Adjuvant Therapy With Low Risk of Relapse?
Adjuvant Therapy With Low Risk of Relapse?
What is the recommended treatment for a 35-year-old woman who underwent quadrantectomy and radiotherapy for a ductal infiltrating carcinoma? The tumor was 1 cm, nodes were negative, and estrogen and progesterone receptors were positive. Given the low risk of relapse, should she take tamoxifen? Is there a role for ovarian ablation?
This case is quite difficult, because the indication of any adjuvant treatment is borderline. Although it is generally accepted that age below 35 years is a poor prognosis factor, this would be the only poor prognosis criterion in this patient. All of the other factors (ie, tumor of 1 cm, grade 1, hormone sensitivity, no axillary nodes) are favorable; the risk of relapse is therefore very low. However, the risk of developing contralateral disease is high in this patient, especially if there are other cases of breast cancer in her family.
Several recommendations have been proposed:
Of major importance are the side effects induced by the adjuvant treatments for a very small benefit (even if it is statistically significant in a large patient population). This is especially true for chemotherapy, all the more with anthracyclines. Conversely, the benefit of adjuvant tamoxifen, especially by decreasing the risk of contralateral breast cancer, seems higher than its potential toxicity. For now, any kind of ovarian ablation should not be proposed since the information on contralateral breast cancer is poor and the side effects are significant.
In conclusion, given current knowledge, we would propose to this patient a 5-year treatment with tamoxifen and no chemotherapy, with a clear explanation to the patient of the potential benefits and risks.
What is the recommended treatment for a 35-year-old woman who underwent quadrantectomy and radiotherapy for a ductal infiltrating carcinoma? The tumor was 1 cm, nodes were negative, and estrogen and progesterone receptors were positive. Given the low risk of relapse, should she take tamoxifen? Is there a role for ovarian ablation?
This case is quite difficult, because the indication of any adjuvant treatment is borderline. Although it is generally accepted that age below 35 years is a poor prognosis factor, this would be the only poor prognosis criterion in this patient. All of the other factors (ie, tumor of 1 cm, grade 1, hormone sensitivity, no axillary nodes) are favorable; the risk of relapse is therefore very low. However, the risk of developing contralateral disease is high in this patient, especially if there are other cases of breast cancer in her family.
Several recommendations have been proposed:
According to the NIH Consensus Development statement, chemotherapy should be recommended to most women with primary breast cancer larger than 1 cm in diameter. Adjuvant hormonal therapy should be recommended to women whose breast tumors contain hormonal receptor protein, regardless of age, menopausal status, involvement of axillary lymph nodes, or tumor size. Thus, based on these recommendations, tamoxifen should be given to this patient and chemotherapy might be proposed.
According to the International Consensus Panel, the patient would be considered "minimal/low risk," warranting either adjuvant treatment with tamoxifen or no treatment.
According to the ESMO Minimum Clinical Recommendations, the patient would be considered at minimal risk (in this group, the tumor must be < 1 cm) and no adjuvant treatment would be warranted. It must be stressed that these are minimal recommendations.
Of major importance are the side effects induced by the adjuvant treatments for a very small benefit (even if it is statistically significant in a large patient population). This is especially true for chemotherapy, all the more with anthracyclines. Conversely, the benefit of adjuvant tamoxifen, especially by decreasing the risk of contralateral breast cancer, seems higher than its potential toxicity. For now, any kind of ovarian ablation should not be proposed since the information on contralateral breast cancer is poor and the side effects are significant.
In conclusion, given current knowledge, we would propose to this patient a 5-year treatment with tamoxifen and no chemotherapy, with a clear explanation to the patient of the potential benefits and risks.