Diagnostic Dilemmas
This is the most common type of breast cancer
What is ER/PR+, HER2 negative?
This is the oncotype score at which you will give adjuvant chemotherapy
What is 26?
These are the patients who derive the most benefit from oncotype testing
Who are lymph node negative, ER+ patients?
Consider for node negative and post menopausal 1-3 lymph nodes
These are the trials that studied Oncotype Testing
TAILORx trial - ER+ lymph node negative(no benefit of chemo with recurrent scores between 16-25 age > 50, some benefit < 50)
Responder trial - Node positive disease and recurrence score of 25 or lower
Postmenopausal women did not show benefit
Premenopausal women - addition of chemotherapy to endocrine therapy was associateed with 5.2% benefit in the invasive DFS RATE
What is estrogen receptor antagonist?
Name 3 risk factors for developing Breast Cancer
BRCA 1 and 2, PALB2, P10, Cowden’s disease, ATN, CHECK2, P53 - LI FRAUMENI, PJEUGER — STK11, Cdh1 - diffuse gastric cancer, Hx of thoracic radiation, LCIS, ADH/ALH, Dense breast tissue, Older age, Early menarche, Absence of breast feeding, Late menopause, Family hx, Alcohol use, Smoking cigarettes
BRCA is the worst risk factor!
This is the standard neoadjuvant/adjuvant combination for HER2+ positive patients with tumors greater than 2 cm without comorbidities and no residual disease?
TCHP, followed by herceptin/perjeta for 1 year
AC TH(P) also okay but high risk of cardio toxicity
What is the other name for Kadcyla?
TDM1 = traztuzumab emtansine
famtraztuzumab/TDXD = enhertu
This trial showed addition of pembrolizumab to neoadjuvant and adjuvant therapy for Stage II-III Breast cancer lead to improvement in both pathologic complete response, event free survival and overall survival?
Keynote 522
This is a steroidal aromatase inhibitor
What is exemestane?
This is the T staging for Breast Cancer
Tis - in situ/DCIS, T1 - up to 2 cm, T2 - 2-5 cm , T3 - more than 5 cm, T4 - into chest wall/skin; D - inflammatory breast cancer
N1 - 1-3 axillary or intrammamary, N2 - 4—9, N3 - MORE THAN 10 lymph nodes; infra or suprclavicular
T1a aka < 5mm don't need chemo!!
This tool can be used for hormone positive patients at 5 years of endocrine therapy to see if additional years of endocrine therapy is beneficial.
What is Breast Cancer Index?
T/F Phyloides tumors respond well to chemo
False
Phyloides tumor
The Create - RX study showed addition of this to HER2 negative patients for stage I patients lead to improvement in OS?
Capecitabine
(but should we also do it in stage II/III? Keynote 522 did not allow capecitabine)
This is the effect of tamoxifen on bone loss.
What is prevents bone loss in postmenopausal women, but causes bone loss in premenopausal women?
This is the age at which you should start screening BRCA patients with breast MRI or mammogram
BRCA - MRI at age 25; mammogram at 30
CDH1/PALB2 - start at age 30
T/F A patient should continue traztuzumab through radiation therapy
What is True?
Data has demonstrated that receiving adjuvant trastuzumab during radiation therapy is not associated with significantly increased cardiac toxicity.
The NSABP B-31 study showed that the rate of CHF was 3.2% for patients treated with left-sided breast radiation and concurrent trastuzumab vs. 4% for those who received only trastuzumab but no left-sided breast radiation (P=0.8). Therefore, giving trastuzumab during radiation therapy is deemed to be safe.
This is who to test for genetic testing in breast cancer patients
Age < 65
Triple negative
Personal/family hx of ovarian cancer
Male breast
Metastatic prostate cancer
Exocrine pancreatic cancer
…maybe universal
The MONARCHE trial showed the addition of abemaciclib increased IDFS for which population of patients
high risk early breast cancer - > 4 positive axillary lymph nodes OR 1-3 ALN and at least one of the following (1. Tumor > 5, histologic grade 3, ki67 > 20)
NATALEE - stage II/III ribociclib for 3 years
These are the side effects of CDK 4/6 inhibitors (distinguish ribociclib vs abemaciclib)
RIBO - QT prolongation, monitor EKG changes, monitor liver enzymes
Abemaciclib - abdominal discomfort, diarrhea, nausea
All can cause fatigue, joint pain, myelosuppresion, ILD (rarely)
In a patient who has HER2+ 1+ testing with a high KI67/high grade, this is the next step in diagnosis.
FISH testing
high-grade breast tumors that are associated with poor fixation and negative hormone receptor status may be considered for further analysis of Her2 status by FISH testing.
This is the risk reduction of hormonal therapy on hormone positive DCIS
What is 32% relative reduction in risk of local recurrence and 53% reduction in risk of contralateral disease over 15 years? NO OVERALL SURVIVAL BENEFIT
NSABP B-24 trial - adjuvant tamoxifen at 20mg for 5 years after BCS plus whole breast irradaition for DCIS resulted in 32% relative reduction in risk of local recurrence and 53% reduction in risk of contralateral disease over 15 eyars
NSABP B-35 trial (postmenopausal women who received BCS) - adjuvant anastrazole was associated with a small improvement in breast cancer-free interval at 10 years vs tamoxifen (93,5 vs 89.2), with benefit mainly limited to women younger than 60
Name 3 contraindication/patients who should not get BCS
Inflammatory breast cancer, diffuse calcifications, hx of prior radiation, connective tissue disease, multifocal disease, grossly positive margins, homozygous ATN
The use of T-DM1 after surgery was associated with improved dfs and a lower risk of distant recurrence compared with trastuzumab. This is supported by which study?
KATHERINE
Of the following, these drugs are safe during 2nd/3rd trimester pregnancy (one is unclear)
Traztuzumab, Adriamycin, Cyclophosphamide, Paclitaxel
There are reports that trastuzumab can lead to oligohydramnios when it is administered to a pregnant patient. This medication is contraindicated to give to a pregnant patient who presents with Her2+ breast cancer.
Adriamycin/Cyclophosphamide have both been shown to be safe to administer to a pregnant patient during the 2nd and 3rd trimesters of pregnancy. The safety of administering
Taxol to a pregnant patient who has breast cancer is more unclear