breast%20cancer
BREAST CANCER
Treatment Guideline Chart
Breast cancer is the presence of malignant breast nodule, mass or abscess.
Most common symptom of breast cancer is a new lump or mass in the breast. The lump or mass is usually painless, hard & irregular but it can also be tender, soft, rounded or painful.
Other signs & symptoms include breast pain or nipple pain, nipple discharge, nipple retraction and presence of breast skin changes (eg peau d' orange, nipple excoriation, scaling, inflammation, skin tethering, ulceration, abscess).

Radiotherapy (RT)

  • Treatment with high-energy rays or particles that destroy cancer cells
  • Also used to treat cancer that has metastasized to other organs
  • Can be given as external beam radiation therapy (EBRT) or brachytherapy
Whole Breast Radiation Therapy (WBRT)
  • Targets the entire breast tissue
  • Recommended for patients with DCIS who had breast-conserving surgery and for postlumpectomy patients to decrease the chance of recurrence
  • Recommended dose: 45-50.4 Gy in 25-28 fractions or 40-42.5 Gy in 15-16 fractions with or without boost to tumor bed at 10-16 Gy in 4-8 fractions to be given 5 days per week
  • Boost RT to tumor bed at 10-16 Gy in 4-8 fractions further reduces the risk for disease relapse especially in patients at high-risk for local recurrence (>50 years old, with grade 3 tumors, with vascular invasion or extensive intraductal component and radical tumor excision)
Chest Wall RT
  • Targets the ipsilateral chest wall, mastectomy scar, and may also drain indicated sites
  • Recommended dose: 45-50.4 Gy in 25-28 fractions to the chest wall with or without scar boost at 1.8-2 Gy per fraction; total dose of approximately 60-66 Gy, to be given 5 days per week
Regional Nodal Radiation
  • Recommended for patients with lymph node (LN) involvement
  • CT-based planning is recommended
  • Recommended dose: 45-50.4 Gy in 25-28 fractions to the regional nodal fields, to be given 5 days per week
Accelerated Partial-breast Irradiation (APBI)
  • Treatment option in patients with low-risk for local recurrence prior to chemotherapy, especially if with history of adjuvant endocrine therapy
  • May consider APBI in low-risk patients if any one of the following is present:
    • ≥50 years old with invasive ductal carcinoma ≤2 cm (T1) with negative margin widths of ≥2 mm, no lymphovascular involvement, ER-positive and BRCA-negative
    • Low/intermediate nuclear grade DCIS detected during screening measuring ≤2.5 cm with negative margin widths of ≥3 mm
  • May also be considered in patients with DCIS
  • Recommended dose: 34 Gy in 10 fractions given 2x/day with brachytherapy or 38.5 Gy fractions 2x/day via EBRT

Radiotherapy for Invasive Breast Cancer Stage I, IIA, IIB, IIIA (T3N1M0)
Post-mastectomy RT

  • RT to the chest wall, infraclavicular region, supraclavicular area, and internal mammary nodes and to any area of involved axillary nodes is recommended for patients with ≥4 positive axilllary nodes
  • RT to the chest wall, infraclavicular region, supraclavicular area, and internal mammary nodes and to any area of involved axillary nodes should be strongly considered in patients with 1-3 positive axilllary nodes
  • RT to the chest wall, with or without coverage of the supraclavicular and infraclavicular region, supraclavicular area, and internal mammary nodes and any area of involved axillary nodes, may be considered in patients without any involved axilllary nodes but with tumor >5 cm in size and those with positive margins if re-excision is not feasible
  • RT to the chest wall, with or without regional nodal radiation in patients with central or medial tumors, tumor ≥2 cm in size with <10 axillary nodes removed and with grade 3, ER-negative or lymphovascular invasion should be considered in patients without axillary node involvement, tumor ≤5 cm, and negative margins but <1 mm
  • Commonly done after chemotherapy except in patients with negative axillary nodes and tumor with ≤5 cm in size and margins ≥1 mm
Post-lumpectomy RT
  • RT to the whole breast with or without boost to tumor bed, supraclavicular and infraclavicular areas, and internal mammary nodes, and within the area of involved axillary nodes is recommended for patients with ≥4 positive axilllary nodes
  • RT to the whole breast with or without boost to tumor bed is recommended for patients with 1-3 positive axillary nodes, with consideration for supraclavicular, infraclavicular, and internal mammary node radiotherapy and to any area of involved axillary nodes
    • Recommended as locoregional treatment in patients with unmet requirements for the ACOSOG Z0011 criteria
    • Boost to tumor bed should be considered in patients with high-risk features (eg high-grade disease, <50 years of age)
  • RT to the whole chest with or without boost to tumor bed is recommended in patients negative for axillary node involvement
    • May consider regional nodal radiation in patients with tumors >2 cm in size or tumors located near or at the center with other high-risk features
  • Commonly done after chemotherapy
  • May be omitted in patients ≥70 years of age with ER-positive, cN0, T1 tumors who received adjuvant endocrine therapy

RT for Invasive Breast Cancer Stage IIIA (except T3N1M0), IIIB, IIIC

  • Adjuvant RT to the chest wall, infraclavicular region, supraclavicular area, and internal mammary nodes and to any area of involved axillary nodes should be considered in postmastectomy patients at risk of invasive disease and axillary LN involvement and indicated if with node involvement
  • WBRT with or without boost to the tumor bed instead of chest wall RT is recommended for postlumpectomy patients
    • RT to the infraclavicular region, supraclavicular area, and internal mammary nodes and to any area of involved axillary nodes should be considered in postlumpectomy patients at risk of invasive disease and axillary LN involvement and should be done if positive for node involvement
  • For patients with inoperable tumor upon initial diagnosis with positive response to preoperative systemic therapy and subsequently underwent surgery, adjuvant RT to the whole breast/chest wall, infraclavicular region, supraclavicular area, internal mammary nodes and to any area of involved axillary nodes is recommended
Editor's Recommendations