What are the next steps for a patient with hormone receptor-positive breast cancer who has completed TCH (Taxotere, Carboplatin, Herceptin) chemotherapy and radiation, and is currently on exemestane (Aromasin), with no evidence of disease?

Management for Hormone Receptor-Positive Breast Cancer After Completion of TCH Chemotherapy and Radiation

For a patient with hormone receptor-positive, HER2-negative breast cancer who has completed TCH chemotherapy, radiation, and is currently on exemestane with no evidence of disease, continuing the current endocrine therapy with exemestane for a total of 5 years is the recommended approach.

Current Treatment Status Assessment

• The patient has completed TCH (Taxotere, Carboplatin, Herceptin) chemotherapy for one year (completed June 2025) 1
• Radiation therapy was completed in January 2025 1
• Axillary lymph node dissection (ALND) was performed in December 2024 1
• The patient is currently on exemestane (Aromasin) 2
• There is no evidence of disease post-chemotherapy 1

Endocrine Therapy Recommendations

• Continue exemestane therapy as part of the standard 5-year adjuvant endocrine therapy regimen for hormone receptor-positive breast cancer 1, 2
• Exemestane is FDA-approved for "adjuvant treatment of postmenopausal women with estrogen-receptor positive early breast cancer" 2
• Aromatase inhibitors like exemestane are superior to tamoxifen in terms of response rate, time to progression, and overall survival in postmenopausal women 1

Monitoring Recommendations

• Regular clinical follow-up visits to assess for:
  • Treatment adherence and side effects 3
  • Signs of disease recurrence 4
• Bone health monitoring is essential as exemestane can lead to reduction in bone mineral density (BMD) over time, increasing risk of osteoporosis and fractures 2
• Consider baseline and periodic bone mineral density testing 2
• Monitor vitamin D levels as recommended before starting treatment with exemestane 2

Management of Side Effects

• Common side effects of exemestane that require monitoring include:
  • Musculoskeletal symptoms (myalgias and arthralgias) 3
  • Hot flashes and increased sweating 2
  • Fatigue and sleep disturbances 2
• These side effects generally do not persist at follow-up, with subsequent return to pretreatment values 3
• Compared to tamoxifen, exemestane has a reduced incidence of endometrial changes, thromboembolic events, and hot flashes 3, 5

Long-term Considerations

• Hormone receptor-positive breast cancer is increasingly considered a chronic disease with ongoing risk of recurrence for years after diagnosis 4
• Early recurrence risk peaks 2-3 years post-diagnosis, but recurrences can occur even after 5 years 4
• Adherence to therapy is critical - studies show nonadherence in 23%-32% of patients with aromatase inhibitors 3
• Patients should be advised not to take estrogen-containing agents while on exemestane as these could interfere with its pharmacologic action 2

Special Considerations

• If the patient is premenopausal, exemestane is not indicated without ovarian suppression 2
• If the patient is experiencing significant bone loss, consider bone-targeted agents 2
• For patients with significant side effects affecting quality of life, consider switching to an alternative aromatase inhibitor or tamoxifen 3, 5

Future Follow-up Schedule

• Regular clinical examinations every 3-6 months for the first 3 years, then every 6-12 months for years 4-5 1
• Annual mammography 1
• Additional imaging (chest X-ray, abdominal ultrasound or CT scans) should be symptom-driven rather than performed routinely 1
• Bone scans or CNS imaging should be performed only if symptoms suggest metastatic disease 1