Case 59Marciha Chatman, Shiny Parsai, Samantha Sagert

Chief Complaint

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

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

Medical History

• Breast carcinoma – newly diagnosed

• Shoulder joint pain

• Hypothyroidism

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

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

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

LabsPatient 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

Medications and AllergiesDrug 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 daysThen off 7 days

Contraception

Allergies: Morphine (rash)

Drug Therapy Problems1. 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

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

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

Additional Therapy: Breast Cancer Adjuvant Therapy Options1

Accesspharmacy.com

Additional Therapy: Breast Cancer Adjuvant Therapy Options2

Adjuvant Chemotherapy (preferred regimens)

• AC (doxorubicin + cyclophosphamide) ± pertuzumab

THEN

Paclitaxel WITH trastuzumab

• TCH (docetaxel + carboplatin + trastuzumab ± pertuzumab)

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

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

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

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

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

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/

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

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

Wrong Drug:Oral Contraceptive

• Discontinue Ortho-Cyclen contraceptive

– Hormonal contraception not recommended

– Barrier methods preferred (diaphragms, condoms)

– Copper IUD

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

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

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 NatlCompr 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.

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.