What are the management options for early breast cancer?

Management of Early Breast Cancer

Early breast cancer should be managed by a multidisciplinary team in specialized breast units/centers, with treatment decisions based on tumor characteristics, biology, and patient factors to optimize survival outcomes and quality of life. 1

Multidisciplinary Approach

Treatment should be provided by a specialized team including:

• Medical oncologists
• Breast surgeons
• Radiation oncologists
• Breast radiologists
• Breast pathologists
• Breast nurses/specialized healthcare practitioners 1

The breast unit should have access to:

• Plastic/reconstructive surgeons
• Psychologists
• Physiotherapists
• Geneticists 1

Diagnosis and Staging

Initial Assessment

• Bilateral mammogram and ultrasound of breasts and axillae 1
• MRI for uncertain cases or special clinical situations
• Pathological evaluation with histology from primary tumor and cytology/histology of axillary nodes if involvement is suspected
• Disease staging according to TNM system 1

Biomarker Testing

• Histological type and grade
• Immunohistochemical evaluation of:
  • Estrogen receptor (ER)
  • Progesterone receptor (PgR)
  • HER2 status
  • Ki67 (proliferation marker) 1
• Validated gene expression profiles for additional prognostic/predictive information 1

Surgical Management

Breast-Conserving Surgery (BCS)

• Preferred option for most early breast cancer patients 1
• Oncoplastic techniques should be used when needed for good cosmetic outcomes
• Margin requirements: no tumor at inked margin for invasive cancer, >2mm for DCIS 1
• Followed by whole breast radiation therapy

Mastectomy

• Indicated when:
  • Large tumor-to-breast ratio
  • Multicentric disease
  • Inability to achieve negative margins
  • Contraindications to radiation therapy
  • Patient preference
• Breast reconstruction should be offered to all patients requiring mastectomy 1
• Immediate reconstruction is appropriate for most patients (except inflammatory cancer) 1

Axillary Management

• Sentinel lymph node biopsy (SLNB) is standard for clinically node-negative disease 1
• Further axillary surgery not required for low axillary disease burden (micrometastases or 1-2 positive SLNs with planned breast radiotherapy) 1
• Axillary radiation is a valid alternative for patients with positive SLNB 1

Radiation Therapy

After Breast-Conserving Surgery

• Postoperative whole breast RT strongly recommended 1
• Boost irradiation for patients at higher risk of local recurrence 1
• Accelerated partial breast irradiation (APBI) acceptable for low-risk patients 1

After Mastectomy

• Recommended for high-risk patients:
  • Involved resection margins
  • Involved axillary lymph nodes
  • T3-T4 tumors 1
• Should be considered for patients with 1-3 positive axillary nodes 1

Regional Irradiation

• Comprehensive nodal irradiation for patients with involved lymph nodes 1
• Routine axillary irradiation should not be done to the operated part of axilla after ALND 1

Systemic Therapy

Selection Criteria

Treatment selection based on:

• Tumor burden/location
• Tumor biology (pathology, biomarkers, gene expression)
• Patient factors (age, menopausal status, general health, preferences) 1

Endocrine Therapy

• Essential for hormone receptor-positive disease 2
• Postmenopausal women: Aromatase inhibitors (e.g., letrozole) have shown superior disease-free survival compared to tamoxifen 3
• Premenopausal women: Tamoxifen ± ovarian suppression based on risk

Chemotherapy

• Decision guided by tumor characteristics and validated gene expression profiles 1
• Neoadjuvant approach preferred for:
  • Triple-negative and HER2-positive subtypes
  • Tumors >2 cm
  • Positive axilla 1

Anti-HER2 Therapy

• Standard for HER2-positive disease 2
• Can be given in neoadjuvant or adjuvant setting

Special Considerations

Fertility Preservation

• Discuss fertility issues and preservation techniques with younger premenopausal patients before systemic treatment 1

DCIS Management

• Options include BCS followed by whole breast irradiation or total mastectomy 1
• 2mm margin preferred for DCIS treated with BCS and radiation 1
• SLNB not routinely needed except for large/high-grade tumors or when mastectomy is required 1
• Radiation may be omitted for low-risk DCIS 1

Post-Neoadjuvant Surgery

• Follow general rules for early breast cancer, considering baseline tumor characteristics and post-treatment outcomes 1
• Tumor site marking required if BCS anticipated 1
• Pre- and post-treatment MRI assessment recommended 1
• Post-neoadjuvant SLNB preferred over pre-treatment SLNB 1

Patient Involvement

• Information on diagnosis and treatment options should be provided repeatedly, both verbally and in writing 1
• Patients should be actively involved in all management decisions 1
• Treatment strategy must be extensively discussed with the patient, considering their preferences 1

Follow-up

• Regular clinical assessment
• Annual mammography
• More intensive surveillance for high-risk patients 1

By following this comprehensive, evidence-based approach to early breast cancer management, clinicians can optimize patient outcomes in terms of survival, local control, and quality of life.