Breast Cancer
Maryam Lustberg, MD, MPH
Nicole Williams, MD
Pavani Chalasani, MD, MPH
Sima Ehsani Chimeh, MD
A 34-year-old woman undergoes a needle biopsy with results exhibiting atypical ductal hyperplasia.
What is the prognostic significance of this finding?
View Answer
Atypical ductal hyperplasia raises future risk of breast cancer.
Absolute risk is estimated at 30% over next 25 years.
Suggested Readings:
Degnim AC, Visscher DW, Berman HK, et al. Stratification of breast cancer risk in women with atypia: a Mayo cohort study. J Clin Oncol. 2007;25:2671-2677.
Hartmann LC, Degnim AC, Santen RJ, Dupont WD, Ghosh K. Atypical hyperplasia of the breast — risk assessment and management options. N Engl J Med. 2015;372:78-89.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 46-year-old premenopausal woman who recently underwent stereotactic core biopsy that showed atypical ductal hyperplasia (ADH).
What is the next step in her care?
View Answer
Excisional biopsy.
1 out of 5 women with ADH on core needle biopsy will have ductal carcinoma in situ (DCIS) or invasive cancer found in their excisional biopsy specimen.
Suggested Readings:
Hartmann LC, Degnim AC, Santen RJ, Dupont WD, Ghosh K. Atypical hyperplasia of the breast — risk assessment and management options. N Engl J Med. 2015;372:78-89.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 50-year-old premenopausal woman presents with routine mammogram screening and is noted have an abnormal area of calcification in the right upper outer quadrant. She undergoes stereotactic biopsy and excisional biopsy both confirming lobular carcinoma in situ (LCIS).
What do you recommend as the next step in her care?
View Answer
Tamoxifen chemoprevention should be discussed as an option in a premenopausal woman with LCIS.
The American Society of Clinical Oncology recommends that chemoprevention be discussed as an option in women at increased risk of breast cancer based on a score of >1.66% on the National Cancer Institute Breast Cancer Risk Assessment Tool (which considers prior diagnosis of atypical hyperplasia or if they have been diagnosed with LCIS).
Suggested Readings:
Visvanathan K, Hurley P, Bantug E, et al. Use of pharmacologic interventions for breast cancer risk reduction: American Society of Clinical Oncology clinical practice guideline. J Clin Oncol. 2013;31:2942-2962.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 40-year-old woman presents to your clinic for consultation. She has a family history of breast cancer in multiple first-degree relatives. There is no known BRCA mutation previously diagnosed in other family members.
What steps would you advise in her care?
View Answer
Recommend genetic counseling and consideration of full genetic panel testing of this patient.
Chemoprevention with tamoxifen or surgical risk reduction may be considered in the absence of a known hereditary mutation with a compelling family history.
Suggested Readings:
Fisher B, Costantino JP, Wickerham L, 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. 1998;90:1371-1388.
Society of Surgical Oncology position statement on prophylactic mastectomy. https://link.springer.com/article/10.1245/s10434-007-9447-z
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 55-year-old postmenopausal woman presents with routine screening. Mammogram and subsequent breast ultrasound of the involved area show a dilated breast duct with a filling defect. She is s/p excision which reveals an intraductal papilloma with a focus of atypia. A 5-year risk of invasive breast cancer >2.1% using Gail model.
What is the most appropriate next step?
View Answer
Aromatase inhibitor or tamoxifen based on Gail model score of >1.66%
Gail model risk factors: Age, age at first period, age at the time of the birth of a first child (or has not given birth), family history of breast cancer (mother, sister or daughter), number of past breast biopsies, number of breast biopsies showing atypical hyperplasia, and race/ethnicity.
Suggested Readings:
Fisher B, Costantino JP, Wickerman 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. 1998;90:1371-1388.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 44-year-old premenopausal female was found on breast imaging to have a new cluster of pleomorphic microcalcifications measuring 2.0 cm in greatest diameter. A biopsy of the microcalcifications showed intermediate-grade ductal carcinoma in situ (DCIS), ER negative and PR negative.
What is the next best step?
View Answer
Lumpectomy if possible, followed by radiation, is indicated in a patient with DCIS.
According to American Society of Clinical Oncology and National Comprehensive Cancer Network guidelines, sentinel lymph node biopsy (SLNB) is recommended in patients with DCIS undergoing mastectomy because SLNB cannot be performed at a subsequent surgery.
Suggested Readings:
Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2014;32:1365-1383.
National Comprehensive Cancer Network (NCCN). NCCN clinical practice guidelines in oncology: breast cancer. www.nccn.org
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
What is thought to be the primary reason for rising incidence of ductal carcinoma in situ (DCIS) over the last few decades in the United States?
View Answer
Rising incidence of DCIS is thought to be due to widespread adoption of screening mammography in the United States and now accounts for 20% of all newly diagnosed breast cancers.
Suggested Readings:
Verdial FC, Etzioni R, Duggan C, et al. Demographic changes in breast cancer incidence, stage at diagnosis and age associated with population-based mammographic screening. J Surg Oncol. 2017;115:517-522.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 70-year-old presents to your medical oncology for discussion after successfully completing surgical management of recently diagnosed ductal carcinoma in situ (DCIS). She has a number of questions of what risk factors may have led her to develop DCIS. In reviewing her history, she has no family history of breast cancer, no alcohol intake, and has not taken hormone replacement therapy.
What would you tell her was her biggest risk for developing DCIS?
View Answer
Advanced age is the biggest risk for developing DCIS.
DCIS incidence tends to increase rapidly with increasing age and peaks during 70 to 79 years of age.
Suggested Readings:
Ward EM, DeSantis CE, Lin CC, et al. Cancer statistics: breast cancer in situ. CA Cancer J Clin. 2015;65:481-495.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 50-year-old woman is recently diagnosed with DCIS of the left breast. She has met with both radiation oncology and surgical oncology and presents to your office for multidisciplinary discussion of her options. Most specifically, she wants to know your opinion on benefits of a contralateral prophylactic mastectomy because she wants to be as proactive as possible. She has undergone genetic testing and is negative for BRCA mutation.
How would you advise her?
View Answer
Current guidelines only recommend contralateral prophylactic mastectomy for BRCA gene mutation carriers.
Prophylactic mastectomy for BRCA-negative patients does not improve long-term survival.
Suggested Readings:
Portschy PR, Kuntz KM, Tuttle TM. Survival outcomes after contralateral prophylactic mastectomy: a decision analysis. J Natl Cancer Inst. 2014;106:dju160.
Wong SM, Freedman RA, Sagara Y, et al. Growing use of contralateral prophylactic mastectomy despite no improvement in long-term survival for invasive breast cancer. Ann Surg. 2017;265:581-589.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 60-year-old woman has been counseled on breast conserving surgery and mastectomy after a core needle biopsy showed DCIS and has decided to proceed with lumpectomy. At her postsurgery follow-up, she was found to have 1.6 cm of DCIS, intermediate grade, ER/PR positive with 1-mm margins.
What is the next step in her treatment?
View Answer
Re-excision.
2-mm or greater margins are recommended for women diagnosed with DCIS treated with lumpectomy and radiation.
Suggested Readings:
Marinovich ML, Azizi L, Macaskill P, et al. The association of surgical margins and local recurrence in women with ductal carcinoma in situ treated with breast-conserving therapy: a meta-analysis. Ann Surg Oncol. 2016;23(12):3811.
Marrow M, Van Zee KJ, Solin LJ, et al. Society of Surgical Oncology-American Society for Radiation Oncology-American Society of Clinical Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in DCIS. Ann Surg Oncol. 2016;23(12):3801.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 55-year-old postmenopausal woman was diagnosed with an intermediate-grade 1-cm ER-positive DCIS with comedo necrosis after undergoing lumpectomy. The surgical margins were at least 2 mm. She is going to be set up for adjuvant breast radiation.
What would you advise her in term of chemoprevention options?
View Answer
Tamoxifen or aromatase inhibitor.
The landmark NSABP-B-35 trial demonstrated that treatment with anastrozole showed a significant improvement in breast cancer-free interval compared to tamoxifen; mainly in younger (<60 years) postmenopausal women. The choice of treatment often depends on the side effect profile of the drugs.
Suggested Readings:
Margolese RG, Cecchini RS, Julian TB, et al. Anastrozole versus tamoxifen in postmenopausal women with ductal carcinoma in situ undergoing lumpectomy plus radiotherapy (NSABP B-35): a randomised, double-blind, phase 3 clinical trial. Lancet. 2016;387(10021):849-856.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 65-year-old postmenopausal woman has been on anastrozole and subsequently exemestane for the last year since her diagnosis. She reports to you debilitating arthralgias and is not sure she can continue this therapy.
What is another possible adjuvant risk-reducing strategy for her?
View Answer
Tamoxifen.
Tamoxifen can be used in both postmenopausal and premenopausal women with DCIS and may have a more favorable toxicity profile in patients with aromatase inhibitor intolerance.
Suggested Readings:
Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials. Lancet. 2015;386:1341-1352.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A patient comes to your office for her first consultation with medical oncology for diagnosis of DCIS. She has undergone lumpectomy showing a 1.5-cm ER-PR-DCIS. She has been doing a lot of reading and asks about Her2 testing of her surgical specimen.
How would you advise her?
View Answer
Her2 testing in patients with DCIS is not recommended.
It has been reported that up to a third or more of DCIS lesions are Her2 positive. However, the significance of Her2 expression on prognosis in patients with DCIS remains controversial and we do not have strong data for treating these with Her2-directed therapy outside of a clinical trial. For this reason, routine Her2 testing of DCIS is not recommended.
Suggested Readings:
Siziopikou KP, Anderson SJ, Cobleigh MA, et al. Preliminary results of centralized HER2 testing in ductal carcinoma in situ (DCIS): NSABP B-43. Breast Cancer Res Treat. 2013;142:415-421.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
Can surgery be omitted in low-risk DCIS?
View Answer
Omission of surgery in low-risk DCIS is not routinely recommended outside the context of a clinical trial unless a patient’s health prohibits safe surgery.
There is an evolving body of work investigating whether surgery can be safely eliminated in certain low-risk DCIS. These include the LORIS, LORD, COMET, and LARRIKIN studies.
Suggested Readings:
Elshof LE, Tryfonidis K, Slaets L, et al. Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ -the LORD study. Eur J Cancer. 2015;51:1497-1510.
Lippey J, Spillane A, Saunders C. Not all ductal carcinoma in situ is created equal: can we avoid surgery for low-risk ductal carcinoma in situ? ANZ J Surg. 2016;86:859-860.
The Alliance for Clinical Trials in Oncology Foundation. Principal Investigator: Hwang S. Comparison of operative versus medical endocrine therapy for low risk DCIS: the COMET trial.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
An asymptotic 64-year-old woman had undergone lumpectomy and sentinel lymph node biopsy which showed invasive ductal cancer measuring 2 cm in greatest diameter, grade 2, negative lymphovascular invasion (LVI), negative margins with 0/2 lymph nodes involved. The invasive cancer is ER positive, PR positive, and Her2 negative. The Oncotype DX recurrence score is 30.
Prior to adjuvant chemotherapy, what additional testing would you recommend?
View Answer
A physical examination and CBC/LFTs would be recommended as she will be receiving adjuvant chemotherapy for her stage I breast cancer.
Routine systemic imaging is not indicated for patients with early-stage breast cancer in the absence of signs and symptoms of metastatic disease. For patients presenting with stage I-II, the NCCN panel does not recommend systemic imaging in the absence of signs and symptoms suspicious for metastatic disease. Additional tests may be considered in patients with locally advanced, T3 N1-3, disease and in those with signs and symptoms suspicious for metastatic disease.
CBC and LFTs may be considered if the patient is a candidate for systemic therapy or if otherwise clinically indicated.
Suggested Readings:
National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology. Breast Cancer Version 4.2020. National Comprehensive Cancer Network.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 55-year-old who was diagnosed with T2N1 (stage IIB) invasive ductal breast cancer which was ER positive, PR positive, and HER2 negative. She received preoperative chemotherapy with dose dense Adriamycin-cyclophosphamide followed by paclitaxel. She then underwent lumpectomy and axillary node dissection. She completed adjuvant radiation and is currently on anastrozole.
What is her scheduled follow-up?
View Answer
An H&P every 3 to 6 months for the first 5 years than annually. A bilateral mammogram is performed annually.
The goal of surveillance following the diagnosis of early-stage breast cancer is to detect curable disease. Thus, screening mammogram for the development of new breast cancer is beneficial; however, the screening for distant disease in an asymptomatic individual is not.
Suggested Readings:
Hayes DF. Clinical practice. Follow up of patients with early stage breast cancer. N Engl J Med. 2007;356:2505-2513.
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. 2016;24:5091-5097.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 40-year-old woman presents to you with a newly diagnosed breast cancer. She underwent a left mastectomy which revealed a 2-cm, invasive ductal carcinoma that is ER negative, PR negative, and HER2 negative. An axillary dissection was also performed, revealing 5 of 10 nodes positive for metastatic breast cancer. Distant staging did not reveal evidence of distant metastases. She has completed adjuvant doxorubicin and cyclophosphamide followed by paclitaxel.
Which of the following is the appropriate next step?
View Answer
Radiation therapy to chest wall, infraclavicular region, supraclavicular region, and internal mammary node.
Patients with four or more positive lymph nodes require radiation therapy to chest wall, infraclavicular region, supraclavicular area, and internal mammary node is indicated.
Postmastectomy radiation is associated with a survival benefit and reduction in local recurrence.
Suggested Readings:
Poortmans PM, Collette S, Kirkove C, et al. Internal mammary and medial supraclavicular irradiation in breast cancer. N Engl J Med. 2015;373:317-327.
Whelan TJ, Olivotto IA, Parvlekar WR, et al. Regional nodal irradiation in early-stage breast cancer. N Engl J Med. 2015;373:307-316.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 48-year-old premenopausal woman diagnosed with left-sided breast cancer. Her breast imaging reveals a 2.2-cm mass with normal lymph nodes. Core biopsy of the breast reveals invasive ductal carcinoma, grade 3, ER is 0%, and PR is 0%. HER2 testing was performed using immunohistochemistry (IHC) and the result was 2+.
What is the appropriate next step?
View Answer
The appropriate next step is to obtain HER2 FISH testing in this patient with equivocal HER2 expression on IHC.
Overexpression of HER2 is seen in approximately 20% of all breast cancers. Either IHC or FISH testing is an acceptable method for initial determination of HER2. Up to 24% of breast cancers that are HER2 2+ by IHC have gene amplification and benefit from HER2-directed therapy; therefore, FISH analysis should be performed on all specimens that are IHC 2+.
Suggested Readings:
Wolff AC, Hammond ME, Allison K, et al. American Society of Clinical Oncology/College of American Pathologist guideline recommendations for human epidermal growth factor 2 testing in breast cancer. J Clin Oncol. 2018;36.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
You are asked to see a 39-year-old woman who has just been diagnosed with right breast cancer. Her breast imaging reveals a 3.2-cm mass, and multiple axillary nodes appear abnormal. Core biopsy of the breast reveals invasive ductal carcinoma, grade 3. ER is 0%; PR is 0%. HER2 testing was performed using immunohistochemistry, and the result was 3+. Core biopsy of an axillary node reveals carcinoma consistent with the breast primary.
What is the appropriate next step?
View Answer
The appropriate next step is to proceed with neoadjuvant chemotherapy with Taxotere, carboplatin, trastuzumab, and pertuzumab every 3 weeks for 6 cycles in this patient with locally advanced invasive ductal carcinoma (IDC).
Patients with HER2 disease who have a pCR had superior event-free survival and overall survival compared to those who did not.
Chemotherapy and dual anti-HER2 blockade has shown significant improvements in the pCR rate in HER2-positive breast cancer.
Suggested Readings:
Broglio KR, Quintana M, Foster M, et al. Association of pathologic complete response to neoadjuvant therapy in HER2-positive breast cancer with long-term outcomes: a meta-analysis. JAMA Oncol. 2016;2(6):751.
Gianni L, Pienkowski T, Im Y-H, et al. Efficacy and safety of neoadjuvant pertuzumab and trastuzumab in women with locally advanced, inflammatory, or early HER2-positive breast cancer (Neosphere): a randomized multicenter, open-label, phase 2 trial. Lancet Oncol. 2012;13:25-32.
Schneeweiss A, Chia S, Hickish T, et al. Pertuzumab plus trastuzumab in combination with standard neoadjuvant anthracycline-containing and anthracycline-free chemotherapy regimens in patients with HER2-positive early breast cancer: a randomized phase II cardiac safety study (TRYPHAENA). Ann Oncol. 2013;24:2278-2284.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 46-year-old woman was diagnosed with invasive ductal cancer of the left breast clinically measuring 4.5 cm in greatest diameter with clinically negative lymph nodes. The invasive cancer was ER positive, PR positive, and HER2 positive. She received preoperative chemotherapy with carboplatin, docetaxel, trastuzumab, and pertuzumab for 6 cycles. She underwent left breast lumpectomy with sentinel lymph node biopsy which showed residual disease measuring 1.2 cm in greatest diameter with 0/5 lymph nodes involved.
What is the next best management strategy?
View Answer
Adjuvant trastuzumab emtansine (TDM1) every 3 weeks for 14 cycles is appropriate in this patient with residual invasive HER2-positive breast cancer.
The KATHERINE study demonstrated that among patients with residual disease after neoadjuvant chemotherapy, the risk of recurrence or death was 50% lower with adjuvant TDM1. The benefit of TDM1 was seen regardless of size of primary nodal tumor or lymph node status at the time of surgery.
Suggested Readings:
Minchwitz G, Huang CS, Mano M, et al. Trastuzumab emtansine for residual invasive HER2-Positive breast cancer. N Engl Med. 2019;380:617-628.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 57-year-old woman was recently diagnosed with left-sided breast cancer. Her breast imaging revealed a 1.2-cm mass and normal-appearing lymph nodes. She underwent a biopsy of the breast which reveals invasive ductal cancer, grade 3, ER positive, PR positive, and HER2 positive. She underwent left breast lumpectomy and sentinel lymph node biopsy which revealed a 1.4-cm tumor with 0/1 lymph nodes involved.
What is the next best management strategy?
View Answer
The recommended adjuvant chemotherapy regimen would be weekly paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer.
The APT trial showed that among women with predominantly stage I HER2-positive breast cancer, treatment with paclitaxel/trastuzumab was associated with a risk of early recurrence of 2%.
Suggested Readings:
Tolaney S, Barry W, Dang C, et al. Adjuvant paclitaxel and trastuzumab for node-negative, HER2-positive breast cancer. N Engl J Med. 2015;372:134-141.
Tolaney S, Guo H, Pernas S, et al. Seven-year follow-up analysis of adjuvant paclitaxel and trastuzumab trial for node-negative, human epidermal growth factor receptor 2-positive breast cancer. J Clin Oncol. 2019;37(22):1868-1875.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 41-year-old woman with invasive ductal cancer of the left breast clinically measuring 2.4 cm in greatest diameter with clinically positive lymph nodes which was ER, PR, and HER2 positive. She received preoperative chemotherapy with carboplatin, docetaxel, trastuzumab, and pertuzumab for 6 cycles. She had surgery which showed a complete pathologic response. She is now receiving trastuzumab and pertuzumab. A routine echo performed 3 months into trastuzumab and pertuzumab was 40%, and she was asymptomatic.
What is the best management strategy for her decreased EF?
View Answer
The best management strategy is to hold trastuzumab for 1 month and consider starting an ACE inhibitor and/or beta-blocker in this patient with trastuzumab-related cardiotoxicity.
The echo should be repeated, and if the ejection fraction normalizes, then resume trastuzumab.
Suggested Readings:
Curigliano G, Lenihan D, Fradley M, et al. Management of cardiac disease in cancer patients throughout oncological treatment: ESMO consensus recommendations. Ann Oncol. 2020;31:171-190.
Ewer MS, Vooletich MT, Durand JB, et al. Reversibility of trastuzumab-related cardiotoxicity: new insights based on clinical course and response to medical treatment. J Clin Oncol. 2005;23:7820-7826.
Perez EA, Suman VJ, Davidson NE, et al. Cardiac safety analysis of doxorubicin and cyclophosphamide followed by paclitaxel with or without trastuzumab in the North Central Cancer Treatment Group N9831 adjuvant breast cancer trial. J Clin Oncol. 2008;26:1231-1238.
Abraham J, Gulley JL. The Bethesda Handbook of Clinical Oncology. 5th ed. Wolters Kluwer; 2018.
DeVita VT, Rosenberg SA, Lawrence SL. DeVita, Hellman, and Rosenberg’s Cancer: Principles & Practice of Oncology. 11th ed. Wolters Kluwer; 2018.
A 42-year-old woman with diagnosed with right-sided breast cancer. She underwent breast imaging which reveals a 1.5 cm mass and normal-appearing lymph nodes. She has a core biopsy of her breast which reveals invasive ductal cancer, grade 3, ER negative, PR negative, and HER2 negative. She underwent right breast lumpectomy with sentinel lymph node biopsy which revealed a 1.5-cm tumor, grade 3, negative LVI, negative margins with 1/4 lymph nodes involved with cancer.
What is the next best management strategy?
View Answer
The best management strategy is adjuvant dose-dense Adriamycin and cyclophosphamide every 2 weeks followed by a taxane for HER2-negative early breast cancer.
The ABC trial showed improved invasive disease-free survival in anthracycline-containing regimens compared to non-anthracycline-containing regimens.
Suggested Readings:
Blum J, Flynn P, Yothers, et al. Anthracyclines in early stage breast cancer: the ABC Trials USOR 06-090, NASABP B46-I/USOR 07132 and NASABP B-49 (NRG Oncology). J Clin Oncol. 2017;35:2647-2655.
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