Updated Guidelines for Treatment After Surgery
Reviewed study: "Updated Guidelines for Treatment After Surgery" by A. Goldhirsch et al., Annals of Oncology, September 7, 2005
Is this for me? If you have early-stage breast cancer and are deciding on treatment after surgery, you might want to read this article.
Background and importance of the study: After surgery for early-stage breast cancer, you have a number of effective treatment options for additional (adjuvant) treatment. The type of treatment you get depends on the particular characteristics of the breast cancer you were diagnosed with. Here are the cancer features:
- size,
- rate and growth of the cancer cells,
- presence or absence of hormone receptors,
- normal or excess levels of the HER-2 protein or gene, and
- whether or not lymph nodes are involved.
Your age at diagnosis, your general health, and your menopausal status also affect your treatment options.
It can be overwhelming to understand which treatment may be right for you. With so many choices available now, and new options emerging all the time, how do you know which treatment suits your specific situation best?
To help guide you and your doctors through these complicated treatment decisions, an international group of experts has written the latest in a series of updates about adjuvant therapy. The experts met at the 2005 Primary Therapy of Early Breast Cancer Conference in St. Gallen, Switzerland. Their previous update about adjuvant therapy was in 2003.
Study design and results: The 31 experts reviewed all the latest research on adjuvant therapy for early-stage breast cancer. Based on this research, the experts developed a list of breast cancer characteristics and the order in which they should be considered when making adjuvant therapy decisions. Here are those characteristics, in order of importance according to the experts:
1. Hormone-receptor status: The experts recommended that hormone-receptor status be the first factor considered when deciding on treatment after surgery. Earlier guidelines had recommended that the size and rate of growth of the cancer and the number of lymph nodes involved be the first factors considered.
How "hormone-receptor-positive" is defined, and the techniques used to determine it, vary around the world. Cancer is generally considered hormone-receptor-positive if either estrogen receptors or progesterone receptors are present in 10% or more of the cancer cells. If less than 10% (and particularly less than 5%) of cells have estrogen receptors or progesterone receptors, the cells' ability to respond to hormonal (anti-estrogen) therapy is somewhat uncertain.
The experts created three categories for hormone-receptor status:
- Endocrine-responsive (hormone-receptor-positive): The cancer has hormone receptors and is likely to respond to hormonal therapy.
- Endocrine–non-responsive (hormone-receptor-negative): The cancer has no hormone receptors and won't respond to hormonal therapy.
- Endocrine response uncertain: The cancer has hormone receptors, but the number of the receptors is low (below 10%) or the receptors don't function very well. These cancers may not respond well to hormonal therapy, which means that chemotherapy may be necessary.
2. Menopausal status: The experts recommended looking at a woman's menopausal status after classifying the hormone receptor status of the cancer.
- Pre-menopause, the time between puberty and menopause, is when a woman gets her period (menstruates).
- Peri-menopause is the time before menopause when the menstrual cycle is irregular. Peri-menopausal women might also have menopausal symptoms such as hot flashes, night sweats, and vaginal dryness.
- Post-menopause, the time after menopause, is when the ovaries have shut down and the menstrual cycle stops.
3. Risk status: After determining the hormonal receptor status of the cancer and the menopausal status of the woman, the experts recommended classifying the cancer into one of three risk categories: low risk, intermediate risk, and high risk.
Low-risk cancers are node-negative AND:
- two centimeters or smaller, AND
- grade 1 (calm, well-organized cell growth with few cells reproducing), AND
- have no cells that have broken into the blood vessels or lymphatic channels in the breast right next to or within the cancer (this breaking through is called peri-tumoral vascular invasion ), AND
- occur in women 35 or older.
Intermediate-risk cancers are either:
- node-positive with one to three lymph nodes involved and HER2-negative, OR
- node-negative AND any one or more of the following:
- larger than two centimeters, OR
- grade 2 or 3 (disorganized, irregular growth, with many cells making new cells), OR
- having cells that have broken into the blood vessels or lymphatic channels in the breast right next to or within the cancer (peri-tumoral vascular invasion), OR
- HER2-positive (the cancer makes too much of the HER2/neu gene or HER2 protein), OR
- occur in women younger than 35.
High-risk cancers are either:
- node-positive with one to three lymph nodes involved and HER2-positive, OR
- node-positive with four or more lymph nodes involved.
Based on the classification of cancer and the menopausal status of the woman, the experts recommended the following systemic treatments (treatments that affect the whole body) after surgery. The treatments are not listed in any order. Each treatment in each category is an option. The treatment you choose depends on your specific situation.
| Systemic treatments after surgery for hormone-receptor-positive cancer | ||
| Pre-menopausal women | Post-menopausal women | |
| Low risk |
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| Intermediate risk |
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| High risk |
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| Systemic treatments after surgery for hormone-receptor-response-uncertain cancer | ||
| Pre-menopausal women | Post-menopausal women | |
| Low risk |
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| Intermediate risk |
|
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| High risk |
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| Systemic treatments after surgery for hormone-receptor-negative cancer | |
| Pre-menopausal and post-menopausal women | |
| Low risk | Not applicable (hormone-receptor-negative cancers are by definition not low risk) |
| Intermediate risk | Chemotherapy |
| High risk | Chemotherapy |
The experts also recommended that radiation therapy should follow chemotherapy. Tamoxifen can be given at the same time or after radiation therapy. A boost dose of radiation may be particularly beneficial for pre-menopausal women.
The expert panel concluded by noting that women with breast cancer have preferences about their treatment.
What breastcancer.org says about this article…
Updated Guidelines for Treatment After Surgery
These recommendations were made at a European conference by an international group of experts. The practice of medicine around the world varies greatly. How medicine is practiced in your own backyard may be different from the guidelines offered here.It can be hard to choose the best breast cancer treatment after surgery for YOU. Looking at the hormone receptor status of the breast cancer, as well as your menopausal status, the size and rate of growth of the cancer, and the number of lymph nodes involved will help you and your doctor develop a list of treatment options to consider. Then you can talk about the benefits, side effects, and long-term effects of each treatment.
The experts suggested the following adjuvant treatments, based on the most current research:
- For pre-menopausal women with hormone-receptor-positive breast cancer, tamoxifen is a standard treatment. Tamoxifen usually is given after chemotherapy. If you've taken tamoxifen for hormone-receptor-positive, node-positive disease, you might consider taking the aromatase inhibitor Femara if you move into menopause during treatment.
- For post-menopausal women with hormone-receptor-positive breast cancer, research shows several good options:
- If you've just had surgery, your best treatment option is probably an aromatase inhibitor. But if you can't tolerate it or have other reasons for not taking it, you can take tamoxifen.
- If you have taken tamoxifen for two or three years, strongly consider switching to an aromatase inhibitor until you complete five years of hormonal therapy.
- If you've just finished taking tamoxifen, strongly consider taking Femara for an additional five years.
- For women with high-risk hormone-receptor-positive cancer, chemotherapy in addition to hormonal therapy can provide a benefit.
- If radiation therapy is recommended, it's usually done after chemotherapy.
- Hormonal (anti-estrogen) treatment can be given at the same time or after radiation. If you're pre-menopausal, you may particularly benefit from a boost dose of radiation.
This study does not specifically address HER2 status. In addition to the tests above, it is critical that all cancers be tested for either the HER2 gene or protein. The life-saving benefits of Herceptin in women with early stage, HER2-positive disease represent an important breakthrough. Any woman with HER2-positive disease needs to talk to her doctor about the potential role of Herceptin.
For women who have hormone-receptor-positive disease with no lymph node involvement, a test called Oncotype DX can help determine if chemotherapy offers enough extra benefit over hormonal therapy alone. This new test looks at many different cancer features to predict how likely it is that the cancer may come back in another place in the body. If the risk of distant recurrence is high, the benefits of extra chemotherapy are likely to outweigh the drawbacks.
When you're deciding on a treatment plan, keep two things in mind:
- Every woman responds differently to treatment. What works for someone else may not work for you—and what works for you may not work for someone else.
- Your treatment plan is not written in stone. You can always change treatments if another treatment has greater benefits and fewer side effects.
These guidelines are not meant to be hard and fast rules, but a combined point of view based on the latest research. Ultimately, treatment choices are made after you and your doctor thoroughly discuss all the benefits and risks of each option.
