Management of Breast Carcinoma (summary)

1) Counseling and early referral to the local breast cancer support group

2) Surgical management

Stage I and II

- Breast conservation surgery followed by radiotherapy

- Mastectomy if

a) Increase risk of local recurrence ( extensive malignant type calcification in mammogram, multiple primary tumor, fail to obtain tumor free margin)

b) Physical disabilities that preclude lying flat or abduct the arm, hence preventing the use of radiotherapy

c) Absoute contraindication for radiotherapy (pregnant, previous irradiation of the breast, SLE, Scleroderma)

d) tumor size more than 4 cm or large tumor in proportion to breast size

e) Patient preference

f) radiotherapy facility not available or non compliance to radiotherapy

Locally Advanced Breast Ca (Stage IIIa and IIIb)

- Mastectomy and axillary dissection or

- Neoadjuvant chemotherapy followed by surgery

If inoperable, try give neo adjuvant chemotherapy first. If respond than may proceed with surgery. If remain un operable, then give radiotherapy.

Metastatic breast ca (stage IV)

- Treat same as IIIb if stage IV + enlarged supraclavicular lymph node only

- Chemotherapy, hormone therapy and immunodulation should be individualized

- Palliative care

-Ovarian ablation for patient with advanced breast cancer that is ER positive to induce menopause.

- Toilet mastectomy for stage IV patient with fungating breast mass and fit and agree to surgery.

3) Breast reconstruction surgery

-Age less than 55 years old

- DCIS, LCIS and stages I and II breast ca

- Patient undergone prophylactic mastectomy

4) Adjuvant hormone therapy (Tab Tamoxifen 20 mg daily for 5 years) in patient with ER positive tumor or if ER status unknown.

* Inform small risk of developing endometrial ca.

5) Follow up

- 3 monthly for the first 2 years

- 6 monthly for the next 3 years

- Yearly thereafter

6) Treatment of complication

- Biphosphonate in patient with bone metasteses and documented lytic lesion

- Radiotherapy or high dose steroid, 16 mg dexamethasone daily if spinal cord compression

- IV biphosphonate if present of malignant hyperglycaemia

7) Screening for bone and liver metastesize in stage III patient

8) doctor must dig history of complementary or alternative therapies as it may interfere with conventional therapy

Reference:

Malaysia Clinical Practice Guideline on MAnagement of Breast Cancer, 2002