Breast Cancer Flashcards by Kim Nguyen

Non-modifiable risk factors for BC

female, older age, FMH, PMH, genetics (BRCA1 and BRCA2), breast changes found on biopsy, ionizing radiation, breast density, early menarche (before age 12), late menopause (after age 55)

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Modifiable risk factors for BC

nulliparity or older age at first childbirth, postmenopausal HRT, postmenopausal obesity, physical inactivity, alcohol consumption

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BC patho: in situ BC

Stays within the lobular and ductal epithelium and doesn’t spread

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BC patho: invasiv BC

Spreads outside the epithelium to other parts of the body

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Clinical presentation of BC

May be asymptomatic if small
Palpable, painless mass
Breast/nipple pain
Nipple discharge, retraction, or dimpling
Skin changes- redness, warmth, edema
Swollen lymph nodes
Signs/symptoms of metastatic disease are dependent on the site of metastasis

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BC subtypes: hormone receptor positive (ER/PR+) features

Slower growing, more responsive to hormonal therapy

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BC subtypes: HER2 positive features

Grows faster than ER/PR+, due to overstimulation of the receptors that control cell growth and replication

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BC subtypes: triple negative (ER/PR/HER2 negative) features

Grows quickly, responds only to chemo

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BC staging

Uses TNM staging

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BC treatment: LCIS

No treatment, just regular monitoring

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BC treatment: DCIS

lumpectomy and radiation OR mastectomy +/- endocrine therapy

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Treatment for invasive BC

Surgery and radiation
Systemic therapy

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BC treatment: if you’re HER2+

You get HER2 therapy and chemo

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HER2+ chemo regimens

Docetaxel/carboplatin/trastuzumab +/- pertuzumab q3w x6 doses
Paclitaxel + trastuzumab qw x12 weeks

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Pertuzumab criteria

≥T2 or ≥N1, HER2 (+) tumor, high risk of recurrence

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HER2+ post-chemo regimens

continue trastuzumab or pertuzumab/trastuzumab to complete 1 year of treatment

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BC treatment: triple negative patients

CHEMO ONLY

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Triple negative chemo regimens: neoadjuvant therapy

pembrolizumab q3w x4 doses and weekly paclitaxel/carboplatin x12 doses → pembrolizumab and doxorubicin/cyclophosphamide q3w x4 doses

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Triple negative chemo regimens: adjuvant therapy

pembrolizumab q3w x9 doses, can also add capecitabine if didn’t receive complete response

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Hormone-positive BC: premenopausal women

Tamoxifen or aromatase inhibitor WITH ovarian suppression with an oophorectomy or LHRH agonist

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Hormone-positive BC: postmenopausal women

Aromatase inhibitor (preferred) OR tamoxifen (I guess)

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BC treatment: ER/PR+ but HER2- and the tumor is >0.5cm

Oncotype Dx to determine if you qualify for chemo

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BC chemo regimen: ER/PR+, HER2- and tumor is >0.5cm

Dose-dense doxorubicin/cyclophosphamide (AC) x4 doses → paclitaxel q2w x4 doses

Dose-dense AC x4 doses → weekly paclitaxel x12 doses

Docetaxel and cyclophosphamide (TC) q3w x4-6 doses

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Goal of therapy in Stage IV BC

palliation, prolongation of life, maximize QoL

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Endocrine therapy for MBC

Palbociclib (Ibrance) Ribociclib (Kisqali) Abemaciclib (Verzenio) Everolimus (Afinitor) Alpelisib (Piqray)

When to begin chemo in Stage IV BC

Failure of multiple endocrine manipulations, visceral crisis, patient is symptomatic, patient decision Good performance status needed

Stage IV BC treatment: Patients are HER2+ with MBC

Pertuzumab + trastuzumab + docetaxel or paclitaxel Fam-trastuzumab deruxtecan-nxki (Enhertu): Ab-drug conjugate Ado-trastuzumab emtansine (T-DM1) (Kadcyla): Ab-drug conjugate Sacituzumab govitecan-hziy (Trodelvy): Ab-drug conjugate Tucatinib + trastuzumab + capecitabine

Stage IV BC treatment: bone metastases

Bisphosphonates, denosumab

Pertuzumab, trastuzumab AEs

Cardiotoxicity (not dose-related and NOT reversible) Diarrhea with pertuzumab Infusion reactions

Pertuzumab, trastuzumab monitoring

ECHO and MUGA at baseline and q3months

Paclitazel, docetaxel AEs

Neuropathy (pace > doce) Alopecia Hypersensitivity reactions- infusion-related Arthralgias/myalgias Peripheral edema (docetaxel, use dexamethasone)

Doxorubicin AEs

Cardiotoxicity: dose-related and REVERSIBLE Red secretions/urine discoloration Secondary malignancy Vesicants- extravasation possible

Doxorubicin monitoring

ECHO or MUGA at baseline and q3months

Cyclophosphamide AEs

Hemorrhagic cystitis: significant bladder irritation due to the active metabolite acrolein Sterility

Tamoxifen AEs

Menopausal symptoms: hot flashes, night sweats, vaginal dryness Menstrual changes in premenopausal women Uterine/endometrial cancer VTE, stroke Pregnancy category D- avoid pregnancy

Tamoxifen DDIs

Avoid strong 2D6 inhibitors like fluoxetine, paroxetine, bupropion

Aromatase inhibitor drugs

Anastrozole, letrozole, exemestane

Aromatase inhibitor AEs

Menopausal symptoms Musculoskeletal symptoms: arthralgia, joint stiffness, bone pain Increased bone loss → osteoporosis/fractures Hypercholesterolemia CV risk

LHRH agonists

Gosrelin, leuprolide

Purpose of LHRH agonists

Ovarian suppression

Purpose of capecitabine

Used in triple-negative patients who haven't achieved pCR with neoadjuvant therapy

Purpose of ado-trastuzumab emtansine

Used in HER2+ patients who haven't achieved pCR with neoadjuvant chemo

Neratinib purpose

Used in HER2+ patients; don't have to be hormone positive if they're not

When to initiate neratinib

Completion of adjuvant trastuzumab (Use loperamide as prophy)

Olaparib purpose

BRCA-mutated cancer

Abemaciclib purpose

Hormone positive, HER2-, high-risk breast cancer Adjuvant therapy given with endocrine therapy

Bisphosphonate AEs

Osteonecrosis of the jaw, arthralgias, fever

Purpose of bisphosphonates in BC

Postmenopausal patients (zoledronate) Also helps in MBC to prevent skeletal-related events (SRE) and fractures, surgery, radiation, spinal cord compression

Cyclin-dependent kinase 4/6 inhibitors

Palbociclib, ribociclib, abemaciclib

Cyclin-dependent kinase 4/6 inhibitors purpose in BC

Hormone positive, HER2- MBC Used in combo with an aromatase inhibitor as initial endocrine therapy or fulvestrant with disease progression following endocrine therapy Abemaciclib can be used as monotherapy after progression following enodcrine therapy and prior chemo

Cyclin-dependent kinase 4/6 inhibitors AEs

Fatigue Neutropenia Anemia Alopecia

Cyclin-dependent kinase 4/6 inhibitors monitoring

Ribociclib and abemaciclib: monitor SCr and LFTs

mTORi in BC

Everolimus

Everolimus purpose in BC

Hormone positive, HER2- MBC in combo with exemestane or fulvestrant after failure of treatment with aromatase inhibitor

Everolimus AEs

Metabolic disturbances Pneumonitis Stomatitis Rash

PI3Ki drug

Alpelisib

Alpelisib purpose in BC

Hormone positive, HER2-, PIK3CA-mutated MBC in combo with fulvestrant

Alpelisib AEs

Hyperglycemia Skin rash Diarrhea Nausea Fatigue Increased SCr

Denosumab purpose in BC

Prevention of SREs in MBC

Denosumab AEs

Hypocalcemia Fatigue Dyspnea Osteonecrosis of the jaw