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39 Cards in this Set
- Front
- Back
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What are RFs for breast cancer? |
Reproductive factors: early menarche and late menopause, first full term prengnany after age 30 years, nulliparity Lifestiy: obesity, etoh, lack of exercise, vt D deficiency Treatment related: radiation, HRT BReast density: > 75% dense, AStypical ductal or lobular hyperplasia - RR 3.8 to 3.5 for atypical hyperplasia and 5.4-8 for LCIS - 30-35% lifetime risk of breast cacner Genetics; family hx breast cancer and familia breast cancer syndromes: 5-10% of all breast cancer tumors BRCA 1/2 RR 3-78 confer a 50% to 87% lifetime risk of breast cancer, and a 20-45% lifetime risk of ovarian cancer |
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Who should be screened for BRCA? |
NON-ASH J heritage Two FIRST degree relatives with breast cancer, one w dx < 50 Three or more first or second degree relatives regardless of age at dx Combination of both breast and ovarian cacner amongst first and second degree relatives First degree relative with BILATERAL breast cancer Combination of two ore more first or second degree relatives with ovarian cancer regardless of age First or second degree relative with both breast and ovarian cancer at any age Hx of breast cancer in male relative OF ASH: Any 1st degree relative or two second degree relatives on same side of the family with breast or ovarian cancer |
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Who is a cnadidate for prophylacitc antiestrogen therapy? |
Women older than 35 years with a 5-year breast cancer risk of 1.7% or higher or with lobular carcinoma in situ are candidates for breast cancer prophylaxis with antiestrogen treatments such as tamoxifen prior to menopause and, in addition, raloxifene or exemestane after menopause (Table 52). Atypical ductal hyperplasia is associated with a high risk of breast cancer independent of the Gail Model risk. |
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Who should be screened with breast MRI? |
Women with BRCA mutations 1st degree relative who is a BRCA carrier but has not been tested Women with a strong family hx of breat cancer, lifetime risk > 2-35% Women with radiation to chest wall between ages of 10-30 years WOmen with a hx of other rare familial breast syndrome |
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How should women with BRCA 1/2 mutations be screened? |
Women with BRCA1/2 mutations should undergo breast cancer screening with MRI beginning at age 25 years and mammography beginning at age 30 years. Ovarian cancer screening with semiannual pelvic examinations, pelvic ultrasonography, and serum CA-125 measurement should begin at age 30 years. However, the effectiveness of ovarian cancer screening is not known, and surgical prophylaxis as detailed below is strongly recommended for BRCA1/2 mutation carriers. Ovarian cancer screening is not recommended in women at average risk of ovarian cancer. |
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What else should be done prophylactically in women with the bRCA gene? |
In women who are BRCA1/2 carriers with one prior diagnosis of breast cancer, tamoxifen decreases the risk of contralateral breast cancer by 40% to 60%. Surgical prophylaxis options for carriers of BRCA1/2mutations include prophylactic bilateral mastectomy, which decreases the risk of breast cancer by greater than 90%, and prophylactic bilateral salpingo-oophorectomy (BSO), which decreases the risk of ovarian cancer by 80%, whether done before or after menopause. . If done before menopause, prophylactic BSO also decreases the risk of breast cancer by 50%. Prophylactic BSO is recommended in women who carry deleterious BRCA1/2 mutations between ages 35 and 40 years, once childbearing is complete. A recent registry study recommends risk-reducing BSO by age 35 years in women withBRCA1 mutations because of a 4% risk of ovarian cancer between ages 35 and 40 years. Women withBRCA2 mutations in this study did not develop ovarian cancer until after age 40 years. |
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In stage I/II disease, when is investigation into metastatic disease warranted? |
Imaging studies to identify occult metastatic disease are not needed in patients with stage I and II breast cancer unless worrisome symptoms or the following poor prognostic features are present: hormone receptor–negative cancer, HER2 overexpression, large tumor size, high tumor grade, positive lymph nodes, and the presence of extensive lymphovascular invasion |
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What is the risk of recurrence in DCIS and what are RFs for recurrence? |
The goal of treatment of DCIS is to prevent progression to invasive cancer. Excision alone without radiation is associated with a 30% risk of local recurrence at 10 years, with half of these recurrences consisting of invasive cancers. Risk factors for recurrence include young age, high tumor grade, the presence of comedo-type necrosis (necrosis in the center of the involved spaces), margin width, and tumor size. |
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When is SN biopsy recommended in DCIS? |
Sentinel lymph node biopsy is recommended if there is microinvasion (≤1 mm foci of invasion) or if a mastectomy is done in those in whom invasion is found on final pathologic results. |
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What is the treatment of DCIS? |
Breast conserving therapy, which consists of wide excision followed by breat radiation or mastectomy 80% of DCIS is ER positive, In patients with estrogen receptor–positive DCIS, adjuvant tamoxifen decreases the risk of local recurrence of both DCIS and invasive cancer by 20% to 25% and of contralateral breast cancer by 50% Because tamoxifen in DCIS confers no apparent benefit for survival, a discussion about treatment decisions should focus on potential toxicities and patients' needs and preferences. With treatment, patients with DCIS have a 15-year cause-specific survival rate of 97%. |
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For invasive breast cancer, when is breast conserving therapy an option? |
Breast-conserving therapy is an effective option in patients with tumors measuring 5 cm or less involving a single quadrant of the breast and with clear margins after excision. Mastectomy is recommended for tumors involving the skin, chest wall, or more than one quadrant of the breast, and for inflammatory breast cancer. Patients with tumors measuring 5 cm or greater who would otherwise be candidates for breast-conserving therapy may receive chemotherapy or antiestrogen treatment before surgery to decrease tumor size to facilitate breast conservation. |
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When is axillary LN dissection required? |
If the sentinel lymph node biopsy is negative, or if there are less than three positive sentinel nodes in a woman who is to receive whole breast radiation and adjuvant therapy, axillary lymph node dissection is not required. In patients with clinically involved lymph nodes or with three or more involved sentinel lymph nodes, axillary lymph node dissection is done to remove additional lymph nodes. |
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What type of radiation is given after surgery? |
Primary breast radiation usually consists of whole breast radiation with a boost given to the lumpectomy bed. Chest wall radiation after MASECTOMY is recommended in patients with tumors measuring greater than 5 cm, positive tumor margins, skin or chest wall involvement, inflammatory breast cancer, or four or more positive axillary lymph nodes. Depending on other risk factors, it may be recommended in women with one to three positive axillary lymph nodes. Postmastectomy radiation in these patients decreases the risk for local recurrence and systemic metastases. |
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What subpopulation of patients do not require radiation or SN biopsy? |
For women aged 70 years and older with tumors measuring less than 2 cm, no clinically involved lymph nodes, and estrogen receptor–positive breast cancer, wide excision without sentinel lymph node biopsy or whole breast radiation followed by antiestrogen therapy alone is an acceptable treatment option. Whole breast radiation in this setting does decrease the risk for local recurrence, but does not increase breast cancer–specific or overall survival. |
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How are men treated w/ breast CA? |
Men with breast cancer have the same surgical options as women; however, owing to smaller breast size and more frequent involvement of the areola, many men are not candidates for breast-conserving therapy, and most are treated with mastectomy. Sentinel lymph node sampling is appropriate in men with clinically lymph node–negative breast cancer, and the indications for postmastectomy radiation are the same for men as for women with breast cancer. |
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To what extent does adjuvant hormonal therapy reduce recurrence in receptor positive breast cancer? j |
Most patients with hormone receptor–positive breast cancer receive adjuvant antiestrogen therapy which includes aromatase inhibitors, tamoxifen, and ovarian suppression in premenopausal women. Hormonal therapies reduce the overall risk of local and distant recurrence by 40% to 50% and the risk of contralateral cancer by 50% to 65%. |
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What is the duration of adjuvant hormonal therapy in pre-menopausal women? |
For premenopausal women, tamoxifen, a selective estrogen receptor modulator, is routinely recommended. Recent results from two large international studies, the ATLAS (Adjuvant Tamoxifen: Longer Against Shorter) and aTTom (Adjuvant Tamoxifen Treatment Offers More) trials, are showing superior results with 10 rather than 5 years of tamoxifen adjuvant therapy, changing the standard of care for premenopausal women. Premenopausal women who previously completed 5 years of tamoxifen also benefit further from taking an aromatase inhibitor for 5 years once they become postmenopausal. Ovarian ablation or suppression decreases the risk of breast cancer recurrence by 25% and is sometimes used in premenopausal women with contraindications to tamoxifen. Clinical trials are investigating whether ovarian suppression may provide additional benefit to patients receiving adjuvant antiestrogen therapy and/or chemotherapy. |
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What is the duration of adjuvant hormonal therapy in post-menopausal women? |
r. A meta-analysis of postmenopausal women with early breast cancer who took adjuvant tamoxifen for 5 years or an adjuvant aromatase inhibitor for 5 years reported a decreased rate of breast cancer recurrence (12% versus 15% at 5 years, rate ratio 0.77) in the aromatase inhibitor arm. Current antiestrogen adjuvant therapy options for postmenopausal women include 2 years of tamoxifen therapy followed by 3 to 5 years of an aromatase inhibitor, or 5 years of an aromatase inhibitor. Women who cannot tolerate more than 2 to 3 years of an aromatase inhibitor can switch to tamoxifen to complete 5 years of antiestrogen therapy. |
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What are aromatase inhibitors? |
Prevent peripheral conversion of androgens to estrogens in post-menopausal women - INactive in premenopausal women because they are inactive in women with intact ovarian function |
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What are the SEs of aromatase inhibotors? |
he main side effects of aromatase inhibitors are arthralgia and bone pain; vaginal dryness; sexual dysfunction; and higher risks of osteoporosis, fractures, cardiovascular risk, and hyperlipidemia. Compared with tamoxifen, the aromatase inhibitors confer a lower risk of venous thrombosis and endometrial cancer. Patients taking aromatase inhibitors should have their bone density monitored, and if the T score falls below -2.5, bisphosphonate treatment can be initiated. |
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What are the SEs of tamoxifen? |
Tamoxifen increases the risk of endometrial cancer and venous thromboembolic events in women over age 55 years. Other toxicities include hot flushes, vaginal discharge, and sexual dysfunction. Yearly pelvic examinations are recommended, and abnormal vaginal bleeding should be reported to their physicians. |
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When is adjuvant chemotherapy initiated? |
Adjuvant chemotherapy is usually recommended for patients with high-risk breast cancer features, such as hormone receptor–negative status, HER2 amplification, high-grade tumor, extensive lymphovascular invasion, and positive lymph nodes. Patients with hormone receptor–negative breast cancer generally have a greater benefit from adjuvant chemotherapy, with a proportional reduction in risk of recurrence and breast cancer–related death of more than 50% compared with a risk reduction of 25% in patients with hormone receptor–positive breast cancer. |
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What are the components most commonly used in adjuvant chemotherapy? |
Anthracyclines (doxorubicin, epirubicin) Cyclophosphamide Taxanes (paclitaxel, docetaxel) SEs: bone marrow suppression with anemia and neutropenia, alopecia, hypersensitivity reactions, neuropathy, nausea, and premature menopause and infertility when given to premenopausal women Rare but serious toxicities include cardiomyopathy from anthracyclines, interstitial pneumonitis from cyclophosphamide or the taxanes, and myelodysplasia and acute leukemia from the anthracyclines and/or cyclophosphamide. |
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When is HER2 antagonist Trastuzumab used? |
For women with HER2-positive breast tumors measuring 0.5 cm or larger and/or positive lymph nodes, adjuvant chemotherapy combined with trastuzumab is recommended. Trastuzumab is a monoclonal antibody directed against the HER2 receptor. When added to adjuvant chemotherapy, trastuzumab decreases the risk of breast cancer recurrence by 53% and the risk of breast cancer–related death by 34%. Adjuvant trastuzumab is given for 1 year. |
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What are trastuzumab toxicities? |
Trastuzumab toxicities include infusion reactions and cardiomyopathy. The risk of cardiomyopathy is higher in patients receiving anthracycline-containing regimens (2% to 4%) compared with non–anthracycline-containing regimens (0.4%) and is higher in older women or those with preexisting cardiac risk factors. Cardiac function should be evaluated at baseline with echocardiography or multigated acquisition scan and every 3 months during adjuvant trastuzumab therapy |
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What is considered locally advanced breast cancer? Stage IIIA-IIIC? |
tumors measuring greater than 5 cm with lymph node involvement, skin or chest wall involvement, and/or extensive axillary lymph node involvement. |
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What is the treatment for locally advanced cancer? |
rapy (neoadjuvant chemotherapy), followed by surgery, and then radiation. Patients with tumors measuring greater than 5 cm without other locally advanced features such as skin or chest wall involvement can often have breast-conserving surgery after chemotherapy. Tumors with chest wall or skin invasion (T4 cancers) require mastectomy after chemotherapy; surgical staging of the axilla is also required. Postmastectomy or postlumpectomy radiation is recommended for these locally advanced breast cancers, which often also require radiation of draining lymph nodes. Locally advanced cancer is associated with a high risk of distant and local recurrence. |
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What is the treatment of inflammatory breast cancer? |
Inflammatory breast cancer is treated with neoadjuvant chemotherapy, followed by mastectomy with axillary node dissection, and then postmastectomy chest wall radiation therapy. Despite multimodality treatment, prognosis is still worse for patients with inflammatory breast cancer than for those with other types of locally advanced breast cancer, with a 5-year relative survival rate of approximately 40%. |
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What is appropriate breast cancer f/u? |
After completing surgery, radiation therapy, and chemotherapy, patients with early-stage breast cancer should receive follow-up monitoring every 3 to 6 months for 2 years, every 6 months during years 2 through 5, and then annually. Monitoring should include annual mammography, whereas screening MRI of the breast is reserved for patients who have a high risk for subsequent breast cancer from BRCA1/2 mutations, a strong family history of breast cancer, or other indications as based on the ACS guidelines (see Most hormone receptor–negative breast cancer recurrences develop within 5 years of diagnosis. However, in patients with hormone receptor–positive breast cancer, half of the recurrences arise 5 years or more after diagnosis. |
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What is therapy for long term SEs of treatment? |
herapy-related hot flushes in breast cancer survivors may be improved with selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, with avoidance of strong and moderately strong CYP2D6 inhibitors, which can inhibit tamoxifen activation.Breast cancer survivors should undergo monitoring for decreased arm mobility and lymphedema, with prompt referral to physical therapy in the presence of such symptoms. |
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What is the treatment of metastatic disease? |
Initial treatment for metastatic breast cancer depends on hormone receptor and HER2 status, disease sites, and patient comorbidities and preferences. For hormone receptor–positive cancer, antiestrogen therapy usually is given initially. Antiestrogen therapy works best in patients with bone and soft tissue metastases and in those with a longer disease-free interval since the initial breast cancer diagnosis. Antiestrogen treatments for metastatic breast cancer include aromatase inhibitors, tamoxifen, ovarian suppression in premenopausal women, fulvestrant (an estrogen receptor down-regulator), megestrol acetate, and estradiol. A newer approach combines antiestrogen treatment with molecularly targeted therapy affecting downstream pathways. The combination of exemestane and the mammalian target of rapamycin (mTOR) inhibitor, everolimus, is effective in patients in whom resistance to aromatase inhibitor therapy has developed. Patients with hormone receptor–negative cancer, those with impending visceral crisis due to extensive metastases, or those who do not respond to antiestrogen therapy are treated with chemotherapy. Generally, single-agent chemotherapy is given, although combination therapy is appropriate in patients with extensive visceral metastases in whom a higher response rate is needed. Chemotherapeutic agents can be used sequentially in patients with good performance status who wish to continue palliative treatment. |
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What are RFs for ovarian cancer? What reduces risk? |
Endometriosis, polycystic ovary syndrome, infertility, intrauterine device use, and cigarette smoking all increase the risk. Ovulation induction for treatment of infertility does not increase ovarian cancer risk. Factors that decrease the risk of ovarian cancer include previous pregnancy, prior oral contraceptive pill (OCP) use, and tubal ligation or hysterectomy. OCP use for 15 years or more decreases the risk of ovarian cancer by 50%, with the protective effect lasting approximately 30 years after OCP cessation, but even shorter use results in some protection. |
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What is the staging of ovarian cancer? |
Stage I disease - cancer in one or both ovaries, not high grade or clear cell, negative peritoneal washings no rupture --> surgery alone Stage I, stage II: unfavorable stage I: high grade of clear cell histology, rupture or positive peritoneal washings but still confined to the ovaries; Stage II spread beyond ovaries but confined to pelvis --> Surgery followed by chemotherapy 3. Optimally debulked stage II disease: spread to abdomen, residual tumor masses < 1cm after debulking surgery --> surgery followed by IV or intraperitoneal chemotherapy 4. Suboptimally debulked or spread beyond the abdomen: surgery with chemotherapy but very poor prognosis |
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What is the surgery for ovarian cancer? |
TAH/BSO Staging exam of abd/pelvis Peritoneal washings and LN evaluation Tumor debulking by removal of all neoplastic tissue that can be safely excised |
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Who should get intraperitoneal chemotherapy? |
For stage II and optimally debulked stage III cancer, intraperitoneal chemotherapy through an indwelling peritoneal catheter should be considered. It results in a 16-month improvement in overall survival in patients with stage III disease compared with intravenous chemotherapy regimens, but is associated with more toxicity. Physicians and patients should discuss the risks and benefits of this approach. |
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What is the most common manifestation of relpase and what is the treatment? |
An elevated serum CA-125 level in a patient with a normal physical examination and CT scan and no disease symptoms constitutes the most common presentation at relapse. Patients with an isolated serum CA-125 recurrence who are not comfortable with surveillance alone can be treated with tamoxifen or an aromatase inhibitor. Initiating cytotoxic treatment confers no known benefit in this setting. Can do repeat debulking if overall life expectancy is > 12 months |
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Which patients with relapse should be treated with cytotoxic chemotherapy? |
Cytotoxic chemotherapy is indicated for patients with significant disease on CT scan or physical examination or in those with disease progression–related symptoms. Treatment options include single-agent or combination chemotherapy, often involving a platinum agent if the cancer has not developed resistance, as well as anti-angiogenesis inhibitors such as bevacizumab. |
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What is the efficacy of HPV vaccine and when should it be given? |
he HPV vaccine is ideally given before sexual activity begins: if given to adolescents and young women before they develop HPV infection, it is 90% effective at preventing infection and 97% to 100% effective at preventing cervical intraepithelial neoplasia and invasive cervical cancer. |
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What is the staging of cervical cancer and treatment? |
StageI: carcinoma confined to the cervix - radical histerectomy ovarian preservation if fertility desired IA: microscopic disease only --> simple hysterectomy, cone biopsy or removal of cervix alone are options Stage II (A is nonbulking, B is bulking) Cervical carcinoma invades beyond uterus but not to the pelvic wall or lower third of vagina - same as for stage I; 2b is same as stage III Stage III: involves pelvic wall and lower third of the vagina - causes hydronephrosis of the nonfunctioning kidney --> tx is radiation w/ concurrent platinum based chemotherapy Stage IV: Byeond pelvis into mucosa of bladder or rectum (IVA is adjacent, IVB is distant). IVA is same as for stage III, stage IV B is pallaitive chemotherapy |
