NON SURGICAL MANAGEMENT

RADIATION THERAPY
-used for all stages of breast cancer , whether
patient is undergoing BCT or mastectomy
-use to maximize local regional control and
disease free survival
 RADIATION THERAPY
CANDIDATES FOR ADJUVANT CHEST WALL AND
SUPRACLAVICULAR LYMPH NODE RADIATION THERAPY
with HIGH RISK OF RECURRENCE
1. Women with mastectomy who have cancer at surgical
margins
2. Women with metastatic disease involving 4+ axillary LN
3. Premenopausal women with metastatic disease
involving 1-3 lymph nodes
4. In advanced local-regional breast cancer (stage IIIA and
IIIB)
 CHEMOTHERAPY ADJUVANT
- Reduces the odds of recurrence and of death
in women <70 yrs old with stage I, IIA, IIB
breast cancers
- Adjuvant chemotherapy is of minimal benefit
to women with negative nodes and cancers
<0.5 cm and is not recommended
 CHEMOTHERAPY ADUVANT
Considered for node + cancers that are >1 cm,
pts with node negative cancers >0.5 cm with
adverse prognostic features:
1.with blood or lymph vessel invasion
2.high nuclear grade
3. high histologic grade
4. HER2/neu overexpression
5. negative hormone status
 NEOADUVANT CHEMOTHERAPY
-In one study at National Cancer Institute in
Milan, 2 groups are randomly assigned to
receive either surgery followed by
chemotherapy or neoadjuvant chemotherapy
followed by surgery
-There was no difference in disease free survival
rates between the groups who received
neoadjuvant chemotherapy but there is a
decrease incidence of node positivity
 NEOADJUVANT CHEMOTHERAPY
National Comprehensive Cancer Network also
recommends for treatment of operable
advanced local regional breast cancer are
neoadjuvant chemotherapy with an
anthracycline or taxane containing regimen or
both followed by lumpectomy or mastectomy
with axillary lymph node dissection
 ANTIESTROGEN THERAPY
TAMOXIFEN
-within the cytosol of breast cancers are receptors that bind
and transfer specific steroid moieties into the cell nucleus
to exert hormonal effects
-after binding to estrogen receptors in the cytosol,
tamoxifen blocks the uptake of estrogen by breast tissue
-studies showed that therapy for 5 yrs reduces breast
cancer mortality by about 1/3 through the first 15 yrs of
follow up
*considered for women with DCIS that is ER+ to
decrease risk of recurrence
 ANTIESTROGEN THERAPY
TOXICITY
-bone pain, hot flashes, nausea, vomiting,fluid
retention, thrombotic events, cataract
-long term risk is endometrial cancer
 AROMATASE INHIBITORS
ANASTROZOLE AND LETROZOLE
-nonsteroidal 3rd generation aromatase inhibitors
-considered 1st line therapy in adjuvant setting or
as a secondary agent after 1-2 yrs of adjuvant
tamoxifen therapy
-recommended if patient is menopausal
-results in fewer and local and distant recurrences
 TOXICITY
-less likely than tamoxifen to cause endometrial
cancer
-changes in bone density (osteoporosis,
fractures)
 Anti- HER-2/neu THERAPY
-determination of tumor HER-2/neu expression is now
recommended
-patients with HER2+ tumors appear to have better outcomes
with anthracycline based adjuvant chemotherapy regimens
-patients with HER2+ tumors benefit if trastuzumab is added
to paclitaxel chemotherapy
-studies showed that it improves 3 yr disease free survival
and reduces mortality in patients
**cardiotoxicity may develop if trastuzumab is delivered
concurrently with anthracycline based therapy
 Anti- HER-2/neu THERAPY
-NEW:
1. Lapatinib- dual tyrosine kinase inhibitor that
targets both HER2 and EGFR
2. Ado-trastuzumab was approved for patients
who had received trastuzumab and taxane
either separately or in combination
3. Pertuzumab-targets HER2 receptor with
trastuzumab and docetaxel for treatment of
metastatic + breast cancer
Adjuvant Chemotherapy for Breast Cancer
HER-2/neu NEGATIVE (NON HER-2/neu POSITIVE (TRASTUZUMAB
TRASTUZUMAB CONTAINING REGIMENS) CONTAINING REGIMENS)

FAC/CAF AC-T+ concurrent Trastuzumab

(T=paclitaxel)
FEC/CEF Docetaxel +trastuzumab- FEC
AC/EC TCH (docetaxel, carboplatin, trastuzumab)
TAC (T=DOCETAXEL) Chemotherapy followed by trastuzumab
sequentially
A CMF AC-docetaxel +trastuzumab
E- CMF
CMF A= adriamycin (doxurubicin);
C=cyclophosphamide; E= epirubicin; F=5-
ACx4 fluorouracil; M=methotrexate; T=taxane
A-T-C (T=PACLITAXEL) (docetacel or paclitaxel)
FEC T (T=DOCETAXEL)
TC (T=DOCETAXEL)