Self-Evaluation: Breast - Partial Mastectomy Follow-Up

Rachel Freedman, MD, MPH- Assistant Professor, Medicine, Harvard Medical School, Dana-Farber Cancer Institute presents a self-assessment question from an ASCO University course focusing on the treatment breast cancer. 

AUDIO TRANSCRIPT

Welcome to the self-evaluation episode of the ASCO University weekly podcast. My name is Rachel Friedman, and I'm a medical oncologist and clinical researcher in the Breast Oncology Center at Dana-Farber Cancer Institute. Today, we feature a self-evaluation question on the treatment of early stage breast cancer. We begin by reading the question stem.

A 75-year-old woman with a past medical history of coronary artery disease and diabetes, with an ECOG performance status of 2, has been seen in the medical oncology office following a partial mastectomy for a 1 centimeter invasive breast cancer. The margins were clear and hormone receptors are reported as positive. The HER2/neu status is reported as negative. An Oncotype recurrence score is reported as 5.

Which of the following is the best adjuvant therapy for this patient? Choice A, doxorubicin, cyclophosphamide, and weekly paclitaxel, followed by an aromatase inhibitor. B, docetaxel and cyclophosphamide for four cycles, followed by an aromatase inhibitor for five years with radiation therapy to the breast. C, radiation therapy to the breast and axilla, followed by an aromatase inhibitor. D, aromatase inhibitor. E, tamoxifen.

The correct answer to this question is D, aromatase inhibitor. This patient has a poor performance status and high co-morbidity burden, with a higher likelihood of non-breast cancer deaths over breast cancer death, over time. The cancer is low risk, with a low likelihood for local and distant recurrence. Radiation and chemotherapy are unlikely to improve her outcome and will increase her toxicity risk. Further, we have multiple randomized trials to support safe omission of radiation and the setting of older age and stage 1 hormone receptor positive disease.

Briefly, the benefit of adjuvant chemotherapy is anticipated to be negligible, and even harmful, in the setting of her low risk disease, advanced co-morbidity, poor functional status, and Oncotype score of 5. Chemotherapy should be avoided in this setting, making answers A and B incorrect. Although radiation should be considered and administered in most patients with invasive breast cancer, undergoing breast conservation, as mentioned earlier, we have prospective randomized controlled trial data, supporting omission of radiation in this clinical scenario, making option C also incorrect for this reason.

Further, there is no indication for radiation to the axilla in a low risk breast cancer, such as the one described here, making option C incorrect for that reason as well. Option E, tamoxifen, is also a treatment option here, but may be less appealing in an older patient who lives a more sedentary lifestyle who may be at more risk for adverse events on tamoxifen, such as thrombosis, and where the use of aromatase inhibitors may be of a small incremental benefit over tamoxifen, with regard to risk for recurrences over time.

Thank you for listening to this week's episode of the ASCO University weekly podcast. For more information on the treatment of breast cancer, including opportunities for self-evaluation and for a review, please visit the comprehensive eLearning center at university.asco.org.

The purpose of this podcast is to educate and to inform. This is not a substitute for professional medical care and is not intended for use in the diagnosis or treatment of individual conditions. Guests on this podcast express their own opinions, experience, and conclusions. The mention of any product, service, organization, activity, or therapy should not be construed as an ASCO endorsement.