it describes the non-surgical management options of breast cancer.

1. NONSURGICAL MANAGEMENT OF
BREAST CANCER
PREPARED BY:
RUHAMA YOSEPH
SURGICAL RESIDENT
JUNE, 2012
10/12/2021 1

2. OUTLINE
 Introduction
 Definitions
 Predictive and prognostic factors
 Radiotherapy
 Hormonal therapy
 Chemotherapy
 Management principles for
different stages of breast cancer
10/12/2021 2

3. INTRODUCTION
 Systemic anticancer therapy is a
developing science
 A century ago median survival was
31 months for untreated breast
cancer
 Chemotherapy was introduced in
1960, since then changes in the
natural course of the diesease were
observed
10/12/2021 3

4. INTRODUCTION
 The rationale
◦ To attack micro metastasis at an early
stage
 Substantial decrease in breast
cancer recurrence and 15 yr
mortality rates after introduction
of endocrine and chemotherapy
10/12/2021 4

5.  Adjuvant Endocrine therapy
 Adjuvant chemotherapy
After 5 year Tamoxifen Rx
15 yr probability of recurrence From 45% to 33%
Mortality rate From 35% to 26%
After 6 mo Anthracycline based chemotherapy Rx
15 yr probability of recurrence From 54%to 41%
Mortality rate From 42% to 32%
10/12/2021 5

6. DEFINITIONS
 DISEASE FREE SURVIVAL (DFS)
 Time interval between randomization and
first evidence of treatment failure or death
 OVERALL SURVIVAL
 Time interval between randomization and
death from any cause
 MEDIAN SURVIVAL
 The time when 50% of patients have died
 HAZARD RATIO
 Risk of dying from a disease in comparison to
a control group
10/12/2021 6

7. DEFINITIONS
 MULTIFOCAL LESIONS
 Distance of less than 4cm between 2 lesions i.e.
within same quadrant
 MULTICENTRIC LESIONS
 Distance of more than 4cm between 2 lesions or
occurrence in 2 different quadrants
 PROGNOSTIC FACTORS
 Influence clinical course (without systemic
treatment)
 PREDICTIVE FACTORS
 Influence response to systemic therapy
10/12/2021 7

8.  PROGNOSTIC FACTORS:
1. Nodal status has direct correlation
with recurrence & death rates
2. Tumor size has positive relation
with nodal metastasis
3. Tumor grade has positive relation
with disease free survival
4. Histological type- tubular, papillary
and mucinous forms have better
prognosis
10/12/2021 8

9.  PREDICITVE FACTORS:
1. Hormone receptor status (ER-
Estrogen receptor and PR-
Progesterone receptor)
2. HER2/neu status
3. Presence of micro-metastasis in
the bone marrow
10/12/2021 9

10.  Predictive factors…
◦ ER is expressed by approximately 70%
of breast cancers, these tend to be
slow growing and more differentiated
◦ ER/PR positive tumors have better
prognosis than ER positive/PR negative
tumors
◦ HER2 is over-expressed in 20% of
breast cancers
10/12/2021 10

11.  Overall survival (OS) correlates to stage of
disease:
TNM 5 year OS (%) 10 year OS (%)
All patients 82 71
T1 N0 M0 98 93
T2 N0 M0 91 81
T2 N1 M0 73 66
T4 N1 M0 50 26
With metastases primary or
secondary 32 19
With local recurrence ´ 51 30
(adapted from: Manual Mammakarzinom, Tumorzentrum München, 9. Auflage 2003, p. 126)
10/12/2021 11

12. ADJUVANT THERAPIES
 ADJUVANT SYSTEMIC THERAPY
 Administration of cytotoxic chemo- or
endocrine therapy after surgery for breast
cancer without clinically evident distant
metastasis in order to prevent clinically
occult micrometastasis
 It has increased effect in high risk
individuals
10/12/2021 12

13. ADJUVANT RADIOTHERAPY
 Is delivered after:
1. Lumpectomy or BCT
2. Mastectomy
 The radiation is delivered via
◦ linear accelerator (delivers radiation
form outside the body)
◦ seeds of material that give-off
radiation from inside the body
10/12/2021 13

14.  BCT is performed for
 Early stage cancers
 Size =< 4cm
 One sited only (not multi-centric)
 Removed with clear margins
 Radiotherapy follows BCT as a
standard
 It was found that BCT followed by
radiotherapy has same outcome as
that of mastectomy alone in regards
to OS and local recurrence rates
 Radiation decreases recurrence by
70%
10/12/2021 14

15.  Indications for post-mastectomy
radiation
 Tumor >5 cm
 T4 tumor
 Involvement of 4 or more axillary lymph nodes
 Gross extracapsular nodal disease
 Residual disease after mastectomy
 Additional Considerations
◦ Involvement of 1 to 3 axillary lymph nodes
◦ Gross multifocality
◦ Extension into the nipple or skin
10/12/2021 15

16.  Contraindication for radiation
◦ Already radiation given to that area
◦ Presence of connective tissue disease
◦ Pregnancy
10/12/2021 16

17.  Can be:
◦ External Radiation
◦ Internal Radiation
◦ Intra Operative Radiation Therapy
(IORT)
10/12/2021 17

18.  External radiation
It uses a machine called Linear
accelerator which releases beam of
high energy radiation onto a limited
area of the body surface
10/12/2021 18

19. 10/12/2021 19

20.  Two treatment fields are used
◦ One that starts from the side of the
Breast and faces the sternum
◦ One that starts at middle of chest and
faces the side
 For lymph nodes additional treatment
fields may be required
10/12/2021 20

21.  To minimize radiation to other parts
◦ Treat breast area with angled fields
◦ Using blocks at opening of machine
◦ Placing wedges in the path of the beam
 Simulation sessions are held prior to start of
therapy when the radiation field will be
adjusted and mapped with x-rays
10/12/2021 21

22.  Radiation schedule
◦ It will be given 5 days per wk for 5-7
wks
 External radiation boost
◦ It is a special session at the final week
where radiation is given at higher dose
than the previous day concentrated on
the original site of cancer. Electron
beams will be used.
10/12/2021 22

23.  Dose of radiation
◦ It should be calculated by an oncologist
before start of therapy
◦ Then, total dose will be broken into
daily fraction doses
◦ It depends on:
 Surgical margins of resection
 Size of cancer
 LN involvement
 Type of surgery
 Type of cancer
10/12/2021 23

24.  For radiation to the breast and/or
LN
4500-5000 centi-Grays (rads) over 5
wks and boost dose of 1000-2000
centi-Grays over 1wk
If partial breast radiation /Internal
Radiation/- 3400 centi-Grays over 1wk
• Supplemental anti-oxidant vitamins
(Vit. C,A,D,E)should be avoided
during this period
10/12/2021 24

25.  Internal Radiation
◦ Also called partial breast radiation or
brachitherapy
◦ Small pieces of radioactive material,
called seeds, are placed around where
the cancer was
◦ The seeds are delivered into the site
using small catheters or balloon
catheter
◦ The radiation will be delivered for
5days, for each day 2 times
10/12/2021 25

26. 10/12/2021 26

27.  Internal radiation boost
 Advantages of internal radiation:
◦ Shorter treatment time
◦ Concentrates on the site where cancer is
likely to recur
◦ Preliminary studies show its effectiveness
as compared to external therapy
 But it lacks long term track studies as
compared to external radiation which
ahs been used for 30 yrs
10/12/2021 27

28.  Intra Operative Radiation Therapy
(IORT)
◦ A single high dose radiation given after
cancerous tissue is removed in a
lumpectomy surgery
◦ It can be delivered via small tube or
linear accelerator
◦ It is a relatively new and expensive
technique
10/12/2021 28

29. ADJUVANT CHEMOTHERAPY
 Survival benefits are not assuring as
it was shown in different studies.
The important role was in palliation
of symptoms
Symptom Relief After Chemotherapy
(100 patients)
Patients Symptom Relief
Bone 63 13%
Malaise/anorexia 52 38%
Dyspnea 44 27%
Soft tissue
discomfort
33 55%
10/12/2021 29

30.  Single agent treatments were shown
to be ineffective
 Combination regimens are rather used
 Combination polychemotherapy targets
the cancer cell at multiple junctures
and thus prevents resistance
 Sequential chemotherapy- optimal
dosage of a single agent given
sequentially
10/12/2021 30

31. ADJUVANT CHEMOTHERAPY
 Factors affecting chemosensitivity
◦ Age
◦ Axillary lymph node status
◦ Additional factors
 HER2/neu status
 Hormone receptor status
 Multi-morbidity
10/12/2021 31

32.  AGE:
Chemotherapy is effective in
younger age groups
Menopausal status has no effect
Age Recurrence Reduction Death Reduction
<4o years 37% 27%
60-69 years 18% 8%
> 70 years Insufficient data
10/12/2021 32

33.  Axillary Lymph Node Status:
Patients with positive axillary LN
benefit more
Reduction of Recurrence and Death
Positive nodes 20-25%
Negative nodes 5-10%
10/12/2021 33

34.  HER2/neu status:
Herceptine (Trastuzumab) based
chemotherapy is more effective
 Herceptin-Perjeta (Pertuzumab) combination
HER2/neu Gene
HER 2 Protein
Aggressive cancer
Growth
signals
10/12/2021 34

35.  Hormone Receptor Status:
Chemotherapy is less effective in
hormone receptor positive patients
than those with absent receptors
10/12/2021 35

36.  Multi-morbidity:
Multiple side-effects delay
effectiveness of chemotherapy
10/12/2021 36

37.  CMF regimen
◦ Cyclophosphamide
◦ Methotrexate
◦ 5-Flourouracil
 Is popular regimen whose
effectiveness is proven in multiple
trials
 It has minimal toxicity and is
suitable for patients with multi-
morbidity
10/12/2021 37

38.  Anti-metabolites
◦ Methorexate, 5-Flourouracil
◦ Become integrated into DNA & RNA
and block nucleotide synthesis
◦ Side effects:
 Mucosisits
 Diarrhoea
 Hand-foot syndrome
 Methotrexate is nephrotoxic
◦ Anti-dote: Folic acid
10/12/2021 38

39.  Alkylating agents:
◦ Cornerstone of breast cancer treatment,
bind with DNA and breaks it
◦ Cyclophosphamide, cisplatin, mitomycin C
◦ Side effects:
 hair loss
 bone marrow suppression
 urinary bladder hemorrhage
 Increased water intake & diuresis should be
encouraged
10/12/2021 39

40.  Anthracyclines
◦ Includes Doxyrubucine, Epirubucine
◦ Side effects
 Myocardial toxicity
 Total hair loss
◦ Anthracycline based regimen, especially
combined with Taxanes are benefical for
chemoresponsive ca’s (eg.Hormone
receptor negative)
◦ AC is well tolerated, for low risk ca
◦ Radiation should be considered only after
1mo
10/12/2021 40

41.  Taxanes
◦ Binding to Tubulin leads to blockage of
cellular mitosis
◦ Docetaxel, paclitaxel
◦ Used with Anthracyclines in high risk
patients
◦ Side effect:
 Neurotoxicity
 Bone marrow suppression
 Hypersensitivity reaction
 Hand-foot syndrome
◦ Anti-histamine medications should often
be considered together
10/12/2021 41

42.  Trastuzumab (Herceptin)
◦ Useful for cancers with HER2/neu
over-expression by blocking of the
epithelial growth factor Her-2-neu
◦ First trial showed 30% reduction of
recurrence in the adjuvant setting
◦ Toxicity profile is excellent, but shows
cardiac toxicitiy, so shouldn‘t be used
with Anthracyclines
10/12/2021 42

43. Purinantagonists
Methotrexate
Pyrimidinanthagonists
Methotrexate, 5-Fluorouracil,
Capecitabine
DNA-Alkylants
Mitomycin-C
Cyclophosphamide
Doxorubicin
Liposomal Doxorubicin
Topoisomeraseinhibitors
Etoposid
Inhibitors of Mitosis
Docetaxel
Paclitaxel
Vinorelbine
Vinblastine
Nucleic acids
DNA
RNA
Protein synthesis
Mitosis
10/12/2021 43

44.  Generaly chemotherapeutic drugs have
the following side effects
◦ Thromboembolic events- especially if used
with Tamoxifen
◦ Cardiomyopathy
If Trastuzumab combined with
Anthracycline
(*cumulative dose should be <500mg/m2)
◦ Ovarian failure
Desirable one in ER positive ca in peri-
menopausal. In younger group it distorts FP
and brings osteoporosis
10/12/2021 44

45. Hormonal Therapy
 They work in either way:
◦ Block the action of Estrogen on breast
cancer cells
◦ Lower Estrogen levels in the body
 Includes:
◦ Selective Estrogen Receptor Modulators
(SERM)
◦ Aromatase Inhibitors
◦ Estrogen receptor downregulators (ERD)
◦ Ovarian ablation
10/12/2021 45

46. SERM
 Selective Estrogen Receptor
Modulator
 On cancerous cells it inhibits cellular growth,
on the other hand, it is Estrogen receptor
activator of endometrium , liver and bone.
 Includes
Tamoxifen,Raloxifen,Toremifen
 Pharmacology
◦ Inhibit competitively high affinity
binding of Estradiol to specific estrogen
receptors (ER) and attenuate biological
effect of the natural hormone
10/12/2021 46

47. H
H
R
R
Competitive inhibition of Tamoxifen
and its selective effects
 Cancerous cell
 Endometrium
Cellular
Growth
DNA
Tamoxifen Tamoxifen
R
Anti-estrogenic
effect
Estrogen
like effect
10/12/2021 47

48. Tamoxifen
Nucleus
DNA
Estrogen
Receptor
Estrogen
helper proteins
Tamoxifen
helper
proteins
10/12/2021 48

49. SERM…
 Meta-anlysis of trials in 1998 that
involved 37,000 patients showed in
those with early breast ca treated
with Tamoxifen
◦ 50% reduction in recurrence rate
◦ 26% reduction in loco-regional
recurrence
◦ 50% prevention of development of
2ocancer in the contra lateral breast
(chemoprevention)
10/12/2021 49

50.  Predictive factors:
◦ ER status
◦ Dominant site of disease
◦ Menopausal status
◦ Previous response to endocrine therapy
Response Rate
ER positive 46%
ER negative 12%
Involved tissue Response Rate
Soft tissue disease 42%
Internal visceral 29%
Bone 26%
Reduction in Recurrence
Pre-menopausal 30-50%
Post-menopausal 40-50%
10/12/2021 50

51. Adjuvant Tamoxifen Treatment
Indication • All hormone receptor positive invasive ca’s
• Chemoprevention
Contraindication • Hx of Endometrial cancer
• Expected or known thromboembolic states
Optimal duration 5 years
Dose 20mg/ day
Additional
benefits
Prevents bone loss
Lowers cholesterol level
Special
considerations
Deficiency of CYP2D6 or drugs that inhibit it
(CYP2D6 is activator of Tamoxifen)
10/12/2021 51

52.  Side effects of Tamoxifen
◦ In general it is a well tolerated drug
except menopausal Sx (50%), vaginal
discharge and irregular bleeding
 The reported ones:
Thromboembolism
Endometrial cancer
Annual HR 1.7/1000 patients
Ocular:- Tamoxifen Induced Retinopathy
But all ocular effects are reversible
Depression (10%)
10/12/2021 52

53. Aromatase Inhibitors
They should be considered in the
following settings:
 Presence of contra-indications to Tamoxifen
 ER positive, PR negative invasive cancer
 HER2/neu over expressive cancer
 After optimal duration of treatment with
Tamoxifen for 2-3 years
 Post-menopausal with hormone receptor
positive metastatic cancer
 Include:
Anastrazole, Exemestane, Letrozole
10/12/2021 53

54. AROMATASE…
 Side effects:
◦ Joint pain and stiffness
◦ Osteoporosis
 The ATAC study finding:
(Arimidix, Tamoxifen Alone or in
Combination)
◦ ↑ time before recurrence in patients where
recurrence is inevitable
◦ ↓metastasis
◦ ↓development of new cancer
10/12/2021 54

55. AROMATASE…
 After 2-3 years treatment with
Tamoxifen, any endocrine therapy should
be changed to Aromatase Inhibitors
 In high risk patients after 5 yrs
treatment with tamoxifen, continuation
with Letrozole for additional 5 yrs is
recommended
Aromatase inhibitors shouldn’t be given
to pre-menopausals since there is no
available data concerning its effect
10/12/2021 55

56.  SERM’s Vs Aromtase Inhibitors
◦ SERM’s can be used in pre- and post-
menpausals
◦ Aromatase Inhibitors were proven to be
beneficial in early hormone receptor
positive invasive cancer in post
menopausals, also less side effects
◦ Switching of SERM’s to Aromatase
Inhibitors after 2-3 yrs of Rx (for total
duration of 5 yrs) was found to be
superior than Tamoxifen treatment for
5 yrs
10/12/2021 56

57. ERD’s
 Estrogen Receptor Downregulators
 Faslodex
◦ A liquid given as IM injection once a
month
◦ Indicated for metastatic breast ca of
post-menopausals that has stopped to
respond to conventional Rx
◦ Research has shown that it is as
effective as Anastrazole
10/12/2021 57

58. OVARIAN ABLATION
 Eliminates estrogen source of the
body
Indication • Hormone receptor positive invasive cancer in pre-
menopausal women
• Hereditary breast cancer syndromes
Options GnRH analogue
(e.g Gosereline)
For 2-3 years
Oopherectomy
Ovarian Irradiation
Side effects •Menopausal Sx
•Osteoporosis
•Depression
•Early CAD
10/12/2021 58

59. OVARIAN ABLATION…
 It reduces risk of recurrence and
death by 25% in pre-menopausal
women
 Gosereline is an expensive drug but
has an advantage of preservation of
fertility in young women
 Chemotherapy has a desirable side
effect of ovarian ablation in pre-
menopausal women
10/12/2021 59

60. PRINCIPLES OF MANAGEMENT
 Insitu Breast Cancer (STAGE 0)
LCIS’s are observed with or without
Tamoxifen
Are markers of increased risk
rather than precursors of invasive
disease
NB There is no identified benefit of
excising LCIS’s
10/12/2021 60

61. PRINCIPLES…
STAGE 0
DCIS are classified into limited and
widespread disease
Widespread ones involve 2 or more
quadrants and they require
Mastectomy
Limited diseases are treated by
lumpectomy plus radiation therapy
10/12/2021 61

62. PRINCIPLES…
DCIS which can be treated by
lumpectomy alone:
◦ low grade DCIS
◦ favorable histological types (solid,
cribriform, papillary)
◦ Diameter < 0.5 cm
Against BCT, Mastectomy is the
gold-standard option since it has
lower local recurrence rate
STAGE 0
10/12/2021 62

63. PRINCIPLES…
 Early Invasive Breast ca:
Two options which were found to
have equivalent outcome:
1. Mastectomy with assessment of
axillary LN status
2. BCT with assessment of axillary
LN status plus radiation therapy
STAGE I, IIa, IIb
10/12/2021 63

64. PRINCIPLES…
STAGE I, IIa, IIb
For clinically node negative cancers (No)
sentinel LN biopsy is performed. If the
results turns up positive or sentinel LN
is unidentifiable then axillary LN
dissection is performed
Adjuvant chemotherapy indicated for:
1. Node-positives
2. Size > 1cm
3. Node- negatives with size < 0.5 cm and
with adverse prognostics features
10/12/2021 64

65. Adverse prognostics features in
node negatives:
 High nuclear grade
 High histologic grade
 HER 2/neu over expression
 Vessel invasion
 Negative hormone receptor status
Tamoxifen indicated for hormone
receptor positive ca > 1cm
PRINCIPLES…
STAGE I, IIa, IIb
10/12/2021 65

66. PRINCIPLES…
Stage IIIa or IIIb
 Advanced locoregional breast ca:
Here surgery integrated with chemo
and radiation therapy is given
Chemotherapy prevents distant
metastasis while radiotherapy
prevents locoregional recurrence
10/12/2021 66

67.  Stage IIIa can be operable or
inoperable
◦ For operable stage IIIa
◦ For inoperable stage IIIa
◦ Stage IIIb is treated as inoperable IIIa
Modified Radical
Mastectomy
Adjuvant Chemo
Adjuvant
Radiotherapy
Neoadjuvant
Chemo
Surgery
Adjuvant Chemo Adjuvant
Radiotherapy
PRINCIPLES…
Stage IIIa or IIIb
10/12/2021 67

68.  Neoadjuvant chemotherapy is
recommended in an attempt to
decrease locoregional cancer burden
 If internal mammary LAP is found
sytemic chemotherapy and radiation
therapy are recommended
PRINCIPLES…
Stage IIIa or IIIb
10/12/2021 68

69. PRINCIPLES…
Stage IV
 Distant Metastasis
◦ Tumor activity outside the mammary
gland, regional lymph nodes, anterior
thoracic wall
◦ Treatment is by no means curative, but
to improve survival and quality of life
◦ Mean survival is 18-25 months
Five year survival 5-10%
Long term survival 2-5%
10/12/2021 69

70.  Hormonal therapy is preferred than
chemotherapy because of its low toxicity
profile
PRINCIPLES…
Stage IV
10/12/2021 70

71.  Candidates for initial hormonal
therapy:
1. Hormone receptor positive cancers
2. Metastasis limited to bones and soft tissue only
3. Limited or asymptomatic visceral metastasis
First Line Second Line Third Line
Pre-menopausals Tamoxifen Ovarian
Ablation
Aromatase
Inhibitor
Post-menauposals Aromatase
Inhibitor
Tamoxifen Megestrolacetate
PRINCIPLES…
Stage IV
10/12/2021 71

72.  Candidates for systemic
chemotherapy:
1. Hormone receptor negative
cancers
2. Symptomatic visceral metastasis
3. Hormone refractory metastasis
 The HER2 status should be determined and if
cancer over-expressive of this Herceptin
(Trastuzumab) should be started
PRINCIPLES…
Stage IV
10/12/2021 72

73. PRINCIPLES…
Stage IV
 Surgical management as an option in
stage IV
◦ Individualized treatment for
anatomically localized metastasis
E.G Brain metastasis
10/12/2021 73

74.  Poor prognostic factors
PRINCIPLES…
Stage IV
10/12/2021 74

75. Brain Metastasis
 6-16% of breast cancer patients
develop brain metastasis
 Sign and Sx in order of frequency:
◦ Headache, focal weakness, mental
status change, seizure, gait ataxia,
speech problem
 MRI is preferred to CT for Dx
10/12/2021 75

76. Brain Metastasis
 Management
◦ Dexamethasone IV
◦ Anti-convulsant
◦ Surgery
 Restricted to those with single metastasis to
the brain and no lesion in other sites
◦ Radiotherpay
 Is standard treatment with 70-90% RR
10/12/2021 76

77. Bone Metastasis
 Commonest site of metastasis
 Presentation of 70-100% of
advanced breast ca patients
10/12/2021 77

78. Bone Metastasis
 Symptoms are:
◦ Bone pain, bone marrow suppression,
hypercalcemia, pathological fractures
 Diagnosis:
◦ Bone scinitigram scan
◦ X ray
◦ Serum Ca levels
10/12/2021 78

79. Bone Metastasis
 Management:
◦ Immobilization
◦ Pain management- NSAID’s
◦ Radiotherapy
◦ Bisophosphonates
◦ Surgery- for impending pathological
fractures
 Prognosis:
◦ Relatively good, 24 month median survival
for bone without other metastasis
10/12/2021 79

80. Carcinoma of the Breast – Distant Metastases
Site Symptoms Early diagnosis Therapy Prognosis > 2
years
Bones Pain,
spontaneous
fracture
Bone scintigram,
tumor markers
Hormonal
therapy
Radiation
53.1%
32.8%
Skin Nodules,
reddening of the
skin
Inspection Hormonal
treatment,
radiation
Lung/pleura Coughing,
respiratory
insufficiency
x-ray, tumor
markers
Chemotherapy 31.2%
Liver Increase in size,
nausea, jaundice
Sonography, CT,
tumor markers
Chemotherapy 10.5%
plus other
locations 3.8%
Brain Headache,
cerebral
dysfunction
CT, markers Surgery,
x-ray
0%
10/12/2021 80

81. Foll0w up
 Year 1-3
◦ 6 monthly sonography and mammography
 After 4 yrs
◦ Sonography and mammography yearly
 During every visit
◦ History
◦ Breast/ thoracic wall examination
◦ Yearly Gynecologic examination with Pap
smear
◦ Laboratory studies
◦ Imaging studies
10/12/2021 81

82. Follow up
 Labraatory studies- for symptomatic
patients
◦ CBC
◦ Liver enzymes
◦ Tumor markers
 Imaging studies- based on Sx
◦ CXR
◦ Bone scan
◦ U/S of abdomen
◦ Brain/ skull CT
◦ MRI
10/12/2021 82

83. Follow up
 Lymphedema
Causes are:
◦ Surgical intervention
◦ Radiation to axilla
◦ Insufficient post op mobilization
◦ ? Cancer recurrence
◦ Thrombosis
10/12/2021 83

84. Risk Stratification
Risk Category Recommended treatment
Minimal Risk Pre-menopauslas:
Tamoxifen
Post-menopausal:
Aromatse Inhibitors
Average Risk Tamoxifen / AI with CMF
High Risk Anthracycline based regimen, also Taxanes
10/12/2021 84

85. 10/12/2021 85

86. REFERENCES
 Schwartz, Principles of Surgery, 8th
ed.
 Collaborating centre for Post-graduate
Training & Research in RH. Module 11:
Breast Cancer
 Uptodate 17.3
 www.breastcancer.org
 Abeloff's Clinical Oncology, 4th ed.
 Powles & Smith. Medical Management
of Breast Cancer,1991
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87. THANKYOU!
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