Breast cancer

Question 1

Non-mod risk factors for Breast cancer

Answer 1

Age
Ethnicity
Genetics (1 relative or p53 BRCA mutations)
Reproductive history (early menarche, age of first live birth, late menopause, parity)

Question 2

Mod risk factors for breast cancer

Answer 2

Smoking
Alcohol
BMI (weight gain after age 18)
Radiation prior to age 30?

Question 3

Signs and symp of breast cancer

Answer 3

palpable mass
pain to breast area
nipple discharge
asymmetric thickening or nodularity
skin changes
unexplained weight loss and fatigue

Question 4

Types of breast cancer

Answer 4

Lobular carcinoma in situ
Ductal carcinoma in situ
Invasive lobulat carcinoma
Invasive ductal carcinoma

Question 5

TMN staging

Answer 5

Tumor size
Nodal involvement
Metastatic disease (only in stage 4)

Question 6

ER/PR

Answer 6

estrogen progesterone receptors
anything greater than 1% is positive
can be treated with endocrine therapy

Question 7

Oncotype DX test

Answer 7

prognostic: how likely to come bank
predicitive: how likely to benefit from chemo
<18 low risk
>30 high risk
Used in early-stage estrogen receptor + or DCIS

Question 8

How to treat early stage noninvasive

Answer 8

LCIS: observation or remove
DCIS: remove +/- radiation, lymph node dissection not recommended

Question 9

Questions to ask treating invasive (3)?

Answer 9

1. Hormone status?
2. HER2 receptor status?
3. Tumor size and node status?

Question 10

How to treat early stage invasive?

1A, 1B, 2A, 2B

Answer 10

goal=cure=5 yr surv

1. Remove
2. Radiation
3. Systemic therapy either endocrine or targeted

Question 11

How to treat Stage 3 invasive?

Answer 11

Operable: Surgery +/- pre and post chemo
Inoperable: pre chemo, irradiation, post chemo

Question 12

Tx for negative axillary noses, tumor>5 cm or positive margins

Answer 12

surgery, radiation, chemotherapy

Question 13

ER+, HER2+

3

Answer 13

Endocrine therapy +/- chemotherapy with trastuzumab

Question 14

ER+, HER2-

3

Answer 14

Endocrine therapy with chemotherapy

Question 15

ER-, HER2+

3

Answer 15

+/- chemotherapy with trastuzumab

Question 16

ER-, HER2-

3

Answer 16

Chemotherapy

Question 17

Tumor markers

Answer 17

Only important in metastatic cancer

CEA, CA 2729, Truquant BR, CA 15-3

Question 18

Preferred HER2-

Answer 18

Dose dense AC –> T
doxorubicin, cyclophosphamide, paclitaxel every 2 weeks
worried about cardiotoxicity
Must use growth factor

Question 19

Preferred HER2+

Answer 19

TCH +/- pertuzimab
TCH=docetaxel, carboplatin, trastuzumab +/- pertuzumab
worried about cardiotoxicity
Every 21 days for 6 cycles then continue only trastuzumab and pertuzumab every 21 days to complete 1 year

Question 20

For nausea

Answer 20

Fosaprepitant, dexameth, Zofran
PRN Compazine and Ativan
If failed: add olanzapine night before then 5 days after

Question 21

For myelosupression

Answer 21

Neulasta x1

or Neupogen x7

Question 22

Trastuzumab (Herceptin)

neo and meta

Answer 22

Binds to EGFR2
For HER2+
Load with 8 mg/kg then 6 mg/kg every 3 weeks for 1 yr.
Give after doxorubicin tx because of cardiotox
ECHO to check if EF>55%

Question 23

Pertuzumab (Perjeta)

neo and meta

Answer 23

HER2 dimerization inh used only with trastuzumab
For HER2+
Always a flat dose. Load then every 3 weeks. Cardiotox

Question 24

Neratinb (Nerlynx)

neo

Answer 24

Tyrosine kinase inhibitor. HER2 dimerization inh used only with trastuzumab after the 1 year of initial treatment.
Causes diarrhea, pre med with loperamide

Question 25

ado-trastuzumab
(Kadcyla)
meta

Answer 25

Drug conjugate for HER2+, every 3 weeks

detaches from tras once in cancer cell

Question 26

Lapatinib (tykerb)

Answer 26

Tyrosine kinase inhibitor (HER2 and EGFR)
oral
Hand and foot syndrome in combo with capecitabine

Question 27

HER2- ER+

metastatic treatment

Answer 27

Use with endocrine therapy
Cyclin-dep kinase inhibitors 
Palbociclib
Ribociclib
Abemaciclib
Causes: neutropenia, mucositis, headaches, n/v

Question 28

Anti-estrogens (3)

Answer 28

Tamoxifen
Toremifene
Raloxifene

Question 29

DOC in premenopausal, anti-est

Answer 29

Tamoxifen
SERM
blocks Est receptors in the breast but not other areas

OK to use in post-meno

Question 30

Tamoxifen properties

check is pt is on SSRIs!!

Answer 30

PO
Prodrug
Hot flashes (treat risk of clotting and endometrial cancer
interacts with 2d6 inh, 3a4 inh, warfarin

Question 31

LHRH agonists

Answer 31

ovary suppression
Goserelin
Leuprolide
Triptorelin
Use in high risk pre-menopausal with an aromatase inhibitor

Question 32

Aromatase inhibitors

Answer 32

Anastrazole
Letrozole
Exemestant
block estrogen in peripheral
use in high risk pre-meno
use in Post-meno because their ovaries don't produce

Question 33

Side effects of aromatase inhibitors

Answer 33

myalgias
osteoporosis
hot flashes
sex dysfunction

must start on Ca2+ and VitD
start denosumab

Question 34

Denosumab

Answer 34

every 6 months
binds to RANKL
increases bone mass in patients

Question 35

Antidepressants for hot flashes

Answer 35

Venlafaxine, citalopram, escitralopram

Question 36

Classes ok for hot flashes

Answer 36

non 2d6 antidepressants
gabapentin/pregabalin
clonidine