Breast Cancer

Question 1

Name the 4 subtypes of breast cancer

Answer 1

HER2+, TNBC, Luminal A and Luminal B

Question 2

List the subtypes of breast cancer in order of highest mortality rate to lowest mortality rate.

Answer 2

HER2+ > TNBC > Luminal A > Luminal B

Question 3

Which type of inheritance pattern do BRCA1 and BRCA2 show?

Answer 3

Autosomal dominant

Question 4

Where does breast cancer develop?

Answer 4

in the terminal duct lobular units of the collecting duct

Question 5

Name the two types of pre invasive histological subtypes.

Answer 5

1. Ductal carcinoma in situ
2. Lobular carcinoma in situ

Question 6

Name the two types of invasive histological subtypes.

Answer 6

1. Ductal carcinoma no special type (NST)
2. Lobular carcinoma (ILC)

Question 7

Name the two molecular pathways of progression.

Answer 7

1. Low grade pathway
2. High grade pathway

Question 8

Which cancer subtypes develop from the low grade pathway.

Answer 8

Luminal A and Luminal B

Question 9

Which cancer subtypes develop from the high grade pathway.

Answer 9

HER2+ and TNBC

Question 10

What drugs are the first line of treatment for treating hormone sensitive breast cancer?

Answer 10

Drugs targeting estrogen.
Tamoxifen (ER antagonists block effects of estrogen on mammary gland)
Aromatase inhibitors (block aromatase enzymes, preventing production of estrogen from androgens (post-menopausal women))

Question 11

At what point does the tumour microenvironment turn from an anti-tumour environment to a tumour promoting environment?

Answer 11

Once the tumour becomes invasive

Question 12

How is a pro-tumour environment induced?

Answer 12

Malignant cells express immune checkpoint regulators (CTLA-4) and (PD-L1). There is also recruitment of immunosuppressive cells, T regs and myeloid-derived stromal cells.

Question 13

How are T regs induced?

Answer 13

induced by tumour associated macrophages (TAMs) and by tumour-secreted and cancer-associated fibroblasts (CAF)-secreted factors.

Question 14

There are two major cores of breast cancer management, locoregional treatment and systemic therapy. What are they?

Answer 14

Locoregional treatment - surgery to remove primary tumour and remove affected axillary lymph nodes and radiation
Systemic therapy - neoadjuvant before surgery or as adjuvant after surgery if result of GES suggests increased recurrence or pathological complete response (pCR) (absence of cancer cells in surgical specimen) is not achieved

Question 15

What is the treatment strategy for luminal early breast cancer in premenopausal patients?

Answer 15

Adjuvant endocrine therapy for 5 years, tamoxifen.
In high risk patients - neo or adjuvant chemotherapy (anthracycline + taxane), aromatase inhibitor anastrozole, GnRH analogue, GnRH analogue + aromatase inhibitor (increased toxicity)

Question 16

What is the treatment strategy for luminal early breast cancer in post-menopausal patients?

Answer 16

Tamoxifen or aromatase inhibitors

Question 17

What is the treatment strategy for HER2-positive early breast cancer?

Answer 17

Neoadjuvant chemotherapy (Anthracycline + Taxane or Docetaxel + Carboplatin (ATDC)) + dual anti-HER2 therapy = gold standard

Question 18

What is the treatment strategy for Luminal-like metastatic breast cancer in advanced breast cancer in premenopausal patients?

Answer 18

Ovarian suppression or ablation + tamoxifen or anastrozole or fulvestrant

Question 19

What is the treatment strategy for Luminal-like metastatic breast cancer in advanced breast cancer in post-menopausal patients?

Answer 19

Tamoxifen or anastrozole or fulvestrant. Dependent of adjuvant therapy received on initial diagnosis

Question 20

What is the treatment strategy for HER2-positive advanced breast cancer in advanced breast cancer?

Answer 20

Patients previously non-treated with trastuzumab: first option is Dual anti-HER2 (trastuzumab + pertuzumab) + Docetaxel or paclitaxel or capecitabine
Second option for treatment: Trastuzumab plus taxane or anthracyclines, platinum, gemcitabine or cyclophosphamide with methotrexate

Question 21

What is the treatment strategy for TNBC advanced breast cancer in advanced breast cancer?

Answer 21

No specific chemotherapy recommendations for patients without BRCA mutations
BRCA associated advanced TNBC, a platinum agent is the preferred option

Question 22

Which drug can be used to delay or overcome endocrine resistance?

Answer 22

CDK4/6 inhibitors (ribociclib)

Question 23

Which drug is ribociclib given with to reduce cardiac toxicity?

Answer 23

Aromatase inhibitor (plus GnRH)

Question 24

Which type of TNBC is a platinum agent the preferred option?

Answer 24

BRCA associated advanced TNBC