Systemic Therapy for Early-Stage Breast Cancer

What the Plastic Surgeon Should Know

Chad M. Teven, MD; Daniel B. Schmid, MD; Mark Sisco, MD; James Ward, MD; Michael A. Howard, MD

Disclosures

ePlasty. 2017;17(e7) 

In This Article

Abstract and Introduction

Abstract

Objective: We review the types, indications, and common regimens of systemic forms of therapy offered in early-stage breast cancer. We further detail the mechanism of action, approved uses, major toxicities, and relevance to breast reconstruction of specific agents.

Methods: A review of the literature on PubMed and Cochrane databases was undertaken to define the indications and common regimens of systemic therapy in early-stage breast cancer. In addition, literature describing relevant information regarding specific systemic agents was reviewed.

Results: The main objectives of systemic therapy, when provided in the perioperative setting, are to reduce the risk for future recurrence and prolong overall survival. Systemic forms of therapy consist of chemotherapy, hormonal therapy, and targeted therapy and are increasingly being offered to women with early-stage breast cancer. Similarly, as more women are diagnosed with disease that is amenable to surgical extirpation, rates of breast reconstruction are on the rise. Many agents have effects that may impact patient safety with respect to breast reconstruction.

Conclusions: Increasingly, women with breast cancer receive 1 or more forms of systemic therapy during the course of their treatment. It is therefore of significant importance that plastic surgeons have a clear understanding of the issues surrounding the use of systemic agents.

Introduction

The American Cancer Society reported that in 2015, approximately 231,840 cases of invasive breast cancer and 50,041 cases of ductal carcinoma in situ were diagnosed in the United States.[1] Breast cancer treatment can include surgery, radiotherapy, systemic modalities, or a combination thereof. In determining the optimal approach for the type, timing, and sequence of treatment, several variables are considered, including disease stage, genetic predisposition, functional status, medical history, social situation, and patient preference. In addition, a variety of prognostic and predictive disease markers that determine the clinicopathologic and molecular subtype of the disease are considered.[2] For early-stage breast cancer (ie, stages IA, IB, IIA, IIB, and IIIA), in which disease is confined to the breast with or without spread to the locoregional lymph nodes, standard treatment includes surgical extirpation, and, in select patients, radiotherapy (Table 1). In addition, it is increasingly common for oncologists to offer systemic therapy to patients with early-stage breast cancer.

Systemic forms of therapy include chemotherapy, hormonal therapy, and targeted therapy. The decision to use systemic therapy depends on several factors, including menopause status, tumor size and behavior, and the presence and activity of specific receptors. While surgery and radiation therapy promote locoregional control, the goal of adjuvant systemic therapy is to improve disease-free and overall survival by eradicating micrometastatic disease.[3] In cases of large or locally advanced cancers, neoadjuvant systemic therapy may facilitate tumor shrinkage and "downstaging," improved surgical outcomes, the ability to safely perform breast conservation, and an understanding of the sensitivity of the tumor to treatment.[4]

Although effective for treating breast cancer, systemic therapy also impairs key processes of normal cells. In particular, wound healing, immune response, and the coagulation cascade can be negatively affected. Therefore, it is of particular importance to consider the optimal choice and timing of systemic therapy in patients also undergoing surgery. Compounding this is the increasing rate of breast reconstructions, particularly immediately following mastectomy.[5] Reconstructive surgeons have become integral to the breast cancer multidisciplinary team and must recognize the effects and implications of systemic therapy on breast reconstruction.[6] The purpose of this article is to review the indications and common regimens of systemic therapy in early-stage breast cancer. Furthermore, the mechanism of action, approved uses, major toxicities, and relevance to breast reconstruction of specific agents are considered.

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