Breast Cancer Flashcards
1.Identify common risk factors associated with breast cancer.
Age, family history, high dose estrogen exposure, diet, not having children
- Describe and apply available cancer screening guidelines to an individual at average and high risk for developing breast cancer
Breast exam, mammogram
Biopsy for staging
CT will show if its metastatic or not
IHC testing: detects protein overexpression if patient is 1+ HER2 low, 2+ should do fish testing, 3+ high and HER2 therapy is needed
FISH - detects gene amplification
Oncotype DX: tests patients recurrence risk, only in select patients (stage I and II, lymph node negative or few, ER positive, or HER2 negative)
- Generate a treatment plan for breast cancer prevention.
self breast exams starting at age 20
Clinical examinations
Start mammogram annually at age 40
- Evaluate specific factors in a patient case to generate a breast cancer treatment plan
need to determine if patient is pre or postmenopausal
Need to know if patient is ER and PR positive or HER2 positive
- Evaluate specific factors in a patient case to develop a breast cancer treatment plan
in metastatic disease.
depends on ER/PR positive or not
if it is we want to do hormone therapy
If this patient has bone disease we can add bisphosphonates as well
For ER/PR negative it depends on if they are HER2 positive if they are we want to do HER2 therapy with chemo
If patient is HER2 negative we want to do chemotherapy
what are the two types of Invasive Breast cancers
Invasive Ductal carcinoma - most common
Invasive lobular carcinoma- second most common
what are the two types of Non-invasive breast cancer
Ductal carcinoma in situ (DCIS) - have not invaded through the basement membrane
Lobular carcinoma in situ (LCIS) - have not invaded through the basement membrane
Inflammatory Breast cancer
Very aggressive form of breast cancer with rapid onset and poor prognosis
redness, swelling, warmth, inflamed (boob looks like an orange)
ONCOTYPE DX testing results
If score is less than 26 you can do hormone therapy alone
if its greater than 26 chemotherapy and hormonal therapy together
-EXCEPTION: if patient is <50 and has a score of 16-24 they will benefit from chemo and hormonal therapy
When to give Neoadjuvant therapy (before surgery)
for those with a tumor larger than 1cm
Hormone positive, lymph node - and +, HER2 negative
Tumor less than or equal to 0.5cm : Adjuvant endocrine therapy
Tumor greater than 0.5cm or 1-3 positive nodes: DO Oncotype dx testing
if patients score is less than 26: adjuvant endocrine therapy
if patients score is greater than 26: Adjuvant chemo followed by endocrine therapy
Hormone positive, lymph node - and +, HER2 POSITIVE
Tumor less than or equal to 0.5cm: Adjuvant endocrine therapy +/- chemo with HER2 targeted therapy
Tumor larger than 0.6cm: Adjuvant chemo with HER2 targeted therapy followed by endocrine therapy
Adjuvant Hormonal therapy options for premenopausal
Surgical ablation: remove the ovaries
Tamoxifen: SERM SE: Hot flashes
Leuprolide: LHRH analog
Goserelin: LHRH analog
can do LHRH analog with Aromatase inhibitor but aromatase inhibitor alone is not for premenopausal
Adjuvant Hormonal therapy options for postmenopausal
Tamoxifen: SERM SE Hot flashes
Anastrozole: AI
Letrozole:AI
Exemestane: steroidal AI
GUIDELINE DIAGNOSIS - Premenopausal
Premenopausal at diagnosis
- Tamoxifen for 5 years +/- leuprolide
OR
- leuprolide and anastrozole/letrozole/ exemestane for 5 years
After 5 years - can continue tamoxifen if patient is still premenopausal for another 5 years
OR
if patient is postmenopausal can consider doing aromatase inhibitor for 5 more years OR tamoxifen for 5 more years
GUIDELINE DIAGNOSIS - Postmenopausal
Aromatase inhibitor for 5 years
After 5 years - continue aromatase inhibitor
Adjuvant chemotherapy regimens
HER2 negative patients with oncotype score greater than 26 (or those 16-25YO)
2 prefered options
Dose dence AC:
Doxorubicin, cyclophosphamide (must give growth factors- filgrastim) followed by paclitaxel
TC:
Docetaxel, cyclophosphamide
GIVE TC to patients who have history of cardiotoxicity
Adjuvant HER2 positive regimens
APT
Paclitaxel, Trastuzumab followed by trastuzumab for 1 year
TCH+ Pertuzumab
Docetaxel, carboplatin, trastuzumab, pertuzumab followed by trastuzumab and pertuzumab for 1 year
APT is good for older patients that might not handle the more aggressive TCH regimen
HER2 positive treatment for residual disease
once patient has completed 6 cycles of chemo and been on HER2 positive targeted therapy for over a year if they still have cancer present then we would treat with a ado-trastuzumab conjugate for 1 year again
Adjuvant therapy for hormone negative, HER2 negative cancer
Pembrolizumab + chemotherapy:
Paclitaxel, carboplatin, pembrolizumab (Immunotherapy) for 3 weeks followed by doxorubicin, cyclophosphamide and pembrolizumab
followed with pembrolizumab for 1 year
Metastatic Disease
ER/PR+, Bone Mets, Asymptomatic visceral disease
Hormone therapy +/- bisphosphonate (bone disease) or denosumab
Metastatic disease
ER/PR- symptomatic visceral disease, or hormone refractory
HER2 + : HER2 therapy +/- chemo (Trastuzumab, Pertuzumab, docetaxel x every 3 weeks)
HER2- : Chemotherapy
Tx for metastatic pts who are HER2 low and have failed multiple treatments
Fam-Trastuzumab deruxtecan
can cause interstitial lung disease so if patient is complaining of SOB D/C the drug immediately
Metastatic Triple negative therapy
Carboplatin is first line
assess PD-1 status and positive score if patient has greater than 10 score they can benefit from pembrolizumab and chemotherapy
