BREAST CANCER Part 03

Adjuvant Therapy – Chemotherapy Indications sub-groups of stage I at high risk of recurrence lymphatic invasi...

Adjuvant Therapy – Chemotherapy

1. Indications
   • sub-groups of stage I at high risk of recurrence
   • lymphatic invasion
   • high-grade tumours
   • high S-phase fraction
   • aneuploid DNA 
2. pre-menopausal patients tend to have better response to cytotoxic chemotherapy because of tendency for more aggressive tumours
3. Treatment
   • postmenopausal patients with positive lymph nodes, negative estrogen receptors
   • CMF (cyclophosphamide, methotrexate and fluorouracil) x 6 months

Adjuvant Therapy – Hormonal

 

1. estrogen and progesterone receptors
   • helps predict likelihood of regression when treated with hormonal therapy
   • prognostic significance 
2. most common adjuvant therapy = Tamoxifen (anti-estrogen) 
3. secondary treatments
   • previous clinical response to one hormonal treatment predicts response to another, thus secondary hormonal therapies therapies are instituted
     • progestins - megestrol acetate (Megace)
     • aromatase inhibitors - induce medical adrenalectomy
     • e.g. amino-glutethamide + hydrocortisone
     • estrogens – diethylstilbestrol
     • androgens – fluoxymesterone
   • oophorectomy - premenopausal patients with metastatic disease no benefit over tamoxifen

Adjuvant Therapy – Radiation

1. with breast-conserving surgery
2. those with high-risk of local recurrence
3. adjuvant radiation to breast decreases local recurrence, increases disease free survival (no change in overall survival)
   

Post-Surgical Breast Cancer

 

1. follow-up of post-mastectomy patient
   • history and physical every 4-6 months
   • yearly mammogram of remaining breast 
2. follow-up of segmental mastectomy patient
   • history and physical every 4-6 months
   • mammograms every 6 months x 2 years,
   • then yearly thereafter
3. when clinically indicated
   • chest x-ray
   • bone scan
   • LFTs
   • CT of abdomen
   • CT of brain
     

Metastatic Disease

 

1. lung 65% bone
2. 56%
3. liver 56%

Screening

 

1. importance of early detection
2. breast self exam, start age 20
3. mammography > 50 years every 1-2 years or every year if high risk

 

Prognosis 

 

1. all patients: 63% 5 year survival, 46% 10 year survival 
2. most reliably determined by stage
3. if disease localized to breast: 75-90% clinical cure rate 
4. if localized and receptor-positive: 90% 5-year survival 
5. if positive axillary nodes: 40-50% 5-year survival, 25% 10-year survival

 

MALE BREAST LUMPS

 

1. gynecomastia
2. breast carcinoma
   • usually > 50 years
   • hard, painless lump +/- nipple retraction, discharge, ulceration
   • often metastatic at time of diagnosis, therefore, poor prognosis