Lecture 16 Breast cancer

Question 1

Describe the risk factors associated with breast cancer, including age, family history, and genes like BRCA1/BRCA2. What role does age at first full term pregnancy play in increasing the risk of breast cancer?

Answer 1

Risk factors for breast cancer include age, family history (especially if young onset or bilateral), and genes like BRCA1/BRCA2. Women over 30 at first full term pregnancy have an increased risk. Clinical assessment involves feeling for lumps, checking for changes in shape, color, nipple appearance, and discharge.

Question 2

What are the common presentations of breast cancer? How does breast cancer typically manifest in terms of symptoms and physical changes?

Answer 2

Breast cancer can present asymptomatically or with a painless lump, changes in breast size/shape, skin changes like Erythema or Beau d’orange, nipple discharge/bleeding/inversion, arm swelling, lymphadenopathy, or symptoms of secondary tumors elsewhere.

Question 3

Explain the pathology of breast cancer. What are the common types of breast cancer based on their origin and invasiveness? How do molecular markers and IHC play a role in predicting outcomes?

Answer 3

Breast cancer typically arises from glandular epithelium and is often invasive at diagnosis. Common types include ductal or lobular. Molecular markers and IHC are increasingly used to predict outcomes. Pathological subtypes include Luminal A, Luminal B, Triple negative, and HER2-type.

Question 4

Describe the characteristics of Luminal A, Luminal B, Triple negative, and HER2-type breast cancer subtypes.

Answer 4

Luminal A: ER/PR positive, HER2 negative, Low Ki-67. Luminal B: ER/PR positive, HER2 positive or negative with High Ki-67. Triple negative: ER/PR negative, HER2 negative. HER2-type: ER/PR negative, HER2 positive.

Question 5

Explain the pathological staging criteria for breast cancer based on T, N, and M categories.

Answer 5

T: <2cm, T2: 2-5cm, T3: >5cm, T4: a- chest wall, b- skin, c- a+b, d- inflammatory breast cancer. N0: 0 nodes, N1: 1-3 nodes, N2: 4-9 nodes, N3: >9 nodes. M0: no metastases, M1: distant metastases.

Question 6

How do breast cancer cells spread locally, nodally, and hematogenously in the body?

Answer 6

Local extension: skin, chest wall. Nodal spread: Axilla, S.C.F, Internal Mammary Nodes. Hematogenous spread: Bone, Liver, Lung, Brain.

Question 7

Define the significance of Ki-67 in breast cancer subtyping and its association with Luminal B subtype.

Answer 7

Ki-67 is a marker of cell proliferation. In Luminal B subtype, high Ki-67 levels are associated with more aggressive behavior, even if HER2 is negative, leading to a different treatment approach.

Question 8

Describe the targeted therapies for Luminal A, Luminal B, Triple negative, and HER2-type breast cancer subtypes.

Answer 8

Luminal A/B: Hormonal therapies. HER2-type: HER2-targeted therapies. Triple negative: No targeted hormonal therapy due to lack of ER/PR/HER2 receptors, often treated with chemotherapy.

Question 9

Describe the prognostic factors used to classify the risk of relapse in breast cancer patients and inform treatment strategies.

Answer 9

Prognostic factors include nodal status, lymphovascular invasion, grade, receptor status (ER/PR/HER2), tumor size, molecular markers like ki-67.

Question 10

How does radiotherapy impact the risk of local recurrence after breast cancer surgery, and what is the equivalent risk reduction compared to mastectomy?

Answer 10

Radiotherapy reduces the risk of local recurrence after BCS from 20-30% to 5-10%, which is equivalent to the risk after mastectomy.

Question 11

Define the role of endocrine therapy in breast cancer treatment and provide examples of medications that inhibit estrogen binding to receptors or stop estrogen production.

Answer 11

Endocrine therapy in breast cancer involves medications like Tamoxifen, Fulvestrant, Oophorectomy, Goserelin, Aromatase inhibitors (e.g., exemestane, anastrazole, letrazole) that inhibit estrogen binding or production.

Question 12

What are the mechanisms of action for endocrine therapy in breast cancer treatment?

Answer 12

Endocrine therapy works by inhibiting estrogen binding to receptors (e.g., Tamoxifen, Fulvestrant) or stopping estrogen production (e.g., Oophorectomy, Goserelin, Aromatase inhibitors like exemestane, anastrazole, letrazole).

Question 13

Describe the role of adjuvant therapy in breast cancer treatment, specifically focusing on hormonal therapy. What are the benefits of using anti-oestrogens like Tamoxifen? What are the potential side effects of hormone therapy?

Answer 13

Adjuvant therapy in breast cancer involves using treatments like Tamoxifen to target hormone receptor-positive tumors. Tamoxifen can improve relative survival by around 30% and reduce the risk of recurrence. However, it may cause side effects such as hot flushes, nausea, weight gain, vaginal dryness, and acceleration of osteoporosis.

Question 14

Explain the aim of adjuvant systemic treatment in breast cancer management. How does chemotherapy play a role in reducing mortality from micro-metastatic disease? What factors are considered when assessing outcomes of chemotherapy in breast cancer patients?

Answer 14

Adjuvant systemic treatment aims to decrease mortality from micro-metastatic disease present at diagnosis. Chemotherapy is used to target these hidden cancer cells. Factors like tumor pathology, molecular markers, gene expression profiling, patient’s age, comorbidities, and preferences are considered when evaluating chemotherapy outcomes.

Question 15

Discuss the significance of incorporating aromatase inhibitors in hormonal therapy for breast cancer. How does the addition of aromatase inhibitors impact survival benefits?

Answer 15

Adding aromatase inhibitors to hormonal therapy for breast cancer can provide a significant survival benefit, especially when switched from Tamoxifen. These inhibitors help further suppress estrogen production, reducing the risk of cancer recurrence and improving long-term outcomes.

Question 16

How do anti-oestrogens like Tamoxifen work in the treatment of hormone receptor-positive breast cancer? What are the key considerations when deciding on the duration of Tamoxifen therapy?

Answer 16

Anti-oestrogens like Tamoxifen work by blocking estrogen receptors in hormone receptor-positive breast cancer, inhibiting tumor growth. The duration of Tamoxifen therapy, typically five years, is based on its ability to improve relative survival by approximately 30% and maintain this benefit even after 15 years of treatment.

Question 17

Describe the regimens currently used in NICC for different types of breast cancer patients.

Answer 17

The regimens used in NICC include FEC-D for high-risk node negative or positive disease, FEC-weekly paclitaxel for certain patients, AC, DC, paclitaxel weekly + trastuzumab for lower risk node negative disease, FEC100, FEC60, and CMF. Each regimen is tailored based on the patient’s condition.

Question 18

What are the side effects associated with fluorouracil and epirubicin in breast cancer treatment?

Answer 18

Fluorouracil side effects include stomatitis, diarrhea, low nausea & vomiting, alopecia, palmer-plantar syndrome, thrombophlebitis, and leucopenia. Epirubicin side effects include myelosuppression, cardiotoxicity, alopecia, stomatitis, and moderate nausea & vomiting.

Question 19

How are the regimens like FEC-D and AC used in the treatment of breast cancer patients with different risk profiles?

Answer 19

FEC-D is used for high-risk node negative or positive disease, while AC is used for lower risk node negative disease. These regimens are tailored based on factors like age, tolerance to specific drugs, and tumor characteristics.

Question 20

Define the side effects of epirubicin in breast cancer treatment and how they impact patients.

Answer 20

Epirubicin side effects include myelosuppression, cardiotoxicity, alopecia, stomatitis, and moderate nausea & vomiting. These side effects can affect the patient’s blood cell count, heart function, hair loss, oral health, and overall well-being during treatment.

Question 21

Describe the significance of paclitaxel weekly + trastuzumab in the treatment of breast cancer patients with specific tumor characteristics.

Answer 21

Paclitaxel weekly + trastuzumab is used for small (T1) node negative breast cancer patients whose tumors overexpress HER2. This regimen is important for targeting HER2-positive tumors and improving outcomes in this specific subgroup of patients.

Question 22

Describe the recommended antiemetic regimen for a patient on day 1 of treatment with Aprepitant, Dexamethasone, Ondansetron, and Levomepromazine.

Answer 22

On day 1 of treatment, the patient should take Aprepitant 125mg orally pre-treatment, Dexamethasone 12mg orally pre-treatment, Ondansetron 8mg orally pre-treatment followed by 8mg in the evening, and Levomepromazine 6mg orally at night.

Question 23

What are the side-effects associated with Cyclophosphamide treatment?

Answer 23

Cyclophosphamide may cause anorexia, moderate nausea & vomiting, alopecia, hemorrhagic cystitis, and neutropenia.

Question 24

How can hemorrhagic cystitis be managed in patients receiving treatment with Cyclophosphamide?

Answer 24

Hemorrhagic cystitis in patients on Cyclophosphamide can be managed by adding mesna to the treatment, which can be administered intravenously or orally, along with encouraging the patient to drink plenty of fluids.

Question 25

List the common side-effects of Taxanes treatment.

Answer 25

Common side-effects of Taxanes treatment include neutropenia, hypersensitivity reactions, fluid retention, low-grade nausea and vomiting, alopecia, and nail changes.

Question 26

Describe the hypersensitivity reactions associated with Phesgo® treatment.

Answer 26

Phesgo® treatment can lead to mild to moderate hypersensitivity reactions such as flushing, rash, chest tightness, back pain, dyspnea, drug fever, chills, fluid retention, and infusion reactions like fever, chills, and headache.

Question 27

How can nail changes manifest in patients undergoing chemotherapy with Phesgo®?

Answer 27

Nail changes in patients on Phesgo® chemotherapy can include halted growth, color changes, and nails falling off. These changes are mainly cosmetic and typically resolve within 6-12 months post-chemotherapy.

Question 28

Define the treatment approach for hypersensitivity and fluid retention during Phesgo® chemotherapy.

Answer 28

The treatment approach involves pre-medication with dexamethasone 16mg daily for three days before chemotherapy to manage hypersensitivity reactions. For nausea and vomiting, metoclopramide 10mg orally three times a day is recommended.

Question 29

What are the side effects associated with Phesgo® treatment?

Answer 29

Phesgo® treatment can lead to side effects like cardiotoxicity, chest or abdominal pain, diarrhea, nausea, vomiting, arthralgia, myalgia, and rash. Additionally, infusion reactions such as fever and chills may occur.

Question 30

How does the choice of systemic therapy differ between hormone therapy and chemotherapy for breast cancer patients?

Answer 30

Hormone therapy is preferred for ER+ve, slow biology, non-critical sites, advanced age, and poor performance status patients. On the other hand, chemotherapy is recommended for ER-ve, aggressive biology, liver/bulky lung involvement, young age, and good performance status patients.

Question 31

Describe the assessment process for outcomes and in metastatic breast cancer treatment.

Answer 31

In metastatic breast cancer treatment, outcomes and toxicity are assessed by restaging at diagnosis of metastases evaluating toxicity every cycle (including performance status, weight change, side effects, and quality of life), monitoring tumour response every three cycles clinically and through imaging, and discontinuing treatment in case of disease progression or intoler toxicity.

Question 32

What are the different endocrine therapy options for metastatic breast cancer, and what is known about the optimal sequencing of hormonal therapies?

Answer 32

Endocrine therapy options for metastatic breast cancer include Tamoxifen (+/- goserelin), Aromatase inhibitors (+/- goserelin), and Fulvestrant. The optimal sequencing of hormonal therapies in metastatic breast cancer is currently unknown.

Question 33

What are the common side effects associated with Capecitabine in metastatic breast cancer treatment?

Answer 33

Common side effects of Capecitabine in metastatic breast cancer treatment include minimal nausea and vomiting, diarrhea, mucositis, and Palmer-plantar syndrome.