general approach to treatment of breast cancer
(JAMA 2019;321:288 & 1716)
DCIS
Mastectomy or lumpectomy ± RT ± chemoprevention (Lancet 2016;387:849 & 866)
I
Surgery + RT
II
- adjuv. chemo if ↑ risk: tumor >2 cm or ⊕ LN or triple ⊖ or Oncotype DX-guided
- hormonal Rx for ER/PR ⊕: add ovarian suppression if ↑ risk (NEJM 2018; 379:122)
- anti-HER2 Rx and chemo if HER2 ⊕ and tumor ≥1 cm or ⊕ LN
III
Neoadjuvant chemo → surgery + RT ± adjuvant chemotherapy
- hormonal Rx for ER/PR ⊕: add ovarian suppression if premenopausal
- anti-HER2 Rx for HER2 ⊕: usually trastuzumab + pertuzumab
IV
- ER/PR ⊕: combined aromatase & CDK4/6 inhibitors (NEJM 2016; 375:1925)
- ER/PR ⊖/HER2 ⊕: chemo + anti-HER2 therapy
- Triple ⊖: chemo ± immune checkpoint inhibitor
- Bony mets: bisphosphonates & denosumab ↓ fractures (Cochrane 2017;CD003474)