This document discusses the management of early stage breast carcinoma. It covers the work up, types of surgery including lumpectomy and mastectomy, reconstructive options, complications of surgery, sentinel lymph node biopsy, radiotherapy techniques including whole breast irradiation and boost to tumor bed, and partial breast irradiation methods like intraoperative radiation therapy. It provides guidelines on indications for radiotherapy and highlights several large randomized trials investigating radiotherapy after lumpectomy and breast conservation surgery.
1. ModeratorModerator
Dr Haresh K.PDr Haresh K.P
Department of RadiotherapyDepartment of Radiotherapy
AIIMS, NEW DELHIAIIMS, NEW DELHI
MANAGEMENT OF EARLY STAGEMANAGEMENT OF EARLY STAGE
BREAST CARCINOMABREAST CARCINOMA
Speaker
Dr Ruchir Bhandari
2. Work up for Early Breast Cancer
(EBC)
Includes all patients with stage I & II
Diagnostic evaluation
– Tru cut biopsy
– B/L Mammography,USG
Metastatic evaluation not mandatory
Routine pre-anesthetic investigations
(HMG, Ser biochemistry, CXR, ECG)
Includes :
Carcinoma in situ
T 1-2 , N0-1 , Mo
5. LUMPECTOMY
Removal of tumor + surrounding margin of1-2 cm of normal breast tissue
Skin encompassing any prior biopsy site should be excised
QuadrantectomyQuadrantectomy
Partial /Segmental mastectomyPartial /Segmental mastectomy
Wide local excision (WLE)Wide local excision (WLE)
Excision biopsyExcision biopsy
Do MRM if
1.Large tumors in small breast
2. EIC
3. –ve margin not attained
4. Diffuse micro calcifications
5. Cx of RT
6. Pt unreliable for f/u.
6. RECONSTRUCTIVE OPTIONS
Either by prosthesis (silicon implants) or
autologous tissue transfer
Can be done in same surgery, better results if
RT can be avoided
After quadrantectomy / WLE
Local fat mobilization
Mini LD flap
Extended LD flap
After mastectomy
Vertical / transverse rectus abdominis flap
Gluteal free flap
7. Complications of surgeryComplications of surgery
I. Lymphoedema – 6-30%
II. Wound infection – 3-15%
III. Seroma – most frequent
IV. Tissue necrosis
V. Pneumothorax – rare
VI. Phantom breast syndrome – continued sensory
presence of breast after it has been removed
VII. Phantom pain – 17.4%
8. Axillary dissectionAxillary dissection
Axillary nodal status determines adj. CT
level I & II ; 10 is minimum
cN0 20 - 40 % pN0
cN+ 20 - 40 % pNO
Skip mets to level II – 15% ,
level III – 1-3%
Level III dissection cN+, skin +
Lymphoedema (3-5% 10-15%)
Absolute benefit of 5.4%
Orr et al, 1999
9. Sentinel lymph node biopsySentinel lymph node biopsy
(SLNB)(SLNB)
should follow negative USG axilla +/- FNAC
Tc 99m sulphur colloid & isosulphan blue dye
IHC- not routine, for suspicious nodes only
50% SLN + have no mets in non SLN on ALND
Methylene blue and 99-Tc – safe in pregnancy ( NCCN 11)
subareolar and intradermal (rather than peritumoral) injection for
multicentric disease
Cx – cN+, large or multiple tumors, prior axillary Sx
10. NSABP B-32
RCT comparing SNB to conventional axillary dissection in
clinically node-negative breast cancer patients
5611 patients, 97% SN identification
FNR = 9.8% in pts with SN followed by ALND
Similar OS & DFS at 5yrs and 8 yrs
SABCS abstracts 2005, Lancet Oncology 2007;8:881-88
11. ACOSOG Z0011
• Hypothesis: Removal of SN achieves similar local
control as Level I And II axillary clearance
• T1-2 N0; 1-3 SLN positive ( Not IHC detected ; Not matted LN )
• No regional nodal irradiation
• Trial underpowered 891/1900 recruited
• BCS patients with <3 nodes; good
prognostic subset
• All had adjuvant radiotherapy, but No
details
• Is LC due to RT and Chemo?
13. Journal of Clinical Oncology
ALND
(n=744)
ART
(n=681)
p value
5 year OS 93.27% 92.52% p=0.3386
5 year
DFS
86.90% 82.65% p=0.1788
5 year
Ly.edema
28% 14% P<0.0001
5 year
recurrence
0.54% 1.03%
14. N =180 post NACT Vs 1346 without NACT
Lower identification rates 85% Vs 89% (p=NS)
False negative rate was 12%-33% after NACT
756 N+ women ------------ NACT node negative
Procedure failed in 50 women
FNR 12.6% -- One SN
31.5% -- Two SN
SENTINA study : Lancet Oncol. 2013
Of 1737 patients, 1022 women underwent SLNB before NACT (arms A and B), with a
detection rate of 99·1%.
In patients ( from cN+ to ycN0 ) after NACT (arm C), the detection rate was 80·1% &
FNR of 14·2%
In pts having 2nd
SLNB after NACT (arm B), the detection rate was 61% & FNR of 51·6%
Meta-analysis of SLNB after NACT- XING et al, BJS 2006
ACOSOG Z1071 results- Oral, 35th
CTRC-AACR SABCS
15. SLNB - ASCO 14 recommendations
SLNB controversial for multi-centric disease, Post NACT, prior RT or SX
18. BCS vs Mastectomy
Fischer et al , NEJM 2002 (1851 patients))
“Lumpectomy followed by breast irradiation continues to
be appropriate therapy for women with breast cancer,
provided that the margins of resected specimens are free
of tumor and an acceptable cosmetic result can be
obtained “
19. Prospective Randomized Trials of
Lumpectomy +/- Radiotherapy
Necessity for Radiation Therapy
(In Early Stage Breast Cancer)……
No subset of patients, where RT can be omitted
20. AbsoluteAbsolute
contraindicationscontraindications
1) MULTICENTRIC
2) Diffuse macro calcifications
3) H/o previous RT to breast
4) Pregnancy
5)Persistent +ve margins
1. Collagen vascular ds
2. Multifocality & indeterminant
calcifications
3. Tumor (>4-5 cm) in small breast
4. Breast too small / large or pendulous
RelativeRelative
contraindicationscontraindications
cN+ or pN+
Subareolar tumors
No risk of secondary cancers
Family h/o
High risk of systemic relapse but
need for adjuvant Rx
SAFE
21. RADIOTHERAPYRADIOTHERAPY
Aims –
1. To decrease chances of LR ; treats microscopic ds
2. Increase local control & hence increase survival
Postop RT - mastectomy
- lumpectomy
Indications -
1. Tumor – >5cm , LVE + , gr2 / 3 , skin/ ms infiltr , EIC
2. Lymph nodes – number, ECE, inadequate ALND
3. Surgery – margins +ve , unknown or close
4. Patient – age <35yrs , premenopausal
22. Radiotherapy
Recurrence –
Chest wall – 90%
Axilla – 10%
Supraclav lymph node
mets – 5-10%
Postop RT decreases local
recurrence by 2/3rd
Recurrence Rate
Stage I 5-10%
Stage II 10-25%
Stage III 50%
Postop RT decreases recurrence rate in
Stage I - <5%
Stage II - <10%
Stage III – 10-15%
25. Supraclav lymph node RT – in pts with
4 or more +ve ALN
tumor size > 4-5cm
apical or central group of LN involved
inadequate ALND
Internal mammary nodal RT – unresolved issue
Pts with pathologically +ve axilla – IMN mets<5%
Relapsein IMN rare (<3%) even without RT
RT leads to fibrosis & cardiac problems
RT AVOIDED >70yrs with ER+, N- , <2cms, wide-ve
margins
26. Radiotherapy - techniqueRadiotherapy - technique
Positioning –
Supine position
Breast board
For large pendulous breasts – full or partial decubitus
When arm angled >90 – ax. nodes overlap head of Humerus
Field opened at 0 degree rotation on chest wall ; Lead wire placed
on lateral border
CLD Best predictor of %age of I/L lung vol. Irradiated
by tangential fields ; Perpendicular distance from post.
tangential field edge to post part of ant chest wall at
centre of field
27. Beam AccessoriesBeam Accessories
1. Wedges or compensators
– Used to produce minimal
(10% or less) dose variation
from base to apex
2. Bolus – increases dose to
skin and scar after
mastectomy ; poor cosmesis
28. Conformal radiotherapy
Supine or prone ; Spiral CT, 3mm slices
I/L breast marked with wires, C/L breast displaced postr.
CTV = entire breast and lumpectomy cavity including
seroma ; excludes skin, chest wall and muscles
6 MV photons ; Dose variation = 5-8 %
OAR = heart, lung , C/L breast
29. 1. Electrons – @ 85 -90% isodose line ; 9-16 MeV ; 10-20Gy
Set up - post lumpectomy volume or scar +2 cm in all directions
2. Interstitial implant - Large breasts & deep seated tumors (>4cm )
INtraoperative ; TV = primary tumor + 2-3 cms
Skin - source distance > 5 mm
Limitation – lack of detailed HPR
3. 3D CRT or IMRT
Greater dose heterogeneity for large breasts (vol>500cm3)
50% reduction in cardiac mortality ,V20 3.4%
Dose inhomogeneity – 15MV > Co60 > 6MV
Geometric uncertainties : patients, clips and cavity position
BOOST TO TUMOR BED
30. Boost ComplicationsBoost Complications
Criticism
3- 15% local recurrences, despite boost treatment
↑ labour/ cost
Pt inconvenience
Complications
↑ chances of s/c fibrosis
↑ telengiectasia & thinning of skin
Dreaded complication – Woody breast
Gr I/II – 25%
Gr III – 5-10%
31. EORTC Boost Trial
• 5318 patients randomized to a 16 Gy boost or no boost after 50 Gy
to whole breast
– Mainly CS T1-2 N0; no tumor on ink
• Boost reduced 5-yr LR by 41%; absolute benefit only 2.5% at 5 yrs
• 10yr local recurrence : 6.2 % Vs 10.2 %
Survival at 10 yrs: 82% for both arms
• This proportional reduction seen in all subsets
Bartelink et al. NEJM 345: 1378, 2001
Age No Boost Boost
< 40 23.9% 13.5%
41-50 12.5% 8.7%
51-60 7.8% 4.9%
> 60 7.3% 3.8%
Jones et al. J Clin Oncol; 27:4939-4947 2009
High Grade
Intd / low Grade
33. Current issues in radiation therapy
Treatment Volume:
Whole breast or Partial breast irradiation
Internal Mammary node irradiation
Fractionation: Standard or Hypofractionation
Indications of radiotherapy in early breast cancer:
Need of radiation for 1-3 lymph node + patients
Radiotherapy as an alternative to ALND in SLNB+ cases.
Treatment Techniques:
WBRT/LRRT: Tangential techniques or IMRT;
APBI: EBRT/Mammosite/Interstitial brachytherapy
Sequence of Radiation with chemotherapy
34. Internal mammary nodal RT
Routine use controversial ; Clinical failures rare
If axilla +ve – 30% IMN involved (else 10%)
Indications – medial / central tumors, large (>3cm) or high grade OR
radiologically positive
Irradiates more critical structures (lung & heart) ; C/L Breast
No difference in DFS or OS
TECHNIQUE : 1. WIDE tangentials – medial border – 3cm across midline
2. Separate field – from midline to 5-6cms laterally &
superiorly from 1st
ICS to cover 1st
three IMNs
3. Electrons
45-50Gy (1.8-2Gy/day)
Mixed photons and electrons
Depth @ 4- 5cms
35. APBI : AdvantagesAPBI : Advantages
Improves underutilization of BCT
Avoids prolonged Rx regimens, more acceptable
Reduces time, cost and inconvenience
Improves QOL & Reduces acute & chronic toxicity
Eliminates scheduling problems with CT / HT
36. Selection criteria
1
Arthur, et al. Accelerated partial breast irradiation: an updated report from the American
Brachytherapy Society. Brachytherapy, 1:184-190, 2003.
2
Consensus statement for accelerated partial breast irradiation. The American Society of Breast
Surgeons. April 30, 2003.
41. One time treatment with INTRABEAM®
(TARGIT trial )
BCS +
IORT
Current treatment methodCurrent treatment method
6-week irradiationBCS
IORT Boost with INTRABEAM®
BCS +
IORT
4-week post-op irrad.
Percutaneous boost
4 weeks
Boost
1 day
6 weeks
INTRABEAM IORT IN BCS
42. 04/06/15 AIIMS 42
START A Trial
•N=2236
•pT1-3a,pN0-1 M0
• requiring radiotherapy after
surgery (breast-conserving
surgery or mastectomy
•with clear tumour margins ≥1
mm
• aged over 18 years,
•did not have an immediate
surgical reconstruction
• available for follow-up
•N=2236
•pT1-3a,pN0-1 M0
• requiring radiotherapy after
surgery (breast-conserving
surgery or mastectomy
•with clear tumour margins ≥1
mm
• aged over 18 years,
•did not have an immediate
surgical reconstruction
• available for follow-up
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50 Gy/25#/5 weeks50 Gy/25#/5 weeks
41.6Gy/13#/5 weeks41.6Gy/13#/5 weeks
39 Gy/13#/5 weeks39 Gy/13#/5 weeks
14% received LRRT
BOOST- 10Gy
61% received BOOST
14% received LRRT
BOOST- 10Gy
61% received BOOST
The principal end points: local-regional relapse, normal tissue effects, and quality of life
43. 04/06/15 AIIMS 43
START B Trial
•N=2215
•pT1-3a,pN0-1 M0
• requiring radiotherapy after
surgery (breast-conserving
surgery or mastectomy
•with clear tumour margins ≥1
mm
• aged over 18 years,
•did not have an immediate
surgical reconstruction
• available for follow-up
•N=2215
•pT1-3a,pN0-1 M0
• requiring radiotherapy after
surgery (breast-conserving
surgery or mastectomy
•with clear tumour margins ≥1
mm
• aged over 18 years,
•did not have an immediate
surgical reconstruction
• available for follow-up
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50 Gy/25#/5 weeks50 Gy/25#/5 weeks
40Gy/15#/3 weeks40Gy/15#/3 weeks
14% received LRRT
BOOST- 10Gy
14% received LRRT
BOOST- 10Gy
The principal end points: local-regional relapse, normal tissue effects, and quality of life
43% received BOOST43% received BOOST
46. First results of the randomised UK FAST Trial of
radiotherapy hypo-fractionation
for treatment of early breast cancer (CRUKE/04/015)
5 weeks and 1 week
treatment associated with
equal disease control
47. ASTRO guidelines for
fractionation Int. J. Radiation Oncology Biol. Phys.; 81(1):59–68, 2011
IMPORT
High
IMPORT
Low
SHARE RTOG
# Pts 840 2100 2796 2150
Sites UK UK France US
Arms Gy
x #
2.4 x 15 (+
concurrent
12 gy or 17 Gy
Boost)
vs
2.67 x 15 (+16
Gy seq. boost)
2.67 x 15 WB
vs
2.4 x 15 WB +
Conc. Boost
vs
2.67 x 15 APBI
2 x 25 WB +
2 x 8 seq
vs
2.67 x 15 WB
vs
APBI
4 x 10
2 x 25
+ seq boost
VS
2.67 x 15 +
conc. Boost
48. No Consensus on the use of PMRT
1-3 LN +ve Pts.
Uncertain :
NIH Consensus Statement 2000
ASCO Guidelines, JCO 2001
ACR Appropriateness criteria, IJROBP, 2009
PMRT strongly considered in patients
with 1-3 positive nodes [NCCN 2012]
PMRT indicated inn 1-3 LN with any
risk factor ( ECE, LVI , young age< 50,
inadequate ALND) [ 8th
WCI-TMH ]
10yr LRR in 1-3 LN +ve
M D Anderson: 12%
ECOG: 13%
NSABP: 6-11%
IBCSG : 14-27%
49. PMRT in 1-3 LN +ve
Nodal ratio >0.20 LRR >20%
consider PMRT
BCG MDACC p
10-year LRR 21.5% 12.6% =0.02
10-year LRR :
NR≤0.20
17.7% 10.9% =0.07
10-year LRR :
NR>0.20
28.7% 22.7% =0.32Pauline et al. IJROBP 2007
- DBCG 82 b & c
- Overgaard et al, 2007
Survival benefit after PMRT was
substantial and similar in patients
with 1–3 and 4+ LN
PMRT No PMRT p
15-yrs LRFR;4+ N 10% 51% <0.001
15-yr LRFR;1-3+ N 4% 27% <0.001
15-yrs OS; 4+N 21% 12% =0.03
15-yrs OS; 1-3+N 57% 48% =0.03
51. Sequencing RT & CCT
A Cochrane review: 3 RCTs sequencing of CT & RT do not appear
to have a major effect on survival or recurrence for women with breast
cancer if RT starts within 7 months after surgery.
- Hickey BE, et al. 2006
52. Adjuvant systemic therapy : Why requiredAdjuvant systemic therapy : Why required ??
Stage 5 yr
survival
Stage I 80%
Stage II 50%
Stage III <30%
Stage IV <10%
Micro metastasis common at time of dx
Major threat of distant mets
CCT more effective than Tmx in younger
pts
Taxanes max benefit in Her2 +ve , N+
Results of loco regional t/t by surgery & RT
53. IndicationsIndications
All pts with node + axilla
Node –ve axilla with -
1. Tumor size >1cm
2. Grade 2-3 tumors
3. Young women
4. Surgical margins – close , +ve or unknown
5. Lympho-vascular emboli
6. High proliferative index
7. ER/PR - -ve
54. Progress in Chemotherapy for Early StageProgress in Chemotherapy for Early Stage
Breast CancerBreast Cancer
Combination chemotherapy (CMF)
Use of anthracyclines
Addition of taxanes
Superior taxane containing regimens
Addition of trastuzumab
1970s
2000s
BUT: ALL chemotherapy is associated with
toxicities and risks… need better ways to identify
which patients will benefit from treatment
55. Improved survival with poly CT; 15 yrs
FU
Anthra. adds benefit in unselected
N+ve tumors
5yr DFS
65% vs 70 %
5yr OS
77% vs 80 %
EBCTG 2005
Peto et al, 2007
CALGB 9344
5yr OS benefit
of 5.1%
EBCTG ‘05
TAXANES
EBCTG ‘05
57. GENOMIC PROFILING
early breast cancer, N- , ER+ve, Her2 –ve
1.Oncotype Dx -- 21 gene signature, RT-PCR on21 gene signature, RT-PCR on
formalin fixed specimenformalin fixed specimen
Prognostic , predictive risk of 10 yr DRPrognostic , predictive risk of 10 yr DR
2.2. Mammaprint- 70 gene signature, paraffin fixed OR- 70 gene signature, paraffin fixed OR
Fresh tissue ; Can be used for ER- andFresh tissue ; Can be used for ER- and
Her2 +ve tumors as wellHer2 +ve tumors as well
3.3. PAM50 (risk of recurrence score) – 50 genes(risk of recurrence score) – 50 genes
4.4. Rotterdam 76 gene signatureRotterdam 76 gene signature
5. Genomic grade index5. Genomic grade index
6. Breast cancer index6. Breast cancer index
RXpONDER Trial – evaluating benfit in 1-3 node+ disease
ERA OF PERSONALISED
MEDICINE
59. Hormonal management – A balance
Fracture
fatigue
Hot flush Hot flush
Endometrial
carcinoma
Thrombo-embolism
Aromatase Inhibitors
Non-Steroidal
Anastrozole
Letrozole
Steroidal
Exemestane
Tamoxifen
ATAC- No OS benefit
BIG 1-98- 4% OS benifit
IES 2.1% OS benefit
ARNO-95- 2.3% OS benifit
ATAC- No OS benefit
BIG 1-98- 4% OS benifit
IES 2.1% OS benefit
ARNO-95- 2.3% OS benifit
Switch /Mono-therapy
60. Tamoxifen
Competitive antagonist of estrogen
EBCTCG ,1998 :
47% - fewer recurrences
26% less mortality
Absolute OS benefit @ 5 yrs in N+ and N- by
10.9% & 5.6%
Decrease risk of C/L breast Ca
regardless of ER/PR status, age
Positive effect on bone density
NSABP B23 – no benefit in ER/PR-
Receptor
status
Response
rate (%)
ER+/PR+ 70
ER+/PR- 50
ER-/PR+ 40
ER-/PR- <10
1 of every 2 recurrences
1 of every 3 deaths
61. Pre or peri menopausal women intolerant to tamoxifen OR
want to preserve fertility offer ovarian suppression ( triptorelin)
with AI [OS+ AI better than OS+T]
- SOFT trial , IBCSG, ASCO 2014
- TEXT trial, IBCSG , ASCO 2014
62. Aromatase InhibitorsAromatase Inhibitors
Prevent periph conversion of androgens to estrogen selective
estrogen deprivation without impairment of adr. androgen synth.
No AI found superior to another *
Less S/E than Tmx, more efficacy in postmenop.
* absolute 2.9% decrease in recurrence & 1.1% OS benefit (NS)absolute 2.9% decrease in recurrence & 1.1% OS benefit (NS)
– metaanalysis; Dowsett, JCO 2010
- BIG 1-98 trial, ATAC Trial
3 generations
1st
: Aminoglutethemide
2nd
: Formestane (Type I) ,
Fadrazole
3rd
: Exemestane (Type I) ,
Anastrazole , Letrozole,
Vorozole
* NCI-CTG MA.27 trial, 2013
63. Effect of anastrozole and tamoxifen as adjuvant treatment
for early-stage breast ca: 10-yr analysis of the ATAC trial
Jack Cuzick et al, Lancet Oncol 2010
Anastrazole showed significant benefit in terms of DFS, LR or DM
but Fractures were more common
64. Five Years of Letrozole Compared With Tamoxifen
As Initial Adjuvant Therapy for Postmenopausal
Women With Endocrine-Responsive Early Breast
Cancer: Update of Study BIG 1-98
Alan S. Coates et al, JCO, 2007
PFS significantly better,
without impact on OS
67. Ovarian ablationOvarian ablation
– Types – surgical / radiation / medical
– Scottish trial:
Ovarian ablation was equally effective as adjuvant CCT with CMF
In ER +ve women a trend towards better survival was found with
ovarian ablation
– ZEBRA trial:
Goserelin ( x 2yrs) was as effective as CMF ( x 6 cycles) in ER
+ve, stage II & node +ve patients.
In the ER –ve subgroup CMF had better OS and DFS.
Thus at best, ovarian ablation is as good as CMF based
CCT ( but not better) in the ER +ve premenopausal
females with early stage disease.
68. TechniqueTechnique
Position: Supine
Field selection: Parallel opposing two field technique
Energy : Co60
or 6 MV LINAC
Dose Schedules:
– In a younger women 10 – 12 Gy in 5 -6 divided fractions is
preferred.
– In older women shorter course of radiation can give equivalent
ovarian ablation.
Field borders:
– The volume of interest is the entire true pelvis
– 10 x 15 cm field is opened.
– Lower border is placed just below the superior border of pubic
symphysis.
69. Study design- Bolero II
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•multicenter,
•open-label
•phase III study
•N=724
•Randomization
2:1 ratio
Exemestane 25 mg OD
+Placebo 20 mg/d
Exemestane 25 mg OD +
everolimus 10 mg/d.
March 2008 and May 2009,
• The primary end point PFS
• Secondary end points: overall survival, overall response
rate, clinical benefit rate, time to deterioration
of ECOG performance status, safety, and quality of life
• The primary end point PFS
• Secondary end points: overall survival, overall response
rate, clinical benefit rate, time to deterioration
of ECOG performance status, safety, and quality of life
• At least one measurable
lesion or mainly lytic bone
lesions in the absence of
measurable disease
• Exclusion criteria included a
history of brain metastases
and previous treatment with
exemestane or mTOR
inhibitors
• At least one measurable
lesion or mainly lytic bone
lesions in the absence of
measurable disease
• Exclusion criteria included a
history of brain metastases
and previous treatment with
exemestane or mTOR
inhibitors
Hormonal
resistance
71. Over expression > 50% DCIS and approx 1/3 rd IDC
Shortened Median Survival
HER2 over expression 3 yrs
HER2 normal 6-7 yrs
Transtuzumab binds to extra-
cellular membrane domain of
Her2 and inhibits signalling and
proliferation
Trastuzumab: Humanized Anti-HER-2 Monoclonal Antibody
72. Trastuzumab significantly reduces the risk of recurrence and prolongs OS
Concurrent administration superior to sequential (NCCTG/NSABP B-31)
A reduction in recurrence also seen with sequential administration (HERA)
Safety issues with trastuzumab include
− Cardiotoxicity, Hypersensitivity, Anaphylaxis
NSABP B31 / N 9831 (2012) OS benefit was significant for
≥ 60 yrs (13.7%), ≥ 10 Nodes + (15.6%), and tumors ≥ 5.0 cm (11.8%).
Methylene blue and 99 m-Technetium (99-Tc) – safe in pregnancy ( NCCN 2011) but ASCO recommends against it
QOL items in the arm symptom scale: swelling (ART better) and movement (ALND better)
Boost field: tumor site + 1.5 cm if “completely excised” (3 cm if not)
percutaneous electron boost
Reduces tte risk for recurrence from 7.3 % to 4.3 % after 5 years
often initiated with a delay of several months after surgery causing higher recurrence rate
It fails to hit the exact former location of the tumor in 50 - 80% of patients(e.g. Benda RK et al., Cancer 2003; 97:905)
Side effects
Hot flashes
Vaginal dryness, discharge
Risk of endometrial cancer
Increased TE events
Cataracts
However timing and duration of switch remain to be established.
Use in premenopausal women not recommended.
Whether AI &gt; 5yrsis beneficial ?? NSABP 42 & NCIC-MA 17R Trial ongoing
Scottish Cancer Trials Breast Group and ICRF Breast Unit GsH, London. Adjuvant ovarian ablation versus CMF chemotherapy in premenopausal women with pathological stage II breast carcinoma: the Scottish trial. Lancet 1993;341:1293–1298.
Jonat W, Kaufmann M, Sauerbrei W, et al. Goserelin versus cyclophosphamide, methotrexate, and fluorouracil as adjuvant therapy in premenopausal patients with node-positive breast cancer: the Zoladex Early Breast Cancer Research Association Study. J Clin Oncol 2002;20:4628–4635.