BREAST CANCER

Common Terms
▪ Carcinoma
▪ A cancer that begins in the lining layer (epithelial cells) of
organs like the breast.
▪ Nearly all breast cancers are carcinomas (either ductal
carcinomas or lobular carcinomas).
▪ Adenocarcinoma
▪ Carcinoma that starts in glandular tissue (tissue that makes
and secretes a substance).
▪ The ducts and lobules of the breast are glandular tissue
(they make breast milk).
 Common Terms …..Con’t (1)
Carcinoma in situ
▪ Early stage of cancer
▪ When the cancer is confined to the layer of cells where it
began
▪ The cells have not grown into (invaded) deeper tissues in the
breast or spread to other organs in the body.
▪ In breast cancer: cancer cells remain confined to ducts

(ductal carcinoma in situ) or lobules (lobular carcinoma in

situ)
▪ Sometimes referred to as non-invasive or pre-invasive breast

cancer
Common Terms….Con’t(2)
Ductal carcinoma in situ (DCIS)
▪ Also known as Intraductal Carcinoma

▪ The most common type of non-invasive breast cancer.

▪ Cancer cells are inside the ducts but have not spread
through the walls of the ducts into the surrounding
breast tissue.
▪ Nearly all women diagnosed at this early stage can be
cured.
▪ A more aggressive type of DCIS is when there is tumor
necrosis called comedocarcinoma
 Patient Encounter, Part 1
 In September 2005, AD, a 41-year-old business executive
mother of two girls, ages 11 and 9 years, had a routine
screening mammography. Upon radiographic review, an
amorphous abnormality is seen in the upper outer quadrant
of the right breast. Fine-needle aspirate of the abnormal
area was performed the following day. Frozen section of
the specimen indicated hyperplastic changes of ductal
epithelial cells. Diagnosis was confirmed on complete
pathologic review.
 plan: Repeat the mammogram in 6 months.
 What factors are relevant when screening for any disease?
 Why is close surveillance necessary in this patient?
 Patient Encounter, Part 2
 HPI: In August of 2006, AD returns for her biannual mammogram.
The abnormal area previously visualized appears to be calcified
with the lesion measuring 1.2 cm. An ultrasound-guided core biopsy
of the lesion was performed the following day. Frozen section of
the specimen indicated dysplastic changes with focal nests of
neoplastic cells invading the ducts. Pathological review of the tissue
sample confirmed a diagnosis of invasive intraductal breast cancer.
 PMH: No comorbid medical problems; oral contraceptives between
19 and 24 years of age and for the past 5 years.
 FH: Mother with breast cancer at age 45 years (succumbed to
disease 2 years after initial diagnosis). Father is alive.
 Plan: Discuss management of the cancer with the multidisciplinary
breast cancer team.
 Is hyperplasia one of the steps in the tumorigenic process?
 What are the patient’s risk factors for developing breast cancer?
 What issues should be considered regarding testing for BRca1 and
BRca2 mutations in this patient? In her two daughters?
Patient Encounter, Part 3
 HPI: Four days after the diagnosis, AD’s case is
presented at the weekly meeting of the
multidisciplinary breast cancer team to determine
the best strategy to manage this patient’s disease.
 plan: Discuss the treatment plan with the patient.
 What factors should guide treatment of this patient’s
breast cancer?
 Introduction
 Breast cancer is a malignancy originating from breast
tissue.
 Disease confined to a localized breast lesion is referred

to as early, primary, localized, or curable.

 Disease detected clinically or radiologically in sites
distant from the breast is referred to as advanced or
metastatic breast cancer (MBC), which is usually
incurable.
 The most common metastatic sites are lymph nodes,
skin, bone, liver, lungs, and brain.
 Epidemiology
 Two variables most strongly associated with
occurrence of breast cancer are
 genderand
 advancing age.

 Additional risk factors include

 endocrine factors (eg, early menarche, nulliparity, late age
at first birth, and hormone replacement therapy),
 genetic factors (eg, personal and family history, mutations
of tumor suppresser genes [BRCA1 and BRCA2]), and
 environmental and lifestyle factors (eg, radiation
exposure).
Risk Factors
Gender
▪ Simply being a woman is the main risk factor for
developing breast cancer.
▪ Men can develop breast cancer, but this disease is
about 100 times more common among women
Aging
▪ Aging is a risk factor of developing breast cancer
▪ Incidence increases with age
‫٭‬30-40 yrs: 1 in 233 ‫٭‬50-60yrs: 1 in 38
‫٭‬40-50yrs: 1 in 69 ‫٭‬60-70yrs: 1 in 27
 Genetic risk factors

▪ About 5% to 10% of breast cancer cases

▪ Both personal and family history
▪ Personal risk factors:
▪ Past medical history of breast cancer increase the
risk of contralateral breast cancer
▪ Cancer of uterus and ovary
Genetic risk factors….Con’t(1)

▪ Dense breast tissue

▪ Increase risk of breast cancer
▪ Associated with hereditary and positive family history of
breast cancer
▪ Many variables including age, weight, menopausal status,
HRT, and parity can influence mammographic breast
density
▪ Women with dense breasts (defined by mammography)
have 2-6 times more risk than women with little density
of the same age.
 Questions
1. A type of carcinoma that starts in the glandular tissue is
called…….
2. When cancer cells are confined to the lobules it is called
……..
3. The most common type of non-invasive breast cancer
is……..
4. Comedocarcinoma is defined as………..
5. Men can develop breast cancer (T/F)
6. Gene defect is the major risk factor for breast cancer.
 Genetic risk factors….Con’t(2)

Family History of breast cancer

▪ Having any first-degree relative with breast cancer increases
a woman’s risk of breast cancer about 1.5- to 3-fold
▪ Risk increases with increasing numbers of affected
first-degree relatives.
▪ The risk is affected by both a woman’s own age and the age
of the relative when diagnosed.
▪ A higher risk is seen when a woman and her relative
at diagnosis are younger than 50 years
 Genetic risk factors….Con’t(3)

Family History of breast cancer….

▪ The risk associated with having a second degree relative
with breast cancer is generally lower
▪ Women with a family history of breast cancer in a father
or brother also have an increased risk of breast cancer.
 Gene Mutation BRCA1 and BRCA2
▪ BRCA1 and BRCA2 genes
▪ Mutation in these genes is the most common cause of
hereditary breast and ovarian cancer
▪ In normal cells, these genes serves as tumor suppressor
genes, maintaining genomic integrity, and DNA repair
▪ Having inherited a mutated copy of either gene from a

parent may have a risk as high as 80%.

▪ These mutation related cancers tends to occur in:

▪ Younger women, associated with increased number of

affected family members, more often affect both breasts, and
males
Gene Mutation BRCA1 and BRCA2…Con’t(1)
▪ Who should be tested?
▪ Personal or family history suggestive of hereditary cancer
▪ BRCA1 and 2 mutant gene positive management options
▪ Prophylactic mastectomy and/ or , oophorectomy
▪ Chemoprevention with Tamoxifen
▪ Benefit not clear but Tamoxifen reduces the risk of
estrogen receptor positive breast cancer with BRCA 2
mutation not BRCA1
▪ Breast cancers associated with BRCA1 mutations
tend to be estrogen receptor negative.
Gene Mutation BRCA1 and BRCA2…Con’t(2)

 Chemoprevention with Tamoxifen…..

❖ Intensive surveillance with annual mammogram and breast
MRI screening, along with clinical breast examinations
every 6 months
❖ Other genes suspected: TP53, CHK2, PTEN, and ATM
Questions
▪ Having inherited a mutated copy of BRCA1 or BRCA2
from a parent may have a high risk for developing breast
cancer.
▪ Having a first-degree relative (mother, sister, or
daughter) with breast cancer approximately triples a
woman's risk.
▪ 85% of women with breast cancer have a family member
with this disease.
 Race and Ethnicity

▪ Overall, white women are slightly more likely to develop

breast cancer than are African-American women
▪ But African-American women are more likely to die of this
cancer

▪ Asian, Hispanic, and Native-American women have a lower

risk of developing and dying from breast cancer.
Match

a. White women 1. High incidence of

b. Asian women developing breast cancer
c. Women with dense 2. More likely to die of
breast tissue this cancer.
d. Hispanic women 3. More glandular tissue
e. Native-American 4. Low risk of developing
women or dying of breast
f. African-American cancer.
 Etiology :-Endocrine Factors
Menstrual Periods
▪ Women who have had more menstrual cycles either because;
▪ they started menstruating at an early age (before age
12) and/or
▪ went through menopause at a later age (after age 55)
❖ have a slightly higher risk of breast cancer.
▪ The increase in risk may be due to a longer lifetime exposure
to the hormones estrogen and progesterone.
 Etiology ….Con’t(1)

Having children at a later age

▪ Women with no children or who had their first child after
age 30 have a slightly higher breast cancer risk
▪ Pregnancy at a young age reduce breast cancer risk
▪ Pregnancy reduces a woman's total number of lifetime
menstrual cycles, which may be the reason for this effect
 Etiology ….Con’t(2)

Recent oral contraceptive use

▪ Women using oral contraceptives have a slightly greater risk of
breast cancer than women who have never used them.
▪ This risk seems to go back to normal over time once the pills are
stopped.
▪ Women who stopped using oral contraceptives more than 10
years ago do not appear to have any increased breast cancer
risk.
 Etiology ….Con’t(3)

Hormone Therapy After Menopause

▪ Using combined hormone therapy for longer duration after
menopause:
▪ Increases risk of getting breast cancer and may also increase the
chances of dying from breast cancer.
▪ This increase in risk can be seen with as little as 2 years of use.
▪ Also increases the likelihood that the cancer may be found at a
more advanced stage
▪ The increased risk appears to apply only to current and recent users.
▪ The risk seems to return to that of the general population within
5 years of stopping combined treatment
 Life Style Related Risks

Alcohol
▪ Linked to an increased risk of developing breast cancer.
▪ The risk increases with the amount of alcohol consumed
▪ Women who consume 1 alcoholic drink a day have a very
small increase in risk.
▪ But those who have 2 to 5 drinks daily have about 1½ times
the risk of women who drink no alcohol.
▪ Excessive alcohol use is also known to increase the risk of
developing several other types of cancer.
Life Style Related Risks….Con’t(1)
Being Overweight or Obese
▪ Has been found to increase breast cancer risk especially for
women after menopause.
▪ Before menopause the ovaries produce most of the
estrogen, and fat tissue produces a small amount of
estrogen But after menopause, most of a woman's estrogen
comes from fat tissue.
▪ Having more fat tissue after menopause can increase the chance
of getting breast cancer by raising estrogen levels.
▪ Also, women who are overweight tend to have higher blood
insulin levels which have been linked to some cancers including
breast cancer.
Breast Cancer Chemoprevention

Tamoxifen
▪ Is a drug that blocks the effects of estrogen on breast tissue.
▪ Although it has anti-estrogenic effect on breast, it possess
estrogenic effect on other tissues
▪ That is why it is called selective estrogen receptor
modulators
▪ It is used :
▪ To reduce breast cancer risk in women at high risk
▪ To reduce the risk of recurrence in localized breast cancer
and
▪ As a treatment for advanced breast cancer when the tumor
is estrogen-receptor positive
 Breast Cancer Chemoprevention…Con’t(1)

Raloxifene
▪ Like tamoxifen, raloxifene also blocks the effect of
estrogen on breast tissue.
▪ Raloxifene is FDA approved to:
▪ Help reduce breast cancer risk in post menopause

women who have osteoporosis and are at high risk for

breast cancer.
Breast Cancer Chemoprevention…Con’t(2)

Side effects
▪ Hot flashes and vaginal bleeding due to estrogen withdrawal

▪ Risks of stroke, pulmonary embolism, deep vein thrombosis

▪ Lower risk with raloxifene compared with Tamoxifene

▪ Risk of endometrial cancer
 Breast Cancer Chemoprevention…Con’t(3)
Preventive (Prophylactic) Mastectomy
▪ Removing both breasts before cancer is diagnosed can
greatly reduce the risk of breast cancer by up to 97%
▪ Some women diagnosed with cancer in one breast, choose
to have the other healthy breast removed as well to prevent
a second breast cancer.
▪ Breast removal does not completely prevent breast cancer
because even a very careful surgeon will leave behind at
least a few breast cells.
 Screening
▪ Women age 40 and older should have a screening mammogram every
year and should continue to do so for as long as they are in good
health
▪ Limitation of mammogram
▪ A mammogram will miss some cancers, and it sometimes leads to
follow up of findings that are not cancer. These follow ups might
include biopsy
▪ Women in their 20s and 30s
▪ Should have a clinical breast exam (CBE) as part of a periodic (regular)
health exam by a health professional, at least every 3 years.
▪ After age 40, ……..
▪ women should have a breast exam by a health professional every year.
▪ CBE is a complement to mammograms
 Signs and Symptoms of Breast Cancer
▪ In 90% of patients, the initial sign is a painless lump that is
typically solitary, unilateral, solid, hard, irregular, and nonmobile
▪ Less common initial signs are pain and nipple changes.
▪ More advanced cases present with prominent skin edema,
redness, warmth, and induration.
▪ Symptoms of metastatic breast cancer depends on the site of
metastasis and may include bone pain, difficulty breathing,
abdominal pain or enlargement, jaundice, and mental status
changes
 Diagnosis
 Initial workup should include
 a careful history,

 physical examination of the breast,

 three-dimensional mammography, and,

 possibly, other breast imaging techniques, such as ultrasound

and magnetic resonance imaging (MRI).
 Breast biopsy is indicated for
 a mammographic abnormality that suggests malignancy or

 for a palpable mass on physical examination.

 Diagnosis…..Con’t (1)
❑ Fine needle aspiration biopsy is indicated for a
mammographic abnormality that suggests malignancy or a
mass that is palpable on physical examination
❖ Bloody or cloudy fluid can mean either a benign cyst
or, very rarely, a cancer.
❖ If the lump is solid, small tissue fragments are drawn
out.
❖ Disadvantage: It can sometimes miss a cancer if the
needle is not placed among the cancer cells.
Diagnosis…..Con’t (2)
STAGING
 TMN Staging

 primary tumor extent and size (T1–4),

 presence and extent of lymph node involvement (N1–3), and
 presence or absence of distant metastases (M0–1).

 The staging system determines prognosis and assists

with treatment decisions.
✓ Early breast cancer
◼ Stage 0: Carcinoma in situ or disease that has not
invaded the basement membrane
◼ Stage I: Small primary invasive tumor without lymph
node involvement
◼ Stage II: Involvement of regional lymph nodes
Diagnosis…..Con’t (3)
 STAGING
✓ Locally advanced breast cancer
◼❖ Stage III: Usually a large tumor with extensive
nodal involvement in which the node or tumor is fixed
to the chest wall; also includes inflammatory breast
cancer, which is rapidly progressive
✓ Advanced or metastatic breast cancer
◼❖ Stage IV: Metastases in organs distant from the
primary tumor
Breast Cancer Staging…Con’t
Lymph Node
Tumor sizes
Nx: LN can not be assessed
TX: Tumor can not be assessed
N0: No LN metastasis
Tis: Carcinoma Insitu
N1: Metastasis in movable ipsilateral
T0 : No evidence of tumor
axillary LN
T1 : ≤2cm
N2:
T2 : 2-5cm
▪ Metastases in ipsilateral fixed
T3: ≥5cm axillary LN, or
T4: Any size but direct
▪ Ipsilateral internal mammary nodes
extension to the chest
with out axillary LN metastasis
wall
Metastasis N3:
Mx : Can not be assessed ▪ Infraclavicular LN + axillary LN
M0: No distant metastasis ▪ Internal mammary LN + axillary
LN
M1: Distant metastasis
▪ Supraclavicular LN
Breast Cancer Staging…Con’t(1)
Examples
▪ T1, N0, M0

▪ T2, N2, M0

▪ T4, N0, M0

▪ T1, N1, M0

▪ Any T, Any N, M1
Breast Cancer Staging…Con’t(1I)
Early Breast Cancers Locally Advanced
Stage 0: Carcinoma in situ Stage III: A large tumor with
Stage 1: Small without LN extensive LN
involvement involvement
▪ T1N0M0 ▪ IIIA: T3, N1, M0

Stage II: Regional LN T0-3, N2, M0

involvement ▪ IIIB: T4, any N, M0

▪ IIA: T0-1, N1, M0 ▪ IIIC: any T, N3, M0

T2, N0, M0 Advanced Breast cancer

▪ IIB: T2, N1, M0 Stage IV: Presence of
T3, N0, M0 metastasis
▪ M1
5-Year Survival Rate by Stage

▪ Stage 0 100%
▪ Stage I 98%
▪ Stage IIA 88%
▪ Stage IIB 76%
▪ Stage IIIA 56%
▪ Stage IIIB 49%
▪ Stage IV 16%

http://www.nationalbreastcancer.org/signs_and_symptoms/index.html. Accessed on 06/29/06.

 Diagnosis…..Con’t (4)
 Pathologic evaluation
 Development of malignancy is a multistep process
involving
◼ preinvasive (or noninvasive) and
◼ invasive phases
 The goal of treatment for noninvasive carcinomas is to
prevent the development of invasive disease.
 Pathologic evaluation of breast lesions establishes the
histologic diagnosis and confirms the presence or
absence of prognostic factors.
 Most breast carcinomas are adenocarcinomas and are
classified as ductal or lobular.
 Treatment
 Goals of Treatment:
 Adjuvant therapy for early and locally advanced breast
cancer is administered with curative intent.
 Neoadjuvant therapy is given to eradicate
micrometastatic disease, determine prognosis, and
potentially conserve breast tissue for a better cosmetic
result.
 Palliation is the desired therapeutic outcome in the
treatment of MBC.
 Treatment can cause substantial toxicity, which differs
depending on the individual agent, administration
method, and combination regimen.
Treatment
Early and locally advanced breast cancer

Surgery
▪

▪ Lumpectomy, Quadrantectomy, Mastectomy

▪ Adjuvant therapy
▪ Chemotherapy, radiotherapy, hormone therapy,
biological therapy
Early breast cancer
 Local-Regional Therapy
 Surgery alone
◼ can cure most patients with in situ cancers, 70% to 80% of
stage I and approximately one half of those with stage II.
 Breast-conserving therapy (BCT)
◼ is often primary therapy for stage I and stage II disease;
◼ it is preferable to modified radical mastectomy because it
produces equivalent survival rates with cosmetically
superior results.
◼ includes removal of part of the breast, surgical evaluation
of axillary lymph nodes, and radiation therapy (RT) to
prevent local recurrence.
Early breast cancer….Con’t(1)

 Local-Regional Therapy….
 RT is administered to the entire breast over 3 to 5 weeks
to eradicate residual disease after BCT.
 Simple or total mastectomy involves removal of the entire
breast without dissection of underlying muscle or axillary
nodes.
◼ This procedure is used for carcinoma in situ where the
incidence of axillary node involvement is only 1% or with
local recurrence following BCT.
 Axillarylymph nodes should be sampled for staging and
prognostic information.
Early breast cancer….Con’t(2)
 Systemic Adjuvant Therapy
 It is the administration of systemic therapy following
definitive local therapy (surgery, radiation, or in
combination) when there is no evidence of metastatic
disease but a high likelihood of disease recurrence.
◼ The goal of such therapy is cure.
 Administration of chemotherapy, endocrine therapy,
targeted therapy, or some combination of these
agents results in
◼ Improved disease-free survival (DFS) and/or overall
survival (OS) for all treated patients.
 Adjuvant Chemotherapy

 Early administration of effective combination chemotherapy at a

time of low tumor burden
❖ Increase the likelihood of cure and minimize emergence
of drug-resistant tumor cell
 Anthracycline-containing regimens (e.g., doxorubicin and
epirubicin) reduce the rate of recurrence and death as
compared with regimens that contain
cyclophosphamide, methotrexate, and fluorouracil.
 Adjuvant Chemotherapy…Con’t(1)
▪ In nodal positive patients, the addition of taxanes,
docetaxel and paclitaxel, resulted in reduced risk of
distant recurrence, any recurrence, and overall
mortality.
▪ Initiate chemotherapy within 12 weeks of surgical
removal of the primary tumor. Optimal duration of
adjuvant treatment is unknown but appears to be 12
to 24 weeks, depending on the regimen used.
Adjuvant Hormonal Therapy
▪ Tamoxifen has been the gold standard adjuvant endocrine therapy for
both pre- menopausal women →20mg/d short after chemotherapy
for 5 years
▪ Another hormonal therapy option for premenopausal women is
ovarian ablation using luteinizing hormone releasing hormone
agonists (goserelin) with or without tamoxifen →its definitive role
however not yet defined
▪ In post-menopausal women, aromatase inhibitor (AIs)(anastrozole,
letrozole, or exemestane) could be an option either in place or after
tamoxifen.
▪ Prevent the peripheral conversion of androgen into oestrogen
in post menopausal women
 Adjuvant Hormonal Therapy…Con’t(1)
▪ The current NCCN guidelines for breast cancer
management state that any of the following are acceptable
endocrine therapy regimens for post menopausal women:
(a) anastrozole or letrozole for 5 years;
(b) tamoxifen for 2 to 3 years followed by anastrozole or
exemestane for a total of 5 years; or
(c) tamoxifen for 5 years followed by letrozole for another
5 years (total of 10 years of endocrine therapy)

▪ Hormonal therapy should only be considered in patients

with oestrogen-receptor (ER) positive tumours
4Some SSRIs like fluoxetine and paroxetine decrease the formation of endoxifen, 4-OH tamoxifen, and active metabolites of
tamoxifen, and may impact its efficacy. Caution is advised about coadministration of these drugs with tamoxifen. However,
citalopram and venlafaxine appear to have minimal impact on tamoxifen metabolism. At this time, based on current data the panel
recommends against CYP2D6 gene testing for women being considered for tamoxifen therapy. Coadministration of strong inhibitors
of CYP2D6 should be used with caution.
 Adjuvant Biological Therapy

Trastuzumab
▪ HER2-positive disease has a worse prognosis than HER2-negative disease
▪ Indicated in HER2-positive early invasive breast cancer
▪ following surgery, chemotherapy, and radiotherapy when applicable:
▪ Should be offered as
▪ An adjuvant treatment given at every 7 days or every 21 days for one
year or until disease recurrence (whichever is the shorter)
▪ It reduces the risk of recurrence of relapse by..
▪ about 50%, and the risk of death by about 31%
▪ Cardiac side effects — mainly heart failure.
 Questions
1. The 5 year survival rate for Stage IV of breast cancer is
16%
2. Chemotherapy should be initiated within ___of surgical
removal of the primary tumor with optimal duration of
about _____
3. Aromatase inhibitors are indicated only for prevention of
recurrence of breast cancer in premenopausal women.
4. Which two classes of chemotherapy drugs indicated for
advanced breast cancer treatment.
Advanced Breast Cancer Treatment Pathway

Decision support

Systemic disease-modifying
therapy
• Hormonal therapy
• Chemotherapy
• Biological therapy

Managing complications

Supportive and palliative care

Locally Advanced Breast Cancer (Stage III)
 Neoadjuvant or primary chemotherapy is the initial
treatment of choice.
 Benefits include rendering inoperable tumors resectable and
increasing the rate of BCT.
 Primary chemotherapy with an anthracycline and taxane-
containing regimen is recommended.
 The use of trastuzumab and pertuzumab with
chemotherapy is appropriate for patients with HER2-
positive tumors.
 Surgery followed by chemotherapy and adjuvant RT should
be administered to minimize local recurrence.
 Cure is the primary goal of therapy for most patients with
stage III disease.
Metastatic Breast Cancer (Stage IV)
 The choice of therapy for MBC is based on
 the extent of disease involvement and
 the presence or absence of certain tumor or patient
characteristics
 The most important factors predicting response to
therapy are the presence of HER2, estrogen, and
progesterone receptors in the primary tumor tissue.
 To treat breast cancer patients with metastases to the
bone
 consider adding bone-modifying agents to decrease rates of
skeletal-related events (eg, pamidronate, zoledronic acid,
or denosumab)
 the need for radiation to the bones or surgery.
 EVALUATION OF THERAPEUTIC OUTCOMES
 EARLY BREAST CANCER
 The goal of adjuvant therapy in early-stage disease is cure.
◼ Becausethere is no clinical evidence of disease when adjuvant
therapy is administered, assessment of this goal cannot be fully
evaluated for years after initial diagnosis and treatment.
 Adjuvantchemotherapy can cause significant toxicity.
Optimize supportive care measures such as antiemetics and
growth factors to maintain dose intensity.
 LOCALLY ADVANCED BREAST CANCER
 Thegoal of neoadjuvant chemotherapy in locally advanced
breast cancer is cure. Complete pathologic response,
determined at the time of surgery, is the desired end point.
EVALUATION OF THERAPEUTIC OUTCOMES

 METASTATIC BREAST CANCER

 Palliationis the therapeutic end point in the treatment of
patients with MBC.
 Optimizing quality of life is an important therapeutic end
point.
 Valid and reliable tools are available for objective
assessment of quality of life in patients with breast cancer.
 The least toxic therapies are used initially, with increasingly
aggressive therapies applied in a sequential manner that
does not significantly compromise quality of life.
 Tumor response is measured by changes in laboratory tests,
diagnostic imaging, or physical examination.