Stage I, II, IIIA, and Operable IIIC Breast Cancer
Adjuvant radiation therapy postmastectomy in axillary node-positive tumors:
- For one to three nodes: unclear role for regional radiation (infra/supraclavicular nodes, internal mammary nodes, axillary nodes, and chest wall).
- For more than four nodes or extranodal involvement: regional radiation is advised.
Adjuvant systemic therapy:
An International Consensus Panel proposed a three-tiered risk classification for patients with negative axillary lymph nodes. This classification, with some modification, is described below:
Table 6. Risk Categories for Women With Node-Negative Breast Cancer
|�||Low risk (has all listed factors) ||Intermediate risk (risk classified between the other two categories) ||High risk (has at least one listed factor)|
|Tumor size ||=1 cm||1-2 cm ||>2 cm|
|ER or PR Status||positive || positive ||negative|
|Tumor grade||grade 1||grade 1-2 ||grade 2-3|
The original Consensus Panel classification also required that women be 35 years or older to be included in the low-risk group and included women 35 years and younger in the high-risk group, based admittedly on indirect evidence. Traditionally, certain uncommon histologies (e.g., tubular, medullary, and mucinous) have also been associated with favorable prognosis and may be considered as low-risk factors. Some additional tumor characteristics that may eventually prove helpful in the prognosis of node-negative disease include the tumor proliferative fraction (S-phase) and the level of HER2/neu expression.
Regardless of how one chooses to characterize node-negative tumors, evidence from clinical trials suggests that various types of adjuvant therapies benefit certain subgroups of patients with these kinds of tumors. The same is true for women with node-positive breast cancer. What has become clear after reviewing results from multiple breast cancer treatment trials is that hormone therapy and chemotherapy regimens generally offer the same proportional benefit to women irrespective of their axillary lymph node status. The selection of therapy is most appropriately based upon knowledge of an individual's risk of tumor recurrence balanced against the short-term and long-term risks of adjuvant treatment. This approach should allow clinicians to help individuals to determine if the gains anticipated from treatment are reasonable for their particular situation. The treatment options presented below should be modified based upon both patient and tumor characteristics.
Table 7. Adjuvant Systemic Treatment Options for Women With Axillary Node-Negative Breast Cancer
a Note: This treatment option is under clinical evaluation.
|Patient group||Low risk ||Intermediate risk||High risk|
|Premenopausal, ER-positive or PR-positive||None or tamoxifen||Tamoxifen plus chemotherapy, tamoxifen alone, ovarian ablation, GnRH analoga||Chemotherapy plus tamoxifen, chemotherapy plus ablation or GnRH analog*, chemotherapy plus tamoxifen plus ovarian ablation or GnRH*, or ovarian ablation alone or with tamoxifen or GnRH alone or with tamoxifen|
|Premenopausal, ER-negative or PR-negative||- ||- ||Chemotherapy|
|Postmenopausal, ER-positive or PR-positive||None or tamoxifen||Tamoxifen plus chemotherapy, tamoxifen alone ||Tamoxifen plus chemotherapy, tamoxifen alone|
|Postmenopausal, ER-negative or PR-negative||- ||- || Chemotherapy|
|Older than 70 years||None or tamoxifen||Tamoxifen alone, tamoxifen plus chemotherapy||Tamoxifen; consider chemotherapy if ER-negative or PR-negative|