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847 > Breast Cancer > Flashcards

Breast Cancer Flashcards

1
Q

Breast Cancer

A
  • Most common malignant neoplasm in women

- Mortality has declined from improvements in medical management and early diagnosis

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2
Q

Breast Cancer Etiology

A
  • Peak age of occurrence ~50 years old

- Variety of factors influence its development

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3
Q

Breast Cancer Factors

A
  • Family history
  • Environment
  • Hormonal influences (menopause/early menarche)
  • Genetics
  • Carriers
  • erbB-2 proto-oncogene
  • p53 - tumor suppression gene
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4
Q

TDT

A
  • Tumor doubling time
  • Very heterogenous
  • May be directly related to patient survival
  • Early breast cancer has mean TDT of 25 days while late has ~129 days
  • Quick TDT could mean that the tumor has been present for 2-17 years before diagnosis
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5
Q

BC as Systemic Disease

A
  • Often appears systemic by diagnosis
  • May bypass lymph nodes and pass directly into blood
  • Demonstrated with survival curves since disease-free survival is impacted several years after diagnosis
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6
Q

Breast Cancer Pathology

A
  • Most are adenocarcinomas
  • Arise from ductal or lobular epithelium
  • Infiltrating ductal carcinoma or lobular carcinoma and two most common forms and have a similar prognosis
  • Inflammatory carcinoma has a poor prognosis
  • Several other forms and pre-malignant lesions also exist
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7
Q

BC Presentation

A
  • Usually painless mass
  • Sometimes has breast pain, skin changes, nipple discharge/retraction/erosion
  • ~5% have signs/symptoms of distant metastasis when they first seek therapy
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8
Q

BC Diagnostic Tests

A
  • Mammogram
  • Controversial for women <50 y.o.
  • Recommended to start at 40 y.o.+ or by individual patient
  • MRI may detect cancer in contralateral breast that is missed by mammography
  • MRI mainly recommended for women at high risk for BC or who have undergone chest wall radiotherapy for Hodgkin’s disease
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9
Q

BC Prognosis

A
  • Determined using TNM system
  • Stage is important for survival predictor
  • Both estrogen and progesterone receptors are important
  • Estrogen shown to have higher recurrence
  • Triple negative cancer has the worst prognosis (ER-, PR-, HER2-)
  • Positive nodal involvement is important to predict distant metastasis (more nodal involvement, less survivability)
  • Most fatal cases involve bone, lung, or liver
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10
Q

Stage 1/2 BC

A
  • Goals: achieve local control and accurately stage disease; ultimate goal: cure
  • Modified radical mastectomy or lumpectomy + radiotherapy for smaller, isoloated lesions
  • Radiotherapy for 4-6 weeks with ~5000cGY
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11
Q

Adjuvant Chemo

A
  • Using systemic chemotherapy as an adjunct to surgery/radiation in patients with primary breast cancer
  • Can also be neoadjuvant therapy for large stage IIA/IIB tumors
  • Administered every 3 weeks, dose dense is administered every 2 weeks
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12
Q

Adjuvant Chemo Examples

A
  • FAC
  • AC => paclitaxel
  • ACTH
  • TCH
  • TAC
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13
Q

AC

A
  • (A) Doxorubicin 60 mg/m^2 + (C) Cyclophosphamide 600 mg/m^2
  • Q21 days x 4 cycles
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14
Q

Paclitaxel

A
  • 175 mg/m^2
  • Q3 weeks x 4 cycles
  • Standard prophylaxis given prior to cycles
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15
Q

Paclitaxel Prophylaxis

A
  • Dexamethasone 40 mg PO/IV
  • Diphenhydramine 50 mg IV
  • H2 antagonist IV 30-60 min prior
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16
Q

Dose Intensity Recommendations

A
  • Important factor in patient outcome
  • Give chemo on schedule as much as possible
  • Do not reduce dosing for manageable toxicities
  • Provide adequate supportive care (N/V protection, FN prevention/treatment, mucositis treatment)
17
Q

ACTH

A
  • AC same as in AC => paclitaxel followed by…
  • (H) Trastuzumab 8 mg/kg once, then 6 mg/kg IV Q3w (Can add pertuzumab as well)
  • (T) Docetaxel 75-100 mg/m^2 IV day 1, Q21 days x 4 cycles (given with prophylaxis)
18
Q

HER-2+ Recommendation

A
  • Add Trastuzumab 4 mg/kg IV once, then 2 mg/kg IV Qweek x 51 weeks
  • Added with paciltaxel after doxorubicin is complete (CHF risk)
  • Shown to improve disease-free survivability and overall survivability
  • Monitor cardiac function at baseline and through treatment
  • Can give with second HER2 antibody for additional coverage
19
Q

Docetaxel Prophylaxis

A

Dexamethasone 6 mg BID x 3 days starting 1 day prior to treatment
-Used to prevent fluid retention/hypersensitivity

20
Q

TCH + Pertuzumab

A

-(T) Doxetaxel 75 mg/m^2 + (C) carboplatin AUC6, Q3weeks x 6 cycles + same (H)/pertuzumab dosing/schedule as in ACTH

21
Q

AUC Carboplatin Dosing

A

(CrCl + 25) * AUC

22
Q

Adjuvant Regimens + G-CSF Therapy

A
  • Dose dense AC => Paciltaxel
  • TAC
  • Give filgastrim 5 mcg/kg IV daily after chemo completion and continue until neutrophil recovery (~10 days)
  • Alternative: PEG-filgastrim 6 mg SQ once on the day after chemo
23
Q

Anthracycline Toxicities

A
  • Myelosuppression
  • N/V
  • Cardiotox.
  • Mucositis
  • Alopecia
24
Q

Taxane Toxicities

A
  • Myelosuppression
  • Hypersensitivity reaction
  • Peripheral neuropathy
  • Myalgia/arthralgia
  • Fluid retention
  • Skin/nail changes
  • Total body alopecia
25
Q

Trastuzumab/Pertuzumab Toxicities

A
  • Increased cardiotox. risk

- Interstitial pneumonitis

26
Q

Cyclophosphamide or Carboplatin Toxicities

A
  • Myelosuppression
  • N/V
  • Cystitis (give adequate hydration to prevent)
27
Q

Adjuvant Hormonal Therapy

A
  • Consider in cancers with at least 1% of ER and/or PR+ cells by IHC
  • More controversial in premenopausal patients
  • Don’t give with chemo
  • Adjuvant tamoxifen 20 mg/day reduces annual odds of death/recurrence by ~30-40%
  • Better results when given long term
  • Antiestrogenic effect on breast cancer cells while giving positive estrogen effect in bones and LDLs
  • Possible may need to type of CYP2D6
  • AE: hot flashes, bleeding, increase uterine cancer risk, thromboembolism
28
Q

Aromatase Inhibitors

A
  • Anastrozole 1 mg/d, letrozole 2.5 mg/d, and exemestane 25 mg/d
  • All mainly options in postmenopausal women
  • May be better tolerated than tamoxifen, but greater risks of myalgias/arthralgias and fractures
  • Recommended as component of adjuvant hormone therapy for women with ER and/or PR+ disease
  • Ideally use for 5 year or along with tamoxifen for a total of 5 years
  • May also give with bisphosphonates or denosumab to prevent bone loss while on AI
29
Q

Stage III/Inflammatory BC

A
  • Goal: prolong survival
  • Benefit from pre-op chemo/radiation and post-op chemo
  • Same chemo/hormone regimens as Stage I/II
  • Evidence supports use of a anthracycline + taxane regimen
  • High dose chemo with bone marrow transplant or progenitor cell support isn’t recommended
30
Q

Stage IV BC

A
  • Goal: palliation and extended survival
  • Treatment with chemo/endocrine therapy often results in disease regression
  • Hormone receptor status is important to its response to hormonal therapy
  • Slowly progressing disease generally utilizes hormone therapy while rapidly advancing disease would consider chemotherapy use instead
  • Use different hormonal therapy than utilized previously especially in recent exposure
31
Q

Premenopausal HER2- Treatment

A
  • Hormone therapy (SERM or AI) +/- CDK inhibitor +/- ovarian ablation or suppression with LHRH analogue
  • Additionally add an HER2 agent of wanted when HER2+
32
Q

Secondary Hormonal Therapy

A
  • Consider additional type of hormone therapy if not refractory
  • Fulvestrant ~equivalent to AIs
  • Recommend palbociclib + fulvestrant for women with HR+/HER- who progressed on prior hormonal therapy
33
Q

Stage IV BC + Chemo

A

Candidates include:

  • Patients with disseminated disease who fail hormonal manipulation
  • Patients with rapidly advancing and widespread disease
  • Patients with estrogen receptor negative metastatic disease
  • Note: Patients who have even a partial response (PR) to chemo or hormonal therapymay have a significant reduction in symptoms (e.g. bone pain)
  • *Chemo continued until progression or unacceptable toxicity**
  • *Chemo options and single/combination agents vary based on HR status and patient’s previous response**
34
Q

Control of Symptomatic Metastasis

A
  • Radiotherapy for local symptoms and make remaining days more tolerable
  • Bisphosphonates, give with calcium/vitamin D3
  • Denosumab if bisphosphonates are toelrated

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