Alberta Breast Cancer Program

Adjuvant Systemic Therapy Guidelines (Stage III Breast Cancer)

Reviewed and approved 30 January 2008. Drug information sheets for the medications mentioned can be found here.

Stage III breast cancer is subdivided into stage IIIA and stage IIIB.

Stage IIIA is defined as T0 - T3 N2 M0 or T3 N1 M0.

In general, most Stage IIIA cancers are surgically removable with exception of the presence of enlarged axillary lymph nodes which are fixed to underlying structures (N2). In some cases, the breast tumor will be too large to consider a breast conserving surgery (T3, larger than 5 cm tumor) and a mastectomy would be the required surgery unless preoperative (neoadjuvant) chemotherapy is considered.

Stage IIIB is defined as T4 any N M0 or any T N3 M0.

Stage IIIB breast cancer is initially inoperable (unable to remove tumor surgically) because the tumor either invades the chest wall (T4a), skin (T4b), both (T4c), or is an inflammatory breast cancer (T4d). The patient must be seen URGENTLY at the nearest Cancer Centre and potentially receive neoadjuvant chemotherapy prior to any attempt to surgically remove an inflammatory breast cancer. Contact the

Appointments Office at the:

Cross Cancer Institute at(780) 432 8548

Tom Baker Cancer Centre at (403) 944-1900

Grand Prairie Cancer Centre at (780) 538-7588

Red Deer Cancer Centre at (403) 343-4526

Lethbridge Cancer Centre at (403) 329-0633

for an urgent referral.

** Selected cases may be considered for less than mastectomy based on clinical/biopsy findings.

Stage IIIB as well as Stage IIIA breast cancers which are considered inoperable are also referred to as locally advanced breast cancer. The use of neoadjuvant chemotherapy has the potential to downstage the tumor, now making surgical removal possible.

** Surgery assessed based on tumor response to chemotherapy. Consideration of patient's preference and feasibility of surgery should be taken into account.

Systemic Therapy Options*

HER2(+)

              Preferred:

                    - FEC x 4 - DH* x 4 - followed by surgery

                        *timing of trastuzumab addition (in relation to preceding anthracycline                          exposure) is at the discretion of the treating physician, in cases                             where concern about potentiating cardiotoxicity exists 

                    - Post Operatively = Adjuvant Radiotherapy, continue trastuzumab +/-                        Endocrine Rx (if hormone receptor positive disease)

HER2(-)  

              Preferred:

                   - FEC x 4 - D x 4 - followed by surgery

                   - Post Operatively = Adjuvant Radiotherapy +/- Endocrine Rx

                     (if hormone receptor positive disease)

Special Considerations:

- Cardiac Risk/Concern: consideration of a non-anthracycline based

                           neo-adjuvant chemotherapy regimen (x4-6 cycles) may be                              made

*** In cases where surgical excision is not advisable/possible                      -      Definitive (Primary) Radiotherapy recommended

-      May be eligible for surgery at some point depending on discussion                      between medical / radiation / and surgical specialists.

      In cases where neoadjuvant chemotherapy is not advisable or possible,             consideration can be given to neoadjuvant endocrine therapy.

Endocrine Therapy (see ABCP Adjuvant Guidelines)