Breast Cancer

What is the risk assessment model for breast cancer?

Gail Model

Breast cancer risk factors → 3

1. endocrine

2. genetic

3. lifestyle

ENDOCRINE RISK FACTORS

Endogenous estrogen exposure

1. ________ (<12 yo)

2. ________ (>55 yo)

3. _________ → people who have never been pregnant with a child

4. ________ (>30 yo)

5. DECREASED risk =

6. Exogenous estrogen exposure →

1. early menarche

2. late menopause

3. nulliparity

4. late age at 1st birth

5. BSO (bilateral salpingo-oophorectomy) before 40 yo

6. OC, HRT

Which is more common, invasive ductal carcinoma (IDC) or invasive lobular carcinoma (ILC)?

IDC

BREAST CANCER SCREENING METHODS

1. Examination →

2. Imaging →

1. self, clinical

2. mammography, ultrasound, MRI

BREAST CANCER SCREENING NCCN GUIDELINES (Age > 40)

1. Breast awareness

2. mammogram

3. CBE (clinical breast exam)

1. counsel

2. annual

3. annual

BREAST CANCER SCREENING USPSTF GUIDELINES

Mammogram

1. Age 40-74

2. Age >75

1. biennial

2. NA

Triple negative =

ER, PR, HER2 negative

BREAST CANCER HORMONAL THERAPY

1. SERMS →

2. ^ which one is for risk reduction only?

3. Aromatase inhibitors →

4. ONLY USE FOR _____ TUMORS!!

1. tamoxifen (Nolvadex/Soltamox), raloxifene (Evista)

2. raloxifene

3. anastrozole (Arimidex)

4. HR+

TAMOXIFEN

1. MOA:

2. Indications →

3. ADEs → 6

4. DDIs →

1. estrogen antag in breast, agonist in bone/cholestrol/endometrium

2. pre AND postmeno tx + risk reduction

3. hot flashes, nausea, VTE, endometrial cancer, vag discharge, cataracts

4. PRODRUG via CYP2D6

TAMOXIFEN DRUG INTERXNS

1. AVOID strong 2D6 inhibitors

2. OKAY TO USE minimal/no 2D6 inhibitors

1. fluoxetine, paroxetine, bupropion, duloxetine

2. escitalopram, venlafaxine, desvenlafaxine, mirtazapine

AROMATASE INHIBITORS (AIs)

1. NON steroidal →

2. Steroidal →

3. Indication →

4. AEs → 6

1. anastrozole, letrozole

2. exemestane

3. postmeno tx + prevention, premeno tx COMBINATION W ovarian supp/ablation (*LNRH agonist)

4. hot flashes, nausea, arthralgias, myalgias, -BMD, vag discharge

ANTI-HER2 THERAPY

1. Agent 1 =

2. *KEY ADE →

3. ^ is _________ and reversible

4. DO NOT GIVE AT THE SAME TIME AS _________

5. Monitoring →

1. trastuzumab (Herceptin)

2. -LVEF, HF

3. transient

4. anthracyclines

5. LVEF baseline + during tx

ANTI-HER2 THERAPY

1. Agent 2 =

2. ALWAYS GIVE WITH ________!!! NEVER MONOTHERAPY

3. ADEs/monitor →

1. pertuzumab (Perjeta)

2. trastuzumab

3. LVEF

CDK 4/6 INHIBITORS

1. Abemaciclib =

2. Palbociclib =

3. Ribociclib =

4. All used for ________, _______, _______ breast cancer

5. ALWAYS USE IN COMBINATION W HORMONAL THERAPY →

6. AEs → 4

7. Co-prescribe _______ to start at 1st sign of diarrhea

1. Verzenio

2. Ibrance

3. Kisqali

4. metastatic, HR+, HER2-

5. tamoxifen, AIs, fulvestrant

6. neutropenia, diarrhea, fatigue, nausea

7. loperamide

NCCN BREAST CANCER REDUCTION

Consider risk reduction for women with life expectancy >10y AND one of the following:

1. History of ______ (lobular carcinoma in situ)

2. ___________

3. Prior ___________ when 10-30 years of age

4. Elevated _____ of breast cancer based on validated risk assessment model (eg. Gail)

5. Possible or known ______ predisposition

1. LCIS

2. atypical hyperplasia

3. thoracic radiotherapy

4. risk

5. genetic

NCCN BREAST CANCER REDUCTION

PHARMACOLOGIC OPTIONS

1. Age _____ only

2. PREmenopausal =

3. POSTmenopausal =

4. For VERY high risk =

1. >/= 35

2. tamoxifen

3. tamoxifen, raloxifene, AIs

4. surgical (bilateral mastectomy or BSO)

BREAST CANCER METASTATIC DISEASE PEARLS

1. HR+ disease =

2. HER2+ disease =

3. Triple negative disease =

1. hormonal therapy, +CDK inhib if HER2-, chemo if symptomatic metastatic

2. chemo + anti-HER2, +hormonal therapy if HR+

3. chemo, sacituzumab govitecan, pembrolizumab + chemo if PDL1+, PARP inhib (-paribs) if BRCA mutation

Which is appropriate for breast cancer risk reduction for a premenopausal patient?

A. raloxifene

B. tamoxifen

C. anastrozole

B

Which is an appropriate therapy for a premenopausal patient diagnosed with HR+ breast cancer?

A. letrozole + leuprolide

B. leuprolide

C. tamoxifen + letrozole

A

Aromatase inhibitors should NEVER be given as monotherapy for treatment of breast cancer in _________ women (HR+ breast cancer)

premenopausal