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Level 3 Organ System: Endocrine / Integumentory / Reproductive Disease State: Gastrointestinal / Infectious / Mental / Oncological Curriculum Topic: Pharmacotherapy / Pharmacy Practice / Social & Behavioral Aspects of Practice Adjuvant Treatment of Newly Diagnosed Breast Cancer John Bossaer, PharmD, BCPS Assistant Professor of Pharmacy Practice, East Tennessee State University Gatton College of Pharmacy Christan M. Thomas, PharmD Candidate East Tennessee State University Gatton College of Pharmacy Family History Key Learning Objectives 1. Identify patient- and tumor-specific factors to consider when treating breast cancer. 2. Describe the different treatment options for breast cancer, considering appropriate indications for chemotherapy, hormonal therapy, and targeted therapy. 3. Describe the risks and benefits of chemotherapy and hormonal therapy in breast cancer. 4. List specific tests and monitoring parameters given a specific chemotherapy regimen for breast cancer. Case Presentation History of Present Illness TM is a 50-year-old premenopausal white female who presented to the cancer clinic following an abnormal mammogram and needle core biopsy that revealed ductal carcinoma in situ of the right breast. Following the biopsy, TM underwent a lumpectomy. During the surgery, a 2.2-cm tumor with negative margins was removed. Cytology revealed the tumor to be invasive ductal carcinoma, grade II, estrogen receptor (ER) positive, progesterone receptor (PR) positive, human epidermal growth factor receptor 2 (HER2) negative. Sentinel lymph node biopsy was negative. TM’s cancer was staged as IIA. After her lumpectomy, TM developed a staph infection of the surgical site and was treated as an inpatient with IV antibiotics (vancomycin). At the time of her clinic visit she was on day 7 of a 10-day course of clindamycin 600 mg PO TID. TM presents to the cancer clinic today in order to discuss treatment options for her breast cancer. She also complains of some slight diarrhea that has developed over the past several days. Father died at age 78 of cerebrovascular accident. He also had a history of Alzheimer’s disease. Mother was diagnosed with ductal carcinoma in situ of the breast at age 77 for which she was treated via lumpectomy. Mother is still living. Patient has four siblings who are all living. One sister has a history of diabetes. Social History Married with three adult children Husband is in poor health and is suffering from metastatic renal cell carcinoma. Denies use of alcohol, tobacco, and drugs Walks approximately three times per week and performs all of her activities of daily living, in addition to providing basic care to her husband. Allergies No known drug allergies Medications Ramipril 20 mg PO daily Paroxetine 40 mg PO daily Non-prescription Medications Multivitamin 1 tab PO daily Vitamin D 1000 units PO daily Probiotic supplement 1 tab PO daily Vi tals : A dmission Temp. HRBP RR (°C) (beats/min) (mmHg) (breaths/min) 37° 88 143/85 18 Past Medical History Hypertension Obesity Iron-deficiency anemia Depression Anxiety R emington P harmacy C omplete C ases • november 2011 / case presentation: Bossaer, page 1 w w w . p h a r m pres s .com/casestudies ©Pharmaceutical Press 2011 Assessment Questions 1. What factors should be examined when considering a treatment regimen for breast cancer? 2. Name possible treatments for TM, including specific agents, when applicable. 3. Should this patient be offered adjuvant chemotherapy? 4. Should this patient be offered hormonal therapy? 5. Should this patient be offered HER-2 targeted therapy with trastuzumab? 6. Given TM’s history of present illness, when would it be appropriate to start any additional treatment? 7. TM is concerned about the possibility of facing chemotherapy while caring for her ailing husband. What is a tool that can be used to help TM make an informed decision on whether or not she will benefit from chemotherapy? 8. TM’s oncologist recommended chemotherapy and chose to administer ACT (four cycles of doxorubicin plus cyclophosphamide, followed by 12 cycles of weekly paclitaxel). What tests should be performed and what, if any, unique pre-medications should be given before this regimen is started? 9. After completing chemotherapy, TM will begin hormonal treatment with tamoxifen for 5 years, followed by anastrozole for 5 years. What main adverse effects of each of these agents should TM be counseled about? 10. What, if any, other issues with TM’s current medications need to be addressed before starting hormonal therapy with tamoxifen. Why? 11. When TM presented to the clinic she was also complaining of diarrhea. What could be the cause of this symptom and what treatment should be recommended? (answers on page 12) Please visit www.pharmpress.com/casestudies to register for electronic versions of the cases and to receive updates about Remington: The Science and Practice of Pharmacy. R emington P harmacy C omplete C ases ©Pharmaceutical Press 2011 • november 2011 / case presentation: Bossaer, page 2 w w w . p h a r m pres s .com/casestudies