Breast Cancer Flashcards
What is the epidemiology of Breast Cancer?
- MOST common in woman
- 2nd MOST common cause of death
- INCREASES with age
What are some of the risk factors for Breast Cancer?
- Age:
- Family Hx: 1st & 2nd degree relatives
- Personal Hx
- Radiation: Prior treatment
- Estrogen Exposure
- Alcohol: Decrease metabolism of estrogen
- Prior Breast biopsies
- First child born
- Body Mass Index: adipose increases estrogen
In what way does genetics play a role in Breast Cancer?
- 5-10% are familial: BRAC 1 [stops DNA repair = increase cancer risk] & BRAC 2 [males]
What are the type of Breast Cancer?
- Invasive [ductal & lobular carinoma]
- Non-invasive [ductal & lobular in situ]
- Inflammatory
What is Invasive Breast Cancer?
- Has invaded beyond the basement membrane of the DUCT or LOBULE
- MOST common is DUCTAL
What is Non-Invasive Breast Cancer?
- Has NOT invaded beyond the basement membrane of the DUCT or LOBULE and is pre-malignant
What is Inflammatory Breast Cancer?
- RAPID onset and AGGRESSIVE form of Breast Cancer
- Signs: Edema, Redness, Warmth, Inflammation, Peau D’Ornage
What is the presentation of Breast Cancer?
- > 90% is painless BUT <10% can be stabby or achy
- 10% might be metastatic
What is FISH testing within Breast Cancer?
- Tests for HER2 by: Immunohistochemistry & FISH [if it detects gene amp]
What is Oncotype DX?
- A genetic test of 21 genes to see if you are likely to get Breast Cancer
- Low Risk < 26 = Hormonal Therapy
- High Risk > 26 = Chemo + Hormonal Therapy
What are some fo the sites of Metastasis in Breast Cancer?
- Bone, Liver, Lungs, Brain, Distant Lymph
What are some fo the modalities of treatment in Breast Cancer?
- Surgey, Radiation, Chemotherapy, Hormonal, Biologics, Immunorherapy
What are some of the general treatment strategies for Breast Cancer?
- Stage I, II, IIIA: GOAL is to CURE [Lumpectomy or Mastectomy +/- XRT; may get neoadjuvant or adjuvant treatment]
- Stage IIIB or IIIC: GOAL is to CURE [neoadjuvant + MRM/Lumpectomy & XRT]
- Stage IV: GOAL to stabilize/pallitate [Chemotherapy, Hormonal, +/- Biologics, +/- immountherapy…]
What are some of the Systemic Adjuvant Therapy regimens [Hormone +, Lymph +/-, HER2 -] for Breast Cancer?
- Small Tumor [<0.5] = Hormonal
- Large Tumor [>0.5] = 21 genes assay [if N/A: Hormonal or Chemo; if < 26: Hormonal; if >26 Chemo then Hormonal]
What are some of the Systemic Adjuvant Therapy Regimens [Hormone +, Lymph +/-, HER2 +] for Breast Cancer?
- Small Tumor [<0.5]: Hormonal +/- Chemo WITH HER2 Therapy
- Large Tumor [>0.5]: Chemo WITH HER2 Therapy
What are some of the Hormonal Therapies used in Breast Cancer?
- SERM
- GnRH Analogs
- Aromatase Inhibitors
What is the Selective Estrogen Receptor Modulators [SERM] used in Breast Cancer?
- Tamoxifen
What is important to know about Tamoxifen in Breast Cancer?
- Against [endometrial & Bones] and Antagonist [Breast]
PRE- & POSTmenopausal - Causes: Hot Flashes, DVT, Endometrial Cancer
What are the GnRHs used in Breast Cancer?
- Leuprolide & Goserelin
What is important to know about Leuprolide & Goserelin in Breast Cancer?
- Cause MAJOR release of LH and FSH = inhibition of LH and FSH = inhibition of estrogen
- POSTmenopausal
What are the Aromatase Inhibitors that are used in Breast Cancer?
- Anastorzole and Letrozole [Non-steroidal]
- Exementane [Steroidal]
What is important to know about Hormonal Therapy in PREmenopausal Breast Cancer?
- Tamoxifen x 5y +/- OS OR AI x 5y + OS
- PRE: Tamoxifen x 5y to = 10y
- POST: AI x 5y to = 10y OR Tamoxifen x 5y to = 10
What is important to know about Hormonal Therapy in POSTmenopausal diagnosis of
Breast Cancer?
- AI x 5y THEN AI x 5y OR
- Tamoxifen x 2-3y THEN AI to = 5y OR
- Tamoxifen x 4-6y THEN AI x 5y or Tamoxifen x 5y to = 10y
What are some of the most common chemotherapy agents that are used as adjuvant therapy?
- Doxorubicin, Epirubicin, Cyclophosphamide, Methotrexate, 5-FU, Carboplatin, Paclitaxel, Docetaxel
What are the two Adujvant Chemotherapy Regimens that are used in HER2 - Breast Cancer?
- Dose Dense AC –> Paclitaxel
- TC
What is in Dose Dense AC –> Paclitaxel in HER2 - Breast Cancer?
- Doxorubicin [60mg/m2], Cyclophosphamide [600mg/m2] repeating every 14 d x4 [MUST BE GIVEN GROWTH FACTOR]
- Followed by: Patlitaxel [175mg/m2] every 14d x 4
What is important to know about the Dose Dense AC –> Paclitaxel in HER2- Breast Cancer?
- Doxorubicin = Cardiotoxicities
- Cyclophosphamide = Nephrotoxicities
- Paclitaxel = Neurotoxicites
What is in TC in HER2 - Breast Cancer?
- Docetaxel [75mg/m2], Cyclophosphamide [600mg/m2] repeating every 21d x4 [MUST BE GIVEN GROWTH FACTOR]
What is important to know about TC in HER2- Breast Cancer?
- CAN be used in a patient that has Heart related issues [no doxorubicin]
What is the CALBG trail?
- It shoed the importance of dose density VS chemptherapy [basically what the Dose Dense AC –> Paclitaxel is]
When giving Paclitaxel to a patient, what should they recieve as pre-medication and why?
- Dexamethasone, Antihistamine, H2 Blocker
- BECAUSE: causes hypersensitivity reaction with Cremophor
What are the three Adjuvant Chemotherapy Regimens for HER2+ in Breast Cancer?
- APT
- TCH
- TCH + Pertuzumab [Best one]
What is in APT for HER2+ Breast Cancer?
- Paclitaxel [80mg/m2], Trastuzumab [4mg/kg with first dose]
- Followed by: Trastuzumab [2mg/kg x11w –> 6mg/kg every 3w to =1y]
What is in TCH for HER2+ Breast Cancer?
- Docetaxel [75mg/m2], Carboplatin, Trastuzumab [8mg/kg] repeating every 21d x6
- Followed by: Trastuzumab [6mg/kg every 21d to = 1y]
What is in TCH + Pertuzumab in HER2+ Breast Cancer?
- Docetaxel [75mg/m2], Carboplatin, Trastuzumab [8mg/kg], Pertuzumab [840mg] repeating every 21d x6
- Followed by: Trastuzumab & Pertuzuamb to = 1y
What was the trail that show the effectiveness of Traztuzumab & Pertuzuamb together?
- HERA [Herceptin Adjuvant Trail]
- STANDARD OF CARE
What is residual disease in Breast Cancer?
- Any invasive Breast Cancer that remains in the body after therapy
What would you use in a patient that has Residual Disease in Breast Cancer?
- IF has: Ado-Trastuzuamb Emtansine [TDM1]
- IF no: Trastuzumab +/- Pertuzumab for 1y
What is Triple Negative Breast Cancer?
- ER-
- PR-
- HER2-
What are the Adjuvant Chemotherapy Regimens for Triple Negative Disease in Breast Cancer?
- AC –> Paclitaxel with Pembrolizumab
What is in AC –> Paclitaxel for Triple Negative Breast Cancer?
- Doxorubicin [60mg/m2] Cyclophosphamide [600mg/m2], Pembrolizumab [200mg] repeating for 21d x4
- Followed by: Paclitaxel [80mg/m2] with Pembrolizumab [200mg] every 3w to = 1y
EXAMPLE: if a patient was HER2+ what chemotherapy regimen would be given?
- Trastuzuamb + Pertuzuamb, Carboplatin, Doxetaxel
- IF RESIDUAL = Ado-traztuzuamb emtansine
What is the goal of metastatic disease?
- GOAL is Palliation
- If symptomatic = Chemotherapy
How do we decide what to give to a patient with Metastatic Breast Cancer?
- Hormonal: ER/PR+, Slow growth, Prior Therapy, Bone ONLY
- Chemotherapy: ER/PR-, Fast Growth, Cant do Hormonal
What are some of the options for Chemotherapy in Metastatic Breast Cancer?
- Single VS Combo
- TNBC
- PD-L1?
- HER2+
- BRAC?
What are the most common Single Agents that are used in Metastatic Breast Cancer?
- Doxorubicin, Paclitaxel
What is the HER2+ targeted regiemen for Metastatic Breast Cancer?
- Tratuzuamb, Pertuzumab, Docetaxel
What is the NEW Chemotherapy + HER2 treatment for Metastatic Breast Cancer?
- Fam-trastuzumab Deruxtecan-nxki
In what setting is Fam-trastuzumab Deruxtecan-nxki used?
- HER2 Low Patients [when HER2 expression is +1 or +2]
What is important about using Fam-trastuzumab Deruxtecan-nxki?
- DESTINY-Breast04: show 12.1% Lung Disease???
What is the recommended treatment for Metastatic Triple Negative Breast Cancer?
- Platinum Agents [Carboplatin or Cisplatin]
What are some of the Hormonal Therapies that are used in Metastatic Disease?
- 1st Line: AI + CDK4/6 Inhibitor
- 2nd Line: Fulvestrant + CDk4/6 Inhibitor OR Everolimus + Endocrine Therpay
What is the role of Cyclin Dependent Kinases?
- Promote G1 to S phase transition by phosphorylating the retinoblastoma
- CDK4/6 are activated in ER+
What are the CDK4/6 inhibitors that are used in Metastatic Breast Cancer?
- AbemaCICLIB, PalboCICLIB, RiboCICLIB
What are the important monitoring Parameters for the CDK4/6 Inhibitors in Metastatic Breast Cancer?
- Complete Blood Counts
- Diarrhea [Abemaciclib]
- QTc Prolongation [Ribociclib]
EXAMPLE: if a patient has eatly stage TNBC, what would be the chemotherapy course?
- AC –> Paclitaxel + Pembro
- Doxorubicin, Cyclophosphamide, Pembrolizumab repeatin 21d x4 THEN Paclitaxel + Pembrolizumab every 3w
EXAMPLE: Women with early stage, ER/PR-, HER2+ disease, what is the chemotherapy course?
- THC+P
- Docetaxel, Carboplatin, Trastuzumab, Pertuzumab repeating 21d x4 THEN Trastuzumab + Pertuzumab
EXAMPLE: Women has early stage, ER/PR+, HER- disease, what is the chemotherapy course?
?
EXAMPLE: What is the 1st line treatment for ER/PR+, HER2- metastatic disease?
- AI + CDK4/6 inhibitor [monitor for ~2 months]
EXAMPLE: what is the treatment for HER2+, ER/PR- metastatic disease?
- Docetaxel, Pertuzumab, Trastuzuamb [every 3w]
