Breast Cancer

Early Stage or Locally Advanced BC Dx

• asymptomatic, palpable lump

• biopsy

• menopause status

• mets/labs

• CT/MRI

Lobular Carcinoma in Situ

pre-cursor to cancer, Dx: biopsy

Treatment:

• observation, endocrine therapy (chemoprevention), surgery

Ductal Carcinoma in Situ

• pre-cancer, Dx: biopsy

• Treatment:

  • surgery, radiation, endocrine therapy

Locally Advanced BC Treatment

• Stage I-III, goal: cure

• Treatment:

  • surgery, radiation, chemo ± targeted therapy

AC Chemo regimen

doxorubicin + cyclophosphamide x 4

AC → T Chemo Regimen

AC followed by paclitaxel weekly x 12

TC Chemo Regimen

Docetaxel + cyclophosphamide x 4-6

Dose-Dense AC → T

AC every 14d x 4, paclitaxel every 14d x 4

Neoadjuvant therapy (local)

• HR+, HER2+

  • chemo + anti-HER2 + endo

• HR+, HER2-

  • endocrine ± chemo

• HR-, HER2+

  • chemo + anti-HER2

• HR-, HER2-

  • chemo

Local HR+, HER2+ Treatment Principles

chemo + anti-HER2 + endo

Local HR+, HER2- Treatment Principles

endocrine ± chemo

Local HR-, HER2+ Treatment Principles

chemo + anti-HER2 therapy

Local HR-, HER2- (TNBC) Treatment Principles

chemo

Trastuzumab

• HER2 Mab

• infusion rxn, cardiotoxic (BL ECHO)

Pertuzumab

• HER2 Mab

• never given as monotherapy, give w/ trastuzumab

• diarrhea, cardiotoxic (BL ECHO)

Ado-trastuzumab emtansine

• HER2 antibody drug conjugate

• infusion rxn, cardio toxic (BL ECHO), peripheral neuropathy

• residual disease

Fam-trastuzumab detruxtecan

• metastatic breast: 2nd line HER2+ & 2nd line HER2 low

• BBW: interstitial lung disease/pneumonitis

• AE: cardiotoxic, peripheral neuropathy, neutropenia, diarrhea

Neratinib

• PO pan HER2 TKI

• HER2+ w/ HR+ and/or node positive disease

• AE: diarrhea

  • PPX: loperamide

Tamoxifen

• SERM, premenopausal endocrine therapy

• bone loss, stroke, VTE

  • Calcium and Vitamin D

Aromatase Inhibitors

• postmenopausal endocrine therapy

• bone loss, arthralgia

  • Calcium + Vit D

Metastatic Breast Cancer

preserve QoL, palliative care, extend survival

assess ER/HR/HER2 status

Metastatic HR+, HER2- Treatment 1st Line

• CDK 4/6 + AI

• Fulvestrant + CDK 4/6

• BRCA 1/2+ → PARPi

• Visceral Crisis/Endocrine refractory

  • systemic chemo

  • fam-tastuzumab detruxtecan

Metastatic HR+, HER2- Treatment 2nd Line

• Fulvestrant + CDK 4/6 (if not used)

• Everolimus + endocrine therapy

• PIK3CA+ → Alpelisib + Fulvestrant

• Visceral Crisis/Endocrine refractory

  • fam-tastuzumab detruxtecan

  • sacituzumab govitecan

LHRH Agonists

must be used with AI in premenopausal patients

ovarian suppression

Fulvestrant (IM), Elacetrant (PO)

SERD, metastatic BC only

AE: hot flashes, arthralgia

Ribociclib

CDK 4/6 inhibitor

HR+, HER2- metastatic BC

AE: QT prolongation, neutropenia, lung inflammation

Palbociclib

CDK 4/6 inhibitor

HR+, HER2- metastatic BC

AE: neutropenia, lung inflammation

Abemaciclib

CDK 4/6 inhibitor

HR+, HER2- metastatic BC

AE: diarrhea, less neutropenia, higher risk of VTE w/ tamoxifen

Alpelisib

PIK3CA inhibitor, HR+ BC

PO taken w/ falvestrant

AE: hyperglycemia

Sacituzumab govitecan

HR+, HER2- BC, target Trop-2 (growth signal receptor)

BBW: neutropenia, diarrhea

AE: hypersensitivity, high emetic risk

PARP inhibitors

olaparib, talazoparib

HR+ BC

AE: N/V, myelosuppression

Metastatic HR+, HER2+ Treatment

1st Line:

• AI ± trastuzumab

• AI ± lapatinib

• AI + lapatinib + trastuzumab

• fulvestrant + trastuzumab

• tamoxifen ± trastuzumab

• abemaciclib + fulvestrant + trastuzumab

Visceral Crisis/Endocrine Refractory

• docetaxel + trastuzumab + pertuzumab

• fam-tastuzumab detruxtecan

2nd Line:

• fam-tastuzumab detruxtecan

Metastatic HR-, HER2+ BC Treatment

1st Line:

• docetaxel + trastuzumab + pertuzumab

• paclitaxel + trastuzumab + pertuzumab

2nd Line:

• fam-tastuzumab detruxtecan

Metastatic HR-, HER2- (TNBC) Treatment 1st Line

CPS >/=10:

• Pembrolixumab + chemo

  • albumin bound paclitaxel

  • paclitaxel

  • caboplatin + gemcitabine

CPS <10 & BRCA 1/2+:

• PARPi

• Cisplatin or carboplatin

CPS <10 & no BRCA

• Paclitaxel

• doxorubicin

• Capecitabine or gemcitabine

Metastatic HR-, HER2- (TNBC) Treatment 2nd Line

• BRCA 1/2+: PARPi (if not tried before)

• Sacituzumab govetecan

• fam-tastuzumab detruxtecan

• 1st line chemo