Breast cancer Treatment Early and locally advanced breast cancer

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Breast cancerTreatmentEarly and locally
advanced breast cancer
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Treatment of early and locally advancedbreast
cancer NICE. CG80. Early and locally advanced
breast cancer. February 2009NICE. Guidance on
cancer services. August 2002

• Surgery
• Breast conservation (wide local excision)
• Mastectomy
• Adjuvant or neo-adjuvant treatments include
• Radiotherapy
• Hormonal therapy
• Chemotherapy
• Biological therapy

Providing information and psychosocial support is
important. Up to one third of women develop
severe anxiety or a depressive illness within a
year of diagnosis.
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Choice of adjuvant treatmentNICE. CG80. Early
and locally advanced breast cancer. February 2009

• Most patients with early breast cancer will need
  adjuvant therapy ? many will need a combination
  of treatments
• Planning adjuvant treatment by MDT is complex
• Decisions about which therapy should be based on
  an assessment of
• Prognostic factors i.e. histological grade, nodal
  status, tumour size
• Predictive factors i.e. oestrogen receptor/HER2
  status
• Potential benefits and side effects of treatment
• Following discussion of these factors with the
  patient.

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Adjuvant hormonal therapyNICE. Full guideline
80. Early and locally advanced breast
cancerFebruary 2009

• Hormonal therapy with tamoxifen or an aromatase
  inhibitor should only be considered in patients
  with oestrogen-receptor (ER) positive tumours
• Aims to reduce the levels, or block the action of
  circulating oestrogens
• Pre-menopausal women, and post-menopausal women
  at low-riska should be offered tamoxifen
• Post-menopausal women not considered to be at
  low-riska should be offered an aromatase
  inhibitor (anastrozole or letrozole).

a Patients in the excellent or good
prognostic groups (Nottingham Prognostic Index)
with 10-year predictive survival of 96 and 93
respectively
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Aromatase inhibitors for early oestrogen-receptor
positive breast cancer (1)NICE. CG80. Early and
locally advanced breast cancer. February 2009

• Post-menopausal women with ER-positive early
  invasive breast cancer, who are not low-risk
  should be offered either anastrozole or
  letrozole, as initial adjuvant therapy
• Offer tamoxifen if an aromatase inhibitor is not
  tolerated or contraindicated
• Offer exemestane or anastrozole, instead of
  tamoxifen, to post-menopausal women with
  ER-positive early invasive breast cancer, who are
  not low-risk and who have been treated with
  tamoxifen for 23 years
• Offer additional treatment with letrozole for 23
  years to post-menopausal women with lymph
  node-positive ER-positive early invasive breast
  cancer who have been treated with tamoxifen for 5
  years.

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Aromatase inhibitors for early oestrogen-receptor
positive breast cancer (2)NICE. CG80. Early and
locally advanced breast cancer. February
2009NICE. Technology appraisal 112. November 2006

• The aromatase inhibitors anastrozole, exemestane
  and letrozole, within their licensed indications,
  are recommended as options for the adjuvant
  treatment of early ER-positive invasive breast
  cancer in post-menopausal women
• The choice of treatment should be made after
  discussion between the responsible clinician and
  the woman about the risks and benefits of each
  option.

Patients starting an adjuvant aromatase inhibitor
should have a baseline DEXA scan to assess BMD.
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Adjuvant chemotherapy Stebbing J, et al.
Clinical Evidence. Search date January 2007
NICE. CG80. Early and locally advanced breast
cancer. February 2009

• In primary operable breast cancer, combination
  chemotherapy improves survival, with greatest
  benefit likely with anthracycline based regimens
  at standard doses for 4 to 6 months
• Adjuvant taxane based regimens may improve
  disease-free survival over standard
  anthracycline-based therapy
• Docetaxel should be offered to patients with
  lymph node ve breast cancer, as part of an
  adjuvant chemotherapy regimen
• Paclitaxel should not be offered as an adjuvant
  treatment for lymph node ve breast cancer.

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Trastuzumab? for HER2-positive early invasive
breast cancer NICE. Full guideline 80. Early and
locally advanced breast cancer.February 2009

• In HER2-positive early invasive breast cancer
  following surgery, chemotherapy, and radiotherapy
  when applicable
• Trastuzumab? should be offered as an adjuvant
  treatment, given at 3-week intervals for one year
  or until disease recurrence (whichever is the
  shorter)
• Trastuzumab reduces the risk of recurrence of
  relapse by about 50, and the risk of death by
  about 30
• Cardiac side effects mainly heart failure.

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Summary

• NICE guidance published February 2009 covers
  diagnosis and treatment of early and locally
  advanced breast cancer
• Surgery usually first option for early invasive
  breast cancer breast conservation more
  frequently performed than mastectomy
• Most patients will need at least one adjuvant
  treatment e.g. radiotherapy, hormonal therapy,
  chemotherapy, biological therapy
• Decisions about treatment(s) should be based on
• prognostic factors e.g. histological grade,
  tumour size
• predictive factors i.e. ER/HER2 status
• potential benefits and side effects
• following discussion of these factors with the
  patient.