Breast Cancer

Front 1

How does breast cancer differ in AA women and white women?

Back 1

Less common overall in AA women, higher mortality rate (38% higher) in AA women, more likely to be receptor negative. Younger AA women are more likely to have the more aggressive basal-type cancer.

Front 2

What is the relationship between age and breast cancer in women?

Back 2

Risk increases with age; the rate of increase declines after menopause, especially after age 80.

Front 3

How much does having one first-degree relative increase a woman's risk of breast cancer?

Back 3

Two-fold. If the relative had bilateral breast cancer or was diagnosed before age 50, the risk can be increased as much as ten-fold.

Front 4

Is having paternal relatives with breast cancer a risk factor?

Back 4

Yes.

Front 5

What are the characteristics of breast cancers associated with BRCA1?

Back 5

High-grade, basal type, receptor negative.

Front 6

What are the characteristics of BRCA2 positive breast cancer?

Back 6

Luminal subtype, Receptor positive

Front 7

What is the lifetime cumulative risk of breast cancer for carriers of BRCA 1 or 2 mutations?

Back 7

50-87%

Front 8

What is the lifetime cumulative risk of ovarian cancer for carriers of BRCA 1 or 2 mutations?

Back 8

15-65%

Front 9

What portion of breast cancers are familial? Of these, what portion is related to BRCA mutations?

Back 9

10% familial, with 66-75% related to BRCA mutations.

Front 10

What is the lifetime risk of contralateral breast cancer in a woman with BRCA mutation already affected by breast cancer?

Back 10

50-65%

Front 11

Other than breast cancer, which cancers are associated with BRCA2 mutations?

Back 11

Cancer of the stomach, gall bladder, bile ducts, pancreas, and prostate

Front 12

Describe Li-Fraumeni syndrome.

Back 12

AD inheritance, early onset breast cancer, sarcoma, leukemia, brain tumors and adrenocortical tumors.

Front 13

Desribe Cowden's syndrome.

Back 13

AKA multiple hamartoma syndrome. PTEN gene.

Front 14

Describe Peutz-Jegher syndrome.

Back 14

AD inheritance, STK1 gene. Predisposes to cancers of stomach, colon, pancreas, small bowel, thyroid, breast, lung and uterus.

Front 15

How much is the risk of breast cancer increased by nulliparity?

Back 15

30-50%

Front 16

Early menarche and late menopause have what effect in breast cancer risk?

Back 16

Increased.

Front 17

What is the relationship between socioeconomic class and breast cancer risk?

Back 17

Higher risk in higher economic classes.

Front 18

Which increases risk of breast cancer more, estrogen only hormone replacement or combined estrogen-progestin therapy?

Back 18

Combined therapy.

Front 19

What is the relationship between alcohol intake and risk of breast cancer?

Back 19

Linear increase in risk after 2 drinks/day

Front 20

What is the increase in risk of invasive breast cancer for patients with atypical ductal or lobular hyperplasia?

Back 20

Four-fold

Front 21

What is the yearly risk of ipsilateral or contralateral DCIS or invasive breast cancer in women with LCIS?

Back 21

1-2%.

Front 22

How do "dense breasts" affect one's risk of invasive breast cancer?

Back 22

Increases risk two to six-fold.

Front 23

What risk factors are included in the Gail model?

Back 23

history of LCIS or DCIS
age
age at menarche
age at birth of first child
history of breast biopsy
race

Front 24

Dose dense AC-T chemotherapy is appropriate for what type of breast cancer?

Back 24

Triple negative.

Front 25

SERMS given for 5 years to hormone-receptor positive women with breast cancer reduces the risk of death by what portion? Recurrence? Contralateral breast cancer?

Back 25

Death reduced by one third.
Recurrence reduced by 50%
Contralateral breast cancer reduced by 40%.

Hint 25

SERM 3.5.4

Front 26

What is the increased risk of endometrial cancer for women on tamoxifen?

Back 26

About 1% increase over normal risk.

Front 27

What is the risk reduction with tamoxifen in women at high risk for breast cancer ?

Back 27

30-50%.

Front 28

Prophylactic bilateral mastectomy reduces risk of breast cancer in BRCA 1 or 2 mutation-positive women by what percentage? What affect does bilateral oopherectomy have on the occurence of breast and ovarian cancer in BRCA mutation carriers?

Back 28

Bilateral mastectomy reduces breast cancer risk by 90%. Oopherectomy reduces both the risk of breast and ovarian cancer by 90%.

Front 29

Screening mammorgraphy reduces breast cancer mortality by what percent in women age 50-74?

Back 29

26%.

Front 30

What is the false-negative rate in postmenopausal women with fatty breasts? What is it in women with dense breasts?

Back 30

Fatty breasts = < 10 percent.
Dense breasts = > 15%.

Front 31

In what group of women is MRI breast screening appropriate?

Back 31

Those with a 20% lifetime risk and those with BRCA mutations.

Front 32

Describe T4a designation in breast cancer? T4b? T4c? T4d?

Back 32

T4a extends through chest wall
T4b extends to skin
T4c extends to chest wall & skin
T4d is inflammatory breast cancer

Front 33

Of what value is neoadjuvant chemotherapy in breast cancer?

Back 33

It may shrink large tumors enough to allow for breast-conserving therapy.

Front 34

How does age independently affect the chances of breast cancer recurrence?

Back 34

Age < 35 increases risk of recurrence and should prompt consideration of mastectomy.

Front 35

Without systemic therapy, what is the risk of recurrence for node-positive breast cancers?

Back 35

50-70%

Front 36

What is the expected relapse rate after LOCAL-REGIONAL therapy for node-NEGATIVE breast cancers?

Back 36

20-35%

Front 37

What is the significance of internal mammary node involvement in breast cancer?

Back 37

Similar to multiple axillary nodes in terms of poor prognosis.

Front 38

What is the role of completion axillary lymph node dissection?

Back 38

•ALND remains the standard approach for women who have three or more positive sentinel nodes or those who have a positive fine needle aspiration of an axillary lymph node. Completion axillary dissection may not benefit women with estrogen receptor positive T1 or T2 tumors that are clinically node negative, with less than three positive sentinel nodes, who will be treated with whole breast radiation.

Front 39

Sentinel lymph node biopsy is not appropriate in patients with what?

Back 39

Clinically palpable nodes.

Front 40

What is the appropriate management of pT1, pT2, or pT3, N0 or N1mi triple positive breast cancer?

Back 40

Definite endocrine therapy. Consider systemic chemo based on the microinvasiveness of the node, or if the tumor is greater than 0.6 cm. If the tumor is greater than 1 cm, then chemo is indicated.

Front 41

How does invasive lobular carcinoma (ILC) differ from invasive ductal carcinoma (IDC) in terms of patient age, nodal involvement and receptor status?

Back 41

Invasive lobular carcinoma occurs in older patients, is less likely to have nodal involvment, and are usually receptor positive, HER2 negative

Front 42

Which breast cancer histologic subtypes have a generally favorable prognosis? Tumors of these types, above what size, should be treated with systemic therapy? Which mixed type should be managed as IDC?

Back 42

tubular, mucinous/colloid, papillary. These types are usually small and found in a node-negative stage, making them amenable to breast conserving therapy and omission of systemic therapy. If the tumor is greater than 3 cm, systemic therapy may be indicated. Tumors with atypical or mixed medullary/ductal histology should be managed as IDC.

Front 43

Describe phyllodes tumor and how they are managed.

Back 43

Similar to fibroadenoma, with both epithelial and stomal components. Managed with wide excision; 25% will recur if inadequately excised. No SLND or adjuvant therapy required.

Front 44

What factors are included in the Nottingham Prognostic Index?

Back 44

tumor size, lymph-node stage, histologic grade

Front 45

What is the pure prognostic value of endocrine receptor status in breast cancer?

Back 45

Little value prognostically, but they are helpful in predicting response to endocrine therapy.

Front 46

What is the difference in response to chemotherapy between ER-positve and ER-negative breast cancers?

Back 46

ER-negative tumors respond more often and more completely.

Front 47

In what portion of breast cancers is HER2 overexpressed?

Back 47

20-30%.

Front 48

What is the mechanism of action of lapatinib (Tykerb)?

Back 48

Tyrosine kinase (dual kinase) inhibitor; inhibits EGFR (ErbB1) and HER2 (ErbB2) by reversibly binding to tyrosine kinase, blocking phosphorylation and activation of downstream second messengers (Erk1/2 and Akt), regulating cellular proliferation and survival in ErbB- and ErbB2-expressing tumors. Combination therapy with lapatinib and endocrine therapy may overcome endocrine resistance occurring in HER2+ and hormone receptor positive disease.

Front 49

What are the indications for lapatinib?

Back 49

As first line treatment, lapatinib has not been compared with trastuzumab and is most commonly used upon trastuzumab progression. In the United States, lapatinib is approved in combination with capecitabine for second-line treatment (ie, for the treatment of patients with HER2-overexpressing metastatic breast cancer who have received prior therapy with an anthracycline, a taxane, and trastuzumab). It is approved as first-line endocrine treatment in combination with letrozole for the treatment of postmenopausal women with HER2-positive, hormone receptor-positive metastatic breast cancer.

Front 50

What is the difference between ER-positive Luminal A and Luminal B breast cancer subtypes?

Back 50

Luminal A - low grade, high receptor expression, low HER2, lower proliferative indices.
Luminal B - higher recurrence score, lower receptor expression, more likely to express HER2, high proliferation indices

Front 51

Describe the basal-like subtype of ER-negative breast cancer.

Back 51

highly proliferative, usually triple negative

Front 52

Which patients are appropriately evaluated on the breast cancer Recurrence Score?

Back 52

those with node negative, hormone receptor positive disease treated with tamoxifen.

Front 53

What is the expected outcome in a breast cancer patient with a Recurrence Score of less than 10?

Back 53

>95% DFS with hormone treatment alone.

Front 54

What is the expected outcome in a breast cancer patient with a Recurrence Score of greater than 30?

Back 54

30% chance of recurrence with hormone treatment alone.

Front 55

What is the expected outcome in a breast cancer patient with a Recurrence Score of less than 10?

Back 55

>95% DFS with hormone treatment alone.

Front 56

What is the expected outcome in a breast cancer patient with a Recurrence Score of greater than 30?

Back 56

30% chance of recurrence with hormone treatment alone.

Front 57

Which trial is evaluating the benefit of chemo + endocrine therapy vs endocrine therapy alone for patients with an intermediate Recurrence Score?

Back 57

TailoRx

Front 58

In breast cancer, what are the cutoffs for the T descriptors?

Back 58

T1 = up to 2 cm
T2 = 2-5 cm
T3 = greater than 5 cm
T4a-d = invasion of chest wall, skin, both or inflammatory breast cancer

Front 59

In breast cancer, what are the N descriptors in TNM staging?

Back 59

N0 = no nodes
N1 = 1-3 nodes or internal mammary node not evident clinically.
N2 = 4-9 nodes, or clinically apparent internal mammary nodes without axillary involvement.
N3 = 10 or more nodes, SC or IC nodes, clinically apparent internal mammary node with axillary involvement.

Front 60

Describe stage I breast cancer.

Back 60

T1 N0 M0

Hint 60

T1 Tumor ≤20 mm in greatest dimension
T1mi Tumor ≤1 mm in greatest dimension
T1a Tumor >1 mm but ≤5 mm in greatest dimension
T1b Tumor >5 mm but ≤10 mm in greatest dimension
T1c Tumor >10 mm but ≤20 mm in greatest dimension

Front 61

Describe stage IIA breast cancer.

Back 61

Tumor of 2-5 cm with no nodes, or less than 2 cm tumor with 1-3 nodes.

Front 62

Describe stage IIB breast cancer.

Back 62

Tumor of greater than 5 cm with no nodes, or 2-5 cm tumor with 1-3 nodes

Front 63

Describe stage IIIA breast cancer.

Back 63

Any size tumor with 4-9 nodes, or a tumor of greater than 5 cm with at least 1-3 nodes.

Front 64

Describe stage IIIB breast cancer.

Back 64

Any tumor with T4 characteristics, regardless of nodes.

Front 65

Describe stage IIIC breast cancer.

Back 65

Any tumor with greater than 10 positive nodes.

Front 66

Is treating DCIS with lumpectomy equivalent to mastectomy?

Back 66

More recurrences with lumpectomy but no change in overall survival.

Front 67

Adding tamoxifen after lumpectomy and radiation for DCIS has what affect on the recurrence rate?

Back 67

40% decrease.

Front 68

In what group of women would omission of radiation after lumpectomy for stage I, ER-positive breast cancer be acceptable?

Back 68

Elderly women with small, well-differentiated tumors with wide (1 cm) surgical margins.

Front 69

Stage one breast cancers greater than 1 cm have what percent risk of recurrence?

Back 69

Greater than 10%. Adjuvant systemic therapy is indicated.

Front 70

Adding chemotherapy to endocrine treatment of ER-positive breast cancer larger than 1 cm decreases the risk or recurrence by what percent in young women? In older women?

Back 70

Reduces recurrence risk in young women by 36%, in older women by 15%.

Front 71

When is TC a good alternative to AC in the adjuvant setting? How do the regimens compare head-to-head?

Back 71

TC is good if the patient has cardiac problems or previous anthracycline exposure.
Patients were observed through 2005 for a median of 5.5 years. At 5 years, DFS rate was significantly superior for TC compared with AC (86% v 80%, respectively; hazard ratio [HR] = 0.67; 95% CI, 0.50 to 0.94; P = .015). Overall survival rates for TC and AC were 90% and 87%, respectively (HR = 0.76; 95% CI, 0.52 to 1.1; P = .13). More myalgia, arthralgia, edema, and febrile neutropenia occurred on the TC arm; more nausea and vomiting occurred on the AC arm as well as one incident of congestive heart failure.

Front 72

What does Herceptin add to chemotherapy in terms of risk of recurrence reduction in stage II HER2 positive breast cancer?

Back 72

30% reduction in risk of recurrence

Front 73

When should adjuvant chemotherapy be considered in breast cancers less than 1 cm in diameter?

Back 73

Young women
Triple negative disease
Grade III tumors

Front 74

In stage II breast cancer, which patients require locoregional radiation therapy after mastectomy?

Back 74

Those with tumors greater than 5 cm in diameter or with four or more positive lymph nodes.

Front 75

Is radiation necessary for breast cancer patients with T2 N0 lesions who undergo total mastectomy?

Back 75

No.

Front 76

Using AIs in postmenopausal women rather than tamoxifen confers what benefit?

Back 76

15% reduction in risk of recurrence for AIs compared to tamoxifen.

Front 77

What are the adverse effects of AIs?

Back 77

MSK pain, osteoporosis

Front 78

How do AIs compare to tamoxifen in terms of risk of cancer or VTE?

Back 78

Lower incidence of both endometrial cancer and thromboembolic events.

Front 79

Which type of drug should be avoided in patients on tamoxifen?

Back 79

CYP 2D6 inhibitors such as buproprion, fluoxetine, paroxetine and quinidine.

Front 80

Why is it important to clarify a woman's menopausal status correctly after adjuvant chemotherapy and before deciding on an endocrine therapy?

Back 80

To avoid giving an AI to a woman with temporary, chemotherapy induced amenorrhea.

Front 81

What is the role of adjuvant ovarian ablation or suppression in the treatment of breast cancer?

Back 81

It is a reasonable addition to tamoxifen in premenopausal patients with hormone receptor positive tumors who will not be receiving chemotherapy.

Front 82

Which patients with stage II breast cancer should be considered for adjuvant chemotherapy?

Back 82

All of them. Recurrence Score can help make the decision, and although the score doesn't apply to triple-positive cancer or hormone receptor negative cancer, you would probably recommend chemo in these instances anyway.

Front 83

Overall, for stage II breast cancer, adjuvant chemotherapy with an anthracycline and a taxane reduces the annual risk or recurrence and death by what percentage in women younger than age 50? In women older than age 50?

Back 83

Recurrence/death reduction in women younger than 50 = 50%/40%
Recurrence/death reduction in women older than 50 = 30%/20%

Front 84

What is the difference in scheduled doses between paclitaxel (Taxol) and docetaxel (Taxotere) in breast cancer?

Back 84

Taxol is usually given weekly or every 2 weeks, Taxotere is given every 3 weeks.

Front 85

Why are endocrine therapies given after chemotherapy in breast cancer?

Back 85

AIs have an antiproliferative effect that may blunt the chemotherapy benefit. VTE risk may be increased with concommitant therapy.

Front 86

Neoadjuvant chemotherapy in breast cancer results in complete pathologic response in what percentage of patients? What percentage convert from node-positive to pathologically-confirmed node-negative?

Back 86

15% complete tumor response, 20-30% complete node response.

Front 87

What is the clinical triad for diagnosis of inflammatory breast cancer? What percentage of newly diagnosed breast cancers are inflammatory?

Back 87

Erythema, warmth and edema. 1-5% of newly-diagnosed breast cancers are inflammatory.

Front 88

Is evidence of dermal lymphatic invasion necessary for a diagnosis of inflammatory breast cancer?

Back 88

No.

Front 89

What is the standard approach to treatment of inflammatory breast cancer?

Back 89

Combination chemotherapy followed by mastectomy and radiation (or radiation first if there is an inadequate response to chemotherapy)

Front 90

What is the prognosis for patients with inflammatory breast cancer who are treated with chemotherapy, in terms of overall response, resectability and 5-year survival?

Back 90

60-90% respond dramatically and 90% become resectable. 5-year survival rates now routinely exceed 40%.

Front 91

How often is the ER/PR and/or HER2 status of metastases in breast cancer different from the primary tumor?

Back 91

About 10%

Front 92

What is the expected response rate to first-line endocrine therapy in patients with ER-positive metastatic breast cancer?

Back 92

30-40% objective response (PR + CR) and another 20-30% with stable disease for at least 6 months.

Front 93

At what level cumulative dose does the risk of cardiac toxicity increase with anthracyclines?

Back 93

350 mg per meter squared.

Front 94

Which chemotherapy agents are hepatically metabolized and should be used cautiously in breast cancer patients with hepatic metastases?

Back 94

Taxanes, vinca alkaloids, anthracyclines

Front 95

What benefit does lapatinib have over Herceptin in breast cancer patients with CNS mets?

Back 95

Lapatinib can cross the blood-brain barrier.