Chapter 086. Breast Cancer (Part 8) Table 86-3 Suggested Approaches to Adjuvant Therapy Age Group Lymp h Node Status a Endocr ine Receptor (ER) Status Tum or Recommenda tion Premenopa usal Positi ve Any Any Multidrug chemotherapy + tamoxifen if ER- positive + trastuzumab in HER- 2/neu positive tumors Premenopa usal Negat ive Any >2 cm, or 1– 2 cm with other poor prognostic variables Multidrug chemotherapy + tamoxifen if ER- positive + trastuzumab in HER- 2/neu positive tumors Postmenopa usal Positi ve Negativ e Any Multidrug chemotherapy + trastuzumab in HER- 2/neu positive tumors Postmenopa usal Positi ve Positive Any Aromatase inhibitors and tamoxifen with or without chemotherapy + trastuzumab in HER- 2/neu positive tumors Postmenopa usal Negat ive Positive >2 cm, or 1– 2 cm with other poor prognostic variables Aromatase inhibitors and tamoxifen + trastuzumab in HER- 2/neu positive tumors Postmenopa usal Negat ive Negativ e >2 cm, or 1– 2 cm with other poor prognostic variables Consider multidrug chemotherapy + trastuzumab in HER- 2/neu positive tumors a As determined by pathologic examination. Data on postmenopausal women are also controversial. The impact of adjuvant chemotherapy is quantitatively less clear-cut than in premenopausal patients, although survival advantages have been shown. The first decision is whether chemotherapy or endocrine therapy should be used. While adjuvant tamoxifen improves survival regardless of axillary lymph node status, the improvement in survival is modest for patients in whom multiple lymph nodes are involved. For this reason, it has been usual to give chemotherapy to postmenopausal patients who have no medical contraindications and who have more than one positive lymph node; tamoxifen is commonly given simultaneously or subsequently. For postmenopausal women for whom systemic therapy is warranted but who have a more favorable prognosis, tamoxifen may be used as a single agent. Large clinical trials have shown superiority for aromatase inhibitors over tamoxifen alone in the adjuvant setting. Unfortunately the optimal plan is unclear. Tamoxifen for 5 years followed by an aromatase inhibitor, the reverse strategy, or even switching to an aromatase inhibitor after 2–3 years of tamoxifen has been shown to be better than tamoxifen alone. No valid information currently permits selection among the three clinically approved aromatase inhibitors. Large clinical trials currently underway will help address these questions. Most comparisons of adjuvant chemotherapy regimens show little difference among them, although small advantages for doxorubicin-containing regimens are usually seen. . Chapter 086. Breast Cancer (Part 8) Table 86-3 Suggested Approaches to Adjuvant Therapy Age Group Lymp h