Breast Cancer Flashcards
Invasive Ductal Carcinoma
Characteristic “lump”
Metastatic sites: bone, liver, lung, brain
Invasive lobular carcinoma
Ill defined thickening of the breast
Metastatic sites: leptomeninges, peritoneal surfaces, retroperitoneum, GI tract, reproductive organs
Inflammatory breast cancer
characterized by skin edema, redness, warmth, and induration of underlying tissue
rapid onset
poor prognosis
Non-modifiable risk factors
Female
older age
family history
personal history
BRCA1 and BRCA2
breast changes found on biopsy
Ionizing radiation
breast density
early menarche (before 12)
late menopause (after 55)
Modifiable risk factors
first child after 30
postmenopausal HRT
postmenopausal obesity
physical inactivity
alcohol consumption
Tumor grade
cell differentiation
Grade 1 = normal looking cells
Grade 3 = very abnormal looking cells
Effect of tumor size on prognosis
tumor > 2 cm = poorer prognosis
Treatment for Lobular Carcinoma in situ (LCIS)
regular monitoring
no treatment
Treatment for Ductal carcinoma in situ (DCIS)
lumpectomy + radiation
mastectomy
+/- endocrine therapy
Treatment for invasive disease
Surgery and radiation
Mastectomy +/- radiation
Systemic therapy
- Chemo
- targeted therapy
- endocrine therapy
Treatment plan options:
ER/PR+ HER2+
Chemotherapy +
HER2 therapy +
Endocrine therapy +
Treatment plan options:
ER/PR+ HER2-
Chemotherapy +
Endocrine therapy
Treatment plan options:
ER/PR- HER2+
Chemotherapy +
HER2 therapy
Treatment plan options:
ER/PR- HER2-
Chemotherapy
Preferred Chemo Neoadjuvant/Adjuvant
HER2 (-) disease
Dose dense doxorubicin/cyclophosphamide x 4 doses -> paclitaxel every 2 weeks x 4 doses
Dose dense doxorubicin/cyclophosphamide x 4 doses -> weekly paclitaxel x 12 doses
Docetaxel and cyclophosphamide every 3 weeks x 4-6 doses
Preferred Chemo Neoadjuvant/Adjuvant
Triple negative
Neoadjuvant
- pembrolizumab every 3 weeks x 4 doses + weekly paclitaxel/carboplatin x 12 doses -> pembrolizumab + doxorubicin/cyclophosphamide every 3 weeks x 4 doses
Adjuvant
- pembrolizumab every 3 weeks x 9 doses
Preferred Chemo Neoadjuvant/Adjuvant
HER2 (+)
docetaxel/carboplatin/trastuzumab +/- pertuzumab every 3 weeks x 6 doses
Paclitaxel + trastuzumab weekly x 12 weeks
Pertuzumab criteria
> /= T2 or >/= N1
HER2 (+) tumor
High risk recurrence
HER2 targeted therapy
Pertuzumab
Trastuzumab
Pertuzumab
Inhibits HER2 dimerization
ADE:
- cardiotoxicity (reversible, not dose related)
- diarrhea (pertuzumab)
- infusion reactions
Monitor:
- ECHO at baseline then every 3 months during treatment
Must be co-administered with Trastuzumab
Trastuzumab
Inhibits HER2 dimerization
ADE:
- cardiotoxicity (reversible, not dose related)
- diarrhea (pertuzumab)
- infusion reactions
Monitor:
- ECHO at baseline then every 3 months during treatment
Can be given alone or with pertuzumab
Chemotherapy Agents
Taxanes (Paclitaxel/Docetaxel)
Neuropathy
Alopecia
Hypersensitivity reactions - infusion related
Arthralgias/myalgias
Peripheral edema (docetaxel)
- dexamethasone prevention
Chemotherapy Agents
Doxorubicin
ADE:
Cardiotoxicity (irreversible, dose related)
Red urine
Secondary malignancies
Extravasation
- give with port
Monitor:
- ECHO or MUGA at baseline and every 3 months throughout treatment
Chemotherapy Agents
Cyclophosphamide
ADE:
- Hemorrhagic cystitis
- sterility
Endocrine therapy agents
Tamoxifen
Aromatase inhibitors
Tamoxifen
MOA:
- Inhibits growth of tumors by competitively antagonizing estrogen at its receptor site
DDI:
- avoid strong CYP2D6 inhibitors: fluoxetine, paroxetine, bupropion
ADE:
- Menopausal sx
- Menstrual changes
- Uterine or endometrial cancer
- VTE, stroke
Avoid in therapy
Aromatase Inhibitors
MOA: inhibit/inactivate the enzyme that is responsible for the synthesis of estrogen
ADE:
- menopausal sx
- Musculoskeletal symptoms (arthralgia, joint stiffness, bone pain
- Osteoporosis/fractures
- Hypercholesterolemia
- CVD risk
Additional adjuvant therapy
Capecitabine
- Triple negative patients
Ado-trastuzumab emtansine
- HER2 (+)
Neratinib
- HER2 (+)
- use prophylactic loperamide
Olaparib
- BRCA +
Abemaciclib
- ER/PR (+), HER2 (-) high risk breast cancer
Zoledronic acid
- postmenopausal patients
Endocrine Therapy for Metastatic Disease
Palbociclib (Ibrance)
- MOA: CKD 4/6 inhibitor
- for ER/PR (+), HER2 (-) MBC
- ADE: fatigue, neutropenia, anemia, alopecia
Ribociclib
- CDK 4/6 inhibitor
- combo with AI as initial endocrine therapy or with fulvestrant as 2nd line therapy
- Monitor: QT interval and livr function tests
Abemaciclib
- CDK 4/6 inhibitor
- monitor: liver function tests and serum Cr
Everolimus
- MOA: inhibits mTOR
- for ER/PR (+), HER2 (-) MBC
- ADE: metabolic disturbances, pneumonitis, stomatitis, rash
Alpelisib
- MOA: PI3K inhibitor
- ER/PR (+), HER2 (-) PIK2CA mutated MBC
- given in combo with fulvestrant
- ADE: hyperglycemia, skin rash, diarrhea, nausea, fatigue, increased serum creatinine
Chemotherapy in MBC
indication:
- failure of multiple endocrine agents
- visceral crisis
- patient is symptomatic
- patient decision
MBC chemo therapy regimens
Preferred single agent
- doxorubicin
- paclitaxel
- capecitabine
- for triple negative or HR + -> sacituzumab govitecan-hziy
- for triple negative, PDL1 positive (pembrolizumab + chemo)
Combinations:
- Doxorubicin/cyclophosphamide
- Carboplatin/paclitaxel
- Gemcitabine/carboplatin
HER2 (+) MBC
Chemotherapy:
- pertuzumab + trastuzumab + [docetaxel-or-paclitaxel ]
Other agents:
- Fram-trastuzumab deruxtecan-nxki
- Ado-trastuzumab ematansine (T-DM1)
- Tucatinib + trastuzumab + capecitabine
MBC bone metastases treatment
Zoledronic acid
Pamidronate
Denozumab
