Breast Cancer Case Presentation

1. Case 59
Marciha Chatman, Shiny Parsai, Samantha Sagert

2. Chief Complaint
• “I just had surgery for my breast cancer. My
surgeon said I’ll need radiation, do I also need
chemotherapy?”

3. Patient Presentation
• DR is a 44 year old pre-menopausal female
• Abnormal mammogram 2 months ago
• Core biopsy  ductal carcinoma
• Mastectomy and 1.4 cm tumor recovered
• T3N0M0 (stage IIB)
• ER/PR+ & HER3+
• Schedule to receive radiation
• Needs adjuvant pharmacological therapy

4. Medical History
• Breast carcinoma – newly diagnosed
• Shoulder joint pain
• Hypothyroidism

5. Family and Social History
• Family history
– Mother: ovarian cancer diagnosed in 40s
– Maternal aunt: breast cancer diagnosed in 40s
• Social history
– Single mother with twins (12 years old)
– Smoked 1/2 pack per day for 6-7 years
– Quit 3 years ago
– Rare alcohol use
• Patient risk factors
– Female, family history, age
– Smoking, childbirth after age 30

6. Physical Exam
• No visual disturbances
• Denies headaches
• No weight loss and no appetite changes
• Scars on breasts from mastectomy
• No palpable lymph nodes
• Thyroid normal size
• No cough

7. Vital Signs
Parameter Patient Value
Blood pressure 130/80 mmHg
Heart rate 62 bpm
Respiratory rate 12
Temperature 37.6 C
Weight 78 kg ~ 172 lbs
Height 163 cm ~ 64 in
BMI 29.4 kg/m2 (overweight)
Pain 2 out of 10
BSA 1.88 m2

8. Labs
Patient Value Reference Range
Na 137 mEq/L 134-146 mEq/L
K 4.2 mEq/L 3.5-5 mEq/L
Cl 102 mEq/L 95-105 mEq/L
CO2 22 mEq/L 22-29 mEq/L
BUN 9 mg/dL 8-18 mg/dL
SCr 0.87 mg/dL 0.5-1.5 mg/dL
Glu 96 g/dL 70-110 mg/dL
WBC 6.4 x 103/mm3 3.6 - 11.2 X 103/mm3
Hgb 13.3 g/dL 12-15 mg/dL
Hct 39.7% 37-47%
Platelets 237 x 103/mm3 140 - 440 X 103/mm3
TSH 2.63 IU/mL 0.4 - 4.2 IU/mL
Calcium 9.2 mg/dL 8.4 - 10.2 mg/dL

9. Medications and Allergies
Drug Dose Indication
Acetaminophen 325 mg
2 tablets PO Q 6 hours PRN
Joint pain
Levothyroxine 112 mcg
1 tablet PO QAM
Empty stomach
Hypothyroidism
Ortho-Cyclen 1 tablet PO QD for 21 days
Then off 7 days
Contraception
Allergies: Morphine (rash)

10. Drug Therapy Problems
1. Additional therapy needed
• Breast cancer adjuvant therapy
• Supportive care for adjuvant therapy
• Overweight lifestyle modification
• Vaccinations prophylaxis
• Genetic counseling for children
2. Wrong drug
• Oral contraceptive
3. Potential drug therapy problems
• Pain and hot flashes

11. Goals of Therapy
• Breast cancer adjuvant therapy: Complete remission, cure
• Supportive care for adjuvant therapy: Prevent chemotherapy
adverse drug reactions
• Overweight lifestyle modification: Goal BMI < 25 kg/m2
• Vaccinations prophylaxis: Prevent flu and pneumonia
• Genetic counseling for children: Increase awareness and
asses risk
• Oral contraceptive discontinuation: Prevent pregnancy
while reducing risk of breast cancer recurrence
• Pain and Hot flashes: Decrease discomfort and increase
adherence

12. Diagnosis
• Stage IIB – early stage breast cancer
• T3N0M0
Tumor Size Lymph Nodes (LN) Metastasis
Tx: cannot be evaluated Nx: cannot be evaluated Mx: cannot be evaluated
T0: no primary tumor N0: no regional LN metastasis M0: no distant metastasis
Tis: carcinoma in situ N1-3: ↑ with more LN M1: distant metastasis
T1-4: ↑ with size and extent
http://www.lifewith4boys.com/2013/10/early-detection-of-breast-cancer-can.html

13. Additional Therapy:
Breast Cancer Adjuvant Therapy Options1
Accesspharmacy.com

14. Additional Therapy:
Breast Cancer Adjuvant Therapy Options2
Adjuvant Chemotherapy (preferred regimens)
• AC (doxorubicin + cyclophosphamide) ± pertuzumab
THEN
Paclitaxel WITH trastuzumab
• TCH (docetaxel + carboplatin + trastuzumab ± pertuzumab)

15. Additional Therapy:
Breast Cancer Adjuvant Therapy Options2
Adjuvant Endocrine Therapy
• Premenopausal at diagnosis
– Tamoxifen 5 years ± ovarian suppression OR
– Ablation
– Further treatment based on menopausal status
• Postmenopausal at diagnosis
– Aromatase inhibitor for 2 to 3 or 5 years OR
– Tamoxifen for 2 to 3 years

16. Treatment Regimen – Part 12
• Doxorubicin 60mg/m2
– 112.8 mg IV bolus over 5 min
– Day 1 of every 21 days x 4 cycles
• Cyclophosphamide 600mg/m2
– 1128 mg IV infusion over 30 min
– Day 1 of every 21 days x 4 cycles

17. Treatment Regimen – Part 22,3
• Paclitaxel 80mg/m2
– 150.4 mg IV infusion once a week x 12 doses over 1 hour
• Trastuzumab
– Week 1 – loading dose of 4 mg/kg (312 mg) IV infusion over 90
min
– Next 11 weeks – 2 mg/kg (156 mg) IV infusion over 30 min
weekly
• At week 13 to week 52
– Trastuzumab 6 mg/kg (468 mg) IV infusion over 30 min Q 3
weeks
• At week 13
– Tamoxifen 20 mg PO QD x 5 years
• Reevaluate at 5 years - based on menopausal status

18. Additional Therapy:
Supportive care for adjuvant therapy4
• Avoiding hemorrhagic cystitis with cyclophosphamide
– 2 to 3 L/day of water during and one to two days after
• Antiemetics with AC regimen
– Fosaprepitant 150 mg IV OR aprepitant 125 mg PO then
80mg PO on days 2 and 3
– Ondansetron 8 mg IV OR other 5-HT3 antagonist
– Dexamethasone 12 mg PO then 8 mg PO on day 2-3
• Infection prophylaxis
– Filgrastim 480 mcg IV on day 3-10 of each treatment cycle

19. Additional Therapy:
Supportive care for adjuvant therapy4
• Infusion reaction prophylaxis
– 30 minutes prior to paclitaxel administration
– Dexamethasone 10 mg IV
• Taper 2 mg weekly after week 4 if no infusion rxn
– Diphenhydramine 25-50 mg IV
• Substitute: loratadine after first 2 weeks of
treatment in patients without infusion reactions
– Ranitidine 50 mg IV prophylaxis for infusion reactions
• Substitute: famotidine 20 mg IV infusion

20. Additional Therapy:
Overweight lifestyle modification5
• Low fat diet
• Casual/moderate exercise 30 minutes 5 times a week
– Decreased fatigue
• BMI 20 – 25
– Improved outcomes
http://www.pinterest.com/pin/492088696755696301/

21. Additional Therapy:
Vaccinations6
• Live vaccines contraindicated with chemotherapy
• Inactivated influenza vaccine
– Prior to chemotherapy if possible (2 weeks)
– Vaccinate family members
• Pneumococcal
– Both PCV13 and PPSV23 pending prior vaccination status
– Prior to chemotherapy
– Avoid during intense chemotherapy due to poor response

22. Additional Therapy:
Genetic counseling2
• Patient
– Criteria for further genetic evaluation
• Breast cancer at any age AND
• ≥ 1 close blood relative with breast cancer ≤ 50 yr
• Children
– Management based on gender and pending results

23. Wrong Drug:
Oral Contraceptive
• Discontinue Ortho-Cyclen contraceptive
– Hormonal contraception not recommended
– Barrier methods preferred (diaphragms, condoms)
– Copper IUD

24. Potential drug therapy problems:
Pain and Hot flashes7,8,9
• Pain from radiation
– Increase APAP dose OR hydrocodone/APAP
• Cross reaction between related opioid analgesics
• True allergic reactions to opioids (morphine) rare
• Hot flashes with tamoxifen
– Physical activity, walking, and yoga
– Vitamin E
– Venlafaxine

25. Monitoring and follow up 4
• CBC with differential platelet count
– Every 2 weeks prior to each treatment cycle
• Serum electrolytes, liver, and renal function test
– Every 2 weeks prior to each treatment cycle
• Assess line site during infusion for extravasation
• Doxorubicin: Cardiac function before and periodically
• Paclitaxel: Neurologic function prior to each treatment cycle
• Tamoxifen: Annual gynecological exams and mammograms
• Physical and depression screening every 6 months
• TSH every year

26. References
1. DiPiro J, Talbert RL, Yee G et al. Pharmacotherapy A Pathophysiologic Approach
9/E. McGraw-Hill Medical; 2014.
2. Gradishar WJ, Anderson BO, Blair SL, et al. Breast cancer version 3.2014. J Natl
Compr Canc Netw. 2014;12(4):542-90.
3. Budd GT, Barlow WE, Moore H et al. S0221: Comparison of two schedules of
paclitaxel as adjuvant therapy for breast cancer. J Clin Oncol 31,2013 (suppl;
abstr CRA1008)
4. Burstein H. Adjuvant chemotherapy for hormone receptor-positive or negative,
HER2- negative breast cancer. In:UpToDate, Dizon DS (Ed), UpToDate,
Waltham, MA, 2014.
5. Ligibel J. Lifestyle factors in cancer survivorship. J Clin Oncol. 2012;30(30):3697-
704.

27. References
6. Hibberd PL. Immunizations in patients with cancer. In: UpToDate, Thorner AR
(Ed), UpToDate, Waltham, MA,2014.
7. Morphine and Related/Morphine and Related Interaction Monograph. In:
Lexicomp Online [Internet database]. Hudson, Ohio: Wolters Kluwer Health.
Updated periodicaly.
8. Muenstedt K, El-safadi S. Nutritive Supplements - Help or Harm for Breast
Cancer Patients?. Breast Care (Basel). 2010;5(6):383-387.
9. Conzen SD. Managing the side effects of tamoxifen. In:UpToDate, Dizon DS
(Ed), UpToDate, Waltham, MA, 2014.