Breast Cancer

Question 1

Breast Cancer Non-Modifiable Risk Factors

Answer 1

B: Breast Density
R: Reproductive Timing (Early Menarche)
E: Extended Hormones (Late Menopause)
A: Age
S: Self-History (Breast change on biopsy)
T: Traits Inherited
Genes: Genetics (BRCA)
Stay: Sex (Female)
+ Ionizing Radiation

Question 2

Breast Cancer Modifiable Risk Factors

Answer 2

Nulliparity
Older age at First Childbirth
Post Menopausal Obesity
Physical Inactivity
Alcohol Consumption

Question 3

What endocrine therapy is given to premenopausal women? Post-Menopausal?

Answer 3

Tamoxifen = Pre
Aromatase Inhibitors = Post Menopausal

Question 4

Who is Oncotype Dx for?

Answer 4

HR (+), HER2(-), Tumor > 0.5 cm

Question 5

For post-menopasual women when would you treat them based on Oncotype Dx?

Answer 5

26+ = Chemotherapy + Endo
<26 = Endo Only

Question 6

For Premenopausal women with no lymph node involement, how would you treat them based on Oncotype Dx?

Answer 6

<15 = Endocrine only
16-25 = Chemo, then endo OR Ovarian supress and Endo
26 + = Chemo, then endo

Question 7

For premenopausal women with lymph involvement, how would you treat them based on Oncotype Dx?

Answer 7

<26 = Chemo, then endo OR OS then + Endo
26+ = Chemo then endo.

Question 8

AC

Answer 8

Doxorubicin/Cyclophosphamide

Question 9

TC

Answer 9

Docetaxel/Cyclophosphamide

Question 10

HR(+), HER2(-) Chemotherapy

Answer 10

1. Dose-Dense AC x4, then Paclitaxel q2w x4
2. Dose Dense AC x4, then paclitaxel qw x12
3. TC q3w x 4-6 weeks

Question 11

Triple Negative Chemotherapy Neoadjuvant

Answer 11

Pembrolizumab q3w x4 + Paclitaxel/Carbo x12
—->
Pembrolizumab + AC q3w x 4 doses

Question 12

Triple Negative Adjuvant Therapy

Answer 12

Pembrolizumab q3w x9

Question 13

HER2 Chemotherapy

Answer 13

Docetaxel/Carbo/Trastuzumab +/- Pertuzumab
q3w x 6 doses

OR

Paclitaxel + Trastuzumab QW x 12 weeks

Continue trastuzumab or pert/trast for 1 year following chemotherapy

Question 14

Who should get pertuzumab?

Answer 14

T2+
OR
N1+, HER2+
OR
High Recurrence Risk

Question 15

Which HER2 mab can be used as monotherapy?

Answer 15

Trastuzumab

Question 16

What is AC –> T

Answer 16

AC: Doxorubicin 60 mg/m2 + Cyclophosphamide 600 mg/m2 (q2w x4)

T: Paclitaxel 80 mg/m2 x 12 or Dose Dense Paclitaxel 175 q2w x4

Endocrine: 5-10 yrs if HR+

Question 17

What is TCHP for HER2

Answer 17

TCHP: Pertuzumab (840–>420 mg), Trastuzumab (6 mg/kg), Docetaxel (75 mg/m2), Carboplatin AUC 6. [q3w x6)

H: Trastuzumab + Pertuzumab q3w x 1 year

Endocrine: 5-10 years if HR +

Question 18

Taxanes ADEs

Answer 18

Alopecia
Peripheral Edema = Docetaxel
Neuropathy = Paclitaxel&raquo_space;

Arthralgias, Myalgias, Hypersensitivity Rxn

Question 19

Doxorubicin ADEs

Answer 19

RED: Red Secretions
HEART: Cardiotoxicity (MLT: 450 mg/m2)
CANCER: Secondary Malignancy
BURN: Extravasation Risk

MUST MONITOR ECHO EVERY 3 MONTHS!!!!!!!

Question 20

Cyclophosphamide ADEs

Answer 20

Sterility
Hemorrhagic Cystitis due to active metabolite

Question 21

HER2 mAB ADEs

Answer 21

1. Cardiotoxicity (reversible, not dose related)
2. Diarrhea (Pertuzumab)
3. Infusion Reactions

MONITOR ECHO EVERY 3 MONTHS!!!!!!

Question 22

Tamoxifen Mechanism

Answer 22

Estrogen Antagonist

Question 23

Tamoxifen Clinical Pearls

Answer 23

Prodrug —> Endoxifen
Avoid Strong CYP2D6i (Paroxetine, Fluoxetine, Bupropion)

Question 24

If an aromatase inhibitor is used in premenopausal women what must also be used?

Answer 24

Ovarian Suppression as AI can cause the ovaries to produce estrogen.

Question 25

How is Ovarian suppression completed?

Answer 25

LHRH Agonists (Goserelin = SQ, Leuprolide = IM)

Question 26

What are the adverse effects of Tamoxifen?

Answer 26

Menopausal Symptoms Menstrual Changes *Uterine or Endometrial Cancer* *VTE/Stroke* Teratogenic

Question 27

What are the adverse effects of Aromatase Inhibitors

Answer 27

Menopausal Symptoms Musculoskeletal Pain Increased Bone Loss (OP/Fractures) Hypercholesterolemia CVD Risk

Question 28

Who can receive Capecitabine

Answer 28

Triple neg not pCR with neoadjuvant

Question 29

Who can receive ado-Trastuzumab emtansine

Answer 29

HER2 not pcR with neoadjuvant

Question 30

Who can receive neratinib

Answer 30

HER2+ +/- HR + Initiate at completion of adjuvant trastuzumab MUST USE PROPHYLACTIC LOPERAMIDE

Question 31

Who can received Olaparib

Answer 31

BRCA Mutated Breast Cancer *DO NOT GIVE TO BRCA WT = Lethal!!!!!*

Question 32

Who can receive Abemaciclib

Answer 32

HR+, HER2(-) In combination with endocrine

Question 33

Who can receive Ribociclib

Answer 33

HR+, HER2-, stage II and Stage III In combination with endocrine

Question 34

Who can receive zoledronic acid

Answer 34

Post Menopausal Patients 4 mg IV q6M x 2 years

Question 35

What is Palbociclib (Ibrance), when is it used?

Answer 35

CDK4/6i --> Block G1 to S phase Used for HR+, HER 2 neg, MBC Must be used with AI as initial therapy Can use with Fulvestrant if second agent following DP.

Question 36

What is Ribociclib?

Answer 36

CDK4/6i Same indication as Palbociclib Monitor QT and LFTs at initiation of therapy.

Question 37

What is Abemaciclib?

Answer 37

CDK4/6i Same indication as palbociclib Monitor LFTs and SCr at initiation of therapy.

Question 38

What is Everolimus, when is it used?

Answer 38

mTOR inhibitor --> Decreased proliferation, angiogenesis, glucose uptake Used for HR+, HER2-, MBC Use in combination with exemestane or fulvestrant following failure of letrozole or anastrozole. ADE: Metabolic, Pneumonitis, Stomatitis, Rash

Question 39

When is Capivasertib used?

Answer 39

AKT inhibitor Used for HR+, HER2 neg, PI3KCA/AKT1/PTEN mutated MBC Use in combination with fulvestrant LOTS OF ADES: Hyperglycemia, Skin Rash, Diarrhea, Nausea, Fatigue, Elevated SCr, Stomatitis

Question 40

HER2(+) MBC Chemotherapy

Answer 40

Pertuzumab + Trastuzumab +docetaxel or pacetaxel

Question 41

When would we give bisphosphonates such as Zoledronic Acid (q12 weeks) or Pamidronate (q28 days)

Answer 41

To prevent Skeletal Related Events (Radiation, Fracture, Hypercalemia of malignancy) Toxicity: Osteonecrosis, Arthralgia, Fever Dose Adjust: CrCL <50

Question 42

What agent can be used to prevent skeletal related events when bisphosphonates are not recommended at low renal function?

Answer 42

Denosumab (q28 days) RANKL ---> Blocks osteoclasts activity Noninferior to Zoledronic Acid

Question 43

Hot to manage hot flashes?

Answer 43

Gabapentin or Venlafaxine

Question 44

How to manage sexual problems with BC?

Answer 44

Vaginal Lubricants, Moisturizers AVOID TOPICAL ESTROGEN PRODUCTS

Question 45

Neuropathy is a dose limiting toxicity of what chemotherapy?

Answer 45

Taxanes

Question 46

What chemotherapy has a maximum lifetime dose to avoid cardiotoxicity?

Answer 46

Doxorubicin (450 mg/m2)