BREAST CANCER

A Case Presentation

Submitted to: Dr. Jan Karlo Ecalne

Submitted by: GROUP 1

Armillo, Claire Marie

Cabrera, Frances Elaine U.
Cerda, Allyzon G.
Consarba, Jennifer L.
Contreras, Allianna Irish M.
Corsiga, April Jomerlynn S.
Cruz, Moira Patrice C.
De Guia, Princess Pauline S.
Deldio, Veronica Lourds A.

BSP3A - BLOCK 3
DISEASE PRESENTATION
Introduction - Cabrera, Frances Elaine
● The outlook for women with breast cancer is improving constantly. Due to increased
awareness, opportunities for early detection, and treatment advances, survival rates
continue to climb. Breast cancer is a disease in which cells in the breast grow out of
control. Moreover, there are different kinds of breast cancer. The kind of breast cancer
depends on which cells in the breast turn into cancer. Breast cancer can begin in
different parts of the breast. A breast is made up of three main parts: lobules, ducts, and
connective tissue. The lobules are the glands that produce milk. The ducts are tubes that
carry milk to the nipple. The connective tissue (which consists of fibrous and fatty tissue)
surrounds and holds everything together. Most breast cancers begin in the ducts or
lobules.

Pathogenesis- Cabrera, Frances Elaine

● Breast cancer develops due to DNA damage and genetic mutations that can be
influenced by exposure to estrogen. Sometimes there will be an inheritance of DNA
defects or pro-cancerous genes like BRCA1 and BRCA2. Thus the family history of
ovarian or breast cancer increases the risk for breast cancer development. In a normal
individual, the immune system attacks cells with abnormal DNA or abnormal growth.
This fails in those with breast cancer disease leading to tumor growth and spread.

Etiology - Cabrera, Frances Elaine

Identifying factors associated with an increased incidence of breast cancer development is

important in general health screening for women. Risk factors for breast cancer can be divided
into 7 broad categories:

1. Age: The age-adjusted incidence of breast cancer continues to increase with the
advancing age of the female population.
2. Gender: Most breast cancers occur in women.
3. Personal history of breast cancer: A history of cancer in one breast increases the
likelihood of a second primary cancer in the contralateral breast.
4. Histologic risk factors: Histologic abnormalities diagnosed by breast biopsy constitute
an important category of breast cancer risk factors. These abnormalities include lobular
carcinoma in situ (LCIS) and proliferative changes with atypia.
5. The family history of breast cancer and genetic risk factors: First-degree relatives of
patients with breast cancer have a 2-fold to 3-fold excess risk for developing the disease.
Five percent to 10% of all breast cancer cases are due to genetic factors, but they may
account for 25% of cases in women younger than 30 years. BRCA1 and BRCA2 are the
2 most important genes responsible for increased breast cancer susceptibility.
6. Reproductive risk factors: Reproductive milestones that increase a woman’s lifetime
estrogen exposure are thought to increase her breast cancer risk. These include the
onset of menarche before 12 years of age, first live childbirth after age 30 years,
nulliparity, and menopause after age 55 years.
 7. Exogenous hormone use: Therapeutic or supplemental estrogen and progesterone are
taken for various conditions, with the two most common scenarios being contraception in
premenopausal women and hormone replacement therapy in postmenopausal women.

Staging/Classifications - Cabrera, Frances Elaine

Stage 0: Stage zero (0) describes disease that is only in the ducts of the breast tissue and has
not spread to the surrounding tissue of the breast. It is also called non-invasive or in situ cancer
(Tis, N0, M0).
Stage IA: The tumor is small, invasive, and has not spread to the lymph nodes (T1, N0, M0).
Stage IB: Cancer has spread to the lymph nodes and the cancer in the lymph node is larger
than 0.2 mm but less than 2 mm in size. There is either no evidence of a tumor in the breast or
the tumor in the breast is 20 mm or smaller (T0 or T1, N1mi, M0).
Stage IIA: Any 1 of these conditions:
● There is no evidence of a tumor in the breast, but the cancer has spread to 1 to 3 axillary
lymph nodes. It has not spread to distant parts of the body. (T0, N1, M0).
● The tumor is 20 mm or smaller and has spread to 1 to 3 axillary lymph nodes (T1, N1,
M0).
● The tumor is larger than 20 mm but not larger than 50 mm and has not spread to the
axillary lymph nodes (T2, N0, M0).
Stage IIB: Either of these conditions:
● The tumor is larger than 20 mm but not larger than 50 mm and has spread to 1 to 3
axillary lymph nodes (T2, N1, M0).
● The tumor is larger than 50 mm but has not spread to the axillary lymph nodes (T3, N0,
M0).
Stage IIIA: The cancer of any size has spread to 4 to 9 axillary lymph nodes or to internal
mammary lymph nodes. It has not spread to other parts of the body (T0, T1, T2, or T3; N2; M0).
Stage IIIA may also be a tumor larger than 50 mm that has spread to 1 to 3 axillary lymph nodes
(T3, N1, M0).
Stage IIIB: The tumor has spread to the chest wall or caused swelling or ulceration of the
breast, or it is diagnosed as inflammatory breast cancer. It may or may not have spread to up
to 9 axillary or internal mammary lymph nodes. It has not spread to other parts of the body (T4;
N0, N1, or N2; M0).
Stage IIIC: A tumor of any size that has spread to 10 or more axillary lymph nodes, the internal
mammary lymph nodes, and/or the lymph nodes under the collarbone. It has not spread to other
parts of the body (any T, N3, M0).
Stage IV (metastatic): The tumor can be any size and has spread to other organs, such as the
bones, lungs, brain, liver, distant lymph nodes, or chest wall (any T, any N, M1). Metastatic
cancer found when the cancer is first diagnosed occurs about 6% of the time. This may be
called de novo metastatic breast cancer. Most commonly, metastatic breast cancer is found after
a previous diagnosis of early breast cancer.

Recurrent: Recurrent cancer is cancer that has come back after treatment and can be
described as local, regional, and/or distant. If the cancer does return, there will be another round
of tests to learn about the extent of the recurrence. These tests and scans are often similar to
those done at the time of the original diagnosis.

Prognosis - Cabrera, Frances Elaine

Worldwide, female breast cancer has now surpassed lung cancer as the most commonly
diagnosed cancer. An estimated 2,261,419 new cases were diagnosed in women across the
world in 2020. The 5-year survival rate tells you what percent of people live at least 5 years after
the cancer is found. Percent means how many out of 100. The average 5-year survival rate for
women in the United States with non-metastatic invasive breast cancer is 90%. The average
10-year survival rate for women with non-metastatic invasive breast cancer is 84%.

Risk Factors - Cabrera, Frances Elaine

● Getting older. The risk for breast cancer increases with age. Most breast cancers are
diagnosed after age 50.
● Genetic mutations. Women who have inherited changes (mutations) to certain genes,
such as BRCA1 and BRCA2, are at higher risk of breast and ovarian cancer.
● Reproductive history. Starting menstrual periods before age 12 and starting
menopause after age 55 expose women to hormones longer, raising their risk of getting
breast cancer.
● Having dense breasts. Dense breasts have more connective tissue than fatty tissue,
which can sometimes make it hard to see tumors on a mammogram. Women with dense
breasts are more likely to get breast cancer.
● Personal history of breast cancer or certain non-cancerous breast diseases.
Women who have had breast cancer are more likely to get breast cancer a second time.
Some non-cancerous breast diseases such as atypical hyperplasia or lobular carcinoma
in situ are associated with a higher risk of getting breast cancer.
● Family history of breast or ovarian cancer. A woman’s risk for breast cancer is higher
if she has a mother, sister, or daughter (first-degree relative) or multiple family members
on either her mother’s or father’s side of the family who have had breast or ovarian
cancer. Having a first-degree male relative with breast cancer also raises a woman’s
risk.
● Previous treatment using radiation therapy. Women who had radiation therapy to the
chest or breasts (for instance, treatment of Hodgkin’s lymphoma) before age 30 have a
higher risk of getting breast cancer later in life.

Signs and Symptoms - Cabrera, Frances Elaine

1. New lump in the breast or underarm (armpit).
2. Thickening or swelling of part of the breast.
3. Irritation or dimpling of breast skin.
4. Redness or flaky skin in the nipple area or the breast.
5. Pulling in of the nipple or pain in the nipple area.
6. Nipple discharge other than breast milk, including blood.
7. Any change in the size or the shape of the breast.
 8. Pain in any area of the breast.

Diagnosis and Detection - Cabrera, Frances Elaine

● Breast exam. Your doctor will check both of your breasts and lymph nodes in your
armpit, feeling for any lumps or other abnormalities.
● Mammogram. A mammogram is an X-ray of the breast. Mammograms are commonly
used to screen for breast cancer. If an abnormality is detected on a screening
mammogram, your doctor may recommend a diagnostic mammogram to further evaluate
that abnormality.
● Breast ultrasound. Ultrasound uses sound waves to produce images of structures deep
within the body. Ultrasound may be used to determine whether a new breast lump is a
solid mass or a fluid-filled cyst.
● Removing a sample of breast cells for testing (biopsy). A biopsy is the only definitive
way to make a diagnosis of breast cancer. During a biopsy, your doctor uses a
specialized needle device guided by X-ray or another imaging test to extract a core of
tissue from the suspicious area. Often, a small metal marker is left at the site within your
breast so the area can be easily identified on future imaging tests.
Biopsy samples are sent to a laboratory for analysis where experts determine whether
the cells are cancerous. A biopsy sample is also analyzed to determine the type of cells
involved in breast cancer, the aggressiveness (grade) of the cancer, and whether the
cancer cells have hormone receptors or other receptors that may influence your
treatment options.

Breast magnetic resonance imaging (MRI). An MRI machine uses a magnet and radio
waves to create pictures of the interior of your breast. Before a breast MRI, you receive
an injection of dye. Unlike other types of imaging tests, an MRI doesn't use radiation to
create the images.

Pharmacological Treatment - Cabrera, Frances Elaine

● In cancer care, doctors specializing in different areas of cancer treatment—such as
surgery, radiation oncology, and medical oncology—work together with radiologists and
pathologists to create a patient’s overall treatment plan that combines different types of
treatments. Some treatments, like surgery and radiation, are local, meaning they treat
the tumor without affecting the rest of the body. Moreover, drugs frequently used to treat
breast cancer include methotrexate, 5-fluorouracil (5-FU), cyclophosphamide,
anthracyclines, taxanes, trastuzumab, tamoxifen, and aromatase inhibitors. These
agents inhibit breast cancer progression by a variety of different mechanisms.

Non-pharmacological Treatment - Cabrera, Frances Elaine

 ● Patients can choose among different effective types of exercise and non-pharmaceutical
interventions to reduce CRF. Typically, treatment is based on the type of breast cancer
and its stage. Other factors, including your overall health, menopause status, and
personal preferences are also taken into account. Some types of adjuvant therapies,
particularly non-pharmacological adjuvant therapies (NPATs) (such as relaxation,
mindfulness-based stress reduction (MBSR), music therapy, massage; yoga,
acupuncture, meditation, qigong, reflexology, and stress management) are usually
combined with chemotherapy and/or radiotherapy.

PATIENT DETAILS - Contreras, Alianna Irish

Patient Name : Rosalita Garza

Age: : 61-year-old
Gender : Female

● Presenting for evaluation of a new mass in her left breast.

● Notice a palpable breast mass on self-examination approximately 14 months ago.
● Experience intermittent pain in the site of the mass.
● Mammogram shows suspicious for malignancy.

SUBJECTIVE - Consarba, Jennifer

Chief Complaint “ I have a lump in my breast”

History of present illness:

● The lump is intermittently painful, according to the patient.
● Prior to the present vis koit, a mammography was conducted that was indicative of
malignancy.

Past medical history :

● Musculoskeletal injury in 2000

● She sustained cervical spine injuries when she fell off a chair at work.
● The patient's right hip to her cervical spine required bone grafting.
● The patient is taking multiple medications for pain control
● Diagnosed with Depression 7 years ago

Family history:

● At age 60, the patient’s sister was diagnosed with breast cancer; now 5 years
post-surgery
● The patient could not remember any other information.
● There is no more serious cancer history identifie
Social History

● The patient resides with her mother, who has dementia, and provides main care for her.
● The patient denies alcohol consumption and does not smoke.
● The patient also resides with her daughter, who is 35 years old.

Allergies :
● No known allergies (NKDA)

Review of system
● Negative except for the aforementioned complaints

OBJECTIVE - Consarba, Jennifer

PHYSICAL EXAMINATION

Vitals Signs Result Remarks

Blood pressure (BP) 127/21 Normal

Pulse rate (PR) 89 Normal

Respiratory rate (RR) 16 Normal

Temperature 36.7 C Normal

Weight 163 lb -

Height 5’5’’ -

Body mass index (BMI) 26.3 Overweight

General
● WDWN 61-year-old Hispanic female. Awake, alert, in NAD.

HEENT
NC/AT; PERRLA; EOMI; ear, nose, throat are clear

Neck/Lymph Nodes
Supple. No lymphadenopathy, thyromegaly, or masses. No supra- clavicular or infraclavicular
adenopathy.

Breasts
Left: Notable for a 2.5-cm mass at the 6 o’clock position, approxi- mately 3 cm from the nipple
margin, not fixated to skin; no nipple retraction or discharge is visualized; the mass is exquisitely
tender to palpation; 1.5 cm, nontender, palpable mass in the axilla noted.
Right: Without mass or lymphadenopathy.

Lungs
● CTA and percussion

CV
● RRR; no murmurs, rubs, or gallops

Abd
● Soft, NT/ND, normoactive bowel sounds. No appreciable hepato- splenomegaly.

Spine
● Slight tenderness to percussion

Ext
● No CCE

Neuro
● No deficits noted

Drug administered and Clinical Data

Menarche at 13, menopause at 55, and first pregnancy at 26; G1P1A0. Last PAP test at 40
years old. Five years following the onset of menopause, Premarin was used as HRT.

RESULT NORMAL REMARKS INDICATION

VALUES

Na 142 mEq/L 135 and 145 Normal -

mEq/L

K 3.7 mEq/L 3.5 to 5.0 mEq/L Normal -

Cl 102 mEq/L 96 to 106 mEq/L Normal -

CO2 26 mEq/L 23 to 29 mEq/L Normal -

BUN 9 mg/dL 7 to 24 mg/dL Normal -

SCr 0.7 mg/dL 0.6 to 1.1 mg/dL Normal -

 Glu 83 mg/dL 70 to 100 mg/dL Normal -

Hgb 12.9 g/dL 13.2 to 16.6 Normal -

Hct 37.9% 38.3% to 48.6% Normal -

RBC 4.13 x 106 /mm3 4.5 to 5.9 x 106 Normal -

/mm3

Plt 410 × 150 to 400 x Above Normal Either essential

10^3/mm^3 10^3 /mm^3 thrombocythemi
a or reactive
thrombocytosis
can be indicated
by an elevated
platelet count.
Essential
thrombocythemi
a is a rare bone
marrow disorder
that causes
excessive
platelet
production

PT 11.9 secs 11 to 13.5 secs Normal -

INR 1.09 1.1 to 2.0 Normal -

aPTT 30.1 secs 21 to 35 secs Normal -

WBC 8.7 × 103 /mm3 4.7 to 11 x 103 Normal -

/mm3

Neurons 55% 40% to 60% Normal -

Eos 2% 1% to 3% Normal -

Lymphs 10% 20% to 40% Normal -

Monos 1% 2% to 8% Normal -

AST 36 IU/L 8 to 33 IU/L Above Normal Findings that fall

outside of the
normal range,
does not
 necessarily
indicate that it
has a medical
issue that
requires
treatment.
Additionally,
elevated AST
levels may also
be a sign of
heart disease or
pancreatitis

ALT 17 IU/L 7 to 56 IU/L Normal -

LDH 488 IU/L 140 to 280 IU/L Above Normal Higher than
normal LDH
levels typically
indicate tissue
damage caused
by an injury ,
disease, or
infection

T. Bili 0.2 mg/dL 0.2 to 1.2 mg/dL Norma -

CA27-29 36.2 U/mL ≤38 Normal -

CEA 1.2 mg/mL 0 to 2.5 mg/mL Normal -

Diagnostic bilateral mammogram

● Highly suspicious for malignancy of the left breast
● Irregular mass (2.2 cm) with clear edges in the lower left lobe of the breast (3 cm from
the nipple)
● No prominent bulk, deformity, or worrisome calcifications were found in the right breast.

Unilateral ultrasound left breast and left axilla with biopsy:

● In the 5:00–6:00 region, there is an ill-defined, hypoechoic mass.

● This object measures roughly 2.5 2.3 1.5 cm and is placed 3 cm from the nip.
● In the axilla, suspicious lymph nodes are observed.
● The largest node has dimensions of 1.8 1.8 1.4 cm.
● A few hypoechoic lymph nodes were also seen in the infraclavicular region, which were
positioned on the side.
 ● The largest node measured 0.08 0.08 0.08 centimeters.
● No internal mammary or supraclavicular lymph nodes were found to be suspicious.

Core needle biopsy of left breast mass:

● Left breast, 6 o’clock: infiltrating ductal carcinoma,
● Modified Black’s nuclear grade II (moderately differentiated),
● ER 95%,
● PR 95%,
● Her2 overexpression 2+,
● Her2 FISH negative (no amplification),
● ki67 30% (moderate).

Fine needle aspiration (FNA) of left axillary and infraclavicular lymph nodes:
● Left axillary lymph node: metastatic adenocarcinoma consistent with breast primary.
● Left infraclavicular lymph node: metastatic adenocarcinoma consistent with breast
primary.

Bone scan:
● No definite evidence of osseous metastases.
● Abnormality in cervical spine consistent with previous history of bone grafting.

Ultrasound liver:
● No lesions suggestive of metastases.

ASSESSMENT - Armillo, Claire Marie

A 61-year-old patient with Stage IIIC breast cancer, as classified by the TNM staging system.

The following are the basis for the diagnosis:

● The size (T) is 25 mm, indicating T2;
● Cancer has spread to the lymph nodes (N) located infraclavicular, indicating N3; and
● The patient still has no evidence of distant metastases (M), indicating M0.
Hence, according to the American Society of Clinical Oncology, T2N3M0 is classified as stage
IIIC breast cancer.

COURSE IN THE WARDS - NOT APPLICABLE

PROBLEM LIST - De Guia, Princess Pauline

● Painful palpalable breast mass
● Above normal platelet count
● Above normal AST
● High level of LDH
PHARMACOTHERAPY GOALS - De Guia, Princess Pauline
● The pharmacotherapy goal for this case are to eradicate tumors, to slow down the
growth of cancer cells, and to prevent recurrences.

GUIDELINES VS ACTUAL MANAGEMENT - Corsiga, April Jomerlynn

GUIDELINES:

NONINVASIVE DISEASE

Stage 0 (lobular carcinoma in situ [LCIS])

Management options include the following:

● Surveillance alone (ie, mammography)

● Surveillance plus raloxifene (for postmenopausal women)
● Tamoxifen (for women of any menopausal status)
● Bilateral prophylactic mastectomy (usually in patients who are very concerned
about breast cancer risk and have either a strong family history or
mammographically dense breasts that impair surveillance)
If LCIS is detected on stereotactic biopsy, wide excision is indicated. In 10-20% of cases, this
may reveal invasive cancer or ductal carcinoma in situ (DCIS) that requires additional local or
systemic therapy

Surgical excision to negative margins is not indicated; however, LCIS is associated with about a
5% 5-y risk and a 20-30% lifetime risk of developing invasive breast cancer, which may be
ipsilateral or contralateral and may be ductal or lobular in origin. Pleomorphic LCIS is a LCIS
variant that warrants special consideration in that treatment should include excision to negative
margins.

Stage 0 (ductal carcinoma in situ [DCIS])

Primary treatment options include the following:

● Lumpectomy without axillary assessment, plus whole-breast radiation therapy (RT);

use of radiation boost (photons, brachytherapy, or electron beam) to the tumor bed
is recommended, especially in patients age ≥50 y or
● Total mastectomy, with or without sentinel node biopsy (SNB) and with or without
breast reconstruction or
● Lumpectomy without lymph node surgery and without radiation therapy (lower-level
evidence)
Considerations include the following:

● Although axillary dissection or SNB is often not performed, SNB may be done in
some cases if an initial core biopsy showed DCIS, because more extensive
sampling may show invasive carcinoma
 ● In the absence of risk factors for recurrence (eg, palpable mass, larger size, higher
grade, close or involved margins, age < 50 y), some patients may not receive RT
● Consider risk-reduction therapy with tamoxifen for 5 years for patients treated with
lumpectomy and RT, especially those with estrogen receptor (ER)–positive DCIS

INVASIVE DISEASE

Stage I, IIA, IIB, or IIIA (T3N1M0)

Treatment for these stages of breast cancer include the following:

● Surgery
● RT in most cases
● Adjuvant chemotherapy, endocrine therapy, or biologic therapy in some cases
Surgical options include the following:

● Lumpectomy to negative margins, plus RT or

● Mastectomy or
● Mastectomy with reconstruction

Axillary assessment is usually performed with SNB. Axillary dissection may be considered in
cases of node-positive breast cancer.

RT is used in patients who undergo lumpectomy or, in selected cases, after mastectomy;
treatment fields are determined by axillary node status. RT should follow chemotherapy if
chemotherapy is indicated.

Patients undergoing lumpectomy with surgical axillary staging

RT recommendations are based on the patient's axillary node status. In patients with ≥4 positive
axillary nodes, treatment is as follows:

● Whole-breast radiation therapy (WBRT) with or without boost to the tumor bed
● Comprehensive regional nodal irradiation (RNI) including any portion of the
undissected axilla at risk
In patients with 1-3 positive axillary nodes, treatment is as follows:

● All of the following criteria met: cT1-T2 cN0, no preoperative chemotherapy, 1-2
positive sentinel lymph node (SLNs) – WBRT with or without boost to the tumor
bed; comprehensive RNI with or without inclusion of axilla
● Not all the above criteria met – WBRT with or without boost, including any portion
of undissected axilla at risk; strongly consider RNI
In patients with negative axillary nodes, treatment is as follows:

● WBRT with or without boost to the tumor bed

 ● Partial breast irradiation (PBI) may be considered in selected patients

Patients undergoing total mastectomy with surgical axillary staging, with or without
reconstruction
RT recommendations are based on the patient's axillary node status, as follows (note that
comprehensive RNI may include any portion of undissected axilla at risk):

● Negative axillary nodes, tumor ≤5 cm, and margins ≥1 mm – No RT needed

● Negative axillary nodes, tumor ≤5 cm, and negative margins < 1 mm – Consider
RT to the chest wall; for high-risk patients, consider adding comprehensive RNI
● Negative axillary nodes and tumor > 5 cm or positive margins – Consider RT to the
chest wall, with or without comprehensive RNI
● 1-3 positive axillary nodes – Consider RT to the chest wall, with or without
infraclavicular and supraclavicular nodes; consider RT to internal mammary nodes
● ≥4 positive axillary nodes – RT to the chest wall plus consider comprehensive RNI
● Margins positive – Re-excision to negative margins (preferred); if unable to excise,
then strongly consider RT with or without comprehensive RNI
Patients with large, clinical stage IIA, IIB, or IIIA (T3N1M0) tumors
Consider preoperative chemotherapy in patients who have any of the following:

● Inflammatory breast cancer (IBC)

● T3-T4 disease
● Node-positive disease
● ER-negative disease
● HER2-positive disease or triple-negative breast cancer (TNBC), if cT≥2 or cN≥1;
may be considered for cT1c, cN0 HER2-positive disease and TNBC
● Tumors that need downsizing for surgery
● Patients in whom definitive surgery may be delayed
If the patient has clinically negative axillary nodes, consider SNB. If the patient has clinically
positive axillary nodes, consider a core biopsy or fine-needle aspiration (FNA), then SNB if FNA
or core biopsy is negative.

Systemic therapy can be streamlined based on histology, menopause, and hormone

receptor/HER2 status

ACTUAL MANAGEMENT

● There are several breast cancer treatment options, including surgery, chemotherapy,
radiation therapy, hormone therapy, immunotherapy and targeted drug therapy. What’s
right for the patient depends on many factors, including the location and size of the
tumor, the results of her laboratory tests and whether the cancer has spread to other
parts of the body. The healthcare provider will tailor the patient's treatment plan
 according to her unique needs. It’s not uncommon to receive a combination of different
treatments, too.
● Stage 3 treatment options vary widely and may consist of mastectomy and radiation for
local treatment and hormone therapy or chemotherapy for systemic treatment. Nearly
every person with a Stage 3 diagnosis will do best with a combination of two or more
treatments.
● Chemotherapy is always given first with the goal to shrink the breast cancer to be
smaller within the breast and within the lymph nodes that are affected. This is known as
neoadjuvant chemotherapy.
● Other possible treatments include biologic targeted therapy and immunotherapy. There
may be various clinical trial options for interested patients with Stage 3 breast cancer.

PLAN (RECOMMENDATIONS AND INTERVENTIONS) - Cruz, Moira Patrice

PHARMACOLOGICAL TREATMENT
Local treatment
RADIATION THERAPY
● As mentioned, surgery may be followed by radiation therapy, especially if the
patient had lumpectomy. Moreover, with the presence of breast tumor on the
axillary and and infraclavicular lymph nodes of the patient, radiotherapy is
recommended to kill any remaining cancer cells after surgery using controlled
doses of radiation, thus, reducing the risk of the recurrence in the breast, chest
area or lymph nodes after surgery. This procedure may either target the chest
after mastectomy, or the armpit (axilla) and the surrounding area to kill any
cancer cells that may be present in the lymph nodes. The treatment begins after
surgery or chemotherapy, about a month, to allow the body to recover.

MASTECTOMY: TOTAL OR PARTIAL (LUMPECTOMY)

● Based on the assessment stated earlier, the patient has stage 3B breast cancer
and axillary and infraclavicular lymph nodes are also affected. With that, surgery
is suggested as the first treatment for the patient. Mastectomy is a surgery that
involves removal of the breast. There are several types of mastectomy but
according to the NCCN, there are only two options considering her Stage
classification of breast cancer–a total mastectomy or a lumpectomy are the
recommended types for invasive breast cancer. Lumpectomy involves the
removal of the tumor only. For Lumpectomy, it is recommended with axillary
lymph node (ALN) staging, meaning a preoperative node evaluation must be
done prior to surgery. Since according to the result, the patient is positive for
metastatic adenocarcinoma in left axillary and infraclavicular lymph nodes, a
whole breast radiation therapy is needed. Chemotherapy might be given prior to
radiation therapy. On the other hand, total mastectomy involves the removal of
the whole breast and some of the affected lymph nodes. Again, radiation therapy
is needed and chemotherapy might be given prior to radiation therapy. The
 survival rate between these two options is the same. The preferences, feelings
and priorities of the patient should also be considered.

Systemic Treatment
ADJUVANT ENDOCRINE THERAPY-HORMONAL THERAPY
Systemic therapy for HER2

Drug Rationale DF/DOA Dose Duration of Reference

Therapy

Letrozole Most PO 2.5 mg 5 years NCCN

(Aromatase effective Guidelines for
inhibitor) aromatase Patients
inhibitor in Invasive
the first-line Breast
advanced Cancer, 2020
breast
cancer
setting.

ADJUVANT CHEMOTHERAPY
● Systemic adjuvant treatment options: ER+ and/or PR+ with HER2- and node+
○ Chemotherapy followed by endocrine therapy
Systemic Therapy for HER2-

Drug Rationale DF/DOA Dose Duration of Reference

Therapy

Paclitaxel Adjuvant IV 175 mg/m2 For 3 hours, NCCN

treatment of cycled every Guidelines for
node-positiv 14 days for Patients
e breast 4 cycles Invasive
cancer. Breast
Cancer, 2020

Doxorubicin Slows down IV 60 mg/m2 Cycled NCCN

the growth of every 14 Guidelines for
cancer cells days for 4 Patients
days cycles Invasive
Breast
Cancer, 2020

Cyclophosph Prevents IV 600 mg/m2 Cycled NCCN

amide cancer cells every 14 Guidelines for
from diving days for 4 Patients
days cycles Invasive
Breast
Cancer, 2020
NON PHARMACOLOGICAL TREATMENT
● Exercise - It may aid in weight control, immunity, and mood regulation, as well as
improving fitness throughout traditional cancer treatments.
● Diet - Diets high in fruits and vegetables, fish, fresh foods, low in animal fat, and high in
olive oil may reduce the risk of breast cancer and many other cancers.. Avoid diets high
in fats and low in fruits and vegetables that may increase risk.
● Supplements - Chemotherapy and adjuvant endocrine agents are associated with
vitamin D deficiency which can result in osteoporosis, weakness, low back pain, and
sternal pain. So, to restore adequate amounts of vitamin D in the body, supplements or
food-containing Vitamin D is one of the ways to fight the deficiency. In addition,
Melatonin has antioxidant, immune enhancing, cytotoxic, and estrogen regulating
properties and it can help in the treatment of insomnia.
● Spiritual and Emotional Care - Psychological therapies for breast cancer patients
supervised by a psychologist and focusing on stress management and ways to maximize
conventional therapy and enhance mood helped reduce recurrence and death.

PATIENT COUNSELING - Cerda, Allyzon

Total mastectomy
❖ For pain management, a prescription vicodin will be given and should be taken for a
regular schedule. Drug allergies, reactions, or medical problems should be notified to the
physician.Vicodin is a narcotic and should not be taken with alcoholic drinks. Do not use
narcotics while driving.
❖ Do not remove the dressing, steri-strips or stitches. It will be removed in seven to 10
days. The sutures will also be removed in one to two weeks unless they absorb on their
own. If the dressing or steri-strips fall off, do not attempt to replace them.
❖ Until the stitches are removed, avoid rigorous activities, heavy lifting, and vigorous
exercise. Tell your caregiver what you do, and he or she will assist you in developing a
personalized plan for "what you can do when" following surgery.
❖ After you've recovered from anesthesia and are able to consume fluids, you can resume
your regular diet.We recommend drinking eight to ten glasses of water and
non-caffeinated beverages every day, as well as eating lots of fruits and vegetables and
avoiding high-fat foods.

Radiation therapy
❖ Towels and sheets should be washed separately from the rest of the household's
laundry.
❖ To avoid splashing bodily waste, sit down when using the toilet.
❖ After each use, flush the toilet twice more and thoroughly wash your hands.
❖ Towels and utensils should be kept separate.
❖ Drink plenty of water to remove the radioactive particles from your system.
❖ No kissing or sexual contact is permitted (often for at least a week).
❖ Keep a safe distance from your family members.You may be instructed to maintain a
distance of one arm's length, or possibly six feet, between yourself and others for a set
 period of time. You may also be instructed to sleep in a different bed in a different room
for a certain number of nights. The type of treatment you receive will determine this.
❖ For a set period of time, avoid contact with newborns, children, and pregnant women.
❖ For a set period of time, avoid contact with pets.
❖ For a set period of time, avoid taking public transportation.
❖ Plan to spend a certain amount of time away from work, school, and other activities.

Adjuvant Endocrine Therapy

❖ Read the manufacturer's printed information sheet from within the pack before beginning
this treatment. The pamphlet will provide you with additional information on tamoxifen as
well as a complete list of potential side effects.
❖ Take one 20 mg tamoxifen pill every day twice a day or as directed by your doctor. Your
dose will also be printed on the pack's label as a reminder.
❖ Tamoxifen can be taken at any time of day that is convenient for you, but try to take your
dosages at the same time each day. This will ensure that you do not miss any dosages.
Tamoxifen can be taken before, during, or after meals.
❖ If you miss taking a dose, remember to do so as quickly as possible. If you don't
remember until the next day that you missed a dose, skip it. To make up for a missed
dose, do not combine two doses.

Adjuvant Chemotherapy
Paclitaxel
❖ An allergic reaction is possible. If you get a fever, chills, chest pain, difficulty breathing,
itching, rash, or feel dizzy, call your doctor or nurse straight away. Before you start
paclitaxel, you will be given medicines to prevent this from happening. Before receiving
paclitaxel, you may be requested to take dexamethasone (a steroid) at home.
❖ While taking this medication, your blood pressure may drop and your heart rate may
slow. This normally returns to normal by itself.
❖ Please notify your nurse if you have any burning or tingling near your IV. If you
experience any swelling or redness after returning home, please contact your doctor or
nurse.
Doxorubicin
❖ Make sure you notify your doctor about any other medications you're taking before
commencing Doxorubicin treatment (including over-the-counter, vitamins, or herbal
remedies)
❖ While taking Doxorubicin, do not get any vaccinations without first consulting your doctor.
❖ Both men and women should use contraception to avoid becoming pregnant while taking
Doxorubicin. While taking Doxorubicin, barrier contraception such as condoms is
recommended.
Cyclophosphamide
❖ If you are allergic to cyclophosphamide or any other drugs, tell your doctor and
pharmacist.
❖ Tell your doctor and pharmacist about all of your prescription and nonprescription
medications, particularly aspirin and vitamins.
 ❖ If you have or have ever had kidney disease, tell your doctor. The cyclophosphamide
dose may need to be changed.
❖ Cyclophosphamide can disrupt a woman's menstrual cycle and stop sperm production in
men. It can also result in infertility that is permanent. However, you should not assume
that you or someone else is incapable of becoming pregnant. To avoid pregnancy, use a
reliable method of birth control, as cyclophosphamide can harm the fetus.
❖ If you're taking cyclophosphamide, stay hydrated because the drug can irritate your
kidneys and bladder.
❖ Cyclophosphamide has been linked to the development of cancer in some people.
Consult your doctor about your chances of developing cancer.

PROBLEM IDENTIFICATION - Deldio, Veronica Lourds

1.a. Create a list of potential drug therapy problems in the patient’s medication regimen.
● Drug interactions between the current medication and the one that was being
used previously:
➔ When taken combined, Neurontin and Ambien may increase the risk of
experiencing side effects such as sleepiness, dizziness, confusion, and trouble
focusing.
➔ In rare cases, taking Neurontin and Zoloft together might bring on a disease
known as hyponatremia, which is characterized by abnormally low amounts of
sodium in the blood.
➔ When taken together, Neurontin and Darvon have the potential to cause
depression in the central nervous system.
● A medication with no particular indication:
➔ Pepcid: since the patient's abdomen examination was normal, it is not required
for the patient to take this prescription.
● ​According to the Food and Drug Administration of the United States (FDA), the narcotic
painkiller known as Darvon has been prohibited and taken off the market because of the
harmful effects it has on the heart, which can lead to lethal heart rhythms.

1.b. Given this clinical information, what is this patient’s clinical stage of breast cancer?
According to the clinical data, the patient is currently in Stage IIIC of their breast cancer. The
following are some examples of patient data:
● For the patient's diagnostic bilateral mammogram, a mass with a high density and an
uneven size, measuring 2.2 centimeters in diameter and with indistinct margins
● A fine needle aspiration (FNA) was performed on the lymph nodes located in the left
axillary and infraclavicular regions. Results to metastatic adenocarcinoma consistent
with breast primary
● The ultrasound of the liver indicates that there are no distant metastases.

DESIRED OUTCOME
2.a What is the primary goal for cancer treatment in this patient? - Deldio, Veronica Lourds
 ● Treatment and medications aimed at curing the illness, extending patients' lives,
enhancing their quality of life, relieving the patient's symptoms, and preventing
complications

2.b. What is the prognosis for this patient based on tumor size and nodal status? - Deldio,
Veronica Lourds
● As a result of the tumor's characteristics and its nodal status, the prognosis is as follows:
T2N3M0. In cases when the maximum dimension of the tumor is greater than 20
millimeters but less than 50 millimeters, the metastases are found in the ipsilateral
infraclavicular lymph nodes, and there is no clinical or radiological indication of distant
metastases.

2.c. In addition to the stage of disease, what other factors are important for determining the
prognosis for breast cancer? - Contreras, Alianna Irish
Factors that affect prognosis and treatment for early and locally advanced breast cancer
are considered together, rather than alone. They include:
● Lymph node status
● Tumor size
● Tumor grade
● Type of tumor (how the cancers cells look under a microscope)
● Hormone receptor status (estrogen and progesterone receptor status)
● HER2 status
● Proliferation rate
● Tumor profiling score:
○ Oncotype DX®
○ MammaPrint®
○ PAM50 (Prosigna®)

THERAPEUTIC ALTERNATIVES - Corsiga, April Jomerlynn

3. List the treatment modalities available for this patient’s breast cancer, and discuss their
advantages and disadvantages.

Alternative for Radiation Advantage/s Disadvantage/s

Therapy

● fewer side effects and ● More expensive than

complications than traditional radiation
conventional radiation therapy
therapy ● Only a few medical
● proven clinical centers are offering
Proton Therapy outcomes for many this therapy in the
cancers Philippines
● improved quality of life
 during and after
treatment because of
fewer side effects
● ability to treat (and
possibly cure) patients
who have failed X-ray
therapy

Alternative for Mastectomy Advantage/s Disadvantages

● No difference in either Risks:

● Recurrence of cancer
Breast Conservation
overall survival or ● Short-term
long-term (temporary) breast
disease-free survival swelling.
when compared with ● A change in the size
mastectomy and shape of the
breast.
in the breast has been ● Hardness due to scar
seen in 3% to 17% of tissue that can form at
the patients in the the incision site.
randomized studies ● Wound infection or
bleeding.
● Swelling
(lymphedema) of the
arm, if lymph nodes
were removed.

Drug Alternative

Paclitaxel Nab-paclitaxel

Advantage/s:
● More effective
● Almost double the response rate
● Increased time to disease progression
● Increased survival in second-line
patients.

Disadvantage/s:
● More expensive
● Not available in the Philippines

Doxorubicin Epirubicin

Advantage/s:
 ● Same efficacy as doxorubicin

Disadvantages:
● Has a different toxicity profile
particularly in regard to cardiotoxicity

OPTIMAL PLAN - Cruz, Moira Patrice

4.Design an a​​ppropriate plan for treating this patient’s breast cancer, focusing on pharmacologic
and nonpharmacologic measures. If the plan includes chemotherapy, identify a specific regimen,
and provide your rationale for selecting it.

PHARMACOLOGICAL PLAN
● Mastectomy (Total or Partial) - Mastectomy is a surgery that involves removal of the
breast. There are several types of mastectomy but according to the NCCN, there are
only two options considering her Stage classification of breast cancer–a total
mastectomy or a lumpectomy are the recommended types for invasive breast cancer.
Lumpectomy involves the removal of the tumor only. For Lumpectomy, it is
recommended with axillary lymph node (ALN) staging, meaning a preoperative node
evaluation must be done prior to surgery. Since according to the result, the patient is
positive for metastatic adenocarcinoma in left axillary and infraclavicular lymph nodes, a
whole breast radiation therapy is needed. Chemotherapy might be given prior to
radiation therapy. On the other hand, total mastectomy involves the removal of the whole
breast and some of the affected lymph nodes. Again, radiation therapy is needed and
chemotherapy might be given prior to radiation therapy.
● Total mastectomy - Total Mastectomy involves the removal of the whole breast and
some of the affected lymph nodes. Again, radiation therapy is needed and chemotherapy
might be given prior to radiation therapy.
● Radiation therapy - As mentioned, surgery may be followed by radiation therapy,
especially if the patient had lumpectomy. Radiotherapy is recommended to kill any
remaining cancer cells after surgery using controlled doses of radiation, thus, reducing
the risk of the recurrence in the breast, chest area or lymph nodes after surgery. This
procedure may either target the chest after mastectomy, or the armpit (axilla) and the
surrounding area to kill any cancer cells that may be present in the lymph nodes. The
treatment begins after surgery or chemotherapy, about a month, to allow the body to
recover.

Drug Rationale DF/DOA Dose Duration of Reference

Therapy
Letrozole Most PO 2.5 mg daily 5 years NCCN
(Aromatase effective Guidelines for
inhibitor) aromatase Patients
inhibitor in Invasive
the first-line Breast
advanced Cancer, 2020
breast cancer
setting.

Anastrozole Stops PO 1 mg daily 5 years NCCN

(Aromatase hormone Guidelines for
inhibitor) androgen Patients
from Invasive
changing into Breast
estrogen Cancer, 2020

Paclitaxel Adjuvant IV 175 mg/m2 For 3 hours, NCCN

treatment of cycled every Guidelines for
node-positive 14 days for Patients
breast 4 cycles Invasive
cancer. Breast
Cancer, 2020

Doxorubicin Slows down IV 60 mg/m2 Cycled NCCN

the growth of every 14 Guidelines for
cancer cells days for 4 Patients
days cycles Invasive
Breast
Cancer, 2020

Cyclophosphami Prevents IV 600 mg/m2 Cycled NCCN

de cancer cells every 14 Guidelines for
from diving days for 4 Patients
days cycles Invasive
Breast
Cancer, 2020

NON PHARMACOLOGICAL TREATMENT

● Exercise - It may aid in weight control, immunity, and mood regulation, as well as
improving fitness throughout traditional cancer treatments.
● Diet - Diets high in fruits and vegetables, fish, fresh foods, low in animal fat, and high in
olive oil may reduce the risk of breast cancer and many other cancers.. Avoid diets high
in fats and low in fruits and vegetables that may increase risk.
● Supplements - Chemotherapy and adjuvant endocrine agents are associated with
vitamin D deficiency which can result in osteoporosis, weakness, low back pain, and
sternal pain. So, to restore adequate amounts of vitamin D in the body, supplements or
food-containing Vitamin D is one of the ways to fight the deficiency. In addition,
 Melatonin has antioxidant, immune enhancing, cytotoxic, and estrogen regulating
properties and it can help in the treatment of insomnia.
● Spiritual and Emotional Care - Psychological therapies for breast cancer patients
supervised by a psychologist and focusing on stress management and ways to maximize
conventional therapy and enhance mood helped reduce recurrence and death.

PATIENT COUNSELING/PATIENT EDUCATION - Cerda, Allyzon

Total mastectomy
❖ For pain management, a prescription vicodin will be given and should be taken for a
regular schedule. Drug allergies, reactions, or medical problems should be notified to the
physician.Vicodin is a narcotic and should not be taken with alcoholic drinks. Do not use
narcotics while driving.
❖ Do not remove the dressing, steri-strips or stitches. It will be removed in seven to 10
days. The sutures will also be removed in one to two weeks unless they absorb on their
own. If the dressing or steri-strips fall off, do not attempt to replace them.
❖ Until the stitches are removed, avoid rigorous activities, heavy lifting, and vigorous
exercise. Tell your caregiver what you do, and he or she will assist you in developing a
personalized plan for "what you can do when" following surgery.
❖ After you've recovered from anesthesia and are able to consume fluids, you can resume
your regular diet.We recommend drinking eight to ten glasses of water and
non-caffeinated beverages every day, as well as eating lots of fruits and vegetables and
avoiding high-fat foods.

Radiation therapy
❖ Towels and sheets should be washed separately from the rest of the household's
laundry.
❖ To avoid splashing bodily waste, sit down when using the toilet.
❖ After each use, flush the toilet twice more and thoroughly wash your hands.
❖ Towels and utensils should be kept separate.
❖ Drink plenty of water to remove the radioactive particles from your system.
❖ No kissing or sexual contact is permitted (often for at least a week).
❖ Keep a safe distance from your family members.You may be instructed to maintain a
distance of one arm's length, or possibly six feet, between yourself and others for a set
period of time. You may also be instructed to sleep in a different bed in a different room
for a certain number of nights. The type of treatment you receive will determine this.
❖ For a set period of time, avoid contact with newborns, children, and pregnant women.
❖ For a set period of time, avoid contact with pets.
❖ For a set period of time, avoid taking public transportation.
❖ Plan to spend a certain amount of time away from work, school, and other activities.

Adjuvant Endocrine Therapy

 ❖ Read the manufacturer's printed information sheet from within the pack before beginning
this treatment. The pamphlet will provide you with additional information on tamoxifen as
well as a complete list of potential side effects.
❖ Take one 20 mg tamoxifen pill every day twice a day or as directed by your doctor. Your
dose will also be printed on the pack's label as a reminder.
❖ Tamoxifen can be taken at any time of day that is convenient for you, but try to take your
dosages at the same time each day. This will ensure that you do not miss any dosages.
Tamoxifen can be taken before, during, or after meals.
❖ If you miss taking a dose, remember to do so as quickly as possible. If you don't
remember until the next day that you missed a dose, skip it. To make up for a missed
dose, do not combine two doses.

Adjuvant Chemotherapy
Paclitaxel
❖ An allergic reaction is possible. If you get a fever, chills, chest pain, difficulty breathing,
itching, rash, or feel dizzy, call your doctor or nurse straight away. Before you start
paclitaxel, you will be given medicines to prevent this from happening. Before receiving
paclitaxel, you may be requested to take dexamethasone (a steroid) at home.
❖ While taking this medication, your blood pressure may drop and your heart rate may
slow. This normally returns to normal by itself.
❖ Please notify your nurse if you have any burning or tingling near your IV. If you
experience any swelling or redness after returning home, please contact your doctor or
nurse.
Doxorubicin
❖ Make sure you notify your doctor about any other medications you're taking before
commencing Doxorubicin treatment (including over-the-counter, vitamins, or herbal
remedies)
❖ While taking Doxorubicin, do not get any vaccinations without first consulting your doctor.
❖ Both men and women should use contraception to avoid becoming pregnant while taking
Doxorubicin. While taking Doxorubicin, barrier contraception such as condoms is
recommended.
Cyclophosphamide
❖ If you are allergic to cyclophosphamide or any other drugs, tell your doctor and
pharmacist.
❖ Tell your doctor and pharmacist about all of your prescription and nonprescription
medications, particularly aspirin and vitamins.
❖ If you have or have ever had kidney disease, tell your doctor. The cyclophosphamide
dose may need to be changed.
❖ Cyclophosphamide can disrupt a woman's menstrual cycle and stop sperm production in
men. It can also result in infertility that is permanent. However, you should not assume
that you or someone else is incapable of becoming pregnant. To avoid pregnancy, use a
reliable method of birth control, as cyclophosphamide can harm the fetus.
❖ If you're taking cyclophosphamide, stay hydrated because the drug can irritate your
kidneys and bladder.
 ❖ Cyclophosphamide has been linked to the development of cancer in some people.
Consult your doctor about your chances of developing cancer.

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