Breast Cancer - Block 4

Question 1

What are the RF of breast cancer?

Answer 1

1. Female
2. Current hormone therapy
3. Increasing age

Question 2

What are the screening recommendation of ACS?

Answer 2

Breast self-exam: ≥20 YO optional
Clinical breast exam: N/A
Mammogram: 40-44 (optional annually)
* ≥55 YO Q2Y

Question 3

What are the screening for USPTF?

Answer 3

Breast self-exam: Not recommended
Clinical breast exam: N/A
Mammogram: 40-50 (optional)
* 50-74 YO: Q2Y

Question 4

What are the screening recommnedations of NCCN?

Answer 4

Breast self-exam: ≥25 breast awareness
Clinical breast exam: 25-39 YO Q1-3Y
Mammogram: ≥40 Y annually

Question 5

How do you diagnose of breast cancer?

Answer 5

1. Mammogram
2. MRI if dense tissue
3. Biopsy

Question 6

What are the stages of breast cancer?

Answer 6

0: carcinoma in situ
1: Small and confined to breast
2: large tumor and/or local lymph node involvement
3: Tumor any size or direct extension into chest wall with more extensive lymph node involvement
4: metastases

Question 7

What are the prognostic factors of breast cancer?

Answer 7

1. Number of affected lymph nodes (most important)
2. Age <35 YO
3. Ethnicity: AA are more at risk
4. Estrogen receptor/Progesterone receptor (ER/PR) Status (most favorable prognosis)
5. HER-2/neu oncogene (most aggressive)
6. Anti-HER2 therapy

Question 8

Tx modalities for breast cancer?

Answer 8

1. Surgery
2. Neoadj
3. Systemic adj (chemo and endocrine therapy)
4. Radiation

Question 9

What are the surgical options for breast cancer?

Answer 9

1. Modified radical mastectomy
2. Breast conserving therapy

Question 10

Outline the modifiedradical mastectomy?

Answer 10

Removal of entire breast to maintain ROM and strengh
* Recommend for those with BRCA 1 o 2 mutations

Question 11

Outline and indications of BCT therapy?

Answer 11

Must follow with radiation (3-5 wks) due to higher risk for local recurrance
Indication: must meet lumpectomy criteria (<5cm, no h/o radiation to the chest, only in one quadrant, positive margins, not pregnant or very early)
* Neoadjuvnt therapy is required

Question 12

When is sentinel lymph node biopsy indicated?

Answer 12

Identified with radiologic dye
Preferred for stage 1-2

• Reduces problems from lymph node the dissection such as lymphedema, sensory loss, pain

Question 13

What are the RF of lymphedema?

Answer 13

1. Extent of axillary surgery
2. Axilliary radiation
3. Infection
4. Obesity

Question 14

What are adj options?

Answer 14

1. Hormone
2. Chemo
3. Radiation

Question 15

Factors you need to consider for adjuvant therapy?

Answer 15

1. ER/PR status
2. HER2 status
3. Menopause status

Question 16

What is the tx option for tumors >1 cm or + lymph nodes?

Answer 16

Question 17

What are the preferred adj regimens for HER2- Stage 1-2?

Answer 17

1. Dose dense AC followed by weekly paclitaxel
2. Dose dense AC followed by q2week paclitaxel
3. Doxetaxel, cyclophosphamide (TC)

AC: doxorubicin/cyclophosphamide

Question 18

What are the preferred adj regimens for HER2+ Stage 1-2?

Answer 18

1. AC followed by paclitaxel + trastuzumab
2. AC followed by paclitaxel + trastuzumab ± pertuzumab
3. Docetaxel, carboplatin, trastuzumab (TCH) ± pertuzumab

AC: doxorubicin/cyclophosphamide

Question 19

What are the HER2 + tx options?

Answer 19

1. Trastuzumab
2. Pertuzumab

Question 20

How do you dose trastuzumab? ADRs?

Answer 20

Don’t administer with antracyclines
* Hypersensitivity >12hrs after admin

ADR: arthralgias, cardiac tox, infusion related rx

Question 21

Monitoring and ADRs of pertuzumab?

Answer 21

Monitoring: LVEF
ADRs: diarrhea, N, alopecia, PN, LV dysfunction, infusion rx

Question 22

Indications for adj endocrine therapy?

Answer 22

1. Estrogen receptor
2. Pregesterone receptor
3. Cancer cells can have 1 receptor or both

Question 23

Types of adjuvant endocrine tx?

Answer 23

1. Ovarian ablation
2. Use of LH-RH agonists
3. Use of aromatase inhibitors
4. Use of SERM

Tx is based on pre/post menopausal

Question 24

What are is the adj endocrin tx for premenopausal?

Answer 24

Question 25

What are is the adj endocrin tx for postmenopausal?

Answer 25

Question 26

Antiestrogen types?

Answer 26

1. Tamoxifen 2. Fulvestrant

Question 27

ADRs and CP of tamoxifen?

Answer 27

**ADR:** VTE and uterine cancer **CP:** DDI with paroxetine or fluoxetine * CYP2D6 interaction decreases tomoxifen efficacy

Question 28

ADR and CP of fulvestrant?

Answer 28

**ADR:** VTE and increased LFTs **CP:** used for progression only, no initial tx

Question 29

What are types of aromatase inhibitors?

Answer 29

1. Anastrozol 2. Letrozole 3. Exemestane

Question 30

ADR and CP of aromatase inhibitors?

Answer 30

**ADR:** Arthralgias, decreased bone density, increased risk of fracture **CP:** Supplemental calcium and vit D, may increase cholesterol

Question 31

Overall tx outline for adjuvant endocrine tx?

Answer 31

Question 32

Tx options for metastatic breast cancer?

Answer 32

1. Surgery (supportive care) 2. Radiation 3. Endocrine therapy 4. HER2 targeted 5. Chemo

Question 33

Metastatic tx for pre menopausal?

Answer 33

**If no endocrine tx within 1 year:** * 1st line tx is tamoxifen OR * Ovarian suppression **If pt received endocrine tx within last year:** * Ovarian ablation/suppression with systemic therapy

Question 34

Metastatic tx for post menopausal?

Answer 34

AI + fulvestrant OR AI + palbociclib

Question 35

What are preferred agents for metastatic chemo?

Answer 35

1. Capcetibine 2. Doxorubicin 3. Gemcitabine 4. Vinorelbine 5. Paclitaxel

Question 36

Preferred agents for metastatic HER2 +?

Answer 36

1. Pertuzumab, trastuzumab, docetaxel 1. Pertuzumab, trastuzumab, paclitaxel

Question 37

Indications for radiation?

Answer 37

1. After chemo 2. After surgery 3. Neoadj 4. Local recurrance 5. Palliative