Breast cancer Flashcards
EPIDEMIOLOGY
i) approx how many cases are there per year? how many women will develop BC in their lifetime?
ii) name three local treatments that can be given and improve outcomes?
iii) name three systemic medical treatments that can be given?
iv) what is pagets disease of the nipple? what % of patients with BC is it present in?
v) what is inflammatory breast cancer?
i) 55,000 cases per year
1 in 7 women develop it
ii) breast conservation, sentinel node biopsy, RT
iii) hormone therapy, chemo and targeted treatments
iv) pagets disease - eczematoid change of the nipple associated with underlying BC - present in 1-2% of patients
v) inflamm - cancerous cells block the lymph draining causing an inflamed breast (1 in 10,000)
BREAST CANCER DIAGNOSIS
i) name five risk factors
ii) name five symptoms
iii) what investigation is doen initially?
iv) what is preinvasive BC called? what is the risk of it becoming invasive?
v) what subtype are 75% of invasive BCs? what are 10%
i) increasing age, hormones (oes/proges), HRT, early menarche, late menopause, late first pregnancy, overweihgt, alcohol, hereditary eg BRCA
ii) painless lump, growing lump, skin change, nipple change, axillary LN
iii) triple assess (US, biopsy, examination)
iv) pre invasive - DCIS (ductal carcinoma in situ) 1 in 5 risk of becoming invasive
v) 75% are ductal and 10% are lobular.
STAGING BREAST CANCER
i) how differentiated are grade I/II/III?
ii) where is early breast cancer limited to?
iii) where is locally advanced found? what therapy does it need?
iv) name three places met BC may have spread to? name two places lobular cancers often spread to?
v) name two scans that may be done
i) grade I = well diff, II = mod diff, III = poorly diff
ii) early = limited to breast and or axillary nodes
iii) local adv is very large mass, involvement of skin or chest wall, LNs or inflamm features
needs systemic therapy or RT to be operable
iv) met spreads to bones, LN, lungs, liver, brain
lobular may spread to peritoneum or ovaries
v) MIBG or CT scan
INVASIVE BREAST CANCER BIOMARKERS
i) which two hormone receptors are routinely assessed? what score is given? what staining is used?
ii) expression of which growth factor is often assessed? which method is used?
iii) name two other biomarkers that may be assessed
i) oestrogen and progesterone
allred score (0-8) - 7-8 is stronly positive - use IHC
ii) HER2 expression using FISH
iii) proliferation index - Ki-67
or genomic profilling - oncotype, progsigna (low scores may be able to avoid chemo)
INVASIVE BREAST CANCER SUBTYPES
i) what are hormone receptor positive cancers aka? what are the two types?
ii) what is seen when HER2 is overexpressed?
iii) what are triple negative BCs?
i) luminal
luminal A = ER and PR strongly positive - have low prolif/genomic score
luminal B = ER+, high grade, high prolif score
ii) HER2 positive - approx half are also oes positive
iii) triple neg is ER, PR and HER2 negative
TREATMENT OF INOPERABLE BREAST CANCER
i) which two types of surgery can be done
ii) where is RT usually given after breast conserving sx? where is it given after masectomy? where may it be given in some high risk patients?
iii) name five types of adjuvant systemic therapy
i) breast surgery - conserving or masectomy
axillary staging - LN dissection
ii) after conserving surgery = breast
after masectomy = chest wall
high risk = give to LNs
iii) anti hormone tx, CD4/6 inhibitiors, chemo, anti HER2 tx, bisphosphonates, may gieve pre op chemo
TREATMENT OF HORMONE RECEPTOR POSITIVE BREAST CANCER
i) how does tamoxifen work? which two groups of women does it work in? what % reduction risk of bc compared to placebo?
ii) name four side effects of tamoxifen? how many years may it be given for?
iii) what type of drugs are letrozole, anastrozole or exemestane? who are they only used in? how do they work? name three side effects, how long may they be given for in standard risk? in high risk?
iv) what is abemaciclib? how does it work? what is the main side effect?
v) how long is ademaciclib usually given for in high risk patients? what other treatment may it be given with?
i) tamoxifen - anti oestrogen (competes with oestradiol at ER level)
works in both pre and post meno women and had 30% reduction risk compared to placebo
ii) SE - hot flushes, arthralgia, mood change, vaginal discharge, VTE, endometrial cancer in 1% post meno patients
iii) aromatase inhibitors - switch off the production of oestrogens - only used in post meno women - block peripheral conversion of steroid precursors
SE - arthralgia, reduced bone density, inc risk of fractures
given up to 5 years for standard risk and up to 10 years for high risk
iv) abemaciclib is a CDK4/6 inhibitor
works by blocking the cell cucle without the toxicity of chemo
diarrhoea is the main side effects
v) give for two years with an aromatase inhibitor in high risk patients eg >3 positive nodes, T>5cm
TREATMENT FOR HER2 POSITIVE BREAST CANCER
i) what is herceptin aka? by what route is it given? how often for how long? what is it combined with for the first 3-4 months?
ii) what are the main SE of herceptin? what organ needs to be monitored? why?
iii) what drug can be added to trastuzumab in node positive patients? how is it given? what is a SE? what organ needs to be monitored?
iv) what is T-DM1? how is it given? name two side effects? what organ needs to be monitored?
v) how does trastuzumab work? how does pertuzumab work?
i) trastuzumab
given subcut every 3 weeks for 6-12 months
combined with chemo for the first 3-4 months
ii) usually no side effects
needs cardiac monitoring to detect asymp changes of LVEF
iii) pertuzumab can be added
given subcut every 3 weeks for.1 year
can cause diarrhoea
monitor cardiac function to det changes in LVEF
iv) T-DM1 is an antibody drug conjugate
given IV every 3 weeks in pts that have less than complete response after pre op chmeo
SE = fatigue and thrombocytopenia
need to monitor cardiac func
v) trastuzumab = binds to subdomain IV of HER2 and inhibits downstream signalling
pertuzumab binds to subdomain II of HER2 and inhibits ligand activated dimerisation
ANTIBODY DRUG CONJUGATES FOR HER2+ BREAST CANCER
i) what three things do ADCs consist of?
ii) what do they do? name two advantages of this?
iii) name two types
i) monoclonal antibody that targets the receptor eg HER2, stable linker, potent cytotoxic agent
ii) target tumour cells to deliver the cytotoxi agent specifically to cancer cells
advantages - minimise effects on normal tissue and reduce cytotoxic effects
iii) T-DM1, EnHerTu
ADJUVANT CHEMOTHERAPY
i) how are they usually given? which one is given orally?
ii) name two types of breast cancer chemo is given for
iii) how is potential resistance to treatment mitigated?
iv) name four main toxicities of treatment? what may happen in pre menopausal patients? when may this be desirable?
i) usually given IV
capecitabine is given orally
ii) used in triple negative and HER2+ breast cancer
iii) use combined or sequential regimens
iv) neutropenia, infections, alopecia, N+V, fatigue, neuropathy
may induce early menopause which can be desirable if ER+
BISPHOSPHONATES
i) which group of patients are they given to?
ii) what three things can they reduce the risk of?
iii) name two side effects of IV zolendronic acid? two side effects of ibandronic acid?
iv) which two supplements should be given alongside bisphos
i) post menopausal patients
ii) reduce risk of recurrence, death and fracture risk
iii) zolendronate - renal tox and osteonecrosis of the jaw
ibandronic - GI tox and osteonecrosis of the jaw
iv) give calcium and vitamin D supplements
PREDICT TOOL
i) what can it be used for?
ii) what chemo regimen is given to patients who have positive nodal disease after resection?
i) looks at how sucessful treatment may be for early invasive breast cancer after surgery
ii) FEC-D = 5FU, epirubicin, cyclo, docetaxel
SURGERY
i) name four indications for a masectomy? DCIS over what size?
ii) name four indications for wide local excision? DCIS under what size?
iii) what prognostic index can be used? what does it take into account? what output does it give?
i) multifocal tumour, central tumour, large lesion in a small breast, patient choice
DCIS >4cm
ii) solitary lesion, peripheral tumour, small lesion in large breast, choice
DCIS <4cm
iii) Nottingham prognostic index
takes into account LNs involved, tumour size and tumour grade
output is % 5 year survival
