Breast Cancer Management

Aka: Breast Cancer Management, Breast Cancer Systemic Therapy, Breast Cancer Adjuvant Therapy, Hormonal Management of Breast Cancer, Estrogen Inhibition in Breast Cancer Recurrence Prevention

II. Management

  1. Stage 0 Lobular Carcinoma in-situ
    1. No treatment needed (biopsied lesion will not progress)
    2. Increased risk of subsequent Breast Cancer development
      1. Consider Tamoxifen for prophylaxis
  2. Stage 0 Ductal Carcinoma in-situ
    1. Breast-Conserving Surgery and Breast radiation or
    2. Mastectomy (if extensive involvment or multifocal involvement)
  3. Stage I and II
    1. Breast-Conserving Surgery
    2. Breast radiation
    3. Sentinel lymph node biopsy or axillary lymph node sampling
    4. Chemotherapy (except in tumor <1 cm and node negative)
    5. Hormone therapy if Estrogen-receptor positive
    6. Trastuzumab (Herceptin) if ERBB2 overexpression
  4. Stage III Non-inflammatory
    1. Induction Chemotherapy (precedes resection)
    2. Breast-Conserving Surgery
    3. Breast radiation
    4. Sentinel lymph node biopsy or axillary lymph node sampling
    5. Hormone therapy if Estrogen-receptor positive
    6. Trastuzumab (Herceptin) if ERBB2 overexpression
  5. Stage III Inflammatory
    1. Induction Chemotherapy (precedes resection)
    2. Mastectomy
    3. Axillary lymph node sampling
  6. Stage IV Metastatic Breast Cancer
    1. Per patient wishes
    2. Consider palliative Radiation Therapy for pain
    3. Consider Bisphosphonates for bone pain
    4. Consider Chemotherapy
    5. Hormone therapy if Estrogen-receptor positive
    6. Trastuzumab (Herceptin) if ERBB2 overexpression
  7. Recurrent Breast Cancer - Local involvement after Breast-Conserving Surgery
    1. Mastectomy
    2. Axillary lymph node sampling
    3. Chemotherapy
    4. Hormone therapy if Estrogen-receptor positive
    5. Trastuzumab (Herceptin) if ERBB2 overexpression
  8. Recurrent Breast Cancer - Local involvement after Mastectomy
    1. Wide excision
    2. Axillary lymph node sampling
  9. Recurrent Breast Cancer - inoperable
    1. Induction Chemotherapy
    2. Axillary lymph node sampling

III. Management: Surgical

  1. Breast Lumpectomy with Breast Radiation
  2. Mastectomy
  3. Breast Reconstruction

IV. Management: Chemotherapy

  1. Indications
    1. Most beneficial
      1. Lymph node involvement
      2. Primary Breast Cancer larger than 1 cm
      3. Hormone receptor negative Breast Cancer
    2. Questionable benefit
      1. Age over 70 years
      2. Small, node-negative Breast Cancers (<1 cm)
      3. Favorable histologic subtypes
        1. Tubular cancers
        2. Mucinous cancers
  2. Anthracyclines
    1. Doxorubicin (Adriamycin) IV q14-21 days for 4-6 cycles
      1. Combined with Taxane (Docetaxel or Paclitaxel), and cyclophosphamide and/or fluorouracil
    2. Epirubicin (Ellence) every 21-28 days for 3-8 cycles
      1. Combined with cyclophosphamide or fluorouracil
  3. Taxanes
    1. Docetaxel IV every 21 days for 3-4 cycles
      1. Combined with anthracycline (doxorubicin or epirubicin), and cyclophosphamide and/or fluorouracil
    2. Paclitaxel IV every 7-21 days for 4-12 cycles
      1. Combined with doxorubicin and cyclophosphamide

V. Management: Hormonal Manipulation (Estrogen inhibition)

  1. Indications: Suppress Estrogen synthesis
    1. Hormone receptor positive
    2. Progesterone receptor positive (possible benefit)
    3. Hormone receptor indeterminate
  2. Protocol: Pre-Menopause
    1. Tamoxifen
      1. Selective Estrogen Receptor Modulator (SERM)
      2. Tamoxifen 20 mg orally daily (generic)
      3. Usually taken for first 5 years after diagnosis (2 years in some cases)
      4. May be followed by Aromatase inhibitor
      5. Adverse effects
        1. Venous Thromboembolism (NNH 200)
        2. Endometrial Cancer (NNH 250)
        3. Cataracts (NNH 38)
      6. Efficacy
        1. Reduces risk of cancer recurrence by 47%
        2. NNT 142 to prevent 1 case of invasive Breast Cancer after taking for 5 years
    2. Gonadotropin-releasing Hormone Agonist (LHRF agonist)
      1. Agent: Goserelin (Zoladex) SQ q1-3 months for 2 years
  3. Protocol: Post-Menopause
    1. Raloxifene
      1. Selective Estrogen Receptor Modulator (SERM)
      2. Raloxifene 60 mg orally daily
      3. Efficacy
        1. NNT 111 to prevent 1 case of invasive Breast Cancer after taking for 5 years
      4. Adverse Effects
        1. Venous Thromboembolism Risk (as with Tamoxifen)
        2. Lowers Osteoporosis risk and does not increase risk of Endometrial Cancer
    2. Aromatase inhibitor
      1. Agents (typically taken for 5 years, may be as short as 2 years in some cases)
        1. Anastrozole (Arimidex) 1 mg orally daily (generic)
        2. Letrozole (Femara) one tablet daily
        3. Exemestane (Aromasin) 25 mg orally daily
      2. Efficacy
        1. NNT 63 to prevent 1 case of invasive Breast Cancer after taking for 5 years
      3. Adverse Effects
        1. Osteoporosis (decreases Bone Mineral Density)
        2. Possible increased cardiovascular disease risk including CVA risk
      4. Consider as sequential treatment with aromatase inhibitor after Tamoxifen discontinued
      5. Osteoporosis risk (see Osteoporosis Prevention)
      6. Avoid in premenopausal women
        1. Osteoporosis risk
        2. Risk of Ovulation stimulation and higher risk of pregnancy
        3. Not as effective as in postmenopausal women

VI. Management: Monoclonal Antibody

  1. Trastuzumab (Herceptin)
    1. Herceptin IV given with first dose of Chemotherapy and then every 1-3 weeks for 1 year
    2. Indicated for Her-2_neu positive, ERBB2 overexpressing patients with metastatic Breast Cancer
    3. Improves survival for overexpressors of HER2 gene
  2. References
    1. Slamon (2001) N Engl J Med 344:783-92 [PubMed]
    2. Smith (2007) Lancet 369:29-36 [PubMed]

VII. Resources

  1. Adjuvant! for Breast Cancer
    1. http://www.adjuvantonline.com
    2. Predicts prognosis and allows comparison of various adjuvant interventions in terms of outcome

VIII. References

  1. (2019) Presc Lett 26(11): 65
  2. (2000) NIH Consensus Guidelines
    1. http://consensus.nih.gov
  3. Golhirsch (2007) Ann Oncol 18(7): 1133-44 [PubMed]
  4. Maughan (2010) Am Fam Physician 81(11): 1339-46 [PubMed]

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