BREAST CANCER
Breast cancer is the most common site of cancer and
is second only to lung cancer as a cause of cancer
death in American women.
More common among white females. Asians/ Pacific
islanders is at the bottom of the list.
Most breast cancer are diagnosed at an early stage,
when tumors are small and localized.
The median age for the diagnosis of breast cancer is
between the ages of 60 and 65 years.
Etiology
Gender and age
Endocrine Factors
O Early menarche
O Increased risk in women with a late age of natural
menopause
O Nulliparity and a late age at first birth (≥30 years)
O Period between the onset of menses and the age
of first pregnancy
O Postmenopausal estrogen replacement therapy
Etiology
Genetic Factors
O PMH of breast cancer is associated with an
increased risk of contralateral breast cancer.
O Breast density
O Having any first-degree relative with breast cancer
increases a woman’s risk of breast cancer about
1.5- to 3-fold.
O The risk is affected by both a woman’s own age
and the age of the relative when diagnosed.
Etiology
O Associated with having any second-degree relative with
breast cancer.
O Affected family members on both the maternal and the
paternal sides.
O Bilateral total mastectomy and/or oophorectomy
reduce the risk of breast cancer occurrence.
Environmental and Lifestyle
O Diet
O Intake of dietary fiber and micronutrients (Vit. A,C,E)
O Phytoestrogens
Etiology
O Increased risk in obese females
O Alcohol consumption
O Radiation
Pathophysiology
Cancer cells:
O They have longer life spans and instead of dying
continue to grow and form new, abnormal cells.
O Cancer cells can also invade other tissues. This
property is called metastasis.
O Cancer cells grow into tumors that are supplied by
a new network of blood vessels. This is called
angiogenesis and is unique in maintaining the
blood supply and supply of nutrients to the cancer
cells.
4 main
breast
tumor
sub-
types
Case Study
Chief Complaint
“I have a lump in my
breast.”
History of Present Illness
Rosalita Garza is a 61-year-old woman presenting for
evaluation of a new mass in her left breast. She first
noticed a palpable breast mass on self-examination
approximately 14 months ago but was unable to
have this further investigated due to loss of health
insurance. The patient describes the mass as
intermittently painful. A mammogram was performed
prior to her current visit, which was suspicious for
malignancy.
Past Medical History
Musculoskeletal injury in 2000. Fell from a chair
while at work and suffered injuries to her cervical
spine. She has required bone grafting from her right
hip to her cervical spine. She is taking multiple
medications for pain control.
Depression (diagnosed 7 years ago).
Family History
Sister diagnosed with breast cancer at age 60, now
5 years post- surgery. The patient was unable to
recall any further details.
No other significant cancer history is noted.
Social History
Lives with and acts as primary caretaker for her
mother, who has dementia.
Denies alcohol use and is a non-smoker.
Has a 35-year- old daughter who also lives with her.
Endocrine History
Menarche age 13; menopause age 55; first child
age 26; G1P1A0. Last PAP smear at age 40. Took
Premarin as HRT for 5 years after the onset of
menopause.
Medications
Famotidine (Pepcid) 20mg po BID
Sertraline (Zoloft) 50mg po once daily
Zolpidem (Ambien) 10mg po at bedtime PRN sleep
Gabapentin (Neurontin) 300mg po TID
Propoxyphene (Darvon) 65mg 1–2 po Q4h PRN pain
Premarin as HRT for 5 years
Allergies
NKDA
ROS
Negative except for complaints noted in the
previous slides
Physical Examination
Gen
WDWN 61-year-old Hispanic female. Awake, alert, in NAD.
VS
BP 127/71, P 89, RR 16, T 36.7°C; Wt 163 lb, Ht 5'5''
HEENT
NC/AT; PERRLA; EOMI; ear, nose, throat are clear
Neck/ Lymph Nodes
Supple. No lymphadenopathy, thyromegaly, or masses. No supra-
clavicular or infraclavicular adenopathy.
Physical Examination
Breasts
Left: Notable for a 2.5-cm mass at the 6 o’clock
position, approximately 3 cm from the nipple margin,
not fixated to skin; no nipple retraction or discharge is
visualized; the mass is exquisitely tender to palpation;
1.5 cm, nontender, palpable mass in the axilla noted.
Right: Without mass or lymphadenopathy.
Lungs
CTA and percussion
Physical Examination
CV
RRR; no murmurs, rubs, or gallops
Abd
Soft, NT/ND, normoactive bowel sounds. No appreciable hepato-splenomegaly.
Spine
Slight tenderness to percussion
Ext
No CCE
Neuro Chest X-Ray
No deficits noted Lungs are clear
Labs
Na 142 mEq/L N aPTT 30.1 sec N
K 3.7 mEq/L N WBC 8.7 × 103/mm3 N
Cl 102 mEq/L N Neutros 55% N
CO2 26 mEq/L N Lymphs 35% N
BUN 9 mg/dL N Monos 8% N
SCr 0.7 mg/dL N Eos 2% N
Glu 83 mg/dL N AST 36 IU/L
Hgb 12.9 g/dL N ALT 17 IU/L N
Hct 37.6% N LDH 488 IU/L
RBC 4.13 × 106/mm3 N T. bili 0.2 mg/dL N
Plt 410 × 103/mm3 CA 27.29 36.2 U/mL N
PT 11.9 sec N CEA 1.2 ng/mL N
INR 1.09 N
Diagnostic bilateral
mammogram:
American College of Radiology
Category V, highly suspicious for
malignancy in the left breast.
There is a high density, irregular
mass measuring 2.2 cm with
indistinct margins seen in the left
breast lower hemisphere at 6
o’clock located 3 cm from the
nipple.
In the right breast, no dominant
mass, distortion, or suspicious
calcifications are identified.
Unilateral ultrasound left breast and left axilla with biopsy:
An ill-defined, hypoechoic mass is noted in the 5:00–6:00
region. This measures approximately 2.5 × 2.3 × 1.5 cm
and is located 3 cm from the nipple. A core biopsy of this
mass was performed.
Suspicious lymph nodes are noted in the axilla. The largest
node measures 1.8 × 1.8 × 1.4 cm. A fine needle aspiration
of this lymph node was performed. In the infraclavicular
region, a few hypoechoic lymph nodes were also seen and
were located in the lateral aspect. The largest node
measured 0.8 × 0.8 × 0.8 cm. A fine needle aspiration of
this infraclavicular lymph node was performed. No
suspicious internal mammary or supraclavicular lymph
nodes were seen.
Core needle biopsy of left breast mass:
Left breast, 6 o’clock: infiltrating ductal carcinoma,
modified Black’s nuclear grade II (moderately
differentiated), ER 95%, PR 95%, Her2 overexpression
2+, Her2 FISH negative (no amplification), ki67 30%
(moderate).
Fine needle aspiration (FNA) of left axillary and
infraclavicular lymph nodes:
1. Left axillary lymph node: metastatic
adenocarcinoma consistent with breast primary.
2. Left infraclavicular lymph node: metastatic
adenocarcinoma consistent with breast primary.
Bone scan:
1. No definite evidence of osseous metastases.
2. Abnormality in cervical spine consistent with
previous history of bone grafting.
Ultrasound liver:
No lesions suggestive of metastases.
Pharmacist Intervention:
Local Treatment
Mastectomy : Partial or Segmental Mastectomy
O aka Quadrantectomy
O The surgeon removes the portion, or segment, of
the breast that contains the tumor. Depending on
the situation, the doctor may want to also remove
some lymph nodes.
Pharmacist Intervention:
Local Treatment
Radiation therapy
O Directs high-energy rays at the breast, chest area,
under the arm, and/or the collarbone area to
destroy any invasive ductal carcinoma cells that
may be left behind.
O This treatment also reduces the risk of recurrence.
Pharmacist Intervention:
Systemic Treatment
Adjuvant Chemotherapy
O Directs high-energy rays at the breast, chest area,
under the arm, and/or the collarbone area to
destroy any invasive ductal carcinoma cells that
may be left behind.
O This treatment also reduces the risk of recurrence.
Pharmacist Intervention:
Systemic Treatment
Adjuvant Chemotherapy:
Anthracycline (Doxorubicin) → Taxane (Paclitaxel)
O Doxorubicin 60 mg/m2 IV, day 1
O Cyclophosphamide 600 mg/m2 IV, day 1
O Repeat cycles every 21 days for 4 cycles
O Followed by:
O Paclitaxel 175 mg/m2 IV over 3 hours
O Repeat cycles every 21 days for 4 cycles
Pharmacist Intervention:
Systemic Treatment
Adjuvant Endocrine Therapy: Hormonal Therapy
O Aka anti-estrogen therapy
O Reduce the amount of estrogen (hormone that
signals the breast cancer cells to grow) produced
in a woman’s body after going through
menopause.
O The main sources of estrogen for post-
menopausal women are the adrenal glands and
fat tissues, not the ovaries.
Pharmacist Intervention:
Systemic Treatment
Adjuvant Endocrine Therapy: Hormonal Therapy
O Aromatase Inhibitor:
Anastrazole for 5 years
1 mg orally daily
S/E: Hot flashes, arthralgias, myalgias, headaches,
diarrhea, mild nausea
Monitoring Parameter
Normalize Laboratory Values of:
O CA 27.29 : <38 U/mL
O CEA : < 3 ng/mL
References
O Pharmacotherapy Casebook: A Patient-Focused Approach Seventh
Edition by Terry L. Schwinghammer and Julia M. Koehler
O Pharmacotherapy: A Pathophysiologic Approach Seventh Edition by
Joseph T. Dipiro, et.al.
O https://www.cancer.gov/about-cancer/diagnosis-
staging/prognosis/tumor-grade-fact-sheet
O https://www.cancer.org/treatment/understanding-your-
diagnosis/tests/understanding-your-pathology-report/breast-
pathology/breast-cancer-pathology.html
O https://emedicine.medscape.com/article/2007112-overview
O https://www.news-medical.net/health/Breast-Cancer-
Pathophysiology.aspx
O http://www.breastcancer.org/symptoms/types/idc/treatment/systemic
