What are the next steps for a 52-year-old woman with hormone receptor positive and HER2 negative infiltrating ductal carcinoma after breast biopsy?

From the Guidelines

For a 52-year-old woman with hormone receptor positive, HER2 negative infiltrating ductal carcinoma after breast biopsy, the next steps should include comprehensive staging, multidisciplinary treatment planning, and consideration of adjuvant therapies based on tumor characteristics and genomic testing results, as outlined in the most recent guidelines 1.

Key Considerations

• Comprehensive staging should involve additional imaging studies, including bilateral mammography, breast MRI, and staging studies such as CT chest/abdomen/pelvis and bone scan to rule out metastatic disease.
• Surgical options include breast-conserving surgery (lumpectomy) with sentinel lymph node biopsy or mastectomy, depending on tumor size, location, and patient preference.
• Adjuvant therapy will likely include endocrine therapy, such as tamoxifen or an aromatase inhibitor, for 5-10 years, considering the patient's menopausal status and tumor characteristics.
• Radiation therapy is typically recommended after breast-conserving surgery.
• Chemotherapy decisions will depend on tumor characteristics, genomic testing results, and lymph node status, with consideration of targeted therapies like CDK4/6 inhibitors for high-risk patients 1.

Adjuvant Therapy

• Endocrine therapy is almost universal for patients with HR-positive invasive breast cancer, reducing the risk of locoregional recurrence, distant metastatic recurrence, and contralateral breast cancer, while improving overall survival (OS) 1.
• The use of adjuvant bisphosphonate therapy can lower the risk of tumor recurrence and mitigate the side-effects of osteopenia/osteoporosis seen with AIs 1.
• Targeted therapy with CDK4/6 inhibitors, such as abemaciclib, has been shown to reduce the absolute risk of recurrence in high-risk patients with HR-positive, HER2-negative breast cancer 1.

Patient-Specific Considerations

• Patient preferences and tumor biology should guide adjuvant treatment recommendations, considering the modest reductions in recurrence or improvement in OS with many common treatments for ER-positive breast cancer, especially in lower-risk tumors 1.
• The St. Gallen International Consensus Conference guidelines provide a framework for systemic therapy decisions based on tumor characteristics, including anatomic stage, tumor biology, and genomic testing results 1.

From the FDA Drug Label

Available evidence indicates that patients whose tumors are estrogen receptor positive are more likely to benefit from tamoxifen therapy. 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.

Given that the patient has hormone receptor positive and HER2 negative infiltrating ductal carcinoma, and no axillary lymph node enlargement was evident, the next steps could include:

• Referral to a medical oncologist to discuss adjuvant therapy options, such as tamoxifen 2, considering the patient's tumor characteristics and overall health.
• Discussion of the benefits and risks of adjuvant tamoxifen therapy, including its potential to reduce the occurrence of contralateral breast cancer 2.
• Consideration of a multidisciplinary team approach to develop an individualized treatment plan, taking into account the patient's preferences and values.
• Further evaluation and management should be based on an individual assessment of the benefits and risks of therapy, as well as current clinical guidelines and evidence-based practices 2.

From the Research

Next Steps for a 52-year-old Woman with Hormone Receptor Positive and HER2 Negative Infiltrating Ductal Carcinoma

• The patient has been diagnosed with infiltrating ductal carcinoma, which is hormone receptor positive and HER2 negative, and has undergone a breast biopsy.
• Given the tumor's characteristics, the next steps should include:
  • Referral to a breast surgeon for further evaluation and discussion of surgical options.
  • Consideration of neoadjuvant endocrine therapy (NET) or neoadjuvant chemotherapy (NACT) as treatment options, with NACT potentially being considered the first choice for neoadjuvant treatment 3.
  • Evaluation of the patient's overall health and medical history to determine the best course of treatment.
• The patient's prognosis will depend on various factors, including the tumor's molecular subtype, with hormone receptor positive and HER2 negative tumors having a relatively better prognosis 4.
• Adjuvant therapy, such as hormone therapy, may be recommended to reduce the risk of recurrence, with studies showing that initiation and adherence to hormone therapy can be low in some patient populations 5.
• The patient's age, menopausal status, and other factors will also be taken into account when determining the best treatment plan, with older patients potentially having different treatment outcomes and responses to therapy 6.