Surveillance
NEOADJUVANT
- Physical exam at each visit
- Tumour marker q cycle if elevated at baseline
- Ensure staging with CT C/A/P and bone scan at baseline
- Baseline breast u/s or MRI and post neoadj chemo u/s or MRI (modality at direction of treating surgeon)
- Day 3 troponin for anthracycline, P/E: JVP/CHF
- Baseline echo (preferred) or MUGA prior to anthracycline and f/u echo/MUGA post anthracycline
- If either troponin bump or asymptomatic EF drop post anthracycline refer to cardiology for enalapril/carvedilol prophylaxis
- Q 12 weekly echo (preferred) or MUGA for trastuzumab
- IO panel q cycle for pembro pts
- Patient review with Med Onc MRP 3-4 weeks post op (review path for indication for adj capecitabine/Kadcyla (Trastuzamab Iretecan)/abemaciclib/Parp inh/ adj endocrine/bisphosphonate recommendations
ADJUVANT
- Baseline staging CT C/A/P and bone scan for node+ patients, otherwise CXR/AST/ALT/ALP and hepatic imaging if LE elevated and bone scan for elevated ALP
- Day 3 troponin for anthracycline, P/E: JVP/CHF
- Baseline echo (preferred) or MUGA prior to anthracycline and f/u echo/MUGA post anthracycline
- If either troponin bump or asymptomatic EF drop post anthracycline refer to cardiology for enalapril/carvedilol prophylaxis
- Q 12 weekly echo (preferred) or MUGA for trastuzumab
- IO panel q cycle for pembro pts, then q 3 monthly X 1 year
- For patients eligible for endocrine therapy, start post RT (if necessary), start concurrently with adj trastuzumab/Kadcyla if anti-HER2 Rx indicated, delay until completed adj capecitabine
- Med Onc will dictate recommended ET (Tam X 5yrs,Tam X 10, AI X 5, AI X 10, or Tam/AI switch)
- If premenopausal and required (neo)adjuvant chemo GnRH agonist/AI preferred (SOFT/TEXT RTC)
- Patients on AI should have baseline bone density and q2 yearly while on AI
- Consider bone builder if osteopenia (10% risk to progress to osteoporosis while on AI otherwise)
- Annual lipid profile (GP)
- High risk ER+/HER2- patients (N+ and Ki 67 >20%, or >3LN, or 1-3LN and Gr3 or T3) benefit from adj abemaciclib X 2 years
- Adjuvant zoledronic acid (prefer BRAJZOL5) for T2/N+ and post menopausal or rendered postmenopausal
- High risk BRCA mutated patients (no PCR post neoadj or 4LN+ and received adj chemo) consider adj olaparib
SURVEILLANCE
- Q 6 monthly H/P X 5 years, then annually for life
- Annual diagnostic mammos (unless mastectomy)
- Lifestyle: encourage aerobic activity and ETOH cessation (post menopausal)
- Monthly self exam (bilat breast/chest wall/incision and axilla)
- NO routine imaging/labs, reserve for symptom work-up.
- Consider discharging to family doctor for completion of surveillance if tolerating ET +/- bisphosphonate and completed systemic chemo/IO/anti-HER2/CDK 4/6 inh/ PARPinh
Dr. Michael Humphreys
Bone Builder
BRAJZOL5
- BRAJZOL5
- Eligibility:
- postmenopausal (including women with chemically induced menopause with LHRH
agonists) - Initial stage II or III only (pT2-4 pN0-3; pT0-4pN1-3), or
- Post neo-adjuvant chemotherapy stage ypT2-4 ypN0-3; ypT0-4 ypN1-3
- Biomarkers: ER any PR any
- Adequate renal function (CrCl greater than or equal to 30 mL/min)
- Bisphosphonate therapy recommended to begin within 1 year of diagnosis and
should start no later than 18 months of definitive breast cancer surgery
- postmenopausal (including women with chemically induced menopause with LHRH
- Eligibility:
BRAJZOL2
- BRAJZOL2
- Eligibility:
- postmenopausal (including women with chemically induced menopause with LHRH
agonists) - Initial stage II or III only (pT2-4 pN0-3; pT0-4pN1-3), or
- Post neo-adjuvant chemotherapy stage ypT2-4 ypN0-3; ypT0-4 ypN1-3
- Biomarkers: ER any PR any
- Adequate renal function (CrCl greater than or equal to 30 mL/min)
- Bisphosphonate therapy recommended to begin within 1 year of diagnosis and
should start no later than 18 months of definitive breast cancer surgery
- postmenopausal (including women with chemically induced menopause with LHRH
- Eligibility:
BRAVZOL
- BRAVZOL
- Eligibility:
- Advanced breast cancer with radiological and/or clinical evidence of metastases to
bone - Acute pain crisis OR to decrease skeletal related events after treatment with
pamidronate (BRAVPAM) for at least 9 doses - Adequate renal function (CrCl ≥ 30 mL/min)
- Advanced breast cancer with radiological and/or clinical evidence of metastases to
- Eligibility:
DENOSUMAB
- Indications Pharmacare:
- For the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis, Prolia
reduces the incidence of vertebral, nonvertebral and hip fractures.
• As a treatment to increase bone mass in men with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy.
• As a treatment to increase bone mass in men with nonmetastatic prostate cancer receiving androgen deprivation therapy (ADT), who are at high risk for fracture.
• As a treatment to increase bone mass in women with nonmetastatic breast cancer receiving adjuvant aromatase inhibitor (AI) therapy, who have low bone mass and are at high risk for fracture.
• As a treatment to increase bone mass in women and men at high risk for fracture
due to sustained systemic glucocorticoid therapy.
• As a treatment to increase bone mass in women and men at high risk for fracture
who are starting or have recently started long-term glucocorticoid therapy.
- For the treatment of postmenopausal women with osteoporosis at high risk for fracture, defined as a history of osteoporotic fracture, or multiple risk factors for fracture; or patients who have failed or are intolerant to other available osteoporosis therapy. In postmenopausal women with osteoporosis, Prolia
Creatinine Clearance
Dr. Johann Schreve
In The Pipeline
- Trastuzumab Deruxtecan in Previously Treated HER2-Low Advanced Breast Cancer
- NATALEE: Phase III study of ribociclib (RIBO) + endocrine therapy (ET) as adjuvant treatment in hormone receptor–positive (HR+), human epidermal growth factor receptor 2–negative (HER2–) early breast cancer (EBC).
- Pembrolizumab for Early Triple-Negative Breast Cancer
- Pembrolizumab plus Chemotherapy in Advanced Triple-Negative Breast Cancer
- Overall Survival with Ribociclib plus Letrozole in Advanced Breast Cancer
- Overall Survival with Ribociclib plus Fulvestrant in Advanced Breast Cancer - MONALEESA-3
- Adjuvant Olaparib for Patients with BRCA1- or BRCA2-Mutated Breast Cancer
