Locally Advanced Breast Cancer
Special points related to locally advanced
breast cancer here
cancer notes for rest.
1. Neoadjuvant Therapy
Has revolutionized the management of locally advanced breast cancer.
Now standard of care for pts with bulky breast or axillary disease.
(And also an option for operable tumours if shrinkage expected to
improve eligibility for breast-conserving therapy.
- ?increased rates of pre-op complications
- ?alteration of prognostic significance of nodal status.
- ?reduced accuracy of SNL
- ?bad to delay time to surgery.
Now known that there are no adverse effects on surgical
complications or survival.
And accuracy of SNL is comparable to those pts undergoing primary
- but need to consider timing:
Neoadjuvant therapy increases the number of women wligible for
breast conserving therapy
But no difference in overall survival with neoadjuvant vs adjuvant
- but pts with a strong ('pathologially complete') response (PCR) to
neoadjuvant therapy have a better prognosis.
--> PCR is a surragate endpoint for overall survival.
2. SNL Timing
- advantages = proven ok, surgical sequence good;
- disadvantages = FN rates undefined, drug-induced lymph drainage
may affect SLN
- advantages: nodal status significance clearer; prognosis up
front may help inform treatment decisions
- disadvantages: potentially for unnecessary ALND (chemo sterilizes
up to 25-35% of +ve nodes); additional treatment risks.
3. Neoadjuvant Endocrine Therapy?
PCR rate lower than with chemo
But hormone positive patients have a lower response to chemo than
hormone negative patients
- so strongly positive ER patients will probably benefit from
neoadjuvant endocrine therapy.
Research focus currently on type of endocrine therapy and patient
4. Adjuvant Chemotherapy
Optimal management of patients with residual disease after
neoadjuvant therapy is uncertain.
- as for those with do not respond well to initial chemo.
In women with HER2 +ve disease, Trastuzumab is highly effective at
improving PCR --> up to 60% (vs 25% without)
Pt care must be individualized.
Adjuvant! Online offers a personalized risk tool.
Gene profiling (Oncotype Dx, AMsterdam 70-gene profile) also
- patients with low risk scores can be spared the risk and
inconvenience of chemotherapy
- in favour of more effective endocrine therapy.
- high scores = chemo indicated.