Breast Cancer - Invasive Stage I-III Treatment Algorithm

Disclaimer

• Developed for MD Anderson using a multidisciplinary approach.
• Intended to support, not replace, independent medical judgment.
• Not for use in treating pregnant women.

Table of Contents

• Initial Evaluation
• Hormone receptor-positive/HER2-negative
• Hormone receptor-positive/HER2-positive or Hormone receptor-negative/HER2-positive
• Hormone receptor-negative/HER2-negative (triple negative breast cancer)
• Evaluation During and Post Neoadjuvant Treatment
• Radiation Therapy
• Surveillance
• Evaluation for Local Recurrence
• Appendices A-E
• Principles of Breast Oncologic Surgery
• Suggested Readings
• Development Credits

Initial Evaluation

• Consider clinical trials for eligible patients.
• Treatment options include definitive breast and nodal surgery.
• Assess tumor characteristics and patient desires for breast conservation therapy (BCT).

Surgical Considerations

• Favorable characteristics (grade I/II, strongly ER/PR positive, low Ki-67) may consider neoadjuvant endocrine therapy.
• Adverse features (large nodal burden, high Ki-67, high grade) may consider neoadjuvant chemotherapy.
• HER2 status and tumor size influence treatment decisions.
• Consider gene expression testing for risk stratification and chemotherapy guidance.
• Adjuvant chemotherapy and endocrine therapy may be recommended based on pathologic findings.

Radiation Therapy

• Consider whole breast radiation therapy for BCT.
• Radiation to regional lymphatics and chest wall may be indicated based on nodal involvement and tumor characteristics.
• Partial breast radiation therapy may be considered for selected patients.

Surveillance

• Physical exams and imaging (mammography, MRI) at specified intervals.
• Bone health assessment.
• Lymphedema screening and management.
• Consideration for referrals to physical therapy, plastic surgery, and radiation oncology for specific concerns.

Evaluation for Local Recurrence

• Treatment options include surgical resection, radiation therapy, and systemic therapy.
• Multidisciplinary team discussion for treatment sequencing.
• Consideration for re-irradiation in certain cases.

Appendices

• A: Gene expression considerations for prognosis and chemotherapy.
• B: Chemotherapy and targeted therapy options.
• C: Endocrine therapy options.
• D: Criteria for omitting axillary node dissection.
• E: Selection of patients for radiation to regional lymphatics.

Principles of Breast Oncologic Surgery

• Multidisciplinary management approach.
• Diagnosis through dedicated breast imaging and biopsy.
• Operative standards for breast conserving surgery and mastectomy.
• Axillary staging through sentinel lymph node dissection or targeted axillary dissection.
• Neoadjuvant systemic therapy in specific cases.
• Management of local-regional recurrence and high-risk patients.
• Special considerations for advanced age or comorbidities.

Suggested Readings

• List of articles and guidelines on breast cancer treatment and management.

Development Credits

• Acknowledgment of the multidisciplinary team involved in developing the algorithm.

This document provides a structured overview of the treatment algorithm for invasive breast cancer stages I-III, including considerations for initial evaluation, surgery, radiation therapy, surveillance, and recurrence management.