Management of Early Stage Breast Cancer

Introduction to Treatment Options

Breast-conserving surgery (BCS) followed by radiation therapy is the preferred treatment option for most patients with early breast cancer, offering equivalent survival outcomes to mastectomy while preserving the breast 1, 2

BCS is the preferred local treatment option for the majority of early breast cancer patients 1
Oncoplastic techniques should be used when needed to maintain good cosmetic outcomes in technically challenging cases 1
Careful histological assessment of resection margins is essential with no tumor at the inked margin required for invasive cancer and >2 mm margins preferred for DCIS 1
For DCIS, both BCS followed by whole breast irradiation or total mastectomy are acceptable treatment options 2
Mastectomy is indicated when BCS is not possible due to tumor size, location, or patient preference 1
Breast reconstruction should be available and proposed to all women requiring mastectomy 1
Immediate breast reconstruction should be offered to most patients, except those with inflammatory cancer 1
The optimal reconstruction technique should be discussed individually, considering anatomic, treatment-related factors and patient preferences 1
Non-high-risk patients who opt for bilateral mastectomy should be counseled that survival outcomes with BCS might be even better than with mastectomy 2

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early, clinically node-negative breast cancer 1
Further axillary surgery following a positive SLNB is not required in cases of low axillary disease burden (micrometastases or 1-2 positive SLNs) when postoperative tangential breast radiotherapy is planned 1
Axillary radiation is a valid alternative in patients with a positive SLNB, regardless of the type of breast surgery 1

Postoperative radiation therapy is strongly recommended after BCS 2
Boost irradiation is recommended to reduce the risk of in-breast relapse in patients at higher risk of local recurrence 2
Accelerated partial breast irradiation (APBI) is an acceptable treatment option in patients with a low risk for local recurrence 2
Post-mastectomy radiation therapy (PMRT) is recommended for high-risk patients, including those with involved resection margins, involved axillary lymph nodes, or T3-T4 tumors 2
PMRT should also be considered in patients with 1-3 positive axillary lymph nodes 2
Comprehensive nodal irradiation is recommended for patients with involved lymph nodes 2

Adjuvant systemic treatment should preferably start within 3-6 weeks after surgery 3

Age should not be the sole determinant for withholding or recommending treatment 1
In younger premenopausal patients, fertility issues and fertility-preservation techniques should be discussed before initiating any systemic treatment 1
Surgery following primary systemic therapy (PST) should follow general rules for early breast cancer, considering baseline tumor characteristics and post-treatment outcomes 2
If BCS is anticipated after PST, marking of the tumor site is essential, and pre/post-treatment breast assessment using MRI should be performed 2

Treatment decisions should be based on tumor burden/location, biology (including biomarkers and gene expression), as well as the patient's age, menopausal status, health status, and preferences 4
The management of early breast cancer requires a multidisciplinary team including medical oncologists, breast surgeons, radiation oncologists, radiologists, pathologists, and breast nurses 5
Patients should be provided with comprehensive information and actively involved in all management decisions 5