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Breast cancer survivor offers wisdom at Faulkner satellite center
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Poet Richard Fox gains insight – and material – through cancer treatment
A family faces cancer in an unfamiliar city – with help
Choosing mastectomy or not: Studying young women's surgical choices
Jeff's targeted therapy has kept his advanced lung cancer at bay.
Ductal carcinoma in situ (DCIS) is a noninvasive condition in which abnormal cells are found in the lining of a breast duct. The abnormal cells have not spread outside the duct to other tissues in the breast.
At the Susan F. Smith Center for Women's Cancers Breast Oncology Program, we know you face challenges beyond your immediate medical care. That knowledge guides how our specialists work with you to create a care plan that takes your individual needs into account.
In addition to offering the latest in clinical care, we provide a wide range of resources — from support groups to nutritional advice to information about complementary therapies — to support you physically and emotionally throughout your treatment.
Your treatment team is made up of some of the world's most experienced and respected oncologists (cancer specialists), who focus their care and research specifically on breast cancer.
They have experience with all types of the disease, including ductal carcinoma in situ, infiltrating (invasive) ductal carcinoma, lobular carcinoma in situ, infiltrating (invasive) lobular carcinoma, Paget's disease, and phyllodes tumors.
We also have a specific program to treat women with inflammatory breast cancer.
We know that young women with breast cancer face different challenges. Our Program for Young Women with Breast Cancer combines treatment, research, and specialized support to meet the needs of women aged 40 and younger who have had a breast cancer diagnosis.
Breast cancer is often thought of as a disease that affects only women, but men can be diagnosed with breast cancer, too. Our Male Breast Cancer Program is dedicated to the unique needs of men.
Whatever your breast cancer diagnosis, we are committed to providing personalized, compassionate, comprehensive care.
Learn more about treatment and support for breast cancer patients.
New patients
If you have never been seen before at Dana-Farber/Brigham and Women's Cancer Center, please call 877-442-3324 or use this online form to make an appointment.
For all other inquiries, please call 617-632-3800
Mailing address:Susan F. Smith Center for Women's Cancers Breast Oncology ProgramDana-Farber Cancer Institute450 Brookline Ave.Boston, MA 02115-5450
The breast is made up of lobes and ducts. Each breast has 15 to 20 sections called lobes, which have many smaller sections called lobules. Lobules end in dozens of tiny bulbs that can make milk. The lobes, lobules, and bulbs are linked by thin tubes called ducts.
Each breast also has blood vessels and lymph vessels. The lymph vessels carry an almost colorless fluid called lymph. Lymph vessels lead to organs called lymph nodes. Lymph nodes are small bean-shaped structures that are found throughout the body. They filter substances in a fluid called lymph and help fight infection and disease. Clusters of lymph nodes are found near the breast in the axilla (under the arm), above the collarbone, and in the chest.
The most common type of breast cancer is ductal carcinoma, which begins in the cells of the ducts. Cancer that begins in the lobes or lobules is called lobular carcinoma and is more often found in both breasts than are other types of breast cancer. Inflammatory breast cancer is an uncommon type of breast cancer in which the breast is warm, red, and swollen.
See the following PDQ summaries for more information:
Anything that increases your chance of getting a disease is called a risk factor. Having a risk factor does not mean that you will get cancer; not having risk factors doesn't mean that you will not get cancer. Talk with your doctor if you think you may be at risk. Risk factors for breast cancer include the following:
NCI's Breast Cancer Risk Assessment Tool uses a woman's risk factors to estimate her risk for breast cancer during the next five years and up to age 90. This online tool is meant to be used by a health care provider. For more information on breast cancer risk, call 1-800-4-CANCER.
The genes in cells carry the hereditary information that is received from a person's parents. Hereditary breast cancer makes up about 5% to 10% of all breast cancer. Some mutated genes related to breast cancer are more common in certain ethnic groups.
Women who have certain gene mutations, such as a BRCA1 or BRCA2 mutation, have an increased risk of breast cancer. Also, women who have had breast cancer in one breast have an increased risk of developing breast cancer in the other breast. These women also have an increased risk of ovarian cancer, and may have an increased risk of other cancers. Men who have a mutated gene related to breast cancer also have an increased risk of this disease. For more information, see the PDQ summary on Male Breast Cancer Treatment.
There are tests that can detect (find) mutated genes. These genetic tests are sometimes done for members of families with a high risk of cancer. See the PDQ summary on Genetics of Breast and Ovarian Cancer for more information.
These and other signs may be caused by breast cancer or by other conditions. Check with your doctor if you have any of the following:
A doctor should be seen if changes in the breast are noticed. The following tests and procedures may be used:
Decisions about the best treatment are based on the results of these tests. The tests give information about:
Tests include the following:
The prognosis (chance of recovery) and treatment options depend on the following:
The process used to find out whether the cancer has spread within the breast or to other parts of the body is called staging. The information gathered from the staging process determines the stage of the disease. It is important to know the stage in order to plan treatment. The following tests and procedures may be used in the staging process:
Cancer can spread through tissue, the lymph system, and the blood:
When cancer spreads to another part of the body, it is called metastasis. Cancer cells break away from where they began (the primary tumor) and travel through the lymph system or blood.
The metastatic tumor is the same type of cancer as the primary tumor. For example, if breast cancer spreads to the bone, the cancer cells in the bone are actually breast cancer cells. The disease is metastatic breast cancer, not bone cancer.
This section describes the stages of breast cancer. The breast cancer stage is based on the results of testing that is done on the tumor and lymph nodes removed during surgery and other tests.
There are 3 types of breast carcinoma in situ:
In stage I, cancer has formed. Stage I is divided into stages IA and IB.
Stage II is divided into stages IIA and IIB.
In stage IIIA:
In stage IIIB, the tumor may be any size and cancer has spread to the chest wall and/or to the skin of the breast and caused swelling or an ulcer. Also, cancer may have spread to:
Cancer that has spread to the skin of the breast may also be inflammatory breast cancer. See the section on Inflammatory Breast Cancer for more information.
In stage IIIC, no tumor is found in the breast or the tumor may be any size. Cancer may have spread to the skin of the breast and caused swelling or an ulcer and/or has spread to the chest wall. Also, cancer has spread to:
For treatment, stage IIIC breast cancer is divided into operable and inoperable stage IIIC.
In stage IV, cancer has spread to other organs of the body, most often the bones, lungs, liver, or brain.
In inflammatory breast cancer, cancer has spread to the skin of the breast and the breast looks red and swollen and feels warm. The redness and warmth occur because the cancercells block the lymph vessels in the skin. The skin of the breast may also show the dimpled appearance called peau d'orange (like the skin of an orange). There may not be any lumps in the breast that can be felt. Inflammatory breast cancer may be stage IIIB, stage IIIC, or stage IV.
Recurrentbreast cancer is cancer that has recurred (come back) after it has been treated. The cancer may come back in the breast, in the chest wall, or in other parts of the body.
Different types of treatment are available for patients with breast cancer. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment. Patients may want to think about taking part in a clinical trial. Some clinical trials are open only to patients who have not started treatment.
Most patients with breast cancer have surgery to remove the cancer from the breast. Some of the lymph nodes under the arm are usually taken out and looked at under a microscope to see if they contain cancer cells.
Breast-conserving surgery, an operation to remove the cancer but not the breast itself, includes the following:
Patients who are treated with breast-conserving surgery may also have some of the lymph nodes under the arm removed for biopsy. This procedure is called lymph node dissection. It may be done at the same time as the breast-conserving surgery or after. Lymph node dissection is done through a separate incision.
Other types of surgery include the following:
Chemotherapy may be given before surgery to remove the tumor. When given before surgery, chemotherapy will shrink the tumor and reduce the amount of tissue that needs to be removed during surgery. Treatment given before surgery is called neoadjuvant therapy.
Even if the doctor removes all the cancer that can be seen at the time of the surgery, some patients may be given radiation therapy, chemotherapy, or hormone therapy after surgery to kill any cancer cells that are left. Treatment given after the surgery, to lower the risk that the cancer will come back, is called adjuvant therapy.
If a patient is going to have a mastectomy, breast reconstruction (surgery to rebuild a breast's shape after a mastectomy) may be considered. Breast reconstruction may be done at the time of the mastectomy or at a future time. The reconstructed breast may be made with the patient's own (nonbreast) tissue or by using implants filled with saline or silicone gel. Before the decision to get an implant is made, patients can call the Food and Drug Administration's (FDA) Center for Devices and Radiologic Health at 1-888-INFO-FDA (1-888-463-6332) or visit the FDA's Web site for more information on breast implants.
Sentinel lymph node biopsy is the removal of the sentinel lymph node during surgery. The sentinel lymph node is the first lymph node to receive lymphatic drainage from a tumor. It is the first lymph node the cancer is likely to spread to from the tumor. A radioactive substance and/or blue dye is injected near the tumor. The substance or dye flows through the lymph ducts to the lymph nodes. The first lymph node to receive the substance or dye is removed. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are not found, it may not be necessary to remove more lymph nodes. After the sentinel lymph node biopsy, the surgeon removes the tumor (breast-conserving surgery or mastectomy).
Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells or keep them from growing. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping them from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the cerebrospinal fluid, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). The way the chemotherapy is given depends on the type and stage of the cancer being treated.
See Drugs Approved for Breast Cancer for more information.
Hormone therapy is a cancer treatment that removes hormones or blocks their action and stops cancer cells from growing. Hormones are substances made by glands in the body and circulated in the bloodstream. Some hormones can cause certain cancers to grow. If tests show that the cancer cells have places where hormones can attach (receptors), drugs, surgery, or radiation therapy is used to reduce the production of hormones or block them from working. The hormone estrogen, which makes some breast cancers grow, is made mainly by the ovaries. Treatment to stop the ovaries from making estrogen is called ovarian ablation.
Hormone therapy with tamoxifen is often given to patients with early stages of breast cancer and those with metastatic breast cancer (cancer that has spread to other parts of the body). Hormone therapy with tamoxifen or estrogens can act on cells all over the body and may increase the chance of developing endometrial cancer. Women taking tamoxifen should have a pelvic exam every year to look for any signs of cancer. Any vaginal bleeding, other than menstrual bleeding, should be reported to a doctor as soon as possible.
Hormone therapy with an aromatase inhibitor is given to some postmenopausal women who have hormone-dependent breast cancer. Hormone-dependent breast cancer needs the hormone estrogen to grow. Aromatase inhibitors decrease the body's estrogen by blocking an enzyme called aromatase from turning androgen into estrogen.
For the treatment of early stage breast cancer, certain aromatase inhibitors may be used as adjuvant therapy instead of tamoxifen or after 2 or more years of tamoxifen. For the treatment of metastatic breast cancer, aromatase inhibitors are being tested in clinical trials to compare them to hormone therapy with tamoxifen.
Targeted therapy is a type of treatment that uses drugs or other substances to identify and attack specific cancer cells without harming normal cells. Monoclonal antibodies and tyrosine kinase inhibitors are two types of targeted therapies used in the treatment of breast cancer. PARP inhibitors are a type of targeted therapy being studied for the treatment of triple-negative breast cancer.
Monoclonal antibody therapy is a cancer treatment that uses antibodies made in the laboratory, from a single type of immune system cell. These antibodies can identify substances on cancer cells or normal substances that may help cancer cells grow. The antibodies attach to the substances and kill the cancer cells, block their growth, or keep them from spreading. Monoclonal antibodies are given by infusion. They may be used alone or to carry drugs, toxins, or radioactive material directly to cancer cells. Monoclonal antibodies may be used in combination with chemotherapy as adjuvant therapy.
Trastuzumab is a monoclonal antibody that blocks the effects of the growth factorproteinHER2, which sends growth signals to breast cancer cells. About one-fourth of patients with breast cancer have tumors that may be treated with trastuzumab combined with chemotherapy.
Pertuzumab is a monoclonal antibody that may be combined with trastuzumab and chemotherapy to treat breast cancer. It may be used to treat certain patients with HER2-positive breast cancer that has metastasized (spread to other parts of the body). It may also be used as neoadjuvant therapy in certain patients with early-stage HER2-positive breast cancer.
Ado-trastuzumab emtansine is a monoclonal antibody linked to an anticancer drug. This is called an antibody-drug conjugate. It is used to treat HER2-positive breast cancer that has spread to other parts of the body or recurred (come back).
Tyrosine kinase inhibitors are targeted therapy drugs that block signals needed for tumors to grow. Tyrosine kinase inhibitors may be used with other anticancer drugs as adjuvant therapy.
Lapatinib is a tyrosine kinase inhibitor that blocks the effects of the HER2 protein and other proteins inside tumor cells. It may be used with other drugs to treat patients with HER2-positive breast cancer that has progressed after treatment with trastuzumab.
PARP inhibitors are a type of targeted therapy that block DNA repair and may cause cancer cells to die. PARP inhibitor therapy is being studied for the treatment of triple-negative breast cancer.
This summary section describes treatments that are being studied in clinical trials. It may not mention every new treatment being studied. Information about clinical trials is available from the NCI Web site.
High-dose chemotherapy with stem cell transplant is a way of giving high doses of chemotherapy and replacing blood-forming cells destroyed by the cancer treatment. Stem cells (immature blood cells) are removed from the blood or bone marrow of the patient or a donor and are frozen and stored. After the chemotherapy is completed, the stored stem cells are thawed and given back to the patient through an infusion. These reinfused stem cells grow into (and restore) the body's blood cells.
Studies have shown that high-dose chemotherapy followed by stem cell transplant does not work better than standard chemotherapy in the treatment of breast cancer. Doctors have decided that, for now, high-dose chemotherapy should be tested only in clinical trials. Before taking part in such a trial, women should talk with their doctors about the serious side effects, including death, that may be caused by high-dose chemotherapy.
For some patients, taking part in a clinical trial may be the best treatment choice. Clinical trials are part of the cancer research process. Clinical trials are done to find out if new cancer treatments are safe and effective or better than the standard treatment.
Many of today's standard treatments for cancer are based on earlier clinical trials. Patients who take part in a clinical trial may receive the standard treatment or be among the first to receive a new treatment.
Patients who take part in clinical trials also help improve the way cancer will be treated in the future. Even when clinical trials do not lead to effective new treatments, they often answer important questions and help move research forward.
Some clinical trials only include patients who have not yet received treatment. Other trials test treatments for patients whose cancer has not gotten better. There are also clinical trials that test new ways to stop cancer from recurring (coming back) or reduce the side effects of cancer treatment.
Clinical trials are taking place in many parts of the country. See the Treatment Options section that follows for links to current treatment clinical trials. These have been retrieved from NCI's listing of clinical trials.
Some of the tests that were done to diagnose the cancer or to find out the stage of the cancer may be repeated. Some tests will be repeated in order to see how well the treatment is working. Decisions about whether to continue, change, or stop treatment may be based on the results of these tests. This is sometimes called re-staging.
Some of the tests will continue to be done from time to time after treatment has ended. The results of these tests can show if your condition has changed or if the cancer has recurred (come back). These tests are sometimes called follow-up tests or check-ups.
Treatment of ductal carcinoma in situ (DCIS) may include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with ductal breast carcinoma in situ. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.
Treatment of lobular carcinoma in situ (LCIS) may include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with lobular breast carcinoma in situ. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.
Treatment of stage I, stage II, stage IIIA, and operablestage IIIC breast cancer may include the following:
Adjuvant therapy (treatment given after surgery to lower the risk that cancer will come back) may include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I breast cancer, stage II breast cancer, stage IIIA breast cancer and stage IIIC breast cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.
Treatment of stage IIIB and inoperablestage IIIC breast cancer may include the following:
Treatment of stage IV or metastaticbreast cancer may include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IIIB breast cancer, stage IIIC breast cancer and stage IV breast cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.
Treatment of inflammatory breast cancer may include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with inflammatory breast cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.
Treatment of triple-negative breast cancer may include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with triple-negative breast cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.
Treatment of recurrentbreast cancer (cancer that has come back after treatment) in the breast or chest wall may include the following:
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with recurrent breast cancer. For more specific results, refine the search by using other search features, such as the location of the trial, the type of treatment, or the name of the drug. Talk with your doctor about clinical trials that may be right for you. General information about clinical trials is available from the NCI Web site.
For more information from the National Cancer Institute about breast cancer, see the following:
For general cancer information and other resources from the National Cancer Institute, see the following:
This information is provided by the National Cancer Institute.
This information was last updated on May 23, 2014.
This summary discusses only
primary epithelial breast cancers. Rarely, the breast may be involved by other
tumors such as lymphomas, sarcomas, or melanomas. (Refer to the PDQ summaries on Adult Hodgkin Lymphoma Treatment, Adult Soft Tissue Sarcoma Treatment, and Melanoma Treatment for more information.)
Estimated new cases and deaths from breast cancer (women only) in the United States in 2014:[1]
Several well-established factors have been associated with an increased risk of
breast cancer, including family history, nulliparity, early menarche,
advanced age, and a personal history of breast cancer (in situ or invasive).
Age-specific risk estimates are available to help counsel and design
screening strategies for women with a family history of breast cancer.[2][3] Of all women with breast cancer, 5% to 10% may have a germ-line
mutation of the genes BRCA1 and BRCA2.[4] Specific mutations of BRCA1 and BRCA2 are more common in women of Jewish ancestry.[5] The estimated lifetime
risk of developing breast cancer for women with BRCA1 and BRCA2 mutations is
40% to 85%. Carriers with a history of breast cancer have an increased risk of
contralateral disease that may be as great as 5% per year.[6] Male carriers of BRCA2 mutations are also at increased risk for breast cancer.[7]
Mutations in
either the BRCA1 or BRCA2 gene also confer an increased risk of ovarian cancer.[7][8][9] In
addition, mutation carriers may be at increased risk of other primary
cancers.[7][9] Genetic testing is available to detect mutations in members of
high-risk families.[10][11][12][13][14] Such individuals should first be referred for
counseling.[15] (Refer to the PDQ summaries on Genetics of Breast and Ovarian Cancer; Breast Cancer Prevention; and Breast Cancer Screening for more
Clinical trials have established that screening with mammography, with or
without clinical breast examination, may decrease breast cancer mortality.
(Refer to the PDQ summary on Breast Cancer Screening for more information.)
Patient management following initial suspicion of breast cancer generally
includes confirmation of the diagnosis, evaluation of stage of disease, and
selection of therapy. At the time the tumor tissue is surgically removed, estrogen receptor (ER) and progesterone receptor (PR) status
should be determined.
Breast cancer is commonly treated by various combinations of surgery, radiation
therapy, chemotherapy, and hormone therapy. Prognosis and selection of therapy
may be influenced by the following clinical and pathology features (based on conventional histology and immunohistochemistry):[16]
Molecular profiling has led to classification of breast cancer into the following five distinct subtypes:[17][18]
The use of molecular profiling in breast cancer includes the following:[17][18]
Although certain rare inherited mutations,
such as those of BRCA1 and BRCA2, predispose women to develop breast cancer, prognostic
data on BRCA1/BRCA2 mutation carriers who have developed breast cancer are conflicting; these women are at greater risk of developing contralateral breast cancer.
Since criteria for menopausal status vary widely, some studies have substituted
age older than 50 years as a surrogate for the postmenopausal state. Breast
cancer is classified into a variety of histologic types, some of which have
prognostic importance. For example, favorable histologic types include
mucinous, medullary, and tubular carcinoma.[19][20][21]
Pathologically, breast cancer can be a multicentric and bilateral disease.
Bilateral disease is somewhat more common in patients with infiltrating lobular
carcinoma. Patients who have breast cancer should have bilateral
mammography at the time of diagnosis to rule out synchronous disease. The role of magnetic resonance imaging (MRI) in screening and follow-up continues to evolve. Having demonstrated an increased detection rate of mammographically occult disease, the selective use of MRI for additional screening is being used with increased frequency despite the absence of randomized, controlled data. Because only 25% of MRI-positive findings represent malignancy, pathologic confirmation prior to treatment action is recommended. Whether this increased detection rate will translate into improved treatment outcome is unknown.[22][23][24]
When BRCA1/BRCA2 mutation carriers were diagnosed at a young age, the risk of a contralateral breast cancer reached nearly 50% in the ensuing 25 years.[25][26]
should continue to have regular breast physical examinations and mammography to
detect either recurrence in the ipsilateral breast in those patients treated
with breast-conserving surgery or a second primary cancer in the contralateral
breast.[27] The risk of a primary breast cancer in the contralateral breast ranges from 3% to 10% at 10 years after diagnosis, although endocrine therapy decreases that risk.[28][29][30][31] The development of a contralateral breast cancer is associated with
an increased risk of distant recurrence.[32][33]
The use of hormone replacement therapy (HRT) poses a dilemma for the rising
numbers of breast cancer survivors, many of whom enter menopause prematurely as
a result of therapy. HRT has generally not been used for women with a history
of breast cancer because estrogen is a growth factor for most breast cancer
cells in the laboratory; however, empiric data on the safety of HRT after breast cancer are limited.[34][35]
Two randomized trials (including Regional Oncologic Center-Hormonal Replacement Therapy After Breast Cancer--Is It Safe [ROC-HABITS]) comparing HRT with no hormonal supplementation have been reported.[36][37] The first trial included 345 evaluable breast cancer patients with menopausal symptoms and was terminated early because of an increased incidence of recurrences and new primaries in the HRT group (hazard ratio [HR], 3.5; 95% confidence interval [CI], 1.5–7.4).[36][Level of evidence: 1iiDii] In total, 26 women in the HRT group and 7 in the non-HRT group developed recurrences or new primaries. This study, however, was not double blinded, and it is possible that patients on HRT were monitored more closely.
Because of the results of the first trial, the second trial, which was conducted under a joint steering committee with the first, closed prematurely after the enrollment of 378 patients.[37] With a median follow-up of 4.1 years, there were 11 recurrences in the hormone replacement group and 13 recurrences in the patients assigned to no hormone replacement (HR, 0.82; 95% CI, 0.35–1.9).[37][Level of evidence: 1iiDii]
The trials differed in several ways;[38] however, until further data become available, decisions concerning the use of HRT in patients with breast cancer will have to be based on the results of these studies and on inferences from the impact of HRT use on breast cancer risk in other settings.[38] A comprehensive intervention,
including education, counseling, and nonhormonal drug therapy, has been shown
to reduce menopausal symptoms and to improve sexual functioning in breast
cancer survivors.[39][Level of evidence: 1iiC]
(Refer to the PDQ summaries on Hot Flashes and Night Sweats and Sexuality and Reproductive Issues for more information.)
For patients who opt for a total mastectomy, reconstructive surgery may be
used at the time of the mastectomy (immediate reconstruction)
or at some subsequent time (delayed reconstruction).[40][41][42][43] Breast contour can
be restored by the submuscular insertion of an artificial implant
(saline-filled) or a rectus muscle or other flap. If a saline implant is used,
a tissue expander can be inserted beneath the pectoral muscle. Saline is
injected into the expander to stretch the tissues for a period of weeks or
months until the desired volume is obtained. The tissue expander is
replaced by a permanent implant. (Visit the U.S. Food and Drug Administration's ( FDA's) Web site for more
information on breast implants.) Rectus muscle flaps require a
considerably more complicated and prolonged operative procedure, and blood
transfusions may be required.
Following breast reconstruction, radiation
therapy can be delivered to the chest wall and regional nodes either in the
adjuvant setting or if local disease recurs. Radiation therapy following
reconstruction with a breast prosthesis may affect cosmesis, and the incidence
of capsular fibrosis, pain, or the need for implant removal may be
Evidence from randomized trials indicates that periodic follow-up with bone
scans, liver sonography, chest x-rays, and blood tests of liver function does not
improve survival or quality of life when compared with routine physical
examinations.[45][46][47] Even when these tests permit earlier detection of
recurrent disease, patient survival is unaffected.[46] Based on these data,
some investigators recommend that acceptable follow-up be limited to physical
examination and annual mammography for asymptomatic patients who complete
treatment for stage I to stage III breast cancer. The frequency of follow-up and the
appropriateness of screening tests after the completion of primary treatment
for stage I to stage III breast cancer remain controversial.
Other PDQ summaries containing information related to breast cancer include the following:
American Cancer Society: Cancer Facts and Figures 2014. Atlanta, Ga: American Cancer Society, 2014. Available online. Last accessed May 21, 2014.
Claus EB, Risch N, Thompson WD: Autosomal dominant inheritance of early-onset breast cancer. Implications for risk prediction. Cancer 73 (3): 643-51, 1994.
Gail MH, Brinton LA, Byar DP, et al.: Projecting individualized probabilities of developing breast cancer for white females who are being examined annually. J Natl Cancer Inst 81 (24): 1879-86, 1989.
Blackwood MA, Weber BL: BRCA1 and BRCA2: from molecular genetics to clinical medicine. J Clin Oncol 16 (5): 1969-77, 1998.
Offit K, Gilewski T, McGuire P, et al.: Germline BRCA1 185delAG mutations in Jewish women with breast cancer. Lancet 347 (9016): 1643-5, 1996.
Frank TS, Manley SA, Olopade OI, et al.: Sequence analysis of BRCA1 and BRCA2: correlation of mutations with family history and ovarian cancer risk. J Clin Oncol 16 (7): 2417-25, 1998.
Cancer risks in BRCA2 mutation carriers. The Breast Cancer Linkage Consortium. J Natl Cancer Inst 91 (15): 1310-6, 1999.
Miki Y, Swensen J, Shattuck-Eidens D, et al.: A strong candidate for the breast and ovarian cancer susceptibility gene BRCA1. Science 266 (5182): 66-71, 1994.
Ford D, Easton DF, Bishop DT, et al.: Risks of cancer in BRCA1-mutation carriers. Breast Cancer Linkage Consortium. Lancet 343 (8899): 692-5, 1994.
Biesecker BB, Boehnke M, Calzone K, et al.: Genetic counseling for families with inherited susceptibility to breast and ovarian cancer. JAMA 269 (15): 1970-4, 1993.
Hall JM, Lee MK, Newman B, et al.: Linkage of early-onset familial breast cancer to chromosome 17q21. Science 250 (4988): 1684-9, 1990.
Easton DF, Bishop DT, Ford D, et al.: Genetic linkage analysis in familial breast and ovarian cancer: results from 214 families. The Breast Cancer Linkage Consortium. Am J Hum Genet 52 (4): 678-701, 1993.
Berry DA, Parmigiani G, Sanchez J, et al.: Probability of carrying a mutation of breast-ovarian cancer gene BRCA1 based on family history. J Natl Cancer Inst 89 (3): 227-38, 1997.
Hoskins KF, Stopfer JE, Calzone KA, et al.: Assessment and counseling for women with a family history of breast cancer. A guide for clinicians. JAMA 273 (7): 577-85, 1995.
Statement of the American Society of Clinical Oncology: genetic testing for cancer susceptibility, Adopted on February 20, 1996. J Clin Oncol 14 (5): 1730-6; discussion 1737-40, 1996.
Simpson JF, Gray R, Dressler LG, et al.: Prognostic value of histologic grade and proliferative activity in axillary node-positive breast cancer: results from the Eastern Cooperative Oncology Group Companion Study, EST 4189. J Clin Oncol 18 (10): 2059-69, 2000.
Sørlie T, Perou CM, Tibshirani R, et al.: Gene expression patterns of breast carcinomas distinguish tumor subclasses with clinical implications. Proc Natl Acad Sci U S A 98 (19): 10869-74, 2001.
Perou CM, Sørlie T, Eisen MB, et al.: Molecular portraits of human breast tumours. Nature 406 (6797): 747-52, 2000.
Rosen PP, Groshen S, Kinne DW: Prognosis in T2N0M0 stage I breast carcinoma: a 20-year follow-up study. J Clin Oncol 9 (9): 1650-61, 1991.
Diab SG, Clark GM, Osborne CK, et al.: Tumor characteristics and clinical outcome of tubular and mucinous breast carcinomas. J Clin Oncol 17 (5): 1442-8, 1999.
Rakha EA, Lee AH, Evans AJ, et al.: Tubular carcinoma of the breast: further evidence to support its excellent prognosis. J Clin Oncol 28 (1): 99-104, 2010.
Lehman CD, Gatsonis C, Kuhl CK, et al.: MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med 356 (13): 1295-303, 2007.
Solin LJ, Orel SG, Hwang WT, et al.: Relationship of breast magnetic resonance imaging to outcome after breast-conservation treatment with radiation for women with early-stage invasive breast carcinoma or ductal carcinoma in situ. J Clin Oncol 26 (3): 386-91, 2008.
Morrow M: Magnetic resonance imaging in the breast cancer patient: curb your enthusiasm. J Clin Oncol 26 (3): 352-3, 2008.
Graeser MK, Engel C, Rhiem K, et al.: Contralateral breast cancer risk in BRCA1 and BRCA2 mutation carriers. J Clin Oncol 27 (35): 5887-92, 2009.
Garber JE, Golshan M: Contralateral breast cancer in BRCA1/BRCA2 mutation carriers: the story of the other side. J Clin Oncol 27 (35): 5862-4, 2009.
Orel SG, Troupin RH, Patterson EA, et al.: Breast cancer recurrence after lumpectomy and irradiation: role of mammography in detection. Radiology 183 (1): 201-6, 1992.
Rosen PP, Groshen S, Kinne DW, et al.: Factors influencing prognosis in node-negative breast carcinoma: analysis of 767 T1N0M0/T2N0M0 patients with long-term follow-up. J Clin Oncol 11 (11): 2090-100, 1993.
Gustafsson A, Tartter PI, Brower ST, et al.: Prognosis of patients with bilateral carcinoma of the breast. J Am Coll Surg 178 (2): 111-6, 1994.
Abbott A, Rueth N, Pappas-Varco S, et al.: Perceptions of contralateral breast cancer: an overestimation of risk. Ann Surg Oncol 18 (11): 3129-36, 2011.
Nichols HB, Berrington de González A, Lacey JV Jr, et al.: Declining incidence of contralateral breast cancer in the United States from 1975 to 2006. J Clin Oncol 29 (12): 1564-9, 2011.
Healey EA, Cook EF, Orav EJ, et al.: Contralateral breast cancer: clinical characteristics and impact on prognosis. J Clin Oncol 11 (8): 1545-52, 1993.
Heron DE, Komarnicky LT, Hyslop T, et al.: Bilateral breast carcinoma: risk factors and outcomes for patients with synchronous and metachronous disease. Cancer 88 (12): 2739-50, 2000.
Cobleigh MA, Berris RF, Bush T, et al.: Estrogen replacement therapy in breast cancer survivors. A time for change. Breast Cancer Committees of the Eastern Cooperative Oncology Group. JAMA 272 (7): 540-5, 1994.
Roy JA, Sawka CA, Pritchard KI: Hormone replacement therapy in women with breast cancer. Do the risks outweigh the benefits? J Clin Oncol 14 (3): 997-1006, 1996.
Holmberg L, Anderson H; HABITS steering and data monitoring committees: HABITS (hormonal replacement therapy after breast cancer--is it safe?), a randomised comparison: trial stopped. Lancet 363 (9407): 453-5, 2004.
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Chlebowski RT, Anderson GL: Progestins and recurrence in breast cancer survivors. J Natl Cancer Inst 97 (7): 471-2, 2005.
Ganz PA, Greendale GA, Petersen L, et al.: Managing menopausal symptoms in breast cancer survivors: results of a randomized controlled trial. J Natl Cancer Inst 92 (13): 1054-64, 2000.
Feller WF, Holt R, Spear S, et al.: Modified radical mastectomy with immediate breast reconstruction. Am Surg 52 (3): 129-33, 1986.
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Rosselli Del Turco M, Palli D, Cariddi A, et al.: Intensive diagnostic follow-up after treatment of primary breast cancer. A randomized trial. National Research Council Project on Breast Cancer follow-up. JAMA 271 (20): 1593-7, 1994.
Khatcheressian JL, Wolff AC, Smith TJ, et al.: American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting. J Clin Oncol 24 (31): 5091-7, 2006.
The following is a list of breast cancer histologic classifications.[1]
Infiltrating or invasive ductal cancer is the most common breast cancer
histologic type and comprises 70% to 80% of all cases.
The following are tumor subtypes that occur in the breast but are not
considered to be typical breast cancers:
Breast. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 347-76.
Yeatman TJ, Cantor AB, Smith TJ, et al.: Tumor biology of infiltrating lobular carcinoma. Implications for management. Ann Surg 222 (4): 549-59; discussion 559-61, 1995.
Chaney AW, Pollack A, McNeese MD, et al.: Primary treatment of cystosarcoma phyllodes of the breast. Cancer 89 (7): 1502-11, 2000.
Carter BA, Page DL: Phyllodes tumor of the breast: local recurrence versus metastatic capacity. Hum Pathol 35 (9): 1051-2, 2004.
The American Joint Committee on Cancer (AJCC) staging system provides a
strategy for grouping patients with respect to prognosis. Therapeutic
decisions are formulated in part according to staging categories but primarily
according to tumor size, lymph node status, estrogen-receptor and progesterone-receptor
levels in the tumor tissue, human epidermal growth factor receptor 2 (HER2/neu) status, menopausal status, and the general health of the
The AJCC has designated staging by TNM classification to define breast cancer.[1] When this system was modified in 2002, some nodal categories that were previously considered stage II were reclassified as stage III.[2] As a result of the stage migration phenomenon, survival by stage for case series classified by the new system will appear superior to those using the old system.[3]
Primary tumor cannot be assessed.
No evidence of primary tumor.
Carcinoma in situ.
Tis (DCIS)
Tis (LCIS)
Tis (Paget)
Paget disease of the nipple NOT associated with invasive carcinoma and/or carcinoma in situ (DCIS and/or LCIS) in the underlying breast parenchyma. Carcinomas in the breast parenchyma associated with Paget disease are categorized based on the size and characteristics of the parenchymal disease, although the presence of Paget disease should still be noted.
Tumor ≤20 mm in greatest dimension.
Tumor ≤1 mm in greatest dimension.
Tumor >1 mm but ≤5 mm in greatest dimension.
Tumor >5 mm but ≤10 mm in greatest dimension.
Tumor >10 mm but ≤20 mm in greatest dimension.
Tumor >20 mm but ≤50 mm in greatest dimension.
Tumor >50 mm in greatest dimension.
Tumor of any size with direct extension to the chest wall and/or to the skin (ulceration or skin nodules).c
Extension to the chest wall, not including only pectoralis muscle adherence/invasion.
Ulceration and/or ipsilateral satellite nodules and/or edema (including peau d'orange) of the skin, which do not meet the criteria for inflammatory carcinoma.
Both T4a and T4b.
Inflammatory carcinoma.
DCIS = ductal carcinoma in situ; LCIS = lobular carcinoma in situ.
aReprinted with permission from AJCC: Breast. In: Edge SB, Byrd DR, Compton CC, et al., eds.: AJCC Cancer Staging Manual. 7th ed. New York, NY: Springer, 2010, pp 347-76.
bThe T classification of the primary tumor is the same regardless of whether it is based on clinical or pathologic criteria, or both. Size should be measured to the nearest millimeter. If the tumor size is slightly less than or greater than a cutoff for a given T classification, it is recommended that the size be rounded to the millimeter reading that is closest to the cutoff. For example, a reported size of 1.1 mm is reported as 1 mm, or a size of 2.01 cm is reported as 2.0 cm. Designation should be made with the subscript "c" or "p" modifier to indicate whether the T classification was determined by clinical (physical examination or radiologic) or pathologic measurements, respectively. In general, pathologic determination should take precedence over clinical determination of T size.
cInvasion of the dermis alone does not qualify as T4.
Regional lymph nodes cannot be assessed (e.g., previously removed).
No regional lymph node metastases.
Metastases to movable ipsilateral level I, II axillary lymph node(s).
Metastases in ipsilateral level I, II axillary lymph nodes that are clinically fixed or matted.
Metastases in clinically detectedb ipsilateral internal mammary nodes in the absence of clinically evident axillary lymph node metastases.
Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another (matted) or to other structures.
Metastases only in clinically detectedb ipsilateral internal mammary nodes and in the absence of clinically evident level I, II axillary lymph node metastases.
Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with or without level I, II axillary lymph node involvement.
Metastases in clinically detectedb ipsilateral internal mammary lymph node(s) with clinically evident level I, II axillary lymph node metastases.
Metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal mammary lymph node involvement.
Metastases in ipsilateral infraclavicular lymph node(s).
Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s).
Metastases in ipsilateral supraclavicular lymph node(s).
bClinically detected is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination and having characteristics highly suspicious for malignancy or a presumed pathologic macrometastasis based on fine needle aspiration biopsy with cytologic examination. Confirmation of clinically detected metastatic disease by fine needle aspiration without excision biopsy is designated with an (f) suffix, for example, cN3a(f). Excisional biopsy of a lymph node or biopsy of a sentinel node, in the absence of assignment of a pT, is classified as a clinical N, for example, cN1. Information regarding the confirmation of the nodal status will be designated in site-specific factors as clinical, fine needle aspiration, core biopsy, or sentinel lymph node biopsy. Pathologic classification (pN) is used for excision or sentinel lymph node biopsy only in conjunction with a pathologic T assignment.
Regional lymph nodes cannot be assessed (e.g., previously removed or not removed for pathologic study).
No regional lymph node metastasis identified histologically.
Note: ITCs are defined as small clusters of cells ≤0.2 mm, or single tumor cells, or a cluster of <200 cells in a single histologic cross-section. ITCs may be detected by routine histology or by IHC methods. Nodes containing only ITCs are excluded from the total positive node count for purposes of N classification but should be included in the total number of nodes evaluated.
No regional lymph node metastases histologically, negative IHC.
Malignant cells in regional lymph node(s) ≤0.2 mm (detected by H&E or IHC including ITC).
No regional lymph node metastases histologically, negative molecular findings (RT-PCR).
Positive molecular findings (RT-PCR), but no regional lymph node metastases detected by histology or IHC.
Metastases in 1–3 axillary lymph nodes.
Metastases in internal mammary nodes with metastases detected by sentinel lymph node biopsy but not clinically detected.c
Micrometastases (>0.2 mm and/or >200 cells but none >2.0 mm).
Metastases in 1–3 axillary lymph nodes, at least one metastasis >2.0 mm.
Metastases in internal mammary nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected.c
Metastases in 1–3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected.
Metastases in 4–9 axillary lymph nodes.
Metastases in clinically detectedd internal mammary lymph nodes in the absence of axillary lymph node metastases.
Metastases in 4–9 axillary lymph nodes (at least 1 tumor deposit >2 mm).
Metastases in ≥10 axillary lymph nodes.
Metastases in infraclavicular (level III axillary) lymph nodes.
Metastases in clinically detectedc ipsilateral internal mammary lymph nodes in the presence of one or more positive level I, II axillary lymph nodes.
Metastases in >3 axillary lymph nodes and in internal mammary lymph nodes with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically detected.c
Metastases in ipsilateral supraclavicular lymph nodes.
Metastases in ≥10 axillary lymph nodes (at least 1 tumor deposit >2.0 mm).
Metastases to the infraclavicular (level III axillary lymph) nodes.
Metastases in clinically detectedd ipsilateral internal mammary lymph nodes in the presence of one or more positive axillary lymph nodes.
Posttreatment ypN
–Posttreatment yp "N" should be evaluated as for clinical (pretreatment) "N" methods above. The modifier "SN" is used only if a sentinel node evaluation was performed after treatment. If no subscript is attached, it is assumed that the axillary nodal evaluation was by AND.
–The X classification will be used (ypNX) if no yp posttreatment SN or AND was performed.
–N categories are the same as those used for pN.
AND = axillary node dissection; H&E = hematoxylin and eosin stain; IHC = immunohistochemical; ITC = isolated tumor cells; RT-PCR = reverse transcriptase/polymerase chain reaction.
bClassification is based on axillary lymph node dissection with or without sentinel lymph node biopsy. Classification based solely on sentinel lymph node biopsy without subsequent axillary lymph node dissection is designated (SN) for "sentinel node," for example, pN0(SN).
c"Not clinically detected" is defined as not detected by imaging studies (excluding lymphoscintigraphy) or not detected by clinical examination.
d"Clinically detected" is defined as detected by imaging studies (excluding lymphoscintigraphy) or by clinical examination and having characteristics highly suspicious for malignancy or a presumed pathologic macrometastasis based on fine-needle aspiration biopsy with cytologic examination.
No clinical or radiographic evidence of distant metastases.
No clinical or radiographic evidence of distant metastases, but deposits of molecularly or microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal tissue that are ≤0.2 mm in a patient without symptoms or signs of metastases.
Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven >0.2 mm.
Posttreatment yp M classification. The M category for patients treated with neoadjuvant therapy is the category assigned in the clinical stage, prior to initiation of neoadjuvant therapy. Identification of distant metastases after the start of therapy in cases where pretherapy evaluation showed no metastases is considered progression of disease. If a patient was designated to have detectable distant metastases (M1) before chemotherapy, the patient will be designated as M1 throughout.[1]
Any T
Any N
bT1 includes T1mi.
cT0 and T1 tumors with nodal micrometastases only are excluded from Stage IIA and are classified Stage IB.
–M0 includes M0(i+).
–The designation pM0 is not valid; any M0 should be clinical.
–If a patient presents with M1 prior to neoadjuvant systemic therapy, the stage is considered Stage IV and remains Stage IV regardless of response to neoadjuvant therapy.
–Stage designation may be changed if postsurgical imaging studies reveal the presence of distant metastases, provided that the studies are carried out within 4 months of diagnosis in the absence of disease progression and provided that the patient has not received neoadjuvant therapy.
–Postneoadjuvant therapy is designated with "yc" or "yp" prefix. Of note, no stage group is assigned if there is a complete pathologic response (CR) to neoadjuvant therapy, for example, ypT0ypN0cM0.
Singletary SE, Allred C, Ashley P, et al.: Revision of the American Joint Committee on Cancer staging system for breast cancer. J Clin Oncol 20 (17): 3628-36, 2002.
Woodward WA, Strom EA, Tucker SL, et al.: Changes in the 2003 American Joint Committee on Cancer staging for breast cancer dramatically affect stage-specific survival. J Clin Oncol 21 (17): 3244-8, 2003.
Ductal carcinoma in situ (DCIS) is a noninvasive condition. DCIS can progress to become invasive cancer, but estimates of the likelihood of this vary widely. Some people include DCIS in breast cancer statistics. The frequency of the diagnosis of DCIS has increased markedly in the United States since the widespread use of screening mammography. In 1998, DCIS accounted for about 18% of all newly diagnosed invasive plus noninvasive breast tumors in the United States.
Very few cases of DCIS present as a palpable mass;
80% are diagnosed by mammography alone.[1] DCIS comprises a heterogeneous
group of histopathologic lesions that have been classified into several
subtypes based primarily on architectural pattern: micropapillary, papillary,
solid, cribriform, and comedo. Comedo-type DCIS consists of cells that appear
cytologically malignant, with the presence of high-grade nuclei,
pleomorphism, and abundant central luminal necrosis. Comedo-type DCIS appears
to be more aggressive, with a higher probability of associated invasive ductal
Until recently, the customary treatment of DCIS was mastectomy.[1] The
rationale for mastectomy included a 30% incidence of multicentric disease, a
40% prevalence of residual tumor at mastectomy following wide excision alone,
and a 25% to 50% incidence of breast recurrence following limited surgery for
palpable tumor, with 50% of those recurrences being invasive carcinoma.[1][3]
The combined local and distant recurrence rate following mastectomy is 1% to
No randomized comparisons of mastectomy versus breast-conserving surgery plus breast radiation are available.
In view of the success of breast-conserving surgery combined with breast radiation for invasive carcinoma, this conservative approach was extended to the noninvasive entity. To determine whether breast-conserving surgery plus radiation therapy was a reasonable approach to the management of DCIS, the National Surgical Adjuvant Breast and Bowel Project (NSABP) and the European Organisation for Research and Treatment of Cancer (EORTC) have each completed prospective randomized trials in which women with localized DCIS and negative surgical margins following excisional biopsy were randomized to either breast radiation (50 Gy) or to no further therapy.[4][5][6][7]
Of the 818 women enrolled in the NSABP-B-17 trial, 80% were diagnosed by mammography, and 70% of the patients' lesions were 1 cm or less. At the 12-year actuarial follow-up interval, the overall rate of in-breast tumor recurrence was reduced from 31.7% to 15.7% when radiation therapy was delivered (P < .005). Radiation therapy reduced the occurrence of invasive cancer from 16.8% to 7.7% (P = .001) and recurrent DCIS from 14.6% to 8.0% (P = .001).[7][Level of evidence: 1iiDii] Nine pathologic features were evaluated for their ability to predict for in-breast recurrence, but only comedo necrosis was determined to be a significant predictor for recurrence.
Similarly, of the 1,010 patients enrolled in the EORTC-10853 trial, mammography detected lesions in 71% of the women. At a median follow-up of 10.5 years, the overall rate of in-breast tumor recurrence was reduced from 26% to 15% (P < .001) with a similarly effective reduction of invasive (13% to 8%, P = .065) and noninvasive (14% to 7%, P = .001) recurrence rates.[7][Level of evidence: 1iiDii] In this analysis, parameters associated with an increased risk of in-breast recurrence included age 40 years or younger, palpable disease, intermediate or poorly differentiated DCIS, cribriform or solid growth pattern, and indeterminate margins. Elsewhere, margins of less than 1 mm have been associated with an unacceptable local recurrence rate, even with radiation therapy.[8] In both of the studies reported here, the effect of radiation therapy was consistent across all assessed risk factors.
Given that lumpectomy and radiation therapy are generally applicable for most
patients with DCIS, can a subset of patients be identified with such a low risk
of local recurrence that postoperative radiation therapy can be omitted? To identify such a favorable group of patients, several pathologic
staging systems have been developed and tested retrospectively, but consensus
recommendations have not been achieved.[9][10][11][12]
The Van Nuys Prognostic Index, which combines three predictors of local recurrence (i.e., tumor size, margin
width, and pathologic classification), was used to retrospectively analyze 333
patients treated with either excision alone or excision and radiation
therapy.[12] Using this prognostic index, patients with favorable lesions, who
received surgical excision alone, had a low recurrence rate (i.e., 2% with a median
follow-up of 79 months). A subsequent analysis of these data was performed to
determine the influence of margin width on local control.[13] Patients whose
excised lesions had margin widths 10 mm or larger in every direction
had an extremely low probability of local recurrence with surgery alone (4%
with a mean follow-up of 8 years). These reviews
are retrospective, noncontrolled, and are subject to substantial selection
bias. By contrast, no subset of patients was identified in the
prospective NSABP trial that did not benefit from the addition of radiation
therapy to lumpectomy in the management of DCIS.[2][4][14][15]
To determine if tamoxifen adds to the efficacy of local
therapy in the management of DCIS, the NSABP performed a double-blind
prospective trial (NSABP-B-24) of 1,804 women.[16] Patients were randomly assigned to
lumpectomy, radiation therapy (50 Gy), and placebo versus lumpectomy, radiation
therapy, and tamoxifen (20 mg/day for 5 years).[16] Positive or unknown
surgical margins were present in 23% of patients. Approximately 80% of the
lesions measured not larger than 1 cm, and more than 80% were detected
mammographically. Breast cancer events were defined as the presence of new
ipsilateral disease, contralateral disease, or metastases. Women in the
tamoxifen group had fewer breast cancer events at 5 years than did those on a
placebo (8.2% vs. 13.4%; P = .009).[16][Level of evidence: 1iDii] With
tamoxifen, ipsilateral invasive breast cancer decreased from 4.2% to 2.1% at 5
years (P = .03). Tamoxifen also decreased the incidence of contralateral breast
neoplasms (invasive and noninvasive) from 0.8% per year to 0.4% per year
(P = .01). The benefit of tamoxifen extended to those patients with positive or
uncertain margins.[17] (Refer to the PDQ summary on Breast Cancer Prevention
for more information.)
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with ductal breast carcinoma in situ. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
General information about clinical trials is also available from the NCI Web site.
Fonseca R, Hartmann LC, Petersen IA, et al.: Ductal carcinoma in situ of the breast. Ann Intern Med 127 (11): 1013-22, 1997.
Fisher ER, Dignam J, Tan-Chiu E, et al.: Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight-year update of Protocol B-17: intraductal carcinoma. Cancer 86 (3): 429-38, 1999.
Lagios MD, Westdahl PR, Margolin FR, et al.: Duct carcinoma in situ. Relationship of extent of noninvasive disease to the frequency of occult invasion, multicentricity, lymph node metastases, and short-term treatment failures. Cancer 50 (7): 1309-14, 1982.
Fisher B, Dignam J, Wolmark N, et al.: Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol 16 (2): 441-52, 1998.
Fisher B, Land S, Mamounas E, et al.: Prevention of invasive breast cancer in women with ductal carcinoma in situ: an update of the national surgical adjuvant breast and bowel project experience. Semin Oncol 28 (4): 400-18, 2001.
Julien JP, Bijker N, Fentiman IS, et al.: Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet 355 (9203): 528-33, 2000.
Bijker N, Meijnen P, Peterse JL, et al.: Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in-situ: ten-year results of European Organisation for Research and Treatment of Cancer randomized phase III trial 10853--a study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol 24 (21): 3381-7, 2006.
Chan KC, Knox WF, Sinha G, et al.: Extent of excision margin width required in breast conserving surgery for ductal carcinoma in situ. Cancer 91 (1): 9-16, 2001.
Page DL, Lagios MD: Pathologic analysis of the National Surgical Adjuvant Breast Project (NSABP) B-17 Trial. Unanswered questions remaining unanswered considering current concepts of ductal carcinoma in situ. Cancer 75 (6): 1219-22; discussion 1223-7, 1995.
Fisher ER, Costantino J, Fisher B, et al.: Response - blunting the counterpoint. Cancer 75 (6): 1223-1227, 1995.
Holland R, Peterse JL, Millis RR, et al.: Ductal carcinoma in situ: a proposal for a new classification. Semin Diagn Pathol 11 (3): 167-80, 1994.
Silverstein MJ, Lagios MD, Craig PH, et al.: A prognostic index for ductal carcinoma in situ of the breast. Cancer 77 (11): 2267-74, 1996.
Silverstein MJ, Lagios MD, Groshen S, et al.: The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med 340 (19): 1455-61, 1999.
Goodwin A, Parker S, Ghersi D, et al.: Post-operative radiotherapy for ductal carcinoma in situ of the breast--a systematic review of the randomised trials. Breast 18 (3): 143-9, 2009.
Goodwin A, Parker S, Ghersi D, et al.: Post-operative radiotherapy for ductal carcinoma in situ of the breast. Cochrane Database Syst Rev (3): CD000563, 2009.
Fisher B, Dignam J, Wolmark N, et al.: Tamoxifen in treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet 353 (9169): 1993-2000, 1999.
Houghton J, George WD, Cuzick J, et al.: Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet 362 (9378): 95-102, 2003.
The term lobular carcinoma in situ (LCIS) is misleading. This lesion is more
appropriately termed lobular neoplasia. Strictly speaking, it is not known
to be a premalignant lesion, but rather a marker that identifies women at an
increased risk for subsequent development of invasive breast cancer. This risk
remains elevated even beyond 2 decades, and most of the subsequent cancers are
ductal rather than lobular. LCIS is usually multicentric and is frequently
bilateral. In a large, prospective series from the National Surgical Adjuvant Breast and Bowel Project (NSABP) with a 12-year follow-up of 182 women with LCIS that was managed with excisional biopsy alone, 26 women developed ipsilateral breast tumors (9 of the tumors were invasive).[1] In addition, 14 women developed contralateral breast tumors (10 of the tumors were invasive).
Most women with LCIS have disease that can be managed without additional local therapy after
biopsy. No evidence is available that re-excision to obtain clear margins is
required. The use of tamoxifen has decreased the risk of developing breast
cancer in women with LCIS and should be considered in the routine management of
these women.[2] The NSABP-P-1 trial of 13,388 high-risk
women comparing tamoxifen to placebo demonstrated an overall 49% decrease in
invasive breast cancer, with a mean follow-up of 47.7 months.[2] Risk was
reduced by 56% in the subset of 826 women with a history of LCIS, and the
average annual hazard rate for invasive cancer fell from 12.99 per 1,000 women
to 5.69 per 1,000 women. In women older than 50 years, this benefit was
accompanied by an annual incidence of 1 to 2 per 1,000 women of endometrial
cancer and thrombotic events. (Refer to the PDQ summary on
Breast Cancer Prevention for more information.)
Bilateral prophylactic mastectomy is sometimes considered an
alternative approach for women at high risk for breast cancer. Many
breast surgeons, however, now consider this to be an overly aggressive approach.
Axillary lymph node dissection is not necessary in the management of LCIS.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with lobular breast carcinoma in situ. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Fisher ER, Land SR, Fisher B, et al.: Pathologic findings from the National Surgical Adjuvant Breast and Bowel Project: twelve-year observations concerning lobular carcinoma in situ. Cancer 100 (2): 238-44, 2004.
Fisher B, Costantino JP, Wickerham DL, et al.: Tamoxifen for prevention of breast cancer: report of the National Surgical Adjuvant Breast and Bowel Project P-1 Study. J Natl Cancer Inst 90 (18): 1371-88, 1998.
Stage I, II, IIIA, and operable IIIC breast cancer often requires a multimodality approach to
treatment. Irrespective of the eventual procedure selected, the diagnostic
biopsy and surgical procedure that will be used as primary treatment should be
performed as two separate procedures. In many cases, the diagnosis of breast
carcinoma is made by core needle biopsy. After the presence of a malignancy is
confirmed, treatment options should be discussed
with the patient before a therapeutic procedure is selected. Estrogen-receptor (ER) and progesterone-receptor (PR) protein status and human epidermal growth factor receptor 2 (HER2/neu) status
should be determined for the primary tumor.[1] Additional pathologic
characteristics, including grade and proliferative activity
may also be of value.[2][3][4][5]
Options for surgical management of the primary tumor include breast-conserving
surgery plus radiation therapy, mastectomy plus reconstruction, and mastectomy
alone. Surgical staging of the axilla should also be performed. Survival is
equivalent with any of these options as documented in randomized prospective
trials (including the European Organization for Research and Treatment of Cancer's trial [EORTC-10801]).[6][7][8][9][10][11][12][13] Selection of a local therapeutic approach depends on the
location and size of the lesion, analysis of the mammogram, breast size, and
the patient's attitude toward preserving the breast. The presence of
multifocal disease in the breast or a history of collagen vascular disease are
relative contraindications to breast-conserving therapy.[14] A retrospective study of 753 patients who were divided into three groups based on receptor status (ER-positive or PR-positive; ER-negative and PR-negative but HER2/neu-positive; and ER-negative, PR-negative, and HER2/neu-negative [triple-negative]) found no differences in disease control within the breast in patients treated with standard breast-conserving surgery; however, there are not yet substantive data to support this finding.[15]
All histologic types of invasive breast cancer may be treated with
breast-conserving surgery plus radiation therapy.[16] The rate of local
recurrence in the breast with conservative treatment is low and varies slightly
with the surgical technique used (e.g., lumpectomy, quadrantectomy, segmental
mastectomy, and others). Whether completely clear
microscopic margins are necessary is debatable.[17][18][19]
Retrospective studies have shown
the following examples of tumor characteristics to correlate with a greater likelihood of finding persistent tumor on re-excision:
Patients whose tumors have these
characteristics may benefit from a more generous initial excision to avoid the
need for a re-excision.[21][22]
Radiation therapy (as part of breast-conserving local therapy) consists of
postoperative external-beam radiation therapy (EBRT) to the entire breast with doses of 45 Gy
to 50 Gy, in 1.8 Gy to 2.0 Gy daily fractions over a 5-week period. Shorter
hypofractionation schemes achieve comparable results.[23][24][25] A further radiation
boost is commonly given to the tumor bed. Two randomized trials conducted in
Europe have shown that using boosts of 10 Gy to 16 Gy reduces the risk of local
recurrence from 4.6% to 3.6% at 3 years (P = .044),[26][Level of evidence: 1iiDiii] and from 7.3% to 4.3% at 5 years (P < .001), respectively.[27][Level of evidence: 1iiDiii] If a boost is used, it can be delivered either by
EBRT, generally with electrons, or by using an interstitial
radioactive implant.[28]
The age of the patient should not be a determining factor in the selection of
breast-conserving treatment versus mastectomy. A study has shown that
treatment with lumpectomy and radiation therapy in women 65 years and
older produces survival and freedom-from-recurrence rates similar to those of
women younger than 65 years.[29] Whether young women
with germ-line mutations or strong family histories are good candidates for
breast-conserving therapy is not certain. Retrospective studies indicate no difference in
local failure rates or overall survival (OS) when women with strong family histories
are compared with similarly treated women without such histories.[30][31][Level of evidence: 3iiiDii] The group with a
positive family history, however, does appear more likely to develop contralateral breast
cancer within 5 years.[30] This risk for contralateral tumors may be even
greater in women who are positive for BRCA1 and BRCA2 mutations.[32][Level of evidence: 3iiiDii] Because of the available evidence indicating no difference
in outcome, women with strong family histories should be considered candidates
for breast-conserving treatment. For women with germ-line mutations in BRCA1 and BRCA2, further study of breast-conserving treatment is needed.
Breast-conserving surgery alone without radiation therapy has been compared
with breast-conserving surgery followed by radiation therapy in six prospective
randomized trials (including the National Surgical Adjuvant Breast and Bowel Project's trial [NSABP-B-06] and the Cancer and Leukemia Group B's trial [CLB-9343]).[6][33][34][35][36][37] In two of these trials, all patients also received adjuvant tamoxifen.[36][37] Every trial demonstrated a lower
in-breast recurrence rate with radiation therapy, and this effect was present in all patient subgroups. In some groups, for example, women with receptor-positive small tumors [36] and those older than 70 years,[38] the absolute reduction in the rate of recurrence was small (<5%). The limited impact of radiation therapy in this group of women was also reported in a confirmatory observational study looking at in-breast control rates using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database.[39] The impact of radiation therapy on local control was additionally clarified by showing that healthy women aged 70 to 79 years were most likely to benefit from radiation therapy (number needed to treat [NNT] to prevent one event = 21–22 patients) when compared with women aged 80 years or older or to those who have comorbidities (NNT = 61–125 patients).[39] The administration of radiation therapy may be associated with short-term morbidity, inconvenience, and potential long-term complications.[38]
The axillary lymph nodes should be staged to aid in determining prognosis and
therapy. Sentinel lymph node (SLN) biopsy is the initial standard axillary staging procedure performed in women with invasive breast cancer. The SLN is defined as any node that receives drainage directly from the primary tumor; therefore, allowing for more than one SLN, which is often the case. Studies have shown that the injection of technetium-labeled sulfur colloid, vital blue dye, or both around the tumor or biopsy cavity, or in the subareolar area, and subsequent drainage of these compounds to the axilla results in the identification of the SLN in 92% to 98% of patients.[40][41] These reports demonstrate a 97.5% to 100% concordance between SLN biopsy and complete axillary lymph node dissection (ALND).[42][43][44][45]
A multicenter randomized phase III trial of 5,611 patients randomly assigned to either SLN plus ALND or to SLN resection alone with ALND only if the SLNs were positive showed no detectable difference in OS, disease-free survival (DFS), and regional control. OS was 91.8% versus 90.3% for SLN plus ALND and SLN resection alone, respectively (P = .12).[46][Level of evidence: 1iiA]
Similarly, a single-center randomized trial of 532 patients with T1 carcinomas undergoing either SLN biopsy plus complete axillary dissection or SLN biopsy alone showed, after a median follow-up of 78 months, no difference in 5-year DFS (92.9% in the SLN biopsy without routine axillary dissection group vs. 88.9% in patients having axillary dissection irrespective of SLN findings, P = .1).[47][Level of evidence: 1iiDii]
The reported false-negative rates of SLN biopsy using axillary node dissection as the gold standard range from 0% to 15% with an average of 8.8%.[48] The
success rate varies with the surgeon's experience and with the primary tumor
characteristics. In general, studies have restricted the use of SLN biopsy to
women with T1 and T2 disease, without evidence of multifocal involvement or
clinically positive lymph nodes.
SLN biopsy alone is associated with less morbidity than axillary lymphadenectomy. In a randomized trial of 1,031 women that compared SLN biopsy followed by axillary dissection when the SLN was positive with axillary dissection in all patients, quality of life at 1 year (as assessed by the frequency of patients experiencing a clinically significant deterioration in the Trial Outcome Index of the Functional Assessment of Cancer Therapy-Breast scale) was superior in the SLN biopsy group (23% vs. 35% deteriorating in the SLN biopsy vs. axillary dissection groups, respectively; P = .001).[49][Level of evidence 1iiC] Arm function was also better in the SLN group. The NSABP-B-32 (NCT00003830) trial, a randomized study of 5,611 women, found the same results with respect to accuracy and technical success.[50] Based on this body of evidence, SLN biopsy is the standard initial surgical staging procedure of the axilla for women with invasive breast cancer.
A multicenter, randomized clinical trial sought to determine whether ALND is required after an SLN biopsy reveals an SLN metastasis of breast cancer.[51] This phase III noninferiority trial planned to randomly assign 1,900 women with clinical T1–T2 invasive breast cancer without palpable adenopathy and with one to two SLNs containing metastases identified by frozen section to undergo ALND versus no further axillary treatment. All patients underwent lumpectomy, tangential whole-breast irradiation, and appropriate systemic therapy, and OS was the primary endpoint. Because of enrollment challenges, a total of 891 women out of a target enrollment of 1,900 women were randomly assigned to one of the two treatment arms. At a median follow-up of 6.3 years, 5-year OS was 91.8% (95% confidence interval [CI], 89.1%–94.5%) with ALND and 92.5% (95% CI, 90.0–95.1%) with SLN biopsy alone. The secondary endpoint of 5-year disease-free survival (DFS) was 82.2% (95% CI, 78.3%–86.3%) with ALND and 83.9% (95% CI, 80.2%–87.9%) with SLN biopsy alone.[51][Level of evidence: 1iiA] In a second, similarly designed trial, 929 women with breast tumors smaller than 5 cm and SLN involvement smaller than 2 mm were randomly assigned to receive or not receive axillary lymph node dissection. Patients without axillary dissection had fewer DFS events (hazard ratio [HR], 0.78; 95% CI, 0.55–1.11). No difference in OS was observed.[52][Level of evidence: 1iiA] On the basis of the results of these trials, the medical necessity of ALND after a positive SLN biopsy in patients with limited SLN-positive breast cancer treated with breast conservation, radiation, and systemic therapy is called into question.
For patients who require an ALND, the standard evaluation usually involves only a level I and II dissection, thereby removing a satisfactory number of nodes for evaluation (i.e., 6–10 at least), while reducing morbidity from the procedure. Several groups have attempted to define a population of women in whom the probability of nodal metastasis is low enough to preclude axillary node biopsy. In these single-institution case series, the prevalence of positive nodes in patients with T1a tumors ranged from 9% to 16%.[53][54] In another series, the incidence of axillary node relapse in patients with T1a tumors treated without ALND was 2%.[55][Level of evidence: 3iiiA] Because the axillary node status remains the most important predictor of outcome in breast cancer patients, insufficient evidence is available to recommend that lymph node staging can be omitted in most patients with invasive breast cancer.
For patients who opt for a total mastectomy, reconstructive surgery may be
used at the time of the mastectomy (i.e., immediate reconstruction)
or at some subsequent time (i.e., delayed reconstruction).[56][57][58][59] Breast contour can
be restored by the submuscular insertion of an artificial implant
(saline-filled) or a rectus muscle or other flap. If a saline implant is used,
a tissue expander can be inserted beneath the pectoral muscle. Saline is
injected into the expander to stretch the tissues for a period of weeks or
months until the desired volume is obtained. The tissue expander is then
replaced by a permanent implant. (Visit the U. S. Food and Drug Administration's ( FDA's) Web site for more
information on breast implants.) Rectus muscle flaps require a
considerably more complicated and prolonged operative procedure, and blood
transfusions may be required.
Following breast reconstruction, radiation
therapy can be delivered to the chest wall and regional nodes either in the
adjuvant setting or if local disease recurs. Radiation therapy following
reconstruction with a breast prosthesis may affect cosmesis, and the incidence
of capsular fibrosis, pain, or the need for implant removal may be
Radiation therapy is regularly employed after breast-conserving surgery. Radiation therapy also can be indicated for postmastectomy patients. The main goal of adjuvant radiation therapy is to eradicate residual disease thus reducing local recurrence.[61]
For women who are treated with breast-conserving surgery without radiation therapy, the risk of recurrence in the conserved breast is substantial (>20%) even in confirmed axillary lymph node-negative women. Thus, whole-breast radiation therapy after breast-conserving surgery is recommended.[62]
Although all trials assessing the role of radiation therapy in breast-conserving therapy have shown highly statistically significant reductions in local recurrence rate, no single trial has demonstrated a statistically significant reduction in mortality. However, a 2011 meta-analysis of 17 clinical trials performed by the Early Breast Cancer Trialists' Collaborative Group (EBCTCG), which included over 10,000 women with early stage breast cancer supported whole-breast radiation therapy after breast-conserving surgery.[63] Whole-breast radiation therapy resulted in a significant reduction in the 10-year risk of recurrence compared with breast-conserving surgery alone (19% vs. 35%, respectively; relative risk (RR), 0.52; 95% CI, 0.48–0.56) and a significant reduction in the 15-year risk of breast cancer death (21% vs. 25%; RR, 0.82; 95% CI, 0.75–0.90).[63][Level of evidence: 1iiA]
With regard to radiation dosing and schedule, conventional whole-breast radiation therapy is delivered to the whole breast (with or without regional lymph nodes) in 1.8 Gy to 2 Gy daily fractions over about 5 to 6 weeks to a total dose of 45 Gy to 50 Gy. However, some studies show that a shorter fractionation schedule of 42.5 Gy over 3 to 4 weeks is a reasonable alternative for some breast cancer patients. A randomized, noninferiority trial of 1,234 patients with node-negative invasive breast cancer analyzed locoregional recurrence rates with conventional whole-breast radiation therapy versus a shorter fractionation schedule.[64] The 10-year locoregional relapse rate among women who received shorter fractionation was not inferior to conventional whole-breast radiation therapy (6.2% vs. 6.7%, respectively with absolute difference, 0.5 percentage points; 95% CI, −2.5 to 3.5).[64][Level of evidence: 1iiDii]
Similarly, a combined analysis of the randomized United Kingdom Standardisation of Breast Radiotherapy trials (START), (START-A [ISRCTN59368779]) and START-B [ISRCTN59368779]), which collectively randomly assigned 4,451 women with completely excised invasive (pT1–3a, pN0–1, M0) early stage breast cancer after breast-conserving surgery to conventional whole-breast radiation therapy dosing versus shorter fractionation, revealed no difference in a 10-year locoregional relapse rate.[65] Additional studies are needed to determine whether shorter fractionation is appropriate for women with higher nodal disease burden.[65][Level of evidence: 1iiDii]
Postoperative chest wall and regional lymph node adjuvant radiation therapy has traditionally been given
to selected patients considered at high risk for local-regional failure
following mastectomy. Radiation therapy can decrease local-regional recurrence
in this group, even among those patients who receive adjuvant chemotherapy.[66]
Patients at highest risk for local recurrence include those with four or more
positive axillary nodes, grossly evident extracapsular nodal extension, large
primary tumors, and very close or positive deep margins of resection of the
primary tumor.[67][68][69]
Patients with one to three involved nodes without any of the previously noted risk factors are at low risk of local recurrence, and the value of routine use of adjuvant radiation therapy in this setting has been unclear. The 2005 EBCTCG update indicates, however, that radiation therapy is beneficial, regardless of the number of lymph nodes involved.[61][Level of evidence: 1iiA] For women with node-positive disease postmastectomy and axillary clearance, radiation therapy reduced the 5-year local recurrence risk from 23% to 6% (absolute gain, 17%; 95%CI, 15.2%–18.8%). This translated into a significant (P = .002) reduction in breast cancer mortality, 54.7% versus 60.1% with an absolute gain of 5.4% (95% CI, 2.9%–7.9%). In subgroup analyses, the 5-year local recurrence rate was reduced by 12% (95% CI, 8.0%–16%) for women with one to three involved lymph nodes and by 14% (95% CI, 10%–18%) for women with four or more involved lymph nodes. In contrast, for women with node-negative disease, the absolute reduction in 5-year local recurrence was only 4% (P = .002; 95% CI, 1.8%–6.2%), and there was not a statistically significant reduction in 15-year breast cancer mortality in these patients (absolute gain, 1.0%; P > .1 95%; CI, -0.8%–2.8%). Further, an analysis of NSABP trials showed that even in patients with large (>5 cm) primary tumors, when axillary nodes were negative, the risk of isolated locoregional recurrence was low enough (7.1%) that routine locoregional radiation therapy was not warranted.[70]
Late toxic effects of radiation therapy, though uncommon, can include
radiation pneumonitis, cardiac events, arm edema, brachial plexopathy, and the
risk of second malignancies. Such toxic effects can be minimized with current
radiation delivery techniques and with careful delineation of the target
In a retrospective analysis of 1,624 women treated with conservative surgery and
adjuvant breast radiation at a single institution, the overall incidence of
symptomatic radiation pneumonitis was 1.0% at a median follow-up of 77 months.[71]
The incidence of pneumonitis increased to 3.0% with the use of a supraclavicular
radiation field and to 8.8% when concurrent chemotherapy was administered.
The incidence was only 1.3% in patients who received sequential
chemotherapy.[71][Level of evidence: 3iii]
Controversy existed as to whether adjuvant radiation therapy to the left chest wall or breast, with or without inclusion of the regional lymphatics, had an association with increased cardiac mortality. In women treated with radiation therapy before 1980, an increased cardiac death rate was noted after 10 to 15 years, compared with women with nonradiated or right-side-only radiated breast cancer.[66][72][73][74] This was probably caused by the radiation received by the left myocardium.
Modern radiation therapy techniques introduced in the 1990s minimized deep radiation to the underlying myocardium when left-sided chest wall or left-breast radiation was used. Cardiac mortality decreased accordingly.[75][76] At this time, cardiac mortality was also decreasing in the United States.
An analysis of SEER data from 1973 to 1989 reviewing deaths caused by ischemic heart disease in women who received breast or chest wall radiation showed that since 1980, no increased death rate resulting from ischemic heart disease in women who received left chest wall or breast radiation was found.[77][78][Level of evidence: 3iB]
Lymphedema consequent to cancer management remains a major quality-of-life
concern for breast cancer patients. Single-modality treatment of the axilla
(surgery or radiation) is associated with a low incidence of arm edema.
Axillary radiation therapy can increase the risk of arm edema in patients who
received axillary dissection from 2% to 10% with dissection alone to 13% to 18% with
adjuvant radiation therapy.[79][80][81] (Refer to the PDQ summary on Lymphedema for more information.)
Radiation injury to the brachial plexus following adjuvant nodal radiation therapy is
a rare clinical entity for breast cancer patients. In a single-institution
study using current radiation techniques, 449 breast cancer patients treated
with postoperative radiation therapy to the breast and regional lymphatics were
followed for 5.5 years to assess the rate of brachial plexus injury.[82] The
diagnosis of such injury was made clinically with computerized tomography to
distinguish radiation injury from tumor recurrence. When 54 Gy in 30 fractions
was delivered to the regional nodes, the incidence of symptomatic brachial
plexus injury was 1.0% compared with 5.9% when increased fraction sizes (45 Gy
in 15 fractions) were used.
The rate of second malignancies following adjuvant radiation therapy is very
low. Sarcomas in the treated field are rare, with the long-term risk at 0.2%
at 10 years.[83] One report suggests an increase in contralateral breast
cancer for women younger than 45 years who have received chest wall
radiation therapy after mastectomy.[84] No increased risk of contralateral
breast cancer occurs for women 45 years and older who receive radiation
therapy.[85] Techniques to minimize the radiation dose to the contralateral
breast should be used to keep the absolute risk as low as possible.[86] In
nonsmokers, the risk of lung cancer as a result of radiation exposure during
treatment is minimal when current dosimetry techniques are used. Smokers,
however, may have a small increased risk of lung cancer in the ipsilateral
Stage and molecular features determine the need for adjuvant systemic therapy and the choice of modalities used. For example, ER-positive and/or PR–positive patients will receive hormone therapy. HER2 overexpression is an indication for using adjuvant trastuzumab, usually in combination with chemotherapy. When neither HER2 overexpression (e.g., triple negative, which is common in the basal-like tumors) nor hormone receptors are present, adjuvant therapy relies on chemotherapeutic regimens, which are often combined with experimental targeted approaches.
If ER status is used to select adjuvant treatment, the study should be
performed in a well-established, skilled laboratory. Immunohistochemical
assays appear to be at least as reliable as standard ligand-binding assays in
predicting response to adjuvant endocrine therapy.[88]
The EBCTCG performed a meta-analysis of systemic treatment of early breast
cancer by hormone, cytotoxic, or biologic therapy methods in randomized trials
involving 144,939 women with stage I or stage II breast cancer. The most recent
analysis, which included information on 80,273 women in 71 trials of adjuvant
tamoxifen, was published in 2005.[89] In this analysis, the benefit of
tamoxifen was found to be restricted to women with ER-positive or ER-unknown
breast tumors. In these women, the 15-year absolute reductions in
recurrence and mortality associated with 5 years of use were 12% and 9%,
respectively.[89][Level of evidence: 1iiA]
Allocation to approximately 5 years of adjuvant tamoxifen reduces the annual breast cancer death rate by 31%, largely irrespective of the use of chemotherapy and of age (<50 years, 50–69 years, ≥70 years), PR status, or other tumor characteristics.[89] This EBCTCG meta-analysis also confirmed the benefit of adjuvant
tamoxifen in ER-positive premenopausal women.[89] Women younger than 50 years obtained a degree of benefit from 5 years of tamoxifen similar to that
obtained by older women. In addition, the proportional reductions in both
recurrence and mortality associated with tamoxifen use were similar in women
with either node-negative or node-positive breast cancer, but the absolute
improvement in survival at 10 years was greater in the latter group (5.3%
vs. 12.5% with 5 years of use).[89][Level of evidence: 1iiA]
Similar results were found in the IBCSG-13-93 trial.[90] Of 1,246 women with stage II disease, only the women with ER-positive disease benefited from tamoxifen.
The optimal duration of tamoxifen use has been addressed by the EBCTCG
meta-analysis and by several large randomized trials.[89][91][92][93][94] Results from the EBCTCG
meta-analysis show a highly significant advantage of 5 years versus 1 to 2 years of tamoxifen with respect to the risk of recurrence (proportionate reduction, 15.2%; P <.001) and a less significant advantage with respect to mortality (proportionate reduction, 7.9%; P = .01).[89]
Whether the optimal duration of adjuvant tamoxifen therapy in premenopausal women is 5 years or 10 years is controversial. Results from the NSABP-B-14 study, which compared a 5-year regimen to a 10-year regimen of
adjuvant tamoxifen for women with early stage breast cancer, indicated no
advantage for continuation of tamoxifen beyond 5 years in women with
node-negative, ER-positive breast cancer.[91][Level of evidence: 1iA] Another
trial demonstrated the equivalence of 5 years and 10 years of therapy.[92][Level of evidence: 1iiDii] In both trials, there was a trend toward a worse outcome
associated with a longer duration of treatment.
In the EST-5181 trial, node-positive
women who had already received 5 years of tamoxifen following chemotherapy were
randomly assigned to continue therapy or observation.[93] In the ER-positive
subgroup, a longer time to relapse was associated with continued
tamoxifen use, but no improvement in OS was observed.
Long-term follow-up of the Adjuvant Tamoxifen Longer Against Shorter (ATLAS) trial, which randomly assigned 12,894 women with early breast cancer between 1996 and 2005, revealed that 10 years of tamoxifen reduced the risk of breast cancer recurrence (617 recurrences vs. 711 recurrences, 10 years vs. 5 years, respectively; P = .002), reduced breast-cancer mortality (331 deaths vs. 397 deaths, P= .01), and reduced overall mortality (639 deaths vs. 722 deaths, P = .01).[94][Level of Evidence: 1iiA]. Of note, from the time of the original breast cancer diagnosis, the benefits of 10 years of therapy were less extreme before than after year 10. At 15 years from the time of diagnosis, breast cancer mortality was 15% versus 12.2%, at 10 years and 5 years, respectively. Compared with 5 years, 10 years of tamoxifen therapy increased the risks of the following:
Notably, the cumulative risk of endometrial cancer during years 5 to 14 from breast cancer diagnosis was 3.1% for women who received 10 years of tamoxifen versus 1.6% for women who received 5 years of tamoxifen. The mortality for years 5 to 14 was 12.2 versus 15 for an absolute mortality reduction of 2.8%.
These trials raise important questions about the optimal duration of endocrine therapy. Of note, the long-term ATLAS data are applicable for women who remain premenopausal after 5 years of tamoxifen therapy. Randomized clinical trial data support the use of aromatase inhibitors in postmenopausal women. (Refer to the Aromatase Inhibitors section of this summary for more information.) For women who remain premenopausal after 5 years of tamoxifen, discussion with the patient about the risks and benefits of extending tamoxifen therapy should occur. Because of the conflict in data, the optimal duration is controversial.
(Refer to the Letrozole section in the Aromatase inhibitors section of this summary for more information.)
That chemotherapy should add to the effect of tamoxifen
in postmenopausal women has been postulated.[95][96] In a trial (NSABP-B-16) of node-positive women older than 50
years with hormone receptor–positive tumors, 3-year DFS and
OS rates were better in those who received doxorubicin,
cyclophosphamide, and tamoxifen versus tamoxifen alone (DFS was 84% vs. 67%; P = .004; OS was 93% vs. 85%; P = .04).[97][Level of evidence: 1iiA] The NSABP-B-20 study compared tamoxifen
alone with tamoxifen plus chemotherapy (cyclophosphamide, methotrexate, and fluorouracil [5-FU] [CMF] or sequential methotrexate and 5-FU)
in women with node-negative, ER-positive breast cancer.[98] After 12 years of
follow-up, the chemotherapy plus tamoxifen regimen resulted in 89% DFS and 87% OS compared with a 79% DFS and
83% OS with tamoxifen alone.[98][Level of evidence: 1iiA]
another study of postmenopausal women with node-positive disease, tamoxifen
alone was compared with tamoxifen plus three different schedules of CMF. A
small, DFS advantage was conferred by the addition of early CMF to
tamoxifen in women with ER-positive disease.[99][Level of evidence: 1iiDii]
However, another study in a similar patient population, in which women were
randomly assigned to receive adjuvant tamoxifen with or without CMF, showed no benefit
in the chemotherapy arm; in this study, intravenous (IV) (day 1 every 3 weeks)
rather than oral cyclophosphamide was used.[100][Level of evidence: 1iiA] The
overall results of the available evidence suggest that the addition of
chemotherapy to tamoxifen in postmenopausal women with ER-positive disease
results in a significant, but small, survival advantage.
The use of adjuvant tamoxifen has been associated with certain toxic effects.
The most important effect is the development of endometrial cancer which, in large
clinical trials, has been reported to occur at a rate that is two times to seven times
greater than that observed in untreated women.[101][102][103][104] Women taking tamoxifen
should be evaluated
by a gynecologist if they experience any abnormal uterine bleeding. Although one
retrospective study raised concern that endometrial cancers in women taking
tamoxifen (40 mg/day) had a worse outcome and were characterized by higher-grade lesions and a more advanced stage than endometrial cancers in women not
treated with tamoxifen, other larger studies using standard tamoxifen doses (20
mg/day) have not supported this finding.[101][105][106] Similar to estrogen,
tamoxifen produces endometrial hyperplasia, which can be a premalignant change.
In a cohort of women without a history of breast cancer who were randomly assigned to receive
tamoxifen or placebo on the British Pilot Breast Cancer Prevention Trial, 16%
of those on tamoxifen developed atypical hyperplasia at varying times from the
start of treatment (range, 3 months–75 months; median, 24 months), while no cases
occurred on the control arm.[107] The value of endometrial biopsy,
hysteroscopy, and transvaginal ultrasound as screening tools is unclear.[108][109]
Of concern is an increased risk of gastrointestinal
malignancy after tamoxifen therapy, but these findings are tentative, and
further study is needed.[110]
Tamoxifen use is also associated with an increased incidence of deep venous
thrombosis and pulmonary emboli. In several adjuvant studies, the incidence
ranged from 1% to 2%.[91][97][111][112][113] Clotting factor changes have been
observed in controlled studies of prolonged tamoxifen use at standard doses;
antithrombin III, fibrinogen, and platelet counts have been reported to be
minimally reduced in patients receiving tamoxifen.[114] The relationship of
these changes to thromboembolic phenomena is not clear. Tamoxifen use may also be
associated with an increased risk of strokes.[113][115][116] In the NSABP Breast
Cancer Prevention Trial (NSABP-P-1), this increase was not statistically significant.[115]
Another potential problem is the development of benign ovarian cysts,
which occurred in about 10% of women in a single study.[117] The relationship between
tamoxifen and ovarian tumors requires further study.[118] Short-term toxic
effects of tamoxifen use may include vasomotor symptoms and gynecologic symptoms
(e.g., vaginal discharge or irritation).[119] (Refer to the PDQ summary on Sexuality and Reproductive Issues for more information.) Ophthalmologic toxic effects have also been reported in patients receiving
tamoxifen; patients who complain of visual problems should be assessed
carefully.[120][121][122] Because the teratogenic potential of tamoxifen is unknown,
contraception should be discussed with patients who are premenopausal or of
childbearing age and are candidates for treatment with this drug.
Tamoxifen therapy may also be associated with certain beneficial estrogenic
effects, including decreased total and low-density lipoprotein levels.[123][124]
A large controlled Swedish trial has shown a decreased incidence of cardiac
disease in postmenopausal women taking tamoxifen. Results were better for
women taking tamoxifen for 5 years than for women taking it for 2 years.[125]
In another trial, the risk of fatal myocardial infarction was significantly
decreased in patients receiving adjuvant tamoxifen for 5 years versus those
treated with surgery alone.[124] In the NSABP-B-14 study, the annual death
rate due to coronary heart disease was lower in the tamoxifen group than in the
placebo group (0.62 per 1,000 vs. 0.94 per 1,000), but this difference was not
statistically significant.[126] To date, three large controlled trials have shown a decrease in heart disease.[124][125][126]
Controlled studies have associated long-term tamoxifen use with preservation of
bone mineral density of the lumbar spine in postmenopausal women.[127][128][129] In
premenopausal women, decreased bone mineral density is a possibility.[130]
The EBCTCG meta-analysis included almost 8,000 premenopausal women who were randomly assigned to undergo ovarian ablation with surgery or radiation therapy (4,317) or ovarian suppression with luteinizing hormone-releasing hormone (LHRH) agonists (3,408). Overall, ovarian ablation or suppression reduced the absolute risk of recurrence at 15 years by 4.3% (P < .001) and the risk of death from breast cancer by 3.2% (P = .004).[89] No evidence showed that the relative benefit of suppression differed from that of ablation, but the benefit of either was less in patients who received chemotherapy.[131][Level of evidence: 1iiA]
A single study of more
than 300 patients that compared cyclophosphamide, methotrexate, 5-FU, and
prednisone (CMFP) with the same chemotherapy regimen plus surgical oophorectomy
showed no additional survival benefit from oophorectomy.[132][Level of evidence: 1iiA] Three trials (including the International Breast Cancer Study Group's trial [IBCSG-VIII] and the Eastern Cooperative Oncology Group's trial [EST-5188]) involving more than 3,000 patients assessed the impact on DFS and OS from the use of an LHRH analog (in one trial, 50% of the patients had radiation oophorectomy rather than an LHRH analog) in addition to chemotherapy.[131][133][134][Level of evidence: 1iiA] None of the trials identified a statistically significant benefit in OS or DFS from ovarian suppression.
As an adjuvant strategy, ovarian ablation has also been compared
with chemotherapy in premenopausal women. In a direct comparison of surgical or
radiation ablation and CMF, DFS and OS rates were
identical in 332 premenopausal women with stage II disease.[135][Level of evidence: 1iiA] A trial of 599 premenopausal node-positive patients found leuprorelin acetate to be similar to CMF with respect to DFS and OS.[136] A Danish trial compared ovarian ablation or suppression to CMF (nine cycles IV every 3 weeks) in premenopausal, ER-positive women and found no difference in OS or DFS in the two study groups.[137][138] The study did not have tamoxifen as an adjuvant arm and also did not use taxanes or anthracyclines. Results may have been different with these two contemporary modifications to the study. A trial of CMF versus tamoxifen plus ovarian ablation (e.g., by surgery,
radiation therapy, or gonadotropin-releasing hormone) in premenopausal or perimenopausal women with
receptor-positive tumors has been reported.[139][Level of evidence: 1iiA] In
this small trial, which did not meet its target accrual, the combination of
tamoxifen and ovarian ablation provided comparable DFS and OS rates.
In three larger trials in which medical ovarian ablation with goserelin was used, the impact of goserelin alone on DFS was found to be comparable to CMF in the subgroup of ER+ patients,[131][140][Level of evidence: 2Dii] whereas the combination of goserelin and tamoxifen was associated with prolonged DFS compared with CMF alone.[141][Level of evidence: 1iiDii] Whether tamoxifen or aromatase inhibitors add to ovarian ablation, and the elucidation of the optimal roles for endocrine manipulation and chemotherapy in receptor-positive premenopausal women, require further evaluation.[142] These issues are the subject of several trials.
In summary, the weight of evidence suggests that ovarian ablation should not be routinely added to systemic therapy with chemotherapy and/or tamoxifen.[131][133][134][143] Ovarian ablation alone should not be routinely used as an alternative to any other systemic therapy.[135][136][137][138][143] Further results of research studies prospectively evaluating the role of adjuvant ovarian ablation are awaited.
Based on DFS advantage as described below, aromatase inhibitors have become the first-line adjuvant therapy for postmenopausal women; however, because there is no demonstrated survival advantage to aromatase inhibitors, tamoxifen remains a reasonable alternative.[144][145]
A large, randomized trial of 9,366 patients has compared the use of the aromatase inhibitor anastrozole and the combination of anastrozole and tamoxifen with tamoxifen alone as adjuvant therapy for postmenopausal patients with node-negative and node-positive disease.[146][147] Most (84%) of the patients in the study were hormone-receptor positive. Slightly more than 20% had received chemotherapy. With a median follow-up of 33.3 months, no benefit was observed for the combination arm relative to tamoxifen. Patients on anastrozole, however, had a significantly longer DFS (HR, 0.83) than those on tamoxifen. In an analysis conducted when all but 8% of the patients had completed protocol therapy at a follow-up of 68 months,[147] the benefit of anastrozole relative to tamoxifen with respect to DFS was slightly less (HR, 0.87; 95% CI, 0.78–0.96; P = .01). A greater benefit was seen in hormone receptor-positive patients (HR, 0.83; 95% CI, .73–0.94; P = .05). There was an improvement in time to recurrence (HR, 0.79; 95% CI, 0.70–0.90; P = .005), distant DFS (HR, 0.86; 95% CI, 0.74–0.99; P = .04) and contralateral breast cancer (42% reduction; P = .01) in patients who received anastrozole.[147][Level of evidence: 1iDii] No difference was shown in OS (HR, 0.97; 95% CI, 0.85–1.12; P = .7 ). Arthralgia and fractures were reported significantly more often in patients who received anastrozole, whereas hot flushes, vaginal bleeding and discharge, endometrial cancer, ischemic cerebrovascular events, venous thromboembolic and deep venous thromboembolic events were more common in patients who received tamoxifen.[147] An American Society of Clinical Oncology (ASCO) Technology Assessment panel has commented on the implications of these results.[148][149]
Three trials examined the effect of switching to anastrozole to complete a total of 5 years of therapy after 2 to 3 years of tamoxifen.[150][151][152] One study, which included 448 patients, demonstrated a statistically significant reduction in DFS (HR, 0.35; 95% CI, 0.18–0.68; P = .001) but no difference in OS.[150][Level of evidence: 1iiA] The other two trials were reported together.[151] A total of 3,224 patients were randomly assigned after 2 years of tamoxifen to continue tamoxifen for a total of 5 years or to take anastrozole for 3 years. After a median follow-up of 78 months, an improvement in all-cause mortality (HR, 0.61; 95% CI, 0.42–0.88; P = .007) was observed.[152]
A meta-analysis of these three studies showed that patients who switched to anastrozole had significant improvements in DFS (HR, 0.59; 95% CI, 0.48–0.74; P < .001), event-free survival (EFS) (HR, 0.55; 95% CI, 0.42–0.71; P < .001), distant DFS (HR, 0.61; 95% CI, 0.45–0.83; P= .002), and OS (HR, 0.71; 95% CI, 0.52–0.98; P = .04) compared with the patients who remained on tamoxifen.[153]
A large double-blinded randomized trial of 8,010 postmenopausal women with hormone receptor-positive breast cancer compared the use of letrozole versus tamoxifen given continuously for 5 years or with crossover with the alternate drug at 2 years.[154] In an updated analysis from the Breast International Group (IBCSG-1-98) including only the 4,922 women who received tamoxifen or letrozole for 5 years, at a median follow-up time of 51 months, DFS was significantly superior in patients treated with letrozole (HR, 0.82; 95% CI, 0.71–0.95; P = .007; 5-year DFS, 84.0% vs. 81.1%).[155][Level of evidence: 1iDii] OS was not significantly different (HR, 0.91; 95% CI, 0.75–1.11; P = .35). Patients on letrozole had significantly fewer thromboembolic events, endometrial pathology, hot flashes, night sweating, and less vaginal bleeding. Patients on tamoxifen had significantly fewer bone fractures, arthralgia, hypercholesterolemia, and cardiac events other than ischemic heart disease and cardiac failures.[155]
A large, double-blinded, randomized trial (CAN-NCIC-MA17 [NCT00003140]) of 5,187 patients compared the use of letrozole with a placebo in receptor-positive postmenopausal women who received tamoxifen for approximately 5 (4.5–6.0) years.[156] After the first planned interim analysis, when median follow-up for patients on study was 2.4 years, the results were unblinded because of a highly significant (P < .008) difference in DFS (HR, 0.57) favoring the letrozole arm.[156][Level of evidence: 1iDii] After 3 years of follow-up, 4.8% of the women on the letrozole arm had developed recurrent disease or new primaries versus 9.8% on the placebo arm (95% CI for the difference, 2.7%–7.3%). Women on letrozole had significantly more hot flashes, arthritis, arthralgia and myalgia, but less vaginal bleeding. New diagnoses of osteoporosis were more frequent on letrozole (5.8% vs. 4.5%), though the difference was not statistically significant (P = .07). Because of the early unblinding of the study, longer-term comparative data on the risks and benefits of letrozole in this setting will not be available.[157][158] An updated analysis including all events prior to unblinding confirmed the results of the interim analysis.[159] In addition, a statistically significant improvement in distant DFS was found for patients on letrozole (HR, 0.60; 95% CI, 0.43–0.84; P = .002). Although no significant difference was found in the total study population, the node-positive patients on letrozole also experienced a statistically significant improvement in OS (HR, 0.61; 95% CI, 0.38–0.98; P = .04), though the P value was not corrected for multiple comparisons. An ASCO Technology Assessment panel has commented on the implications of these results.[148][149]
A large, double-blinded, randomized trial (EORTC-10967 [ICCG-96OEXE031-C1396-BIG9702]) of 4,742 patients compared continuing tamoxifen with switching to exemestane for a total of 5 years of therapy in women who had received 2 to 3 years of tamoxifen.[160][161] After the second planned interim analysis, when median follow-up for patients on the study was 30.6 months, the results were released because of a highly significant (P < .005) difference in DFS (HR, 0.68) favoring the exemestane arm.[160][Level of evidence: 1iDii] After a median follow-up of 55.7 months, the HR for DFS was 0.76 (95% CI, 0.66–0.88; P = .001) in favor of exemestane.[162] At 2.5 years after random assignment, 3.3% fewer patients on exemestane had developed a DFS event (95% CI, 1.6–4.9). The HR for OS was 0.85 (95% CI, 0.7–1.02; P = .08).[162][Level of evidence: 1iA] Women on exemestane had significantly more arthralgia, diarrhea, hypertension, fractures, arthritis, musculoskeletal pain, carpal tunnel syndrome, insomnia, and osteoporosis, but women on tamoxifen had significantly more gynecologic symptoms, muscle cramps, vaginal bleeding and discharge, thromboembolic disease, endometrial hyperplasia, and uterine polyps. (Refer to the PDQ summary on Gastrointestinal Complications for information on diarrhea and for information on insomnia, refer to the PDQ summary on Sleep Disorders.)
A large, randomized trial of 9,779 patients compared DFS of postmenopausal women with hormone receptor–positive breast cancer between initial treatment with sequential tamoxifen for 2.5 to 3 years followed by exemestane for a total of 5 years versus exemestane alone for 5 years.[163] The primary endpoints were DFS at 2.75 years and 5.0 years. Five-year DFS was 85% in the sequential group and 86% in the exemestane-alone group (HR, 0.97; 95% CI, 0.88–1.08; P = .60).[163][Level of evidence: 1iDii] The results of this trial support the use of exemestane, either sequentially after tamoxifen or as initial treatment for early-stage hormone receptor–positive breast cancer in postmenopausal women.
The mild androgen activity of exemestane prompted a randomized trial to evaluate whether exemestane might be preferable to anastrozole, in terms of its efficacy and toxicity, as upfront therapy for postmenopausal women diagnosed with hormone receptor-positive breast cancer.[164][Level of evidence: 1iiA] The MA27 (NCT00066573) trial randomly assigned 7,576 postmenopausal women to receive 5 years of anastrozole versus exemestane. At a median follow-up of 4.1 years, no difference in efficacy was seen.
Standard chemotherapy regimens for the adjuvant treatment of operable breast cancer that is given in the modern era are described in Table 6. There is no evidence favoring any regimen as superior to another. Therefore, any of these standard regimens is acceptable therapy.
Some of the most important data on the benefit of adjuvant chemotherapy came from the EBCTCG, which meets every 5 years to review data from global breast cancer trials. The year 2000 overview analysis (published in 2005) summarized the results of randomized adjuvant trials initiated by 1995.[89] The analyses of adjuvant chemotherapy involved 28,764 women participating in 60 trials of combination chemotherapy (polychemotherapy) versus no chemotherapy, 14,470 women in 17 trials of anthracycline-containing versus CMF-type chemotherapy, and 6,125 women in 11 trials of longer versus shorter chemotherapy duration.
For women younger than 50 years, polychemotherapy reduced the annual risk of disease relapse and death from breast cancer by 37% and 30%, respectively. This translated into a 10% absolute improvement in 15-year survival (HR, 42% vs. 32%).
For women aged 50 to 69 years, the annual risk of relapse or death from breast cancer was decreased by 19% and 12%, respectively. This translated into a 3% absolute gain in 15-year survival (HR, 50% vs. 47%).
The absolute gain in survival for polychemotherapy versus no adjuvant therapy in women younger than 50 was twice as great at 15 years as it was at 5 years (10% vs. 4.7%), while the main effect on disease recurrence was seen in the first 5 years.[89] The 15-year cumulative reduction in mortality from 6 months of an anthracycline-based regimen (e.g., fluorouracil, doxorubicin, cyclophosphamide [FAC] or fluorouracil, epirubicin, cyclophosphamide [FEC]) was 38% in women younger than 50 years, and 20% in those aged 50 to 60 years.
The meta-analysis also showed that the reduction in risk of
recurrence was similar in the presence or absence of tamoxifen, irrespective of
age (<50 years vs. 50–69 years), though the result did not attain statistical
significance in those randomly assigned women younger than 50 years. This
finding, however, is most likely the result of the relatively small number of younger women in trials
of combined chemoendocrine therapy. Few women older than 70 years had been studied, and specific conclusions could not be reached in this group.
Importantly, these data were derived from clinical trials in which patients were not selected for adjuvant therapy according to ER status, and they were initiated before the advent of taxane-containing, dose-dense, or trastuzumab-based therapy.[89] As a result, they may not reflect treatment outcomes based on evolving treatment patterns.
Results of individual trials are generally in agreement with the conclusions of
the meta-analysis. The NSABP-B-13 study demonstrated a benefit for
chemotherapy with sequential methotrexate and 5-FU versus surgery alone in
patients with node-negative, ER-negative tumors.[97][98][165][166][Level of evidence: 1iiA]
Cycle Number and Duration (d)
Cytoxan (mg/m²)
5-FU (mg/m²)
Doxorubicin (mg/m²)
Paclitaxel/Docetaxel (mg/m²)
6 × 21
500, IV d 1
50, IV d 1
4 × 21
600, IV d 1
60, IV d 1
Dose-dense AC-T [179]
P: 175, IV d 1
D: 75, IV d 1
4 x 21
D: 75, IV d 1
AC = cyclophosphamide, doxorubicin; AC-T = cyclophosphamide, doxorubicin, taxol; CAF = cyclophosphamide, doxorubicin, fluorouracil; d = day; D = docetaxel; IV = intravenously; P = paclitaxel; T = taxol; TAC = docetaxel, doxorubicin and cyclophosphamide; TC = docetaxel and cyclophosphamide; 5-FU = fluorouracil.
The EBCTCG meta-analysis analyzed 11 trials that began in 1976 through 1989 in
which women were randomly assigned to receive regimens containing anthracyclines (e.g., doxorubicin or epirubicin) versus CMF alone. The EBCTCG overview analysis directly compared anthracycline-containing regimens (mostly 6 months of FEC or FAC) with CMF (either oral or IV) in approximately 14,000 women, 64% of whom were younger than 50 years.[89] Compared with CMF, anthracycline-based regimens were associated with a modest but statistically significant 11% proportional reduction in the annual risk of disease recurrence, and a 16% reduction in the annual risk of death. In each case, the absolute difference in outcomes between anthracycline-based and CMF-type chemotherapy was about 3% at 5 years and 4% at 10 years.[167][Level of evidence: 1iiA]
The largest direct comparison of
cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF) (six cycles) versus CMF (six cycles) occurred in a U.S. Intergroup study (SWOG-8897), which was not included in the meta-analysis.[168] In this study, 2,691 patients were
randomly assigned to receive CAF or CMF with a second random assignment to 5 years of
tamoxifen versus no tamoxifen. Ten-year follow-up estimates indicated that CAF was not significantly better than CMF (P = .13) for the primary outcome of DFS (77% vs. 75%; HR, 1.09; 95% CI, 0.94–1.27). CAF had slightly better OS than CMF (85% vs. 82%, HR, 1.19 for CMF vs. CAF; 95% CI, 0.99–1.43), though values were statistically significant in the planned one-sided test (P = .03). Toxicity was greater with CAF and did not increase with tamoxifen. Overall, tamoxifen had no benefit (DFS, P = .16; OS, P = .37), but the tamoxifen effect differed by high-risk groups. For high-risk node-positive patients, tamoxifen was beneficial (DFS: HR, 1.32 for no tamoxifen vs. tamoxifen; 95% CI, 1.09–1.61; P = .003; OS: HR, 1.26; 95% CI, 0.99–1.61; P = .03) but not for high-risk node-negative patients (DFS: HR, 0.81 for no tamoxifen vs. tamoxifen; 95% CI, 0.64–1.03; OS: HR, 0.79; 95% CI, 0.60–1.05). The conclusion of this trial was that CAF did not improve DFS, compared with CMF; and, there was a slight effect on OS. Given greater toxicity, CAF cannot be concluded to be superior to CMF. Tamoxifen was effective in high-risk node-positive disease but not in high-risk node-negative disease.[168][Level of evidence: 1iiA]
Several investigators have attempted to improve outcomes by combining CMF and
anthracycline-containing regimens. Two Italian studies have evaluated these
regimens.[169][170] In one study, 490 premenopausal and postmenopausal women with one to three axillary
lymph nodes were randomly assigned to receive CMF (12 cycles) or CMF (eight cycles)
followed by doxorubicin (four cycles).[169] After a median observation of 17.5 years, no statistically significant difference was documented in the first study (relapse-free survival [RFS], HR, 1.06; total survival, HR, 1.03). In contrast, the delivery of doxorubicin first, followed by CMF significantly reduced the risk of disease relapse (HR, 0.68; 95% CI, 0.54–0.87; P =.0017) and death (HR, 0.74; 95% CI, 0.57–0.95; P = .018) compared with the alternating regimen. In the other study, 403 premenopausal and postmenopausal
women with four or more positive axillary lymph nodes were randomly assigned to receive
doxorubicin (four cycles) followed by CMF (eight cycles) or CMF (two cycles) alternating
with doxorubicin (one cycle) for a total of 12 cycles.[170] Women who received
doxorubicin followed by CMF had better RFS (42% vs. 28%; P = .002)
and OS (58% vs. 44%; P = .002).[170][Level of evidence: 1iiA]
The NSABP-B-15 trial randomly assigned 2,194 patients with axillary node-positive breast cancer
and tumors determined nonresponsive to tamoxifen to doxorubicin and cyclophosphamide (AC) (four cycles), CMF (six cycles), or AC (four cycles) followed after a
6-month delay by CMF (three cycles).[171] No differences were seen in DFS or
OS among the three groups.[171][Level of evidence: 1iiA] This study
has also shown no difference in survival rates between four cycles of AC and six
cycles of CMF.
The results of these various studies comparing and combining CMF and
anthracycline-containing regimens suggest a slight advantage for the
anthracycline regimens in both premenopausal and postmenopausal patients. Uncertainty remains, however, about whether there is an advantage to combining both regimens.
Evidence suggests that particular tumor characteristics may
predict anthracycline-responsiveness. Data from retrospective analyses of
randomized clinical trials suggest that, in patients with node-positive breast
cancer, the benefit from standard-dose versus lower-dose adjuvant CAF,[2] or the
addition of doxorubicin to the adjuvant regimen,[3] is restricted to those
patients whose tumors overexpress HER2/neu.[Level of evidence: 1iiA] A retrospective analysis of the HER2/neu status of 710 premenopausal, node-positive women was undertaken to see the effects of adjuvant chemotherapy with CMF or cyclophosphamide, epirubicin, and fluorouracil (CEF).[172][Level of evidence: 2A] HER2/neu was measured using fluorescence in situ hybridization, polymerase chain reaction, and immunohistochemical methods. The study confirmed previous data indicating that the amplification of HER2/neu was associated with a decrease in RFS and OS. In patients with HER2/neu amplification, the RFS and OS were increased by CEF. In the absence of HER2/neu amplification, CEF and CMF were similar to RFS (HR for relapse, 0.91; 95% CI, 0.71–1.18; P = .049) and OS (HR for death, 1.06; 95% CI, 0.83–1.44; P = .68). Similar results were seen in a meta-analysis that included 5,354 patients in whom HER2 status was known from eight randomized trials (including the one just described) comparing anthracycline-containing regimens with nonanthracycline-containing regimens.[173]
A number of trials have addressed the benefit of adding a taxane (paclitaxel or docetaxel) to an anthracycline-based adjuvant chemotherapy regimen. A literature-based meta-analysis of 13 such studies demonstrated that the inclusion of a taxane improved both DFS and OS (DFS: HR, 0.83; 95% CI, 0.79–0.87; P < .001; OS: HR, 0.85; 95% CI, 0.79–0.91; P < .001).[174][Level of evidence: 1iiA] Five-year absolute survival differences were 5% for DFS and 3% for OS in favor of taxane-containing regimens. There were no differences in benefit observed in patient subsets defined by nodal status, hormone receptor status, or age/menopausal status. There was also no apparent difference in efficacy between the two agents. However, none of the studies reviewed involved a direct comparison between paclitaxel and docetaxel.
An Eastern Cooperative Oncology Group–led intergroup trial (E1199 [NCT00004125]) involving 4,950 patients compared, in a factorial design, two schedules (weekly and every 3 weeks) of the two drugs (docetaxel vs. paclitaxel) following standard-dose AC chemotherapy given every 3 weeks.[175][Level of evidence: 1iiA] There was no difference observed in the overall comparison with regard to DFS of docetaxel to paclitaxel (odds ratio [OR], 1.03; 95% CI, 0.91–1.16; P = .61) or between the 1-week and 3-week schedules (OR, 1.06; 95% CI, 0.94–1.20; P = .33). However, there was a significant interaction between the drug administered and schedule for both DFS (0.003) and OS (0.01). Thus, compared with paclitaxel given every 3 weeks, paclitaxel given weekly improved both DFS (OR, 1.27; 95% CI, 1.01–1.57; P = .006) and OS (OR, 1.32; 95% CI, 1.02–1.72; P = .01). Docetaxel given every 3 weeks was also superior in DFS to paclitaxel given every 3 weeks (OR, 1.23; 95% CI, 1.00–1.52; P = .02), but the difference was not statistically significant for OS (OR, 1.13; 95% CI, 0.88–1.46; P = .25). Docetaxel given weekly was not superior to paclitaxel given every 3 weeks. There was no stated a priori basis for expecting that varying the schedule of administration would have opposite effects for the two drugs. Thus, these results are hypothesis generating and should be confirmed.
A U.S. Intergroup study (CLB-9344) randomly assigned women with node-positive tumors to three
dose levels of doxorubicin (60, 75, and 90 mg/m2) and a fixed
dose of cyclophosphamide (600 mg/m2) every 3 weeks for four cycles.
After AC chemotherapy, patients were randomly assigned for a second time to paclitaxel
(175 mg/m2) every 3 weeks for four cycles versus no further therapy, and women with
ER-positive tumors also received tamoxifen for 5 years. Although the
dose-escalation of doxorubicin was not beneficial, the addition of paclitaxel
resulted in statistically significant improvements in DFS (5%) and
OS (3%).[176][Level of evidence: 1iiA] The results of a second trial (NSABP-B-28) have also been reported.[177]
This trial randomly assigned 3,060 women with node-positive breast cancer to four
cycles of postoperative AC or four cycles of AC followed by four cycles of
paclitaxel. All women older than 50 years, and those younger than 50 years with receptor-positive disease, received tamoxifen. In this trial,
DFS was significantly improved by the addition of paclitaxel (HR, 0.83; 95% CI, 0.72–0.96; P = .006; 5-year DFS, 76% vs. 72%). The difference in OS was small (HR, 0.93), however, and not statistically significant (P = .46).[177][Level of evidence: 1iiA]
The regimen of FAC compared with docetaxel plus doxorubicin and cyclophosphamide (TAC) has been studied in 1,491 women with node-positive disease in the Breast Cancer International Research Group's (BCIRG-001) trial. Six cycles of either regimen were given as adjuvant postoperative therapy. A 75% DFS rate existed at 5 years in the TAC group, compared with a 68% survival in the FAC group (P = .001). TAC was associated with a 30% overall lower risk of death (5% absolute difference) than FAC (HR, .70; 98% CI, 0.53–0.91; P < .008). Anemia, neutropenia, febrile neutropenia, and infections were more common in the TAC group. No deaths were associated with infections in either group.[178][179][Level of evidence: 1iiA] (Refer to the PDQ summary on Fatigue for information on anemia.)
Retrospective and some prospective data support the view that physicians should
avoid arbitrary reductions in dose intensity.[180][181] The data for
the benefit of dose escalation in breast cancer, however, are more controversial. The CLB-8541 trial compared three dose intensities of CAF in
1,550 patients with node-positive breast cancer. Patients received either CAF
(300/30/300 mg/m2 every 4 weeks for four cycles; low-dose arm), CAF
(400/40/400 mg/m2 every 4 weeks for six cycles; moderate-dose arm),
or CAF (600/60/600 mg/m2 every 4 weeks for four cycles; high-dose
arm). The high-dose arm had twice the dose intensity and twice the drug dose
as the low-dose arm. The moderate-dose arm had 66% of the dose intensity
as the high-dose arm but the same total drug dose. At a median follow-up of 9
years, DFS and OS on the high-dose and intermediate-dose
arms were superior to the corresponding survival measures on the low-dose arm
(P = .001) with no difference in these measures between the high-dose and
intermediate-dose arms.[180][Level of evidence: 1iiA] The higher dose levels used
in this trial are currently considered standard, so it is unclear whether this
trial is supportive of the value of dose intensity or, rather, supportive of
the concept of a threshold level below which treatment becomes ineffective.
Other trials have clearly escalated doses beyond the standard range. The NSABP-B-22 and NSABP-B-25 trials, for example, escalated the dose of cyclophosphamide to 1,200 mg/m2 (without granulocyte-colony stimulating factor [G-CSF]) and
2,400 mg/m2 (with G-CSF), respectively, with no
significant advantage observed in DFS or OS compared with
the standard dose of 600 mg/m2.[182][183][Level of evidence: 1iiA]
A U.S. Intergroup study (CLB-9344) randomly assigned women with node-positive tumors to three
dose levels of doxorubicin (60, 75, and 90 mg/m2). Following
treatment with doxorubicin, a second random assignment occurred to paclitaxel or to
no further therapy. After chemotherapy, patients with ER-positive tumors were
offered a planned course of tamoxifen for 5 years. No difference in DFS related to the dose of doxorubicin was found.[176] In contrast, a Canadian trial (CAN-NCIC-MA5) in
which cyclophosphamide, epirubicin, and 5-FU (CEF) were given to
a total dose of 720 mg/m2 for a period of six 4-week cycles
demonstrated at a median follow-up of 10 years for live patients, a 10-year RFS of 52% for patients who received CEF compared with 45% for CMF patients (HR for CMF vs. CEF, 1.31; stratified log-rank, P = .007).[184] The 10-year OS for patients who received CEF and CMF was 62% and 58%, respectively (HR for CMF vs. CEF, 1.18; stratified log-rank, P = .085). The rates of acute leukemia have not changed since the original report, whereas the rates of congestive heart failure were slightly higher (four patients [1.1%] in the CEF group vs. one patient [0.3%] in the CMF group).[184][Level of evidence: 1iiA] The
design of the trial does not allow a determination of whether anthracycline or
dose-intensity or both is responsible for the improved outcome. A French trial
showed that higher doses of epirubicin led to a high survival rate in women
with poor-prognosis disease.[185] A randomized trial that increased duration of epirubicin did not lead to increased survival at 10 years in node-positive premenopausal women.[186]
A U.S. Intergroup trial (CLB-9741) compared, in a 2 × 2 factorial design, the use of adriamycin, cyclophosphamide, and paclitaxel concurrently (adriamycin and cyclophosphamide followed by paclitaxel) versus sequentially (adriamycin followed by paclitaxel followed by cyclophosphamide), given every 3 weeks or every 2 weeks with filgrastim, in 2,005 node-positive premenopausal and postmenopausal patients.[187] At a median follow-up of 68 months, dose-dense treatment improved the primary end point, DFS in all patient population (HR, 0.80; P =.018) but not OS (HR, 0.85; P =.12). There was no interaction between density and sequence. Severe neutropenia was less frequent in patients who received the dose-dense regimens.[187][188] Grade 2 anemia (hemoglobin <10g/dL) was more frequent in the adriamycin and cyclophosphamide followed by paclitaxel every 2 weeks' arm (P < .001). At cycle five, this same arm had the lowest nadir hemoglobin of 10.7 g/dL, 0.9 g/dL lower than the other arms. Also, epoetin alpha use was highest in this arm compared with the three other arms (P = .013). In conclusion, dose-dense adriamycin and cyclophosphamide followed by paclitaxel every 14 days in C2 was associated with a greater incidence of moderate anemia, higher use of epoetin alpha, and more red cell transfusions than the other arms.[189][Level of evidence: 1iiA]
Several clinical trials (including EST-2190) have tested high-dose chemotherapy with bone marrow
transplant (BMT) or stem cell support in women with more than ten positive lymph
nodes and in women with four to nine positive lymph nodes.[190][191][192][193][194][195][196][197] A prospective, randomized trial of 403 patients testing the use of two tandem high-dose chemotherapy courses demonstrated a statistically significant (P = .02) difference in 5-year survival (75% vs. 70%) with a 49-month median follow-up.[196][Level of evidence: 1iiA] The remaining trials comparing
conventional chemotherapy to high-dose chemotherapy with BMT or stem cell
support in high-risk patients in the adjuvant setting indicated no OS or
EFS benefit from the high-dose chemotherapy with BMT or stem
cell support.[190][191][192][193][194][195][197][198][199][Level of evidence: 1iiA] The information to date does not support the use of high-dose
chemotherapy outside the context of a randomized clinical trial.
Also, a systematic review of nine randomized, controlled trials comparing the effectiveness of high-dose chemotherapy and autograft with conventional chemotherapy for women with early poor prognosis breast cancer was performed.[197] In total 1,758 women were randomly assigned to receive high-dose chemotherapy with autograft, and 1,767 women were randomly assigned to receive conventional chemotherapy. There were 48 noncancer-related deaths on the high-dose arm and four on the conventional-dose arm (RR, 7.74; 95% CI, 3.43–17.50). There was no statistically significant difference in OS between women who received high-dose chemotherapy with autograft and women who received conventional chemotherapy, either at 3 years (RR, 1.02; 95% CI, 0.98–1.06), or at 5 years (RR, 0.98; 95% CI, 0.93–1.05). There was a statistically significant benefit in EFS at 3 years for the group who received high-dose chemotherapy (RR, 1.11; 95% CI, 1.05–1.18). However, this
significance was lost at 5 years (RR, 1.00; 95% CI, 0.92–1.08).[197]
The regimen of docetaxel and cyclophosphamide (TC) compared with AC was studied in 1,016 women with stage I or stage II invasive breast cancer. Patients were randomly assigned to receive four cycles of either TC or AC as adjuvant postoperative therapy. At 5 years, DFS was statistically significantly superior for TC compared with AC (86% vs. 80%, HR, 0.67; 95% CI, 0.50–0.94; P = .015).[200][Level of evidence: 1iiA] At the time of the original report, OS was not statistically significantly improved. However, a 7-year update of results for DFS and OS demonstrated that four cycles of TC was superior to standard AC for both DFS and OS.[201][Level of evidence: 1iiA]. At 7 years, DFS was significantly superior for TC compared with AC (81% vs. 75%, HR, 0.74; 95% CI, 0.56–0.98; P = .033). At 7 years, OS was significantly superior for TC compared with AC (87% vs. 82%, HR, 0.69; 95% CI, 0.50–0.97; P = .032). With TC, patients had fewer cardiac-related toxic effects but other side effects included more myalgia, arthralgia, edema, and febrile neutropenia compared with AC.
The role of bisphosphonates as part of adjuvant therapy for early stage breast cancer is unclear. The ABCSG-12 (NCT00295646) trial was a 2 × 2 factorial-design randomized trial that assigned 1,803 premenopausal patients with ER-positive breast cancer to receive ovarian function suppression with goserelin and tamoxifen versus goserelin and anastrozole. These patients then underwent a second random assignment to receive zoledronic acid (4 mg IV every 6 months) versus no zoledronic acid.[202][Level of evidence: 1iiA] There was no significant difference in DFS between the anastrozole and tamoxifen groups. However, the addition of zoledronic acid to endocrine therapy, as compared with endocrine therapy without zoledronic acid, resulted in a relative reduction of 36% in the risk of disease progression (HR, 0.64; P = .01) but did not significantly reduce the risk of death. Similar results were obtained in the trial (NCT00171340) in which 1,065 postmenopausal women received letrozole and were randomly assigned to receive zoledronic acid (4 mg IV every 6 months) immediately or only after the development of bone loss or fractures. Immediate administration of zoledronic acid resulted in a 34% improvement in DFS (HR, 0.66; 95% CI, 0.44–0.97, P = .035) but did not affect OS.[203][Level of evidence: 1iiA]
While bisphosphonates appear to improve DFS in a population with low-to-intermediate-risk breast cancer, this benefit does not appear to be seen in all patients with breast cancer. The AZURE trial was a randomized, phase III trial that assigned 3,660 patients with stage II or III breast cancer to receive chemotherapy and/or hormone therapy with or without zoledronic acid.[204][Level of evidence: 1iiA] At a median follow-up of 59 months, there was no significant benefit in the DFS in both groups (77% in each group; HR, 0.98; P = .79). OS was also similar, at 85.4% in the zoledronic acid group and 83.1% in the control group (adjusted HR, 0.85; P = .07).
Based on the conflicting results of these trials, the exact role for bisphosphonates in adjuvant therapy for breast cancer is controversial. An ongoing phase III trial (NCT01077154) is examining the activity of the bone-modifying agent, denosumab, in stage II and III breast cancer.
Several phase III clinical trials have addressed the role of the anti-HER2/neu antibody, trastuzumab, as adjuvant therapy for patients with HER2-overexpressing cancers.
In the HERceptin Adjuvant (HERA) (BIG-01-01 [NCT00045032]) trial, which is the largest study (5,090 patients), trastuzumab was given every 3 weeks within 7 weeks of the completion of primary therapy that included, for most patients, an anthracycline-containing chemotherapy regimen given preoperatively or postoperatively, plus or minus locoregional radiation therapy.[205][Level of evidence: 1iiA] Also, 3,387 patients were enrolled in a comparison regimen of 1 year of trastuzumab (1,694 patients) versus observation (1,693 patients).[205] Of these patients, the median age was 49 years, about 33% had node-negative disease, and nearly 50% had hormone receptor (ER and PR)-negative disease. Patients who were treated with 1 year of trastuzumab experienced a 46% lower risk of a first event (HR, 0.54; 95% CI, 0.43–0.67; P < .001), corresponding to an absolute DFS benefit of 8.4% at 2 years (95% CI, 2.1–14.8). The updated results at 23.5 months' follow-up showed an unadjusted HR for the risk of death with trastuzumab compared with observation of 0.66 (95% CI, 0.47–0.91; P = .0115), corresponding to an absolute OS benefit of 2.7%.[206] There were 218 DFS events reported with trastuzumab compared with 321 DFS events reported with observation. The unadjusted HR for the risk of an event with trastuzumab was 0.64 (0.54–0.76; P < .001), corresponding to an absolute DFS benefit of 6.3%. After a median follow-up of 8 years, the results of the comparison of 1 year versus 2 years of trastuzumab were analyzed.[207] No difference in DFS was found between the groups (HR, 0.99; 95% CI, 0.85–1.14; P = .86).[207][Level of evidence: 1iiA] The benefit of 1 year of trastuzumab over observation persisted, despite crossover of 52% of the patients on observation (HR, 0.76; 95% CI, 0.65–0.88; P = .0005).[207][Level of evidence: 1iiA]
In the combined analysis of the NSABP-B-31 (NCT00004067) and Intergroup NCCTG-N9831 trials, trastuzumab was given weekly, concurrently, or immediately after the paclitaxel component of the AC with paclitaxel regimen.[208][Level of evidence: 1iiA] The HERA results were confirmed in a joint analysis of the two studies, with a combined enrollment of 3,676 patients, that demonstrated a highly significant improvement in DFS (HR, 0.48; P < .001; 3-year DFS, 87% vs. 75%), as well as a significant improvement in OS (HR, 0.67; P = .015; 3-year OS, 94.3% vs. 91.7%; 4-year OS, 91.4% vs. 86.6%).[209] Patients treated with trastuzumab experienced a longer DFS with a 52% lower risk of a DFS event (HR, 0.48; 95% CI, 0.39–0.59; P < .001), corresponding to an absolute difference in DFS of 11.8% at 3 years and 18% at 4 years. The risk of distant recurrence was 53% lower (HR, 0.47; 95%CI, 0.37–0.61; P < .001) in patients treated with trastuzumab, and the risk of death was 33% lower (HR, 0.67; 95%CI, 0.48–0.93; P = .015) in these patients.
In the BCIRG-006 (NCT00021255) trial, 3,222 women with early stage HER2-overexpressing breast cancer were randomly assigned to receive AC followed by docetaxel (AC-T) versus AC followed by docetaxel plus trastuzumab (AC-T plus trastuzumab) versus docetaxel, carboplatin, plus trastuzumab (TCH, a nonanthracycline-containing regimen).[210][Level of Evidence: 1iiA] A significant benefit with respect to DFS and OS was seen in both groups treated with
trastuzumab-containing regimens compared with the control group that did not receive trastuzumab.
The control group had a 5-year DFS rate of 75% and an OS rate of
87%. For patients receiving AC-T plus trastuzumab, the 5-year DFS rate was 84% (HR for the comparison with AC-T, 0.64; P < .001), and the OS rate was 92% (HR, 0.63; P < .001). For patients receiving TCH, the 5-year DFS rate was 81% (HR, 0.75; P = .04), and the OS rate was 91% (HR, 0.77; P = .04).
The authors stated that there was no significant difference in DFS or OS between the two trastuzumab-containing regimens.
However, the study was not powered to detect equivalence between the two trastuzumab-containing regimens. The rates of congestive heart failure and cardiac dysfunction were significantly higher in the group receiving AC-T plus trastuzumab than in the docetaxel and carboplatin plus 52 weeks of trastuzumab (TCH) group (P < .001). These trial findings raise the question of whether anthracyclines are needed for the adjuvant treatment of HER2-overexpressing breast cancer. The group receiving AC-trastuzumab showed a small but not statistically significant benefit over TCH. This trial supports the use of TCH as an alternative adjuvant regimen for women with early-stage HER2-overexpressing breast cancer, particularly in those with concerns about cardiac toxic effects.
The AVENTIS-TAX-GMA-302 study was a three-arm large trial containing two anthracycline arms (AC-D: doxorubicin, cyclophosphamide, docetaxel or AC-DH: doxorubicin, cyclophosphamide, docetaxel, and trastuzumab) and a nonanthracycline one (DCbH: docetaxel, carboplatin, trastuzumab).[211] In its second interim efficacy analysis with a median follow-up of 36 months, there were 462 DFS events and 185 deaths. For DFS, the HR was 0.61 for patients in the AC-DH arm (95% CI, 0.48–0.76; P < .001) and 0.67 for patients in the DCbH arm (95% CI, 0.54–0.83; P = .003), compared with the AC-D arm. This translated to absolute benefits (from years 2 to 4) of 6% and 5%, respectively with the addition of trastuzumab. Nevertheless, longer follow-up is needed in patients in the DCbH arm to warrant the omission of anthracyclines in these patients.
The Finland Herceptin (FINHER) study assessed the impact of a much shorter course of trastuzumab.[212] In this trial, 232 women younger than 67 years with node-positive or high-risk (>2 cm tumor size) node-negative HER2-overexpressing breast cancer were given nine weekly infusions of trastuzumab concurrently with docetaxel or vinorelbine followed by FEC. At a 3-year median follow-up, the risk of recurrence and/or death was significantly reduced in patients receiving trastuzumab (HR, 0.41; P = .01; 95% CI, 0.21–0.83; 3 year DFS, 89% vs. 78%). The difference in OS (HR, 0.41) was not statistically significant (P = .07; 95% CI, 0.16–1.08).[212][Level of evidence: 1iiA]
In contrast, a recent French trial failed to demonstrate that 6 months of adjuvant trastuzumab was noninferior to 12 months of treatment. A 2-year DFS rate was 93.8% (95% CI, 92.6–94.9) in the 12-month group and 91.1% (89.7–92.4) in the 6-month group (HR, 1.28; 95% CI, 1.05–1.56; noninferiority, P = .29). The authors concluded that 12 months should remain the standard duration of trastuzumab adjuvant therapy.[213][Level of evidence: 1iiA]
A number of studies have evaluated the use of subcutaneous (SQ) trastuzumab in the neoadjuvant and adjuvant settings and are described in the Timing of Adjuvant and Primary Therapy section of this summary.
Lapatinib is a small molecule tyrosine kinase inhibitor that is capable of dual-receptor inhibition of both epidermal growth factor receptor and HER2. In the Adjuvant Lapatinib and/or Trastuzumab Treatment Optimization trial (ALTTO [NCT00553358]), the role of lapatinib (in combination with, in sequence to, in comparison with, or as an alternative to trastuzumab) in the adjuvant setting is being investigated. In phase I/II studies as a single agent, lapatinib has resulted in objective responses between 4.3% and 7.8% in HER2-positive patients who had progressed on multiple trastuzumab-containing regimens with a substantial number having stable disease at 4 months (34%–41%) and 6 months (18%–21%).[214] In a phase III trial (GSK-EGF100151), lapatinib plus capecitabine was superior to capecitabine alone in women with HER2-positive advanced breast cancer that has progressed after treatment with regimens that included an anthracycline, a taxane, and trastuzumab.[215]
The HR for time to progression was 0.49 (95% CI, 0.34–0.71; P < .001), with 49 events in the combination-therapy group and 72 events in the monotherapy group. The median time to progression was 8.4 months in the combination-therapy group as compared with 4.4 months in the monotherapy group.
The combination of lapatinib and trastuzumab in the ALTTO trial is further supported by a demonstration that lapatinib combined with trastuzumab confers a significantly improved progression-free survival in patients with metastatic breast cancer who experience progression on prior trastuzumab-containing treatment when compared with lapatinib alone.[216]
In September 2011, the ALTTO trial was amended to discontinue the lapatinib alone arm of the trial. The Independent Data Monitoring Committee of the trial determined that the patients assigned to the lapatinib alone arm were not likely to do as well as the patients assigned to the trastuzumab alone control arm. Final results of this trial are pending.
In the HERA (BIG-01-01) trial, severe congestive heart failure (CHF) (New York Heart Association class III–IV) occurred in 0.6% of patients treated with trastuzumab.[205] Symptomatic CHF occurred in 1.7% and 0.06% of patients in the trastuzumab and observation arms, respectively. Fifty-one patients experienced a confirmed left ventricular ejection fraction (LVEF) decrease (defined as an ejection fraction decrease of >10 points from baseline to an LVEF <50%) with trastuzumab, which recovered or stabilized within 3 to 6 weeks of initial treatment in 86% of cases. In the NSABP B-31 (NCT00004067) trial, 31 of 850 patients in the trastuzumab arm had confirmed symptomatic cardiac events, compared with 5 of 814 patients in the control arm.[217] The 3-year cumulative incidence of cardiac events for trastuzumab-treated patients was 4.1%, compared with 0.8% of patients in the control arm (95% CI, 1.7%–4.9%). Asymptomatic decline in LVEF (defined by >10% decline or to 55%) occurred in 17% of patients in the trastuzumab arm (95% CI, 15%–20%) and 34% of patients in the control arm (95%CI, 31%–38%), with a HR, 2.1 (95%CI, 1.7–2.6; P < .001). In the NCCTG-N9831 trial, 39 cardiac events were reported in the three arms over a 3-year period. The 3-year cumulative incidence of cardiac events in arm A was 0.35% (no trastuzumab), arm B, 3.5% (trastuzumab following paclitaxel) and arm C, 2.5% (trastuzumab concomitant with paclitaxel).
In the AVENTIS-TAX-GMA-302 (BCIRG 006) trial, clinically symptomatic cardiac events were detected in 0.38% of patients in the AC-D arm, 1.87% of patients in the AC-DH arm, and 0.37% of patients in the DCbH arm.[211] There was also a statistically significant higher incidence of asymptomatic and persistent decrease in LVEF in the AC-DH arm than with either the AC-D or DCbH arms. No cardiac deaths were reported in the AVENTIS-TAX-GMA-302 trial.
In the FINHER trial, none of the patients who received trastuzumab experienced clinically significant cardiac events. In fact, LVEF was preserved in all of the women receiving trastuzumab, but the number of patients receiving adjuvant trastuzumab was very low.
A number of studies have also evaluated newer anti-HER2 therapies (e.g., lapatinib, pertuzumab) and combinations of anti-HER2 therapy (dual blockade) in both the early breast cancer and metastatic settings. These studies have incorporated close monitoring of LVEF. A pooled analysis of cardiac safety in 598 patients with cancer treated with pertuzumab was performed using data supplied by Roche and Genentech. Asymptomatic left ventricular systolic dysfunction was observed in 6.9% of patients receiving pertuzumab alone (n = 331; 95% CI, 4.5–10.2), 3.4% of patients receiving pertuzumab in combination with a nonanthracycline-containing chemotherapy (n = 175; 95% CI, 1.3–7.3), and 6.5% of patients receiving pertuzumab in combination with trastuzumab (n = 93; 95% CI, 2.4–13.5). Symptomatic heart failure was observed in 1 (0.3%), 2 (1.1%), and 1 (1.1%) patients, respectively.[218][Level of evidence: 3iiiD]
A meta-analysis of six studies reported no increased risk of cardiac toxic effects with dual blockade of the HER2 pathway.[219][Level of evidence: 1iiA] The overall incidence results for CHF in the combined anti-HER2 therapy and the anti-HER2 monotherapy were 0.88% (95% CI, 0.47–1.64%) and 1.49% (95% CI, 0.98–2.23%). The incidence of LVEF decline was 3.1% (95% CI, 2.2–4.4%) and 2.9% (95% CI, 2.1–4.1%), respectively. The OR of CHF between anti-HER2 combination and monotherapy was 0.58 (95% CI, 0.26–1.27, P = .17) while the OR of LVEF decline was 0.88 (95% CI, 0.53–1.48, P = .64). This meta-analysis suggests comparable cardiac toxicity between anti-HER2 combination therapy and anti-HER2 monotherapy. However, a number of limitations are noted within this analysis including the heterogeneity of the agents and disease settings evaluated, and that the data are trial level versus patient-level data.
Treatment options for HER2-positive early breast cancer:
The optimal time to initiate adjuvant therapy is uncertain. A single study that addressed the use of perioperative adjuvant chemotherapy in node-positive
patients showed no advantage in DFS when a single cycle of
perioperative chemotherapy was given in addition to standard therapy initiated
4 weeks after surgery.[220] A single cycle of immediate postoperative
chemotherapy alone was inferior.[221]
A randomized clinical trial (NSABP-B-18) has been performed to evaluate
preoperative chemotherapy in the management of patients with stage I or stage
II breast cancer.[222] After preoperative therapy with four cycles of doxorubicin and
cyclophosphamide, 80% of the assessable patients had a reduction in tumor size
of at least 50%, and 36% of the patients had a complete clinical response. More patients
treated with preoperative chemotherapy were able to have breast-conserving
procedures as compared with those patients in the postoperative chemotherapy
group (68% vs. 60%). Twenty-seven percent of the women in the preoperative
therapy group for whom a mastectomy had been planned prior to being randomly assigned
underwent a lumpectomy. No statistically significant
difference existed, however, in DFS, distant DFS, or OS in the
patients who received preoperative chemotherapy as compared with those who received
postoperative chemotherapy.[222][223][224][Level of evidence: 1iiA]
An EORTC randomized trial (EORTC-10902)
likewise demonstrated no improvement in DFS or
OS, but showed an increased frequency of conservative surgery with the
use of preoperative versus postoperative FEC chemotherapy.[225][Level of evidence: 1iiA] Preoperative
chemotherapy may be beneficial in women who desire breast-conserving surgery
but who would otherwise not be considered candidates because of the size of their
tumor. In a meta-analysis including all trials that compared the use of the same chemotherapy preoperatively and postoperatively, the use of preoperative chemotherapy was associated with a higher rate of local recurrence.[226] Although preoperative chemotherapy affects the results of SLN biopsy,
one small study indicated that SLN biopsy technique was feasible in this
setting.[227] However, the results of two prospective studies (NCT02031042 and NCT00881361) indicate that SLN biopsy is associated with false-negative rates of 14.2% and 12.6%, respectively, when undertaken after neoadjuvant chemotherapy in patients who convert from a clinically positive to a clinically negative axillary status.[228][229][Level of evidence: 3iiD] These rates are higher than those observed when SLN biopsy is done before adjuvant chemotherapy. The role of this procedure in the neoadjuvant setting is uncertain.
HER2-directed therapies
In HER2-overexpressed disease, pilot studies have demonstrated remarkable clinical and pathologic responses when trastuzumab is given preoperatively in combination with chemotherapy.[230] A randomized phase III study (NOAH) in patients with HER2-positive locally advanced or inflammatory breast cancers confirmed that the addition of concurrent neoadjuvant and adjuvant trastuzumab to neoadjuvant chemotherapy with sequential doxorubicin plus paclitaxel followed by CMF resulted not only in improved clinical responses (87% vs. 74%) and pathologic responses (breast and axilla, 38% vs. 19%) but also in EFS, the primary outcome.[231] This was defined as the time from random assignment to disease recurrence or progression—whether local, regional, distant, or contralateral—or death from any cause.
At 3 years, of all of the patients, 71% (95% CI, 61–78) showed improvement in EFS with trastuzumab versus 56% without trastuzumab (95% CI, 46–65), HR, 0.59 (95% CI, 0.38–0.90, P = .013), thereby favoring the addition of trastuzumab. The 3-year OS was 87% versus 79% at the time of the report (P = .114, not significant). Symptomatic cardiac failure developed in two patients receiving concurrent doxorubicin and trastuzumab for two cycles. Close cardiac monitoring of (LVEF and the total dose of doxorubicin not exceeding 180 mg/m2 accounted for the relatively low number of declines in LVEF and only two cardiac events. (See the Cardiac toxic effects with adjuvant trastuzumab section in this summary.)[231][Level of evidence: 1iiD]
A phase III (Z1041 [NCT00513292]) trial randomly assigned patients with operable HER2-positive breast cancer to receive trastuzumab sequential to or concurrent with the anthracycline component (fluorouracil, epirubicin, cyclophosphamide) of the neoadjuvant chemotherapy regimen. All patients received trastuzumab concurrent with paclitaxel. There was no significant difference in pathological complete response (pCR) in the breast between the arms (56.5% sequential, 54.2% concurrent; difference 2.3% with 95% CI, -9.3–13.9). In addition, asymptomatic declines in LVEF during neoadjuvant chemotherapy were identified in similar proportions of patients in each arm. The conclusion was that concurrent administration of trastuzumab with anthracyclines is not warranted based on these findings.[232][Level of evidence: 1iiDiv]
A phase III (HannaH [NCT00950300]) trial also demonstrated that the pharmacokinetics and efficacy of neoadjuvant SQ trastuzumab is noninferior to the IV formulation. This international, open-label trial (n = 596) randomly assigned women with operable, locally advanced, or inflammatory HER2-positive breast cancer to neoadjuvant chemotherapy (anthracycline/taxane-based), concurrent with either SQ-administered or IV-administered trastuzumab every 3 weeks before surgery. Patients received adjuvant trastuzumab to complete 1 year of therapy. The pCR rates between the arms differed by 4.7% (95% CI, 4.0–13.4); 40.7% in the IV-administered group versus 45.4% in the SQ-administered group, demonstrating noninferiority for the SQ formulation. Data regarding the DFS and OS differences between the arms are not yet available.[233][Level of evidence: 1iiD]
PrefHer (NCT01401166) (n = 248) was a randomized, cross-over design trial in which all patients were randomly assigned to receive four cycles of 600 mg, fixed-dose, SQ-administered, adjuvant trastuzumab followed by four cycles of standard IV-administered trastuzumab, or the reverse sequence. Almost all patients preferred the SQ formulation; the primary endpoint was the proportion of patients indicating an overall preference for SQ-administered or IV-administered trastuzumab, which was assessed by patient interview.[213][Level of evidence: 1iiC] An ongoing trial, SafeHer, is evaluating the safety of self-administered versus clinician-administered SQ trastuzumab. SQ trastuzumab is approved for use in Europe in early and late stage breast cancer.
Pertuzumab, in combination with trastuzumab with or without chemotherapy, has been evaluated in two clinical trials. In the open-label, randomized, phase II NeoSPHERE trial (NCT00545688),[234] 417 women with tumors that were larger than 2 cm or node-positive, and who had HER2-positive breast cancer, were randomly assigned to one of four preoperative regimens:
The pCR rates were 29%, 46%, 17%, and 24%, respectively.[234][Level of evidence: 1iiDiv] Therefore, the highest pCR rate was seen in the preoperative treatment arm with dual HER2 blockade plus chemotherapy. The addition of pertuzumab to the docetaxel plus trastuzumab combination did not appear to increase toxic effects, including the risk of cardiac adverse events.
The open-label, randomized, phase II TRYPHAENA trial (NCT00976989) sought to evaluate the tolerability and activity associated with trastuzumab and pertuzumab.[235][Level of evidence: 1iiDiv] All 225 women with tumors that were larger than 2 cm or node-positive, and who had operable, locally advanced, or inflammatory HER2-positive breast cancer, were randomly assigned to one of three preoperative regimens:
The pCR rate was equivalent across all three treatment arms (62%, 57%, and 66%, respectively.) All three arms were associated with a low incidence of cardiac adverse events of 5% or less.
On the basis of these studies, the FDA granted accelerated approval for the use of pertuzumab as part of neoadjuvant treatment for women with early-stage, HER2-positive breast cancer. The FDA approved no more than 3 to 6 cycles of pertuzumab. The ongoing APHINITY trial (NCT01358877), a randomized, phase III, adjuvant study for women with HER2-positive breast cancer, is the confirmatory trial for this accelerated approval. Results are expected in 2016.
The role of lapatinib in the neoadjuvant setting was examined in the GeparQuinto [NCT00567554] trial.[236] This phase III trial randomly assigned women with HER2-positive early stage breast cancer to receive chemotherapy with trastuzumab versus chemotherapy with lapatinib with pCR as the primary endpoint.[236][Level of Evidence: 1iiDiv] pCR in the chemotherapy and lapatinib arm was significantly lower than it was with chemotherapy and trastuzumab (22.7% vs. 30.3%; P = .04). Other endpoints of DFS, RFS, and OS have not been reported. The results do not support the use of single-agent lapatinib with chemotherapy in the neoadjuvant setting.
Neoadjuvant therapy with dual HER2 inhibition was studied in the NeoALTTO [NCT00553358] trial.[237][Level of evidence: 1iiDiv] This phase III trial randomly assigned 455 women with HER2-positive early stage breast cancer (tumor size >2 cm) to receive neoadjuvant lapatinib compared with neoadjuvant trastuzumab compared with neoadjuvant lapatinib plus trastuzumab. This anti-HER2 therapy was given alone for 6 weeks and then weekly paclitaxel was added to the regimen for an additional 12 weeks for all enrolled patients. The primary endpoint of this study was pCR. pCR was significantly higher in the lapatinib plus trastuzumab combination arm (51.3%; 95% CI, 43.1–59.5) than in the trastuzumab alone arm (29.5%; 95% CI, 22.4–37.5). No significant difference in pCR was seen between the lapatinib (24.7%, 95% CI, 18.1–32.3) and trastuzumab groups (difference -4.8%, -17.6–8.2; P = -.34).
The DFS, RFS, and OS rates have not been reported in this trial. pCR rates, while hypothesis-generating, do not substitute for these other efficacy endpoints. Interestingly, there was a numerical but not a statistically significant difference in pCR rate in patients observed in a phase III (NSABP B-41 [NCT00486668]) trial in which women with operable HER2-positive breast cancer were randomly assigned to doxorubicin and cyclophosphamide, followed by paclitaxel concurrent with trastuzumab (52.5%, 95% CI, 44.9–59.5), lapatinib (53.2%, 95% CI, 45.4–60.3), or the combination of trastuzumab and lapatinib (62%, 95% CI, 54.3–68.8; P = .095).[238][Level of evidence: 1iiDiv] Results from the similarly designed, ongoing, CALGB-40601 (NCT00770809) trial are pending. More definitive efficacy data will also be provided by the phase III ALLTO trial that is randomly assigning women to trastuzumab or trastuzumab plus lapatinib in the adjuvant setting.
At present, there is no established role for the use of bevacizumab as part of neoadjuvant chemotherapy for breast cancer. Bevacizumab is a monoclonal antibody that works against vascular endothelial growth factor A and has shown some degree of efficacy in the metastatic setting. Two randomized, phase III clinical trials of chemotherapy with or without bevacizumab have reported results. [239][240]
One trial randomly assigned 1,206 patients with primary operable HER2-negative breast cancer to receive chemotherapy with or without bevacizumab.[239] The addition of bevacizumab significantly increased the rate of pCR (28.2% without bevacizumab vs. 34.5% with bevacizumab, P = .02).[239][Level of evidence: 1iiDiv] However, the addition of bevacizumab increased the rates of hypertension, cardiac toxicity, hand-foot syndrome, and mucositis.
Another study randomly assigned 1,948 patients with operable HER2-negative breast cancer to receive neoadjuvant epirubicin and cyclophosphamide followed by docetaxel with or without concomitant bevacizumab.[240] The addition of bevacizumab in this study also significantly increased the rate of pCR (14.9% without bevacizumab vs. 18.4% with bevacizumab, P = .003).[240][Level of evidence: 1iiDiv] Similarly to other clinical trials, the addition of bevacizumab increased the toxic effects, with higher rates of febrile neutropenia, mucositis, hand-foot syndrome, infection, and hypertension, but it did not increase surgical complications. A preplanned subgroup analysis subsequently revealed that the addition of bevacizumab to neoadjuvant chemotherapy significantly increased the pCR rate from 27.9% to 39.3% in patients with triple-negative breast cancer (P = .003).[241][Level of evidence: 1iiDii]
Of note, OS and DFS outcomes were not reported in either clinical trial.[239][240] Based on these results, bevacizumab should not be used in the treatment of operable breast cancer. Caution should be used in interpreting pCR as a primary clinical outcome. However, further study of bevacizumab for the treatment of operable breast cancer may be warranted.
The optimal sequence of adjuvant chemotherapy and radiation therapy after
breast-conserving surgery was studied in a randomized trial.[242] Patients
received either chemotherapy first (n = 122), consisting of CMFP plus doxorubicin
repeated every 21 days for four cycles, followed by breast radiation, or breast
radiation first (n = 122), followed by the same chemotherapy. With a median
follow-up of 5 years, OS was 73% for the radiation-first group
and 81% for the chemotherapy-first group (P = .11).[242][Level of evidence: 1iiA]
The 5-year crude rates of first recurrence by site in the radiation-first and
chemotherapy-first groups, respectively, were 5% and 14% for local recurrence
and 32% and 20% for distant or regional recurrence or both. This difference in
the pattern of recurrence was of borderline statistical significance (P = .07).
Further analyses revealed that differences in recurrence patterns persisted for
most subgroups with the exception of those who had either negative tumor
margins or one to three positive lymph nodes. For these two subgroups, sequence
assignment made little difference in local or distant recurrence rates,
though the statistical power of these subgroup analyses was low. Potential
explanations for the increase in distant recurrence noted in the radiation
therapy-first group are that chemotherapy was delayed for a median of 17 weeks
after surgery, and that this group received lower chemotherapy dosages due to
increased myelosuppression.
Two additional randomized trials, though not specifically designed to address
the timing of radiation therapy and adjuvant chemotherapy, do add useful
information.[171][243] In the NSABP-B-15 trial, patients who had undergone
breast-conserving surgery received either one course of CMF (n = 194) followed by
radiation therapy followed by five additional cycles of CMF, or they received four
cycles of AC (n = 199) followed by radiation therapy. No differences in
DFS, distant DFS, and OS were
observed between these two arms.[171][Level of evidence: 1iiA] The International
Breast Cancer Study Group trials VI and VII also varied the timing of
radiation therapy with CMF adjuvant chemotherapy.[243] These studies showed
that delays from 2 to 7 months in radiation therapy after surgery had no effect
on the rate of local recurrence.
These findings have been confirmed in a meta-analysis.[244][Level of evidence: 1iiA]
Based on the above studies, delaying radiation therapy for several months after
breast-conserving surgery until the completion of adjuvant chemotherapy does not appear to have a negative impact on overall outcome. Additionally, initiating chemotherapy soon after breast-conserving therapy may be preferable for patients at high risk of distant dissemination.
In an unplanned analysis of patients treated on a phase III trial evaluating the benefit of adding trastuzumab in HER2/neu-positive breast cancer patients, there was no associated increase in acute adverse events or frequency of cardiac events in patients who received concurrent adjuvant radiation therapy and trastuzumab.[245] Therefore, delivering radiation therapy concomitantly with trastuzumab appears to be safe and avoids additional delay in radiation therapy treatment initiation.
Several retrospective reviews have indicated that statistically significantly better
DFS is achieved for premenopausal women with breast cancer
and positive axillary lymph nodes if breast surgery is performed during the
luteal phase (days 15–36) as compared with the follicular phase (days 0–14) of
the menstrual cycle.[246][247][248][Level of evidence: 1iiA]; [249] Several other
studies, however, have failed to support this finding or have found opposite
results.[250][251][252]; [253][Level of evidence: 1iiA] Because of the inconsistent
findings of these studies, it would be premature to mandate a modification in
the scheduling of breast cancer operations according to the patient's menstrual
cycle. A prospectively controlled trial (UCLA-9810046) has been completed but is not yet analyzed.
Adjuvant chemotherapy is associated with several well-characterized toxic
effects that vary according to the individual drugs used in each regimen.
Common toxic effects include nausea and vomiting, myelosuppression, alopecia,
and mucositis. Less common, but serious, toxic effects include heart failure
(if an anthracycline is used), thromboembolic events,[254] and premature
(Refer to the PDQ summary on Nausea and Vomiting and for information on mucositis, refer to the PDQ summary on Oral Complications of Chemotherapy and Head/Neck Radiation; for information on symptoms associated with premature menopause, refer to the PDQ summary on Hot Flashes and Night Sweats.)
Cognitive impairment has been reported to occur after the administration of some chemotherapy regimens.[256] However, data on this topic from prospective, randomized studies are lacking.
The EBCTCG meta-analysis revealed that women who received adjuvant combination
chemotherapy did have a 20% (standard deviation = 10) reduction in the annual
odds of developing contralateral breast cancer.[167] This small proportional
reduction translated into an absolute benefit that was only marginally
statistically significant, but it indicates that chemotherapy does not increase
the risk of contralateral disease. In addition, the analysis showed no
statistically significant increase in deaths attributed to other cancers or to
vascular causes among all women randomly assigned to receive chemotherapy. The use of anthracycline-containing regimens, however—particularly those containing an increased dose of cyclophosphamide—has been associated with a cumulative risk of developing acute leukemia of 0.2% to 1.7% at 5 years.[257][258] This risk increases to more than 4% in patients receiving high cumulative doses of both epirubicin (>720 mg/m2) and cyclophosphamide (>6,300 mg/m2).[259]
Adjuvant combinations of tamoxifen and chemotherapy administered concurrently
to enhance efficacy may also have enhanced toxic effects. A single study
randomly assigned postmenopausal women with node-positive, ER-positive tumors
to receive tamoxifen (30 mg/day for 2 years) plus CMF (IV for 6
months) (n = 353) or tamoxifen alone (n = 352).[254] Of the women receiving
combined chemohormonal therapy, 13.6% developed one or more thromboembolic events
compared with 2.6% in the tamoxifen-alone group (P < .001). Also,
statistically significantly more women were on combined treatment who developed
severe thromboembolic events (grade 3–5), most of which (39 of 54) occurred
while the women were actually receiving chemotherapy. Not all studies
that compared concurrent chemotherapy plus tamoxifen with tamoxifen alone, however, have
reported such high rates. In the NSABP-B-16 study that compared
tamoxifen (20 mg/day for 5 years) plus chemotherapy with doxorubicin plus
cyclophosphamide (four cycles) with tamoxifen alone, 4.9% of the women on combined
treatment had thromboembolic events versus 2.1% of women on tamoxifen
alone.[97] Whether tamoxifen should be given concurrently or after the completion of chemotherapy was addressed in an Intergroup trial (INT-0100 [NCT00929591], formerly SWOG-8814) that compared the concurrent and sequential administration of CAF and tamoxifen in postmenopausal hormone receptor-positive patients. Sequential administration resulted in superior DFS that was significant at 8 years (67% vs. 62%; P = .045).[260][Level of evidence: 1iiDii]
Candidates for whom adjuvant therapy may not be necessary include individuals with small primary tumors (<1 cm) and negative axillary nodes who have
an excellent prognosis, with nearly 90% of patients alive and free of disease
at 20 years in one series.[261] A U.S. Intergroup study (SWOG-8897) observed patients off
treatment with tumors of low risk (tumors too small for biochemical ER/PR
assay) and uncertain-risk (tumors <2 cm, ER-positive and PR-positive, and low S-phase
fractions). This low-risk and uncertain-risk subset had a 96% 5-year survival
rate without adjuvant therapy. Whether this group of patients would
derive long-term benefit from tamoxifen for either its adjuvant or preventive
effects remains uncertain. Clearly, this group has a risk of developing a new
breast cancer that would meet the eligibility criteria that were used in the
Breast Cancer Prevention Trial that demonstrated a benefit with tamoxifen.
Proposals have been made to treat elderly patients with tamoxifen alone and without
surgery. This approach has unacceptably high local failure rates and, outside
of a clinical trial setting, should be used only for patients who are not
candidates for mastectomy or breast-conserving surgery plus radiation therapy,
or for those who refuse these options.[262][263][264]
Local-regional treatment:
Adjuvant radiation therapy postmastectomy in axillary node-positive tumors:
Adjuvant systemic therapy:
An International Consensus Panel proposed a three-tiered risk classification for
patients with negative axillary lymph nodes.[55] This classification, with
some modification, is described below:
Low Risk (Has All Listed Factors)
Intermediate Risk (Risk Classified Between the Other Two Categories)
High Risk (Has at Least One Listed Factor)
Tumor size
= 1 cm
1–2 cm
>2 cm
ER or PR status
Tumor grade
grade 1
grade 1–2
grade 2–3
ER = estrogen receptor; PR = progesterone receptor
The original Consensus Panel classification also required that women be 35
years or older to be included in the low-risk group and included women
35 years and younger in the high-risk group, based admittedly on
indirect evidence. Traditionally, certain uncommon histologies (e.g., tubular,
medullary, and mucinous) have also been associated with favorable prognosis and
may be considered as low-risk factors. Some additional tumor characteristics
that may eventually prove helpful in the prognosis of node-negative disease
include the tumor proliferative fraction (S-phase) and the level of HER2/neu expression.
Regardless of how one chooses to characterize node-negative tumors, evidence
from clinical trials suggests that various types of adjuvant therapies benefit certain subgroups of patients with these kinds of tumors. The same is true for
women with node-positive breast cancer. What has become clear after reviewing
results from multiple breast cancer treatment trials is that hormone therapy
and chemotherapy regimens generally offer the same proportional benefit to
women irrespective of their axillary lymph node status. The selection of
therapy is most appropriately based upon knowledge of an individual's
risk of tumor recurrence balanced against the short-term and long-term risks of
adjuvant treatment. This approach should allow clinicians to help individuals
to determine if the gains anticipated from treatment are reasonable for
their particular situation. The treatment options presented below should be
modified based upon both patient and tumor characteristics.
Patient Group
Low Risk
Intermediate Risk
High Risk
Premenopausal, ER-positive or PR-positive
None or tamoxifen
Tamoxifen plus chemotherapy, tamoxifen alone, ovarian ablation, GnRH analoga
Chemotherapy plus tamoxifen, chemotherapy plus ablation or GnRH analog*, chemotherapy plus tamoxifen plus ovarian ablation or GnRH*, or ovarian ablation alone or with tamoxifen or GnRH alone or with tamoxifen
Premenopausal, ER-negative or PR-negative
Postmenopausal, ER-positive or PR-positive
None or upfront AI or tamoxifen followed by AI
Upfront AI or tamoxifen followed by AI +/- chemotherapy
Upfront AI or tamoxifen followed by AI +/- chemotherapy
Postmenopausal, ER-negative or PR-negative
AI = aromatase inhibitor; ER = estrogen receptor; GnRH = gonadotropin-releasing hormone; PR = progesterone receptor
aNote: This treatment option is under clinical evaluation.
Patient Group
Premenopausal, ER-positive or PR-positive
Chemotherapy plus tamoxifen, chemotherapy plus ovarian ablation/GnRH analog, chemotherapy plus tamoxifen plus ovarian ablation/GnRH analoga, ovarian ablation alone or with tamoxifen or GnRH alone or with tamoxifen
Premenopausal, ER-negative or PR-negative
Postmenopausal, ER-positive or PR-positive
Upfront AI or tamoxifen followed by AI plus chemotherapy, upfront AI or tamoxifen followed by AI alone
Postmenopausal, ER-negative or PR-negative
AI= aromatase inhibitors; ER = estrogen receptor; GnRH = gonadotropin-releasing hormone; PR = progesterone receptor
a Note: This treatment option is under clinical evaluation.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage I breast cancer, stage II breast cancer, stage IIIA breast cancer and stage IIIC breast cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
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Gerber B, Loibl S, Eidtmann H, et al.: Neoadjuvant bevacizumab and anthracycline-taxane-based chemotherapy in 678 triple-negative primary breast cancers; results from the geparquinto study (GBG 44). Ann Oncol 24 (12): 2978-84, 2013.
Recht A, Come SE, Henderson IC, et al.: The sequencing of chemotherapy and radiation therapy after conservative surgery for early-stage breast cancer. N Engl J Med 334 (21): 1356-61, 1996.
Wallgren A, Bernier J, Gelber RD, et al.: Timing of radiotherapy and chemotherapy following breast-conserving surgery for patients with node-positive breast cancer. International Breast Cancer Study Group. Int J Radiat Oncol Biol Phys 35 (4): 649-59, 1996.
Hickey BE, Francis DP, Lehman M: Sequencing of chemotherapy and radiotherapy for early breast cancer. Cochrane Database Syst Rev 4: CD005212, 2013.
Halyard MY, Pisansky TM, Dueck AC, et al.: Radiotherapy and adjuvant trastuzumab in operable breast cancer: tolerability and adverse event data from the NCCTG Phase III Trial N9831. J Clin Oncol 27 (16): 2638-44, 2009.
Veronesi U, Luini A, Mariani L, et al.: Effect of menstrual phase on surgical treatment of breast cancer. Lancet 343 (8912): 1545-7, 1994.
Badwe RA, Gregory WM, Chaudary MA, et al.: Timing of surgery during menstrual cycle and survival of premenopausal women with operable breast cancer. Lancet 337 (8752): 1261-4, 1991.
Senie RT, Rosen PP, Rhodes P, et al.: Timing of breast cancer excision during the menstrual cycle influences duration of disease-free survival. Ann Intern Med 115 (5): 337-42, 1991.
Goldhirsch A, Gelber RD, Castiglione M, et al.: Menstrual cycle and timing of breast surgery in premenopausal node-positive breast cancer: results of the International Breast Cancer Study Group (IBCSG) Trial VI. Ann Oncol 8 (8): 751-6, 1997.
McGuire WL, Hilsenbeck S, Clark GM: Optimal mastectomy timing. J Natl Cancer Inst 84 (5): 346-8, 1992.
Nathan B, Bates T, Anbazhagan R, et al.: Timing of surgery for breast cancer in relation to the menstrual cycle and survival of premenopausal women. Br J Surg 80 (1): 43, 1993.
Brown GS, Kramer S, Brady L, et al.: Primary irradiation of stage I and stage II adenocarcinoma of the breast. Int J Radiat Oncol Biol Phys 2 (11-12): 1145-8, 1977 Nov-Dec.
Hagen AA, Hrushesky WJ: Menstrual timing of breast cancer surgery. Am J Surg 175 (3): 245-61, 1998.
Pritchard KI, Paterson AH, Paul NA, et al.: Increased thromboembolic complications with concurrent tamoxifen and chemotherapy in a randomized trial of adjuvant therapy for women with breast cancer. National Cancer Institute of Canada Clinical Trials Group Breast Cancer Site Group. J Clin Oncol 14 (10): 2731-7, 1996.
Shapiro CL, Manola J, Leboff M: Ovarian failure after adjuvant chemotherapy is associated with rapid bone loss in women with early-stage breast cancer. J Clin Oncol 19 (14): 3306-11, 2001.
Schagen SB, Muller MJ, Boogerd W, et al.: Change in cognitive function after chemotherapy: a prospective longitudinal study in breast cancer patients. J Natl Cancer Inst 98 (23): 1742-5, 2006.
Smith RE, Bryant J, DeCillis A, et al.: Acute myeloid leukemia and myelodysplastic syndrome after doxorubicin-cyclophosphamide adjuvant therapy for operable breast cancer: the National Surgical Adjuvant Breast and Bowel Project Experience. J Clin Oncol 21 (7): 1195-204, 2003.
Crump M, Tu D, Shepherd L, et al.: Risk of acute leukemia following epirubicin-based adjuvant chemotherapy: a report from the National Cancer Institute of Canada Clinical Trials Group. J Clin Oncol 21 (16): 3066-71, 2003.
Praga C, Bergh J, Bliss J, et al.: Risk of acute myeloid leukemia and myelodysplastic syndrome in trials of adjuvant epirubicin for early breast cancer: correlation with doses of epirubicin and cyclophosphamide. J Clin Oncol 23 (18): 4179-91, 2005.
Albain KS, Green SJ, Ravdin PM, et al.: Adjuvant chemohormonal therapy for primary breast cancer should be sequential instead of concurrent: initial results from intergroup trial 0100 (SWOG-8814). [Abstract] Proceedings of the American Society of Clinical Oncology 21: A-143, 2002.
Rosen PP, Groshen S, Saigo PE, et al.: Pathological prognostic factors in stage I (T1N0M0) and stage II (T1N1M0) breast carcinoma: a study of 644 patients with median follow-up of 18 years. J Clin Oncol 7 (9): 1239-51, 1989.
Gazet JC, Ford HT, Coombes RC, et al.: Prospective randomized trial of tamoxifen vs surgery in elderly patients with breast cancer. Eur J Surg Oncol 20 (3): 207-14, 1994.
Akhtar SS, Allan SG, Rodger A, et al.: A 10-year experience of tamoxifen as primary treatment of breast cancer in 100 elderly and frail patients. Eur J Surg Oncol 17 (1): 30-5, 1991.
Dixon JM: Treatment of elderly patients with breast cancer. BMJ 304 (6833): 996-7, 1992.
Multimodality therapy delivered with curative intent is the standard of care
for patients with clinical stage IIIB disease. In a retrospective series, approximately 32% of patients with ipsilateral supraclavicular node involvement and no evidence of distant metastases (pN3c) had prolonged disease-free survival (DFS) at 10 years with combined modality therapy.[1] Although these results have not been replicated in another series, this result suggests such patients should be treated with the same intent.
Initial surgery is generally
limited to biopsy to permit the determination of histology, estrogen-receptor (ER) and progesterone-receptor (PR) levels,
and human epidermal growth factor receptor 2 (HER2/neu) overexpression. Initial treatment with anthracycline-based
chemotherapy and/or taxane-based therapy is standard.[2][3] In one series of
178 patients with inflammatory breast cancer, DFS was 28% at
15 years with a combined-modality approach.[2][Level of evidence: 3iiiDii] For
patients who respond to neoadjuvant chemotherapy, local therapy may consist of
total mastectomy with axillary lymph node dissection followed by postoperative
radiation therapy to the chest wall and regional lymphatics. Breast-conserving
therapy can be considered in patients with a good partial or complete response
to neoadjuvant chemotherapy.[3] Subsequent systemic therapy may consist of
further chemotherapy. Hormone therapy should be administered to patients whose
tumors are ER-positive or unknown. All patients should be considered
candidates for clinical trials to evaluate the most appropriate fashion in
which to administer the various components of multimodality regimens.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IIIB breast cancer, stage IIIC breast cancer and inflammatory breast cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Recurrent breast cancer is often responsive to therapy, though treatment is
rarely curative at this stage of disease. Patients with localized
breast or chest wall recurrences, however, may be long-term survivors with appropriate
therapy. Prior to treatment for recurrent or metastatic cancer,
restaging to evaluate extent of disease is indicated. Cytologic or histologic
documentation of recurrent or metastatic disease should be obtained whenever
possible. The ER levels and PR levels, HER2/neu positivity at the time of recurrence, and previous treatment should be
considered, if known, when selecting therapy. ER status may change at the time
of recurrence. In a single small study by the Cancer and Leukemia Group B (MDA-MBDT-8081), 36% of hormone receptor–positive
tumors were found to be receptor negative in biopsy specimens isolated at the
time of recurrence.[4] Patients in this study had no interval treatment. If
ER and PR status is unknown, then the site(s) of recurrence, disease-free
interval, response to previous treatment, and menopausal status are useful in
selecting chemotherapy or hormone therapy.[5]
Patients with local-regional breast cancer recurrence may become long-term survivors
with appropriate therapy. A clinical trial indicated that between 10% and 20%
of patients will have locally recurrent disease in the breast between 1 and 9
years after breast-conserving surgery plus radiation therapy.[6] Nine
percent to 25% of these patients will have distant metastases or locally
extensive disease at the time of recurrence.[7][8][9] Patients with local-regional
recurrence should be considered for further local treatment (e.g., mastectomy).
In one series, the 5-year actuarial rate of relapse for patients treated for
invasive recurrence after initial breast conservation and radiation therapy was
52%.[8] A phase III, randomized study showed that local control of cutaneous metastases could be achieved with the application of topical miltefosine; however, the drug is not currently available in the United States.[10][Level of evidence: 1iiDiii]
Local chest wall recurrence following mastectomy is usually the harbinger of
widespread disease, but, in a subset of patients, it may be the only site of
recurrence. For patients in this subset, surgery and/or radiation therapy may
be curative.[11][12] Patients with chest wall recurrences of less than 3
cm, axillary and internal mammary node recurrence (not
supraclavicular, which has a poorer survival), and a greater than 2-year
disease-free interval prior to recurrence have the best chance for prolonged
survival.[12] The 5-year disease-free survival DFS rate in one series of such
patients was 25%, with a 10-year rate of 15%.[13] The local-regional control
rate was 57% at 10 years. Systemic therapy should be considered in patients
with local regional recurrence because of the high risk of subsequent metastases.[14] No randomized controlled studies are available to guide patient care in this
Treatment for systemic disease is palliative in intent. Goals of treatment
include improving quality of life and prolongation of life. Although median
survival has been reported to be 18 to 24 months,[15] some patients experience
long-term survival. Among patients treated with systemic chemotherapy at a
single institution between 1973 and 1982, 263 patients (16.6%) achieved
complete responses. Of those, 49 patients (3.1% of the total group) remained
in complete remission for more than 5 years, and 26 patients (1.5%) were still
in complete remission at 16 years.[16][Level of evidence: 3iiDiii]
Treatment of metastatic breast cancer will usually involve hormone therapy
and/or chemotherapy with or without trastuzumab. Radiation therapy
and/or surgery may be indicated for patients with limited symptomatic
metastases. All patients with metastatic or recurrent breast cancer should be
considered candidates for ongoing clinical trials.
Surgery may be indicated for selected patients. Examples include patients who
need mastectomies for fungating/painful breast lesions, parenchymal brain or
vertebral metastases with spinal cord compression, isolated lung metastases,
pathologic (or impending) fractures, or pleural or pericardial effusions.
(Refer to the PDQ summary on Pain for more information and for information on pleural and pericardial effusions, refer to the PDQ summary on Cardiopulmonary Syndromes.)
Radiation therapy has a major role in the palliation of localized symptomatic
metastases. Indications include painful bony metastases, unresectable central
nervous system metastases (i.e., brain, meningeal, and spinal cord), bronchial
obstruction, and fungating/painful breast or chest wall lesions. Radiation
therapy should also be given following surgery for decompression of
intracranial or spinal cord metastases and following fixation of pathologic
fractures. Clinical trials (including the completed Radiation Therapy Oncology Group's (RTOG) trial [RTOG-9714]) are exploring the optimal radiation fractionation
schedule. Strontium 89, a systemically administered radionuclide, can be
administered for palliation of diffuse bony metastases.[17][18]
(Refer to the PDQ summary on Pain for more information.)
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IV breast cancer and recurrent breast cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
The use of bisphosphonates to reduce skeletal morbidity in patients with bone
metastases should be considered.[19] Results of randomized trials of
pamidronate and clodronate in patients with bony metastatic disease show
decreased skeletal morbidity.[20][21][22][Level of evidence: 1iC] Zoledronate has been at least as effective as pamidronate.[23] (Refer to the PDQ summary on Pain for more information on bisphosphonates.)
Hormone therapy should generally be considered as initial treatment for a
postmenopausal patient with newly diagnosed metastatic disease if the patient's
tumor is ER-positive, PR-positive, or ER/PR-unknown. Hormone therapy is
especially indicated if the patient's disease involves only bone and soft
tissue and the patient has either not received adjuvant antiestrogen therapy or
has been off such therapy for more than 1 year. While tamoxifen has been used
in this setting for many years, several randomized trials suggest equivalent or superior response rates and progression-free survival (PFS) for the aromatase inhibitors (AIs) compared with tamoxifen.[24][25][26][Level of evidence: 1iiDiii] In a meta-analysis that included randomized trials in patients who were receiving an AI as either their first or second hormonal therapy for metastatic disease, those who were randomly assigned to a third-generation drug (anastrozole, letrozole, exemestane, or vorozole) lived longer (hazard ratio [HR] for death, 0.87; 95% confidence interval [CI], 0.82–0.93) than those who received standard therapy (tamoxifen or a progestational agent).[27][Level of evidence: 1iA]
Several randomized but underpowered trials have tried to determine if combined
hormone therapy (luteinizing hormone-releasing hormone [LHRH] agonists + tamoxifen) is superior to either approach
alone in premenopausal women. Results have been inconsistent.[28][29][30] The best
study design compared buserelin (an LHRH agonist) versus tamoxifen versus the
combination in 161 premenopausal women with hormone receptor–positive
tumors.[31] Patients receiving buserelin and tamoxifen had a significantly
improved median survival of 3.7 years compared with those receiving tamoxifen or
buserelin who survived 2.9 and 2.5 years, respectively (P = .01).[31][Level of evidence: 1iiA] Very few women in this trial received adjuvant tamoxifen,
which makes it difficult to assess whether these results are applicable to women
who relapse after adjuvant tamoxifen.
Women whose tumors are ER-positive or unknown, with bone or soft tissue
metastases only, who have received an antiestrogen within the past year, should
be given second-line hormone therapy. Examples of second-line hormone therapy
in postmenopausal women include selective AIs, such as
anastrozole, letrozole, or exemestane; megestrol acetate; estrogens;
androgens;[32][33][34][35][36][37][38][39][40] and the ER down-regulator, fulvestrant.[41][42] In comparison to megestrol
acetate, all three currently available AIs have demonstrated, in
prospective randomized trials, at least equal efficacy and better
tolerability.[32][33][34][35][36][37][38][43] In a meta-analysis that included randomized trials of patients who were receiving an AI as either their first or second hormonal therapy for metastatic disease, those who were randomly assigned to a third-generation drug (e.g., anastrozole, letrozole, exemestane, or vorozole) lived longer (HRdeath 0.87; 95% CI, 0.82–0.93) than those who received standard therapy (tamoxifen or a progestational agent).[27][Level of evidence: 1iA] Two randomized trials that enrolled 400 and 451
patients who had progressed after receiving tamoxifen demonstrated that
fulvestrant yielded similar results to anastrozole in terms of its impact on PFS.[44][45] The proper sequence of these therapies is currently not known.[43][46]
While there is a biologic rationale for combining fulvestrant with a third-generation AI for patients with recurrent or metastatic disease, the benefits of such combination therapy have not been established.[47]
Premenopausal women should undergo oophorectomy (surgically, with external-beam
radiation therapy or with an LHRH agonist).[48] Patients with lymphangitic
pulmonary metastases, major liver involvement, and/or central nervous system
involvement should not receive hormone therapy as a single modality. Patients
with structural compromise of weight-bearing bones should be considered for
surgical intervention and/or radiation in addition to systemic therapy.
Patients with vertebral body involvement should be evaluated for impending cord
compression even in the absence of neurologic symptoms. Increasing bone pain
and increasing alkaline phosphatase within the first several weeks of hormone
therapy does not necessarily imply disease progression.[49] Patients with
extensive bony disease are at risk for the development of symptomatic
hypercalcemia early in the course of hormone therapy.[49] Early failure (e.g.,
<6 months) on hormone therapy suggests that cytotoxic chemotherapy should be
the next modality employed.
Endocrine therapy is recommended for patients with metastatic hormone receptor-positive (HR+) disease. However, patients inevitably develop resistance to endocrine therapy. Preclinical models and clinical studies suggest that mammalian target of rapamycin (mTOR) inhibitors might enhance the efficacy of endocrine therapies.
BOLERO-2 [NCT00863655], is a randomized, phase III, placebo-controlled trial, of randomly assigned patients with HR+ metastatic breast cancer resistant to nonsteroidal aromatase inhibition who received the mTOR inhibitor everolimus plus exemestane versus placebo plus exemestane.[50][Level of Evidence: 1iDiii]. At the interim analysis, median PFS was 6.9 months for everolimus plus exemestane and 2.8 months for placebo plus exemestane (HR, 0.43; 95% CI, 0.35–0.54; P < .001). The addition of everolimus to exemestane was more toxic with the most common grade 3 or 4 adverse events (AEs) being stomatitis (8% vs. 1%), anemia (6% vs. <1%), dyspnea (4% vs. 1%), hyperglycemia (4% vs. <1%), fatigue (4% vs. 1%), and pneumonitis (3% vs. 0%). The results of this study report a benefit in PFS with the addition of an mTOR inhibitor to endocrine therapy but there were more side effects. Final overall survival (OS) outcomes on this trial are awaited.
Approximately 25% of patients with breast cancer have tumors that overexpress HER2/neu.[51] Trastuzumab is a humanized monoclonal antibody that
binds to the HER2/neu receptor.[51] In patients previously treated with
cytotoxic chemotherapy whose tumors overexpress HER2/neu, administration of
trastuzumab as a single agent resulted in a response rate of 21%.[52][Level of evidence: 3iiiDiv] In a prospective trial, patients with metastatic disease
were randomly assigned to receive either chemotherapy alone (doxorubicin and
cyclophosphamide or paclitaxel) or the same chemotherapy and trastuzumab.
Patients treated with chemotherapy plus trastuzumab had an OS advantage as compared with those receiving chemotherapy alone (25.1 months vs.
20.3 months, P = .05).[53][Level of evidence: 1iiA] When combined with
doxorubicin, trastuzumab is associated with significant cardiac toxicity.[54]
Consequently, patients with metastatic breast cancer with substantial
overexpression of HER2/neu are candidates for treatment with the combination of
trastuzumab and paclitaxel or for clinical studies of trastuzumab combined with
taxanes and other chemotherapeutic agents.[55]
Clinical trials comparing multiagent chemotherapy plus trastuzumab versus single-agent chemotherapy have yielded conflicting results. In one randomized study of patients with metastatic breast cancer treated with trastuzumab, paclitaxel, and carboplatin, patients tolerated the combination well and had a longer time-to-progression, compared with trastuzumab and paclitaxel alone.[56][Level of evidence: 1iDiii]
However, a phase III Breast Cancer International Research Group (BCIRG) trial (BCIRG-007 [NCT00047255]) comparing carboplatin and docetaxel plus trastuzumab versus docetaxel plus trastuzumab as first-line chemotherapy for metastatic HER2-overexpressing breast cancer showed no difference in OS, time to progression, or response rate.[57][Level of evidence: 1iiA] Outside of a clinical trial, standard first-line treatment for metastatic HER2-overexpressing breast cancer should consist of single-agent chemotherapy plus trastuzumab.
Lapatinib is an orally administered tyrosine kinase inhibitor of both HER2/neu and the epidermal growth factor receptor.
Lapatinib has shown activity in combination with capecitabine in patients who have HER2-positive metastatic breast cancer that progressed after treatment with trastuzumab. A nonblinded, randomized trial (GSK-EGF100151) compared the combination of capecitabine and lapatinib with capecitabine alone in 324 patients with locally advanced or metastatic disease that progressed after therapies that included anthracyclines, taxanes, and trastuzumab.[58] At the first planned interim analysis of the trial, a highly significant difference was found that favored the combination arm with respect to the primary study endpoint and time to progression (median time to progression 8.4 months vs. 4.4 months; HR, 0.49; 95% CI, 0.34–0.71; P < .001). There was no difference in OS (HR, 0.92; 95% CI, 0.58–1.46; P = .72).[58][Level of evidence: 1iiA] Patients on combination therapy were more likely to develop diarrhea, rash, and dyspepsia. No data on quality of life or treatment after progression are available. (Refer to the PDQ summary on Gastrointestinal Complications for more information on diarrhea.)
The combination of lapatinib and trastuzumab has been evaluated for patients with HER2-positive metastatic breast cancer whose disease progressed while they were being treated with trastuzumab in a phase III trial.[59][Level of evidence: 1iiA] A total of 291 patients were randomly assigned to treatment with lapatinib alone or in combination with trastuzumab. Compared with lapatinib alone, the combination of lapatinib and trastuzumab significantly improved PFS (HR, 0.74; 95% CI, 0.58–0.94; median, 11 weeks vs. 8 weeks) and OS (HR, 0.74; 95% CI, 0.57–0.97; median, 14 months vs. 10 months). The control arm of lapatinib alone is a nonstandard treatment arm. These data offer heavily pretreated metastatic HER2-positive breast cancer patients an alternative chemotherapy-free treatment regimen using dual HER2 blockade.
A double-blind, randomized phase III study compared paclitaxel and lapatinib with paclitaxel plus placebo as first-line therapy in patients with metastatic breast cancer.[60] In the intention-to-treat population, no benefit was found with the combination treatment. However, specimens were evaluated retrospectively to determine HER2/neu status. When used in HER2/neu-positive patients, treatment with paclitaxel and lapatinib showed improvement in time to progression, event-free survival, response rate, and clinical benefit rate; OS did not increase. Toxicities, specifically alopecia, diarrhea, and rash were higher in the HER2/neu-positive lapatinib group. A series of AE were low and existed in both arms.[60][Level of evidence: 1iDiii]
Pertuzumab is a humanized, monoclonal antibody that binds to a different epitope at the HER2 extracellular domain than trastuzumab. The binding of pertuzumab to HER2 prevents dimerization with other ligand-activated HER receptors, most notably HER3. Given their potentially complementary mechanisms of action, the phase III CLEOPATRA [NCT00567190] trial assessed the efficacy and safety of pertuzumab plus trastuzumab plus docetaxel versus placebo plus trastuzumab plus docetaxel, in the first-line HER2+ metastatic setting.[61][Level of evidence: 1iA]. The median PFS was 12.4 months in the control group versus 18.5 months in the pertuzumab group (HR, 0.62; 95% CI, 0.51–0.75; P < .001). Final OS results are pending. The toxicity profile was similar in both treatment groups with no increase in cardiac toxic effects seen in the pertuzumab combination arm.
Ado-trastuzumab emtansine (T-DM1) is an antibody-drug conjugate that incorporates the HER2–targeted antitumor properties of trastuzumab with the cytotoxic activity of the microtubule-inhibitory agent DM1. T-DM1 allows specific intracellular drug delivery to HER2-overexpressing cells, potentially improving the therapeutic index and minimizing exposure of normal tissue. The phase III EMILIA or TDM4370g (NCT00829166)
study was a randomized, open-label trial enrolling 991 patients with HER2-overexpressing, unresectable, locally advanced or metastatic breast cancer who were previously treated with trastuzumab and a taxane.[62][Level of evidence: 1iiA]
Patients were randomly assigned between T-DM1 versus lapatinib plus capecitabine. Median PFS was 9.6 months with T-DM1 versus 6.4 months with lapatinib plus capecitabine (HR, 0.65; 95% CI, 0.55–0.77; P < .001). Median OS at the second interim analysis crossed the stopping boundary for efficacy (30.9 months vs. 25.1 months; HR, 0.68; 95% CI, 0.55–0.85; P < .001). The incidences of thrombocytopenia and increased serum aminotransferase levels were higher in patients who received T-DM1, whereas the incidences of diarrhea, nausea, vomiting, and palmar–plantar syndrome were higher in patients who received lapatinib plus capecitabine.
Further evidence of T-DM1's activity in metastatic HER2-overexpressed breast cancer was shown in a randomized phase II study of T-DM1 versus trastuzumab plus docetaxel.[63][Level of evidence: 1iiDiii] This trial randomly assigned 137 women with HER2-overexpressed breast cancer in the first-line metastatic setting. At median follow-up of 14 months, median PFS was 9.2 months with trastuzumab plus docetaxel and 14.2 months with T-DM1 (HR, 0.59; 95% CI, 0.36–0.97). T-DM1 had a favorable safety profile compared with trastuzumab plus docetaxel, with fewer grade 3 AE, (46.4% vs. 90.9%), AE leading to treatment discontinuations (7.2% vs. 40.9%), and serious AE (20.3% vs. 25.8%). Preliminary OS results were similar between treatment arms.
Patients whose tumors have progressed on hormone therapy are candidates for
cytotoxic chemotherapy. Patients with hormone receptor–negative tumors and
those with visceral metastases are also candidates for cytotoxic agents.[64]
Single agents that have shown activity in metastatic breast cancer include the following:
Combination regimens that have shown activity in metastatic breast cancer:
Whether single-agent chemotherapy or combination chemotherapy
is preferable for first-line treatment is unclear. An Eastern Cooperative Oncology Intergroup study (E-1193) randomly assigned patients to receive paclitaxel and doxorubicin given both as a combination and sequentially.[89] Although response rate and time-to-progression were both better for the combination, survival was the same in both groups.[89][Level of evidence: 1iiA];[90][91] The rate of disease progression,
the presence or absence of comorbid medical conditions, and physician/patient
preference will influence the choice of therapy in individual patients. At
this time, no data support the superiority of any particular
regimen. Sequential use of single agents or combinations can be used for
patients who relapse. Combinations of chemotherapy and hormone therapy have
not shown an OS advantage over the sequential use of these
A systematic review of 17 randomized trials found that the addition of one or more chemotherapy drugs to a chemotherapy regimen in the attempt to intensify the treatment improved tumor response but had no effect on OS.[93][Level of evidence: 1iiA]
The optimal treatment duration for patients with responsive or stable disease
has been studied by several groups. For patients who attain a complete
response to initial therapy, two randomized trials have shown a prolonged
DFS from immediate treatment with a different chemotherapy
regimen compared to observation with treatment upon relapse.[94][95][Level of evidence: 1iiA] Neither of these
studies, however, showed an improvement in OS for patients who received
immediate treatment, and in one of these studies,[95] survival was actually
worse in the immediately treated group. Similarly, no difference in survival
was noted when patients with partial response or stable disease after initial
therapy were randomized to receive either a different chemotherapy versus
observation [96] or a different chemotherapy regimen given at higher versus
lower doses.[97][Level of evidence: 1iiA] These four studies indicate that
different combination regimens of additional chemotherapy immediately following
a patient's best response to an induction chemotherapy regimen does not improve
OS. In view of the lack of a standard approach, patients
requiring second-line regimens are good candidates for clinical trials.
The potential for doxorubicin-induced cardiac toxic effects should be considered in
the selection of chemotherapeutic regimens for an individual patient.
Recognized risk factors for cardiac toxicity include advanced age, prior
chest-wall radiation therapy, prior anthracycline exposure, hypertension, diabetes,
and known underlying heart disease. The cardioprotective drug, dexrazoxane, has
been shown to decrease the risk of doxorubicin-induced cardiac toxicity in
patients in controlled studies. The use of this agent has permitted patients
to receive greater cumulative doses of doxorubicin and allowed patients with
cardiac risk factors to receive doxorubicin.[98][99][100][101] Dexrazoxane has a similar
protective effect in patients receiving epirubicin.[102] The risks of cardiac
toxicity may also be reduced by administering doxorubicin as a continuous
intravenous infusion.[103]
Studies comparing high-dose chemotherapy with stem cell support to conventional
chemotherapy in patients with metastatic disease indicate no
OS or relapse-free survival benefit for patients receiving high-dose
chemotherapy with stem cell support.[104][105][Level of evidence: 1iiA] In the
absence of data suggesting a benefit from high-dose chemotherapy with stem cell
support, this remains an area of clinical evaluation.[106][107]
Bevacizumab is a humanized monoclonal antibody directed against all isoforms of vascular endothelial growth factor-A. Its role in the treatment of metastatic breast cancer remains controversial. The efficacy and safety of bevacizumab as a second- and third-line treatment for patients with metastatic breast cancer were studied in a single, open-label, randomized trial.[108] The study enrolled 462 patients who had received prior anthracycline and taxane therapy and were randomly assigned to receive capecitabine with or without bevacizumab. The study failed to demonstrate a statistically significant effect on PFS (4.86 months vs. 4.17 months; HR, 0.98) or OS (15.1 months vs. 14.5 months).[108][Level of Evidence: 1iiA]
ECOG-2100 (NCT00028990), a completed, open-label, randomized, phase III trial, demonstrated that the addition of bevacizumab to paclitaxel significantly prolonged median PFS compared with paclitaxel alone as the initial treatment for patients with metastatic breast cancer (11.8 months vs. 5.9 months; HR, 0.60; P <.001).[109][Level of Evidence: 1iiA] However, the addition of bevacizumab did not improve OS (26.7 months vs. 25.2 months, P = .16). Notably, patients treated on the bevacizumab-containing arm had significantly higher rates of severe hypertension, proteinuria, cerebrovascular ischemia, and infection.
The AVADO (NCT00333775) trial randomly assigned 736 patients to docetaxel plus either placebo or bevacizumab at 7.5 mg/kg or 15 mg/kg every 3 weeks as the initial treatment for patients with metastatic breast cancer. The combination of bevacizumab at 15 mg/kg, but not 7.5 mg/kg, with docetaxel modestly improved median PFS compared with placebo (10.1 months vs. 8.1 months) but did not improve OS (30.2 months vs. 31.9 months; P = .85).[110][Level of Evidence: 1iiA] Again, more toxic effects were seen in patients in the bevacizumab-containing arms with significantly higher rates of bleeding and hypertension compared with the placebo arms.
Similarly, the RIBBON 1 (NCT00262067) trial randomly assigned 1,237 patients in a 2:1 fashion to standard chemotherapy plus bevacizumab or standard chemotherapy plus placebo.[111] Median PFS was longer for each bevacizumab-containing combination (Cape cohort: increased from 5.7 mo. to 8.6 mo.; HR, 0.69; 95% CI, 0.56–0.84; log-rank, P < .001; and Taxane/Anthracycline cohort: increased from 8.0 mo. to 9.2 mo.; HR, 0.64; 95% CI, 0.52–0.80; log-rank, P < .001).[111][Level of Evidence: 1iiA] However, no statistically significant differences in OS between the placebo- and bevacizumab-containing arms were observed. Toxicities associated with bevacizumab were similar to those seen in prior bevacizumab clinical trials.
The RIBBON-2 (NCT00281697) trial studied the efficacy of bevacizumab as a second-line treatment for metastatic breast cancer.[112] This trial randomly assigned 684 patients in a 2:1 fashion to standard chemotherapy plus bevacizumab or standard chemotherapy plus placebo. Median PFS increased from 5.1 to 7.2 months for the bevacizumab-containing treatment arm (stratified HR for PFS, 0.78; 95% CI, 0.64 to 0.93; P = .0072). However, no statistically significant difference in OS was seen (16.4 months vs. 18.0 months for chemotherapy plus placebo vs. chemotherapy plus bevacizumab, respectively, P = .3741).[112][Level of evidence: 1iA] Toxicities associated with bevacizumab were again similar to those seen in prior clinical trials.
In November 2011, based on the consistent finding that bevacizumab only modestly improved PFS but not OS, and given bevacizumab's considerable toxicity profile, the Food and Drug Administration revoked approval of bevacizumab for the treatment of metastatic breast cancer.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with stage IIIB breast cancer, stage IIIC breast cancer, stage IV breast cancer, recurrent breast cancer and metastatic cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
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Triple-negative breast cancer (TNBC) is defined as the absence of staining for estrogen receptor, progesterone receptor, and HER2/neu. TNBC is insensitive to some of the most effective therapies available for breast cancer treatment including HER2-directed therapy such as trastuzumab and endocrine therapies such as tamoxifen or the aromatase inhibitors. Combination cytotoxic chemotherapy administered in a dose-dense or metronomic schedule remains the standard therapy for early-stage TNBC.[1] A prospective analysis of 1,118 patients who received neoadjuvant chemotherapy at a single institution, of whom 255 (23%) had TNBC, found that patients with TNBC had higher pathologic complete response (pCR) rates compared with non-TNBC patients (22% vs. 11%; P = 0.034).[2][Level of evidence: 3iiDiv] Improved pCR rates may be important since in some studies, pCR is associated with improved long-term outcomes.
Platinum agents have recently emerged as drugs of interest for the treatment of TNBC. One trial that treated 28 women with stage II or stage III TNBC with four cycles of neoadjuvant cisplatin resulted in a 22% pCR rate.[3][Level of evidence: 3iiiDiv] A randomized clinical trial, CALGB-40603 (NCT00861705), evaluated the benefit of carboplatin added to paclitaxel and adriamycin plus cyclophosphamide chemotherapy in the neoadjuvant setting. Another trial, entitled the Triple Negative Trial (NCT00532727), is evaluating carboplatin against docetaxel in the metastatic setting. These trials will help to define the role of platinum agents for the treatment of TNBC. Currently, there is no established role for adding platinum agents to the treatment of early-stage TNBC outside of a clinical trial.
The poly (ADP-ribose) polymerase (PARP) inhibitors are emerging as promising therapeutics for the treatment of TNBC.[4] PARPs are a family of enzymes involved in multiple cellular processes, including DNA repair. Because TNBC shares multiple clinicopathologic features with BRCA-mutated breast cancers, which harbor dysfunctional DNA repair mechanisms, it is possible that PARP inhibition, in conjunction with the loss of DNA repair via BRCA-dependent mechanisms, would result in synthetic lethality and augmented cell death. PARP inhibitors are currently being evaluated in clinical trials for patients with BRCA mutations and in TNBC.
Check for U.S. clinical trials from NCI's list of cancer clinical trials that are now accepting patients with triple-negative breast cancer. The list of clinical trials can be further narrowed by location, drug, intervention, and other criteria.
Mehta RS: Dose-dense and/or metronomic schedules of specific chemotherapies consolidate the chemosensitivity of triple-negative breast cancer: a step toward reversing triple-negative paradox. J Clin Oncol 26 (19): 3286-8; author reply 3288, 2008.
Liedtke C, Mazouni C, Hess KR, et al.: Response to neoadjuvant therapy and long-term survival in patients with triple-negative breast cancer. J Clin Oncol 26 (8): 1275-81, 2008.
Silver DP, Richardson AL, Eklund AC, et al.: Efficacy of neoadjuvant Cisplatin in triple-negative breast cancer. J Clin Oncol 28 (7): 1145-53, 2010.
Anders CK, Winer EP, Ford JM, et al.: Poly(ADP-Ribose) polymerase inhibition: "targeted" therapy for triple-negative breast cancer. Clin Cancer Res 16 (19): 4702-10, 2010.
This information was last updated on July 11, 2014.
Our licensed social workers are here to help adult patients and their loved ones face the many new concerns and anxieties following a cancer diagnosis, offering emotional support and assistance with obtaining needed resources.
Our support groups are geared to specific cancers and methods of treatment. They give patients the opportunity to meet and share information and moral support. Our experienced, compassionate staff facilitates and guides discussion.
If you are dealing with the death of a loved one, grief can be a lonely and isolating experience. The Bereavement Program provides support to bereaved family members and friends following the death of a patient.
Concierge Services is your one-stop place to learn about Dana-Farber programs, services and resources, as well as information on getting around Boston, finding lodging or restaurants, and activities in the area.
The Expressive Arts Therapy program, sponsored by the Leonard P. Zakim Center for Integrative Therapies, provides adult patients, family members, and caregivers with a variety of options to support well-being during cancer treatment. From live music meditation to painting technique workshops, the program offers a range of creative outlets to suit every interest.