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Breast Cancer ManagementAka: Breast Cancer Systemic Therapy, Breast Cancer Adjuvant Therapy

Surgical Management
1. Breast Lumpectomy with Breast Radiation
2. Mastectomy
3. Breast Reconstruction
Chemotherapy
1. Indications
  1. Most beneficial
    1. Lymph node involvement
    2. Primary Breast Cancer larger than 1 cm
  2. Questionable benefit
    1. Age over 70 years
    2. Small, node-negative Breast Cancers
    3. Favorable histologic subtypes
      1. Tubular cancers
      2. Mucinous cancers
2. Protocols
  1. Protocols with Anthracycline most effective
  2. CMF Chemotherapy Protocol (best tolerated)
  3. AC Chemotherapy Protocol
Hormonal Manipulation (Estrogen inhibition)
1. Indications
  1. Hormone receptor positive
  2. Progesterone receptor positive (possible benefit)
  3. Hormone receptor indeterminate
2. Protocols
  1. Estrogen receptor blockade (e.g. Tamoxifen)
    1. Usually taken for first 5 years after diagnosis
    2. Reduces risk of cancer recurrence by 47%
  2. Suppress Estrogen synthesis
    1. Pre-Menopause
      1. Estrogen receptor blockade (Tamoxifen) as above
      2. LHRF agonist (e.g. Goserelin)
    2. Post-Menopause: Aromatase inhibitor
      1. Agents: Arimidex, Femara, Aromasin
      2. Start after Tamoxifen discontinued
      3. Osteoporosis risk (see Osteoporosis Prevention)
      4. Not as effective in premenopausal women
  3. Ovarian ablation
    1. Surgical oophorectomy
    2. Radiation therapy
Transplantation
1. Bone Marrow Transplantation
  1. Likely to be replaced by Stem Cell Transplant
2. Stem Cell Transplantation
Monoclonal Antibody
1. Herceptin (trastuzumab) for metastatic Breast Cancer
  1. Improves survival for overexpressors of HER2 gene
2. References
  1. Slamon (2001) N Engl J Med 344:783
  2. Smith (2007) Lancet 369:29
References
1. (2000) NIH Consensus Guidelines
  1. http://consensus.nih.gov

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This page was written by Scott Moses, MD, and was last revised 1/13/2008. Please send comments and questions to the editor. Contact information may be found on the page About the Family Practice Notebook. These pages are best viewed with Microsoft Internet Explorer 5.0.