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Breast cancer.pptx
- 1. Breast Cancer THE PHARMACIST PERSPECTIVE Pharm. ANGELA OGBECHE B.Pharm University of Uyo BY
- 2. PRECEPTOR: Pharm Kamal A. IBRAHIM SUPERVISORS: PHARM MASOK OTHNIEL PHARM RIMFA PONTIM OUR TEAM MEMBERS PHARM EZE KINGSLEY PHARM ARIKPO ONEN PHARM JUBRIL OGEDENGBE
- 3. EPIDEMIOLOGY 01 INTRODUCTION 06 02 07 03 CASE STUDY 11 04 prevention 08 05 MANAGEMENT 10 Table of Contents CLASSIFICATION PATHOPHYSIOLOGY RISK FACTORS DIAGNOSIS 09 ROLE OF PHARMACIST CONCLUSION 12 REFERENCES 13 staging
- 4. INTRODUCTION • The breast plays and important role in the female body. • It is an organ where breast milk is produced • The major organelles involved in the production of breast milk are the lobules and ducts • Another important structure which plays a role is the axilla
- 5. ANATOMY OF THE BREAST
- 6. INTRODUCTION CONT’D • Breast cancer is a disease whereby the cells found in the breast begin to divide uncontrollably. • It can occur in the ducts or lobules or within the accessory organelles within the breast • Breast cancer has become a thing of worry due to its increasing prevalence. • Breast Cancer occurs due to the interplay between genetic and environmental factors.
- 7. TYPES OF BREAST CANCER Non invasive or Insitu BC Invasive BC Others • Ductal carcinoma insitu • Lobular cancer insitu • Invasive ductal carcinoma • Invasive Lobular carcinoma • Inflammatory breast Cancer • Pagets disease • Other rare types
- 8. MOLECULAR CLASSIFICATION OF BC Luminal A Luminal B HER-2 ENRICHED Basal type HER-2- HER2+ HER2+ HER2- ER+ ER+ ER- ER- PR+ PR+ PR- PR- GOOD POOR Poor Prognosis WORST PROGNOSIS • Luminal A and B are associated with BRCA-2 mutation • Triple negative breast cancer are associated with BRCA-1 mutation
- 9. EPIDEMOLOGY 2M Worldwide have breast cancer 5TH GLOBOCAN in 2020 identified breast cancer to be the 5th cause of cancer related deaths.
- 10. EPIDEMOLOGY • Breast cancer is prevalent in patients > 50 years • The GLOBOCAN Study showed that an incidence rate of approximately 88% in Transitioning countries compared to western countries. • In Nigeria it is the number one cause of female cancer related deaths with 14,274 in 2020.
- 11. RISK FACTORS (NON MODIFIABLE ) Female sex Older age Family history of breast or ovarian cancer Genetic mutations Density of Breast tissue Early Menarche Late menopause Previous history of breast cancer Previous radiation therapy race/ethnicity
- 12. RISK FACTORS (MODIFIABLE) ● Overweight/obesity ● Nulliparity ● Nil Breast-feeding ● Hormonal Drugs ● Alcohol intake ● Smoking ● Exposure to carcinogens through processed foods
- 14. SIGNS AND SYMPTOMS OF BC CONT’D
- 15. SIGNS AND SYMPTOMS OF BC CONT’D
- 16. PREVENTION OF BC Limit hormonal drug use No smoking exercise Breast feeding Healthy eating
- 18. STAGES OF BREAST CANCER
- 19. Genetic factor Hormonal changes Environment Factors Alteration in Apoptotic Genes Reduction in Apoptosis Disrupted Proliferation of Cell Growth of Colony Permanent Damage to DNA Inhibition of Tumor suppressor gene Activation Of Growth Inducer Oncogenes PATHOPHYSIOLOGY OF BC
- 20. MECHANISMS OF CARCINOGENESIS 0F BC Resisting Cell Death Sustaining Proliferative Signal Evading Growth Suppressor Evading Replicative Mortality Activating Invasion and metastasis Inducing Angiogenesis Deregulating Cellular Energies Avoiding Immune destruction Genome Instability and Mutation Tumuor Promoting Inflammation
- 21. MANAGEMENT OF CANCER BREAST CANCER SURGERY RADIOTHERAPY PHARMACOTHERAPY
- 22. •Improve life expectancy •Reduce drug related toxicity •Improve patients’ quality of life •Delay progression of disease •Optimize pain management •Manage drug related side effects GOALS OF THERAPY
- 23. SURGICAL TREATMENT OF BREAST CANCER ● Surgery remains the main stay for treatment of Breast cancer ● It is divided into lumpectomy, partial mastectomy and total mastectomy ● Surgery is usually accompanied by neoadjuvant therapy or adjuvant therapy which may be hormonal therapy, chemotherapy, and radiotherapy.
- 24. SURGICAL TREATMENT OF BC Lumpectomy • Higher rate of recurrence • It is limited by multicentric tumors and large tumuors Lumpectomy + Radiation • Has a lesser rate of recurrence • Most useful in Dcis/Tis • i.e. stage 2 B Mastectomy • It is used for advanced stage of the disease t2>5cm • for multicentric, multinodular breast cancer • It can be used prophylactical ly
- 25. RADIATION THERAPY OF BREAST CANCER ● It is aimed at eradicating local subclinical residual disease ● It reduces recurrence rates by 75% ● There are two general approaches used to deliver radiation therapy ● Whole breast radiotherapy ● Partial breast irradiation ● Indicated for patients ≥ 45years ○ Dcis ○ T ≤3cm
- 26. CLASSES OF DRUGS USED TO TREAT BREAST CANCER Cytotoxic drugs • Nitrogen mustards • Alkylating agents • Antimytotic drugs • Anthracycline • Vinca alkaloids • Taxanes • Platinum compounds • Antimetabolite [ • Aromatase inhibitors • Selective estrogen modifiers • Selective estrogen deregulators • luteinizing hormone–releasing hormone. Hormonal drugs • Tyrosine kinase inhibitors • Monoclonal antibodies Targeted Therapy
- 27. CHEMOTHERAPY IN BC Drugs Dose Side effects MOA Doxorubicin 60-75mg/m2 iv q21 Neutropenia Anemia Leukopenia Inhibits DNA repair Epirubicin 100mg/m2 with 5fc and capecitabine in 6 cycles Extravesication Neutropenia Anemia Leukopenia Intercalates between DNA pairs, inhibits replication and transcription. Paclitaxel 175mg/m2 with Doxorubicin Neutropenia Alopecia Leukopenia Diahorea Prevents depolymerization of microtubules, leading to DNA and RNA synthesis inhibition.
- 28. CHEMOTHERAPY IN BC Drugs Dose Side effects MOA Docetaxel 60-100mg/m2 q21 with doxorubicin and cyclophosphamid e Alopecia Anemia Leukopenia Nausea and vomiting Prevents depolymerizati on of microtubules, leading to DNA and RNA synthesis inhibition 5-Flurouracil 500-600mg/m2 q28 days with cyclophosphamid e Nausea and vomiting Hand and foot syndrome Mucositis Inhibits thymidilate synthase needed for DNA synthesis
- 29. CHEMOTHERAPY IN BC Drugs Dose Side effects MOA Capecitabine 1250mg/m2 bd q21 days with cyclophospham ide Stomatitis Neutropenia Hand foot syndrome Inhibits thymidilate synthase needed for DNA synthesis Carboplatin 300mg/m2 with cyclophospham ide q28 Leucopenia Increase ALP Neurotoxicity Neuropathy Covalently binds to DNA
- 30. CHEMOTHERAPY IN BC Drugs Dose Side effects Moa Vinorelbine 20-30mg/m2 q 7 days Leukopenia Anemia, constipation Neuropathy Depolarization of microtubules during S and M phase
- 31. 00 AC-T CAF CMF FEC TAC AC Common Chemotherapy Regimens • A-DOXORUBICIN • C-CYCLOPHOSPHAMIDE • E-EPIRUBICIN • F-5-FLUROURACIL • M-METHOTREXATE • T-DOCETAXEL
- 32. How is Chemotherapy done • Antiemetics • Steroids • Monoamine antagonist • Serotonin antagonist • P/NK1 antagonist Prechemotherapy • FEC • CMF CHEMOTHERAPY • Antiemetics • CSF(colony stimulating factor) POST CHEMOTHERAP Y
- 33. HORMONAL THERAPY IN BC Hormonal drugs Examples Dose MOA Aromatase inhibitors Anastrozole Letrozole Exemestane 1 mg PO every day 2.5 mg PO every day 25 mg PO every day Inhibits reversibly aromatase the enzyme responsible of converting other hormones to estrogen Irreversible inhibition of aromatase
- 34. HORMONAL THERAPY IN BC Hormonal drugs Examples Dose MOA SERMS Tamoxifene 20 mg PO every day Selectively binds to estrogen receptors in the breast. Mimics estrogen SERDS Fulvesterant 500 mg IM on days 1, 15, 29, and once monthly thereafter It binds to estrogen receptors on the breast
- 35. HORMONAL THERAPY IN BC Hormonal drugs Examples Dose MOA Luteinizing hormone- releasing hormone agonist Leuprolide 7.5 mg IM depot q28d, 22.5 mg IM q3mo, 30 mg IM q4mo. Stops ovarian production of oestrogen.
- 36. TARGETED THERAPY IN BREAST CANCER Drugs Target Example MOA Dose Tyrosine kinase inhibitors PI3K pathway Lapatinib Block growth signals via the PI3K pathway 1250mg PO q day with capecitabin e Mtor(mamm alian target of rapamycin) inhibitor VEGFR (vascular Endotheli al Growth factor receptor) Everolimus Inhibits growth factors which stimulate cell growth and angio genesis 10mg po qday
- 37. TARGETED THERAPY IN BC Drugs Target Example MOA Dose PARP inhibitors PARP (poly adipose ADP Ribose) Olaparib Prevents damaged DNA from repairing themselves , enables apoptosis 300mg PO BD with concurrent medication s Monoclonal antibodies HER2 (Human Epidermal growth factor receptor 2) Trastuzuma, pertuzumab Binds to HER2 receptors and stop their growth IV 40mg/kg for 90 minutes stat
- 38. MANAGEMENT OF STAGE 0 BREAST CANCER Ductal Carcinoma Insitu ● Lumpectomy with whole breast radiation ● Total mastectomy with or without sentinel node biopsy with or without breast reconstruction Lobular carcinoma Insitu ● Surveillance alone ● Surveillance plus raloxifene or Tamoxifen ● Prophylactic mastectomy
- 39. MANAGEMENT OF INVASIVE BREAST CANCER: STAGE II,III ● Surgery ● Lumpectomy to negative margins plus RT ● Mastectomy plus or minus reconstruction ● Radiotherapy ● Adjuvant chemotherapy (endocrine or biological therapy)
- 40. MANAGEMENT OF STAGE IV BC ● Surgery i.e Total mastectomy ● targeted therapy according to Histopathological findings ● Pembrolizumab in the event of TNBC ● Chemotherapy is used in the event of resistant hormone positive BC ○ In the event of bone disease or metastasis, Biphosphonates can be used
- 41. CLINICAL CASE REVIEW Age 45 years NO ALLERGIES Location Nasarawa June 2022 Wound on the left breast(over 2 years) 2019 Attained menopause 2012-2022 history of Oral Bimonthly contraceptive use Doesn’t smoke nor drink MQ
- 42. Physical Examination Afebrile left axillary and inguinal lymphadenopathy Edematous with peau d ‘orange
- 44. LIVER FUNCTION TEST RESULT RANGE UNIT SGOT 23.6 <40 UMOL/L SGPT 14.0 <34 UMOL/L ALP 270.8 <244 UMOL/L TOTAL BILIRUBIN 4.4 3.4-1.7 UMOL/L BILIRUBIN 1.0 <2.4 MOL/L
- 45. RESULTS: E/U/CR PARAMETER RESULT RANGE UNIT NA + 141.5 135-145 MMPL/L K+ 4.3 3.5-5.5 MMOL/L CL- 102.4 98-108 MMOL/L HCO3 20.5 21-28 MMOL/L UREA 5.5 2.1-7.4 MMPL/L CREATININE 27.1 53-106 UMOL/L
- 46. RESULTS: FBC FULL BLOOD COUNT PARAMETERS RESULT RANGE UNIT PCV 23% 35-45% TWBC 11.8*10^10 4.5-11.0*10^9 /UL MCH 83 27.5-33.2 Pg LYMPHOCYTE 23% 20-40% MONOPHILS 9% 2-8% EOSINOPHILS 5% 1-4% BASOPHILS 00% <0.1 MCV 25 27-21 Pg/Cell
- 47. June 2022 • Presented to GOPD • Diagnosed of metastatic breast cancer T4N3M1 July 2022 • Toilet mastecto my • Biopsy result August 2022 • 1st Chemotherap y • FEC October 2022 • 2nd chemotherapy November 2022 • Patient Passed on Invasive ductal carcinoma, SBR grade ii. Triple negative breast CA Plan!!! Case Summary
- 48. MQ’S 1st CHEMOTHERAPY • IV Ondasetron 4mg Stat • IV Hydrocort 100mg Stat • IV Omeprazole 4mg Stat PRECHEMO • Iv 5FU 1g in 5% dextrose water 500ml for 1hr • Iv Epirubicin 50mg in ivf Normal Saline 6500ml for 1hr • Iv Cyclophosphasmide 1g in 5% dextrose water 500ml for 1hr • Ivf normal saline 500mls stat CHEMO • IV Ondasetron 4mg stat POST CHEMO
- 49. what can I do for patients with breast cancer?? 1. Patient education 2. Dose calculation 3. Reconstitution of drugs 4. Storage 5. Management of side effects and drug interactions Role of the Clinical Pharmacist
- 50. CONCLUSION The mortality Toll of Breast Cancer keeps rising. Breast cancer is a multi disciplinary approach provides the best care for the patient. Clinical pharmacists should equip themselves with more knowledge and participate in educating our patients as well as contributing in ensuring responsible and adequate therapy in their care.
- 51. REFERENCES ● Kuchenbaecker KB, Hopper JL, Barnes DR, et al: Risks of breast, ovarian, and contralateral breast cancer for BRCA1 and BRCA2 mutation carriers. JAMA 317 (23):2402–2416, 2017. doi: 10.1001/jama.2017.7112 ● Dorling, Leila, et al. "Breast Cancer Risk Genes-Association Analysis in More than 113,000 Women." The New England journal of medicine 384.5 (2021): 428- 439. ● American College of Obstetricians and Gynecologists (ACOG): Committee opinion no. 625: Management of women with dense breasts diagnosed by mammography. Obstet Gynecol 125 (3):750–751, 2015. Reaffirmed2020. doi: 10.1097/01.AOG.0000461763.77781.79 Accessed 3/7/22. ● Giuliano AE, Hunt KK, Ballman KV, et al: Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: A randomized clinical trial. JAMA 305 (6):569-575, 2011. doi:10.1001/jama.2011.90
- 52. CREDITS: This presentationtemplate was created by Slidesgo, includingicons by Flaticon, and infographics & images by Freepik. Thanks For Listening
Editor's Notes
- Breast Cancer is a leading cause ofcancer related deaths in women.