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Clinical 2 (Part B) > 22 - Breast Cancer > Flashcards

22 - Breast Cancer Flashcards

1
Q

What is the problem if a patient expresses HER2 genes?

A

amplification/overexpression generally imparts a poorer prognosis; chemotherapy sensitivity (such as with anthracyclines, this is controversial); endocrine therapy resistance (also controversial)

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2
Q

What increases risk of breast cancer?

A
  • family Hx
  • early age of menarche (before 12 yo)
  • late age of natural menopause (>55 yo)
  • women who don’t have kids before age 30
  • diet and alcohol use
  • exposure to radiation

-early induced menopause (before 50 yo) decreases risk

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3
Q

What is human breast tissue composed of?

A
  • connective tissue and fat with an elaborate duct system
  • abundant blood supply
  • not fully developed until first pregnancy
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4
Q

Where does breast cancer most commonly spread to ?

A

-lung, bones, liver and brain most commonly

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5
Q

What type of surgery requires post operative radiation ?

A

Breast conserving surgery (lumpectomy)

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6
Q

What is TNM staging?

A 
T = primary tumor (number based on size usually)
N = regional lymph node involvement
M = metastatic spread
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7
Q

What does stage 4 mean?

A

it has spread (in breast cancer that means most likely spread to lungs, skin, bones, liver, brain)

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8
Q

Number of lymph nodes affected is ____ related to disease recurrence

A

directly

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9
Q

What is a tumor grade?

A
  • How aggressive the cancer is
  • Look at level of cell differentiation by evaluating amount of tubule formation, nuclear size, and mitotic count
  • Grade 1 = well differentiated (more favourable)
  • Grade 2 = moderately differentiated
  • Grade 3 = poorly differentiated (less favourable)
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10
Q

What is HER2-neu associated with?

A

increased tumor aggressiveness

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11
Q

What is the treatment for DCIS (ductal carcinoma in situ) ?

Stage 0 cancer

A
  • Surgery (generally do not need axillary lymph node dissection)
  • Radiation
  • Tamoxifen
  • Role of aromatase inhibitors not yet established
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12
Q

What is the Tx for stage 1 breast cancer?

A
  • surgery
  • radiation
  • adjuvant chemo +/- endocrine therapy +/- biologic therapy
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13
Q

What is Tx for stage 2 and 3 breast cancer?

A
  • surgery
  • radiation
  • systemic chemotherapy
  • management is usually a combined approach of surgery followed by chemotherapy and then radiation to try to reduce the rate of local recurrence
  • additionally, many patients will receive 1-2 cycles of neoadjuvant chemo to improve surgical resectability
  • hormonal therapy in estrogen receptor positive patients is certainly of value as would be any therapy directed at Her-2ne over expression
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14
Q

If they have bone cancer, most will get a _______ prescribed to them

A

bisphosphonate

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15
Q

If they have spread to visceral organs (lung, liver), what do we consider for Tx ?

A

Most oncologists will consider systemic chemotherapy with an anthracycline based regimen or taxane based regimen

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16
Q

What is the Tx for brain or spinal cored metastases ?

A

usually radiation +/- corticosteroids

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17
Q

If a person has 3 cm invasive ductal cancer will Her2 neu positive, do they need adjuvant therapy ?

A

yes

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18
Q

What are some possible indications for radiation therapy ?

A
  • breast conserving surgery
  • mastectomy with positive margins
  • lymph node positive disease
  • large tumors
  • neo-adjuvant indications

*may be used in metastatic disease to treat metastatic site (bone, brain)

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19
Q

Describe the Tx for early stage (stage 1-3) breast cancer ?

A
  • surgery
  • radiation
  • chemotherapy
  • endocrine therapy

Goals of Tx: long term remission or cure

*patients may receive all of the above or any combination depending on the cancer and patient specific factors

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20
Q

Describe the Tx for metastatic breast cancer (stage 4)

A
  • Typically systemic therapy
  • Palliative radiation
  • Balance symptom relief with chemotherapy toxicities
  • Exposure patient to what they have not been given before

Goals of Tx: Palliation

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21
Q

Most regimens in early breast cancer are combinations of two or more drugs and contain a _______, a ______ or both

A

an anthracycline, a taxane, or both

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22
Q

Doxorubicin:

______ antibiotic

A

anthracycline

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23
Q

Doxorubicin:

Lifetime cumulative dose of ?

A

500-550 mg/m2 - 21 day regimen

700 mg/m2 for weekly regimen

*usually administered in a 50 mg/m2 per dose

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24
Q

Doxorubicin:

Usually the first agent of choice for patients with ____ disease, unless patient has received an anthracycline in the adjuvant setting.

A

metastatic

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25
Q

Doxorubicin:

Most serious dose-limiting side effect is _______

A

cardiomyopathy

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26
Q

Doxorubicin:

What do we test before to prevent cardiomyopathy ?

A

baseline EF

want at least EF > 50%

if below 50%, then they need more MUGA scans

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27
Q

Doxorubicin:

Other side effects ?

A
  • alopecia
  • neutropenia
  • n/v/d
  • red urine
  • vesicant (blistering)
  • stomatitis (inflammation of mucous membranes)
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28
Q

Epirubicin:

Enantiomer of the molecule, ______

A

doxorubicin

29
Q

Epirubicin:

What is the cumulative lifetime dose?

A

1000 mg/m2

30
Q

Epirubicin:

used in ____ setting

A

adjuvant

31
Q

Epirubicin:

SE ?

A
  • alopecia
  • neutropenia
  • n/v/d
  • mucositis
  • pink urine
  • vesicant
32
Q

Paclitaxel:

possibility of developing _____ reactions and require premedications (histamine blockade & corticosteroids)

A

hypersensitivity

33
Q

Paclitaxel:

used in the _____ setting

A

adjuvant

34
Q

Paclitaxel:

SE

A
  • hypersensitivity reactions
  • neutropenia
  • alopecia
  • arthralgias/myalgias
  • peripheral neuropathy
  • diarrha
35
Q

Paclitaxel:

What is the pre-treatment to avoid hypersensitivity rxn?

A
  • dexamethasone
  • ranitidine
  • benadryl

*corticosteroid and then H2 and H1 blockade

36
Q

Docetaxel:

Place in therapy?

A

2nd line metastatic Tx

37
Q

Docetaxel:

What do we give it with?

A

dexamethasone bc docetaxel can cause fluid retention syndrome

38
Q

Capecitabine:

metabolized to ___

A

FU

39
Q

Capecitabine:

Can be delivered at ___

A

home

40
Q

Capecitabine:

Side effects

A
  • n/v/d
  • hand foot syndrome
  • fatigue
  • hyperbilirubinemia
41
Q

What 3 drugs can block HER2-neu?

A
  • Trastuzumab
  • Pertuzumab
  • Lapatinib
42
Q

Trastuzumab:

Used in _____ setting

A

metastatic

43
Q

Lapatinib:

how do you take it

A

once daily on empty stomach

44
Q

Trastuzumab:

Can contribute to ______

A

cardiomyopathy

*prob don’t give with doxorubicin lol

45
Q

Trastuzumab:

other SE

A
  • possibility of infusion related reaction with first dose - fever, chills, riggers, n/v, headache, cough
  • myelosuppression - more so when in combo with chemotherapy
  • diarrhea
  • arthralgia, bone pain
46
Q

List some 4th or 5th line agents

A
  • Vinorelbine
  • Gemcitabine
  • Eribulin
47
Q

Risks associated with anthracycline containing regimen?

A
  • myelosuppression
  • n/v/d
  • cardiotoxicity
  • stomatitis
  • alopecia
48
Q

Risks associated with taxane containing regimen?

A
  • myelosuppression
  • hypersensitivity reactions
  • peripheral neuroapthy
  • fluid retention
  • arthralgia/myalgias
  • skin/nail changes
  • total body alopecia
49
Q

Risks associated with trastuzumab containing regimens?

A

increased cardio toxicity

50
Q

If they don’t have a taxane in adjuvant setting, what should they get in metastatic setting?

A

taxane

51
Q

What is a type of hormonal therapy used in breast cancer?

A

aromatase inhibitors

52
Q

List some aromatase inhibitors

A
  • anastrozole
  • letrozole
  • exemestatne
53
Q

MOA of aromatase inhibitors

A

inhibit adrenal steroids converting to estrogen

54
Q

Who are aromatase inhibitors going to work in?

A

only going to work in post-menopausal women bc in pre-menopausal women 95% of estrogen comes from ovaries

so aromatase inhibitors will only prevent 5% of estrogen

55
Q

SE of aromatase inhibitors

A
  • myalgias/arthralgias
  • headaches
  • nausea
  • vaginal dryness
  • weight gain
  • hot falshes
  • bone fractures
56
Q

Tamoxifen:

Place in therapy ?

A

agent of choice in the Tx of hormone receptor positive, premenopausal breast cancer

*still can be used in certain postmenopausal hormone receptor positive breast cancer patients

57
Q

Tamoxifen:

Positive effects on ?

A

bone and lipid levels

58
Q

Tamoxifen:

Describe MOA

A

SERM (selective estrogen receptor modulator)

  • antagonist effect in breast - inhibits ER
  • agonist effect in bones, lipids, endometrium
  • standard dose is 20mg PO daily
  • not given concurrently with chemo
  • may antagonist benefit of chemo - better outcomes when given sequentially
  • can further increase VTE risk
59
Q

Tamoxifen:

SE

A
  • hot flashes
  • n/v
  • vaginal bleeding/discharge
  • increased incidence of cataracts
  • endometrial changes? cancer
  • thromboembolic events (DVT or PE)
60
Q

List some bisphosphonates

A
  • Pamidronate
  • Zoledronic acid
  • Clodronate
  • Denosumab
61
Q

When is hormonal therapy of value?

A

if they have an estrogen receptor/progesterone receptor positive cancer

62
Q

What are our options for hormonal therapy ?

A
  • aromatase inhibitors (for post-menopausal women)

- tamoxifen

63
Q

How do we treat premenopausal breast cancer?

A
  • Tamoxifen 20mg orally once a day for 5 years remains the Tx of choice
  • Risk vs benefit begins to change after 5 years
64
Q

How do we treat post menopausal cancer in metastatic setting?

A
  • Tamoxifen remains a choice for patients
  • All 3 of the aromatase inhibitors have been shown to be effective either after progression on tamoxifen or as first-line
65
Q

How do we treat post menopausal cancer in adjuvant setting?

A
  • Tamoxifen still remains a choice for patients
  • Anastrozole has been studied vs tamoxifen as first line therapy
  • Showed that anastrozole is superior to tamoxifen
  • Letrozole is superior to tamoxifen

*after 5 years we can start them on letrozole, but we don’t know how long they should be on letrozole for?

66
Q

If they have thromboembolic events, what do we avoid?

A

tamoxifen

67
Q

If they have family Hx of osteoporosis, what do we avoid?

A

aromatase inhibitor

68
Q

If they have previous MI, what do we avoid?

A

aromatase inhibitors

69
Q

What about if they have fibromyalgia?

A

keep in mind the drugs that have SE of arthralgias and myalgia (taxanes and trastuzumab)

Clinical 2 (Part B) (30 decks)

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