BREAST CANCER

Staging
Prevention
Carcinoma in situ
Surgery
Adjuvant Therapy
Metastatic Disease
Special Situations
Guidelines
Radiation

 

STAGING (TNM Definitions, Stage Groupings, Grave Signs, Survival Data)

ESSENTIAL FEATURES

I _____ < 2cm and LN-
IIA ____ 2-5cm OR LN+
IIB ____ >5cm OR 2-5cm AND LN+
IIIA ___ >5cm AND LN+ OR Fixed lymph nodes
IIIB ___ Chest/Skin OR Int Mam lymph nodes
IV ____ Distant mets

TNM STAGING

 

Tis (DCIS)

Tis (LCIS)

Tis (Paget) [When no tumor is found. If tumor is found, then the T stage is based on the primary, not the Paget’s.]

T1 <= 2 cm
      microinvasive = < 1 mm
      a = 0.1-0.5 cm
      b = 0.6-1.0 cm
      c = 1.1-2.0 cm

T2  2.1 - 5 cm
T3  >5cm
T4  Any size involving chest wall or skin (automatic Stage IIIB min.)

 

pN0(i-) = histologically and immunohistochemically negative

pN0(i+) = negative histology, but positive IHC no > 0.2 mm in size

pN0(mol-) = negative histology, negative RT-PCR

pN0(mol+) = negative histology, positive RT-PCR

pN1mi = micrometastases 0.2-2 mm

pN1a = metastases in 1-3 axillary nodes

pN1b = subclinical spread to an internal mammary node by sentinel node (SN) dissection

pN1c = 1-3 axillary nodes AND subclinical internal mammary node by SN biopsy

pN2 = 4-9 axillary nodes OR clinically apparent internal mammary node in the absence of an axillary node

pN3 = 10 or more axillary nodes, ipsilateral infraclavicular or supraclavicular node, OR a clinically apparent internal mammary node with 1 or more positive axillary nodes OR subclinical internal mammary nodes when 1-3 positive axillary nodes

N1 Movable axillary
N2 Fixed axillary
N3 Ipsilateral internal mammary, infraclavicular, or supraclavicular (supraclavicular nodes used to be classified as M1)

Staging Groupings and (5YS)

I    T1 N0 M0 (95)
IIA    T0-2 N0     (84)
IIB     T3N0 or T2N1 (66)
IIIA   T0-3 N2 (49)
IIIB   T4 or N3     (46)
IV      M1         (15)

GRAVE SIGNS (Categorically inoperable)
Skin edema up to 1/3 breast
Fixed to chest wall
Axillary LNs > 2.5cm
Fixed axillary LNs

 

ADJUVANT THERAPY

Data, Hormonal, Chemo

Adjuvant Data

Adjuvant Therapy: 10-Year Survival Data
ER- <=50
ER- 51+
ER+ <=50
ER+ 51+

Adjuvant: NIH 2000 Consensus
Key Questions
Who Doesn’t Need It?

NSABP Trials

Chemotherapy Regimens

Adjuvant, Neoadjuvant, Metastatic

BREAST ADJUVANT CHEMOTHERAPY

TAXOTERE/CYCLOPHOSPHAMIDE (TC)

Taxotere 75 mg/m2 IV
Cytoxan 600 mg/m2 IV
Give every 3 weeks

TAC (NEJM 352:2302, 2005)
(for LN+ disease. Comparable to AC x 4 --> Taxotere x 4)

 

Dox 50 mg/m2
Taxotere 75 mg/m2
CTX 500 mg/m2

 

   Repeat q 3 weeks x 6

 

DOSE DENSE AC-T

(JCO 21:1431, 2003)

 

AC q 2wks x 4 then

Taxol 175 mg/m2 q 2 wks x 4

G-CSF given days 3-10 each cycle

 

AC
(NSABP B-15, JCO 8:1483,1990)

DOX 60 mg/m2 IV
CTX 600 mg/m2 IV

Repeat q 3 wks x 4.

As good as CMF x 6 in LN+ disease.

IV CMF - 21 Day
(AJM 83:455 '87)

CTX    600 mg/m2 IV
MTX   40 mg/m2 IV
5FU    600 mg/m2 IV
Repeat q 3 wks x 6

IV CMF - 28 Day
(in Salmon: Adj Therapy of Cancer VI, 1990)

CTX    600 mg/m2 IV d 1,8
MTX   40 mg/m2 IV d 1,8
5FU    600 mg/m2 IV d 1,8
Repeat q 4 weeks.

Classical CMF
(Bonadonna NEJM:1976)

CTX    100mg/m2 po d1-14
MTX   40mg/m2 iv d1&8
FU  600mg/m2 iv d1&8
Repeat q 4wks x 6 (Preferred by Bonnadonna for patients with <4 LNs)

FAC
(SE Ca Stud Gp CANCER 40:1977)

CTX 500 mg/m2 IV
DOX 50 mg/m2 IV
5FU 500 mg/m2 IV
Repeat q 3 wks

BREAST: METASTATIC

Click here for Herceptin regimens

NAVELBINE-GEMCITABINE

Navelbine 25 mg/m2 IV
Gemcitabine 1000 mg/m2 IV
Give every 2 wks

This was a relatively non-toxic palliative regimen with a 54% RR. (JCO 20:37 1/02)

TAXOTERE/XELODA

Xeloda 1250mg/m2 BID x 14 days
Taxotere 75/m2
Give q 3 weeks or as tolerated

AC-NSABP

DOX 60mg/m2 iv d1
CTX    600mg/m2 iv d1
Repeat q 3wk

(Dana-Farber uses 45 mg/m2 dose for dox)

CAF
Southeastern Cancer Study Grp
(Cancer 40:625 '77)

5FU    500mg/m2 iv
DOX   50mg/m2 iv
CTX    500mg/m2 iv
Repeat q 3wk

FAC-CALGB

CTX    100mg/m2 po d1-14
DOX   25mg/m2 iv d1&8
5FU    500mg/m2 iv d1&8
Repeat q 4wk

CNF (Bennet, JCO 6 1988)

CTX    500 mg/m2 IV d1
DHAD 10 mg/m2 IV d1
5-FU   500 mg/m2 IV d1
Repeat q 3wk

NFL (Dana-Farber)

DHAD 12 mg/m2 IV d1
LV  300 mg IV d1-3
5FU    350 mg/m2 IV d1-3 (after LV)
Repeat q 3wk

TAXOL

TAX    175 mg/m2 IV/3h
Repeat q 3wk

BREAST: NEOADJUVANT FOR LOCALLY ADVANCED

AT (ASCO #550 '96)

DOX   60 mg/m2
Taxol 175 mg/m2 IV/3hrs
Repeat q 3wks x 3
(Give DOX first because Taxol slows DOX clearance causing > toxicity.)
PR=60, CR=20. Those with CR had 84% reduction in tumor size.

 

BREAST: HERCEPTIN REGIMENS

If Hercept assay is 2+ (equivocal), need to confirm with FISH.

TAXANE-HERCEPTIN

Weekly:
Taxol 80 mg/m2/wk OR
Taxotere 35 mg/m2/wk
Herceptin 4mg/kg x 1 dose, then 2mg/kg/wk

Every 3 Weeks:
Taxol 175 mg/m2 OR
Taxotere 75 mg/m2
Herceptin 8 mg/kg once, then 6 mg/kg q 3 wks

 

GUIDELINES

NCCN Treatment Guidelines

Primary Treatment
DCIS, LCIS
Stage I-IIB
Stage III (Locally Advanced)

Guidelines for Follow Up: (NCCN, ASCO)

 

ADJUVANT 10y DFS DATA

ER Negative, <=50 yo

< 1 cm
LN___None_AC__AC+P
0_____90___92___95
1-3 ___60___72___78
4-6 ___46___61___69
6-9 ___36___52___61
10+___22___38___49

1-2 cm
LN___None_AC__AC+P
0____81___87____90
1-3___56___69____76
4-6___42___57____66
6-9___32___48____58
10+___19___35____46

2-3 cm
LN___None_AC__AC+P
0_____75___83___87
1-3___50___64___72
4-6___38___54___63
6-9___29___46___56
10+___17___33___44

3-4 cm
LN___None_AC__AC+P
0____69___79___84
1-3___47___62___70
4-6___35___51___61
6-9___26___43___53
10+___16___32___43

4-5 cm
LN___None_AC__AC+P
0____63___74___80
1-3___42___57___66
4-6___31___47___57
6-9___21___37___48
10+___14___29___40

>5 cm
LN___None_AC__AC+P
0____56___69___76
1-3___37___53___62
4-6___27___44___54
6-9___18___34___45
10+___13___28___39

ER Negative, 51+ yo

< 1 cm
LN___None_AC__AC+P
0____90___92___94
1-3___xx___xx___xx
4-6___xx___xx___xx
6-9___26___35___46
10+___16___24___35

1-2 cm
LN___None_AC__AC+P
0____81___85____88
1-3___56___63____71
4-6___42___50____60
6-9___32___41____51
10+___19___27____38

2-3 cm
LN___None_AC__AC+P
0_____75___79___84
1-3___50___58___66
4-6___38___46___57
6-9___29___38___48
10+___17___25___36

3-4 cm
LN___None_AC__AC+P
0____69___74___80
1-3___47___55___64
4-6___35___44___54
6-9___26___35___46
10+___16___24___35

4-5 cm
LN___None_AC__AC+P
0____63___69___76
1-3___42___50___60
4-6___31___40___50
6-9___21___29___40
10+___14___21___32

>5 cm
LN___None_AC__AC+P
0____56___63___71
1-3___37___46___56
4-6___27___36___47
6-9___18___26___37
10+___13___20___31

ER Positive, <= 50 yo

< 1 cm
LN__None__Tam_AC+T
0____90___92___94
1-3___60___68___76
4-6___46___56___66
6-9___36___47___58
10+___22___33___45

1-2 cm
LN__None__Tam_AC+T
0____81___85___89
1-3___56___65___73
4-6___42___53___63
6-9___32___43___54
10+___19___30___42

2-3 cm
LN__None__Tam_AC+T
0____75___81___86
1-3___50___60___69
4-6___38___49___59
6-9___29___40___52
10+___17___27___39

3-4 cm
LN__None__Tam_AC+T
0____69___76___82
1-3___47___57___67
4-6___35___46___57
6-9___26___37___49
10+___16___26___38

4-5 cm
LN__None__Tam_AC+T
0____63___71___78
1-3___42___53___63
4-6___31___42___53
6-9___21___32___44
10+___14___24___36

>5 cm
LN__None__Tam_AC+T
0____56___65___73
1-3___37___48___59
4-6___27___38___50
6-9___18___28___40
10+___13___23___34

ER Positive, 51+ yo

< 1 cm
LN__None__Tam_AC+T
0____90___92___93
1-3___60___68___72
4-6___46___56___61
6-9___36___47___52
10+___22___33___38

1-2 cm
LN__None__Tam_AC+T
0____81___85___87
1-3___56___65___69
4-6___42___53___57
6-9___32___43___48
10+___19___30___35

2-3 cm
LN__None__Tam_AC+T
0____75___81___83
1-3___50___60___64
4-6___38___49___54
6-9___29___40___46
10+___17___27___33

3-4 cm
LN__None__Tam_AC+T
0____69___76___79
1-3___47___57___62
4-6___35___46___51
6-9___26___37___42
10+___16___26___33

4-5 cm
LN__None__Tam_AC+T
0____63___71___74
1-3___42___53___57
4-6___31___42___47
6-9___21___32___37
10+___14___24___29

>5 cm
LN__None__Tam_AC+T
0____56___63___71
1-3___37___46___56
4-6___27___36___47
6-9___18___26___37
10+___13___20___31

 

NIH 2000 CONSENSUS ON ADJUVANT THERAPY

FIVE KEY QUESTIONS:

1. Which factors should be used to select adjuvant therapy? Ans: Age, tumor size, histology, node status, hormone receptor status, mitotic rate. Potential factors in future: HER2, p53, vascular invasion, and quantitative parameters of vascular invasion.

2. Who should receive adjuvant hormonal therapy? Only women whose tumors express hormonal receptor protein, regardless of age, menopausal status, LN status, or tumor size. 5 years of tamoxifen is standard. Ovarian ablation is an alternative in select premenopausal women. Tamoxifen plus chemotherapy further reduces the risk of recurrence and should be considered for premenopausal women in particular.

3. Who should get chemo, and what? Chemo should be recommended to most women whose tumor is >1 cm regardless of nodal, menopausal, or ER status. Standard is 4-6 cycles of an anthracycline-containing regimen using at least 2 drugs. AC x 4 = CMF x 6. CAF, CEF, and FEC are > CMF. AC has not been compared to CAF or CEF. So not known whether 3 drugs are better than two are.

Update on NSABP B-28 (AC x 4 v AC x 4 --> Taxol x 4 in LN+ disease): Adding Taxol did not significantly add to DFS or OS although there was a trend. Update on CALGB 9344, which had initially shown a trend towards improved survival with AC+T no longer shows that, especially in ER+ patients, presumably because those patients also get tamoxifen which works well enough. Conclusion: Adding Taxol to AC is helpful only in LN+ ER- disease.

There is some concern that 4 cycles of AC may not be enough, and Europeans use 6 or more cycles for all their adjuvant therapies. Ravdin and Hortobagyi think best is FEC (5FU, Epirubicin, CTX) or FAC x 6.

There are no convincing data to support the use of any biological factors in selecting specific regimens, including HER2 for anthracycline-based therapy.

ER+ patients should also receive tamoxifen.

Unknown benefit in women more than 70 years old.

4. Who should get post- mastectomy RT? Women with 4+ positive LNs. RT should NOT be given concurrent with chemotherapy. RT should be given within 6 months of surgery.

5. How do QOL issues play in? Need decision aids...

 

ADJUVANT TX: WHO DOES NOT NEED IT (NIH Consensus conf, 11/00 p98)

Chemotherapy is not warranted in:
1) < 1 cm and LN negative
2) Special histologic subtypes (tubular, medullary, etc) up to 3 cm in size and node negative
3) Grade I stage I breast cancers
4) ER+ LN- patients in favorable prognostic groups
5) LN- ER- patients > 70 yo

In women over 70, chemo extends survival less than 2 months when adjusted for quality of life. In one study of women 60-80 years old, the survival benefit never exceeded the duration of chemotherapy.

 

BREAST ADJUVANT TRIALS

LN-   10YS=80%
1-3+  60
4+ 20

Who are we helping?

|\_
|\\_ Cured without chemo
| \ \___
| \  \____________
| \_
| \__Those we are helping
|    \_______
|
| Die in spite of chemo
|-----------------------

B-6: MRM v LUMP v LUMP+RT
No diff in survival
30% > local recurrence in lump wo RT

B-9:
Chemo+TAM of value in post-
menopausal with >4 LNs

B-14: LN-/ER+

TAM --> > DFS and OS
10years of TAM is no better than 5
TAM --> 50% less risk of contralateral breast cancer (60/1400) (absolute risk without TAM: 4%)

B-15: ACx4 v CMFx6 v ACx4--> CMFx3 (in ER- )
No difference in survival
Better QOL in ACx4 arm

B-18: Surg --> AC v ACx4 --> Surg
Neoadjuvant --> > incidence of LN-
dz
Neoadjuvant --> smaller primaries
Too early to know whether any diff in survival

B-22: AC v Dose Intense AC (CTX INCREASED)
No difference

CALGB: (NEJM 5/94)
Dose intense CMF slightly better than standard

Main finding: LOSE efficacy if fail to attain 85% of planned dose. I.e., don't decrease dose!

>4 LNs: Ax4 --> CMFx8 v alternating CMF/Adriamycin

Sequential better

GENES

BRCA1

Located on 17q
HER2 gene also found here

Carriers of BRCA1 gene have 85% risk of breast cancer by age 70 as well as 45% risk of ovarian cancer by same age

However, only 1/2 of hereditary breast cancer pts have this

BRCA2

Chrom 13

 

NCCN GUIDELINES

PRIMARY TREATMENT

1) Initial Surgery:
Lumpectomy + Level 1-2 LNs + RT
OR
Mastectomy + Level 1-2 LNs, then:

2) Radiation:

Postchemo RT to chest and SCV:

4 or more LNs+
1-3 LNs and Premenopausal (Consider) Tumor >5cm or + margins

No RT

· Premenopausal with <5cm and LN- and negative margins
· Postmenopausal with <5cm and <4 LNs and negative margins

 

GUIDELINES: DCIS

- Most DCIS is unicentric (1 lobule) but often multifocal (several spots in same lobule).

- Doesn't matter what operation you do because the overall survival is the same regardless of lumpectomy, mastectomy, or lump + RT. Risk is local recurrence, not distant.

- Silverstein (USC Van Nuys) thinks RT not needed as long as margins >= 1cm. RT is NOT a substitute for inadequate excision or poor pathology.

- Microinvasion: < 1 mm extension beyond basement membrane. But may be hard to distinguish from LCIS or normal tissue cut at angle.

- E-cad (cadherin- an adhesion molecule): + in DCIS, - in LCIS & invasive cancer.

NCCN:

Widespread (2 or more quadrants): Mastectomy w/o LND +/- reconstruction.

Margins negative: Excision + RT OR total mastectomy w/o LND +/- reconstruction

Small (<0.5 cm), unicentric, low grade: Same as negative margins EXCEPT that some think excision alone is enough.

In all cases consider tam x 5 years.

 

GUIDELINES: LCIS

Observation preferred OR bilateral mastectomy +/- reconstruction in special cases. Consider tamoxifen.

 

GUIDELINES: Stage I-IIB

<0.5cm OR microinvasive: None

Special type (Tubular, Colloid, Medullary, Adenoidcystic): If >=3cm, give adjuvant. Consider if 1-2.9. None if <1cm.

If infiltrating ductal:

LN- : CMF, FAC, AC

LN+ : FAC; CMF, A-->CMF, AC +/- Taxol (no added benefit to adding Taxol in ER+ women, presumably because they get enough benefit from Tamoxifen;

 

GUIDELINES: STAGE III

STAGE IIIA: Operable: Mastectomy + Axillary LND first or Neoadjuvant (like IIIB).

STAGE IIIB:

Neoadjuvant chemo. If responds --> mastectomy (or consider lumpectomy + RT) + Axillary LND --> RT to chest and SVC LNs --> additional chemo + Tam.

If no response to neoadjuvant chemo, individualize.

 

LOCALLY ADVANCED (III A)

See NSABP-18. Use AC 60/600 x 3-4 cycles or to best response, then surgery. If unable to tolerate chemo, consider TAM.

 

FOLLOW UP (NCCN)

Exam q 4 months x 2 years, then q 6 months x 3 years, then annually.
Mammography annually.
Pelvic exam annually if on Tam.

If recurrence: CBC, LFTs, CXR, Bone scan, X-ray symptomatic bones, CT/MRI if symptoms.
Biopsy documentation of first recurrence, if possible.

FOLLOW UP (ASCO)
(JCO 18:2345 6/2000)

Monthly self exam
OV q 3-6 months x 3 years, then q 6-12 months for years 4-5, then yearly.
Mammograms at 6 months if lumpectomy, then annually.
Do NOT recommend CXR, Scans, Lab, or tumor markers.

 

HORMONAL TX FOR BREAST CANCER

ANASTROZOLE (Arimidex) 1 mg QD – non-steroidal aromatase inhibitor. Recently shown in ATAC trial to be better than tamoxifen in adjuvant therapy. Arimidex reduced risk of recurrence by 17% over tamoxifen. In women with ER+ tumors, the risk reduction was 22%. Arimidex also reduced the risk of contralateral breast cancers by 58% compared with 50% with tamoxifen. The combination of Arimidex plus tamoxifen yielded no added benefit. Because it has no estrogen-like activity, Arimidex also produced fewer side effects than tamoxifen with fewer cases of endometrial cancer (0.1% vs. 0.5%), fewer thromboembolic events (1% vs. 1.7%), and less vaginal bleeding (4.5% vs. 8.1%). Hot flashes and weight gain were also slightly more common with tamoxifen. However, the incidence of bone fractures was higher in the anastrozole group (5.8% vs. 3.7%).  A complete risk/benefit analysis of the ATAC trial is still pending to determine whether the bone loss outweighs the benefits. In another trial Aromasin was not associated with bone loss.

LETROZOLE (Femara) 2.5 mg QD – non-steroidal aromatase inhibitor. (Blocks conversion of androgen to estrogen.) Recently shown to be better than Tamoxifen in metastatic disease, with better RR (32% v 21%) and TTP (10 months v 6 months).

EXEMESTANE (Aromasin) 25 mg QD – Irreversible steroidal aromatase inactivator. The other aromatase inhibitors are non-steroidal and are reversible. Interferes with the principle enzyme (aromatase) that converts androgens to estrogens. Gives 98% inhibition. May be associated with a lower incidence of hot flashes than SERM’s (selective estrogen receptor modulators). The steroid configuration of exemestane may confer a better safety profile. It has a neutral effect on bone and lipid metabolism.

TAMOXIFEN (Nolvadex) 10 mg BID (or 20 mg QD) – non-steroidal antiestrogen. Blocks estrogen receptors on cells that need estrogen to thrive.

MEGESTROL ACETATE (Megace) 40 mg QID – progestin. Works by unknown mechanism to inhibit growth of progestin-sensitive breast or endometrial cancer.

Treatment for Hot Flashes

 

INFLAMMATORY BREAST CANCER

Most aggressive form of non-metastatic breast cancer
1-4% of all breast cancer

Essentials to clinical diagnosis:

-Rapid enlargement and general induration of breast
-Usually no associated mass
-Reddened skin over >1/3 of breast
-Common: peau d'orange, breast warmth

- Most have palpable axillary adenopathy
- More than 30% have distant metastases at diagnosis
- Pathologic hallmark is dermal lymphatic invasion
- Controversy over whether dermal lymph involvement must be demonstrated to make the diagnosis or whether clinical is sufficient

Response to chemo good predictor of survival

CR --> 5YS 50%
PR --> 15
NR --> 0

Surgery improves loco-regional DFS.

 

METAPLASTIC BREAST CANCERS

Rare. Less than 5% breast cancers. Tend to be larger at presentation. Grow rapidly. Usually ER negative. Tend to be less responsive to systemic therapy. Tend to have a somewhat worse prognosis than typical adenocarcinomas despite being LN-.

Refs:
J Surg Oncol 8/99 71:220
Ann Oncol (Mayo) 4/99 10:413

 

NSABP TRIALS

B-1-5: First 5 trials showed no benefit to chemo adjuvant therapy in premenopausal women with LN+ dz.

B-06: DCIS: Lump+RT = Mast and both > Lump alone

B-13: LN-/ER-: MF v none: MF_30% less recur & 25% less death

B-14: LN-/ER+ dz: TAM v placebo, 5years v 10years:
- Showed benefit for 5 years, but no diff 5 & 10years
- Also showed small risk for endometrial cancer

B-15: ACx4 is equal to CMFx6 in LN+ PR- women.

B-17: Positive or unclear margins or comedo at higher risk for recurrence in DCIS.
- Tx recommended: Lump+XRT.

B-18: Neoadjuvant trial: ACx4 --> Surg vs Surg --> ACx4
- At 5years same DFS & OS same, but more patients able to have lumpectomy, especially when tumor >5cm.
- Preop chemo --> 36% CR.

B-19: Like B-13, but CMF v MF: CMF > MF

B-28: AC x 4 v AC x 4 --> Taxol x 4 in LN+ disease – Benefit seen only in ER- women. See above.

 

POST-MASTECTOMY RT

1997 Danish trial (NEJM) - 7-8% increase in overall survival in pts who got RT post-MRM. Local failures eventually lead to distant dissemination, so local control helps. Indicated in pts with 4+ LNs. There is benefit in pts with 1-3 LNs, but controversial whether worth it. Treat the chest wall, apex of the axilla, and supraclavicular nodes. Treatment of the internal mammary nodes is controversial. IM nodes are positive in 30% of pts with + axillary nodes.

 

MISCELLANEOUS SURVIVAL DATA

BASED ON CLINICAL STAGE

Stage 5YS 10 YS
0        >90   90
I        80     65
II       60     45    
IIIA        50     40
IIIB        35     20
IV & inflammatory 10     5

SURVIVAL BASED ON LNs

LNs        5YS   10YS
0        80%  65%
1-3         65 40
>3     30 15

10YS BASED ON TUMOR SIZE
(without adjuvant therapy)

<1 80
3-4    55
5-7.5 45

Chance of 4 or more +LNs based on size of primary:

<1     25%
1-2         35
2-3         50
>3     55-65

 

SENTINEL LNs IN BREAST CANCER

Most appropriate for patients with small primaries since these are the ones most likely to have a change in therapy if upstaged.

Don't need ALND. It does not affect OS.

DON'T do IHC on sentinel LN. May find occult LN metastases, but no worsening of OS. IHC upstages by 10%.

 

NET BENEFIT/RISK INDICES FOR PREVENTIVE TAMOXIFEN

White women (with uterus, without uterus)
Black women (with uterus, without uterus)

Note: The 5-year risk is based on the Gail model calculation. For women who have a previous history of invasive breast cancer (recent or remote) or DCIS, use 3.3% as the risk of developing a new primary invasive breast cancer (IBC).

A positive index means more good things are likely to occur than negative events. The higher the number, the greater the benefit outweighs the risk. And vice versa for negative numbers.

White Women with Uterus

Age: 35-39, 40-49, 50-59, 60-69, 70-79

White Women with Uterus
5 Yr Risk of IBC----Age 35-39
1.5 .... 77
2.0 .... 107
2.5 .... 139
3.0 .... 169
3.5 .... 200
4.0 .... 230
4.5 .... 261
5.0 .... 292
5.5 .... 322
6.0 .... 352
6.5 .... 383
7.0 .... 413

White Women with Uterus
5 Yr Risk of IBC----Age 40-49
1.5 .... 43
2.0 .... 73
2.5 .... 105
3.0 .... 135
3.5 .... 166
4.0 .... 296
4.5 .... 227
5.0 .... 258
5.5 .... 288
6.0 .... 318
6.5 .... 349
7.0 .... 379

White Women with Uterus
5 Yr Risk of IBC----Age 50-59
1.5 .... -103
2.0 .... -75
2.5 .... -46
3.0 .... -18
3.5 .... 10
4.0 .... 38
4.5 .... 66
5.0 .... 94
5.5 .... 122
6.0 .... 149
6.5 .... 176
7.0 .... 204

White Women with Uterus
5 Yr Risk of IBC----Age 60-69
1.5 .... -260
2.0 .... -232
2.5 .... -203
3.0 .... -175
3.5 .... -147
4.0 .... -119
4.5 .... -92
5.0 .... -64
5.5 .... -36
6.0 .... -9
6.5 .... 19
7.0 .... 47

White Women with Uterus
5 Yr Risk of IBC----Age 70-79
1.5 .... -383
2.0 .... -355
2.5 .... -326
3.0 .... -298
3.5 .... -270
4.0 .... -242
4.5 .... -215
5.0 .... -187
5.5 .... -160
6.0 .... -132
6.5 .... -104
7.0 .... -77

White Women Without Uterus

Age: 35-39, 40-49, 50-59, 60-69, 70-79

White Women without Uterus
5 Yr Risk of IBC----Age 35-39
1.5 .... 79
2.0 .... 109
2.5 .... 141
3.0 .... 171
3.5 .... 202
4.0 .... 232
4.5 .... 263
5.0 .... 294
5.5 .... 324
6.0 .... 354
6.5 .... 385
7.0 .... 415

White Women without Uterus
5 Yr Risk of IBC----Age 40-49
1.5 .... 59
2.0 .... 89
2.5 .... 121
3.0 .... 151
3.5 .... 182
4.0 .... 212
4.5 .... 243
5.0 .... 274
5.5 .... 304
6.0 .... 334
6.5 .... 365
7.0 .... 395

White Women without Uterus
5 Yr Risk of IBC----Age 50-59
1.5 .... 18
2.0 .... 46
2.5 .... 75
3.0 .... 102
3.5 .... 130
4.0 .... 158
4.5 .... 186
5.0 .... 214
5.5 .... 242
6.0 .... 269
6.5 .... 296
7.0 .... 324

White Women without Uterus
5 Yr Risk of IBC----Age 60-69
1.5 .... -54
2.0 .... -26
2.5 .... 4
3.0 .... 31
3.5 .... 59
4.0 .... 87
4.5 .... 115
5.0 .... 143
5.5 .... 171
6.0 .... 198
6.5 .... 225
7.0 .... 253

White Women without Uterus
5 Yr Risk of IBC----Age 70-79
1.5 .... -160
2.0 .... -132
2.5 .... -103
3.0 .... -75
3.5 .... -47
4.0 .... -19
4.5 .... 9
5.0 .... 37
5.5 .... 64
6.0 .... 92
6.5 .... 119
7.0 .... 146

Black Women with Uterus

Age: 35-39, 40-49, 50-59, 60-69, 70-79

Black Women with Uterus
5 Yr Risk of IBC----Age 35-39
1.5 .... 47
2.0 .... 77
2.5 .... 109
3.0 .... 139
3.5 .... 170
4.0 .... 200
4.5 .... 231
5.0 .... 262
5.5 .... 292
6.0 .... 322
6.5 .... 353
7.0 .... 383

Black Women with Uterus
5 Yr Risk of IBC----Age 40-49
1.5 .... -17
2.0 .... 14
2.5 .... 46
3.0 .... 76
3.5 .... 107
4.0 .... 137
4.5 .... 168
5.0 .... 199
5.5 .... 229
6.0 .... 259
6.5 .... 290
7.0 .... 320

Black Women with Uterus
5 Yr Risk of IBC----Age 50-59
1.5 .... -215
2.0 .... -187
2.5 .... -158
3.0 .... -130
3.5 .... -102
4.0 .... -74
4.5 .... -46
5.0 .... -19
5.5 .... 10
6.0 .... 37
6.5 .... 64
7.0 .... 92

Black Women with Uterus
5 Yr Risk of IBC----Age 60-69
1.5 .... -442
2.0 .... -414
2.5 .... -385
3.0 .... -358
3.5 .... -330
4.0 .... -302
4.5 .... -274
5.0 .... -246
5.5 .... -219
6.0 .... -191
6.5 .... -164
7.0 .... -137

Black Women with Uterus
5 Yr Risk of IBC----Age 70-79
1.5 .... -513
2.0 .... -485
2.5 .... -456
3.0 .... -429
3.5 .... -401
4.0 .... -373
4.5 .... -345
5.0 .... -317
5.5 .... -290
6.0 .... -262
6.5 .... -235
7.0 .... -208

Black Women Without Uterus

Age: 35-39, 40-49, 50-59, 60-69, 70-79

Black Women Without Uterus
5 Yr Risk of IBC----Age 35-39
1.5 .... 48
2.0 .... 78
2.5 .... 110
3.0 .... 140
3.5 .... 171
4.0 .... 201
4.5 .... 232
5.0 .... 263
5.5 .... 293
6.0 .... 323
6.5 .... 354
7.0 .... 384

Black Women Without Uterus
5 Yr Risk of IBC----Age 40-49
1.5 .... -11
2.0 .... 20
2.5 .... 52
3.0 .... 82
3.5 .... 113
4.0 .... 143
4.5 .... 174
5.0 .... 205
5.5 .... 235
6.0 .... 265
6.5 .... 296
7.0 .... 326

Black Women Without Uterus
5 Yr Risk of IBC----Age 50-59
1.5 .... -163
2.0 .... -135
2.5 .... -106
3.0 .... -78
3.5 .... -50
4.0 .... -22
4.5 .... 6
5.0 .... 34
5.5 .... 62
6.0 .... 89
6.5 .... 116
7.0 .... 144

Black Women Without Uterus
5 Yr Risk of IBC----Age 60-69
1.5 .... -316
2.0 .... -288
2.5 .... -259
3.0 .... -232
3.5 .... -204
4.0 .... -176
4.5 .... -148
5.0 .... -120
5.5 .... -93
6.0 .... -65
6.5 .... -38
7.0 .... -11

Black Women Without Uterus
5 Yr Risk of IBC----Age 70-79
1.5 .... -394
2.0 .... -366
2.5 .... -337
3.0 .... -310
3.5 .... -282
4.0 .... -254
4.5 .... -226
5.0 .... -189
5.5 .... -171
6.0 .... -143
6.5 .... -116
7.0 .... -89

 

PREVENTION

Who is High Risk? (> 50yo)
+ family history
atypical hyperplasia on biopsy
parity > 30 yo
menses at <= 11 year old

Tamoxifen: Net Benefit/Risk Indices

 

SURGERY

Grave Signs

 

CARCINOMA IN SITU

Guidelines
NSABP B6 and B17

 

SURGERY

Sentinel Nodes

 

METASTATIC DISEASE

Hormonal, Chemotherapy

 

SPECIAL SITUATIONS

Inflammatory Breast Cancer
Metaplastic Breast Cancer