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Solid Tumor Oncology > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

First line management for metastatic ER+ breast cancer

A

CDK 4/6 inhibitor + AI

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2
Q

Only CDK 4/6 inhibitor that is approved for monotherapy in the metastatic setting?

A

Abemaciclib

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3
Q

Which CDK4/6 inhibitor has the least incidence of neutropenia?

A

Abemaciclib

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4
Q

Fulvestrant is approved in first line metastatic breast cancer. It is most efficacious in what population?

A

Those without visceral metastases

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5
Q

What CDK4/6 inhibitor(s) have OS benefit in metastatic setting?

A

Ribociclib
and abemaciclib

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6
Q

You have a patient with ER+ metastatic breast cancer, previously treated with with anastrozole and develops progression. No comorbidities. What is best treatment option?

A

CKD4/6 inhibitor + Fulvestrant

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7
Q

Which CDK4/6 inhibitor has good CNS penetration?

A

Abemaciclib

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8
Q

Which CDK4/6 inhibitor has QTc prolongation?

A

Ribociclib

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9
Q

Which CDK4/6 inhibitor causes the most N/V/D?

A

Abemaciclib

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10
Q

What is the difference in treatment schedule between the CDK4/6 inhibitors?

A

Ribo and Palbo are 3 weeks on, 1 week off.
Abemaciclib is continuous

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11
Q

2nd line treatment for metastatic ER+ breast cancer without any targeted mutations?

A

Everolimus + Exemestane

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12
Q

2nd line treatment for metastatic ER+ breast cancer for those with PIK3CA mutations?

A

Alpelasib + fulvestrant

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13
Q

Second line treatment for ER+ metastatic breast cancer who develop ESR1 mutation?

A

Elacestant

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14
Q

SEcond line treatment for metastatic ER+ breast cancer who has a PTEN, PIK3CA, or AKT mutation?

A

Capivasertib + Fulvestrant

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15
Q

First line treatment for HER2+ metastatic breast cancer

A

THP
Docetaxel
Herceptin
Pertuzumab

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16
Q

SEcond line therapy for metastatic HER2+ breast cancer

A

Trastuzumab dereuxtecan

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17
Q

Third line therapy for HER2+ metastatic breast cancer

A

Trastuzumab emtansine TDM-1

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18
Q

Most significant toxicity seen with trastuzumab deruxtecan

A

Pneumonitis

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19
Q

Third line treatment(+) for HER2+ metastatic breast cancer, for those with CNS mets

A

Capecitabine, Tucatinib, Trastuzumab

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20
Q

Patient with metastatic HER2+ breast cancer previously treated with THP, Enhertu, TDM1, and Cape+Tucatinib+Trastuzumab. What are options for next line? (3)

A

Neratinib + Capecitabine
Margetuximab + Chemotherapy
Lapatinib + Chemo

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21
Q

You have a patient with triple positive metastatic breast cancer. You start them on THP. What else can you add for treatment?

A

AI. Don’t add CDK4/6 inhibitor

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22
Q

You have a patient with HER2+ metastatic breast cancer and are treating with THP. They have a BRCA1 mutation and ask about olaparib. can you use it?

A

Not with THP, hasn’t been studied

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23
Q

First line for metastatic TNBC with PD-L1 CPS >=10

A

Pembrolizumab + Chemo (Gem+Carbo or taxane)

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24
Q

First line for metastatic TNBC and PD-L1 CPS <10

A

Single agent chemotherapy
Taxanes, anthracyclines, gem+carbo

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25
Q

Third line treatment for metastatic TNBC who progressed on Chemo+Pembro and another chemo line.

A

Sacituzumab govitecan

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26
Q

Treatment options for patients with HER2- metastatic breast cancer with BRCA1/2 mutation?

A

Olaparib
Talazoparib

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27
Q

What is the indication for Enhertu in the HER2 low setting?

A

1-2 prior lines of chemo in the metastatic setting

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28
Q

Ways to stage a pregnant patient with breast cancer?

A

CXR with fetal shielding
RUQ US
Suspicious nodal disease: Axillary US and FNA
Avoid bone scans, breast MRI

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29
Q

What 4 breast cancer treatments is contraindicated during the entirety of a pregnancy?

A

Radiation
Methotrexate
Trastuzumab (oligohydramnios)
Endocrine therapy

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30
Q

You have a pregnant patient with new diagnosis of breast cancer and needs chemotherapy. When do you need to avoid chemo?

A

In first trimester and
Avoid after week 35 to avoid neutropenia during delivery

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31
Q

For ER+ male breast cancer, what consideration needs to be made for endocrine therapy?

A

If using an AI, need to use GnRH agonist.
Most use tamoxifen

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32
Q

You see a patient with 2 cm ER- PR- pure tubular carcinoma, Grade 3. What is the next step?

A

Repeat markers. Because tubular is a favorable histology and is almost never ER/PR negative

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33
Q

Adjvuant Treatment for <1 cm ER/PR+ tubular or mucinous breast cancer

A

No adjuvant treatmen

34
Q

Adjuvant treatment for >3 cm ER+ tubular or mucinous breast cancer

A

Endocrine therapy

35
Q

What 4 breast cancer chemotherapy regimens are at high risk of causing neutropenic fever (>20%)

A

ddAC-T
ACT
TC
TCH-P

36
Q

How to manage grade 1-2 neutropenia associated with CDK4/6 inhibitors? How do you classify G1-2 neutropenia?

A

ANC 1000 to LLN
Hold drug until recovery, no dose adjustment

37
Q

How to manage grade 3 neutropenia associated with CDK4/6 inhibitors? How do you classify G3 neutropenia?

A

ANC 500-1000
Hold Ribo until recovery above 1000, then resume at same dose. If recurrent, then dose reduce

38
Q

How to manage grade 4 neutropenia associated with CDK4/6 inhibitors? How do you classify G4 neutropenia?

A

ANC <500
Stop Ribo until ANC >1000, then resume at lower dose

39
Q

How to manage neutropenic fever associated with CDK4/6 inhibitor?

A

HOld treatment until ANC >1000, then dose reduce

40
Q

Patient with T2N1 ER-/PR-/HER2+ breast cancer is treated with neoadjuvant TCHP. She undergoes lumpectomy and SLNB and has a pCR. What is treatment in adjuvant setting?

A

HP for 1 year, no need for RT for those that convert from LN+ to LN- with neoadjuvant chemo

41
Q

What HER2 directed therapy can be given to a patient with any degree of CHF?

42
Q

Two treatment regimens for metastatic HER2+ breast cancer that have good CNS penetration?

A

Tucatinib + Cape + Herceptin
Cape + Neratinib

43
Q

Best treatment option for patient with metastatic ER+ breast cancer who has progressed on CDK4/6i + AI, fulvestrant, then everolimus+exemestane. No targetable mutation, HER2 is 0.

A

Sacituzimab govitecan

44
Q

3 options for risk recution in post menopausal women with LCIS, DCIS, or ADH?

A

tamoxifen
raloxifene
Anastrozole and exemestane are not FDA approved but used

45
Q

What are optimal surgical margins for DCIS?

45
Q

Who should get breast cancer screening with breast MRI?

A

BRCA mutation
first degree relative of BRCA carrier
Radiation to chest between age 10-30

46
Q

What are the size cutoffs for T1a, b, c, and T2?

A

T1a: <0.5 cm
T1b: 0.6 - 1 cm
T1c: 1-2 cm
T2: >2 cm but <5 cm

47
Q

What is considered a positive margin for surgery on a stage I-II cancer?

A

Ink on tumor

48
Q

When can SLNB be safely omitted?

A

Clinically node negative women >70 with early stage HR+, HER2- cancer

49
Q

Clinically node negative patient is found to have 1 or 2 positive SLNs at time of surgery. Do they need axillary dissection?

50
Q

What are the T and N scores that make a patient an Oncotype candidate?

A

T1b-T2 (0.5 cm to 5 cm)
pN1mi or pN1

51
Q

At what Oncotype score should we recommend chemo for a node negative pre-menopausal woman?

52
Q

At what Oncotype score should we recommend chemo for a node negative post-menopausal woman?

53
Q

At what Oncotype score should we recommend chemo for a node positive post-menopausal woman?

54
Q

At what Oncotype score should we recommend chemo for a node positive pre-menopausal woman?

A

Trick question. Node positive pre-menopausal women shouldn’t get Oncotype, go straight to chemo

55
Q

In general, for pre-menopausal women with local ER+ HER2- breast cancer, when should we recommend OS+ET instead of ET alone?

A

If their disease was significant enough for chemotherapy, they should get OS+AI

56
Q

What are 3 indications for post-mastectomy RT?

A

Tumor >5 cm
Tumor <5 cm and close margins
4+ LNs

57
Q

Indications for adjuvant abemaciclib?

A

N2 (4+ LNs) or:
N1 (1-3 LNs) AND G3, T3 (>5 cm), or Ki67 >20%

58
Q

Indication for adjuvant ribociclib?

A

Stage II or III
If stage II and LN negative, need to be G2 or higher or high genomic risk (Oncotype >26)

59
Q

Indications for adjuvant olaparib in HR+ breast cancer?

A

Obviously BRCA mutation
pN2 (4+ LNs) and if received neoadjuvant chemotherapy, they must have had residual disease

60
Q

What is the use of bisphosphonates in the adjuvant setting for HR+ breast cancer?

A

Useful for postmenopausal women with nonmetastatic cancer at high risk of recurrence: TxN2 or T2N1 or TxN1 with G3
Decreases bone recurrence, fracture rate, BCSS

61
Q

Side effects of elacestrant (get the unique one)

A

High cholesterol
MSK pain
Nuasea, diarrhea
HA
hot flash
AKI
anorexia

62
Q

What is a distinct side effect of everolimus and what can be used for prophylaxis?

A

Stomatitis: use steroid mouth wash

63
Q

Side effects of Sacituzumab govitecan

A

Hyperglycemia
Alopecia
Leukopenia, anemia
diarrhea
fatigue

64
Q

Who shouldn’t get adjuvant treatment for HER2+ breast cancer?

65
Q

What is the appropriate treatment (neo or adjuvant) with T1N0 HER2+ breast cancer?

A

Adjuvant TH

66
Q

Who should get neoadjuvant TCHP in HER2+ breast cancer?

A

Any N+ patients

67
Q

Who should have Neratinib added to adjuvant treatment for HER2+ breast cancer?

A

Those that are HR+

68
Q

Most significant side effect of neratinib?

69
Q

Patient with HER2+ disease receives neoadjuvant TCHP and has residual disease at time of surgery. What is the adjuvant treatment?

70
Q

Patient with HER2+ breast cancer receives neoadjuvant TCHP and has a pCR. What is the adjuvant treatment?

A

HP to complete 1 year of therapy

71
Q

In early TNBC, who shouldn’t receive adjuvant chemotherapy?

A

T1aN0, T1bN0

72
Q

Indications for neoadjuvant chemotherapy in TNBC

A

Pretty much everyone. T1c and up, N+

73
Q

Indications for neoadjuvant AC-Pembro, TC-Pembro (KEYNOTE-522)

A

T2Nx, T1N+ TNBC

74
Q

Treatment for a patient with T1cN0 TNBC?

A

Neoadjuvant ddAC-T

75
Q

Indications for Adjuvant Olaparib in TNBC?

A

If treated with adjuvant chemo, require N+ or T2 (>2cm).
If treated with neoadjuvant chemo, require residual disease at surgery

76
Q

Indications for adjuvant capecitabine in TNBC

A

Patients with residual disease after neoadjuvant chemotherapy and surgery.
BRCA negative

77
Q

Treatment for localized malignant Phyllodes tumor

A

Wide local excision to obtain >1 cm margin
Consider RT
No benefit for chemo

78
Q

Treatment for localized benign Phyllodes tumor

A

Excisional biopsy

79
Q

How to diagnose Paget’s disease of breast

A

Full thickness skin biopsy of NAC
Need to biopsy any breast lesion seen on imaging

80
Q

Treatment of Paget’s disease of breast

A

Mastectomy or central lumpectomy/NAC excision + whole breast RT

Solid Tumor Oncology (20 decks)

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