What adjuvant therapy is recommended for a 36-year-old woman with T1c, Node 0 (N0), Estrogen Receptor (ER) positive, Human Epidermal growth factor Receptor 2 (HER2) negative breast cancer?

From the Guidelines

For a 36-year-old woman with T1c N0 ER-positive HER2-negative breast cancer, I recommend adjuvant endocrine therapy with tamoxifen 20 mg daily for 5-10 years, as supported by the most recent guidelines from the National Comprehensive Cancer Network 1. Given her premenopausal status, tamoxifen is the preferred initial approach. Additionally, based on her young age and T1c tumor size, adjuvant chemotherapy should be considered, with the decision informed by a genomic assay like Oncotype DX to determine the benefit of chemotherapy, as suggested by the St. Gallen International Consensus Guidelines for the primary therapy of early breast cancer 1. If the patient has concerns about fertility, referral for fertility preservation should occur before starting treatment. Ovarian suppression with a GnRH agonist added to tamoxifen could be considered, especially if she remains premenopausal after chemotherapy, as this provides additional benefit in reducing recurrence risk. The recommendation for endocrine therapy is based on the tumor's ER-positive status, which indicates responsiveness to hormonal manipulation, while the consideration for chemotherapy reflects the patient's young age and the higher risk of recurrence associated with premenopausal breast cancer. It's also important to consider the patient's preferences and the potential side effects of extended therapy, as outlined in the ASCO clinical practice guideline focused update on adjuvant endocrine therapy for women with hormone receptor-positive breast cancer 1.

Some key points to consider in the management of this patient include:

• The use of tamoxifen as the initial endocrine therapy, given its established benefit in reducing recurrence risk in premenopausal women with ER-positive breast cancer 1.
• The consideration of adjuvant chemotherapy, with the decision informed by a genomic assay to determine the benefit of chemotherapy, as suggested by the St. Gallen International Consensus Guidelines 1.
• The potential addition of ovarian suppression to tamoxifen, especially if the patient remains premenopausal after chemotherapy, to provide additional benefit in reducing recurrence risk.
• The importance of considering the patient's preferences and the potential side effects of extended therapy in the decision-making process, as outlined in the ASCO clinical practice guideline focused update 1.

Overall, the management of this patient should be individualized, taking into account her specific clinical characteristics, preferences, and values, as well as the most recent evidence-based guidelines.

From the FDA Drug Label

Tamoxifen citrate tablets are indicated for the treatment of axillary node-negative breast cancer in women following total mastectomy or segmental mastectomy, axillary dissection, and breast irradiation The estrogen and progesterone receptor values may help to predict whether adjuvant tamoxifen therapy is likely to be beneficial. Current data from clinical trials support 5 years of adjuvant tamoxifen therapy for patients with breast cancer

For a 36-year-old woman with T1c No ER positive HER2 negative breast cancer, tamoxifen is recommended as an adjuvant therapy. The treatment should be given for 5 years, as supported by clinical trials 2 and 2.

• Key points:
  • Tamoxifen is indicated for the treatment of axillary node-negative breast cancer
  • Estrogen receptor positive status is a predictor of benefit from tamoxifen therapy
  • 5 years of adjuvant tamoxifen therapy is supported by clinical trials

From the Research

Adjuvant Therapy for T1c No ER Positive HER2 Negative Breast Cancer

• The patient in question is a 36-year-old woman with T1c No ER positive HER2 negative breast cancer.
• According to the study 3, for women with early-stage oestrogen receptor (ER)-positive breast cancer, adjuvant tamoxifen reduces 15-year breast cancer mortality by a third.
• However, aromatase inhibitors are more effective than tamoxifen in postmenopausal women but are ineffective in premenopausal women when used without ovarian suppression.
• The study 4 discusses the management of hormone receptor-positive, HER2-negative early breast cancer, including the role of adjuvant endocrine therapy, specific endocrine therapy agents, and the duration of adjuvant endocrine therapy.
• The study 5 examines the utility of Oncotype DX score in clinical management for T1 estrogen receptor positive, HER2 negative, and lymph node negative breast cancer, and finds that patients with low grade (1 or 2), T1a ER+/HER2-/LN- breast cancer may not need RS for treatment decision-making.

Treatment Options

• Adjuvant endocrine therapy is a recommended treatment option for hormone receptor-positive, HER2-negative breast cancer 4.
• Aromatase inhibitors may be considered for premenopausal women with ER-positive breast cancer who are receiving ovarian suppression 3.
• The choice of adjuvant therapy should be individualized based on patient characteristics, tumor biology, and other factors 4.
• The study 6 discusses the treatment landscape for HR+, HER2- metastatic breast cancer, including the use of aromatase inhibitors, selective estrogen receptor modulators, and CDK4/6 inhibitors.

Considerations

• The patient's age, tumor size, and grade should be taken into account when selecting adjuvant therapy 5.
• The potential benefits and risks of each treatment option should be carefully considered, including the risk of recurrence and the potential for treatment-related side effects 3, 4.