Board Preparation: Breast Cancer, Cancer in Elderly Patients

Aug 24, 2016

Test your knowledge of breast cancer and geriatric oncology to assist your preparations for Board examinations with questions from a past edition of ASCO-SEP®, ASCO’s self-evaluation program in oncology.

The new fifth edition of ASCO-SEP is available for purchase in the ASCO University® bookstore. Featuring 21 updated chapters and more than 180 new self-assessment questions in the book, as well as a 120-question comprehensive mock exam online, this resource is perfect for Board preparation, and can be used to earn Maintenance of Certification and Continuing Medical Education credit. Visit ASCO University for information about the latest edition of ASCO-SEP and other self-assessment resources.

Correct answers, rationales, and suggested reading are listed at the bottom of the page.

1. A healthy, asymptomatic 56-year-old woman is diagnosed with a 1.9-cm invasive ductal carcinoma with lymphovascular involvement and two negative sentinel nodes. It is ER-negative, PR-negative, and HER2-positive. Prior to initiating adjuvant systemic therapy, you recommend the following tests:

  1. An ECHO cardiogram, bone scan and CT of the chest, abdomen and pelvis
  2. An ECHO cardiogram and PET/CT
  3. An ECHO cardiogram
  4. An ECHO cardiogram, PET/CT and MRI of the brain

2. A 74-year-old man presents with left cervical adenopathy and drenching night sweats over a duration of 3 months. He has lost 20 lbs over the past 3 weeks. The patient undergoes an excisional left supraclavicular lymph node biopsy and this confirms a diffuse large B-cell lymphoma that is CD20+. Positron emission tomography scan reveals activity in the mediastinum and para-aortic lymph nodes. A bone marrow biopsy is negative for lymphomatous involvement. Laboratory studies indicate his WBC is 7.3 K/µL, his hemoglobin is 12.0 g/dL, and his platelet count is 175,000 K/µL. Lactate dehydrogenase is 450 µL. Creatinine is 0.8 mg/dL. The patient is very functional, independent, and has no comorbidities. He plays golf twice weekly and is very keen on preserving his quality of life.

Which of the following do you recommend?

  1. Involved field radiation therapy to the left neck
  2. Cyclophosphamide, doxorubicin, vincristine, and prednisone (CHOP) for six cycles
  3. Dose-attenuated CHOP plus rituximab for four cycles followed by radiation to the left neck
  4. CHOP plus rituximab for six cycles

 

Rationales

1: C

The likelihood of presenting with distant metastasis when diagnosed with stage I disease (T1c, N0) is less than 1%, therefore extensive radiographic studies for staging are not indicated in an asymptomatic patient. Given this patient’s hormone receptor–negative and HER2-positive disease, a trastuzumab-containing regimen should be offered as adjuvant therapy. Trastuzumab carries a risk of congestive heart failure; therefore, baseline ECHO cardiograms are indicated and are repeated during adjuvant treatment.

Suggested Reading

Slamon D, Eiermann W, Robert N, et al. Adjuvant trastuzumab in HER2-positive breast cancer. N Engl J Med. 2011;365:1273-1283. PMID: 21991949.

Perez EA, Romond EH, Suman VJ, et al. Four-year follow-up of trastuzumab plus adjuvant chemotherapy for operable human epidermal growth factor receptor 2-positive breast cancer: joint analysis of data from NCCTG N9831 and NSABP B-31. J Clin Oncol. 2011;29:3366-3373. PMID: 21768458.

 

2: D

The patient has at least stage III diffuse large B-cell lymphoma and thus has no indication for local field radiation. The practice-changing GELA study in patients with diffuse B-cell lymphoma has been conducted in patients age 60 to 80 and compared CHOP with CHOP plus rituximab (R-CHOP). The patients who received R-CHOP had a higher complete response rate (76% vs. 63%), 2-year event-free survival, and overall survival, thus making R-CHOP the standard of care for this group of patients.

Suggested Reading

Coiffier B, Lepage E, Briere J, et al. CHOP chemotherapy plus rituximab compared with CHOP alone in elderly patients with diffuse large-B-Cell lymphoma. N Engl J Med. 2002;346:235-242. PMID: 11807147.

 

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