Breast Cancer Treatment

 

Breast cancer is the leading cause of death from cancer in women worldwide, and the second most common cause of death from cancer in women in the United States. Risk assessment tools can identify the risk of breast cancer, and patients at high risk may be candidates for risk-reducing medications. The choice of medication varies with menopausal status. Breast cancer treatment depends on the stage. Stage 0 is ductal carcinoma in situ, which is noninvasive but progresses to invasive cancer in up to 40% of patients. Ductal carcinoma in situ is treated with lumpectomy and radiation or with mastectomy. If ductal carcinoma in situ is estrogen receptor–positive, patients may also receive endocrine therapy. Early invasive stages (I, IIa, IIb) and locally advanced stages (IIIa, IIIb, IIIc) are nonmetastatic and have three treatment phases. The preoperative phase uses systemic endocrine or immunotherapies when tumors express estrogen, progesterone, or ERBB2 receptors. Preoperative chemotherapy may also be used and is the only option when tumors have none of those three receptors. There are two options for the surgical phase with similar survival rates; a lumpectomy with radiation if the tumor can be excised completely with good cosmetic results, or a mastectomy. Sentinel lymph node biopsy is also performed when there is suspected nodal disease. The postoperative phase includes radiation, endocrine therapy, immunotherapy, and chemotherapy. Postmenopausal women should also be offered postoperative bisphosphonates. Stage IV (metastatic) breast cancer is treatable but not curable. Treatment goals include improving the length and quality of life.

Breast cancer is the second most common cancer diagnosed in women, exceeded only by nonmelanoma skin cancer. It is the leading cause of death from cancer in women worldwide. In the United States, breast cancer is the second most common cause of death from cancer in women, exceeded only by lung cancer, with approximately 316,000 patients diagnosed with breast cancer annually.1,2

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

After a histologic diagnosis of breast cancer, all pathology samples should be identified for estrogen, progesterone, or ERBB2 receptor status to direct treatment.24,25

C

Consensus and expert opinion

Sentinel lymph node biopsy is preferred over axillary lymph node dissection for patients without clinical evidence of nodal disease.30

C

Clinical guideline based on systematic review of randomized controlled trials

Patients with advanced breast cancer and metastases to the bones should be offered treatment with denosumab (Prolia) or bisphosphonates such as zoledronic acid (Reclast) or pamidronate (Aredia).24

C

Consensus and expert opinion

For locally recurrent breast cancer initially treated with breast conserving therapy (i.e., lumpectomy plus radiation), further radiation is not recommended; total mastectomy is the standard of care.24

C

Consensus and expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

After a histologic diagnosis of breast cancer, all pathology samples should be identified for estrogen, progesterone, or ERBB2 receptor status to direct treatment.24,25

C

Consensus and expert opinion

Sentinel lymph node biopsy is preferred over axillary lymph node dissection for patients without clinical evidence of nodal disease.30

C

Clinical guideline based on systematic review of randomized controlled trials

Patients with advanced breast cancer and metastases to the bones should be offered treatment with denosumab (Prolia) or bisphosphonates such as zoledronic acid (Reclast) or pamidronate (Aredia).24

C

Consensus and expert opinion

For locally recurrent breast cancer initially treated with breast conserving therapy (i.e., lumpectomy plus radiation), further radiation is not recommended; total mastectomy is the standard of care.24

C

Consensus and expert opinion


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

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BEST PRACTICES IN ONCOLOGY

Recommendations from the Choosing Wisely Campaign

RecommendationSponsoring organization

Do not routinely recommend follow-up mammography more often than annually for women who have had radiotherapy following breast-conserving surgery.

A

The Authors

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KATHRYN P. TRAYES, MD, is an assistant professor in the Department of Family and Community Medicine at Thomas Jefferson University Hospital, and associate dean in the Office of Student Affairs and Career Counseling at Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pa....

SARAH E.H. COKENAKES, MD, is a fellow at Tacoma (Wash.) Family Medicine. At the time the article was written, Dr. Cokenakes was a resident in the Department of Family and Community Medicine at Thomas Jefferson University Hospital.

Address correspondence to Kathryn P. Trayes, MD, Thomas Jefferson University, 1020 Locust St., Ste. 157, Philadelphia, PA 19107 (email: kathryn.trayes@jefferson.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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