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 (!).
