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Hematology, oncology > Breast cancer > Flashcards

Breast cancer Flashcards

1
Q

Indication for obtaining oncotype score

A

Assesses 16 cancer-related genes and 5 normal comparator reference genes, and is therefore sometimes known as the 21-gene assay.
**It was designed for use in estrogen receptor (ER) positive tumors. The test is run on formalin fixed, paraffin-embedded tissue. Oncotype results are reported as a Recurrence Score (RS), where a higher RS is associated with a worse prognosis, referring to the likelihood of recurrence without treatment. In addition to that prognostic role, a higher RS is also associated with a higher probability of response to chemotherapy, which is termed a positive predictive factor.

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2
Q

interpretation of oncotype score

A

For women older than 50 years of age:

Recurrence Score of 0-25: The cancer has a low risk of recurrence. The benefits of chemotherapy likely will not outweigh the risks of side effects.
Recurrence Score of 26-100: The cancer has a high risk of recurrence. The benefits of chemotherapy are likely to be greater than the risks of side effects.
For women age 50 and younger:

Recurrence Score of 0-15: The cancer has a low risk of recurrence. The benefits of chemotherapy likely will not outweigh the risks of side effects.
Recurrence Score of 16-20: The cancer has a low to medium risk of recurrence. The benefits of chemotherapy likely will not outweigh the risks of side effects.
Recurrence Score of 21-25: The cancer has a medium risk of recurrence. The benefits of chemotherapy are likely to be great than the risks of side effects.
Recurrence Score of 26-100: The cancer has a high risk of recurrence. The benefits of chemotherapy are likely to be greater than the risks of side effects.

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3
Q

anthracyclines

A

*All the -rubicins

Doxorubicin, epirubicin, idarubicin, daunorubicin, Pegylated liposomal doxorubicin

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4
Q

Perjeta generic name

A

pertuzumab

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5
Q

high risk features of early stage breast cancer

A

high-grade tumor, large tumor size (≥2 cm), pathologically involved lymph nodes, and/or high 21-gene recurrence score

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6
Q

what is atypical ductal hyperplasia (ADH)?

A

Precursor to DCIS

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7
Q

duration of adjuvant endocrine therapy

A

Given node+ (>3), continue ET for 10 years (ATLAS – DFS + OS benefit)
Given 1-3 (CONFIRM), Determine Breast cancer index (BCI) to predict risk
Given node negative (<3)
high risk of recurrence (based on breast cancer index) → continue ET for 10 years (ATLAS)
low risk of recurrence → continuation for 5 years is individualized

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8
Q

Highest risk race for breast cancer

A

Higher risk among white females

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9
Q

Histologic subtypes of in situ breast cancer

A

Ductal

Lobular

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10
Q

most favorable histologic subtypes

A

Tubular and mucinous

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11
Q

Define the histologic subtypes of breast cancer

A
  • Invasive ductal carcinoma
  • lobular
  • mixed
  • mucinous
  • tubular
  • medullary
  • metaplastic
  • papillary
  • cribriform
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12
Q

most common histologic subtypes

A 
infiltrating ductal (75%)
infiltrating lobular (5-10%)
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13
Q

Receptor phenotype of lobular carcinoma

A
  • vast majority are ER positive + display loss of E-cadherin
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14
Q

Role for clinician and self breast exams

A

Some organizations recommend clinical breast exam yearly after age 40. Breast SELF-exam not recommended.

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15
Q
  • mammogram features concerning for malignancy

- feature suggesting benignity

A
  • spiculated soft tissue mass (most specific)
  • microcalcifications
  • irregularly outlined more common than rounded
  • solid mass suggests benign
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16
Q

Clinical utility of US

A
  • distinguishing between cystic and solid masses

- further information on likely of a solid mass being malignant

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17
Q

Test characteristics + clinical utility of MRI for assessment of breast cancer

A

Most sensitive modality but low specificity (benign breast lesions also enhance), but improvement in specificity hasn’t shown survival benefit in preoperative planning

  • Complement to mammogram for dense breasts
  • for invasive cancers contiguous to the chest wall, MRI may be needed for surgical planning.
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18
Q

effect of ER and PR status on breast cancer prognosis

A

ER/PR-negative tumors have a worse prognosis

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19
Q

what is oncotype DX?

A
  • 21-gene assay that provides a numerical score to quantify risk of recurrence for ER positive breast cancer
  • also predictive of adjuvant chemotherapy benefit
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20
Q

Management of lobular carcinoma in situ (LCIS)

A

Primary surgery, followed by risk reduction – (tamoxifen, raloxifine, aromatase inhibitors, bilateral prophylactic mastectomy)

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21
Q

Risk of future invasive breast cancer in a patient with LCIS?

A

1% per year

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22
Q

Management of DCIS

A

Mastectomy with SLNB OR lumpectomy with XRT

- tamoxifen if ER positive, unless undergoing bilateral mastectomy

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23
Q

Survival benefit of mastectomy versus lumpectomy

A

None

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24
Q

Initial treatment options for operable, early stage breast cancer?

A

1) Lumpectomy with surgical staging of the axillary lymph nodes
2) Total mastectomy with surgical staging of the lymph nodes
3) Neoadjuvant chemotherapy to permit breast conserving therapy

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25
Q

Next step for BiRads 0

A

Additional evaluation is required for further characterization, which may include additional mammographic views and or ultrasound and, rarely, magnetic resonance imaging (MRI).

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26
Q

why microcalcifications suggest breast cancer

A

They are intraductal calcifications in areas of necrotic tumor

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27
Q

management of brca 1 and 2 carrier and age

A

BRCA1 carrier:
Bilateral salpingo-oophorectomy by age 35-40 after childbearing (earlier in BRCA1)
+ Prophylactic bilateral mastectomies
BRCA2 carrier:
Bilateral salpingo-oophorectomy by age 40-45
Prophylactic bilateral mastectomies

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28
Q

what is the function of aromatase?

A

converts circulating androgens to estrogen

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29
Q

Name some of the common non-trastuzumab-based regimens for neoadjuvant and adjuvant treatment of breast cancer

A

ACT (docetaxel, doxorubicin, cyclophosphamide) (taxane-AC)
Dose-dense AC
TC (docetaxel/cyclophosphamide)

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30
Q

what is is AC regimen?

A

doxorubicin/cyclophosphamide

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31
Q

Firstline systemic therapy for HER2-positive metastatic disease

A

trastuzumab + pertuzumab + taxane until maximum tumor response, followed by maintenance trastuzumab + pertuzumab

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32
Q

Palbociclib indication

A

ER/PR+ metastatic breast cancer in postmenopausal women

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33
Q

indication for lapatinib

A

Second line for HER2-positive breast cancer (confirm)

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34
Q

Management of fibroadenoma

A
  • Primary surgery
  • path to rule out phyllodes tumor
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35
Q

What is a phyllodes tumor

A

Large, fast-growing masses that form from the periductal stromal cells of the breast.

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36
Q

Upper limit of breast cancer screening per ASCO and underling point

A

Life expectancy of 10 or more years. It should really be individualized based on someone’s health status, not some arbitrary cutoff.

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37
Q

Stage at which most patients present

A

Vast majority present without metastatic disease

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38
Q

Locally advanced includes which stages?

A

IIIA-IIIC

Subset of patients with IIb

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39
Q

Early stage breast cancer includes

A

Stage I, IIA, or subset of IIb

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40
Q

Management of early stage breast cancer

A

Primary surgery and surgical axillary staging with or without RT
Adjuvant chemo depending on tumor size, grade, number of involved lymph nodes, ER/PR status, HER2
However — triple negative typically treated with neoadjuvant chemo

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41
Q

Criteria precluding BCT

A

Multi centric disease
Large tumor size in relation to breast
*Diffuse malignant calcification on imaging
*Prior chest RT
Persistently positive margins despite attempts at re-excision

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42
Q

Initial workup (in addition to imaging)

A

1) Bilateral mammogram
2) US
3) Determination of ER/PR status and HER2
4) Genetic counseling if at risk for hereditary breast cancer syndrome
5) Pregnancy counseling
6) Imaging based on symptoms
PET/CT if stage IIIA or higher

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43
Q

Management of early stage patient with suspicious axillary lymph nodes

A

US + FNA or core biopsy

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44
Q

Management of patient with early stage BC and positive biopsy of axillary nodes

A

If going directly to surgery — axillary node dissection

45
Q

Management of patient with early stage BC and negative biopsy of axillary nodes

A

Sentinel lymph node biopsy at time of surgery

46
Q

Management of early stage patient with negative axillary examination

A

SLNB at time of surgery

47
Q

Role for HER2-directed therapy in early stage

A

Used if tumor is greater than 1 cm, in combination with chemo.
Use for small cancers is controversial.

48
Q

Adjuvant management of triple negative early stage breast cancer AND indication

A

Adjuvant chemo if tumor greater than 0.5 cm

49
Q

Goal of systemic therapy for locally advanced BC

A

Induce a tumor response and enable BCT

50
Q

Management of patient progressing on neoadjuvant systemic therapy

A

Proceed directly to surgery rather than switching regimen

51
Q

Management of patient who has complete clinical and/or radiographic response to NAC

A

Proceed to surgery still

52
Q

Role for adjuvant therapy in locally advanced

A

— HER2 positive following completion of surgery to complete a year of treatment
— continue endocrine therapy

53
Q

Breast cancer surveillance

A

Annual diagnostic mammo for 3-5 years then switch to screening mammo

54
Q

Prognostic significance of intramammary lymph nodes

A

Worse prognosis

55
Q

Mammogram laterality in surveillance

A

IF mastectomy –> no need
IF BCT –> still need
Always need bilateral otherwise (women with BC in one breast are at higher risk of breast cancer in other breast)

56
Q

Risk factors for breast cancer

A
  • Age
  • White
  • Dense breast tissue
  • Obesity
  • Hormone therapy
  • Smoking (modest)
  • RT (hodgkins patients)
  • Increased age at first full-term pregnancy
57
Q

Role for clinical breast exam

A

As part of physical exam in surveillance period

58
Q

Options for risk reduction following surgery for LCIS

A

tamoxifen, raloxifine, aromatase inhibitors, bilateral prophylactic mastectomy

59
Q

adriamycin generic name

A

doxorubicin

60
Q

Palbociclib mechanism

A

CDK4/6 inhibitor

61
Q

lapatinib mechanism

A

Small molecule inhibitor of VEGF + HER2

62
Q

Generally what differentiates early stage from locally advanced

A

presence of axillary adenopathy

63
Q

Common mechanism of resistance to anti-estrogen therapy

A

activation of the mTOR signaling pathway

64
Q

Phenotype of most BRCA1 breast cancers

A

triple negative

65
Q

Phenotype of most BRCA2 breast cancers

A

ER+

66
Q

Additional cancer types associated with BRCA2

A
  • ovarian, gastric, melanoma, prostate, pancreatic
67
Q

Additional cancer types associated with BRCA1

A
  • ovarian
68
Q

SRE reduction in anyone on an aromatase inhibitor

A

Zometa for up to 2 years

69
Q

When to start screening women for breast cancer who’ve had chest wall radiation (eg for hodgkins)

A
  • 10 years after XRT OR at age 40, whichever comes first
70
Q

Management of localized tubular carcinoma of the breast

A

Partial mastectomy with axillary sentinel lymph node biopsy

71
Q

tubular carcinoma of the breast clinical behavior

A

Excellent outcomes, do well

72
Q

First line for postmenopausal woman with ER, PR + breast cancer

A

CDK4,6 inhibitor + AI (letrozole)

73
Q

First line neoadjuvant for locally advanced triple negative breast cancer?

A

carbo/taxol + pembrolizumab, followed by doxorubicin/cyclophosphamide

74
Q

Management of residual disease after neoadjuvant therapy in locally advanced breast cancer

A

Capecitabine

75
Q

adjuvant therapy in early stage for HER2+, ER+

A

taxol-trastuzumab followed by aromatase inhibitor

76
Q

Firstline for triple negative MBC

A

Chemoimmunotherapy
Pembro if CPS greater than 10

77
Q

First line for triple negative MBC + chemo options

A

Single agent chemo(taxol vs. abraxane vs. gem/carbo) +- IO if PD-L1 CPS greater than 10%

78
Q

First line for HER2 positive MBC

A

Trastuzumab + pertuzumab + taxane

79
Q

Imaging modality + frequency needed for hodgkin’s patients treated with chest wall radiation

A

annual mammogram + MRI

80
Q

Second line for HER2 + metastatic

A

Trastuzumab deruxtecan (T-DXd) (newer ADC w/ higher payload + bystander effect) (DESTINY-Breast03)

81
Q

Adjuvant therapy for male breast cancer

A

Tamoxifen (can’t use AI due to concerns it may lead to incomplete estradiol suppression)

82
Q

What is TCHP?

A

Docetaxel (Taxotere)
Carboplatin (Paraplatin) Trastuzumab (Herceptin) Pertuzumab (Perjeta)

83
Q

Indications for neoadjuvant chemotherapy with HER2+ disease

A

Node positive or large tumors (greater than 2 cm)

84
Q

Management of HER2 positive breast cancer with pathCR

A

continue trastuzumab with pertuzumab (Dual HER2 blockade) for total 1 year

85
Q

Management of HER2 positive with incomplete response to NAC

A

adjuvant ado-trastuzumab emtansine (T-DM1) for 14 cycles, rather than trastuzumab (KATHERINE)

86
Q

when raloxifene is indicated

A

postmenopausal

87
Q

Indications for neoadjuvant for triple negative

A

T2 or T1N+ (CONFIRM)

88
Q

Additional RF

A

OCP’s (patients at increased risk, with family members with BC) should consider stopping oral contraceptives

89
Q

Intervention with survival benefit in BRCA patients

A

BSO
bilateral mastectomy has NOT been shown to have a survival benefit

90
Q

Drug indicated for PIK3CA + for what receptor status

A
  • alpelisib
  • hormone receptor positive
91
Q

Role for PIKC3A therapy in breast

A

Second line for metastatic hormone receptor positive

92
Q

Indication for bisphosphonate in breast cancer

A

IF adjuvant therapy planned AND postmenopausal REGARDLESS of receptor phenotype

93
Q

Sequencing of adjuvant XRT, endocrine, and chemotherapy for adjuvant hormone positive

A

Adjuvant chemotherapy, radiation therapy, followed by adjuvant endocrine therapy

94
Q

Nodal involvement warranting adjuvant radiation therapy

A

More than 3

95
Q

T-Dxd payload mechanism of action

A

Topoisomerase inhibitor

96
Q

NAC for HER2 positive and why

A

Trastuzumab/pertuzumab + nonanthracycline based chemo (TCHP)
- study showed nonanthracyclne based regimen had similar OS, so TCHP is less toxic with comparable outcomes

97
Q

what is considered locally advanced disease

A

*T3 or greater, N2 or N3 disease

98
Q

Adjuvant therapy for early stage node negative HER2+ breast cancer

A

Taxol + trastuzumab (de-escalation appropriate)

99
Q

Management of breast cancer in patient with Li fraumeni syndrome

A

mastectomy rather than lumpectomy with radiation (high risk of recurrent cancer so no radiation)

100
Q

BiRADS 2 management

A

Repeat mammogram every 6-12 months for 2-3 years to document stability
IF enlarging, biopsy

101
Q

BI-RADS 2 management

A

Continue regular screening

102
Q

Evidence for PARP inhibitors for BRCA mutant patients with metastatic disease

A

PFS but no OS benefit so not recommended (Confirm)

103
Q

Risk of developing contralateral breast cancer in BRCA2 mutant patient with breast cancer over 20 years AND risk of developing ovarian cancer

A

25%
- ovarian cancer - 15-20%

104
Q

Which BRCA mutation is higher risk for ovarian cancer? What is the risk over 20 years?

A

BRCA1 (40-45%)

105
Q

NAC regimen for PD-L1 positive triple negative

A

carbo/taxol + pembrolizumab, followed by doxorubicin/cyclophosphamide

106
Q

Adjuvant endocrine therapy in premenopausal woman

A

ovarian suppression + aromatase inhibitor

107
Q

Surveillance modality for patients who’ve had chest wall radiation

A

annual breast MRI (after age 25 years) and annual screening mammogram (after age 30 years). MRI and mammogram are often alternated every six months.

108
Q

Systemic therapies contraindicated in pregnancy

A
  • HER2-directed therapy
  • antiestrogen therapy
    *you can use anthracyclines and cytoxan during second trimester
109
Q

When is axillary lymph node dissection required after surgery in breast?

A

Greater than 3 lymph nodes involved on sentinel lymph node biopsy

Hematology, oncology (218 decks)

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