast cancer - 1) postmenopausal 2) premenopausal
Given postmenopausal,
AI + CDK4/6 inhibitor
Given premenopausal,
Ovarian suppression w/ AI + GNRH concurrently
64
palbociclib SE to know
neutropenia
65
alpelisib SE's to know
- rash
- hyperglycemia
66
Indication for dexrazoxane in patient with doxorubicin
cumulative dose > 300 mg/m2
67
First line for HER2 positive metastatic breast cancer
Trastuzumab + pertuzumab + taxane (THP or DHP) (docetaxel vs. paclitaxel)
68
sacituzumab SE's
- neutropenia
- diarrhea
- fatigue
69
Management of residual disease in TNBC
capecitabine
70
Neoadjuvant systemic therapy for HER2+
Trastuzumab/pertuzumab + nonanthracycline based chemo (TCHP)
71
Neoadjuvant systemic therapy for triple positive breast cancer
TCHP
72
management of residual disease in HER2 positive breast cancer
TDM1
73
Chemo that is okay to use in pregnant breast cancer patient
doxorubicin, cytoxan, 5-FU (FAC)
74
Lymph node threshold for requiring adjuvant chemo in ER/PR positive breast cancer
4 or more always need chemo
75
genetic syndromes associated with breast cancer
BRCA1/2
PALB2
PTEN/coden
CHEK2
Li fraumeni
Peutz jeghers
CDH1
76
1) other breast cancer RF's 2) protective factors
*ALH/ADH
- DCIS/LCIS
- early menarchy (earlier estrogen exposure)
- late menopause (longer period of time for estrogen exposure)
- older age
*lower age at first childbirth, having more children, breastfeeding are protective.
77
Gail model cutoff for high risk (when risk reduction is indicated)
Greater than 1.7
78
DCIS management if mastectomy
sentinel lymph node biopsy (in case pathology reveals invasive disease)
79
High risk breast patients that are indicated for chemoprevention
ADH
ALH
LCIS/DCIS
strong family history
Gail >1.7%
80
raloxifene 1) approval 2) SE caveat to know
1) only approved in postmenopausal women
2) does not increase risk of endometrial cancer
81
DCIS other nomenclature
Tis
82
BRCA1 breast cancer typical phenotype
Triple negative
83
Management of tamoxifen in woman wishing to become pregnant
Stop and resume after pregnancy (teratogenci)
84
ADH management
- excision
- no adjuvant XRT required
85
Effect of hormonal IUDs on breast cancer risk
None
86
Management of axillary recurrence of hormone receptor positive breast cancer
- excision and axillary node dissection, followed by XRT
87
Management of woman with lumpectomy and 1+ lymph node with HR positive disease and 21 gene assay of 21
- Whole breast radiation, then AI for 5-10 years (RxPonder showed recurrence score fo 25 or lower in setting of N1 in postmenopausal does not benefit from adjuvant chemo)
88
LCIS management
*Depends on subtype
IF classic LCIS, observation with imaging follow-up
IF pleomorphic and florid types, surgery
89
Clinical benefit of biosphosphonates
- reduced distant recurrence risk
*reduced breast cancer mortality
*benefits primarily seen in postmenopausal women
90
PD-L1 status for KEYNOTE regimen
irrespective of PD-L1
91
RF's for breast angiosarcoma
- radiation
- chronic arm or breast edema
92
Premenopausal adjuvant ET
ovarian suppression (GNRH agonist - zoladex q 3 months) + aromatase inhibitor or tamoxifen
***AI preferred
93
Eligibility criteria for adjuvant PARP for BRCA1 pts
- pT2 or pN1 (eg node positive)
94
Role of PARP in metastatic setting for TNBC patients
second line as monotherapy
95
Recurrent metastatic HER2 breast cancer management
IF treated w/ taxane TCHP neoadjuvantly AND recurrence <6 months, T-DxD (directly to enhertu)
IF recurrence >6 months after adjuvant (including if T-Dm1 received), taxane + trastuzumab/pertuzumab (See de novo metastatic, recurrent metastatic enrolled in trial)
96
Radiation recall dermatitis clinical features
- inflammatory skin reaction during or after chemo in an area previously irradiation
**Can be a long time after radiation
97
Management of radiation recall dermatitis
- dose reduction or interruption of culprit agent
- steroids
98
Neoadjuvant for locally advanced HR+ and HER2+ breast cancer
TCHP
99
First imaging modality for breast mass in a woman under 30
US
100
Risk of local recurrence with and without radiation in old women with early stage HR+ breast cancer
- 10% without radiation
- 2% with radiation
101
Management post surgery of woman with LCIS or ADH in 45 year old
Chemoprevention with tamoxifen 5 mg for 3 years (data now supporting lower dose)
102
Next step after core needle biopsy reveals ADH
- excisional biopsy (rule out DCIS or invasive carcinoma)
103
When risk reducing bilateral salpingo-oophorectomy is indicated in BRCA patients
- age 35-40 and when childbearing no longer desired
104
Metastatic pattern of lobular breast cancer
serosa, ovaries, meningies, and GI tract (peritoneum and GI tract)
105
IHC stain for pembro in metastatic TNBC
22C3
106
Pathognomic finding for inflammatory breast cancer
- dermal lymphovascular tumor emboli on a punch biopsy
107
Essential feature of inflammatory breast cancer to differentiate vs locally advanced breast cancer
- symptom duration of no more than 5 months (rapid onset) (locally advanced breast cancer that is neglected for a long time can have shared features)
108
Management of HR+ locally recurrent breast cancer in the lumpectomy bed that is node negative
Adjuvant ET
NO chemo
109
Systemic therapy for pregnant pt with triple positive breast cancer
AC-T
110
Clinical benefit of adjuvant ET in DCIS
- reduces risk of ipsilateral recurrence and contralateral breast cancer
- no benefit in OS
111
Has oncotype been validated in men?
Yes, apparently
112
Indication for olaparib in adjuvant setting for BRCA patients
*residual disease following neoadjuvant
112
Bisphosphonate of choice in women on adjuvant AI + dosing
Zoledronate 4 mg IV once every 6 months for 2 years
112
Management of breast adenoid cystic carcinoma
- local therapy alone (mastectomy or BCT)
113
Clinical benefit of bisphosphonates in breast cancer
- decreased risk of bone mets
- small but significant OS benefit with zoledronate
114
Management of locally recurrent TNBC
Surgery w/ *adjuvant chemo
115
Breast papilloma management
Observation
IF high risk features (atypia or ductal hyerplasia), surgical excision
116
Preferred staging for pregnant breast cancer patients
- CXR w/ abdominal shielding and liver ultrasound
117
Neoadjuvant for CT1NO triple-negative breast cancer
- dose dense AC-T
118
Inclusion criteria for KEYNOTE for TNBC
T2 or N+
119
Only chemoprevention with demonstrated OS in BRCA patients
bilateral salpingo-oophorectomy
120
Recommended means of preserving fertility in breast
GnRH analogue every 28 days starting 2 weeks before chemo
*Embryo freezing can only be done with a fertilized egg and delays start of chemo
121
Preferred first line for triple positive metastatic breast
THP
122
Adjuvant management of HER2+ breast cancer with pathCR
trastuzumab + pertuzumab to complete 12 months of HER2-directed therapy
123
Hypofractionated vs. conventional whole breast irradiation
hypofractionated better and correct answer per boards
124
When continuation of endocrine therapy is indicated + duration
- high risk, node positive
- 10 years total
125
CHEK2 guidelines for cancer screening
- colonoscopy starting at age 40
- annual breast
126
Adjuvant management of tubular carcinoma
Endocrine therapy alone
127
Recommended breast cancer staging modalities per boards
CT torso
*NOT pet
128
Firstline for metastatic TNBC that is PD-L1 negative and BRCA mutant
platinum
129
Breast angiosarcoma management
- upfront wide local excision
IF locally advanced, neoadjuvant w/ taxol
130
How to reduce risk of lymphedema in node positive patients
- still need radiation to the regional lymph nodes (axillary dissection is what increases risk of lymphedema0
131
management of axillary recurrence of TNBC
neoadjuvant or adjuvant chemo and axillary lymph node dissection
132
Do OCP's increase risk of breast cancer
Yes, should be stopped in high risk women
133
When is systemic imaging required in breast cancer
1) Stage I and II if other concerning symptoms
2) Stage III
134
Recommended systemic imaging for stage III
CT torso + bone scan
135
Clinical benefit of adjuvant XRT for DCIS
- NO OS benefit
136
When breast cancer index is indicated
- hormone receptor positive
- negative lymph nodes or 1-3 positive
137
First line for HR+ breast cancer
*Remember that it's chemo if in visceral crisis
138
Role of bisphoshonates in adjuvant setting for women on hormonal therapy
*zometa specifically
- indicated for postmenopausal women and women on GNRH agonist + AI (medical menopause) regardless of baseline bone density because there is a survival benefit
139
Adjuvant management of node positive TNBC pt with pathCR after mastectomy
***still needs radiation given node positive disease despite mastectomy
140
Paget disease clinical features
- scaly, raw, vesicular, or ulcerated lesion that begins on the nipple and then spreads to the areola (picture 1). Occasionally, a bloody discharge is present. P
141
First step in Paget's management
breast imaging (often associated with carcinoma in situ)
142
Indication for chemo in early stage TNBC
0.5 cm (remember that small tumors, stage I) still need adjuvant because TNBC is aggressive
143
Definition of premenopausal for adjuvant ET
amenorrheic for 12 months
144
Next line of therapy for progression on adjuvant endocrine therapy
IF progression >12 months from end of ET, first line AI + CDK4/6
IF progression within 12 months, subsequent line ET + CDK4/6 (So if progression on AI, fulvestrant + CDK4/6)
145
Medullary breast cancer management
neoadjuvant indications same as triple negative
- surgical management the same
146
Age at which germline testing is indicated for breast cancer
Younger than 50
