<prompt> Which of the following isare used in hormonal therapy of breast carcinoma?LetrozoleAnastrozoleTamoxifenAll of the above  <response>: Ans. d All of the above Ref. Sabiston I8,h Table 34-17; H-17,hTable 86-3Endocrine-Active Agents Used in the Treatment of Breast Cancer ClassCommon examplesClinical use1Selective estrogen receptor modulators SERMsQTamoxifen, Raloxifene, ToremifeneAdjuvant therapy for metastatic disease2Aromatase inhibitors AIsAnastrozole Letrozole Exemestane Adjuvant therapy for metastatic disease3Pure antiestrogensFulvestrantSecond-line therapy for metastatic disease4LHRH agonistsGoserelin, LeuprolideAdjuvant therapy for metastatic disease5Progestational agentsMegestrolSecond-line agent for metastatic disease6AndrogensFluoxymesteroneThird-line agent for metastatic disease7High-dose estrogensDiethylstilbestrolThird-line agent for metastatic diseaseHORMONAL THERAPY FOR CARCINOMA BREASTIn patients with node-negative cancer, certain groups may suffer higher relapse rates, and the absolute benefits of chemotherapy are greater. Poor prognostic signs follow:1. Tumor size 2 cm2. Poor histologic and nuclear grade3. Absent hormone receptors4. High proliferative fraction S phase5. Content of certain oncogenes such as erb-B2 HER-2neuDrug tamoxifen is an estrogen agonist-antagonist and currently the first-line Rx of estrogen-sensitive breast cancer.Educational PointsNew Agents for Ca breast Trastuzumab Herceptin is a humanized murine monoclonal ab raised against the erb-B2 or HER-2 surface receptor. Agents that specifically target EGFR include erlotinib and gefitinib and the monoclonal antibody cetuximab. These drugs have found most use in non-small cell lung, pancreatic, and colorectal cancer. Dual inhibitors of both EGFR and HER-2 have been developed and are finding their way into the treatment of breast cancer e.g., lapatinib, a dual inhibitor of both enzymes.Age GroupLymph Node StatusEndocrine Receptor ER StatusTumorRecommendationPremenopausalPositiveAnyAnyMultidrug chemotherapy tamoxifen if ER-positive trastuzumab in HER-2neu positive tumorsPremenopausalNegativeAny2 cm, or 1-2 cm with other poor prognostic variablesMultidrug chemotherapy tamoxifen if ER-positive trastuzumab in HER-2neu positive tumorsPost-menopausalPositiveNegativeAnyMultidrug chemotherapy trastuzumab in HER-2neu positive tumorsPostmenopausalPositivePositiveAnyAromatase inhibitors and tamoxifen with or without chemotherapy trastuzumab in HER-2neu positive tumorsPostmenopausalNegativePositive2 cm, or 1-2 cm with other poor prognostic variablesAromatase inhibitors and tamoxifen trastuzumab in HER-2neu positive tumorsPostmenopausal NegativeNegative2 cm, or 1-2 cm with other poor prognostic variablesConsider multidrug chemotherapy trastuzumab in HER-2neu positive tumors. 