From the Guidelines
For a 71-year-old patient with invasive lobular breast carcinoma, a multidisciplinary approach including surgery, radiation, and adjuvant therapy is recommended to optimize morbidity, mortality, and quality of life outcomes. The treatment plan should be based on disease stage, hormone receptor status, and overall health. Initial management usually includes surgery (either breast-conserving surgery with radiation or mastectomy), followed by appropriate adjuvant therapy. For hormone receptor-positive ILC (which represents about 90% of cases), endocrine therapy is recommended, typically with an aromatase inhibitor such as anastrozole (1 mg daily), letrozole (2.5 mg daily), or exemestane (25 mg daily) for 5-10 years, as suggested by the NCCN guidelines 1.
Key considerations in the treatment plan include:
- Disease stage: localized, locoregional, or metastatic
- Hormone receptor status: ER/PR positive or negative
- Overall health: comorbid conditions, age, and menopausal status
- Tumor characteristics: size, grade, and lymph node involvement
The prognosis for ILC is generally favorable, with 5-year survival rates of approximately 90% for localized disease, though slightly lower for this age group, as noted in the ESMO guidelines 1. ILC tends to have a more indolent course than invasive ductal carcinoma but may present with unique metastatic patterns including spread to peritoneum, ovaries, and gastrointestinal tract.
Follow-up care is crucial to detect early local recurrences or contralateral breast cancer, evaluate and treat therapy-related complications, and provide psychological support. Regular follow-up with clinical exams every 3-6 months for the first 3 years, then every 6-12 months for 2 years, and annually thereafter is recommended, along with annual mammography and ultrasound for lobular invasive carcinomas 1. Additionally, routine blood tests are usually indicated to follow-up patients on endocrine therapy due to potential side-effects, and regular bone density evaluation is recommended for patients on aromatase inhibitors 1. A healthy lifestyle, including regular exercise and nutritional counseling, is also essential for improving outcomes and reducing the risk of recurrence 1.
From the Research
Prognosis and Treatment of Invasive Lobular Breast Carcinoma
- Invasive lobular breast carcinoma (ILC) has unique clinicopathologic features, and data on optimal treatment modalities are scarce 2.
- A study of 15,271 patients with early-stage hormone receptor-positive (HR+) and human epidermal growth factor receptor-2 negative (HER2-) ILC found that chemotherapy demonstrated no added survival benefit, even in tumors with high OncotypeDX scores 2.
- Another study of 998 patients who underwent breast-conserving therapy found that the 10-year local recurrence rate was similar for ILC, invasive ductal carcinoma (IDC), and mixed histology breast cancers, despite inherent histologic differences 3.
Treatment Choices for Patients with Invasive Lobular Breast Cancer
- A survey of doctors found that there is variation in beliefs, management, and opinions regarding the quality of evidence for the management of ILC, and clinical trials are required to guide clinical practice 4.
- A study of elderly postmenopausal patients with locally advanced, HR-positive breast cancer treated with preoperative aromatase inhibitors found that breast-conserving surgery was performed in 84% of patients, and achievement of breast-conserving surgery and grade G1 were significantly associated with longer disease-free survival and overall survival 5.
HER2-Positive Invasive Lobular Carcinoma
- A population-based study found that HER2-positive ILC is rare and poorly characterized, and patient outcomes compared to those associated with HER2-positive IDC and HER2-negative ILC are not well established 6.
- The study found that anti-HER2 therapy was associated with a survival benefit in patients with HER2-positive IDC, but not in patients with HER2-positive ILC, whose survival was similar to that of HER2-negative ILC patients 6.