Breast Cancer Treatment Guidelines

Transcription

1 Breast Cancer Treatment Guidelines DCIS Stage 0 TisN0M0 Tamoxifen for 5 years for patients with ER positive tumors treated with: -Breast conservative therapy (lumpectomy) and radiation therapy -Excision alone Hormone Receptor Positive and Her2 neu positive a) Tumor 0.5 cm: Adjuvant endocrine therapy (premenopausal: tamoxifen; postmenopausal: aromatase inhibitor) b) Tumor 0.6 1cm: ± Adjuvant chemotherapy + adjuvant endocrine therapy + trastuzumab c) Tumor > 1cm: Adjuvant chemotherapy + adjuvant endocrine therapy + trastuzumab Adjuvant chemotherapy + Adjuvant endocrine therapy + trastuzumab Hormone Receptor Positive and Her2 neu negative a) Tumor 0.5 cm: Adjuvant endocrine therapy b) Tumor > 0.5 cm: 21-gene RT-PCR assay -Not done: ± Adjuvant chemotherapy + Adjuvant endocrine therapy -Low recurrence score (< 18): Adjuvant endocrine therapy -Intermediate recurrence score (18-30): ± Adjuvant chemotherapy + Adjuvant endocrine therapy -Hight recurrence score ( 31) Adjuvant chemotherapy + Adjuvant endocrine therapy Adjuvant chemotherapy + Adjuvant endocrine therapy

2 Hormone Receptor Negative and Her2 neu positive a) Tumor 0.5 cm: No adjuvant therapy b) Tumor 0.6 1cm: ± Adjuvant chemotherapy + trastuzumab c) Tumor > 1cm: Adjuvant chemotherapy + trastuzumab Adjuvant chemotherapy + Adjuvant endocrine therapy + trastuzumab Hormone Receptor Negative and Her2 neu negative a) Tumor 0.5 cm: No adjuvant therapy b) Tumor 0.6 1cm: ± Adjuvant chemotherapy c) Tumor > 1cm: Adjuvant chemotherapy Adjuvant chemotherapy + Adjuvant endocrine therapy Neoadjuvant Chemotherapy -Indications: According to clinical stage -Stage IIA: T2, N0, M0 -Stage IIB: T2, N1, M0 or T3, N0, M0 -Stage IIIA: T3, N1, M0 -Fulfills criteria for breast conserving surgery except for tumor size -Work up: - History and physical -CBC, CMP (LFTs and alk phos) -Determination of tumor ER/PR status and Her2 neu status -CT scan chest abdomen and pelvis 1.- No response after 3-4 cycles or progressive disease or Partial response, lumpectomy not possible Consider alternative chemotherapy -No response after 3-4 cycles or progressive disease or partial response, lumpectomy not possible: Mastectomy

3 -Complete response or partial response, lumpectomy possible: Lumpectomy 2.- Partial response, lumpectomy possible or complete response Lumpectomy Surveillance/ Follow up - History and physical exam 3-6 m for 5 y then every 12m - Annual mammogram - Women on tamoxifen: annual gynecologic exam every 12m if uterus present - Women on aromatase inhibitor or who experienced ovarian failure secondary to treatment should have baseline bone mineral density test at baseline and annually thereafter - Assess and encourage adherence to adjuvant therapy Initial work up for Stage IV disease - History and physical exam - CBC and CMP - CT scan chest, abdomen and pelvis - Bone scan - X-rays of symptomatic bones and long weight bearing bones abnormal on bone scan - First recurrence should be biopsied, consider determination of tumor ER/PR and Her2 status Local only recurrence - Initial treatment with lumpectomy + radiation therapy: Total mastectomy + axillary lymph node staging if level I/II axillary dissection not previously done. - Initial treatment with mastectomy and axillary dissection and prior radiation therapy: Surgical resection if possible - Initial treatment with mastectomy, no prior radiation therapy: Surgical resection if possible + radiation therapy to chest wall and supraclavicular and infraclavicular lymph nodes Regional only or Local and regional recurrence - Axillary recurrence: Surgical resection if possible + radiation therapy if possible to chest wall, supraclavicular and infraclavicular nodes and axilla - Supraclavicular recurrence: radiation therapy if possible to chest wall and supraclavicular and infraclavicular nodes

4 - Internal mammary node recurrence: radiation therapy if possible to chest wall, supraclavicular and infraclavicular nodes and internal mammary nodes Systemic disease - Bone disease present: add zolendronic acid or pamidronate or denusomab. - Bone disease not present: evaluate ER/PR status and Her2 neu status. ER and/or PR positive; Her 2 neu negative or positive - Prior endocrine therapy within 1 year -Premenopausal: ovarian ablation or suppression, plus endocrine therapy as postmenopausal (aromatase inhibitor) -Postmenoapausal: -Visceral crisis: consider initial chemotherapy - No prior endocrine therapy within 1 year -Premenopausal: ovarian ablation or suppression plus endocrine therapy as postmenopausal (aromatase inhibitor) or tamoxifen. -Postmenopausal: aromatase inhibitor or tamoxifen -Visceral crisis: consider initial chemotherapy ER and PR negative; ER and/or PR positive and endocrine refractory - Bone or soft tissue only or asymptomatic visceral: consider additional trial of endocrine therapy if not endocrine refractory or chemotherapy - Visceral crisis: chemotherapy (no response to 3 sequential regimens or ECOG performance status 3, consider no further cytotoxic therapy, transition to palliative care. If Her2 neu positive add trastuzumab

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