Treatment - by stage

Stage 0: DCIS

• Surgery

  • Most commonly BCT, potentially including SNLB

  • Simple mastectomy when DCIS is too large for BCT, potentially including SNLB

• Radiation therapy: following BCT

• Systemic therapy: adjuvant hormone therapy if DCIS is hormone receptor-positive

• Surgery: BCT or mastectomy, in combination with either SNLB or axillary lymph node dissection

• Radiation therapy: following BCT

• Systemic therapy

  • Adjuvant hormone therapy for hormone receptor-positive breast cancer

  • Adjuvant chemotherapy for tumors larger than 1 cm in diameter and/or breast cancer that is hormone receptor-negative/HER2-positive

  • Adjuvant targeted therapy for HER2-positive breast cancer

• Surgery: BCT or mastectomy, in combination with either SNLB or axillary lymph node dissection

• Radiation therapy

  • Following BCT

  • After mastectomy, when lymph node status is positive or margins are not tumor-free after mastectomy

• Systemic therapy: Depending on the individual case, hormone therapy, chemotherapy, and targeted therapy can be either neoadjuvant, adjuvant, or both.

• Neoadjuvant approach

  • In most cases, treatment of stage III begins with neoadjuvant chemotherapy, potentially in combination with targeted therapy for HER2-positive breast cancer to shrink the tumor.

  • Afterwards, either BCT or mastectomy is performed, usually in combination with ALND.

  • This is usually followed by radiation and, in some cases, chemotherapy and/or targeted therapy.

  • Individuals with hormone receptor-positive breast cancer will receive adjuvant hormone therapy.

• Surgical approach

  • In most cases, mastectomy for locally advanced cancer, together with ALND

  • Surgery is followed by radiation, adjuvant chemotherapy, and, depending on receptor status, hormone therapy and/or targeted therapy.

• Palliative therapy in stage IV consists of systemic treatment (chemotherapy, hormone therapy, targeted therapy, and possibly immunotherapy), possibly in combination with radiation therapy.

• Additionally, drugs to relieve symptoms of metastatic disease can be given (e.g., bisphosphonates, pain medication, antiemetics).

• In some cases, palliative surgery can be done to control local symptoms (e.g., mastectomy).

• Stage 0

• Stage I: Tumor ≤ 2 cm with or without micrometastases to regional lymph nodes

• Stage II: Tumor > 5 cm without level I-II regional lymph node involvement or tumor > 2 cm and ≤ 5 cm with or without level I-II regional lymph node involvement; no distant metastases

• Stage III: Any tumor size with involvement of level III lymph nodes or tumor that invades chest wall; no distant metastases

• Stage IV: Distal metastases are present

• Surgery is the treatment of choice.

• Radiation therapy is contraindicated during pregnancy.

• Adjuvant chemotherapy only in the second and third trimester