Treatment Plan for Elderly Patient with pT2N0 Triple-Negative Breast Cancer After Partial Mastectomy
This elderly patient with grade 3,1.8 cm triple-negative breast cancer (pT2N0) after partial mastectomy and negative sentinel lymph node biopsy should receive adjuvant chemotherapy with an anthracycline and taxane-based regimen followed by adjuvant radiation therapy to the breast.
Adjuvant Systemic Chemotherapy
Chemotherapy is mandatory for this patient despite the node-negative status, given the triple-negative biology and high-grade tumor. 1
Chemotherapy Regimen Selection
Standard regimen options include anthracycline-taxane combinations such as doxorubicin/cyclophosphamide (AC) followed by a taxane, or dose-dense regimens. 2, 1
For elderly patients, careful consideration of toxicity is essential, but age alone should not preclude standard chemotherapy in fit patients with high-risk disease. 1
The tumor size of 1.8 cm (pT2) combined with grade 3 histology and triple-negative status places this patient at high risk for recurrence, making chemotherapy essential even without nodal involvement. 1, 3
Key Considerations for Elderly Patients
Dose-dense anthracycline and taxane combinations achieve pathological complete response rates exceeding 20% in triple-negative disease and should be considered the standard approach. 1
Capecitabine is NOT indicated in this setting, as it is reserved for patients with residual disease after neoadjuvant chemotherapy, not for adjuvant treatment after primary surgery. 2
Functional status and comorbidities should guide intensity of treatment, but triple-negative breast cancer remains aggressive regardless of age. 4, 5
Adjuvant Radiation Therapy
Radiation therapy to the breast is mandatory after partial mastectomy (breast-conserving surgery). 2, 1
Radiation Approach
Whole-breast irradiation is the standard approach following breast-conserving surgery. 2
Partial breast irradiation may be considered in select elderly patients, though whole-breast radiation remains standard. 2
Radiation should be administered after completion of chemotherapy. 2
Additional Considerations
Genetic Testing
BRCA1/2 germline mutation testing should be offered, as triple-negative breast cancer has substantial overlap with BRCA1-related cancers. 5, 6
If a germline BRCA1/2 mutation is identified, adjuvant olaparib for 1 year should be considered after completion of chemotherapy. 1
Surveillance and Follow-up
The peak risk of relapse in triple-negative breast cancer is at 3 years after surgery, with rapid decrease thereafter. 3
Regular clinical follow-up with physical examination is essential, as triple-negative disease has shorter median time to relapse compared to other subtypes. 6
Treatment Algorithm
Confirm final pathology: pT2N0, grade 3, ER-negative, PR-negative, HER2-negative 2
Assess patient fitness: Evaluate performance status and comorbidities to determine chemotherapy tolerance 1
Initiate adjuvant chemotherapy: Anthracycline-taxane combination (e.g., AC followed by paclitaxel or docetaxel) 2, 1
Consider BRCA testing: Offer germline BRCA1/2 testing given triple-negative status 1, 5
Administer adjuvant radiation: Whole-breast irradiation after chemotherapy completion 2
If BRCA mutation identified: Add adjuvant olaparib for 1 year 1
Critical Pitfalls to Avoid
Do not omit chemotherapy based solely on node-negative status in triple-negative disease—the aggressive biology and grade 3 histology mandate systemic therapy. 1, 3
Do not use capecitabine in this adjuvant setting after primary surgery—it is only indicated for residual disease after neoadjuvant therapy. 2
Do not omit radiation therapy after partial mastectomy—this significantly increases local recurrence risk. 2
Do not assume elderly patients cannot tolerate standard chemotherapy—functional status, not chronological age, should guide treatment intensity. 1
Ensure margins are confirmed negative on final pathology; positive margins require re-excision before radiation. 7