Locally Advanced Breast Cancer

32.A. 40-year-old premenopausual woman . . .
32.B. 80-year-old postmenopausual woman . . .
with a six centimeter mass in upper outer quadrant of right breast. Core biopsy reveals well-differentiated infiltrating ductal carcinoma, ER/PR+. Patient has ample breast size and prefers not to lose her breast. Your suggested next step in management:

Patrick Borgen, MD

Case A.
We have really been convinced that doxorubicin is the induction agent of choice. And she would get monitored very closely. There is some interest in preoperative MRIs in patients, to really take a hard and fast mathematical look at how much tumor aggression we have. And that's something that we've done on a research protocol. I think it's useful, but this would be a good patient for neoadjuvant therapy.

Andrew Seidman, MD

Case A.
Chemotherapy is standard of care for patients with large tumors where primary surgery would either not be feasible or not result in an acceptable cosmetic result. Down-staging of breast cancers in young women —even in the presence of estrogen receptor over-expression —is most efficiently and reliably done with chemotherapy. There are some studies in elderly patients who have received neoadjuvant endocrine strategy as a way to down-stage a primary tumor.

In a woman with a six centimeter mass, she likely would receive both an anthracycline and taxane before she went to the operating room. I think there's a role for both. I tend to be a mono-therapist. I use drugs sequentially. But this is one circumstance where I think the high efficacy of the anthracyclines-taxane doublet is justifiable. Doxorubicin and paclitaxel or doxorubicin/docetaxel or now epirubicin with either taxane.

Patrick Borgen, MD

Case B.
It depends on her comorbid factors. But you certainly could put a patient like this on a brief trial of tamoxifen or Arimidex, follow her closely, and see whether you were getting regression of the tumor. I think that would be very reasonable.

Andrew Seidman, MD

Case B.
I think here there is a real potential role for primary neoadjuvant anti-estrogen therapy. Only 14 percent of respondents chose tamoxifen. None chose an aromatase inhibitor. There have been some reports on the use of neoadjuvant tamoxifen or anti-estrogen strategies for elderly patients with locally advanced breast cancer. And I have such patients in my practice —a 90-year-old woman right now who's receiving tamoxifen for apparent Stage III breast cancer that's ER/PR-positive. However, there are some 80-year-old women who, after getting off the tennis court, will come into your office, and some of those women are appropriate candidates for chemotherapy.

33. 35-year-old woman with six centimeter BCA has neoadjuvant chemotherapy. After four cycles there in no evidence of tumor on PE or mammogram. What is your management?

Radiation therapy only 2% Attempt biopsy of previous cancer site 20% Mastectomy 21% Quadrantectomy 48% Brachytherapy plus external beam RT 1% MRM 8%

Patrick Borgen, MD

I think mastectomy for a six centimeter tumor. The tumor tells you something about its biology. I think that there's no evidence that relying on either radiation or brachytherapy is reasonable, and I would do a mastectomy.

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