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Oncology boards > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

What is the keynote-522 regimen?

A

carbo/taxol (TC) + pembrolizumab, followed by doxorubicin/cyclophosphamide (AC)

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1
Q

Adjuvant treatment of DCIS

A
  • None if mastectomy
  • ET after BCT is a risk/benefit discussion given no proven OS benefit.
    IF ER+ (PR doesn’t matter) AND premenopausal → tamoxifen 20 mg daily for 5 years
    IF ER+ and postmenopausal –> AI for 5 years
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2
Q

Class effects of CDK4/6 inhibitors

A
  • Fatigue
  • Myelosuppression
  • Pneumonitis (2%)
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3
Q

Abemaciclib SE to know

A
  • GI toxicity (nausea, diarrhea)
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4
Q

Schedule of CDK4/6 inhibitors

A

Abemaciclib is continuous, others are given 3 weeks on 3 weeks off

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5
Q

CDK4/6 inhibitor with good CNS penetration

A

abemaciclib

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6
Q

CDK4/6 inhibitor with demonstrated OS benefit

A

ribociclib

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7
Q

Clinical significance of RB1 gene mutation

A

Confers resistance to CDK4/6

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8
Q

Second line for ER PR + breast cancer patient with PI3k gene mutation

A

alpelisib + fulvestrant

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9
Q

Second line for ER PR + breast cancer patient with ESR1 gene mutation

A

elacestrant

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10
Q

Second line for ER PR + breast cancer patient with AKT1 or PTEN

A

fulvestrant + capivasertib

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11
Q

First line for HER2 positive breast cancer

A

Trastuzumab + pertuzumab + taxane (THP or DHP)

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12
Q

Second line for HER2 positive

A

T-Dxd

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13
Q

What is T-Dxd conjugated to?

A

Topoisomerase I

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14
Q

Third line for HER2 positive

A

IF no brain mets, T-DM1 (Preferred – Well tolerated. Used to be standard second line) (TH3ERESA – PFS 6.2, OS 22.7)
Given brain mets, tucatinib/capecitabine/trastuzumab (HER2CLIMB - median OS 21.9 months, Preferred if CNS disease because only Phase II data for T-DxD and proven OS benefit)

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15
Q

margetuximab mechanism

A

HER2 ADC

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16
Q

First line for metastatic TNBC

A
  • Given PD-L1 CPS>10% AND absence of rapidly progressive visceral disease, pembrolizumab for up to 2 years + chemotherapy (taxol vs. abraxane vs. gem/carbo) – (KEYNOTE-355 – mOS 23, mPFS 9.7 months)
  • Given PD-L1 negative AND absence of rapidly progressive visceral disease, single agent chemotherapy
    ***Given extensive and rapidly progressive visceral disease (diffuse, aggressive disease), combination chemotherapy (taxane vs carbo/gem preferred - but no proven OS benefit w/ combination)
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17
Q

Second line for metastatic TNBC

A
  • sacituzumab
  • IF HER2 low, T-DxD also an option
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18
Q

Third line for metastatic TNBC

A

Given BRCA+, olaparib (OlympiAD)
Single agent chemo
IF no neuropathy, Abraxane
Doxil
Gemcitabine

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19
Q

CPS threshold for TNBC first line addition of immunotherapy

A

10

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20
Q

most common localized breast cancer in terms of receptor phenotype

A

ER PR +

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21
Q

When it is ok to defer radiation

A
  • Over age 65 + less than 3 cm + node negative + ER positive (can just have adjuvant endocrine)
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22
Q

Other indications for adjuvant radiation to chest wall (if undergoing mastectomy)

A

*greater than 5 cm
*close margins (less than 1 mm)
- positive lymph nodes
- positive margins

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23
Q

Indications for neoadjuvant systemic therapy in node negative breast cancer

A

1) Inoperable (Need to shrink tumor to permit BCT or better cosmetic outcome with BCT)
2) Desires BCT but is not a candidate for BCT (Conversion chemotherapy (make operable))
3) Unlikely to have a good cosmetic outcome with BCT (Due to tumor location or size relative to patient’s breast)
Eg. high tumor: breast size ratio
4) Delay in definitive surgery
5) Downstage from limited N1 to N0 (could be candidate for sentinel lymph node biopsy if converted to node-negative with neoadjuvant)
6) Inflammatory breast cancer
7) Select operable breast cancer:
HER2 and TNBC if >cT2

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24
Q

What is ACT

A

Doxorubicin
Cyclophosphamide
Taxol

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25
Q

Sequencing of chemo vs. radiation adjuvantly for localized breast cancer

A

Adjuvant chemo is completed before starting XRT (IF no neoadjuvant received) (but institution dependent. decrease risk of radiation recall).

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26
Q

neoadjuvant regimens for TNBC

A

ACT
TC
CMF

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27
Q

What is CMF

A

cyclophosphamide
Methotrexate
5-Fu

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27
Q

When you can give TC rather than ACT

A

small node negative
(low risk (<1cm AND node negative OR cardiac RF’s))

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28
Q

TC?

A

Taxol
Cyclophosphamide
*but seems also used to refer to taxol carboplatin in breast cancer

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29
Q

Indication for neoadjuvant for TNBC based on size (confirm)

A

Greater than 0.5 cm

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30
Q

Endocrine therapy for men with breast cancer

A

tamoxifen

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31
Q

When you can omit adjuvant chemo in ER/PR + breast based on oncotype

A
  • oncotype less than 26 + over the age of 50
  • less than 50 (premenopausal)
    IF node positive, chemo regardless of score (there was a subset analysis showing benefit but thought to be from ovarian suppression from chemo)
    IF node negative, no chemo if <16 (some benefit for intermediate risk)
    *just think of as premenopausal only if node negative and <16
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32
Q

Tamoxifen SE’s

A
  • increased risk of endometrial cancer
  • increased arterial and VTE risk
  • *cataracts
  • menopausal symptoms
  • weight gain
  • hepatic steatosis
    *photosensitivity
    *bone strengthening but has been shown to cause bone density loss in some women
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33
Q

AI SE’s

A
  • vaginal dryness
  • osteoporosis
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34
Q

management of AI induced arthralgias (aside from medication switch)

A
  • duloxetine
  • exercise
  • acupuncture
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35
Q

Tamoxifen contraindicated with what medication?

A
  • certain SSRI’s - duloxetine or paroxetine
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36
Q

How can you reduce risk of infertility in women after chemo?

A

GNRH agonists - triptorelin, goserelin

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37
Q

Size cutoff for withholding systemic therapy for HER2

A

0.5 cm

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38
Q

Size threshold in HER2 disease for which you can use TH (taxol herceptin)

A

Less than 2 cm

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39
Q

Herceptin contraindication

A

pregnancy

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40
Q

Management of residual disease after neoadjuvant for HER2+ breast cancer

A

T-DM1

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41
Q

Management of localized inflammatory breast cancer

A

Neoadjuvant systemic therapy
Mastectomy w/ axillary nodal dissection

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42
Q

Contraindications in management of breast cancer during pregnancy 1) chemo? 2) endocrine therapy?

A
  • herceptin
  • CT scans and nuclear imaging
  • chemo can be used in second trimester but ideally postpartum
  • XRT
  • endocrine therapy
    *no axillary nodal dissection since can’t get XRT
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43
Q

locoregional recurrence management in breast cancer

A
  • mastectomy w/ axillary nodal dissection
  • radiation if not previously done
  • if TNBC adjuvant chemo per CALOR trial (not indicated if HR+)
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44
Q

Genetic syndromes associated with increased risk of breast cancer

A

BRCA1-2
PALB2
PTEN
ATM
CHEK2
P53
STK11
SDH1

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45
Q

Other

A
  • Thoracic XRT
  • ALH/ADH (atypical lobular and atypical ductal hyperplasia)
  • Older age
  • *early menarchy
  • late menopause
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46
Q

When to start screening for breast cancer in patients with history of thoracic breast radiation

A

30 or 8 years after completion of radiation

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47
Q

Breast cancer screening age now

A

40

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48
Q

When to start screening BRCA patients

A

MRI + mammo starting at age 25
*high yield

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49
Q

LCIS management

A
  • surgery +/- endocrine therapy depending on menopausal status (similar to DCIS)
    *No XRT
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50
Q

Margin required in DCIS

A

2 mm

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51
Q

When endocrine therapy is indicated in DCIS

A

lumpectomy, NOT with mastectomy

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52
Q

Clinical benefit of ET for DCIS

A
  • reduces risk of ipsilateral and contralateral breast cancer recurrence
    *no effect on OS
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53
Q

phylodes tumor management + margin size requirement

A
  • surgery alone
    *with larger margins (>1 cm)
    *hormone therapy is not effective
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54
Q

metastatic phylodes tumor management

A

taxane based chemo

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55
Q

Contraindications to BCT

A
  • diffuse calcifications
  • multifocal disease
  • grossly positive margins
    *homozygous ATM
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56
Q

Positive lymph node in breast cancer

A

0.2 mm or greater or >200 cells

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57
Q

Axillary lymph node dissection indications

A

1) More than 2 positive sentinel lymph nodes on SLNB
2) Clinically palpable axillary lymph node
3) Positive FNA
4) inflammatory breast cancer
5) pregnancy

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58
Q

What is the HER2 climb regimen?

A

tucatinib/capecitabine/trastuzumab

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59
Q

Management of clinically node positive ER+ breast cancer?

A
  • Neoadjuvant downstaging chemo (eg ACT) w/ goal of downstaging axilla to prevent axillary nodal dissection
  • surgery
  • adjuvant endocrine therapy
60
Q

CDK4/6 inhibitor mechanism

A
  • Cause cell cycle arrest in G1 phase (not cytotoxic)
61
Q

When abemaciclib is indicated in addition to endocrine therapy adjuvantly

A

4 or more positive axillary lymph nodes
or 1-3 nodes with tumor > 5cm, G3, or Ki-67 > or equal to 20%

62
Q

aromatase inhibitors

A

anastrozole
letrozole
exemestane

63
Q

First line for metastatic ER positive breast cancer - 1) postmenopausal 2) premenopausal

A

Given postmenopausal,
AI + CDK4/6 inhibitor
Given premenopausal,
Ovarian suppression w/ AI + GNRH concurrently

64
Q

palbociclib SE to know

A

neutropenia

65
Q

alpelisib SE’s to know

A
  • rash
  • hyperglycemia
66
Q

Indication for dexrazoxane in patient with doxorubicin

A

cumulative dose > 300 mg/m2

67
Q

First line for HER2 positive metastatic breast cancer

A

Trastuzumab + pertuzumab + taxane (THP or DHP) (docetaxel vs. paclitaxel)

68
Q

sacituzumab SE’s

A
  • neutropenia
  • diarrhea
  • fatigue
69
Q

Management of residual disease in TNBC

A

capecitabine

70
Q

Neoadjuvant systemic therapy for HER2+

A

Trastuzumab/pertuzumab + nonanthracycline based chemo (TCHP)

71
Q

Neoadjuvant systemic therapy for triple positive breast cancer

72
Q

management of residual disease in HER2 positive breast cancer

73
Q

Chemo that is okay to use in pregnant breast cancer patient

A

doxorubicin, cytoxan, 5-FU (FAC)

74
Q

Lymph node threshold for requiring adjuvant chemo in ER/PR positive breast cancer

A

4 or more always need chemo

75
Q

genetic syndromes associated with breast cancer

A

BRCA1/2
PALB2
PTEN/coden
CHEK2
Li fraumeni
Peutz jeghers
CDH1

76
Q

1) other breast cancer RF’s 2) protective factors

A

*ALH/ADH
- DCIS/LCIS
- early menarchy (earlier estrogen exposure)
- late menopause (longer period of time for estrogen exposure)
- older age
*lower age at first childbirth, having more children, breastfeeding are protective.

77
Q

Gail model cutoff for high risk (when risk reduction is indicated)

A

Greater than 1.7

78
Q

DCIS management if mastectomy

A

sentinel lymph node biopsy (in case pathology reveals invasive disease)

79
Q

High risk breast patients that are indicated for chemoprevention

A

ADH
ALH
LCIS/DCIS
strong family history
Gail >1.7%

80
Q

raloxifene 1) approval 2) SE caveat to know

A

1) only approved in postmenopausal women
2) does not increase risk of endometrial cancer

81
Q

DCIS other nomenclature

82
Q

BRCA1 breast cancer typical phenotype

A

Triple negative

83
Q

Management of tamoxifen in woman wishing to become pregnant

A

Stop and resume after pregnancy (teratogenci)

84
Q

ADH management

A
  • excision
  • no adjuvant XRT required
85
Q

Effect of hormonal IUDs on breast cancer risk

86
Q

Management of axillary recurrence of hormone receptor positive breast cancer

A
  • excision and axillary node dissection, followed by XRT
87
Q

Management of woman with lumpectomy and 1+ lymph node with HR positive disease and 21 gene assay of 21

A
  • Whole breast radiation, then AI for 5-10 years (RxPonder showed recurrence score fo 25 or lower in setting of N1 in postmenopausal does not benefit from adjuvant chemo)
88
Q

LCIS management

A

*Depends on subtype
IF classic LCIS, observation with imaging follow-up
IF pleomorphic and florid types, surgery

89
Q

Clinical benefit of biosphosphonates

A
  • reduced distant recurrence risk
    *reduced breast cancer mortality
    *benefits primarily seen in postmenopausal women
90
Q

PD-L1 status for KEYNOTE regimen

A

irrespective of PD-L1

91
Q

RF’s for breast angiosarcoma

A
  • radiation
  • chronic arm or breast edema
92
Q

Premenopausal adjuvant ET

A

ovarian suppression (GNRH agonist - zoladex q 3 months) + aromatase inhibitor or tamoxifen
***AI preferred

93
Q

Eligibility criteria for adjuvant PARP for BRCA1 pts

A
  • pT2 or pN1 (eg node positive)
94
Q

Role of PARP in metastatic setting for TNBC patients

A

second line as monotherapy

95
Q

Recurrent metastatic HER2 breast cancer management

A

IF treated w/ taxane TCHP neoadjuvantly AND recurrence <6 months, T-DxD (directly to enhertu)
IF recurrence >6 months after adjuvant (including if T-Dm1 received), taxane + trastuzumab/pertuzumab (See de novo metastatic, recurrent metastatic enrolled in trial)

96
Q

Radiation recall dermatitis clinical features

A
  • inflammatory skin reaction during or after chemo in an area previously irradiation
    **Can be a long time after radiation
97
Q

Management of radiation recall dermatitis

A
  • dose reduction or interruption of culprit agent
  • steroids
98
Q

Neoadjuvant for locally advanced HR+ and HER2+ breast cancer

99
Q

First imaging modality for breast mass in a woman under 30

100
Q

Risk of local recurrence with and without radiation in old women with early stage HR+ breast cancer

A
  • 10% without radiation
  • 2% with radiation
101
Q

Management post surgery of woman with LCIS or ADH in 45 year old

A

Chemoprevention with tamoxifen 5 mg for 3 years (data now supporting lower dose)

102
Q

Next step after core needle biopsy reveals ADH

A
  • excisional biopsy (rule out DCIS or invasive carcinoma)
103
Q

When risk reducing bilateral salpingo-oophorectomy is indicated in BRCA patients

A
  • age 35-40 and when childbearing no longer desired
104
Q

Metastatic pattern of lobular breast cancer

A

serosa, ovaries, meningies, and GI tract (peritoneum and GI tract)

105
Q

IHC stain for pembro in metastatic TNBC

106
Q

Pathognomic finding for inflammatory breast cancer

A
  • dermal lymphovascular tumor emboli on a punch biopsy
107
Q

Essential feature of inflammatory breast cancer to differentiate vs locally advanced breast cancer

A
  • symptom duration of no more than 5 months (rapid onset) (locally advanced breast cancer that is neglected for a long time can have shared features)
108
Q

Management of HR+ locally recurrent breast cancer in the lumpectomy bed that is node negative

A

Adjuvant ET
NO chemo

109
Q

Systemic therapy for pregnant pt with triple positive breast cancer

110
Q

Clinical benefit of adjuvant ET in DCIS

A
  • reduces risk of ipsilateral recurrence and contralateral breast cancer
  • no benefit in OS
111
Q

Has oncotype been validated in men?

A

Yes, apparently

112
Q

Indication for olaparib in adjuvant setting for BRCA patients

A

*residual disease following neoadjuvant

112
Q

Bisphosphonate of choice in women on adjuvant AI + dosing

A

Zoledronate 4 mg IV once every 6 months for 2 years

112
Q

Management of breast adenoid cystic carcinoma

A
  • local therapy alone (mastectomy or BCT)
113
Q

Clinical benefit of bisphosphonates in breast cancer

A
  • decreased risk of bone mets
  • small but significant OS benefit with zoledronate
114
Q

Management of locally recurrent TNBC

A

Surgery w/ *adjuvant chemo

115
Q

Breast papilloma management

A

Observation
IF high risk features (atypia or ductal hyerplasia), surgical excision

116
Q

Preferred staging for pregnant breast cancer patients

A
  • CXR w/ abdominal shielding and liver ultrasound
117
Q

Neoadjuvant for CT1NO triple-negative breast cancer

A
  • dose dense AC-T
118
Q

Inclusion criteria for KEYNOTE for TNBC

119
Q

Only chemoprevention with demonstrated OS in BRCA patients

A

bilateral salpingo-oophorectomy

120
Q

Recommended means of preserving fertility in breast

A

GnRH analogue every 28 days starting 2 weeks before chemo
*Embryo freezing can only be done with a fertilized egg and delays start of chemo

121
Q

Preferred first line for triple positive metastatic breast

122
Q

Adjuvant management of HER2+ breast cancer with pathCR

A

trastuzumab + pertuzumab to complete 12 months of HER2-directed therapy

123
Q

Hypofractionated vs. conventional whole breast irradiation

A

hypofractionated better and correct answer per boards

124
Q

When continuation of endocrine therapy is indicated + duration

A
  • high risk, node positive
  • 10 years total
125
Q

CHEK2 guidelines for cancer screening

A
  • colonoscopy starting at age 40
  • annual breast
126
Q

Adjuvant management of tubular carcinoma

A

Endocrine therapy alone

127
Q

Recommended breast cancer staging modalities per boards

A

CT torso
*NOT pet

128
Q

Firstline for metastatic TNBC that is PD-L1 negative and BRCA mutant

129
Q

Breast angiosarcoma management

A
  • upfront wide local excision
    IF locally advanced, neoadjuvant w/ taxol
130
Q

How to reduce risk of lymphedema in node positive patients

A
  • still need radiation to the regional lymph nodes (axillary dissection is what increases risk of lymphedema0
131
Q

management of axillary recurrence of TNBC

A

neoadjuvant or adjuvant chemo and axillary lymph node dissection

132
Q

Do OCP’s increase risk of breast cancer

A

Yes, should be stopped in high risk women

133
Q

When is systemic imaging required in breast cancer

A

1) Stage I and II if other concerning symptoms
2) Stage III

134
Q

Recommended systemic imaging for stage III

A

CT torso + bone scan

135
Q

Clinical benefit of adjuvant XRT for DCIS

A
  • NO OS benefit
136
Q

When breast cancer index is indicated

A
  • hormone receptor positive
  • negative lymph nodes or 1-3 positive
137
Q

First line for HR+ breast cancer

A

*Remember that it’s chemo if in visceral crisis

138
Q

Role of bisphoshonates in adjuvant setting for women on hormonal therapy

A

*zometa specifically
- indicated for postmenopausal women and women on GNRH agonist + AI (medical menopause) regardless of baseline bone density because there is a survival benefit

139
Q

Adjuvant management of node positive TNBC pt with pathCR after mastectomy

A

***still needs radiation given node positive disease despite mastectomy

140
Q

Paget disease clinical features

A
  • scaly, raw, vesicular, or ulcerated lesion that begins on the nipple and then spreads to the areola (picture 1). Occasionally, a bloody discharge is present. P
141
Q

First step in Paget’s management

A

breast imaging (often associated with carcinoma in situ)

142
Q

Indication for chemo in early stage TNBC

A

0.5 cm (remember that small tumors, stage I) still need adjuvant because TNBC is aggressive

143
Q

Definition of premenopausal for adjuvant ET

A

amenorrheic for 12 months

144
Q

Next line of therapy for progression on adjuvant endocrine therapy

A

IF progression >12 months from end of ET, first line AI + CDK4/6
IF progression within 12 months, subsequent line ET + CDK4/6 (So if progression on AI, fulvestrant + CDK4/6)

145
Q

Medullary breast cancer management

A

neoadjuvant indications same as triple negative
- surgical management the same

146
Q

Age at which germline testing is indicated for breast cancer

A

Younger than 50

Oncology boards (41 decks)

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