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864 > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

Epidemiology

  • Most ___ malignancy in women in US
  • 2nd most common cause of cancer related ___ in women
  • Lifetime risk of developing breast cancer is 1 in __ women (risk increases with age)
A
  • common
  • death
  • 8
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2
Q

T or F: increased HRT could contribute to the decreased in mortality based on results from the WHI study.

A

FALSE
- decreased HRT

decreased mortality is believed to be due to better treatments for both early and advanced breast cancer as well as screening

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3
Q

Risk Factors

More than 60% of patients will not have any risk factors
- increasing age
- Family history - relatives with disease increases risk
- Radiation
- ___ exposure endogenous - Early menarche late menopause
- Exogenous ___ OC/HRT
- alcohol - decreases hepatic ___ of estrogen
- Prior breast ___ with proliferative histology
- ___ or age > 30 years old before first birth
- Elevated BMI/Diet

A
  • estrogen
  • estrogen
  • metabolism
  • biopsies
  • nulliparity
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4
Q

Genetics

Only ~ 5-10% of breast cancers are familial

Tumor Suppressor Genes
BRCA-1
- increased risk of ___ cancer (up to 40% lifetime risk) and ___ cancers (up to 60%)
- High prevalence of variants in Ashkenazi Jews

BRCA-2
- Greater risk for breast cancer (~50%), lower risk for ovarian (~20%)
- Greater incidence in male breast cancer

A
  • ovarian
  • breast
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5
Q

Types: Invasive Breast Cancer

Invasive carcinoma -invaded beyond the basement membrane of the duct or lobule
1. Invasive ___ carcinoma (IDC) – Most common accounting for 70% of all breast cancers
2. Invasive ___ carcinoma (ILC) – Second most common type ~ 15% of breast cancers

A
  • ductal
  • lobular
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6
Q

Types: Non-Invasive Breast Cancer

Ductal carcinoma in situ (DCIS) –
- Normal cells have undergone pre-malignant genetic transformation
- Typically seen as microcalcifications on a ___

Lobular carcinoma in situ (LCIS)
- Has not invaded beyond the ___ basement membrane
- Usually, an incidental finding on biopsy specimen obtained because of symptoms or mammographic findings consistent with benign lesions

A
  • mammogram
  • lobule
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7
Q

Types of Breast Cancer

Inflammatory:
- ___ form of breast cancer with rapid onset and poor prognosis
- The onset is typically days and weeks
- peau d’ ___
- delayed in diagnosis because most often thought of as cellulitis, so typically treated with multiple antibiotics before the diagnosis is made

A
  • aggressive
  • orange
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8
Q

FISH Testing

Can test for HER2 status in 2 different ways:
1. Immunohistochemistry (IHC): Detects ___ overexpression (1+, 2+, 3+)
2. Fluorescence In-Situ Hybridization (FISH): Detects gene ___ (if gene: chromosome copies are ≥ 2 considered positive)

A
  • protein
  • amplification
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9
Q

Oncotype DX

  • Genetic test for expression of 21 genes which gives a recurrence score
  • Can determine the likelihood that the breast cancer will ___ and whether the patient is likely to benefit from ___

Multi-gene assay validated for use in:
- ___ diagnosed breast cancer
- Stage __ or __
- Lymph node negative and positive (1-3 nodes)
- ER positive
- HER2 negative

A
  • return
  • chemo
  • newly
  • I, II
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10
Q

Oncotype DX: TAILORx

Low risk (< 26) = ___ therapy only

High risk (≥ 26) = ___ and
___ therapy
- the medium score group did not benefit from chemo (score of 16 to 25)
- women < ___ years of age and score of 16-25 did have a benefit from chemo

Demonstrates ~ 85% of people can be spared chemo

A
  • hormone
  • chemo, hormone
  • 50
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11
Q

Natural History of Breast Cancer

T or F: Breast cancer can metastasize anywhere

A

T
- Malignant progression involves early changes in proliferation by systemic hormones
- Sites of metastasis: Bone, liver, lungs, brain, distant lymph nodes and/or skin

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12
Q

Adjuvant: ___ surgery
Neoadjuvant: ___ surgery

A
  • after
  • before
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13
Q

Stages I, II, and IIIA-C
- Goal is ___
- Lumpectomy + XRT
- Mastectomy + XRT

stage II and IIIA patients may have
___ chemo
- Most women will receive adjuvant therapy

Stage IV
- Treatment is ___
- primarily consists of chemo, hormonal therapy, +/- biologics, +/- immunotherapy
– radiation may be used to palliate symptoms
– Surgery only used for ___ relief

A
  • cure
  • neoadjuvant
  • palliative
  • symptomatic
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14
Q

T or F: radiation is an example of a neoadjuvant therapy

A

FALSE:
can only use XRT after surgery

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15
Q

Neoadjuvant therapy

Stage I, IIA, IIB, III disease

Goal: cure
- For patients with ___ tumors (> __ cm)

Benefits of neoadjuvant chemotherapy:
» 1. Allows less extensive ___
» 2. Allows you to see ___ to chemo while the tumor is still intact

A
  • larger
  • 1
  • surgery
  • response
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16
Q

Systemic Adjuvant Therapy

A
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17
Q

Adjuvant Hormonal Therapy

Surgical ablation:
– Oopherectomy: Removes the largest source of ___

Selective Estrogen Receptor Modulators (SERMs) - ___ (Nolvadex)
- Anti-estrogenic effects in breast but estrogenic properties in
other tissues (bones, lipids)
- Reduces risk of developing contralateral breast cancer
* Dosage: 20 mg daily
* Major toxicities – ___ , endometrial cancer and DVT (uncommon)

A
  • estrogen
  • tamoxifen
  • hot flashes
18
Q

Adjuvant Hormonal Therapy

LHRH Analogs
- ___ (Lupron): Monthly or Q 3 months
- ___ (Zoladex implant): Monthly or Q 3 months
- Flare: Initially causes increased release of ___ and ___
- Long-term, sustained exposure inhibits ___ production by the ovaries
- Estrogen and progesterone levels fall to ___ status after 2 - 4 weeks

A
  • leuprolide
  • goserelin
  • FDH, LH
  • estrogen
  • post-menopausal
19
Q

Aromatase Inhibitors (AI)

  • Use only in ___ patients
  • Will need to use ___ suppression if in a premenopausal woman
  • Fewer adverse effects: No DVT/endometrial cancer, no protective effect on ___ (like tamoxifen)
  • Osteoporosis, hot flashes, muscle aches, and pains

anastrozole, letrozole, exemestane
- used for ___ years and then reevaluated

A
  • postmenopausal
  • ovarian
  • bone
  • 5 years
20
Q

T or F: Durations longer than 3 to 6 months of adjuvant chemotherapy improve survival

A

FALSE
- do not appear to improve survival

21
Q

Most common chemotherapeutic agents: (8)

A
  • doxorubicin
  • epirubicin
  • cyclophosphamide
  • methotrexate
  • fluorouracil
  • carboplatin
  • paclitaxel
  • docetaxel
22
Q

Chemotherapy Regimens

Standard chemotherapy consists of __ - __ cycles given every __ - __weeks

A
  • 4-6
  • 3-4
23
Q

Adjuvant Chemotherapy Regimens

HER 2 negative disease (2)

Dose Dense ___→ ___ (NCCN preferred)
- ___ and ___
- repeat every ___ days
- must give ___
- followed by ___

___ (NCCN preferred)
- ___ and ___

A
  • AC, Paclitaxel
  • doxorubicin, cyclophosphamide
  • 14
  • growth factors
  • paclitaxel
  • TC
  • docetaxel, cyclophosphamide
24
Q

Dose Dense Anthracyclines

CALBG trial
- Evaluated dose density and sequential versus combination chemotherapy questions
- Group 4 = (every __ weeks plus ___ ) = Concurrent doxorubicin and cyclophosphamide x 4 followed by paclitaxel x 4
- Sequential therapy was found to be less ___
- Patients got same amount of chemo but in ___ time (hence, dose dense)

A
  • 2, filgrastim
  • toxic
  • less
25
Q

If cardiac problems, can consider ___ chemo regimen to avoid anthracyclines

A

TC
- docetaxel, cyclophosphamide

26
Q

Adjuvant HER2 (+) Regimens

3 regimens
1. APT
2. TCH
3. TCH + ___

A
  1. APT = paclitaxel and trastuzumab
  2. TCH = docetaxel, carboplatin, trastuzumab
  3. TCH + pertuzumab
27
Q

Duration of Therapy

HERA (Herceptin Adjuvant Trial)
- standard of care is to complete ___ year of adjuvant trastuzumab therapy
- Now with pertuzumab, will complete ___ year
of combined trastuzumab and pertuzumab

A
  • one
  • one
28
Q

Residual Disease Therapy

Katherine Trial: HER2 (+), with residual
disease found on pathology after surgery
- Received ≥ 6 cycles of ___ (TDM-1) or trastuzumab IV every 3 weeks x 14 cycles
- ___ = Risk of recurrence or death was 50% lower compared to trastuzumab alone
- New standard of care
- If no residual disease, continue trastuzumab +/- pertuzumab x total of ___ year

A
  • ado-trastuzumab emtansine
  • TDM-1
  • 1
29
Q

TNBC: Triple Negative Breast Cancer: Standard of Care

Immunotherapy now is incorporated into chemo regimen for TNBC
- improved OS with addition of ___ to standard chemotherapy
- should be added into
chemo regimen and continued for __

A
  • pembrolizumab
  • 1
30
Q

Adjuvant Chemotherapy Regimens

Triple negative disease (1)
___ + chemo
- ___ + ___ + Pembrolizumab - Repeat every 21 days x 4, then followed by:
- ___ + ___ + Pembrolizumab - Repeat every 21 days x 4, then followed by:
- Pembrolizumab to complete __ year of therapy

A

pembrolizumab
- paclitaxel, carboplatin
- doxorubicin, cyclophosphamide
- 1

31
Q

Metastatic Disease

Goal of therapy is ___
- Median survival is ~ 3 years
- Bone and soft tissue metastases tend to have a better prognosis and respond to ___ therapy
- Symptomatic disease: ___
* ___(+) tumors tend to be more indolent

A
  • palliation
  • hormonal
  • chemo
  • ER/PR
32
Q

How to Decide What to Give

Hormonal Therapy
- ER/PR+
- ___ disease free survival
- prior response to therapy
- ___ only disease

Chemo
- ER/PR - disease
- ___ disease free interval
- ___ progressing disease
- Disease ___ to hormonal
therapy

A
  • long
  • bone
  • short
  • rapidly
  • refractive
33
Q

HER2+ metastatic disease:
First line
___ + ___ + ___

A

trastuzumab
pertuzumab
docetaxel

34
Q

___ is now considered 2nd line after failure of trastuzumab / pertuzumab and a taxane
- also now an option in
those with HER2 ___ disease

A

Fam-trastuzumab deruxtecan
- low

35
Q

Triple Negative Breast Cancer (TNBC)

___ agents have shown benefit (2)

A

platinum
- carboplatin
- cisplatin

36
Q

Triple Negative Breast Cancer (TNBC)

___ + chemotherapy is better than chemo alone in patients with a combined positive score of ≥ 10
- if no positivity, the platinum-based chemo is preferred

combined positive score: number of PD-L1 staining cells

A

pembrolizumab

37
Q

Hormonal Therapy: Metastatic

Common to use sequential endocrine therapies in the metastatic setting
- If a patient responds to one endocrine therapy, it is ___ they will respond to another agent
- As the response time shortens with each line of therapy, it is likely that the patient will no longer respond to endocrine therapy and then
___ should be initiated

A
  • likely
  • chemo
38
Q

Hormonal Therapy: Metastatic

1st Line
- ___ inhibitor + ___ inhibitor (abemaciclib, palbociclib, or ribociclib)

2nd Line
- ___ + CDK4/6 inhibitor (abemaciclib, palbociclib, or ribociclib) if not used before
- ___ + endocrine therapy (exemestane, Fulvestrant, or tamoxifen)

A
  • aromatase, CDK4/6
  • fulvestrant, everolimus
39
Q

Breast Cancer Prevention Trials

Three agents have been studied in the
preventative setting

A
  • tamoxifen
  • raloxifene
  • exemestane
40
Q

Prevention

Tamoxifen and Raloxifene are effective
- both drugs reduce breast cancer by 50%
- Raloxifene did not reduce the risk of ___ or ___ like tamoxifen

A
  • LCIS, DCIS

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