Treatment/Prognosis Flashcards

Question

What is EIC?

Answer 1

EIC is defined as DCIS both admixed and adjacent to invasive Dz, and comprising >25% of the total tumor mass. DCIS with focal microinvasive Dz also fits this category.

Answer 2

Yes, but it is largely dependent on SM status. From studies mainly out of JCRT, EIC is only prognostic for LF if the margin status is considered. If there is a close or +margin, EIC is associated with a higher risk of recurrence. (Gage I et al., Cancer 1996)

Answer 3

NSABP B21 (Fisher B et al., JCO 2002): 1,009 pts with ≤1-cm tumors s/p lumpectomy randomized to 3 arms: (a) tamoxifen alone (10 mg bid × 5 yrs), (b) RT alone (50 Gy), and (c) RT + tamoxifen. After 8-yr f/u, the IBTR was 16.5% with tamoxifen alone vs. 9.3% with RT alone vs. 2.8% with RT + tamoxifen. There was no difference in OS. No benefit was seen in ER– tumors. Contralat breast tumor recurrence was 0.9%, 4.2%, and 3.0% in the 3 arms, respectively.

Answer 4

Yes. Recent trials suggest that pts with advanced age (≥65–70 yrs) and ER+ T1N0 tumors have an acceptably low rate of LR with Sg and endocrine Tx, although LR risk is further reduced by RT. The data suggest that the risk is very low only for pts >70 yo and possibly in those with very small tumors (<1 cm), so a discussion can be made about withholding RT if the pt is being treated with tamoxifen. The 3 most important trials are the Toronto, CALGB 9343/Intergroup, and PRIME II trials: Princess Margaret Hospital/Canadian trial (Fyles AW et al., NEJM 2004): 769 women ≥50 yo (median age 68 yrs) with T1 or T2 (≤5 cm) –nodes (in women age ≥65 yrs, either clinical or pathologic evaluation was sufficient and SLN Bx was not routinely done) underwent lumpectomy to –margins and were randomized to (a) tamoxifen alone (20 mg/day × 5 yrs) vs. (b) tamoxifen + RT (40 Gy in 16 fx with a boost of 12.5 Gy in 5 fx). After 8-yr f/u, RT reduced LR from 17.6% to 3.5%. But for tumors ≤1 cm, the risk of relapse was 2.6% vs. 0% for the RT group (p = 0.02). In those ≥60 yo with ≤1-cm tumor, the risk was no different b/t the 2 arms (1.2% vs. 0%), but this was unplanned analysis with a short f/u. CALGB 9343/Intergroup trial (Hughes KS et al., NEJM 2004; updated JCO 2013): 636 women ≥70 yo with T1, clinically N0, ER+ tumors were randomized to tamoxifen vs. tamoxifen + RT after lumpectomy with –margins. Axillary dissection was allowed but not encouraged. RT was 45 Gy to the whole breast with a boost of 14 Gy. At a median of 12.6-yr f/u, the 10-yr LF rate in the tamoxifen alone arm was 10% vs. 2% in tamoxifen + RT. There was no difference in time to mastectomy, DM, breast cancer survival, or OS. PRIME II (Kunkler, Lancet Oncol 2015): 1,326 women ≥65 yo T1–T2 (up to 3 cm) N0, ER+ tumors receiving adj endocrine Tx randomized to WBI (40–50 Gy) or no RT. 5-yr IBTR 1.3% with RT and 4.1% no RT (p < .05). While addition of RT was SS, they question the need for RT given relatively low rates of recurrence.

Answer 5

In certain cases. Previous era trials in cN0 pts (esp NSABP B04 and Institut Curie) have demonstrated equivalent LC, DM, and OS with nodal RT vs. axillary dissection. In the modern era, the AMAROS trial randomized SLN+ pts to completion ALND or nodal RT; 5-yr results showed no significant difference in LRR, DM, or OS and overall better arm function in the RT arm. (Donker M et al., Lancet Oncol 2014) 5-yr axillary recurrence 0.4% ALND vs. 1.2% with axillary RT.

Answer 6

Yes. 2 randomized trials (MA.20 and EORTC 22922/10925) have examined this question. MA.20 (Whelan TJ et al., NEJM 2015) targeted women with +axillary nodes or –nodes but with high-risk features (≥5 cm tumor, or ≥2 cm tumors with inadequate nodal dissection or adverse tumor features. There was a decrease in regional recurrences (2.7% vs. 0.7%) with the addition of nodal irradiation to the upper axillary nodes, SCV region and IM nodes. Distant recurrence was also decreased from 17.3% to 13.4% and DFS increased from 77% to 82% at 10 yrs. EORTC 22922/10925 (Poortsmans PM et al., NEJM 2015) targeted women with centrally/medially localized primary tumor +/– axillary nodes or externally localized primary with + axillary nodes. At 10-yr f/u, there was a decrease in regional recurrences from 4.2% to 2.7% and a distant metastases rate decrease from 19.6% to 15.9%, as well as breast cancer mortality (14.4%–12.5% [HR 0.82, p = 0.02]). However, neither trials showed OS benefit.

Answer 7

JCRT sequencing trial (“Upfront-Outback” trial) (Bellon J et al., JCO 2005): per the initial report (Recht A et al., NEJM 1996), the 5-yr crude rate of distant recurrence was better in the chemo 1st arm (20% vs. 32%). However, in the 11-yr f/u update, there was no difference in DFS, LR, DM, or OS. For those with a –margin, the crude LR rate was 6% in the chemo 1st arm vs. 13% in the RT 1st arm. However, the study was not powered to show any differences. Thus, either sequence is acceptable, depending on pt convenience. Often, the Oncotype DX takes a few wks to return, and radiotherapy can be given in the meantime.

Answer 8

NSABP B39/RTOG 0413, which randomized women with stage 0, 1, or 2 breast cancer with tumors ≤3 cm and ≤3 +LN to whole breast RT vs. APBI by any of 3 methods (interstitial, intracavitary, or EBRT). Publication pending.

Answer 9

34 Gy in 3.4 Gy bid fx for interstitial and intracavitary Tx and 38.5 Gy in 3.85 Gy bid fx for EBRT. All APBI is given over 5 days. The volume treated is the surgical cavity plus a 1-cm margin for brachytherapy and a 2–2.5 cm for EBRT.

Answer 10

ASTRO has published updated guidelines on who may be considered for PBI (Correa C et al., PRO 2017). “Suitable” pts are ≥50 yo, Tis or T1, with DCIS allowed only if screen-detected, low to intermediate grade, size ≤2 cm and resected with margins negative at ≥3 mm. Age 40–49 are allowed if all other “suitable” criteria are met. Pts ≥50 yo may have one of the adverse pathologic factors without DCIS >3 cm. Pts with <2 mm margins, DCIS ≤3 cm without meeting “suitable” criteria, or age <40 yrs should be considered cautionary.

Answer 11

There is potentially data to indicate that homogeneous dose distribution of IMRT benefits pts in terms of acute effects and late-term cosmesis. Canadian study (Pignol JP et al., JCO 2008) demonstrated in 358 pts that IMRT reduced the occurrence of moist desquamation c/w standard wedge technique (31.2% vs. 47.8%, p = 0.002). MVA shows breast IMRT and smaller breast sizes were associated with decreased risk of moist desquamation. British study (Mukesh MB et al., JCO 2013) showed in 1,145 pts with 5-yr f/u that overall cosmesis was improved with IMRT c/wstandard techniques (OR 0.68, p = 0.027) as well as skin telangiectasia (OR 0.58, p = 0.021). This benefit was maintained on multivariable analysis. In these settings, IMRT refers to advanced planning techniques that can be achieved with forward planning with dose modulation.

Answer 12

Only in limited circumstances. NCCN 2018 guidelines recommend no RT for −axillary nodes, tumor ≤5 cm and margins ≥1 mm. For all other pts, the decision is based on other risk factors, including close or +margins, extensive LVSI, central/medial tumors, young age, etc. If there are +margins, tumor >5 cm, or +axillary nodes, RNI is recommended. PMRT in node-negative pts does not improve survival per EBCTCG 2005 meta-analysis data.

Answer 13

Management depends on the stage of pregnancy. Timing of Sg depends on need for chemo and RRs to fetus and mother. Chemo can be used to delay Sg until after delivery. Non-taxane chemo (most commonly, FAC) can be used in the 2nd and 3rd trimesters of pregnancy; chemo should be D/C 3 wks before expected delivery to reduce infection and bleeding risks. RT and endocrine therapy must be deferred until postpartum.

Treatment/Prognosis Flashcards

(37 cards)