Breast Cancer Treatment Protocols Flashcards
Localized disease - What stage?
0, I, II, IIIA.
In the USA and other developed nations where screening is performed, most patients present with …?
Localized BC that is detected by a screening mammogram.
Less commonly, pts present with a palpable mass that is either self-detected or detected by a health care provider.
Stage 0 - LCIS - Management includes:
- Surveillance alone (ie, mammography).
- Surveillance plus raloxifene (for postmenopausal women).
- Tamoxifen (for women of any menopausal status).
- Bil proph mastectomy (usually in patients who are very concerned about breast cancer risk and have either a strong family history of 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 INV CA or DCIS that requires additional local or systemic Tx.
LCIS - Surgical excision?
Surgical excision to NEGATIVE MARGINS is NOT indicated.
LCIS is a/w about a …?
5% 5y risk.
+ 20-30% lifetime risk of developing inv BC.
==> which may be ipsilateral/contralateral and may be ductal/lobular in origin.
PLEOMORPHIC LCIS:
Is a LCIS variant that warrants special consideration.
***Tx should include excision to NEGATIVE MARGINS.
Stage 0 - DCIS - Primary Tx options include:
- Lumpectomy without axillary assessment, + whole-breast RT.
* Use of radiation boost (photons, brachytherapy, or electron beam) to the tumor bed is recommended, especially in pts age >50y. - Total mastectomy +/- SNLB +/- Breast reconstruction.
- Lumpectomy without LN surgery and without RT (lower-level evidence).
Stage 0 - DCIS - Considerations include the following:
- Although ALND or SLNB is often NOT performed, SLNB 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 <50y), SOME pts may NOT receive RT.
- Consider risk-reduction therapy with tamoxifen for 5y for pts treated with lumpectomy and RT, especially those with ER(+) DCIS.
Stage I, IIA, IIB, or IIIA (T3N1M0) - Tx for these stages of BC include the following:
- Sx.
- RT in most cases.
- Adjuvant chemo, endocrine therapy, or biologic therapy in some cases.
Stage I, IIA, IIB, or IIIA (T3N1M0) - Sx options include:
- Lumpectomy to (-)margins + RT.
- Mastectomy.
- Mastectomy with reconstruction.
Axillary assessment is usually performed with …?
SLNB.
ALND may be considered in cases of (+)node BC.
Stage I, IIA, IIB, IIIA (T3N1M0) - RT is used in …?
Pts who undergo lumpectomy or, in selected cases, after mastectomy;
==> Tx fields are determined by axillary node status.
**RT should FOLLOW chemo, if chemo is indicated.
Pts undergoing lumpectomy with surgical axillary staging - RT recommendations are based on the pts axillary node status, as follows:
4 or more nodes ==> Whole-breast RT +/- boost to the tumor bed +/- to the infraclavicular and supraclavicular areas should also be considered.
1-3 nodes ==> Whole-breast RT +/- boost to the tumor bed +/- to the infraclavicular and supraclavicular areas should be considered + as should RT to internal mammary nodes.
(-)Nodes ==> Whole-breast RT +/- boost to the tumor bed.
*partial breast irradiation (PBI) may be considered in selected pts.
Pts undergoing total mastectomy with surgical axillary staging, +/- reconstruction - RT recommendations are based on the pts axillary node status, as follows:
4 or more nodes ==> Post-chemo RT to the chest wall + the infra/supraclavicular areas. Consider RT to internal mammary nodes.
1-3 nodes ==> Consider post-chemo RT to the chest wall +/- the infra/supraclavicular areas. Consider RT to internal mammary nodes.
Negative nodes, tumor <5cm, margins <1mm ==> Post-chemo RT to the chest wall is recommended.
Negative nodes, tumor <5cm, margins >1mm ==> NO RT IS NEEDED (!).
Pts with large, clinical stage IIA, IIB, IIIA (T3N1M0) tumors:
PRE-op chemo should be considered in these pts if they have any of the following:
- T3-T4.
- (+)Nodes.
- ER(-).
- HER2(+).
- Tumors that need downsizing for Sx.
***If the pt has clinically (-)nodes, consider SLNB.
***If the pt has clinically (+)nodes, consider a core Bx or FNA, then SLNB if FNA or core Bx is negative.
Chemo regimens are as follows:
TAC ==> Docetaxel (Taxotere) + Doxo + Cyclophos /3wk for 6 cycles.
Dose-dense ACP ==> Doxo + Cyclo /2wk for 4 cycles. Followed by PACLITAXEL with CSF support.
AC ==> Doxo + Cyclo /3wk for 4 cycles (comparable to CMF).
TC ==> Docetaxel + Cyclo /3wk for 4 cycles.
For HER2(+) tumors, the following NEOadjuvant regimen is administered every 3wk for 3-6 cycles:
Pertuzumab (Perjeta) + Trastuzumab + Docetaxel
Adjuvant chemotherapy - HER2(+) localized disease - Stage I, IIA, IIB, IIIA (T3N1M0):
Anti-HER2 directed therapy is indicated for use + CHEMO in pts with HER2(+) disease.
Tx considerations regarding trastuzumab:
- CURRENTLY, the ONLY anti-HER2 shown to REDUCE RECURRENCE.
- In studies of trastuzumab, pts were randomly assigned to receive chemo alone or + trastuzumab.
- Overlapping trastuzumab Tx with TAXANE Tx ==> Suggested to be more effective than a strategy of completing all chemo first AND THEN administering trastuzumab.
- Trastuzumab cannot be given CONCURRENTLY with anthracyclines, because of the high risk of cardiotoxicity.
Adjuvant chemotherapy - HER2(+) localized disease - Stage I, IIA, IIB, IIIA (T3N1M0) - NON-trastuzumab regimens:
TAC ==> Docetaxel + Doxo + Cyclo /3wk for 6cycles.
Dose-dense ACP ==> Doxo + Cyclo /2wk for 4cycles ==> Followed by PACLITAXEL /2wk + CSF support.
AC ==> Doxo + Cyclo /3wk for 4 cycles (comparable to CMF).
TC ==> Docetaxel + Cyclo /3wk for 4 cycles.
Adjuvant chemotherapy - HER2(+) localized disease - Stage I, IIA, IIB, IIIA (T3N1M0) - Trastuzumab-containing regimens:
- AC-PACLITAXEL-TRASTUZUMAB:
==> Doxo + Cyclo /3wk ==> Followed by paclitaxel /wk for 12 cycles OR /3wk for 4 cycles CONCURRENTLY with trastuzumab ==> Followed by trastuzumab /3wk for 14 doses, for 1y.
- AC-DOCETAXEL-TRASTUZUMAB:
Doxo + Cyclo /3wk for 4 cycles ==> Followed by docetaxel /3wk for 4 cycles given CONCURRENTLY with trastuzumab for 12wks ==> Followed by trastuzumab /3wk to complete the 1y.
- TCH:
Docetaxel + Carboplatin /3wk for 6 cycles + trastuzumab weekly for 18wks ==> Followed by trastuzumab /3wk to complete 1y.
**this regimen is more appropriate for pts with contra to anthracyclines.
Adjuvant chemo, HER2(-), Localized Disease - Stage I, IIA, IIB, or IIIA (T3N1M0) - FIRST-gen regimen role:
Considered LESS effective than 2nd, 3rd-gen regimens - Do play a role in selected situations.
CMF ==> Pts with contra to anthracycline (cardiac disease) and/or taxane Tx.
AC ==> Pts with contra to taxane Tx (neuropathy).
Adjuvant chemo, HER2(-), Localized Disease - Stage I, IIA, IIB, or IIIA (T3N1M0) - 1st gen regimens:
CMF ==> Cyclo + MTX + 5FU 6 cycles.
AC ==> Doxo + Cyclo 4 cycles.
CMF (PO) ==> Cyclo + MTX + 5-FU 6 cycles.
CMF (IV) ==> Cyclo + MTX + 5FU 8 cycles.
Adjuvant chemo, HER2(-), Localized Disease - Stage I, IIA, IIB, or IIIA (T3N1M0) - 2nd gen regimens importance:
More effective than other regimens (eg CMF).
==> Some of them appropriate for pts who desire LESS PROLONGED REGIMENS.
==> Geographic variation in the use of these regimens:
DC and AC-P are more commonly used in the USA, and epirubicin-containing regimens are more commonly used in Europe.
Adjuvant chemo, HER2(-), Localized Disease - Stage I, IIA, IIB, or IIIA (T3N1M0) - 2nd gen regimens:
FAC ==> 5FU + Doxo + Cyclo 6 cycles. (More effective than CMF)
CEF ==> Cyclo + Epirubicin + 5FU 6 cycles (more toxic than other alternatives in this category; with cotrimoxazole support).
Dose-dense AC-P ==> Doxo + Cyclo 4 cycles ==> Followed by paclitaxel 4 cycles with CSF support.
TC ==> Docetaxel + Cyclo 4 cycles (more effective than AC).
Adjuvant chemo, HER2(-), Localized Disease - Stage I, IIA, IIB, or IIIA (T3N1M0) - 3rd gen regimens importance:
More effective than some 2nd gen. Include both taxanes and anthracyclines.
Adjuvant chemo, HER2(-), Localized Disease - Stage I, IIA, IIB, or IIIA (T3N1M0) - 3rd gen regimens:
AC-P ==> Doxo + Cyclo ==> Followed by paclitaxel.
TAC ==> Docetaxel + Doxo + Cyclo (more effective than FAC; CSF support recommended).
FEC-docetaxel ==> 5FU + Epirubicin + Cyclophosphamide ==> Followed by docetaxel (more effective than 6 cycles of FEC).
FEC-paclitaxel ==> 5FU + Epirubicin + Cyclo ==> Followed by paclitaxel.
