Today three new patients with recently diagnosed breast cancer are due at the clinic. As the oncologist who will be seeing them for a decision about adjuvant chemotherapy, you review the notes and histology. The salient features are as follows:
Patient 1: age 42, premenopausal, no comorbidity, 3.5 cm, G3 tumour, no lymph node (LN) positive, oestrogen receptor (ER) and progesterone receptor (PR) negative, HER-2 negative Patient 2: age 56, postmenopausal, no comorbidity. Screen-detected tumour, 1 cm, G2 tumour, no LN positive, ER negative, PR positive, HER-2 negative Patient 3: age 61, postmenopausal, obese, previous small inferior myocardial infarction, currently asymptomatic on medical treatment; 2 cm G2 tumour, 5/15 LN positive, ER and PR positive, HER-2 negative
What is each woman's risk of recurrence and death from breast cancer?
How might these be influenced by the use of chemo- and/or hormone therapy?
What specific short-term and long-term issues will you take into account when deciding on treatment and follow-up?
The strongest prognostic factors that predict for future recurrence and death from breast cancer are age, comorbidity, tumour size and grade, number of involved lymph nodes and HER-2/neu status (Table 36.1). Adjuvant!Online (www.adjuvantonline.com) is an example of a computer-based model that uses algorithms to estimate 10-year disease-free and overall survival. It incorporates all of the above prognostic factors, except for HER-2/neu level of expression. The risk estimate, derived from Surveillance, Epidemiology and End Results registry data, has been independently validated and is consistent with the published literature.1 This tool is a great resource to the clinician, as it facilitates the objective estimation of outcome with local treatment alone and of the absolute benefits expected from systemic adjuvant hormonal therapy and/or chemotherapy. These estimates can be used by the clinician and patient in shared decision-making regarding the risks and benefits of systemic adjuvant therapy. With the development of DNA micro-arrays, there have been many attempts to subclassify breast cancers further by gene expression profiles, stratifying patients into prognostic subsets. Although certain 'molecular signatures' have been identified as strongly predictive of outcome, these differ between studies. There is no prospective clinical data yet proving the utility of these techniques, or their superiority over pathological and clinical parameters, in guiding the choice of adjuvant treatment in breast cancer patients.
Table 36.1Definition of risk categories for patients with breast cancer* |Favorite Table|Download (.pdf) Table 36.1 Definition of risk categories for patients with breast cancer*
|Low risk || |
Node-negative and all of the following
Tumour ≤2 cm
No peritumoural vascular invasion
Age ≥35 years
|Intermediate risk || |
Node-negative and ≥1 of the following
Tumour >2 cm
Peritumoral vascular invasion
HER-2/neu gene overexpressed or amplified
Age 35 years
Node positive (1–3) and HER-2/neu negative
|High risk |
Node positive (1–3) and HER-2/neu gene overexpressed or amplified
Node positive (≥4)...