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Case #829
Breast Cancer

A 58-year-old woman with breast cancer and a previous history of anthracycline exposure

Release Date: November 16, 2009
Expiration Date: November 15, 2010

To Start Case:

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History of Present Illness

Martha, a 58-year-old woman, was treated 11 years ago for a pT2 pN0 invasive lobular carcinoma of the left breast. She underwent breast-conserving surgery followed by whole-breast radiation. The tumor was estrogen receptor negative. She received adjuvant systemic therapy with doxorubicin, cyclophosphamide, and docetaxel (ACT). She tolerated her treatments well without significant complications. She recently developed a contralateral, right-breast, poorly differentiated, estrogen receptor-negative, pT1c pN1. Martha was treated with breast-conserving therapy, sentinel node biopsy, and subsequent completion of axillary node dissection (1/14 nodes found positive). The tumor is human epidermal growth factor receptor 2 (Her2)-positive (3[+] immunohistochemical [IHC] staining). She had a metastatic workup that included a CT of the chest/abdomen, a bone scan, complete blood count (CBC), platelet count, and liver function tests. There was no evidence of distant metastatic disease. Martha was referred to you for further evaluation and treatment.


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Disclosures and Important Information

Supported by educational grants from Genentech BioOncology and Sanofi-Aventis.

Release Date: November 16, 2009

Expiration Date: November 15, 2010

Estimated time to complete this activity: 2.0 hours

Accreditation Statement

MedCases, LLC is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education.

Credit Designation Statement

MedCases designates this educational activity for a maximum of 2.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Responsibility

MedCases takes responsibility for the content, quality, and scientific integrity of this CME activity.

Faculty

Professor of Medicine
University of Miami
Division of Hematology/Oncology
Braman Family Breast Cancer Institute
Miami, Florida

Assistant Professor of Medicine
Dana-Farber Cancer Institute
Harvard Medical School
Boston, Massachusetts

Independent Reviewer

Co-Chair, Breast Cancer Research
Baylor Sammons Cancer Center
Texas Oncology
U.S. Oncology
Dallas, Texas

Target Audience

This activity is intended for medical oncologists, community oncologists, pathologists, and other allied healthcare professionals involved in managing patients with breast cancer.

Prerequisites

There are no prerequisites.

Statement of Need

The development of effective systemic agents, in addition to advances in research, has introduced several novel approaches and effective treatment options for patients with breast cancer. While these agents have dramatically improved disease-free and overall survival rates, the advent of these new therapies has also been associated with potential toxicity in a subset of patients. As with previous data, reports continue to demonstrate the importance of medical oncologists being aware of the potential treatment-related toxicities, as well as the importance of implementing steps for appropriate monitoring, prevention, and management.

In particular, the risk for and management of cardiotoxicity associated with the use of certain systemic agents in the treatment of breast cancer remains an important issue. Considering the widespread use of potentially cardiotoxic agents and the increasingly long-term survival of most patients with early-stage breast cancer, the risk for chemotherapy-induced cardiac dysfunction is a growing concern in the medical oncology community. A greater understanding of the relationship between therapeutic agents and potential adverse cardiac events is therefore needed to effectively treat patients with breast cancer while minimizing treatment-related complications. Such understanding then needs to be applied to improving patient care through effective screening for cardiac risk factors, careful scheduling and selective use of specific agents, appropriate cardiac monitoring, and early intervention when there are signs of heart failure.

Objectives

Upon completion of this case, you should be able to:

Discuss the various mechanisms of cardiac injury attributed to anthracyclines and trastuzumab including the multiple-hit hypothesis responsible for underlying cardiac risks and increased cardiac mortality
Examine feasible alternatives to anthracycline-based chemotherapy that confer lower cardiac risks, including the role of TC and TCH regimens
Describe strategies for early detection of cardiac injury by using biomarkers and routine diagnostic tests of cardiac function
Analyze the need for formal baseline cardiovascular disease risk assessment before treatment for breast cancer with either Framingham or Reynolds risk scores
Identify the methods to reduce cardiac injury to myocytes and for the timely treatment of heart failure

Method of Participation

This Internet-based activity takes approximately 2 hours to complete. You should review the objectives and case, answer the multiple-choice post-test and complete an evaluation form online. Once completed, you will be able to save your certificate to your own computer and print it on your own printer.

Disclosure Statement

As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), it is MedCases policy to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a provider has with the any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients. The following was reported:

Program Chair
Mark D. Pegram, MD, PhD	Grants/Research Support: sanofi-aventis US Advisory Board member: Takeda Pharmaceuticals, Wyeth Pharmaceuticals
Faculty
Susana M. Campos, MD, MPH	Consultant Fees: Genentech, Inc. Grants/Research Support: Genentech, Inc. Speakers' Bureau: Eli Lilly & Company, Genentech, Inc. and GlaxoSmithKline
Independent Reviewer
Joyce A. O'Shaughnessy, MD	Speakers' Bureau: Abraxis BioScience Inc., AstraZeneca Pharmaceuticals, Eli Lilly & Company, Genentech, Inc. and sanofi-aventis US

Planning Committee

Ted James, MD; Carolyn Darrow, MPH; and Daryl Lynn Ehrentreu, RPh, MBA indicated that they have not received financial support for consultation, research, or, evaluation, or have a financial interest relevant to this online activity.

Off-label Statement/Unapproved Uses

In accordance with US Food and Drug Administration (FDA) requirements regarding the disclosure of off-label, investigational, or unapproved recommendations for the use of drugs or devices, you are advised that content in this activity does not contain reference(s) to uses of drugs or devices that are off-label, investigational, or unapproved in the United States. The following information is provided for educational purposes and not to endorse off-label use.

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Hardware/Software Requirements and Technical Assistance

This Web-based CME activity is best experienced using a current generation browser, such as Internet Explorer 5.5 or higher. This Web site requires that JavaScript and session cookies be enabled. In addition, you will require the Adobe Flash Player plugin to view the case simulation.

Detailed Requirements:

128 MB RAM
Windows 98 or newer
Adobe Flash Player 8 minimum needed
Audio playback with speakers for programs that have video content
Internet Explorer 5.5 or higher or Mozilla Firefox 1.0 or higher or Apple Safari
1024 x 768 resolution
Broadband connection highly recommended

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Confirmation

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