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Chief Complaint

“I found this painless lump”

History of Present Illness

Our patient is a 65-year-old female who inadvertently identified an immobile mass in their right Breast. Upon workup, it is clear that the patient has locally advanced (Stage IIIA) HER2+, HR-, PR - breast cancer and is eager to begin treatment.

Student Work-Up

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Missing Information?


Patient Database

Drug Therapy Problems

Care Plan (by Problem)


  1. List the risk factors that increase a patient’s risk for developing breast cancer. Which of these are exhibited by our patient?

    Hint: See Epidemiology and Etiology in PPP

  2. Distinguish and list the prognostic factors that our patient exhibits and whether they are Good or Poor prognostic factors? How would SR, a 32-year-old woman with Stage 1 breast cancer, (1.5 cm tumor and node negative), demonstrating a Luminal A pattern including ER+, PR+, HER2- disease with poorly differentiated tumor, compare to our patient in prognosis?

    Hint: See Clinical Presentation and Diagnosis in PPP

  3. What are the dose-limiting, common toxicities, and counseling points for anthracyclines, alkylating agents, taxanes, platinum agents and HER2 targeted agents (trastuzumab, pertuzumab and ado-trastuzumab)?

    Hint: See Early Breast Cancer Treatment and Table 89-5 in PPP; Platinum agents and HER2 therapies may require review in tertiary drug references

  4. After neoadjuvant therapy has been completed and the final surgery has been performed, how would therapy recommendations in the adjuvant setting differ based on the presence or absence of breast cancer within the residual tissue (positive or negative for residual disease)? What counseling points might help a patient make an informed decision regarding adjuvant therapy?

    Hint: See Table 90-5 and Metastatic Breast Cancer (Stage IV) Treatment in PPP, “Outcome evaluation” and “Locally advanced breast cancer treatment - Pharmacologic Therapy”; See references #28 in PPP breast cancer chapter (von Minckwitz et al)

  5. Would our patient be a candidate for other adjuvant treatments to further reduce their overall recurrence risk, with therapies such as:

    A) Anti-hormonal therapies? Why?

    B) Bone resorption inhibiting agents? Why?

    Hint: See Locally Advanced Breast Cancer Treatment and Metastatic Breast Cancer (Stage IV) Treatment in PPP


Ten years after initial presentation, and long after completion of any adjuvant therapies, the patient begins to experience deep pains (level 4/10) she describes as bone pain in her hips, and lower back. Imaging demonstrates lytic bone lesions, and inadvertently discovers small liver lesions. Pathologic evaluation confirms a diagnosis of metastatic breast cancer; however, the tumor has a different phenotype from her original primary, now expressing a HER2-, HR+, PR+ immunohistochemistry profile. The patient’s labs are grossly within normal limits and no severe symptoms are present.


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