Breast Cancer Flashcards
What SSRIs should be avoided with Tamoxifen and what is the impact of this?
Fluoxetine and Paroxetine. These meds can decrease the level of Tamoxifen.
Which SSSRI should a patient be switched to if taking Tamoxifen?
Velafaxine and Citalopram
For those who are intolerant of AIs what is the best next step? Name the category 1 recommendation in terms of how long they should be on the agent and the alternative
The category 1 recommendation is Tamoxifen for 5 years but the alternative is for 10 years but this option does not have a category 1 recc
For those patients with early stage breast cancer who have 4 or more positive nodes how long should they be on endocrine treatment? For those with 3 or less?
They should receive extended duration treatment so beyond 5 years up to 10 years. For those with 3 or less you can use the BCI tool to determine if they would benefit from extended endocrine therapy.
When deciding what patients with early stage breast cancer need chemotherapy, what is the tumor size cutoff? What is the exception with both HR+ and TNBC?
Any tumor less than or equal to 0.5cm does not require chemo. If there is micro mets to a lymph node (2 or less mm tumor present) these patients should receive chemo.
For any early stage HER2+ patient, what is the preferred treatment? When is it preferred to add Pertuzumab?
Regardless of tumor size, every patient will need adjuvant chemotherapy plus Trastuzumab. If they have pN1 disease (greater than 2mm) then you add Pertuzumab to Trastuzumab.
When giving chemo for T1a node neg HER2+ disease, what is the preferred regimen in the adjuvant setting and what is the category recommendation per NCCN? In the study that looked at this regimen up to what tumor size did they look at?
So the APT trial showed that for tumors that are node negative up to 3 cm in size patients have good survival outcomes with adjuvant weekly Paclitaxel with Trastuzumab. This is the recommended regimen, so this include T1 and T2 tumors (T2: 2-5 cm).
For those who are postmenopausal with HR+ disease and need adjuvant therapy, what number of lymph nodes being positive negates doing oncotype and giving them chemo?
Those with 4 or more ipsilateral lymph nodes (pN2 or pN3).
For post-menopausal patients who have undergone surgery for HR+ disease, what patients require chemo?
For those tumors greater 0.5cm with micro mets (2mm or less), PN0, or PN1-3 and who have a oncotype score of 26 or higher. Also if the test was not done or the patient declined the oncotype score, then they should get chemo also.
What does the NCCN guidelines say for premenopausal patients with HR+ early stage disease with node positive or negative disease and who needs chemo?
So for tumors greater than 0.5cm and a oncotype score less than or equal to 15 the cat 1 recc is adjuvant endocrine +/- OFS. For a oncotype score of 16-25 you can do adjuvant endocrine +/- OFS or you can do chemo w/adjuvant endocrine +/- OFS. Those with a score>25 (26 or higher) will need chemo in addition to endocrine and +/- OFS.
For those early stage HR+ premenopausal patients who did not get a oncotype score done what is the cat 1 recommendation?
Adjuvant chemo with adjuvant endocrine therapy +/- OFS. It says another rec is just to give adjuvant endocrine and OFS.
What is the recommendation for adjuvant therapy in premenopausal patients who have HR+ node positive disease?
All of these patients still need a oncotype. But it says in NCCN those with 1-3 nodes can get either chemo with endocrine and OFS or you can do endocrine and OFS alone. For those with 4 or more nodes they need chemo. A very high RS, these patients should get chemo (>25).
Per NCCN Guidelines, for those patients with early stage HER2+ disease what chemo can you give and specifically what T/N stage?
For those patients with tumors up to 2cm. NCCN says you can give Weekly Paclitaxel with Trastuzumab. Of note the APT trial that backs this up and included patients with tumors up to 3cm-T2 lesions.
What is the treatment that is indicated for HER2+ disease that has not achieved a pCR? What if the patient doesn’t tolerate TDM-1?
TDM-1 is indicated for 14 cycles. If TDM-1 is stopped due to side effects put them on Trastuzumab +/- Pertuzumab. NCCN says if the patient was node positive and you give Trastuzumab you need to add Pertuzumab.
What additional therapy can be offered to patients in early stage cancer, particularly postmenopausal patients to decrease the risk of distant recurrence in addition to endocrine/HER2/chemo?
Bisphosphonates or Xgeva which helps in both naturally and induced postmenopausal patients, NCCN says to give for 3-5 years. Per ASCO question: Zoledronic Acid is the only one that is assoc with a survival benefit (also decreases risk of bone mets). Xgeva also decreases risk of bone mets.
What are the indications for adjuvant Abemaciclib in HR+ early stage disease in high risk patients?
So you give it to patients who have: 4 or more positive lymph nodes, 1-3 lymph nodes with either grade 3 disease OR tumor size of 5cm or more. Per ASCO, also use for Ki67 of 20 or higher
What is the indication for adjuvant Olaparib in TNBC patients?
Residual disease after preoperative chemotherapy or pT2 or higher or pN1 or higher after adjuvant chemotherapy in those with a BRCA mutation.
What is the indication for adjuvant Olaparib for HR+ disease?
For patients who have 4 or more positive lymph nodes after adjuvant chemo (cat 2 rec) or for those patients with residual disease after preoperative therapy and a CPS+EG score of 3 or higher
What are the indications to give the Keynote-522 regimen in TNBC?
Stage II: T1 w/N1 or N2
Stage III: T2-T4 w/ N0-N2
T1-lesion up to 2 cm
T2-lesion from 2cm to 5 cm
Any lymph node positive disease is Stage II
What is the follow up for a patient with early stage breast cancer?
1-4 times a year for the first 5 years and then yearly afterwards. Mammogram should be done yearly.
What is the first line tx option for HER2+ metastatic/unresectable disease?
Pertuzumab, Trastuzumab with Docetaxel or you can do Paclitaxel
What is the 2nd line option for HER2+ metastatic disease? What is the survival benefit seen with this drug?
Trastuzumab deruxtecan. There is a huge PFS benefit, for the OS the median hasn’t been reached.
