End-Stage Breast cancer

• 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).

Distal metastases are present.

• Overview

  • Can be given as neoadjuvant or adjuvant chemotherapy

  • Usually combination therapy

• Indications

  • Tumor size > 2 cm

  • Triple-negative breast cancer and tumor size ≥ 0.5 cm

  • HER-2 positive breast cancer and tumor size > 1 cm

  • Positive lymph nodes

  • Aggressive tumor histology

• Regimens

  • FEC-D: 5-fluorouracil PLUS epirubicin PLUS cyclophosphamide, followed by docetaxel

  • CMF: cyclophosphamide PLUS methotrexate PLUS fluorouracil

• Contraindication: pregnancy (first trimester)

• Indication: all ER/PR-positive tumors

• Goal: suppression of extraovarian hormone production and blockade of estrogen receptors in order to decrease the risk of breast cancer recurrence

• Contraindication: pregnancy

• Premenopausal

  • Tamoxifen (see “Selective estrogen receptor modulators”)

  • GnRH agonists

• Postmenopausal: aromatase inhibitors

• Preventive: raloxifene (see “Selective estrogen receptor modulators”)

Trastuzumab

• Definition: humanized monoclonal antibody against the HER2 tyrosine kinase receptor that is used in the treatment of HER2-positive breast and gastric cancer

• Mechanism of action: targets HER2/neu (c-erbB2) tyrosine kinase receptor → ↓ of HER2 initiated cellular signaling and ↑ antibody-dependent cytotoxicity → ↓ tumor growth

• Indication: all HER2-positive tumors

• Side effects

  • Cardiotoxicity (e.g., dilated cardiomyopathy with systolic CHF): An echocardiogram is recommended prior to initiating treatment to evaluate cardiac function.

  • Gastrointestinal symptoms (e.g., diarrhea, nausea)

• Contraindication: pregnancy