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PHRM 864 Exam 2 > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

Epidemiology

A

Most common malignancy in women in the US

2nd most common cause of cancer related death in women

Men do get breast cancer

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2
Q

Risk factors

A

More than 60% of patients will not have any risk factors

Age

Family history–> number of 1st and 2nd degree relatives with disease increases risk

Personal hx

Prior radiation

Estrogen exposure–> endogenous

Exogenous estrogen–> OC/HRT

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3
Q

Risk factors continued

A

Alcohol

Prior breast biopsies with proliferative histology

Nulliparity or age > 30 years old before first birth

Obesity/Diet: estrogen stores in fat

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4
Q

Genetics

A

Only 5-10% of breast cancers are familial

Tumor supressor genes:

BRCA-1: increased risk of ovarian cancer

BRCA-2: great risk of breast cancer, lower risk of ovarian, greater in male breast cancer

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5
Q

History of disease

A

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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6
Q

Presentation

A

> 90% of patients present with a painless lump in the breast

< 10% of patients have stabbing or aching pain as the first symptom

Other presentations include: nipple discharge, retraction, or dimpling

In more advanced cases, prominent skin edema, redness, warmth, and induration of underlying tissue

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7
Q

Presentation continued

A

Asymptomatic disease may be detected on screening mammography

10% of patients will present with metastatic disease and for those patients, the symptoms mirror their metastatic site: bone pain, SOB

50% of patients with an initial diagnosis of breast cancer will ultimately develop metastatic disease despite potentially curative multimodality therapy

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8
Q

Diagnosis

A

History and PE, clinical breast exam, 3-D mammogram, and potentially a breast ultrasound

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9
Q

slide 22

A
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10
Q

Prognostic tools

A

Oncotype DX

Can determine the likelihood of the breast cancer returning and whether the patient will benefit from chemo or not

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11
Q

Oncotype DX

A

Low risk (<26)=hormonal therapy only

High risk (>26)=chemotherapy and hormonal therapy

Women < 50 yo and score of 16-25 did incur benefit from chemotherapy

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12
Q

Neoadjuvant and Adjuvant Therapy

A

Stage 1, IIA, IIB, III dx

Goal of therapy is to achieve cure

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13
Q

Neoadjuvant therapy

A

For patients with larger tumors (>1 cm)

  1. allows less extensive surgery
  2. allows you to see response to chemotherapy while the tumor is still in tact
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14
Q

slide 38

A
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15
Q

slide 39

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16
Q

Adjuvant hormonal therapy

A

Surgical ablation–>Oophorectomy

SERMS–>Tamoxifen (pre/post menopausal)

LHRH agonists–>Leuprolide (premenopausal), Goserelin

Aromatase inhibitors–>postmenopausal

17
Q

Premenopausal at diagnosis

A

T x 5 yrs +/- OS OR AI x 5 yrs + OS

Premenopausal
1. T x 5 more years to complete a total of 10 years or

  1. No further endocrine therapy

Postmenopausal
1. Could consider an additional 5 years of AI to total 10 years OR

  1. Consider T x 5 more yrs to complete 10 years
18
Q

Postmenopausal at diagnosis

A

AI x 5 yrs then consider AI for additional 5 years

19
Q

Chemotherapy regimens

A

Standard chemo consists of 4-6 cycles given every 3-4 weeks

Neoadjuvant consists of 4-6 cycles

20
Q

Adjuvant Chemotherapy Regimen for HER2 negative

A

Dose Dense AC–> Paclitaxel

Doxorubicin
Cyclophosphamide

Repeat every 2 weeks x 4 (Must give growth factors) followed by: Paclitaxel every 2 weeks x 4 (must give growth factors) or weekly x 12 weeks

TC: Docetaxel and cyclophosphamide; repeat every 3 weeks x 4

21
Q

Chemotherapy considerations

A

Discussion of whether to have an anthracycline based regimen or non-anthracycline based regimen

Cardiac risks

If cardiac problems, can consider docetaxel and cyclophosphamide regimen

22
Q

Adjuvant HER2 Postive regimens

A

APT:
-Paclitaxel weekly x 12 weeks
-Trastuzumab with the first dose of paclitaxel

Followed by: Trastuzumab weekly x 11 weeks, every 3 weeks for 1 year

TCH:
-Docetexal, Carboplatin, Trastuzumab–>repeat every 3 weeks x 6

Followed by: Trastuzumab every 3 weeks weekly to complete 1 year of trastuzumab

TCH-P:
-Docetaxel, Carboplatin, Trastuzumab, Pertuzumab–> repeat every 3 weeks x 6

Followed by: both trastuzumab and pertuzumab to complete 1 year

23
Q

Adjuvant Chemotherapy regimen for Triple negative dx

A

AC + Pembrolizumab–> 3 weeks x 4

Pembrolizumab-> repeat every 3 weeks x 4; followed by: AC

Pembrolizumab every 3 weeks for total of 1 year

24
Q

Metastatic dx

A

Goal of therapy is palliative

Median survival is 3 years

Symptomatic dx: Chemo

ER/PR + tumors tend to be more indolent

25
Q

HER2 Targeted Regimens (metastatic setting)

A

1st line option:

-Trastuzumab
-Pertuzumab
-Docetaxel

OR
-Trastuzumab
-Pertuzumab
-Paclitaxel

Given every 3 weeks

26
Q

HER2-low patients

A

Fam-trastuzumab deruxtecan

Has shown benefit after failed treatment

27
Q

TNBC (metastatic setting)

A

Platinum agents have shown benefit:

Carboplatin single agent (1st line)

Cisplatin single agent (1st line)

Pembrolizumab + chemo is better than chemo alone in patients with a combined positive score of > 10

28
Q

Hormonal therapy (metastatic setting)

A

HER2 negative and Pre/post menopausal receiving OS

1st line: AI + CDK 4/6 inhibitor

2nd line: Fluvestrant + CDK inhibitor if not used before
OR
Everolimus + endocrine therapy

29
Q

Abemaciclib

A

1st line + AI
2nd line + Fluvestrant
2nd line as a single agent

Monitoring parameters: Complete blood counts, diarrhea, elevation in LFTs, pneumonitis, and thromboembolism

30
Q

Palbociclib

A

3 weeks then 7 days off

1st line + AI
2nd line + fluvestrant

Monitoring parameters: Complete blood count, diarrhea, elevation in LFTs, pneumonitis

31
Q

Ribociclib

A

3 weeks then 7 days off

1st line + AI
2nd line + fluvestrant

Monitoring parameters: complete blood count, diarrhea, elevation in LFTs, QTc prolongation (ECG), pneumonitis

32
Q

Mammogram

A

Age 40-44 opportunity for annual exams

Age 45-54: annual

Age > or equal to 55: Biennial mammograms or the opportunity for annual exams

33
Q

Breast cancer prevention

A

Prophylactic mastectomy

Bilateral oophorectomy

Tamoxifen

Raloxifene

Exemestane

34
Q

Hormone postive, HER2 negative, lymph-node negative (premenopaunsal)

A

Asses tumor:

Tumor < 0.5 cm–> adjuvant endocrine therapy

Pre-menopausal:
Regimen: GnRH agonist + AI x 5 years
- If still premenopausal–>Tamoxifen x 5 years or no further endocrine therapy
-If postmenopausal after–> AI x 5 years or Tamoxifen x 5 years

Agents:
Oophorectomy
SERM
GnRH agonists (monthly or q3 months)
May add AI after OS via GnRH agonist

35
Q

Hormone postive, HER2 negative, lymph-node negative (postmenopausal)

A

Aromatase inhibitor x 5 years and consider for 5 more

Agents:
SERM
AI

PHRM 864 Exam 2 (17 decks)

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