What are the management options for breast cancer?

Management of Breast Cancer

Breast cancer management requires a multidisciplinary approach involving surgical oncology, radiation oncology, and medical oncology, with treatment decisions based on disease stage, tumor characteristics, and patient factors to optimize survival and quality of life. 1

Initial Assessment and Diagnosis

• Tumor Characteristics Assessment:

  • Hormone receptor (ER/PR) status
  • HER2 overexpression status
  • Tumor size and grade
  • Lymph node involvement
  • Genomic testing when appropriate

• Staging Workup:

  • Mammography and ultrasound
  • MRI when indicated
  • Biopsy for histological confirmation
  • Assessment for distant metastases

Treatment Algorithm by Stage

Non-Invasive Breast Cancer (DCIS/LCIS)

• Primary Treatment: Breast-conserving surgery with radiation or mastectomy
• Adjuvant Therapy: Consider tamoxifen or aromatase inhibitors for ER+ disease

Early-Stage Invasive Breast Cancer (Stage I-II)

Surgical Approach:

• Preferred: Breast-conserving surgery with surgical axillary staging when possible 1
• Alternative: Mastectomy with surgical axillary staging when breast conservation not feasible

Radiation Therapy:

• After breast-conserving surgery: Whole breast radiation with or without boost to tumor bed (Category 1) 1
• After mastectomy: Based on risk factors:
  • ≥4 positive nodes: Chest wall + regional nodal radiation (Category 1)
  • 1-3 positive nodes: Strongly consider chest wall + regional nodal radiation
  • Negative nodes but tumor >5cm or positive margins: Consider chest wall radiation

Systemic Therapy Based on Nodal Status and Receptor Status:

Node Positive Disease:

• ER+/PR+ and Premenopausal: Chemotherapy followed by tamoxifen 1
• ER+/PR+ and Postmenopausal: Tamoxifen; consider chemotherapy 1
• ER-/PR- (regardless of menopausal status): Chemotherapy 1
• HER2+: Add trastuzumab to chemotherapy regimen 2

Node Negative Disease with Risk Factors:

• ER+/PR+: Consider chemotherapy followed by endocrine therapy 1
• ER-/PR-: Consider chemotherapy 1
• HER2+: Consider trastuzumab-containing regimen 2

Locally Advanced Breast Cancer (Stage III)

• Standard Approach: Neoadjuvant chemotherapy followed by surgery and radiation 1
• For HER2+ disease: Include trastuzumab in neoadjuvant regimen 2
• For ER+/PR+ disease: Add endocrine therapy after completing chemotherapy 1
• Post-mastectomy: Chest wall radiation is indicated (standard) 1

Metastatic Breast Cancer (Stage IV)

• Primary goal: Palliate symptoms, prolong survival, and maintain quality of life 1

• Treatment selection based on:

  • Hormone receptor status
  • HER2 status
  • Tumor burden
  • Patient preference 1

• ER+/PR+ Disease:

  • First-line: Endocrine therapy unless rapid response needed
  • Consider CDK4/6 inhibitors with endocrine therapy

• HER2+ Disease:

  • HER2-targeted therapy (trastuzumab) with chemotherapy 2
  • For ER+/HER2+: Consider combination of HER2-targeted and endocrine therapy

• Triple-Negative Disease:

  • Chemotherapy (consider paclitaxel-containing regimens) 3
  • Consider immunotherapy for PD-L1+ disease

Follow-Up Recommendations

• Clinical examination yearly for 10 years 1
• Annual mammogram starting 6 months after completing treatment 1
• For conserved breast: yearly follow-up for 10 years, then adjusted based on recurrence risk 1
• For contralateral breast: clinical examination and mammogram at same frequency as conserved breast 1

Important Considerations

• Multidisciplinary approach is essential for optimal outcomes 1, 4
• Patients with metastatic disease should be offered appropriate supportive care and symptom management 1
• Clinical trials should be considered at all stages of disease 1
• Rehabilitation should begin before treatment with clear information about possible complications and management 1

Common Pitfalls to Avoid

• Delaying systemic therapy: Adjuvant therapy should be initiated promptly after surgery
• Overlooking axillary management: Proper axillary staging is crucial for treatment decisions
• Inadequate follow-up: Regular surveillance is necessary to detect recurrence early
• Neglecting supportive care: Address psychosocial needs and quality of life throughout treatment
• Failing to consider genetic factors: Approximately 8-10% of breast cancers have hereditary components 5

By following this comprehensive approach to breast cancer management, clinicians can optimize patient outcomes in terms of morbidity, mortality, and quality of life.