Reproduction 2024

Question 1

In premenopausal women, only ______________ is approved for breast cancer chemoprevention after a diagnosis of DCIS and in other high-risk patients

Answer 1

tamoxifen

Question 2

___________________is similar to tamoxifen in its mechanism, but has a lower risk of blood clots and actually has a beneficial effect on bone density

Answer 2

Raloxifene

Question 3

Breast cancer post-menopausal, chemoprevention options:

Answer 3

Aromatase inhibitors (AIs), tamoxifen and raloxifene. Three medications, letrozole, anastrozole and exemestane, fall into the class of aromatase inhibitors, and none is generally favored over any other.

Question 4

Breast screening for high-risk breast lesions

Answer 4

In patients with high-risk lesions such as DCIS, LCIS, and atypical ductal or lobular hyperplasia (ADH and ALH), patients may be offered high-risk screening. This consists of annual screening mammography coupled with annual screening breast MRI, along with semiannual provider
breast exams. Mammography and MRI are often staggered by six months, so that patients undergo some form of imaging semiannually, but the guidelines do not specific timing of imaging – the scan can be concurrent if desired.

Question 5

__________ is only used in the prophylactic (i.e., chemoprevention) setting

Answer 5

raloxifene is only used in the prophylactic (i.e., chemoprevention) setting

Question 6

In order to allow premenopausal women with high-risk breast cancers to take advantage of the superior risk reduction from AI therapy, they must _______________________

Answer 6

Aromatase inhibitors (AIs) are generally offered to postmenopausal women, because large RCTs (the so-called SOFT and TEXT trials) have shown AIs confer a small advantage over tamoxifen in risk of recurrence. Only tamoxifen can be offered to premenopausal women. In order to allow premenopausal women with high-risk breast cancers to take advantage of the superior risk reduction from AI therapy, they must be made functionally or surgically postmenopausal via a GNRH agonist (e.g., leuprolide) or a bilateral oophorectomy.

Question 7

Why must a premenopausal woman undergo ovarian suppression (OS) in order to take an AI, while tamoxifen can be taken without OS?

Answer 7

The reason aromatase inhibitors are typically not used in premenopausal women is that their ovaries are still actively producing estrogen. In premenopausal women, the primary source of
estrogen is the ovaries, while in postmenopausal women, estrogen is primarily produced in peripheral tissues through the conversion of androgens by aromatase enzymes.
In premenopausal women, the ovaries are the primary source of estrogen. Aromatase inhibitors primarily target the peripheral conversion of androgens to estrogen, so they are less effective in
reducing overall estrogen levels in premenopausal women.
When estrogen levels are decreased in premenopausal women using aromatase inhibitors, the body’s feedback mechanisms may respond by increasing the production of estrogen from the ovaries. This can offset the intended effects of the aromatase inhibitors.
To make aromatase inhibitors more effective in premenopausal women, a simultaneous approach to suppress ovarian function is often required. This can involve ovarian ablation (removal) or the use of drugs like luteinizing hormone-releasing hormone (LHRH) agonists to temporarily shut down ovarian function. These strategies are sometimes used in combination with aromatase inhibitors in specific cases.
For premenopausal women with HR+ breast cancer, other hormonal therapies are often considered, such as tamoxifen. Tamoxifen works differently by binding to the estrogen receptors in breast cancer cells and preventing estrogen from binding to them. This is a more suitable
option for premenopausal women because it doesn’t rely on reducing systemic estrogen levels

Question 8

standard regimen to treat HER2 positive breast cancer either
adjuvantly or neoadjuvantly.

Answer 8

TCHP (Taxotere® + Carboplatin + Herceptin® + Perjeta®)
“T” stands for docetaxel, a cytotoxic chemotherapy regimen that falls into the Taxane family of drugs. Cyclophosphamide is also a cytotoxic chemotherapy drug. Toxicities for these drugs include a standard side effects most people associate with chemotherapy, i.e., alopecia, nausea and vomiting, fatigue, myelosuppression (low white blood cell count, and specifically neutropenia), as well as taxane-induced neuropathy. In HER2-positive breast cancer, these drugs are combined with HER2
targeted therapies trastuzumab (brand name Herceptin) and Pertuzumab. The primary toxicity of these therapies is cardiomyopathy which is usually reversible when the drug is withdrawn.

Question 9

Breast cancer modifiable risk factors

Answer 9

Obesity, especially after menopause, is associated with an increased risk of breast cancer, as is a sedentary lifestyle. While high body adiposity is theoretically modifiable, metabolism slows after menopause (including medication-induced menopause) and weight loss, while always challenging for a variety of reasons, becomes even more difficult.
* Physical activity, which is more realistically modifiable, has also been shown to reduce breast cancer risk. Patients are advised to engage in at least 150 minutes of moderate-intensity exercise or 75 minutes of vigorous-intensity exercise per week.
* Drinking alcohol, even in moderation, is associated with an increased risk of breast cancer. Limiting alcohol consumption or avoiding it altogether can help reduce this risk.
* Other modifiable risk factors include hormone replacement therapy (HRT) and breast feeding. HRT that combines estrogen and progestin has been shown to increase the risk of breast cancer, while breastfeeding for an extended period may reduce the risk of
breast cancer.
Finally, patients with a strong family history of breast cancer, as with MC, may be offered high-risk screening, consisting of annual mammography and breast MRI, combined with semiannual clinical breast exam.