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Oncology Exam 3
Frei Breast Cancer Curable A
| Question | Answer |
|---|---|
| 1 in how many men will be diagnosed in US with cancer? | men: 1 in 2 women: 1 in 3 |
| Review: Which cancer has the HIGHEST MORTALITY in women in the US? | Lung Cancer |
| Which cancer is the most common in women in US? | Breast Cancer |
| Which of the following is a risk factor for breast cancer? | older than 40 |
| Which of the following medications is recommended for breast cancer prevention? | Anastrozole |
| Which of the following pts is most likely to develop breast cancer? -42 yo white male -33 yo hispanic woman who gave birth for the first time at age 20 and has 3 kids -37 yo white female with a female history of breast cancer and has tested positive for BRCA 1 deletion -70 yo Asian female who has had normal mammograms since she was 40 yo. had her first child at age 24 yo | -37 yo white female with a female history of breast cancer and has tested positive for BRCA 1 deletion mutation |
| Older you get and white caucausian--> | Higher risk of breast cancer |
| The # 1 cancer in terms of "incidence" in women is? | Breast Cancer |
| The 2nd most common cause of cancer-related mortality in women in the US? | Breast Cancer |
| The lifetime risk of developing breast cancer is 1 in ___ women | 8 |
| The way cancer occurs--> it has malignant progression from normal ductal cells so its: | atypical hyperplasia--> ductal carcinoma in situ--> invasive ductal carcinoma *in situ (in the place it started); |
| 10% of breast cancers are caused by genetic mutations i.e. (_____) | mostly BRCA 1 and BRCA 2 |
| What are the risk factors for breast cancer? | Gender, age, family history of breast cancer, endogenous estrogen exposure, benign breast disease, radiation exposure, obesity and BMI in postmenopausal setting only, physical activity, exogenous estrogen exposure (controversial), alcohol, having children increases risk of breast cancer (<25 decreases risk of breast cancer) |
| If you have kids after 30, or unable to have kids ("null parity" on a pt case) that would? | increase your risk of breast cancer |
| Mammogram screening recommendations for AVERAGE risk women based on the NCCN? | Annual mammogram from >/= 40 |
| Breast cancer screening high risk women: annual mammogram starting age __ and clinical breast exam every __-___ months OR can start mammograms 10 years before first affected family member | 30; 6-12 |
| The group unlikely get mammograms are the _____ and those with less education | uninsured (they don't have insurance to help cover the cost) |
| Breast cancer prevention: there are non-pharmacologic ways to prevent breast cancer and there are pharmacologic ways. Non-Pharm? | eat healthy, maintain a healthy weight especially in that postmenopausal setting, decrease alcohol intake, exercise, and not taking exogenous estrogen |
| Breast cancer prevention: there are non-pharmacologic ways to prevent breast cancer and there are pharmacologic ways. Pharm therapy--> Step 1? | 1. calculate the person's 5 year risk of IBC to see if they have a high enough risk of breast cancer to warrant trying a medication that would also potentially cause SE in a pt |
| Breast cancer prevention: --> 1. calculate pt's 5 year risk of breast cancer (online quiz) and if its ____ or higher and they are expected to live for ___ years, we will give medication | 3%; 10 |
| Breast cancer: Less than 3% for their 5-year risk of breast cancer, Tx or no Tx? | No intervention (Non-pharm) |
| Breast Cancer: If you find that its >/=3% and have > 10 years of life expectancy, you would then investigate what is their ______ status | menopause (pre/post)--> bc that makes a difference in which drugs we use |
| Breast cancer: If they are >/=3% and have > 10 years of life expectancy and have pre or perimenopausal status. What agent do we give? | Tamoxifen |
| Breast cancer: If they are >/=3% and have > 10 years of life expectancy and have POSTmenopausal status. What agents can we give? | Raloxifene, Tamoxifen, Aromatase Inhibitors |
| What is the clinical presentation of breast cancer? | -Painless mass - 90% -stabbing or aching pain may be first symptom - 10% -nipple discharge, retraction, or dimpling - less common -80% of women first detect some abnormality themselves |
| Breast cancer: Only about 10% of pts present initially with _______ disease | metastatic; unlcear the % of pts that later develop metastatic disease |
| Sites of metastasis in breast cancer are? | -Bone (most common)⭐️ -liver -lung -brain -distant lymph nodes |
| ⭐️Breast cancer risk factors that CANNOT be changed--> | Age, gender (all women are at risk), family/personal history, race, tx with DES, Radiation, Genetic factors, Menstrual history, Reproductive history |
| ⭐️Breast cancer risk factors that CAN be controlled--> | Obesity, exercise, alcohol, hormone replacement therapy, birth control pills, not having children |
| The trial LANCET analysis used the intervention Tamoxifen and the results were--> | Overall reduction in breast cacner incidence of 30-40% ⭐️; -no effect on all-cause mortality |
| The STAR trail (NSABP P2) used the intervetnion of Tamoxifen vs Raloxifene and the results were--> | Tamoxifen had statistically significant reduction in invasive breast cancer than Raloxifene *Tamoxifen is superior to Raloxifene in preventing breast cancer however Raloxifene also had less SE than Tamoxifen ⭐️ |
| Anastrozole and Examestane which are Aromatase inhibitors, the takeaway is that they--> | have not been compared to any of the other tx, only to Placebo they were compared to. |
| STAR trial takeaway is that Raloxifene significantly was better wiht the risk of? | uterine cancer, blood clots, and cataracts *better tolerated whereas Tamoxifen has a higher risk |
| You cannot use Aromatase inhibitors in pre and perimenopausal pts, its only _____ | Tamoxifen |
| Postmenopausal women can use which agents? | Raloxifene, Exemestane, Anastrozlole |
| Tamoxifen and Raloxifene can _____ Bone mineral density because they are SERMS. Exemestane and Anastrozole _______ BMD | increase; decrease |
| A downside to Tamoxifen is due to its drug interaction with? | CYP 2D6 inhibitors |
| Adverse effects to remember for our Aromatase inhibitors (Exemestane and Anastrozole) are? | Arthralgias / Myalgias/ Fatigue |
| Tamoxifene ADR--> | Endometrial hyperplasia and Venous thromboembolism and cataracts; *Raloxifene can cause minimal EH |
| Diagnosis and Staging of Breast Cancer--> Abnormal mammogram requires? | -Diagnostic mammogram (gives radiologist that something is wrong) -History and Physical exam -Biopsy |
| Diagnosis and Staging of Breast Cancer--> If Biopsy shows breast cancer? | -BRCA 1 / 2 testing recommend for women < 65 yo and all men -Testing in women ≥ 65 yo if meet certain criteria -Consider CT of Chest, Abd, Pelvis and Bone scan if lymph node positive or large primary tumor -Hormone receptor (ER & PR) & HER2 expression testing |
| A&P: The lymph nodes we're most concerned about when we're staging for breast cancer is the ______ _____ lymph nodes | under-arm aka axillary (AXE body spray) |
| A&P: The other thing we're worried about with breast cancer is where it arises from. Two major parts are the ____ (milk producing sacs). Other are the ____ (highway between the lobes and the nipples) | Lobes; Ducts *this is where breast cancer mostly arises from and helps with staging and diagnosis |
| Pathology of Breast cancer--> Insitu? Invasive? | Still in the place it started (stage 0); spreading into surrounding tissue |
| Pathology of Breast cancer--> know that ductal (IDC) is more common at ___% | 70 (worst prognosis of all types of breast cancer *In general, tx decisions aren;t based on lobular or ductal |
| Important Breast Cancer Characteristics for treatment decisions: Need to know--> | -Hormone Receptor (HR) Status -Estrogen Receptor (ER & Progesterone Receptor (PR) -Status of Her2/neu Expression -Size of invasive cancer (T) (tumor size) -# of local lymph nodes with cancer (N) (node) -Metastatic status (M) – means incurable ⭐️ *TNM to stage people (0,1,2,3) and HR, ER, PR and status of Her2/neu expression go into assigning drug therapy and prognosis |
| Treatment options for curable breast cancer is? | -Surgery -Radiation -Medications |
| Breast cancer Management--> Stages I, IIa, IIb, IIIa, IIIb, IIIc are all considered? | curable. Stage IV is not |
| Breast cancer Management-->5-year survival rate for stage IV? | 20% (Stage III sees a decrease for 5-year suvival rate due to lymph nodes involved and higher liklihood of metastatic disease) |
| Breast cancer Management--> Surgery is the _______ treatment | DEFINITIVE. Not an option for Stage IV since its metastatic, more so for symptom control but definitely will be using cancer drug therapy |
| Breast cancer Management-->Stage 1 may be fixed with surgery and not so much with cancer drug therapy, why? | cancer found early on mammogram |
| Treatment for curable Breast cancer (Stages 1-3)--> Radiation (XRT) | -Lumpectomy--> Breast XRT -Mastectomy --> No Breast XRT -LN (lymph nodes) + ≥ 3 --> Axillary XRT *breast or under armpits (axilary) |
| Treatment for curable Breast cancer (Stages 1-3)--> Surgery | -Lumpectomy -Mastectomy (took out breast) *both have good clinical outcomes |
| Treatment for curable Breast cancer (Stages 1-3)--> Medications | -Her2+ --> Her2 medications + chemotherapy -HR+(hormone therapy or Endocrine therapy -->Hormone therapy (possible chemo) -TNBC --> Chemotherapy |
| Types of Tx for curable Breast cancer--> Reasons for radiation? | -If Lumpectomy surgery, usually receive breast radiation -If 3 or more Axillary Lymph nodes positive, usually receive axillary radiation *Radiation given usually after chemotherapy and immunotherapy completed *Can be given concurrently with hormone therapy *Not all patients receive radiation |
| Meds for Curable Breast Cancer (Stages I-III)--> TNBC (Triple negative breast cacner (ER(-) PR(-) Her2 (-) (*negative for all)--> Give? | old-school chemo |
| Meds for Curable Breast Cancer (Stages I-III)--> HER2+ and HR- --> give? | Chemo + 1 year adjuvent trastuzumab (Her2 drugs) |
| Meds for Curable Breast Cancer (Stages I-III)--> HER2+ and HR+, give? | Chemo + 1 year adjuvant trastuzumab + 5-10 years of antihormone tx *pt is expressing estrogen receptors or progesterone receptors and might call these pts triple + and get all drugs |
| Meds for Curable Breast Cancer (Stages I-III)--> HR + and Her2-, give? | 5-10 years of antihormone tx + chemo (MAYBE) |
| Curable Triple Negative Breast cancer (TNBC), these pts get? | No homrone therapy; No Her2 therapy; Chemotherapy (KEYNOTE 522 trial) -- preferred regimen for stage 2 & 3. |
| What drugs are in the KEYNOTE trial? | Part A: Combination of Carboplatin (Paraplatin) + Pembrolizumab IV + Paclitaxel for 4 cycles And another combo of Pembrolizumab with Doxyrubicin and Cyclophosphomide *conduct ECHO to check heart function bc of Doxyrubicin (anthracycline drug and monitor for cardio-mypopathy so ECHO Pre and post; moniot rwith Pembrolizumab (checkpoint inhibitor) |
| Curable Triple Negative Breast Cancer (TNBC)--> | -BRCA 1 / 2 mutation positive – could receive adjuvant olaparib for 1 year *Olaparib (PERP inhibitor drug) targets the repair mechanisms that are faulty in people with BRCA 1 and 2 mutations |
| Curable HER2+ and HR - Breast cancer--> | No hormone therapy; Yes Her2 therapy & Chemo; Use the TCHP regimen (brand names)--> Docetaxel (Taxotere + Carboplatin (Paraplatin) + Trastuzumab (Herceffin) + Pertuzumab (Perjeta); *monitot with ECHO TH regimen: Paclitaxel + Trastuzumab *both will have a total of 1 year of trastuzumab |
| Curable HER2+ and HR+ Breast cancer--> | -Yes - hormone therapy, Her2 therapy & Chemo -Chemo and Her2 therapy first once completed can start hormone therapy -Hormone therapy ⭐️ *same drug regimen as curable HER2+ but adding on hormone therapy. remember the TCHP and TH regimen |
| Curable HER2+ and HR+ Breast cancer--> This medication is considered the "standard of care" in Her2+ pts? | Trastuzumab |
| Curable HER2+ and HR+ Breast cancer--> BBW of Trastuzumab? | Infusion rxn Blackbox warning for cardiomyopathy hence why we monitor with ECHO |
| Curable HER2+ and HR+ Breast cancer--> Ado-trastuzumab emtricitabine is considered an antibody drug conjugate and linking the chemo moiety (emtransine) is actually well ______. AE? | tolerated bc of its delivery system; -AE: Fatigue, N, Thrombocytopenia, Increased LFTs, Decreased LVEF *used adjuvant if residual invasive disease after neoadjuvant |
| Curable HER2+ and HR+ Breast cancer--> Point to remember about administering Trastuzumab/ Ado-trastuzumab emtansine/ Pertuzumab si that we do not take at the same time as? | anthracyclines, bc of SE (cardiotoxicity was multiplied) |
| Curable HER2 - and HR+ Breast Cancer--> information? | -Yes - hormone therapy -No - HER2 therapy -BRCA 1 / 2 mutation positive –adjuvant olaparib for 1 year -Adjuvant CDK 4/6 inhibitor (abemaciclib or ribociclib) -Chemo? |
| Curable HR+ Her2 neg – Do they get Chemo? Premenopausal? 1. Low, recurrence score <16, recommendation? 2. Intermediate, RS 16-25, recommendation? 3. High, RS >/= 26, recommendation? | 1. Endocrine Tx 2. Consider chemo + endocrine 3. Chemo + endocrine Tx *16 or higher--> give Chemo |
| Curable HR+ Her2 neg – Do they get Chemo? Postmenopausal? 1. Low, recurrence score <26, recommendation? 2. High, RS >/= 26, recommendation? | 1. Endocrine Tx 2. Chemo + endocrine Tx * greater than 26--> give chemo |
| Postmenopausal is defined as? | 1. Dr. Frei states it; >60 yo; haven't had a menstrual period in 10 years, or if they had a hysterectomy |
| Curable HR+ Her2 (-)--> if we need to give chemotherapy, what are the most common regimens we give? | ddAC-> Doxorubicin and Cyclophosphamide followed by paclitaxel *palcitaxel (allergic rxns). dose limiting toxicity is NEUROPATHY, myelosupppression, full body allopecia (gets rid of all hair)⭐monitor for neuropathy and myelosuppression TC--> Docetaxel and Cyclophsophamide (used when can't use anthracycline (i.e. cardiac pt) *(taxotere, Cytoxin); anthracyclines are more effective but can't for cardiac so we give TC regimen. Monitor for neuropathay, and would give growth factor since it gives severe FN |
| Chemo/Immuno/Targeted Therapy for curable BC cancer medications: Chemotherapy includes? | -Doxorubicin -Epirubicin -Cyclophosphamide -Paclitaxel -Docetaxel -Carboplatin -Capecitabine |
| Chemo/Immuno/Targeted Therapy for curable BC cancer medications: Her2 Medications include? | -Trastuzumab -Pertuzumab -Kadcyla (ado-trastuzumab emtansine) |
| Chemo/Immuno/Targeted Therapy for curable BC cancer medications: Targeted therapies include? | -Olaparib -Pembrolizumab -Abemaciclib -Ribociclib |
| ADRs of Breast Cancer Treatment: Doxorubicin | -Nausea/Vomiting -Vesicant -Mouth sores -Cardiomyopathy (Dec EF) ⭐️ -Alopecia -Myelosuppression -Reddish colored body fluids |
| ADRs of Breast Cancer Treatment: Cyclophosphamide | -Nausea/Vomiting -Hemorrhagic Cystitis ⭐️ -Myelosuppression |
| ADRs of Breast Cancer Treatment: Paclitaxel | - Allergic reaction -Full body Alopecia -Neuropathy ⭐️ -Myelosuppression |
| ADRs of Breast Cancer Treatment: Carboplatin | -Nausea/Vomiting -Mouth sores -Myelosuppression ⭐️ -Neuropathy -Nephrotoxicity *Carboplatin dosing is Calvert formula Carboplatin dose = AUC X (25 + GFR) *asked on NAPLEX Example: 80 yo female with CrCl is 50 ml/min and AUC 5 dose = 375 mg |
| ADRs of Breast Cancer Treatment: Pembrolizumab | -Fatigue -Decreased appetite -Dyspnea -Immune-mediated toxicities ⭐️ *Pembrolizumab – Checkpoint inhibitor also known as immune mediated therapy |
| ADRs of Breast Cancer Treatment: Docetaxel | -Full body Alopecia -Neuropathy -Myelosuppression -Lower extremity edema |
| Breast Cancer Treatment: Things to Know About Regimens | -How long do you treat with trastuzumab and/or pertuzumab? 1 year in the adjuvant curable setting ⭐️ -Know expected ADRs and monitoring -Know when to give PARP inhibitor (Oliparib for pt with BRCA 1 mutation) -Know when CDK 4/6 inhibitor is used in curable setting |
| Hormonal Therapy: Menopausal status: Post--> 1st line therapy? Duration? | Aromatase Inhibitor *Minimum of 5 years but can continue up to 10 years |
| Hormonal Therapy: Menopausal status: Pre--> 1st line therapy? Duration? | -Tamoxifen -Tamoxifen + ovarian suppression (i.e. leuprolide) -AI + ovarian suppression (i.e. leuprolide) *Minimum of 5 years but can continue up to 10 years |
| What is the main takeaway from the ATAC Trial? | *In curable setting, AIs (Aromatase Inhibitors) are superior to tamoxifen only in POSTmenopausal pts *higher recurrence rate in Tamoxifen |
| Types of Treatment for Curable BC Hormone* Therapy--> LHRH Agonist (Hormonal therapy): Medications? ADRs? DI? | Meds: Leuprolide, triptolerin, goserelin (injectibles) ADRs: Hot flashes, reduced libido, Osteoporosis; CV disease DI: Used in combo with AI if pt is premenopausal |
| Types of Treatment for Curable BC Hormone* Therapy--> SERM (Hormonal therapy): Medications? ADRs? DI? | Meds: Tamoxifen ADRs: Endometrial cancer, uterine sarcoma, hot flashes, mood swings, DVT, inc risk of cataracts DI: 2D6 Inhibitors *Raloxifene is not used in the tx of breast cancer ⭐️ |
| Types of Treatment for Curable BC Hormone* Therapy--> Aromatase Inhibitors (Hormonal therapy): Medications? ADRs? DI? | Meds: Anastrazole, Letrozole, Exemestane ADRs: Osteoporosis; hot flashes, mood swings; inc cholesterol; fatigue; arthralgias/myalgias DI: None |
| Types of Treatment for Curable BC Hormone Therapy: Need to Know? | -Do not give in combination with CHEMO (no hormone tx and chemo at same time) *Decreased disease free survival -Can be given at same time as radiation therapy and trastuzumab |
| Tamoxifen vs Antidepressants | *we need to be aware that Tamoxifen has DI with antidepressants, 2D6 inhibitors *exceptions are Venlafaxine, desvenlafaxine, citalopram, and escitalopram |
| Tamoxifen Drug Interactions: | -Interactions with CYP 2D6 (primary) and 3A4 (to a lesser degree) -Tamoxifen requires conversion (CYP 2D6) to active metabolites, the most important of which is endoxifen -Antidepressants you can use *Venlafaxine (also citalopram and escitalopram but watch out for QTc prolongation) -Avoid strong and moderate inhibitors of 2D6 |
| Additional Therapy for Patients with High Risk of Cancer Recurrence? Breast Cancer Type (HR+): Tx? Notes? | Tx: Abemaciclib 150 mg po BID for 2 years Or Ribociclib 400 mg po daily for 21 days followed by 7 days off for a total of 3 years Notes: Start at same time as hormone therapy. |
| Additional Therapy for Patients with High Risk of Cancer Recurrence? Breast Cancer Type (BRCA deletion mutations): Tx? Notes? | Tx: Olaparib 300 mg po BID for 1 year Notes: Start after chemotherapy and radiation is finished |
| Summary Cancer Tx Curable BC? | -HR + patients –receive a minimum of 5 years (up to 10 years) of hormone therapy -HER2+ patients –a total of 1 year of trastuzumab therapy (can add pertuzumab) -Chemotherapy when indicated is usually between 4 – 8 months in length -Use Oncotype to decide if chemo beneficial in |
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Xander635
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