Breast%20cancer Management

Stratification for Systemic Therapy

• Recommended in early breast cancer
• May guide in patient selection for chemotherapy addition
• Patients are further stratified based on responsiveness to endocrine therapy, Trastuzumab and risk for disease recurrence

Categories of Endocrine Responsiveness

Highly Endocrine Responsive

• Majority of tumor cells express high levels of ER and PR

Incompletely Endocrine Responsive

• Lower-level expression of ER and/or PR, or absence of either ER or PR

Endocrine Non-responsive

• Total absence of ER and PR expression

• Clinical evaluation every 6-12 months x5 years, then annually
• Mammogram every 12 months (6-12 months if after breast conservation therapy)
• Patients on endocrine therapy
  • Breast cancer surveillance
  • Gynecologic evaluation annually
  • Ophthalmologic exam for vision problems
  • Bone density monitoring

• Assess for suspected recurrence
• Clinical evaluation 1-4 times/year x 5 years, then annually
• Annual mammography
• Annual gynecologic exam in women with uterus taking Tamoxifen
• Bone mineral density determination in women taking an aromatase inhibitor or who have ovarian failure from treatment
• Educate on lymphedema management
• Advise adherence to therapy, active and healthy lifestyle and maintenance of ideal body weight

• Disease progression is characterized by ≥1 of the following factors: Worsening symptoms, worsening signs or new disease on physical examination, declining performance status, unexplained weight loss, increased alkaline phosphatase, AST, ALT, bilirubin or serum calcium level, new lesions on imaging exams, increased lesion size on imaging, increasing tumor markers (eg carcinoembryonic antigen, CA 15-3, CA 27.29)
• History taking and physical exam, performance status assessment, weight measurement, liver function test (LFT) and CBC should be done every 1-3 months for patients given endocrine therapy and to be done before the start of each chemotherapy cycle
• Follow-up CT scan of the chest, abdomen or pelvis is recommended every 2-6 months for patients given endocrine therapy and every 2-4 cycles for patients undergoing chemotherapy
• Bone scan every 4-6 cycles is recommended for patients undergoing chemotherapy and every 2-6 months for patients given endocrine therapy
• Repeat PET/CT scan and tumor markers may be obtained as clinically indicated