breast cancer

Question 1

What are the most common histological types of breast cancer?

Answer 1

ductal

lobular

Question 2

If you see a triple negative tumour, what are you thinking? What are the associations?

Answer 2

Usually a high grade ductal Ca
Associated with BRCA
more aggressive

Question 3

How long is adjuvant endocrine therapy administered?

Answer 3

5 years, or ten in select cases (for tamoxifen)
only ever 5 years for aromatase inhibitors
Always commenced after chemo, if this is being given

If metastatic disease and going well on aromatase inhibitor, just keep it going even after the 5 year mark

Question 4

What are the side effects of tamoxifen?

Answer 4

Risk of breast cancer reduction far outweighs risk of endometrial cancer
VTE
Hot flushes

Question 5

How does tamoxifen work?

Answer 5

Blocks binding of activated oestrogen receptors in nucleus to oestrogen response elements, which decreases downstream signalling

Question 6

What impact does tamoxifen have on risk of death?

Answer 6

30% reduction risk of death

Question 7

side effects of aromatase inhibitors?

Answer 7

arthralgias
bone loss- dexa at baseline and every2 years
no endometrial cancer or VTE risk like tamoxifen

Question 8

AI reduce recurrence and death how much compared with tamoxifen?

Answer 8

Reduce recurrence by 4 percent

Reduce death by nothing

Question 9

Indications for chemo

Answer 9

node positive
triple negative
younger premenopausal
large high grade even if node negative

greatest benefit for young women

Question 10

What chemo is often given for breast ca?

Answer 10

doxorubicin and a taxane (docetaxel and paclitaxel)

Question 11

Is herceptin oral or IV?

Answer 11

IV, three weekly, for a year!

Question 12

Trastuzumab side effects

Answer 12

Decrease LVEF (usually asymptomatic)- check cardiac function every three months. ?Myocyte hibernation. Check LVEF every 3 months on therapy
Sometimes intercept with antifailure therapy like and ACE

Question 13

How long do metastatic breast cancer mets ppl live?

Answer 13

bone only- can live for years

visceral- months

Question 14

Where do met’s usually happen?

Any correlation with histological subtype?

Answer 14

Bone, lung, liver
CNS especially HER2 positive disease
Unusual sites for lobular- gastric, peritoneal (not seen with ductal)

Question 15

What do you do when hormone sensitive metastatic breast cancer becomes resistant to aromatase inhibitors, tamoxifen?

Answer 15

This is thought to be secondary to increased downstream activity in the mTOR pathway.
Hence can add in everolimus!! (new therapy)

Question 16

In HER2 positive metastatic breast cancer, what drug is given?

Answer 16

Pertuzumab!
Recently listed in au! Now standard of care
Binds to another site on the HER2 extracellular region

If have progressed on trastuzumab, pertuzumb and docetaxel or have relapsed from trastuzumab within six months of completion of treatment, standard of care is trastuzumab emtansine (TDM-1)

If this progresses, lapatinib/capecitabine. Lapatenib acts IN the cell, ihibits TK domain of the HER2 receptor. It’s oral. Pimply rash, nail changes, finger skin splitting

Question 17

What is a skeletal related event with bony mets?

Answer 17

Hyper calcaemia
spinal cord compression
pathological fracture
pain needing radiotherapy

Question 18

Bony mets patients should be on what?

Answer 18

Zoledronic acid every 12 weeks (reduce skeletal related events by 15%)

small risk ONJ
NO impact on breast cancer survival

Denosumab monoclonal Ab against RANKL- greater reduction in SRE
Still can cause ONJ
Doesn’t have the same risk with renal impairment

Question 19

When would you test for BRCA without strong FH?

Answer 19

under age 30
triple negative under age 40
ovarian cancer under age 70 for certain pathological subtypes
male breast cancer under age 60

Question 20

Risks conferred by BRCA 1 and 2

Answer 20

1: 40-80% lifetime breast, 10-60% ovarian, also prostate
2: 40-80% breast, 10-40% ovarian, male breast, pancreas, prostate

Question 21

who gets breast screening?

Answer 21

Breast cancer screening is two yearly from 50-79 for free but also free for 40-49 and over 75 but no invitations

Question 22

premenopausal and mets to bone

-what extra gives survival benefit

Answer 22

tamoxifen and GnRH analogue

Question 23

Which drug can you not be on with tamox?

Answer 23

parox or fluvox

as inhibit 2D6 and so tamox prodrug cannot be converted to active form

Question 24

Aromatase inhibitor MOA

Answer 24

inhibit NZ in fat that blocks conversion of androgens to oestrogens

Question 25

Li fraumneni mutation and cancers

Answer 25

p53

breast
sarcoma
brain 
colon
leukaemia
adrenocortical

Question 26

cowden syndrome mutation

Answer 26

PTEN

breast
thyroid
endometrial
GU

Question 27

PJ syndrome mutation

Answer 27

STKII/LKB1

BC
small bowel
colorectal
uterine
testicular

Question 28

What fits in the normal risk bracket for breast ca?

Answer 28

one first degree over age 50
two second degree over age 50
one second degree under age 50
two first or second degree over 50 different sides family

do mammogram every 2 years 50-69

Question 29

who is in high risk group

Answer 29

two first or second degree rel same side plus any of

another relative
a jew
breast and ovarian in same person
breast under age 40
one sarcoma instead of the second cancer
known BRCA
bilateral breast cancer
male breast

mastectomy
ovaries out reduces breast ca risk in pre men by half and ovarian by 90%
mammogram age 40 onwards
MRI yearly from 5 years younger than youngest relative
tamox can reduce risk 40%
OCP reduces OC risk but may increase breast risk

Question 30

What does ER positive mean on IHC - 1 + ? 2+ ? 3+ ?

Answer 30

0/1+ is NEG
2+ is equiv
3+ is positive

TRICKY