Breast Cancer MKSAP and Board Review

Risk Factors & Prevention

Anti-Estrogen Management

Treatment Paradigms

Surveillance and Staging

Drug Toxicities

How much of all breast cancer is hereditary?

A. 10 percent

B. 15 percent

C. 20 percent

D. 25 percent

A. 10 percent

True or False: Aromatase inhibitors work in pre-menopausal patients

False

The backbone of treatment for:

1. ER+ tumors

2. HER2+ tumors

3. Triple negative tumors

1. Endocrine therapy (SERM or Aromatase Inhibitor)

2. anti-HER2 based therapy (Trastuzumab)

3. Chemotherapy

A 61-year-old woman is evaluated in the office 1 month after a 1.2-cm left breast mass was detected on screening mammography. She was diagnosed with estrogen receptor–positive, progesterone receptor–positive, and human epidermal growth factor receptor 2–negative invasive ductal carcinoma. She is asymptomatic. She has hypertension, and her only medication is lisinopril.

On physical examination, there is a healing biopsy scar. There is no axillary or supraclavicular adenopathy.

Complete blood count and comprehensive metabolic profile, including alkaline phosphatase level, are normal.

Which of the following is the most appropriate pretreatment testing for this patient?

A. Chest radiograph

B. Fluorodeoxyglucose PET/CT

C. Measurement of serum markers CA15-3 and CA27-29

D. No further testing

Imaging studies for staging are not recommended in asymptomatic patients with newly diagnosed stage 0 to II breast cancer.
There is no role for the serum breast cancer markers CA15-3 and CA27-29 in early-stage breast cancer.

Name a potentially irreversible side effect of taxane based therapy and a known prevention strategy?

Peripheral Neuropathy

Cyrotherapy: Cooling Gloves and Socks

200

A 62-year-old woman is evaluated in the office following a diagnosis of atypical ductal hyperplasia. She underwent a right total hip replacement 2 years ago complicated by deep venous thrombosis. Medical history is otherwise unremarkable, and she takes no medications.

On physical examination, vital signs are normal. There is a well-healed left breast incision with no skin changes and no palpable mass or nodule.

Which of the following is the most appropriate breast cancer chemoprevention for this patient?

A. Aspirin

B. Exemestane

C. Raloxifene

D. Tamoxifen

B. Exemestane

Tamoxifen, raloxifene, and the aromatase inhibitors exemestane and anastrozole reduce invasive breast cancer in women without preexisting breast cancer but do not reduce breast cancer–specific or all-cause mortality.
Exemestane may be used as a preventive measure in women who are at high risk of breast cancer with a previous history of venous thromboembolic disease.

200

Which of these is NOT a side effect of tamoxifen?

A. Hot flashes

B. Thromboembolism

C. Endometrial cancer

D. Osteoporosis

200

A 64-year-old woman is evaluated in the office following a diagnosis of metastatic breast cancer. Six years ago, she was diagnosed with breast cancer and treated with lumpectomy, irradiation, and a complete course of adjuvant hormonal therapy. Two weeks ago, a bone lytic lesion was found on a lumbar spine radiograph taken for low back pain after a fall while playing tennis. Subsequent CT scans revealed diffuse involvement of her axial skeleton with no associated fractures and no epidural extension. The patient is currently asymptomatic. Medical history is unremarkable, and she takes no medications.

On physical examination, vital signs are within normal limits, and examination findings are unremarkable.

Systemic therapy for metastatic breast cancer is planned.

Which of the following is the most appropriate additional treatment?

A. Calcium and vitamin D

B. Spine irradiation

C. Teriparatide

D. Zoledronic acid

For patients who have breast cancer with bone metastases, bone-modifying agents such as zoledronic acid or denosumab are recommended to prevent bone-related events such as bone pain, cord compression, need for palliative irradiation, and hypercalcemia.

200

A 52-year-old woman is evaluated in the office for a left breast lump that developed 3 months ago. She is asymptomatic. Medical history is unremarkable, and she takes no medications.

On physical examination, there is a 1.8-cm firm mass in the upper outer left breast. There is no axillary or supraclavicular adenopathy.

Complete blood count and comprehensive metabolic profile, including alkaline phosphatase level, are normal.

Mammogram and ultrasound confirm a 1.8-cm mass in the left upper outer breast.

Core biopsy of the left breast reveals estrogen receptor–negative, progesterone receptor–negative, and human epidermal growth factor receptor 2–negative invasive ductal carcinoma.

Which of the following is the most appropriate pretreatment imaging for this patient?

A. Chest radiograph and bone scan

B. CT of the chest, abdomen, and pelvis

C. CT of the chest, abdomen, and pelvis and MRI of the brain

D. No imaging

Imaging studies for staging are not recommended in asymptomatic patients with newly diagnosed stage 0 to II breast cancer.
Brain metastasis occurs in only a small proportion of patients with metastatic breast cancer and generally later in the disease course.

200

Name a key toxicity of anthracycline based therapy and prevention strategies?

Cardiomyopathy

Cardio-Onc Referral, Baseline BNP/Troponin, EKG, ECHO and Monitoring, Considering BB and ARB

300

A 54-year-old postmenopausal woman had an abnormal screening mammogram that revealed new calcifications in multiple areas of her right breast. A biopsy showed estrogen receptor–positive ductal carcinoma in situ with high nuclear grade. She underwent a bilateral mastectomy and a right sentinel node biopsy, which revealed ductal carcinoma in situ of the right breast and two negative sentinel nodes.

On physical examination, there are healing bilateral mastectomy incisions with tissue expanders in place.

Which of the following is the most appropriate next treatment for this patient?

A. Anastrozole

B. Radiation therapy

C. Tamoxifen

D. No adjuvant treatment

Neither radiation therapy nor hormonal therapy provides benefit after bilateral mastectomy for patients with ductal carcinoma in situ.
After lumpectomy, adjuvant hormone therapy is offered to patients with estrogen receptor–positive ductal carcinoma in situ to reduce the risk of local recurrence; however, endocrine therapy has no impact on overall survival in this setting.

300

A 62-year-old woman was diagnosed 2.5 years ago with left-sided, stage IIB, estrogen receptor–positive, human epidermal growth factor receptor 2–negative breast cancer treated with mastectomy, postmastectomy irradiation, and letrozole, which was started 2 years ago. Medical history is otherwise unremarkable. Current medications are letrozole, a calcium supplement, and cholecalciferol.

Which of the following is the most appropriate screening or surveillance test to perform at this time?

A. CT of the chest, abdomen, and pelvis

B. Dual-energy x-ray absorptiometry

C. Echocardiogram

D. Pelvic Ultrasound

B. Dual-energy x-ray absorptiometry

Aromatase inhibitors are associated with bone loss and an elevated risk of fracture; patients on aromatase inhibitors should have bone density studies every 2 years.

300

A 70-year-old woman undergoes consultation following a diagnosis of breast cancer. She has no other medical conditions.

Core biopsy of a left breast mass revealed grade III, estrogen receptor–positive, progesterone receptor–positive, and human epidermal growth factor receptor 2–positive invasive ductal carcinoma. Left lumpectomy revealed invasive ductal carcinoma measuring 1.9 cm in size. Two sentinel nodes were negative.

Which of the following is the most appropriate adjuvant treatment?

A.Chemotherapy and anti-HER2 antibody, breast irradiation, and endocrine therapy

B.Endocrine therapy

C.Obtain a gene expression profile

D.Radiation therapy followed by endocrine therapy

A. Chemotherapy and anti-HER2 antibody, breast irradiation, and endocrine therapy

300

63-year-old woman is evaluated for a mass in her right axilla. She first noticed the mass 2 months ago. She has also had a persistent cough. She was diagnosed 3 years ago with stage IIB right breast cancer for which she underwent lumpectomy, chemotherapy, and breast irradiation.

On physical examination, vital signs are normal. There is a firm, fixed, 2-cm mass in the right axilla. Bilateral breast examination reveals no masses or nodules. The remainder of the examination is normal.

Chest radiograph shows multiple bilateral pulmonary nodules. CT scan of the chest, abdomen, and pelvis shows new right axillary adenopathy and multiple peripheral pulmonary nodules measuring up to 1.5 cm in size. There is no hilar or mediastinal adenopathy.

Which of the following is the most appropriate management?

A. Biopsy pulmonary nodule

B. Biopsy right axillary mass

C. Initiate chemotherapy

D. Initiate endocrine based therapy

A. Biopsy pulmonary nodule

Breast cancer can undergo subtype switch between the primary disease and metastatic disease, and biopsying the metastatic site allows treatment to be tailored to the metastatic disease subtype.
When evaluating a patient with newly diagnosed metastatic breast cancer, the lesion that upstages the patient to the greatest degree should be biopsied.

300

What is the basic mechanism of action of immunotherapy?

What do we generally do to treat side effects?

Activates T-Cells to fight cancer

Steroids

400

A 43-year-old woman is evaluated after genetic testing revealed a deleterious BRCA2 mutation. Testing was performed because of a history of breast cancer in her sister and a history of ovarian cancer in her aunt. The patient is not interested in prophylactic mastectomies. She has no other medical problems and takes no medications.

Physical examination findings, including vital signs, are normal.

Results of laboratory studies are normal.

Which of the following is the most appropriate approach to screening?

A. Annual Breast MRI

B. Annual PET/CT

C. Combined annual breast MRI and mammography

D. Mammography every 6 months

E. Measurement of CA27-29/CA15-3

C. Combined annual breast MRI and mammography

Breast cancer screening with annual MRI beginning at age 25 years with the addition of annual mammography at age 30 years would be appropriate in high-risk patients who have a BRCA1/2 mutation, a strong family history of breast cancer, a history of other rare familial breast cancer syndromes, or a history of radiation to the chest wall between ages 10 and 30 years (e.g., mantle radiation therapy for Hodgkin lymphoma).

400

A 45-year-old woman is evaluated after undergoing partial left mastectomy and postoperative radiation therapy for intermediate-grade ductal carcinoma in situ. The tumor is estrogen and progesterone receptor positive. She is premenopausal. She has no other medical problems and takes no medications.

On physical examination, vital signs are normal. Other than a well-healed left breast surgical incision, the remainder of the examination is unremarkable.

Which of the following is the most appropriate additional therapy?

A. Anastrozole

B. Doxorubicin and cyclophosphamide followed by paclitaxel

C. Tamoxifen

D. Trastuzumab

C. Tamoxifen

Because her DCIS is estrogen receptor (ER) positive and she is PREmenopausal, endocrine therapy with tamoxifen for 5 years is recommended to decrease risk for local recurrence and contralateral breast cancer.

400

A 58-year-old woman undergoes follow-up evaluation for recently diagnosed breast cancer following lumpectomy and sentinel lymph node biopsy. Pathology of the primary tumor revealed a 2.3-cm, grade II, estrogen receptor–positive, human epidermal growth factor 2–negative breast cancer. Two sentinel axillary lymph nodes were negative for cancer. Her medical history is otherwise unremarkable, and she takes no medications. Local irradiation is planned.

Which of the following is the most appropriate management of the patient's systemic therapy?

A. Chemotherapy alone

B. Chemotherapy followed by endocrine therapy for 5 years

C. Endocrine therapy alone

D. Multigene recurrence assay

For patients with hormone receptor–positive, human epidermal growth factor 2–negative breast cancers with no positive axillary nodes, the use of multigene assays informs the decision regarding the need for chemotherapy.

400

A 43-year-old woman is evaluated after undergoing lumpectomy and axillary lymph node dissection for a 2.5-cm, triple-negative infiltrating ductal carcinoma with three out of seven positive lymph nodes. Following surgery, she was treated with a course of doxorubicin, cyclophosphamide, and paclitaxel and radiation therapy. She has no other medical problems and takes no medications.

On physical examination, vital signs are normal. Healed right lumpectomy and axillary incisions are noted. There are no breast masses or adenopathy. The chest is clear. No hepatomegaly is noted.

Laboratory study results are normal.

In addition to annual mammography, which of the following is the most appropriate surveillance for the next 3 years?

A. Annual echocardiography

B. Annual PET/CT

C. CA27-29 testing every 6 months

D. History and physical examinations every 6 months

Following breast cancer treatment, patients should be evaluated for a detailed cancer-related history and undergo physical examination every 3 to 6 months for the first 3 years, every 6 to 12 months for the next 2 years, and then annually.

400

Name the toxicity associated with cyclophosphamide

Hemorrhagic Cystitis

500

Name three features of a hereditary cancer syndrome?

1. Young Age

2. Individual with multiple cancers

3. 1 or more family members with same cancer

4. Specific cancers like triple negative breast cancer, ovarian cancer, and male breast cancer

500

A 41-year-old woman is evaluated for a 3-month history of depressed mood nearly every day, low energy, loss of interest in nearly all activities, fatigue, and poor concentration. Medical history is significant for stage II, estrogen receptor–positive, human epidermal growth factor 2–negative breast cancer diagnosed 2 years ago. Her only medication is tamoxifen.

On physical examination, vital signs are normal. The remainder of the examination is unremarkable.

Complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone level are all normal.

Which of the following is the most appropriate treatment?

A. Discontinue tamoxifen

B. Prescribe bupropion

C. Prescribe fluoxetine

D. Prescribe venlafaxine

Depression and anxiety are common in women with breast cancer.
Antidepressants with strong CYP2D6 inhibition, such as bupropion or fluoxetine, may decrease tamoxifen activation and should be avoided.

500

A 56-year-old woman is evaluated for findings suspicious for inflammatory breast cancer.

On physical examination, vital signs are normal. The right breast is enlarged, and the skin is thickened and erythematous. There is a 5- × 4-cm mass in the lower outer breast. There is an enlarged right axillary node.

Right breast mammogram reveals a mass in the lower outer breast with calcifications that span approximately 5 cm in size. Right axillary ultrasound reveals an enlarged axillary lymph node. Core biopsy of the breast reveals estrogen receptor–negative, progesterone receptor–negative, and human epidermal growth factor 2–negative invasive ductal carcinoma. CT of the chest, abdomen, and pelvis and bone scan show no evidence of distant metastatic disease.

Which of the following is the most appropriate sequence of therapies for this patient?

A. Mastectomy, chemotherapy, irradiation

B. Preoperative chemotherapy, lumpectomy, irradiation

C. Preoperative chemotherapy, mastectomy, irradiation

D. Irradiation, mastectomy, chemotherapy

C. Preoperative chemotherapy, mastectomy, irradiation

Patients with inflammatory breast cancer often present with breast enlargement or swelling that is often misdiagnosed as mastitis.
Inflammatory breast cancer is usually treated initially with neoadjuvant chemotherapy, followed by surgery, and then radiation therapy.

500

A 45 y/o woman presents with a palpable right breast mass. Breast imaging shows dense breast tissue with no mass seen on mammogram. On physical exam, the mass measures 4cm with enlarged lymph node in the right axilla

Which of the following is your recommendation?

A. Given mammogram is normal, return in 1-3 months for breast exam to see if mass persists

B. Start antibiotics and see her in 2 weeks to see if there is clinical improvement

C. Obtain breast US to evaluate the mass

D. Obtain CT CAP and MRI Brain

C. Obtain breast US to evaluate the mass

500

Name the fatal toxicity associated with trastuzumab deruxtecan (TDxD)

Interstitial Lung Disease