Breast cancer case

1. BREAST CANCER
PRESENTED BY,
REIMA ELIZABETH JACOB
PHARMD INTERN

2. • Breast cancer is the most frequently diagnosed cancer globally and is the
leading cause of cancer related death in women.
• Since 1991, breast cancer mortality has been declining, suggesting a
benefit from the combination of early detection and more effective
treatment.

3. INDIAN SCENARIO
After cervical and uterine cancer the most common cancer among Indian women is
breast cancer.
It is estimated that by the year 2025, the number of people suffering from breast
cancer in India will double.
There are number of factors that lead to this deadly disease.

4. PATHOLOGY AND TYPES OF BREAST CANCER
CARCINOMA
IN SITU
•LOBULAR
CARCINOMA IN
SITU
•DUCTAL
CARCINOMA IN
SITU
INVASIVE
BREAST
CANCER
METASTATIC
BREAST
CANCER
RECURRENCE
BREAST
CANCER

5. SYMPTOMS OF BREAST CANCER

7. DIAGNOSIS
• Self Breast examination
• Clinical Breast exam
• Mammogram
• Magnetic resonance imaging (MRI)
• Biopsy

8. RISK FACTORS
 Increasing age
 Family history
 Early menarche ( < 12 years )
 Late Menopause ( >55 years)
 Older age at first child birth ( > 30 years)
 Diet ( Increase fat intake)
 Alcohol intake
 Previous exposure to chest wall radiation.
 Prolonged hormonal replacement therapy
 Post menopausal obesity
 Lack of breast feeding

9. TREATMENT OVERVIEW
1) LCIS: Surgery  Breast cancer risk reduction  Surveillance
( screening & Diagnosis)
2) DCIS: Surgery ± sentinel lymph node biopsy  Breast radiation
 Evaluate ER/ PR  Follow up.
3) Invasive Breast cancer
a) Stage 1
b) Stage 2A, 2B
c) Stage 3A, 3B, 3C

10.  Neo-adjuvant CT  Surgery  Adjuvant C.T   Radiation  Taxane
( If lymph node involved)
TREATMENT FOR ADVANCED BREAST CANCER

11. COMMON CHEMOTHERAPY REGIMENS
Adriamycin 50 mg/m2 + Cyclophosphamide 500 mg/m2 4 cycles q21 days
Cyclophosphamide 600 mg/m2 + Liposomal Doxorubicin citrate complex 60 mg/m2
Cyclophosphamide 500 mg/m2 + Epirubicin 100 mg/m2 + 5 – fluorouracil 500 mg/m2 3
cycles q21 days
Peggylated liposomal Doxorubicin 50 mg/m2 6 cycles q28 days
Epirubicin 75 mg/m2 + Docetaxel 75 mg/m2 6 cycles q21 days
Docetaxel 100 mg/m2 + Bevacizumab 15 mg/kg

12. Estrogen and progesterone are hormones that cause breast cancer cells to grow.
Endocrine therapy should be started after chemotherapy is finished if the patient is
on chemotherapy.
•Tamoxifen for 5 yearsPREMENOPAUSAL
WOMEN
•Aromatase Inhibitor
for 5 years
POSTMENOPAUSAL
WOMEN

13. Single agent
Paclitaxel
Gemcitabine
Doxorubicin/ Liposomal doxorubicin
Combination:
AC regiment
FEC regimen
Paclitaxel/ Bevacizumab
Gemcitabine/ Carboplatin
METASTATIC AND RECURRENT BREAST CANCER

14. REAL
CASE

15. SUBJECTIVE INFORMATION
 AGE : 52 YEARS
 IP NO : 37694
 UNIT : BHIO (ITU)
 SEX : Female
 BSA: 1.6 , Ht: 152 cm, Weight: 68 kg

16. REASON FOR ADMISSION
 She is a known case of Breast cancer, she was diagnosed in 2014
 She is admitted for Chemotherapy and supportive care.

17. PAST MEDICAL HISTORY
• K/C/o : Breast cancer, HTN and Diabetes on treatment
• Family history : Nothing significant
• Diet : Non veg.
• Smoking : Non smoker
• ER / PR : Positive
• HER 2: Negative.
OBJECTIVE

18. PROVISIONAL DIAGNOSIS
 She was diagnosed with Invasive ductal carcinoma
(Stage 3, i.e T1N3aMo) in sept 2014
 Now the disease have progressed into secondary
tumour to Liver
( FNAC- positive) in September 2017

19. BREAST CANCER
WITH LIVER METS.

20. PAST MEDICATION HISTORY

21. NEOADJUVANT THERAPY
• 1ST CYCLE OF CHEMOTHERAPY (10th JUNE 2014)
• LAB reports : Hb – 14.03g% ; TC – 8500cells/cumm ; N – 70% ; L – 24% ; E – 06%
urea : 28mg/dl ; Cr – 1.4mg/dl
 Inj. Palanosetron 0.25 mg + Dexamethasone 12mg in 100ml NS over 30 min
 Inj Adriamycin 90 mg in 500ml 5% I.V over 60 min
 Inj. Cyclophosphamide 900 mg in 500 ml NS over 1 hrs
 Flush I.V line after chemotherapy
AC
regimen

22. • 2ST CYCLE OF CHEMOTHERAPY (1st JUlY 2014)
• LAB reports : Hb – 13.04g% ; TC – 2800cells/cumm ; N – 20%
• CT was with held due to neutropenia
• ADV : neurokine 300mEq , review on 8/7/14
 2ST CYCLE OF CHEMOTHERAPY (8TH JUlY 2014)
LAB REPORTS: TC : 13500cells/cum N – 60
 Inj. Palanosetrone 0.25 mg + Dexamethasone 12mg in 100ml NS over 30 min
 Inj Adriamycin 90 mg in 500ml 5% I.V over 60 min
 Inj. Cyclophosphamide 900 mg in 500 ml NS over 1 hrs
 Flush I.V line after chemotherapy

23. • 3rd CYCLE OF CHEMOTHERAPY (29th JUNE 2014)
• LAB reports : Hb – 14.0g% ; TC – 26200cells/cumm ; N – 76% ; Cr – 1.5mg/dl; Platelet-
7.70000
 Inj. Palanosetrone 0.25 mg + Dexamethasone 12mg in 100ml NS over 30 min
 Inj Adriamycin 90 mg in 500ml 5% I.V over 60 min
 Inj. Cyclophosphamide 900 mg in 500 ml NS over 1 hrs
 Flush I.V line after chemotherapy

24. • 4th CYCLE OF CHEMOTHERAPY (19th SEPTEMBER 2014)
• LAB reports : Hb – 10.09g% ; TC – 3700cells/cumm ; N – 52%
 Inj. Palanosetrone 0.25 mg + Dexamethasone 12mg in 100ml NS over 30
min
 Inj Adriamycin 90 mg in 500ml 5% I.V over 60 min
 Inj. Cyclophosphamide 900 mg in 500 ml NS over 1 hrs
 Flush I.V line after chemotherapy

25. DISCHARGE MEDICATION
1. T. Rabeprazole 20mg 1-0-0 7 days
2. T. Palonosetrone 1-0-0 3 days
3. Multivitamin ( folic acid, cyanocobalmin)
SURGERY
She underwent Left breast mastectomy + Left axillary dissection

26. ADJUVANT CHEMOTHERAPY
Paclitaxel 4 cycle
 Inj. Palonosetrone 0.25 mg + Dexona 12mg in 100ml N.S over 30’
 Inj. Avil ( Pheniramine) iv 2cc stat
 Inj Ranitidine 450 mg iv stat
• Inj Paclitaxel 280 mg in 500 ml NS for 3 hrs ( Use codon set & watch for hypersensitivity
reaction)
• Discharge medication
1. T. Rabeprazole 1-0-0 7 days
2. T. Palonosetrone 1-0-0 3 days
3. Multivitamin ( folic acid, cyanocobalmin

27. RADIATIONAL AND HORMONAL THERAPY
 Patient underwent EXRT 45 grey / 25# / 5 weeks
 Tab. Anastrozole 1mg OD for 5 years and Zoledronic acid 4 mg I.V every
6 month and advice to follow up every 3 month
 During follow up, they found liver mets and they give 2nd line
chemotherapy ( Gemcitabine + Carboplatin )

28. METASTASIS STAGE
1ST CYCLE OF CHEMOTHERAPY
LAB reports : Hb – 14.03g% ; TC – 8500cells/cumm ; N – 70% ; L – 24% ; E –
06%
• urea : 28mg/dl ; Cr – 1.9mg/dl
Gemcitabine + carboplatin
 Inj. Palonosetrone 0.25mg + Dexona 8 mg in 100ml NS over 30’
 Inj. Gemcitabine 1400 mg in 250 ml NS over 30’
 Inj. Carboplatin 350 mg in 500ml 5% D over 2 hrs
 In day 8 Gemcitabine is administer again.

29. DISCHARGE MEDICATION
• T. Pantoprozole 40 mg 1-0-0 7 day
• T. Ondansetrone 4 mg 1-0-0 3 day
• T. Multivitamin 1-0-0 7 days

30. INTERVENTION
 Adriamicin + cyclophosphamide induced
neutropenia
 nk1 receptor antagonist was not given

31. MY PLAN
 Inj. Palonosetrone 0.25mg + Dexona 8 mg in
100ml NS over 30 min
 Inj. Gemcitabine 1400 mg in 250 ml NS over 30
min on day 1 and 8
 Inj. Carboplatin 200 mg in 500ml 5% D over 2
hrs on day 1

32. MONITORING PARAMETERS
• BP
• ECG
• CBG
• CBC
• Serum electrolytes
• LFT’s
• Urea, creatinine
• CXR
• Bone scan
• CT scan
• ADR’s

33. PATIENT COUNSELING
REGARDING DISEASE:
Educated the patient about all the important aspect of breast cancer and its
treatment .
 Adviced the patient that even after the breast cancer treatmnet is completed the
patient should be causious and should come for follow up to prevent reccurrence.
REGARDING DRUGS:
Chemotherapeutic agents given to the patient may cause many side effects which
include vomiting, Nausea, Alopecia, Dizziness, Myelodepression, Sedation etc.
Tramadol is given for pain control.
Cardiac function should be monitored since cyclophosphamide and doxorubicin
are given together.

34. III. About life style modifications:
• To use soft bristle tooth brush.
• To drink plenty of water.
• Frequent urination.
• To avoid caffeine containing products.
• To consume frequent short meals.
• Diet control for hyperglycemia.
• Nutritional diet.
• Physical exercise.
• Relaxation.

35. BRAND NAMES
GENERIC NAME BRAND NAME
Carboplatin Biocarb, Blastocarb
Gemcitabine Abingem, biogem
Dexamethasone Dexona, alexa
Palanosetrone Chepatron, Palnox
Ondansetron Ondem, Afon
Pantoprezole Aar-zole, Abipanta
Zoledronic acid Aclasta, Bomeza

36. TAKE AWAY POINTS
• Abemaciclib (trade name Verzenio) is a drug for the treatment of
advanced or metastatic breast cancers. It was developed by Eli Lilly and
it acts as a CDK inhibitor selective for CDK4 and CDK6.Since September
2017 Abemaciclib is approved in the US for "adult patients who have
hormone receptor (HR)-positive, human epidermal growth factor
receptor 2 (HER2)-negative advanced or metastatic breast cancer that has
progressed after taking therapy that alters a patient’s hormones"