Tiêu đề FINAL breast cancer algorithm.pdf ✅

• 8th AJCC staging • Early breast cancer management Breast Cancer Algorithms
• Screening 3 yearly mammograms age 50-71 • Initial diagnosis: Triple assessment : Examination, Biopsy and Mammogram breast /US axilla + breast • If Inflammatory breast cancer suspected - Skin biopsy • Don’t forget CT staging if 4 or more nodes or T3 above • Consider MRI breast if discrepancy between mammogram/US in size or lobular breast cancer (10% risk of B/L cancers in older data sets) • Consider genetics referral depending on family history • See STAGING for all Breast cancer
Early Breast Cancer Management Anatomical Stage I - IIIA (upto T3N2M0 disease) Risk of recurrence Low Risk Intermediate Risk High Risk <2cm Grade 1 ER+ HER2 -ve No LVI clear margins No nodes Post menopausal (>65 yrs) >5cm T3 Grade 3 ER -ve, HER2 +ve TNBC LVI close margins 4 or more nodes Young age, <50 years Neoadjuvant chemotherapy IF Stage II or >2cm HER2+ tumour > 2cm Triple negative breast cancer (many would give for 1-2cm in these settings too) ER+ HER2-ve tumour where downstaging needed for Sx due to tumour bulk/inflammatory breast cancer 2-5cm Grade 2 HER2 +ve 1-3 lymph nodes WLE / Breast conservation surgery Mastectomy SLNB ANC Adjuvant chemotherapy Adjuvant hormonal therapy Adjuvant bisphosphonates x approx 3 years (If ER+, HER2 -ve) Oncotype Dx recurrence score for N0 or 1-3 nodes to guide chemotherapy Adjuvant radiotherapy BRCA positive (consider prophylactic double mastectomy) Multicentric disease Unable to get clear margins despite repeated Sx Large tumour:breast ratio C/I for RT patient choice AMAROS cN0, T1/T2 (<5cm), no nodes, 1-2 LN + on SLNB. AMAROS: SLNB and then RT non inferior to ANC POSNOC: recruiting. ANC/RT vs NO axillary treatment for cN0. SLNB allowed. nodes+ inflammatory BC 3/> SLN +ve Can consider avoiding RT if ALL low risk features met residual disease post Sx? Yes No HER2+ve TNBC TDM-1 Capecitabine HER2+ve anti HER2 therapy POSNOC Axillary surgery ER+ve post menopausal Mainstream genetic testing for BRCA: • Cancer at age <30 • B/L cancers at age <50 • TNBC at age <60 • Cancer at age <45 AND • 1 first degree relative with cancer at age <45 • Ashkenazi jew and breast cancer • Breast and ovarian cancer
Neoadjuvant Chemotherapy Back to contents Systemic Chemotherapy regimens Hormone + : EC - T (3-4 cycles each, 3 weekly) Consider accelerated chemotherapy (2 weekly) HER2 + : Either EC x 3 and then Docetaxel x 3 with HP or 6 cycles Carbo-Docetaxel with HP (Tryphaena study) TNBC (BrighTNess Trial): Use carboplatin/paclitaxel - EC (3-4 cycle each) Can use pembrolizumab with chemo for any PDL1 as per KEYNOTE 522 ie,if >2cm or any node positive Keynote 522: If TNBC and Stage II or above, can have pembro neoadjuvant and 9 cycles adjuvant. EFS at 3 yrs 76%—>84% and 60% pCR TNBC: 1.Capecitabine (CREATEX trial) 2. OR continue pembro as maintenance for 9 cycles (cap + pembro not allowed) 3. OR oral olparib for 1 year as adjuvant treatment if BRCA variant (germ line and TNBC) Baseline imaging (USS/ MRI and identify best imaging modality for interval follow up) Image axilla and biopsy for baseline staging Skin biopsy if inflammatory breast cancer suspected Consider CT staging if locally advanced Breast clips if WLE being considered (tumour might disappear with NACT) Interval imaging after 3 cycles of chemotherapy Imaging post 6 cycles of chemotherapy and refer to surgical team NEO- AJDUVANT CHEMO