51-year-old female underwent Lumpectomy and sentinel lymph node biopsy for infiltrating duct carcinoma of her left breast. The tumor was completely excised and concluded as stage I. The estrogen and progesterone receptor status were optimal, and therefore the expert recommends hormone therapy. He also recommends to complete the ongoing adjuvant irradiation program, to complete staging procedures, and to undergo genetic counseling.
The patient asks about different treatment options and further investigation.
This 51 year old woman underwent Lumpectomy and sentinel lymph node biopsy for infiltrating duct carcinoma of her left breast. The tumor was completely excised and three lymph nodes were extracted. It was found to be a T1 lesion (1.7cm) N0 (0/3) Mo, thus concluded as stage I. There was no vascular invasion. The tumor was of grade I category. Estrogen and progesterone receptor status were optimal, as 100% of cells stained positively. Her-2 status was negative.
In view of these characteristics I suggest her:
1. To complete the ongoing adjuvant irradiation program.
2. Regarding her systemic adjuvant treatment I suggest that the tumor be subjected to the Oncotype genetic evaluation. Chemotherapy should not be offered unless a high recurrence score is found, which seems very unlikely in view of the available immune staining results. Hormone therapy, on the other hand, is recommended based on the hormonal receptor status. This would serve both to further minimize the recurrence risk and as chemoprevention. However, the components of this treatment depend on several factors.
2a. if she is in postmenopausal status and has been on hormonal replacement treatment, this should be stopped.
2b. if she still has full functioning ovaries then I would suggest to ablate this function, preferentially by laparoscopic ovariectomy, or possibly by a course of LHRH-A, which at the current age should be of limited length
2c. In addition, the patient should receive at least a 5 year treatment by Tamoxifen switched to aromatase inhibitor. The particulars of this program should be discussed by her and the treating oncologist, considering the different toxicity profiles.
I further suggest her:
1. To complete her staging procedures by chest and abdominal-pelvic CT, and bone
scan, that will serve for base line description as well.
2. To undergo genetic counseling.
3. To discus improving her way of life, controlling her diet and her physical activities.
4. To pursue strict follow up, including annual mammography.