Chapter 086. Breast Cancer (Part 8)

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Table 86-3 Suggested Approaches to Adjuvant Therapy Age Group h Lymp Endocr Tum tion Recommenda Node ine Receptor or (ER) Status Statusa Premenopa usal ve Positi Any Any Multidrug chemotherapy tamoxifen positive if + ER+ trastuzumab in HER- 2/neu tumors positive Premenopa usal ive Negat Any 2 Multidrug + ER+ cm, or 1–2 chemotherapy cm with tamoxifen if other poor positive prognostic trastuzumab in HERvariables 2/neu tumors positive Postmenopa usal ve Positi e Negativ Any Multidrug chemotherapy + trastuzumab in HER2/neu tumors positive Postmenopa usal ve Positi Positive Any Aromatase inhibitors and tamoxifen with or without chemotherapy + trastuzumab in HER2/neu tumors positive Postmenopa usal ive Negat Positive 2 Aromatase and + cm, or 1–2 inhibitors cm with tamoxifen other poor trastuzumab in HERprognostic 2/neu variables tumors positive Postmenopa usal ive Negat e Negativ 2 Consider ...

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Chapter 086. Breast Cancer (Part 8) Table 86-3 Suggested Approaches to Adjuvant Therapy Age Group Lymp Endocr Tum Recommenda h Node ine Receptor or tion Statusa (ER) Status Premenopa Positi Any Any Multidrug usal ve chemotherapy + tamoxifen if ER- positive + trastuzumab in HER-
2/neu positive tumors Premenopa Negat Any >2 Multidrug usal ive cm, or 1–2 chemotherapy + cm with tamoxifen if ER- other poor positive + prognostic trastuzumab in HER- variables 2/neu positive tumors Postmenopa Positi Negativ Any Multidrug usal ve e chemotherapy + trastuzumab in HER- 2/neu positive tumors Postmenopa Positi Positive Any Aromatase usal ve inhibitors and tamoxifen with or without
chemotherapy + trastuzumab in HER- 2/neu positive tumors Postmenopa Negat Positive >2 Aromatase usal ive cm, or 1–2 inhibitors and cm with tamoxifen + other poor trastuzumab in HER- prognostic 2/neu positive variables tumors Postmenopa Negat Negativ >2 Consider usal ive e cm, or 1–2 multidrug cm with chemotherapy + other poor trastuzumab in HER- prognostic 2/neu positive variables tumors a As determined by pathologic examination.
Data on postmenopausal women are also controversial. The impact of adjuvant chemotherapy is quantitatively less clear-cut than in premenopausal patients, although survival advantages have been shown. The first decision is whether chemotherapy or endocrine therapy should be used. While adjuvant tamoxifen improves survival regardless of axillary lymph node status, the improvement in survival is modest for patients in whom multiple lymph nodes are involved. For this reason, it has been usual to give chemotherapy to postmenopausal patients who have no medical contraindications and who have more than one positive lymph node; tamoxifen is commonly given simultaneously or subsequently. For postmenopausal women for whom systemic therapy is warranted but who have a more favorable prognosis, tamoxifen may be used as a single agent. Large clinical trials have shown superiority for aromatase inhibitors over tamoxifen alone in the adjuvant setting. Unfortunately the optimal plan is unclear. Tamoxifen for 5 years followed by an aromatase inhibitor, the reverse strategy, or even switching to an aromatase inhibitor after 2–3 years of tamoxifen has been shown to be better than tamoxifen alone. No valid information currently permits selection among the three clinically approved aromatase inhibitors. Large clinical trials currently underway will help address these questions. Most comparisons of adjuvant chemotherapy regimens show little difference among them, although small advantages for doxorubicin-containing regimens are usually seen.