What are the recommended treatment options for a patient with breast cancer or at high risk of developing breast cancer, considering their individual risk factors, medical history, and preferences, as part of the Choosing Wisely (CW) trial for breast cancer management?

Choosing Wisely in Breast Cancer Management

Core Principle: Multidisciplinary Care in Specialized Centers

All breast cancer treatment must be delivered in specialized breast units by a multidisciplinary team including medical oncologists, breast surgeons, radiation oncologists, radiologists, pathologists, and breast nurses, with access to plastic surgeons, psychologists, physiotherapists, and geneticists when needed 1.

Patient-Centered Decision Making

• Information on diagnosis and treatment must be provided repeatedly, both verbally and in writing, in comprehensive and easily understandable form 1.
• Patients must be actively involved in all management decisions, with treatment strategy extensively discussed and accounting for patient preferences 1.
• A breast nurse or similarly trained practitioner should act as patient navigator to coordinate care 1.

Treatment Strategy Framework

Treatment decisions are based on three key domains 1, 2:

1. Tumor Characteristics

• Size and location of primary tumor
• Number of lesions and extent of lymph node involvement
• Pathology including biomarkers (ER, PR, HER2) and gene expression profiles 1, 2

2. Patient Factors

• Age and menopausal status
• General health status and comorbidities
• Fertility concerns in premenopausal women (must be discussed before any systemic treatment) 1

3. Patient Preferences

• Age alone should never be the sole determinant for withholding or recommending treatment 1

Surgical Management Principles

For Early Breast Cancer

• Breast-conserving surgery (BCS) is the preferred option for the majority of early breast cancer patients, using oncoplastic techniques when needed to maintain cosmetic outcomes 1, 2.
• No tumor at inked margin is required; >2 mm margin is preferred for in situ disease 1.
• Sentinel lymph node biopsy (SLNB) is standard for axillary staging in clinically node-negative disease 1, 2.
• Further axillary surgery after positive SLNB is not required for low disease burden (micrometastases or 1-2 positive nodes with postoperative tangential breast radiation) 1.
• Axillary radiation is a valid alternative to completion dissection in patients with positive SLNB, regardless of breast surgery type 1, 2.

For Mastectomy Cases

• Breast reconstruction should be offered to all women requiring mastectomy 1, 2.
• Immediate reconstruction should be offered to the vast majority except those with inflammatory cancer 1.
• Reconstruction technique should be discussed individually considering anatomic, treatment-related, and patient factors 1.

Surveillance and Follow-Up

After Curative Treatment

• History, symptom assessment, and physical examination every 3-6 months for first 3 years 3, 2.
• Every 6-12 months for next 2 years, then annually thereafter 3, 2.
• Annual mammography on intact breast(s) 3.
• Do not perform routine laboratory tests or imaging (except mammography) for detection of recurrence in asymptomatic patients 3.

High-Risk Surveillance

• MRI screening should not be offered routinely unless patient meets high-risk criteria per American Cancer Society guidelines 3.
• Assess cancer family history and offer genetic counseling if hereditary risk factors suspected (strong family history or age ≤60 years with triple-negative breast cancer) 3.

Risk Reduction Strategies

For High-Risk Women

• Tamoxifen reduces breast cancer incidence in high-risk women (5-year predicted risk ≥1.67% by Gail Model) but does not eliminate risk 4.
• Tamoxifen is indicated for women ≥35 years with appropriate risk factors including family history, benign biopsies with atypical hyperplasia, or LCIS 4.
• Raloxifene is an alternative for postmenopausal high-risk women 5, 6.
• Exemestane may be optimal for high-risk postmenopausal women 6.

Critical Monitoring on Tamoxifen

• Women must seek prompt medical attention for new breast lumps, vaginal bleeding, gynecologic symptoms, leg swelling/tenderness, unexplained shortness of breath, or vision changes 4.
• Breast examination, mammogram, and gynecologic examination required before initiation and at regular intervals 4.
• Periodic complete blood counts including platelets and liver function tests 4.
• Effective nonhormonal contraception is mandatory for all premenopausal women on tamoxifen 4.

Adjuvant Endocrine Therapy

• Patients must be counseled to adhere to adjuvant endocrine therapy 3.
• Current data support 5 years of adjuvant tamoxifen therapy for patients with breast cancer 4.
• For hormone receptor-positive tumors, endocrine therapy is mandatory; aromatase inhibitors are alternatives for postmenopausal women 7.

Metastatic Disease Management

Treatment Goals

• The vast majority of metastatic breast cancer is incurable; main goal is palliation to maintain/improve quality of life 8.
• Realistic treatment goals must be discussed with patient and family from the beginning 8.

Systemic Therapy Selection

• For HR-positive metastatic disease, endocrine therapy with or without targeted therapy is preferred over chemotherapy unless rapid response needed 9, 2.
• Single-agent chemotherapy is preferred over combination therapy for HR-positive HER2-negative metastatic disease, except for symptomatic or immediately life-threatening disease 9.
• For triple-negative metastatic disease with germline BRCA1/2 mutations after prior chemotherapy, offer oral PARP inhibitor (olaparib or talazoparib) rather than chemotherapy 9.
• Sacituzumab govitecan should be offered for metastatic triple-negative breast cancer after at least two prior therapies 9.

Common Pitfalls to Avoid

• Do not prescribe hormone replacement therapy for postmenopausal symptoms after breast cancer treatment, except in specific cases 10, 11.
• Do not use concomitant chemo-hormonal therapy in metastatic breast cancer 2.
• Do not perform routine SLNB in DCIS, except when mastectomy planned or suspicion of invasion 1.
• Do not screen with routine imaging beyond mammography in asymptomatic survivors 3.
• Women requiring coumarin-type anticoagulants should have careful prothrombin time monitoring if tamoxifen is used, though this combination increases thromboembolic risk 4.