Therapeutics V Exam 2- Adult Cancer I

Front 1

American Joint Committee on Cancer (AJCC) – Cancer Staging (3 components)

Back 1

T: tumor size

N: nodes

M: metastasis

Front 2

Tumor size- how to classify (4 stages)

Back 2

Tx: primary tumor cannot be assessed
T0: no evidence of primary tumor
Tis: carcinoma in situ
T1-4: increase in size and/or local extent of the tumor

Front 3

how to document/classify nodes for cancer staging (3)

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Nx: regional lymph nodes cannot be assessed
N0: no regional lymph nodes metastasis
N1-3: increasing number of lymph nodes involved

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how to classify/document mets for cancer staging(3)

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Mx: distant metastases cannot be assessed
M0: no distant metastasis
M1: distant metastasis

Front 5

breast cancer- statistics (death, incidence...)

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most common malignancy

2nd leading cause of cancer death among females

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race with highest incidence to lowest for breast cancer (4)

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White > African American > Asian = Hispanic

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5 age related/hx related risk factors for BC

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current age > 40

less than 12 years at menarche
greater than 55 yr at menopause
>= 30 yr at first live birth

personal or fam h/o breast cancer

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other risk factors for BC (drug/substance related, body..related) (5)

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nullparity
radiation
alcohol > 2/day
HRT or current use of oral contraceptives for > 10 yrs
high density boobies tissue

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4 genes related to BC

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BRCA1 (main breast cancer gene)
BRCA2
p53
PTEN

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BRCA2 properties (2- other associations with cancers)

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ovarian ca risk lower
- assoc with male breast cancer

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p53 gene associated with what type of BC

Back 11

Li-Fraumeni syndrome: pre-menopausal BC assoc with a host of other shit

Front 12

PTEN- associated with what syndrome (and say what it is)

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Cowden’s Syndrome: characterized by an excess of breast cancer, gastrointestinal malignancies, and thyroid disease, both benign and malignant

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candidates for BC prevention therapy (5)

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BRCA1, BRCA2, PTEN, or p53 mutations
>2 first-degree relatives with breast or ovarian cancer
h/o thoracic irradiation
h/o LCIS (lobular carcinoma in situ)
>35 years with a 5-year breast cancer risk >= 1.7%

Front 14

BC prevention therapies (2 pharm, 1 non pharm)

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Tamoxifen 20 mg daily x 5 years (for premenopausal)
Bilateral mastectomy ± reconstruction- reserved only for major risk like genetic mutations or LCIS)
Statins (not sure...about this)

Front 15

tamoxifen- reduces BC risk by how much?

don't give if...(2)

give what instead

Back 15

reduces breast cancer risk by 49%
Post menopausal >35 yrs give roloxifene

Front 16

4 s/sx of localized BC

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Painless lump is the most common sign
Change in size, shape, color, or feel of the breast/areola/nipple
Nipple discharge, erosion, tenderness, inversion
Stabbing or aching pain

note that 10% have no sx

Front 17

5 sx of advanced BC ( I assume this means mets)

Back 17

Bone pain
Difficult breathing
Abdominal enlargement
Jaundice
MS changes (wtf is MS)

Front 18

3 screening options

Back 18

Monthly Self-Breast Exams (optional)
Clinical Breast Exam
Mammogram

Front 19

when to start self breast exams and frequency

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Starting at age 20
monthly

Front 20

clinical breast exam- at what age range do you start?

initial frequency?

at what age do you increase freq and to what?

Back 20

Age 20-40: q1-3 years
Annually after age 40

Front 21

mammogram- when to start, freq

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Annually beginning at age 40

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high risk women- when to screen (general)

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Earlier screening for high risk women

Front 23

dx of breast cancer is done through...

what other testing do we have to do?

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for any biopsy done- determine hormone receptor status (estrogen or progestin) and also Her-2-neu status

Front 24

dx tests for BC (5)

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H&P, FH
Clinical breast exam
Mammography
Ultrasound
Breast biopsy

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3 types of biopsy

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Fine needle aspiration
Core
Excisional

Front 26

4 types of breast cancer

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noninvasive carcinoma
invasive carcinoma
paget's disease
inflammatory breast cancer

Front 27

inflammatory breast cancer properties (2)

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rapid onset
poor prognosis

Front 28

2 types of noninvasive carcinoma

Back 28

Lobular carcinoma in situ (LCIS)
Ductal carcinoma in situ (DCIS)

Front 29

AJCC stage 0 BC (2)

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Stage 0: LCIS, DCIS

Front 30

AJCC stage 1 (2)

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<2 cm, confined to breast

Front 31

AJCC stage II (2)

Back 31

less than 5 cm ± moveable ipsilateral LN (lymph node) metastases
greater than 5 cm without LN involvement

Front 32

AJCC stage III (3)

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Direct extension to ipsilateral LN or chest tissue
>5 cm with metastases to moveable ipsilateral LN
Any size with metastases to fixed ipsilateral LN (internal mammary?)

Front 33

AJCC stage IV

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distant metastases (bone, liver, lung, brain)

Front 34

survival rates of stage I-IV BC

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stage I- 70-90% 5 year survival
stage II- 50-70
stage III 20-30%
stave IV 0-10%

Front 35

treatment goals for BC carcinoma in situ

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cure

Front 36

treatment goals for stage I-III BC (2)

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Cure
Prevent recurrence

Front 37

treatment goals for stage IV BC (3)

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Palliation of symptoms
Improve QOL
Prolong survival

Front 38

LCIS is a marker for...

Back 38

Marker identifying women at
high risk for breast cancer (25%)

Front 39

treatment options for LCIS following biopsy (3)

Back 39

Observation following biopsy

Offer tamoxifen x 5 years

Bilateral prophylactic total mastectomies

Front 40

what is LCIS?

Back 40

area (or areas) of abnormal cell growth that increases a person’s risk of developing invasive breast cancer later on in life

not a true cancer

Front 41

what is DCIS?

Back 41

Noninvasive, precancerous lesion

Front 42

DCIS- progression

% that progresses

Back 42

May progress to become invasive
cancer (<30% within 5-10 yrs)

Front 43

DCIS treatment options (3)

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Breast conservation: local excision & RT (want...negative margins)

Consider post-surgical tamoxifen x 5 years, esp if hormone receptor positive

Total mastectomy ± reconstruction

Front 44

4 treatment options for stage I-III (indicate which is for stage I)

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Breast Conservation: lumpectomy with LN dissection with RT?? (stage I)
Total mastectomy with axillary LN dissection
Simple mastectomy with SLN biopsy
Adjuvant therapy

Front 45

adjuvant therapy- what is given? (2 options)

when are each of them given?

Back 45

hormonal therapy, chemo or both together

hormonal is given to ER/PR + patients

chemo is given if LN involved, or tumor > 1 cm

Front 46

gold std chemo therapy for BC (and frequency of dose and for how many times)

Back 46

AC x 4 (Q21 days)- i guess you give it 4 times, once every 21 days

Doxorubicin (Adriamycin)
Cyclophosphamide

Front 47

2 other chemo options for BC (freq of dose and how many times and what's in the drug combos)

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FAC or FEC x 6 (Q21 days) (Fluorouracil
Doxorubicin or epirubicin
Cyclophosphamide)

CMF x 6 (Q28 days) (anthracyclines CI) (Cyclophosphamide
Methotrexate
Fluorouracil )

Front 48

for LN positive patients (??) add what 2 drugs to which regimen (for BC)

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Consider addition of docetaxel (TAC) or paclitaxel (ATC) to AC regimen for LN positive patients

Front 49

how to choose chemo therapy for BC

Back 49

age and ability to tolerate chemo (older/frail don't treat as aggressively- so give less intensive regimen like CMF)

Front 50

5 options for hormone therapy in BC

Back 50

tamoxifen for 5 years
anastrazole
letrozole
exemestane
LHRH (luteinizing hormone releaseing hormone)-agonists (investigational)

Front 51

adjuvant hormonal therapy should be given to whom?

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Adjuvant hormonal therapy should be recommended to ALL women whose tumors are hormone receptor positive regardless of age, menopausal status, involvement of axillary LN, or tumor size

Front 52

tamoxifen indication

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Women with ER/PR+ tumors w/o CI (former gold-standard)

Front 53

indication of aromatase inhibitors (2)

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Preferred initial treatment for post-menopausal women
Sequential therapy after 2-3 years of tamoxifen (just has to add up to 5 years)

Front 54

beneficial effects of tamoxifen (2)

Back 54

Decrease breast cancer recurrence and mortality

Estrogenic effects on bone and lipid profile

Front 55

advantages of aromatase inhibitors (vs tamoxifen) (3)

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Fewer SE vs tamoxifen

Decrease breast cancer recurrence and mortality

Fewer incidences of cancer recurrences vs tamoxifen

Front 56

AE/bad things with tamoxifen (4)

Back 56

Hot flashes
Vaginal discharge
CVA/PE/DVT (clots)
Endometrial cancer

Front 57

7 AE of aromatase inhibitors

Back 57

Nausea
Hot flashes
Arthralgias
Myalgias
Mild fatigue
Diarrhea
Osteoporosis

Front 58

CI for tamoxifen (2)

Back 58

hx DVT or risk of endometrial cancer

Front 59

metastatic BC treatment options (4)

Back 59

Endocrine therapy- if ER or PR positive
Chemotherapy
Trastuzumab- if HER-2/neu overexpression
Palliative Care

Front 60

metastatic BC/ER/PR positive- therapy if post menopausal (2)

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aromatase inhibitor or antiestrogen

Front 61

metastatic BC/ER/PR positive- therapy if pre menopausal

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Antiestrogen ± ovarian ablation (e.g. oophorectomy, ovarian irradiation, LHRH analogs)

Front 62

if metastatic ER/PR positive BC progresses after therapy initiation (2)

Back 62

Trial of new hormone therapy
Chemotherapy

Front 63

treatment for ER/PR negative or hormone refractory or symptomatic visceral disease (Her2 positive vs negative)

Back 63

Her-2/neu overexpression: trastuzumab + chemotherapy
Her-2/neu not overexpressed: chemotherapy

Front 64

Metastatic Breast Cancer Endocrine Therapy options (first line- 3, second line, if disease progresses)

Back 64

tamoxifen and aromatase inhibitors (post menopause) first line

SERDS second line

LHRH (use with tamoxifen) for pre menopausal

progestins, androgens if progress

don't need to know does, just drug and class

Front 65

2 SERMs

Back 65

tamoxifen
toremifen

Front 66

SERD

Back 66

Fulvestrant

Front 67

3 LHRH analogs

Back 67

goserelin
leuprolide
triptorelin

Front 68

Megesterol acetate - class

Back 68

progestin

Front 69

fluoxymesterone- what is it

Back 69

androgen

Front 70

SERMS indication for MBC

Back 70

First line therapy for
MBC pts who are antiestrogen naïve or who have been antiestrogen free for >1 year

Front 71

fulvestrant indication for MBC

Back 71

Second line for MBC in post-menopausal women (not studied in pre-menopausal)

Front 72

aromatase inhibitor indication for MBC (2)

Back 72

First line for MBC in post-menopausal women (preferred if h/o antiestrogen use)
Sequential therapy after 2-5 years of tamoxifen

Front 73

efficacy of fulvestrant

advantages (decreased risk of...3 things)

Back 73

Similar efficacy to anastrazole
Decreased risk of thromboembolism, tumor flare, or endometrial cancer

Front 74

advantages of aromatase inhibitors in MBC (2)

Back 74

Improved survival over tamoxifen

Lower incidence of thromoboembolic event and vaginal bleeding vs tamoxifen

Front 75

6 AE of tamoxifen

Back 75

Hot flashes
Vaginal discharge
CVA/PE/DVT
Endometrial cancer
Tumor flare
Hypercalcemia

Front 76

AE of fulvestrant (4)

Back 76

Injection site reactions
Hot flashes
Asthenia
Headaches

Front 77

LHRH analogs- first line when?
second line when?

Back 77

With tamoxifen as first-line therapy for pre-menopausal women with MBC
Used alone as second-line therapy for pre-menopausal women with MBC

Front 78

benefits of using LHRH analogs

Back 78

Increased survival and progression-free survival when used in combo with tamoxifen

Front 79

AE of LHRH analogs (6)

Back 79

Amenorrhea
Hot flashes
Nausea
Tumor flare
Menopausal symptoms
Injection reactions

Front 80

megesterol AE (5)

Back 80

Weight gain
Fluid retention
Vaginal bleeding
Hot flashes
Thromobembolism

Front 81

megesterol indication

Back 81

Third-line therapy for MBC

Front 82

fluoxymesterone indication (2)

Back 82

Last-line therapy for MBC
May be effective in premenopausal women refractory to other therapies

Front 83

megesterol efficacy

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Response equivalent to tamoxifen

Front 84

6 AE of fluoxymesterone

Back 84

Deepening voice
Alopecia
Hirsutism
Acne
Irregular menses
Cholestatic jaundice

Front 85

Metastatic Breast CancerChemotherapy: preferred single agents (5)

Back 85

Anthracyclines ** taxanes**, capecitabine, vinorelbine, gemcitabine

Front 86

preferred combo chemo used for MBC (4)

Back 86

AC, FAC/FEC, CMF
AT (doxorubicin with docetaxel or paclitaxel)

Front 87

combo chemo vs. single agent
how to pick in palliative setting

Back 87

Combo chemo is associated with higher response rates h/e there is no compelling evidence that they are superior to single agents for delaved time to progression and overall survival.

-in the palliative setting the least toxic approach is preferred when efficacy is considered equal

Front 88

trastuzumab - efficacy when used with other drugs

Back 88

Additive effect with first-line chemotherapies

Front 89

trastuzumab- avoid admin with what other drugs

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Avoid administration with anthracyclines

Front 90

AE of trastuzumab (4)

Back 90

infusion-related reactions, hypersensitivity, pulmonary reactions, cardiotoxicity

Front 91

trastuzumab pre-medication (2)

why?

Back 91

Premedicate with APAP and/or diphenhydramine

hypersensitivity/infusion rxns

Front 92

Metastatic Breast Cancer: treatment for bone and CNS mets

Back 92

bone- bisphosphonates and RT (radiation therapy)

CNS mets- RT

Front 93

2 bisphosphonates used for bone mets of BC

Back 93

Pamidronate
Zolendronate