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Fall 2021: Therapeutics III > Therapeutics of Breast Cancer (Weddle) > Flashcards

Therapeutics of Breast Cancer (Weddle) Flashcards

1
Q

Provide some risk factors for breast cancer.

A
  • age
  • 1st- and 2nd-degree relatives with breast cancer
  • personal history
  • prior treatment for lymphoma with mediastinal XRT or environmental radiation exposure
  • endogenous estrogen exposure (early menarche, late menopause)
  • exogenous estrogen (oral contraceptives, HRT)
  • alcohol
  • prior breast biopsies
  • nulliparity or age >30 before 1st birth
  • elevated BMI
  • diet
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2
Q

BRCA 1 and 2 are ________________.

A

tumor suppressor genes

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3
Q

Which BRCA type has a high prevalence of variants in Askenazi Jews?

A

BRCA1

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4
Q

Which BRCA type is more often implicated in male breast cancers?

A

BRCA2

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5
Q

What is the purpose of the GAIL model?

A

determines relative risk (RR) of developing breast cancer

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6
Q

Data on clinical exams was shown to be ___________ to demonstrate benefits.

A

insufficient

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7
Q

Which organization is more supportive of annual mammograms?

A

American Cancer Society

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8
Q

At what age does the American Cancer Society endorse annual mammograms?

A

45-54

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9
Q

What three agents have been studied for breast cancer prevention?

A

tamoxifen, raloxifene, and exemestane

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10
Q

What was the most important conclusion of the NSABP Breast Cancer Prevention Trial?

A

tamoxifen decreased the risk of invasive/noninvasive breast cancer in all women (50% risk reduction)

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11
Q

Although tamoxifen has been shown to decrease risk of breast cancer, what were some drawbacks from the Breast Cancer Prevention Trial?

A
  • increased endometrial cancer
  • increased risk of stroke/PE/DVT
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12
Q

Which agent did the MORE Trial evaluate?

A

raloxifene

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13
Q

What did the STAR trial reveal?

A

that raloxifene was just as effective as tamoxifen (both drugs showed 50% reduction)

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14
Q

Which agent is known to have more toxicities: tamoxifen or raloxifene?

A

tamoxifen

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15
Q

Which agent did the NCIC-CTG MAP.3 Study investigate?

A

exemestane

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16
Q

True or false: both exemestane and anastrazole are FDA-approved for breast cancer prevention

A

false; neither is FDA-approved, although they do appear to be reasonable prevention options

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17
Q

Most invasive carcinomas of the breast are ________.

A

ductal (IDC)

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18
Q

How will a patient with inflammatory breast cancer present?

A
  • edema
  • redness
  • warmth
  • inflammation
  • peau d’orange
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19
Q

Why would inflammatory breast cancer be delayed in diagnosis?

A

it is often misdiagnosed as cellulitis

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20
Q

Which breast cancer type is typically seen as microcalcifications on a mammogram?

A

ductal carcinoma in situ (DCIS)

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21
Q

When might an ultrasound be useful in diagnosing breast cancer?

A

in younger women with denser breasts; can distinguish between a solid mass or cyst

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22
Q

Define fine needle aspiration.

A

fluid and/or cells are removed from the breast lump using a thin needle

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23
Q

Define core biopsy.

A

a thick needle is used to remove tissue from the breast (gold standard, helps determine if invasive)

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24
Q

Define surgical biopsy.

A

removal of the entire lesion for pathological examination

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25
Q

What are the two ways that we can test a patient’s HER2 status?

A

immunohistochemistry or FISH

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26
Q

In which breast cancer groups is Oncotype DX validated for use?

A
  • newly-diagnosed
  • stage I or II
  • lymph node -/+
  • ER+
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27
Q

What TAILORx score would warrant chemotherapy and hormonal therapy?

A

26 or greater

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28
Q

True or false: breast cancer can metastasize anywhere.

A

true

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29
Q

What are the two breast cancer tumor markers?

A

CA 27.29 and CA 15-3

30
Q

Describe the general treatment strategy for stage I, II, and IIIA breast cancer.

A
  • lumpectomy + XRT OR mastectomy +/- XRT
  • some stage II and IIIA may have neoadjuvant chemo, and most will receive adjuvant chemotherapy, hormonal therapy, biologic therapy, and/or immunotherapy
31
Q

Describe the general treatment strategy for stage IIIB and IIIIC breast cancer.

A

neoadjuvant therapy followed by MRM or lumpectomy + XRT

32
Q

Describe the general treatment strategy for stage IV breast cancer.

A

palliative chemo/hormone therapy +/- biologics/immunotherapy

33
Q

During an SLN dissecton, the first lymph node that the blue dye reaches is considered the _____________.

A

sentinel node

34
Q

XRT should always be done in conjunction with modified radical mastectomy (MRM), except in what case?

A

patients 70+ (ER+, node-, T1 disease)

35
Q

What treatment modality is NOT used as neoadjuvant therapy for breast cancer?

A

radiation

36
Q

What adjuvant therapy would you recommend for a hormone(+), lymph node(+/-), HER2(-) tumor ≤ 0.5 cm?

A

consider adjuvant endocrine therapy

37
Q

What adjuvant therapy would you recommend for a hormone(+), lymph node(+/-), HER2(-) tumor > 0.5 cm or 1-3 positive lymph nodes?

A

strongly consider 21-gene assay

  • if not done: adjuvant endocrine therapy or adjuvant chemo followed by endocrine therapy
  • if <26: adjuvant endocrine therapy
  • if 26+: adjuvant chemo followed by adjuvant endocrine therapy
38
Q

What two factors must be assessed if a patient presents with a breast tumor > 1 cm, node negative?

A

ER and HER2 status

39
Q

Recommended adjuvant therapy for a breast tumor > 1 cm, node(-), ER(+), HER2(+)?

A

chemotherapy, HER2 therapy, endocrine therapy

40
Q

Recommended adjuvant therapy for a breast tumor > 1 cm, node(-), ER(+), HER2(-)?

A

chemotherapy + endocrine therapy

41
Q

Recommended adjuvant therapy for a breast tumor > 1 cm, node(-), ER(-), HER2(+)?

A

chemotherapy + HER2 therapy

42
Q

Recommended adjuvant therapy for a breast tumor > 1 cm, node(-), ER(-), HER2(-)?

A

chemotherapy + immunotherapy

43
Q

What are the three major toxicities associated with tamoxifen use?

A

hot flashes, endometrial cancer, DVT

44
Q

Ideally, aromatase inhibitors should only be used in ___________ patients.

A

postmenopausal

45
Q

What needs to happen if you want to use an aromatase inhibitor in a premenopausal woman?

A

ovarian suppression

46
Q

What is a pro of using an aromatase inhibitor over tamoxifen?

A

fewer adverse effects

47
Q

How long should tamoxifen/aromatase inhibitors INITIALLY be used for in breast cancer patients who are premenopausal at diagnosis?

A

5 years

48
Q

What is the next logical treatment step after a woman has completed her 5 years of tamoxifen/AI, but remains premenopausal?

A

5 more years of tamoxifen (10 years total) OR no further endocrine therapy

49
Q

What is the next logical treatment step if a woman who has initiated tamoxifen/AI when premenopausal is now postmenopausal 5 years later?

A

consider tamoxifen/AI for 5 more years (10 years total)

50
Q

What adjuvant hormonal therapy is recommended for women who are postmenopausal at the time of breast cancer diagnosis?

A

AI for 5 years, then consider AI for an additional 5 years

51
Q

What are the two NCCN preferred adjuvant chemotherapy regimens for HER2- breast cancer?

A
  • dose-dense AC (doxorubicin + cyclophosphamide) + paclitaxel
  • TC (docetacel + cyclophosphamide)
52
Q

The CALBG trial demonstrated that ____________.

A

sequential vs. concurrent chemotherapy did not show any difference (although sequential was less toxic)

53
Q

What is the most prevalent risk to be concerned about with using an anthracycline-based regimen for breast cancer?

A

cardiac risks; if cardiac problems, consider TC chemotherapy

54
Q

HER2+ disease benefits greatly from the incorporation of which biologic?

A

trastuzumab

55
Q

Give an example (or 3) of an adjuvant HER2+ regimen.

A
  • APT (paclitaxel + trastuzumab)
  • TCH (docetaxel + carboplatin + trastuzumab)
  • TCH + pertuzumab
56
Q

What did the standard of care for HER2 therapy become after the HERA trial?

A

1 year of adjuvant trastuzumab/pertuzumab therapy

57
Q

What should the plan of care be if a HER2(+) patient shows residual disease after surgery?

A

stop trastuzumab/pertuzumab and start ado-trastuzumab emtansine

58
Q

What is the likely course of treatment in a patient with triple negative breast cancer?

A

anthracycline and taxane chemotherapy regimen

59
Q

What did the CREATE-X study demonstrate?

A

that capecitabine can be used as adjuvant therapy for TNBC residual cancer

60
Q

What did the KEYNOTE-522 study demonstrate?

A

that pembrolizumab should be added to a TNBC regimen and continued for 1 year if PD-1+

61
Q

When would metastatic breast cancer warrant chemotherapy?

A

if symptomatic

62
Q

Which is preferred in metastatic breast cancer: combination or sequential chemotherapy?

A

sequential

63
Q

What are the two first-line agents for metastatic TNBC?

A

single-agent platinums (carboplatin/cisplatin)

64
Q

What therapy is 1st line for HER2- and postmenopausal/OS metastatic breast cancer?

A

AI + CDK4/6 (abemaciclib, palbociclib, or ribociclib)

65
Q

True or false: palbociclib is the preferred CDK 4/6 inhibitor for metastatic breast cancer.

A

false; no one agent is preferred

66
Q

List the four monitoring parameters for palbociclib.

A
  1. neutropenia
  2. pulmonary embolism
  3. diarrhea
  4. pneumonitis
67
Q

What is everolimus’ mechanism of action?

A

mTOR inhibitor

68
Q

Which two agents did the BOLERO-2 trial evaluate?

A

everolimus + exemestane

69
Q

What is the most notable side effect of everolimus?

A

mucositis

70
Q

What drug should be avoided in combination with tamoxifen (to avoid heat flashes)?

A

strong - moderate CYP2D6 inhibitors

Fall 2021: Therapeutics III (25 decks)

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