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18 Cards in this Set

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Breast pain most commonly signifies:
Commonly due to benign conditions, and is uncommonly the first symptom of breast cancer
Risk factors for breast cancer: (8)

Factors that reduce breast cancer risk: (3)
1) older age
2) personal/Family history, or genetic mutations
3) proliferative changes in benign breast disease
4) early menarche/late
5) menopause/nulliparity, or 1st birth at late age.
6) long term estrogn/progesterone use (↑risk 40%)
7) ↑education/socioeconomic status
8) high fat intake

may also ↑risk: alcohol, abortion, ↓exercise, chemical(DDT), high soy in starting in adulthood (from infancy ↓risk)

1) estrogen by itself, starting in 50s
2) first full term preg <18
3) exercise
BRCA1

frequency in breast cancer:
freq in population:
lifetime risk of carriers:

characteristics of these breast cancers:(4)
screening once mutation found:
risk/protective factors w/in pop:
2-5% of all breast cancer
1:300 to 1:800
85-90% lifetime risk

1) early onset
2) bilaterality
3) multi generation- breast and ovarian, and male breast
4) Ashkenazi Jewish ancestry

annual MRI+mammogram
• prophylactic sx (↓risk)
• bilateral oophorectomy ↓risk for BOTH breast and ovarian cancer
• low parity ↑risk
Effect of prophylactic tamoxifen use

on breast cancer?
on endometrial cancer?
on pulmonary embolism?
on deep vein thrombophlebitis?
on bone fractures?
on myocardial infarctions?
Clinical trial showed:
↓risk of both invasive and noninvasive breast cancers in tamoxifen group in ♀ in the study (>35yrs, high risk)

endometrial cancer: ↑risk
PE: ↑risk
DVT: ↑risk
(especially older women)

bone fractures: ↓risk
MI: no difference
Raloxifene:

use in breast cancer prevention?
STAR trial: determined works as well as tamoxifen.
• tested on postmenopausal, high risk ♀
TNM Classification in breast cancer:

TO:
Tis:
T1 - T4:

NO:
N1-N3:

M:
T0 – no evidence of primary tumor
Tis – noninvasive (carcinoma in situ)
T1 – less than or equal to 2 cm diameter
T2 – 2 to 5 cm
T3 – over 5 cm
T4 extends to chest wall or has satellite nodules or edema , or inflammatory carcinoma

N0 – No regional node involvement
N1 - Metastases to axillary nodes (no more than 3 nodes)
N2 – Clinically fixed or matted axillary nodes (or N2a = 4 to 9 nodes)
N3 – 10 or more involved nodes

Distant metastatic disease
Breast Cancer Stages:

Stage 0:
Stage I:
Stage II:
Stage III:
Stage IV:
Stage 0 is DCIS (TisN0M0)
Stage I is T1N0
Stage II is T0 N1 or T1 N0 or T1 N1 or T3 N0
Stage III is T0 N2 or T1 N2 or T3 N1 or any T N3
Stage IV is any M1
Ductal Carcinoma In Situ

Treatment choices: (3)
1) Breast conserving sx and radiation, ± tamoxifen

2) Total mastectomy ± tamoxifen

3) Breast conserving therapy without radiation, + tamoxifen…being studied
Lobular Carcinoma in situ

what is it:
management choices; (3)
Lobular neoplasia: marked for subsequent invasive cancer, EITHER breast.

1) Observation alone, after biopsy
2) Tamoxifen or Raloxifene
3) Bilateral prophylactic mastectomy without node dissection
Stage I, II, or IIIA breast cancer

primary therapy choices: (2)
1) Breast conserving therapy (lumpectomy, sentinel node biopsy, breast irradiation), consider MRI before sx.
2) Mastectomy with sentinel node biopsy ± reconstruction. Adjuvant radiotherapy if ≥ 4 nodes involved.
What is sentinel node biopsy?

How many nodes should be removed beyond sentinel nodes?
Injection or marker (radioactive or blue dye or both) into areolar area, removal of node(s) that “light up.”

No further axillary node removal needs to be done for nonpalpable nodes, once SNB is done.
Adjuvant systemic therapy for stage I, II, and IIIA

choices: (3)
1) Hormonal therapy (tamoxifen for premenopausal, aromatase inhibitors for postmenopausal;

2) Chemotherapy (doxorubicin, cyclophosphamide, taxanes)

3) Trastuzumab for Her 2 neu +
"Risk" categories for breast cancers that are node-negative

low risk:
intermediate risk:
high risk:
Low; tumor <1cm, Receptor +, grade 1

Intermediate: tumor 1-2cm, receptor +, grade 1-2

high: One of the following:
1) >2cm
2) receptor neg
3) grade 2-3
4) Her2neu positive (maybe)
Inoperable stage IIIB, or inflammatory

treatment option types (3)
palliation, not cure

1) local therapy (CNS/choriod metastases, spinal cord compression, impending bone fracture, pleural or pericardial effusion, symptoms that fail to respond to systemic tx)
local recurrence, painful bone mets, single met site after long disease-free interval.

2) Innovative/Experimental Tx: (for indiv. w/ limited prior tx, few symptoms, low prob of needing palliation 3-6monts, strong desire for tx.

3) Systemic (eg: endocrine, chemo):
Best palliation with least toxicity, balance local and systemic, need not use systemic (qual of life), or system followed by local for unresponsive sites.
When should endocrine tx be used as initial systemic?
Can you switch endrocrine tx after one becomes ineffective?
1) more indolent disease
2) estrogen-receptor positive tumors
3) long disease-free interval
4) Metastases in bone or soft tissue sites

Yes: Responders should be considered for another when it loses its effectiveness. Least toxic used first.
When should chemo be used as systemically in advanced breast cancer?

least cross resistance agents: (6)

should combinations of drugs be used?

Use of
1) very high-dose tx w/ autologous bone marrow rescue:
2) combinations or seq of chemo/endo, or alternating:
3) chemo plus trastuzumab:
1) patients w/o characteristics of an endocrine therapy responder
2) disease failed to respond to a course of endocrine therapy

1)cyclophosphamide, 2)doxorubicin, 3)paclitaxel, 4)docetaxel, 5)vinorelbine, 6)capecitabine

Drug combin = higher response rate, but more toxicity. Not always justified.

• high dose: No evidence to suggest prolonged survival.
• seq/alternating end/chemo: no evidence of better palliation or survival.
• better than either alone, for tumors that overexpress her-2-neu
Resonses to tx of advanced breast cancer:

complete response:
partial response:
stable disease:
progressive disease:

survival of responders:
Complete response: No detectable tumor (4-27%)
Partial response: Sum of cross-products of measurable disease reduced by half
(patients with PR or CR: 43-82%)

Stable disease: Less than partial response.
Progressive disease: New lesions or increase in sum of cross-products of measureable sites

survival of responders: median: 15 to 33 months; maximum, 180+ months
Zolendronic acid

used for:
advantages:
disadvantages:
Osseous Metastases in palliation of bone metastases

• Fewer fractures, less need for radiation for treatment of painful sites.
• Osteonecrosis of mandible; IV administration