What are the treatment guidelines for breast cancer?

From the Guidelines

Breast cancer treatment guidelines involve a multidisciplinary approach based on cancer stage, type, and patient factors, with the most recent and highest quality study 1 recommending personalized treatment strategies. The treatment approach includes local disease management with surgery, radiation therapy, or both, and systemic treatment with chemotherapy, endocrine therapy, biologic therapy, or combinations of these, as outlined in the NCCN clinical practice guidelines 1. Key considerations in treatment selection include tumor histology, clinical and pathologic characteristics of the primary tumor, axillary lymph node status, tumor hormone receptor content, tumor HER2 status, multigene testing, presence or absence of detectable metastatic disease, patient comorbid conditions, patient age, and menopausal status.

Treatment Options

• For early-stage hormone receptor-positive breast cancer, adjuvant endocrine therapy is recommended: tamoxifen 20mg daily for 5-10 years for premenopausal women, or aromatase inhibitors (anastrozole 1mg, letrozole 2.5mg, or exemestane 25mg daily) for 5-10 years in postmenopausal women.
• HER2-positive cancers require anti-HER2 therapy like trastuzumab (Herceptin) 6mg/kg every 3 weeks for one year.
• Chemotherapy regimens often include anthracycline and taxane combinations such as AC-T (doxorubicin/cyclophosphamide followed by paclitaxel) or TC (docetaxel/cyclophosphamide).
• Triple-negative breast cancers typically require chemotherapy, with the addition of immune checkpoint inhibitors for programmed cell death ligand-1–positive MBC, as recommended in the updated ASCO guideline 1.
• Radiation therapy is generally recommended after breast-conserving surgery or for high-risk post-mastectomy patients, typically delivered over 3-6 weeks.

Follow-up and Monitoring

Regular follow-up with physical exams every 3-6 months for the first 3 years, then every 6-12 months for 2 years, and annually thereafter is essential, along with annual mammography, as outlined in the guidelines 1. This comprehensive approach targets cancer cells through different mechanisms while minimizing recurrence risk and maximizing survival outcomes, with the goal of improving morbidity, mortality, and quality of life for patients with breast cancer.

From the FDA Drug Label

1 INDICATIONS AND USAGE

1.1 Adjuvant Breast Cancer Ogivri is indicated in adults for adjuvant treatment of HER2 overexpressing node positive or node negative (ER/PR negative or with one high risk feature [see Clinical Studies (14.1)]) breast cancer as part of a treatment regimen consisting of doxorubicin, cyclophosphicide, and either paclitaxel or docetaxel as part of a treatment regimen with docetaxel and carboplatin as a single agent following multi-modality anthracycline based therapy.

1.2 Metastatic Breast Cancer Ogivri is indicated in adults: In combination with paclitaxel for first-line treatment of HER2-overexpressing metastatic breast cancer As a single agent for treatment of HER2-overexpressing breast cancer in patients who have received one or more chemotherapy regimens for metastatic disease

The treatment guidelines for breast cancer are as follows:

• Adjuvant Breast Cancer: Trastuzumab can be used as part of a treatment regimen consisting of doxorubicin, cyclophosphamide, and either paclitaxel or docetaxel, or with docetaxel and carboplatin as a single agent following multi-modality anthracycline-based therapy.
• Metastatic Breast Cancer: Trastuzumab can be used in combination with paclitaxel for first-line treatment, or as a single agent for treatment of HER2-overexpressing breast cancer in patients who have received one or more chemotherapy regimens for metastatic disease. Note: The dosage and administration of trastuzumab and paclitaxel should be based on the recommendations in the drug labels 2 2 and 3.

From the Research

Treatment Guidelines for Breast Cancer

The treatment guidelines for breast cancer vary depending on the stage and subtype of the disease.

• For nonmetastatic breast cancer, treatment goals are tumor eradication and preventing recurrence 4.
• The choice of treatment depends on the stage, with Stage 0 being ductal carcinoma in situ, which is noninvasive but progresses to invasive cancer in up to 40% of patients 5.
• Early invasive stages (I, IIa, IIb) and locally advanced stages (IIIa, IIIb, IIIc) are nonmetastatic and have three treatment phases: preoperative, surgical, and postoperative 5.
• The preoperative phase uses systemic endocrine or immunotherapies when tumors express estrogen, progesterone, or ERBB2 receptors, while preoperative chemotherapy may also be used 5.
• The surgical phase has two options: lumpectomy with radiation or mastectomy, with similar survival rates 5.
• The postoperative phase includes radiation, endocrine therapy, immunotherapy, and chemotherapy, with postmenopausal women also being offered postoperative bisphosphonates 5.

Treatment by Subtype

Breast cancer is categorized into three major subtypes based on the presence or absence of molecular markers for estrogen or progesterone receptors and human epidermal growth factor 2 (ERBB2) 4.

• Hormone receptor-positive/ERBB2 negative tumors are treated with endocrine therapy, and a minority receive chemotherapy as well 4.
• ERBB2-positive tumors are treated with ERBB2-targeted antibody or small-molecule inhibitor therapy combined with chemotherapy 4.
• Triple-negative tumors are treated with chemotherapy alone 4.

Metastatic Breast Cancer

Stage IV (metastatic) breast cancer is treatable but not curable, with treatment goals including improving the length and quality of life 5.

• Metastatic breast cancer is treated according to subtype, with goals of prolonging life and palliating symptoms 4.
• Median overall survival for metastatic triple-negative breast cancer is approximately 1 year, compared to approximately 5 years for the other two subtypes 4.

Evolving Treatment Strategies

Breast cancer treatment has evolved significantly over the years, with a shift towards personalized and multidisciplinary approaches 6.

• The use of primary systemic (neoadjuvant) therapy has become widespread in the treatment of patients with locally advanced and operable breast cancer 7.
• Combined modality therapy, including primary chemotherapy, surgery, and radiation therapy, has improved treatment outcomes for patients with locally advanced breast cancer 8.