Cáncer de Mama en Mujeres

8/11/21 19:13 Cáncer de mama en mujeres - ClinicalKey
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RESEÑA CLÍNICA
Cáncer de mama en mujeres

Punto de atención de Elsevier (ver detalles)
Actualizado el 12 de febrero de 2021 . Copyright Elsevier BV. Reservados todos los derechos.
Sinopsis
Puntos clave Acción urgente

El cáncer de mama es una neoplasia maligna de la mama, que se La metástasis de la médula
presenta con mayor frecuencia como carcinoma ductal o lobulillar. espinal que causa compresión
de la médula requiere
Puede presentarse como una anomalía mamográfica en la detección o
radioterapia urgente o
una masa palpable en la mama descubierta por el médico o por el
laminectomía descompresiva
paciente
urgente
Las pruebas de diagnóstico suelen incluir una tríada de mamografía,
La hipercalcemia asociada con
ecografía y biopsia central; La determinación del estado de los
malignidad requiere
receptores de crecimiento y hormonas y el perfil genómico
tratamiento urgente con
proporciona información de pronóstico importante y guía las
líquidos intravenosos y
decisiones terapéuticas.
bifosfonatos
El enfoque del tratamiento se basa en la etapa de pronóstico clínico o

La metástasis cerebral con
patológico en el momento del diagnóstico y requiere un enfoque
edema cerebral requiere
multimodal que incluye cirugía, radioterapia y farmacoterapia
dexametasona y radioterapia
(agentes hormonales, quimioterapia y modificadores biológicos)
para las lesiones que ocupan
espacio.
Complications include metastases (typically bone, brain, lung,
and liver), spinal cord compression, hypercalcemia, upper
extremity lymphedema, cardiac dysfunction secondary to
systemic therapy, and infertility in premenopausal patients
Encontraste tu respuesta? ×
sí No
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Pitfalls
Isolated nipple discharge without other breast symptoms is not commonly caused by breast
cancer and generally arises from benign conditions
With advanced disease, presentation may not be straightforward, as occurs with paraneoplastic
syndromes, pathologic fractures from bone metastases, neuropathic pain from spinal cord
compression, and visual disturbance or headache from brain metastases
Suspect inflammatory breast cancer in women with rapidly progressive inflammation of breast
that does not improve with antibiotic therapy
Terminology
Clinical Clarification
Breast cancer is a malignant neoplasm most commonly arising from the glandular epithelium
of the breast
Most frequently diagnosed form of cancer worldwide and a leading cause of cancer mortality in
women 1
Classification
Histopathologic subtypes
Invasive carcinoma 1 2
Common subtypes accounting for most cases
Ductal (about 75%) 3
Lobular (about 8%) 4
Mixed: ductal and lobular (about 5%) 4
Rare subtypes account for around 10% of cases altogether 1 3
Inflammatory Encontraste tu respuesta? ×

sí No
Mucinous
Medullary
Papillary
Tubular
Paget disease, infiltrating
Squamous cell
Adenoid cystic
Secretory
Cribriform
Undifferentiated
In situ carcinomas
Ductal carcinoma in situ
Noninvasive neoplasm of ductal origin that can progress to invasive cancer
Variable histopathology and malignant potential
Paget disease of breast
Lobular carcinoma in situ 1
Now considered a benign entity and removed from TNM staging; however, it may be
associated with high risk for invasive cancer
Hormone and growth receptor status 1
Estrogen receptor expression
Progesterone receptor expression
HER2 overexpression (about 15%-20% of cases 5)
Androgen receptor expression 6 7
Triple-negative (ie, estrogen receptor–negative, progesterone receptor–negative, and HER2-

negative; about 15%-20% of cases) sí No
Major molecular subtypes

Luminal subtypes (overlap with estrogen receptor positivity)
Luminal A
Luminal B
HER2-enriched
Basal-like (typically estrogen receptor–negative, progesterone receptor–negative, and HER2-

negative)
Estadificación anatómica según el sistema de clasificación TNM del American Joint Committee on Cancer;
Consulte las pautas de cáncer de mama de la Red Nacional Integral del Cáncer para la estadificación del
pronóstico clínico y patológico según la estadificación TNM y el estado de los receptores de crecimiento y
hormonas 1 2
Tumor (T)
TX: no se puede evaluar el tumor primario
T0: sin evidencia de tumor primario
Tis: tumor in situ (carcinoma ductal in situ)
Tis (Paget): enfermedad de Paget del pezón no asociada con carcinoma ductal in situ y / o carcinoma
invasivo en el parénquima mamario
T1: tumor de hasta 20 mm en su mayor dimensión
T2: tumor mayor de 20 mm, hasta 50 mm en su mayor dimensión
T3: tumor mayor de 50 mm en su mayor dimensión
T4: tumor de cualquier tamaño con invasión regional
Nodos (cN, clínico; pN, patológico) 2
cNX: no se pueden evaluar los ganglios regionales
cN0: sin metástasis en los ganglios regionales por imagen o examen clínico
cN1: ganglios axilares ipsilaterales móviles
Encontraste
cN2: ganglios axilares ipsilaterales tu respuesta?
fijos o ganglios mamarios internos ipsilaterales ×
sí No
cN3: ganglios ipsolaterales además de ganglios axilares

pNX: no se pueden evaluar los ganglios regionales
pN0: sin metástasis en los ganglios regionales en el examen histológico
pN1: micrometástasis o metástasis en 1 a 3 ganglios; y / o ganglios mamarios internos no detectados

clínicamente
pN2: 4 a 9 ganglios axilares; o ganglios mamarios internos detectados clínicamente
pN3: cualquiera de los siguientes:
10 o más ganglios axilares
Ganglios infraclaviculares ipsolaterales
Ganglios mamarios internos detectados clínicamente con ganglios axilares
Ganglios mamarios internos no detectados clínicamente con más de 3 ganglios axilares
Ganglios supraclaviculares ipsolaterales
Metástasis (cM, clínica; pM, patológica) 2
M0: sin evidencia clínica o radiológica de metástasis
cM1: metástasis a distancia detectada por examen clínico o radiológico
pM1: metástasis a distancia probada histológicamente
Etapas 2
Etapa 0: TisN0M0
Estadio IA: T1N0M0
Estadio IB: T0N1M0 o T1N1M0
Estadio IIA: T0N1M0, T1N1M0 o T2N0M0
Estadio IIB: T2N1M0 o T3N0M0
Estadio IIIA: T0N2M0, T1N2M0, T2N2M0, T3N1M0 o T3N2M0
Estadio IIIB: T4N0M0, T4N1M0 Encontraste

o T4N2M0 tu respuesta?
×
sí No
Estadio IIIC: cualquier T, N3, M0

Etapa IV: cualquier T, cualquier N, M1
Diagnóstico
Presentación clínica
Historia
Comúnmente asintomático y detectado durante la mamografía de detección 8
Síntomas mamarios
Masa firme indolora en la mama detectada por el autoexamen de la paciente
Cambios en la piel o los pezones observados por el paciente
Secreción o sangrado del pezón
Poco común en cáncer de mama; si está presente, generalmente acompañado de otros síntomas
mamarios
Retracción del pezón
Eritema, engrosamiento o formación de hoyuelos en la piel suprayacente
Ulceración de la piel
Síntomas de la enfermedad metastásica
Hueso
Dolor de huesos
Hinchazón ósea
Cerebro
Dolor de cabeza persistente que empeora, particularmente al estar acostado

sí No
Alteraciones de la visión
Náuseas y vómitos
Embargo
Hígado
Ictericia
Prurito
Anorexia
Dolor abdominal
Pulmones
Disnea
Tos crónica
Dolor de pecho
Examen físico
Seno
La masa mamaria palpable es el signo más común 9
Clásicamente firme e indolora con bordes irregulares.
Signos epidérmicos 9 10
Asociado con cáncer de mama inflamatorio
Eritema, engrosamiento y sensibilidad de la piel
Hoyuelos en la piel (piel de naranja)
Asociado con la enfermedad de Paget
Escoriación o descamación del pezón
Ulceración de la piel
Secreción sanguinolenta del pezón Encontraste tu respuesta?

×
sí No
Retracción del pezón

Signos de diseminación locorregional o metastásica
Linfadenopatía axilar o supraclavicular palpable
Consolidación torácica (derrame pleural) en la auscultación
Hepatomegalia
Sensibilidad en los puntos óseos
Causas y factores de riesgo
Causas
La mayoría de los casos de cáncer de mama esporádico son causados por la acumulación de varias
alteraciones genéticas somáticas (incluidas variantes en loci particulares, así como reordenamientos
estructurales) que transforman el epitelio mamario normal en células malignas 11
Factores de riesgo y / o asociaciones
La edad
Las tasas de incidencia son más altas entre las mujeres de 40 años o más 1
El riesgo aumenta con la edad en las mujeres 12
Riesgo de por vida: 1 de cada 8
Desde el nacimiento hasta los 49 años: 1 de cada 49
De 50 a 59 años: 1 de cada 42
De 60 a 69 años: 1 de cada 28
70 años o más: 1 de cada 14
Sexo
Large majority (99% or more) of breast cancer
Encontraste tu cases occur in women 13
respuesta? ×
sí No

Genetics
Hereditary influences are implicated in 5% to 10% of cases of breast cancer in women 14 15
Genetic predisposition to breast cancer is associated with germline deleterious variants in

the BRCA1 and BRCA2 genes (OMIM #604370 and #612555) 16 17
Autosomal dominant inheritance
Lifetime breast cancer risk ranges from 80% to 90% for BRCA1 variant carriers and 60%
to 85% for BRCA2 variant carriers 14 18 19
Somatic alterations in tumor suppressor gene CHEK2 and in BRCA1- and BRCA2-modifier

genes BRIP1 and PALB2 confer a 20% to 40% lifetime risk of breast cancer 20 21
Genetic predisposition to basal-like (triple-negative) breast cancer is associated with variants

in BRCA1, BRCA2, PALB2, BARD1, RAD51D, RAD51C, and BRIP1 genes; however, most
triple-negative cancers do not carry these variants 22
An additional 5% of cases are associated with allelic variants in multiple genes, with low to
moderate penetrance, together contributing to the overall susceptibility to carcinogenesis 23
Other hereditary cancer syndromes associated with increased risk of breast cancer
Li-Fraumeni syndrome (germline variant in TP53) 24
Ataxia-telangiectasia (germline variant in ATM) 24
Cowden syndrome 25 or Bannayan-Riley-Ruvalcaba syndrome 26 (germline variants in PTEN)
Lifetime breast cancer risk is estimated to be between 25% and 50% in Cowden syndrome
25
Peutz-Jeghers syndrome (germline variant in STK11) 24
Neurofibromatosis (germline variant in NF1) 24
Ethnicity/race
In the United States, White women have the highest breast cancer incidence overall; American
Indian/Alaska Native women have the lowest incidence 27
Black women have highest breast cancer incidence

Encontraste among women younger than 40 years
tu respuesta? ×
sí No

Other risk factors/associations
Family history of breast cancer 28
Higher risk is associated with increasing number of first-degree relatives diagnosed with
breast cancer before age 50 years
Personal history of cancer in the ipsilateral or contralateral breast 29
Atypia or atypical hyperplasia or lobular carcinoma in situ on prior biopsies 30
Confers about 4.3 times greater risk of breast cancer compared with the general population
Reproductive factors
Early onset of menarche
Menarche at age 10 years or younger is associated with nearly 2-fold increased risk 31
Age at first birth older than 30 years 31
Nulliparity
Later onset of menopause (older than 50 years)
Menopausal hormone therapy
Combination menopausal hormone therapy with estrogen-progesterone is associated with

an increased risk of both total cases and invasive breast cancer, with relative risk of about 1.2
32
Risk is dependent on duration of use and agents used
Risk increases with duration of use; short-term use does not appear to be associated with an
increased risk of breast cancer 33 34
Estrogen-only menopausal hormone therapy (used after hysterectomy) is not associated with
increased risk 32
Radiation
Exposure of the breast to therapeutic radiation is associated with an increased risk of

developing breast cancer, starting 10 years after exposure and persisting throughout lifetime
Dense breasts Encontraste tu respuesta? ×

sí No

Women with dense breasts have increased risk, proportionate to degree of density
Slightly increased breast density: relative risk of about 1.8, compared with lowest density
35
Very dense breasts: relative risk of about 4.6, compared with lowest density 35
Obesity
Obese postmenopausal women (BMI of 30 kg/m² or greater) are at increased risk, with
relative risk of about 1.3 compared to women with weight within reference range (BMI less
than 25 kg/m²) 36
Alcohol consumption 37
Associated with increased risk in a dose-dependent fashion; the greater the consumption,
the greater the risk
At 3 to 6 drinks per week, relative risk is about 1.15
Diagnostic Procedures
Primary diagnostic tools

Palpable breast mass 9
Evaluation consists of history (including breast cancer risk assessment), physical

examination, and imaging, followed by biopsy
In women aged 30 years or older, diagnostic mammography or digital breast

tomosynthesis followed by ultrasonography is the initial imaging modality of choice for
evaluating clinically detected palpable breast masses 10 38
Typically mammogram and ultrasonogram are ordered simultaneously
For some women aged 30 to 39 years, ultrasonography can be used for the initial
evaluation if there is a low clinical suspicion or suspected simple cyst 10
In women younger than 30 years, ultrasonography is the initial imaging modality of

choice for evaluating a clinically detected palpable breast mass 38
Observation for 1 or 2 menstrual cycles may be considered in young women when

Encontraste tu respuesta?
there is low clinical suspicion ×
sí No
10
10
Mammography is recommended
Traducido al: español
if there is high suspicion for malignancyOpciones ▼
Mostrar texto original
Nonpalpable abnormalities on screening mammogram
Confirm findings with diagnostic mammogram and/or ultrasonography, followed by

biopsy if indicated 9
All patients with a clinically or radiologically suspicious breast lesion require biopsy
For nonpalpable abnormalities, biopsy guided by mammography, ultrasonography, or

MRI is standard
If breast cancer is confirmed at biopsy, additional investigations may include the following:
1
Assessment of axillary nodes with ultrasonography and fine-needle aspiration or core

biopsy of palpable or suspicious axillary nodes
Patients with clinically positive nodes will typically undergo axillary lymph node
dissection, and those with clinically negative nodes will undergo sentinel lymph node
biopsy
Breast MRI may be considered to characterize nodal disease or identify

mammographically occult tumors
Pregnancy testing if patient is of childbearing age
Determination of estrogen receptor, progesterone receptor, and HER2 status (on biopsy
specimen) 39
HER2 is ERBB2 (erb-b2 receptor tyrosine kinase 2)
Genomic molecular testing
Genetic molecular biomarker tests have an important role in providing prognostic

information and guiding treatment decisions 1 40
Testing can aid in determining need for adjuvant therapy in patients with hormone
receptor–positive breast cancers by identifying subset of patients with good
prognosis, in whom chemotherapy is of potentially limited benefit;
41
recommended for any hormone receptor–positive tumors that are at least 1 cm
and T1b lesion measuring 5 to 9 mm with unfavorable features 42
Performed on core biopsy or surgical specimens 42

sí No
Commercially available,
validated tests include Oncotype DX, MammaPrint,
Mostrar texto original
PAM50,
Opciones ▼
1 40
EndoPredict, and Breast Cancer Index
Additional testing in early-stage disease is not routinely required; obtain the following
as directed by symptoms: 1
CBC and comprehensive metabolic panel (including liver function tests and alkaline
phosphatase level)
Abdominal/pelvic CT or MRI if patient has elevated alkaline phosphatase level,

abnormal results on liver function tests, abdominal symptoms, or abnormal physical
examination findings in abdomen or pelvis
American College of Radiology recommends that, given the lack of difference in

survival or quality of life, there is little justification for imaging to detect or rule
out metastasis in asymptomatic women with newly diagnosed stage I breast cancer
43
Chest CT if pulmonary symptoms are present
Fludeoxyglucose F 18 PET-CT may be considered if findings on standard staging

investigations are equivocal or suspicious; it is not usually indicated in early-stage
disease
Bone scan or sodium fluoride PET-CT if localized bone pain or elevated alkaline
phosphatase level (may not be required if fludeoxyglucose F 18 PET-CT clearly
demonstrates bone metastases)
For metastatic (stage IV) disease, obtain the following: 1
CBC and comprehensive metabolic panel (including liver function tests and alkaline
phosphatase level)
Abdominal/pelvic CT or MRI, chest CT; optional fludeoxyglucose F 18 PET-CT
Brain MRI if symptoms are suggestive
Bone scan or sodium fluoride PET-CT
Consider germline BRCA1/2 testing if HER2-negative tumors are being considered

for chemotherapy
PD-L1 biomarker testing in triple-negative breast cancers
PIK-3CA variant testing ifEncontraste

hormonetureceptor–positive/
respuesta? HER2-negative and ×
considering therapy with alpelisib
sí No
Echocardiography or multiple gated acquisition scan

Performed to assess right and left ventricular function before start of cardiotoxic
chemotherapy (such as with doxorubicin) or anti-HER2 therapy
Laboratory
Imaging
Procedures
Differential Diagnosis
Most common
Simple breast cysts 54 Benign mass filled with serosanguineous or nonbloody fluid
May be solitary or part of spectrum of fibrocystic breast

changes
Most common breast mass, occurring in approximately 37%

of women undergoing screening ultrasonography 55
Well-circumscribed, ballottable mass on examination; may be

painless or tender and may fluctuate in size according to
stage of menstrual cycle
Expansion of cyst may cause acute onset of localized pain
Differentiated based on ultrasonographic appearance
Fibrocystic breast changes Nonmalignant breast condition that produce symptoms such
30
as breast lumps, diffuse swelling, and tenderness
Symptoms often fluctuate at different stages of menstrual

cycle
Widespread
the single most common finding of the breast
×
in women aged 20 years or older, representing
sí No

Breast tissue may have nodular consistency
Mostrar texto original Opciones ▼
Definitive exclusion of malignancy requires histologic

analysis in setting of suspicious findings
Fibroadenoma 56 Benign solid tumor composed of both the stromal and

epithelial elements of the breast
May increase in size over several months of observation
Fibroadenomas account for 50% of breast biopsies in women

older than 20 years and 75% in women younger than 20 years
56
Differentiated on examination by their firm, rubbery,

smooth, and distinct feel; carcinomas are typically firm but
less circumscribed, and moving them produces a drag of
adjacent tissue
Mammography is not useful for distinguishing between cysts

and fibroadenomas, but ultrasonography usually
demonstrates benign appearing, well-defined solid mass
Core needle biopsy confirms diagnosis but is not usually

indicated
Treatment
Goals
Cure where possible (stages I-III)
Palliation of symptoms, improvement in quality of life, and prolonged survival in metastatic

disease
Disposition
sí No

Admission criteria
Definitive surgery for primary tumor
Mastectomy often requires hospital admission depending on extent of surgery, presence of

medical comorbidities, and surgeon preference
Lumpectomy may be done on an outpatient basis
Emergent conditions requiring inpatient therapy include: 57
Spinal cord compression requiring urgent radiation therapy or urgent decompressive

laminectomy
Neutropenic fever
Severe hypercalcemia (calcium level more than 12 mg/dL) requiring IV fluids and/or
bisphosphonates
Pleural effusions requiring thoracentesis, chest tube placement, and/or supplemental

oxygen for palliative relief of dyspnea and hypoxia
Visceral crisis (presence of lymphangitic lung metastases, bone marrow replacement, brain
metastases, carcinomatous meningitis, and/or liver metastases), which requires aggressive
systemic cytotoxic therapy
Brain metastasis with cerebral edema requires dexamethasone and radiation therapy to
the space-occupying lesions
Recommendations for specialist referral

Multidisciplinary team approach is typically used, consisting of a breast surgeon, medical
oncologist, and radiation oncologist
Refer to plastic surgeon for reconstructive surgery
Refer to fertility specialist for counseling of women who are of childbearing age regarding
options for fertility preservation
Refer to genetic counselor, medical geneticist, or clinician experienced in cancer genetics if

genetic testing for breast cancer susceptibility genes is indicated 58
Refer to palliative care team for advanced disease

sí No

Treatment Options
Treatment approach is based on clinical and pathologic characteristics at diagnosis (as described
in National Comprehensive Cancer Network guidelines); stages are assigned according to
American Joint Committee on Cancer TNM anatomic stage 2 and hormone and growth receptor
status 1
Ductal carcinoma in situ (noninvasive breast cancer, stage 0)
Treatment consists of either lumpectomy (with or without whole-breast or partial-beast

radiation therapy) or total mastectomy (with or without sentinel node biopsy) 1
Decision to proceed with radiation therapy after breast-conserving surgery depends on

extent of surgery and/or involvement of surgical margins or lymph nodes 1
Some experts recommend that sentinel node biopsy be performed with mastectomy when
ductal carcinoma in situ is extensive, when there are large masses that contain it, or when
pathologic examination (intraoperative) finds high-grade ductal carcinoma in situ or
microinvasion
Complete axillary lymph node dissection is not required in the absence of invasive
cancer or axillary nodal involvement found on lymph node biopsy 1
Long-term, cause-specific survival with mastectomy appears to be equivalent to that with

local excision and whole-breast irradiation, based on data from randomized controlled
trials
After surgery, endocrine therapy for 5 years (tamoxifen in premenopausal women, and either
tamoxifen or an aromatase inhibitor in postmenopausal women) can be considered for
patients treated with breast-conserving therapy with or without radiation therapy who have
positive estrogen receptor status 1
Reduces risk of recurrent breast cancer in ipsilateral and contralateral breast in patients
with hormone receptor–positive ductal carcinoma in situ; however, no reduction in
overall mortality has been shown
Benefit of endocrine therapy for estrogen receptor–negative ductal carcinoma in situ is

uncertain; however, some patients elect for it to prevent new estrogen receptor–positive
ipsilateral or contralateral disease
Invasive breast cancer
Early stage (stages I, II, operable IIIA)

sí No

Treatment consists of either mastectomy or breast-conserving therapy, usually followed
by radiation therapy 1
Type of postoperative radiation therapy depends on status of axillary nodes and margins;
radiation therapy may not be required after mastectomy in patients with negative axillary
nodes, tumor measuring 5 cm or smaller, negative surgical margins, and no high-risk
features 1
Type and need for adjuvant systemic therapy is based on size of the cancer, axillary lymph
node status, hormone receptor status, and HER2 receptor status; patients may be treated
with neoadjuvant therapy preoperatively
Locally advanced (stages IIIA to IIIC)
Treatment for most patients consists of neoadjuvant systemic therapy followed by surgery,
postoperative radiation therapy, and adjuvant systemic therapy 1
Breast-conserving therapy or mastectomy may be performed depending on extent of

disease, response to preoperative systemic therapy, and patient preference 59
Metastatic disease (stage IV)
Treatment intent is palliative
Systemic therapy is standard treatment with options including endocrine therapy, HER2-
targeted therapy, CDK4/6inhibitors, mTOR inhibitors, PIK3CA inhibitors, PARP
inhibitors, and chemotherapy 59
Choice of treatment depends on prior endocrine therapy, hormone receptor and HER2
status, presence of BRCA variant, possibility of impending visceral crisis, and
reproductive status 1
Endocrine agents are typically the preferred initial treatment for most patients with
hormone receptor–positive cancers, owing to better tolerability and equivalent efficacy
Breast surgery may be performed palliatively for symptomatic metastases 59
Although surgery to remove the primary tumor is not standard treatment in metastatic
breast cancer, some retrospective studies have suggested that this could improve local
progression-free survival rates 60
Surgical treatment of metastatic disease sites may be required (eg, for isolated lung
metastases, pathologic fractures)
sí No
Radiation therapy may be administered for palliation of localized symptomatic metastases

59
Bone metastases may also be treated with bone-modifying agents (eg, denosumab,
pamidronate, zoledronic acid) to prevent skeletal adverse events, such as bone fractures,
bone pain, and hypercalcemia 1 61 62
Treatment modalities 1
Surgical treatment 1
Selection of surgical procedure depends on location and size of lesion, multifocality, breast
size, and patient preference for conserving breast; long-term survival outcomes are similar
for both approaches
Breast-conserving therapy
Consists of breast-conserving surgery (lumpectomy) to completely remove tumor with

sentinel lymph node sampling, followed by radiation therapy to eradicate any residual
disease and prevent recurrence
Total mastectomy with surgical axillary staging (sentinel lymph node sampling or
complete axillary lymph node dissection) with or without reconstruction
May also be followed by radiation therapy for patients with high risk of locoregional
recurrence
Surgical axillary staging may be performed concurrently 1
Patients with confirmed involvement of lymph nodes undergo axillary node dissection;
clinically suspicious lymph nodes should be biopsied before surgery
Clinically node negative patients undergo sentinel lymph node mapping and biopsy; if
lymph node involvement is identified may proceed with axillary lymph node dissection or
postoperative axillary radiation therapy
Patients with inflammatory breast cancer or locally advanced tumors with skin and/or
chest wall involvement should undergo axillary node dissection rather than sentinel node
biopsy 63
Radiation therapy 1
After breast-conserving therapy, either:
Whole-breast radiation targeting

or regional nodes, or
the entire breast; may be given with boost to tumor bed
sí No
Partial-breast irradiation (accelerated partial-breast irradiation), may be considered in

selected low-risk patients
After total mastectomy, both:
Chest wall irradiation targeting ipsilateral chest wall, mastectomy incision/scar, and drain
sites
Regional nodal irradiation targeting involved nodes or at-risk nodes identified at CT

staging/treatment planning
Systemic therapy
Includes chemotherapy, endocrine therapy, and HER2-targeting biologic therapies, other

targeting agents, and immune checkpoint inhibitors
Type and need for neoadjuvant and/or adjuvant systemic therapy is based on extent of
cancer, hormone receptor status, HER2 receptor status, and genomic information; regimens
are similar whether given preoperatively or as adjuvant therapy 1
There is no significant difference in long-term outcomes between preoperative and

postoperative systemic therapy 1
However, preoperative therapy may improve likelihood of successful breast

conservation, allow time for genetic testing and surgical planning, and provide
prognostic information based on tumor response 1
Systemic therapy is the primary treatment for metastatic or recurrent breast cancer;
endocrine agents are the preferred initial treatment for most patients with hormone
receptor–positive cancers, owing to better tolerability 1
Types of therapy
Endocrine therapy 1
Patients with estrogen receptor–positive and/or progesterone receptor–positive breast

cancers should be given adjunctive endocrine therapy to reduce risk of recurrence 64 65
All patients with lymph node–positive breast cancer, and some with lymph node–
negative disease, should be offered up to a total of 10 years of adjuvant endocrine
treatment 64
Choice of agent depends on reproductive status 64
Premenopausal women
sí No

Tamoxifen for 5 years with or without ovarian suppression or ablation, followed
by either an additional 5 years of tamoxifen or an aromatase inhibitor to
complete 10 years of endocrine treatment
Aromatase inhibitor therapy for 5 years plus ovarian suppression or ablation
Postmenopausal women
Tamoxifen for 4.5 to 6 years followed by either an additional 5 years of

tamoxifen or an aromatase inhibitor to complete 10 years of endocrine
treatment
Tamoxifen for 2 to 3 years, followed by an aromatase inhibitor to complete 5

years of endocrine therapy or for up to 5 years
Aromatase inhibitor for 2 to 3 years, followed by tamoxifen to complete 5 years

of endocrine therapy
Aromatase inhibitor for 5 years; consider continuing for an additional 3 to 5

years to complete 10 years of endocrine treatment 66 67
Tamoxifen for 5 to 10 years (if aromatase inhibitors are contraindicated or not

tolerated)
Some patients with low-risk luminal cancers or comorbidities may be given

preoperative endocrine therapy alone 1
Preoperative endocrine therapy is typically given for 6 months with aromatase

inhibitors the preferred option (with ovarian suppression in premenopausal women)
HER2-targeted therapy 68
Standard adjuvant treatment of HER2 receptor–positive disease is trastuzumab with or

without pertuzumab for 1 year after surgery 1
Standard treatment of metastatic HER2 receptor–positive disease is trastuzumab with

or without pertuzumab in conjunction with chemotherapy 1
Other targeted therapies and immune checkpoint inhibitors
Various other therapies are used in metastatic or recurrent disease based on breast
cancer subtype and molecular analysis
The following agents may be added to endocrine therapy in hormone-receptor positive

disease to help overcome resistance to hormonal agents 59
×
sí No

Mammalian target of rapamycin inhibitor (everolimus) may be used for metastatic
hormone receptor–positive disease that is resistant to endocrine therapy
Cyclin-dependent kinase inhibitors (palbociclib, abemaciclib, ribociclib)
Phosphatidylinositol kinase inhibitor (alpelisib)
Tyrosine kinase inhibitor (lapatinib) may be used in HER2 receptor–positive disease

that has progressed on trastuzumab
Poly (ADP-ribose) polymerase inhibitors (olaparib, talazoparib) may be used if BRCA1/2

variant is present
PD-L1 inhibitor (atezolizumab) if PD-L1 expression is present
Larotrectinib or entrectinib if NTRK gene fusion–positive disease
PD-1 inhibitor (pembrolizumab) if MSI-MMR variants are present
Chemotherapy 1 59
Standard adjuvant and neoadjuvant chemotherapy regimens are typically

anthracycline- or taxane-based
Given in conjunction with HER2-targeted therapy and/or endocrine therapy in patients

who test positive for these markers
Premenopausal women risk permanent amenorrhea and infertility after chemotherapy
Before treatment, arrange counseling regarding fertility preservation options (eg,

cryopreservation of mature oocytes or embryos)
Patients with triple-negative disease are treated with chemotherapy alone or with
immunotherapy
Preoperative and adjuvant regimens are similar
Single-agent chemotherapy is the standard treatment of metastatic or recurrent

disease; combination of agents may be used in some patients with high tumor burden,
rapidly progressive disease, or visceral crisis 1
Bisphosphonates
Recommended in treatment of bone tu

Encontraste metastases
respuesta? ×
sí No
May be considered inMostrar

postmenopausal
texto original
women (and premenopausal womenOpciones ▼
receiving
ovarian suppression) with early-stage breast cancer, particularly in patients at higher
risk of recurrence, who are receiving adjuvant endocrine therapy 69 70
Bisphosphonates have potential anticancer effects that appear to improve long-term

outcomes (ie, reduce distant recurrence, bone recurrence, and breast cancer
mortality) in postmenopausal women or those receiving ovarian suppression therapy
69 71
Zoledronic acid and clodronate are the recommended bisphosphonates for adjuvant
therapy in breast cancer 69 70 72
While results for adjuvant denosumab look promising, data are insufficient to make
any recommendation regarding its use in the adjuvant setting 69
Nondrug and supportive care

Radiation therapy
Administered daily over multiweek periods 9
Whole-breast irradiation is the most common form administered after breast-conserving

surgery 73
Radiation therapy is directed at the whole breast and may or may not include a boost or
extra dose of radiation to the initial tumor site; boost to tumor bed may improve local
control but does not appear to have other benefits 74
May also involve irradiation of regional nodes and chest wall 1
Radiation therapy to the conserved breast reduces mortality rate by approximately 15% 75
Adjuvant radiation therapy after mastectomy may consist of regional node and/or chest wall
irradiation
Associated with reduced rates of locoregional recurrence and improved long-term survival
rates in patients with high-risk breast cancers 76 77
Radiation therapy may be palliative for symptomatic metastases
Complications
Radiation pneumonitis
Brachial plexopathy (dose-response effect)

sí No
78
Secondary malignancies
(low risk) 78
Cardiac events
Arm edema (increased risk in patients who received axillary dissection)
Procedures
Breast-conserving surgery (lumpectomy)
General explanation 79
Surgical excision of primary tumor with adequate margins
Stage 0 disease does not require lymph node surgery; stage I, II, and IIIA disease require
surgical axillary staging
Usually followed by whole-breast irradiation
Rate of recurrence and overall survival are equivalent to that of mastectomy when followed by
radiation therapy to ensure eradication of any residual disease
Indication 79
Localized breast carcinoma (eg, ductal carcinoma in situ, stages I-III)
Appropriate for all histologic subtypes
Contraindications 1
Absolute
Pregnancy, owing to need for radiation after lumpectomy
Diffuse suspicious microcalcifications
Widespread or multifocal disease
Diffusely positive pathologic margins
Homozygous for ATM variant

Inflammatory breast cancer sí No
RelativeTraducido al: español Mostrar texto original Opciones ▼
Prior radiation therapy to chest wall (eg, mantle radiation for lymphoma)
Active collagen vascular disease
Positive pathologic margin
Known or suspected genetic predisposition to breast cancer
Large tumor (relative to size of breast), owing to risk of poor cosmetic outcome
Complications
Lymphedema (5%-20%) 9
Mastectomy
General explanation 9
Surgical removal of breast, unilaterally or bilaterally
A variety of techniques are used, including modified radical mastectomy, total mastectomy,
skin-sparing mastectomy, and nipple-sparing mastectomy; technique will depend on
indication for mastectomy and on whether patient is having reconstructive surgery or requires
postoperative radiation therapy
Breast reconstructive surgery may be performed at same time as mastectomy (immediate) or

after breast cancer treatment is complete (delayed)
Procedures may incorporate breast implants placed immediately or after tissue expanders,
autologous tissue transplant, or both
Axillary nodes are evaluated by sentinel lymph node biopsy if clinically node-negative, or by
axillary lymph node dissection if clinically node-positive or if sentinel node biopsy results are
positive 63 80
Indication 9
Local recurrence of previously treated breast cancer
Multifocal breast cancer, including multifocal ductal carcinoma in situ

sí No
Large tumor (relative to size of breast) that would preclude a lumpectomy owing to predicted
poor aesthetic outcome
Presence of contraindication to radiation therapy, precluding breast-conserving therapy

(lumpectomy followed by local breast irradiation), such as pregnancy
Breast cancer with a known genetic cause; bilateral mastectomy for breast cancer risk reduction
Inflammatory breast cancer
Contraindications 9
Known coagulopathy and anticoagulant therapy are relative contraindications
Complications
Seroma or hematoma
Skin flap necrosis
Chronic postmastectomy pain
Complications secondary to axillary node dissection
Lymphedema (5%-20%); may be disfiguring and permanent, and it may be associated with
an increased risk for cellulitis in the affected arm 9
Nerve injury
Comorbidities
Cardiac disease
Coexisting cardiac conditions may limit choices for some systemic therapies
Use of anthracycline-based chemotherapy and anti-HER2 therapy in women with known

heart disease requires careful monitoring of cardiac condition
If severe heart disease coexists, anthracycline-based treatment is contraindicated
Hepatic or renal disease
Chemotherapeutic agent selection requires consideration of kidney and liver function,

because most agents are excreted by one of these routes
×
sí No

Special populations
Pregnant patients 81
Breast cancer is the most common cancer in pregnant and postpartum women; it occurs in
approximately 1 in 3000 pregnant patients
Surgery is recommended as the primary treatment of breast cancer in pregnant patients
Modified radical mastectomy is treatment of choice if breast cancer diagnosis is made

early in pregnancy
If diagnosis is made late in pregnancy, breast-conserving surgery followed by postpartum

radiation therapy has been used for breast preservation
Data suggest that it is safe to administer many chemotherapeutic drugs after the first
trimester
Advanced stage at presentation accounts for poorer prognosis and survival
Avoid endocrine therapy and trastuzumab during pregnancy
Breastfeeding patients
Breastfeeding after breast-conserving treatment is not contraindicated, but quantity and

quality of milk may be insufficient
Breastfeeding during active treatment with chemotherapy and endocrine therapy is

inadvisable
Older women (eg, those aged 65 years or older)
Cancers in older patients are as aggressive as those in younger patients; treat them similarly
Healthy older women with life expectancies exceeding 10 years are advised to receive
contemporary standard of care in breast cancer treatment 82
Older women may opt to forgo axillary lymph node surgery or radiation therapy if treated
with endocrine therapy after breast-conserving surgery
For women with hormone receptor–positive disease who cannot undergo surgery owing
to limited life expectancy or comorbidities, primary endocrine therapy with either
tamoxifen or an aromatase inhibitor can be used and can provide years of disease control
even in the absence of surgery 83
sí No
Adolescents and young adults

Premenopausal women risk permanent amenorrhea and infertility after chemotherapy
Before treatment, arrange counseling on fertility preservation options (eg,

cryopreservation of mature oocytes or embryos)
Pregnancy should not occur during treatment with radiation therapy, systemic therapy, or
endocrine therapy
Contraceptive options to offer include intrauterine devices, barrier methods, or tubal

ligation; hormone-based birth control, regardless of hormone receptor status of the
cancer, is contraindicated
Endocrine therapies frequently result in menopausal signs and symptoms in younger

women 84
Management with lifestyle interventions, integrative therapies, and nonhormonal

medications (eg, selective serotonin reuptake inhibitors, serotonin-norepinephrine
reuptake inhibitors, gabapentin) is preferred 85
Menopausal hormone therapy is contraindicated in patients with history of breast cancer
Women with osteopenia or osteoporosis
Ovarian failure secondary to use of chemotherapy or induced by aromatase inhibitor therapy

is common
Provide bone protection for the duration of aromatase inhibitor therapy in all women with t
score of −2 or less, or with t score of less than −1.5 and 1 additional risk factor, or with 2 or
more risk factors (not including bone mineral density) 86
Bisphosphonates are the preferred pharmacologic agents to prevent bone loss induced by
adjuvant endocrine therapy and to increase bone density in women with breast cancer (or
history thereof ) who have osteopenia or osteoporosis 87
In premenopausal women, zoledronic acid is preferred 88
In postmenopausal women, either an oral bisphosphonate or IV zoledronic acid may be

used; both have been shown to be effective in reducing bone loss caused by aromatase
inhibitor therapy 87
Continue treatment with bisphosphonates at least until adjuvant therapy is complete;

optimal duration beyond this point is not established 87
Alternative agent is denosumab; evidence

Encontraste base is less extensive than for bisphosphonates,
tu respuesta?
but denosumab has also been foundsíto reduce fractures in postmenopausal women with
×
No
88
hormone receptor–positive breast cancer treated with adjuvant aromatase inhibitors 88

Bisphosphonates also have potential anticancer effects that appear to improve long-term
outcomes (ie, reduce distant recurrence, bone recurrence, and breast cancer mortality) in
postmenopausal women or premenopausal women receiving ovarian suppression therapy 69
71
Zoledronic acid and clodronate are the recommended bisphosphonates for adjuvant
therapy in breast cancer 69 70
Avoid estrogen and selective estrogen receptor modulators in women with breast cancer 1
Women with known pathologic variants in breast cancer susceptibility genes 89
Women with BRCA1/2 variants are at increased risk of developing contralateral breast
cancers and new cancers in the ipsilateral breast
May be managed same as for noncarriers (including breast-conserving surgery if

indicated); however, discussion is warranted regarding bilateral mastectomy at time of
treatment of primary cancer 90
In advanced disease, PARP inhibitors (olaparib or talazoparib) are options for

nonchemotherapeutic treatment, and platinum agents are preferable over taxanes
Women with variants in moderate-risk genes may be treated as for noncarriers (including
breast-conserving surgery and radiation therapy if appropriate)
In women with germline variants associated with sensitivity to radiation (eg, ATM, TP53,
RB), mastectomy is recommended and radiation therapy is contraindicated in most cases
Women with inflammatory breast cancer
Rare aggressive form of locally advanced breast cancer 91
May initially be presumed to be mastitis based on clinical presentation
Suspect in rapidly progressive inflammation of breast that does not improve with antibiotic
therapy
Diagnostic evaluation is similar to that of noninflammatory breast cancer; additionally,

a full-thickness skin punch biopsy should be obtained 92
Treatment is similar to that of noninflammatory locally advanced breast cancer, consisting

of systemic therapy in addition to mastectomy, axillary lymph node dissection, and radiation
therapy; breast-conserving therapy and sentinel
Encontraste lymph node biopsy are contraindicated 63
tu respuesta? ×
sí No
Associated with poorer prognosis and higher risk of early recurrence compared with
noninflammatory breast cancers 93
Monitoring
For staging or assessment of response to therapy in patients with locally advanced breast
cancer and suspected metastatic disease, either whole-body PET-CT or bone scan combined
with contrast-enhanced abdominal CT remains the standard, with the choice varying primarily
by institutional preferences 47
Follow-up includes monitoring for recurrent disease and complications arising from disease
or treatment, management of any ongoing treatment, coordination of care, and counseling
regarding measures to reduce risk of recurrence 84
Patients on endocrine therapy require monitoring of bone health (including bone density

assessment at baseline and every 2 years) 84 and annual gynecologic assessment if uterus is
intact
Encourage adherence to endocrine therapy and address any adverse effects such as hot
flashes or sexual dysfunction 84
National Comprehensive Cancer Network 85 and American Society of Clinical Oncology 84

provide detailed guidance regarding issues such as nutrition, physical activity,
immunizations, and the management of common ongoing concerns in breast cancer
survivors including menopause, cardiovascular disease, pain, and neuropsychiatric issues
Monitoring for recurrent disease
Ductal carcinoma in situ 1 94
History and physical examination every 6 to 12 months for 5 years, then annually
Mammogram every 12 months (6-12 months after radiation therapy if breast is conserved)
For those treated with endocrine therapy, monitor for hot flashes and abnormal vaginal
bleeding 79
Breast cancer after completed primary therapy with curative intent 1
History and physical examination 2 to 4 times per year for 5 years, and annually thereafter
94
Annual mammography
sí No

Consider supplemental screening in those diagnosed at age younger than 50 years or
with dense breasts 95
In the absence of clinical signs or symptoms suggesting recurrence or metastasis, no

additional screening is required
There are no survival differences between women who obtain intensive screening and
surveillance with imaging and laboratory studies compared with women who undergo
testing only after development of symptoms or findings on clinical examinations 43
Monitoring patients with metastatic disease 1
Periodically assess symptoms, physical examination findings, laboratory test results, and
imaging findings
Frequency of interval examination and testing varies and is primarily based on monitoring
strategies used in breast cancer clinical trials
Monitoring parameters include:
Symptom assessment (pain, dyspnea, or adverse effects from systemic therapy)
Physical examination, including body weight
Performance status
Liver function tests, serum calcium level, and CBC
Tumor biomarkers, when appropriate
Complications and Prognosis
Complications
Locoregional recurrence
Typically involves chest wall, axillary or supraclavicular lymph nodes, or skin
Metastases
May involve any organ; most common sites include bone, brain, lung, and liver ×
sí No

Such metastases manifest as pleural effusions, bone marrow infiltration, liver failure,
pain, and pathologic fractures
With advanced disease, presentation may not be straightforward and may involve
paraneoplastic syndromes or neuropathic pain from spinal cord involvement
Hypercalcemia associated with malignancy 96
Presents with a constellation of variable symptoms, including neurocognitive dysfunction

(eg, anxiety, mood disturbance, cognitive impairment, altered mental status), polyuria,
anorexia, constipation, and arrhythmia
Requires prompt treatment with IV fluids and bisphosphonates if calcium levels exceed 14
mg/dL (some clinicians choose lower thresholds)
Second breast cancer
High risk of second primary tumor in women with genetic predisposition to breast cancer
Complications of treatment
Upper extremity lymphedema 97
Upper extremity musculoskeletal or neurologic injuries
Radiation-induced soft tissue necrosis or fibrosis
Premature menopause and infertility 98
Cardiac dysfunction (cardiomyopathy and congestive heart failure) 99
Malignancies (eg, myelodysplastic syndrome, acute myelogenous leukemia) 100
Cognitive impairment
Prognosis
Prognosis after curative therapy depends on the following:
Patient age and ethnicity
Tumor size, type, and histology
Extent of nodal or distant metastases ×
sí No
Hormone and growth receptor

status of tumor
Genomic profile
5-year relative survival (all ages, all races) 27
All stages: 90%
Stage 0 (in situ): 100%
Stage I (local): 98.9%
Stage II or III (regional): 85.7%
Stage IV (distant): 28.1%
Unstaged: 55.1%
Screening and Prevention
Screening
At-risk populations
All women are considered at risk owing to the relatively frequent incidence in the general
population
Individual patient risk can be stratified based on presence of the following risk factors;
presence of any of these factors indicates that the patient is at higher than average risk for
developing breast cancer: 10
Personal or family history of breast, ovarian, fallopian tube, or peritoneal cancer
Earlier history of high-risk benign breast lesion
Lobular neoplasia (lobular carcinoma in situ or atypical lobular hyperplasia)
Atypical ductal hyperplasia (when lifetime breast cancer risk is 20% or greater)
Known genetic predisposition to breast cancer

sí No

Most commonly associated with germline deleterious variants in BRCA1 and BRCA2
genes
Other hereditary cancer syndromes associated with increased risk of breast cancer include
Li-Fraumeni syndrome (germline variant in TP53), ataxia-telangiectasia (germline variant
in ATM), Cowden syndrome and Bannayan-Riley-Ruvalcaba syndrome 26 (both germline
variants in PTEN), Peutz-Jeghers syndrome (germline variant in STK11), and
neurofibromatosis (germline variant in NF1)
Other pathogenic gene variants may be identified (eg, in CHEK2 or PALB2)
Ancestry associated with BRCA1/2 variants (eg, Ashkenazi Jewish descent)
Thoracic radiation therapy between ages 10 and 30 years
Women without any of these risk factors are considered to be at average risk for developing
breast cancer (defined as less than 15% lifetime risk) 10
Clinical risk prediction calculators may be used to aid risk stratification
Breast Cancer Risk Assessment Tool (Gail model) is most widely used 101
Calculates patient risk based on age, age at menarche, age at first live birth, first-degree
relatives with breast cancer, previous breast biopsies, presence of atypical hyperplasia in a
breast biopsy, and race
Women aged 35 years or older with a 5-year Gail model risk of invasive breast cancer of
1.7% or more are considered at increased risk
This applies only to women without strong family history of breast and related cancers
Familial risk assessment tools such as the BOADICEA model (Breast and Ovarian Analysis of
Disease Incidence and Carrier Estimation Algorithm), BRCAPRO, Ontario Family History
Risk Assessment Tool, and IBIS tool (International Breast Cancer Intervention Study, Tyrer-
Cuzick model) are alternatives for women with strong family history or known BRCA
variants 102 103
Women whose lifetime risk of breast cancer is 20% or more according to these models are
considered at increased risk 10
Women with breast implants are at risk of developing breast implant–associated anaplastic
large cell lymphoma (a form of T-cell lymphoma) 10
Observe for development of implant-related symptoms such as effusion, enlargement, or ×
sí No
ulcerating mass more than a year after implant surgery (on average after 7-9 years)
Evaluate only if symptomatic

Screening tests
All women, especially Black women and those of Ashkenazi Jewish descent, should be
evaluated for baseline breast cancer risk no later than age 30 years, so that those at higher risk
can be identified and can benefit from supplemental screening 104
Discuss potential benefits and harms of breast cancer screening with mammography;
balance between benefits and harms depends on patient age and baseline risk
Clinical breast examination for breast cancer screening among average-risk women at any
age is not essential; however, it is often performed in combination with mammography
Consider genetic testing for breast cancer susceptibility genes in selected patients to
determine approach to surveillance 105
Discuss supplemental screening with contrast-enhanced breast MRI in conjunction with

mammography for women who are at high risk for breast cancer (more than 20% lifetime
risk) 10
Genetic testing for breast cancer susceptibility genes
Women with personal or family history of cancer of breast, ovary, fallopian tube, or
peritoneum, or with ancestry associated with BRCA1/2 variants, should be evaluated using a
and referred for genetic testing accordingly 102
Refer to genetic counselor, medical geneticist, or clinician experienced in cancer genetics

26
Women who had negative genetic test results in the past, particularly if before 2014, should
be considered for repeated evaluation and testing with contemporary multigene panels 106
National Comprehensive Cancer Network recommends testing for breast cancer

susceptibility genes in patients with the following: 26
Relative with known pathogenic variant in a cancer susceptibility gene
Personal history of breast cancer
Diagnosed at age 45 years or younger
Diagnosed at age 46 to 50 years with a second breast cancer at any age, or unknown
family history, or 1 or moreEncontraste
cancer at any age
close relatives with breast, ovarian, pancreatic, or prostate
tu respuesta? ×
sí No
Triple-negative cancer diagnosed at age 60 years or younger

Diagnosed at any age with Ashkenazi Jewish ancestry, or 1 or more close relative with
breast cancer aged younger than 50 years, or ovarian, pancreatic, or prostate cancer at
any age, or 3 or more cases of breast cancer among patient and close relatives
Personal history of ovarian, fallopian tube, peritoneal, or exocrine pancreatic cancer
Family history of cancer
First-degree relative who meets any of the above criteria
Greater than 5% probability of BRCA1/2 pathogenic variant based on a probability

model
May also be considered in patients with bilateral breast cancer diagnosed at ages 50 to 65
years, Ashkenazi Jewish ancestry, or 2.5% to 5% probability of BRCA1/2 pathogenic variant
based on a probability model
Testing may identify pathogenic variants in BRCA1, BRCA2, TP53, ATM, CDH1, CHEK2,
PALB2, PTEN, and various other genes 26
Results may dictate subsequent screening intervals and modalities and risk reduction
measures
Breast cancer screening modalities
Mammography
Primary breast cancer screening modality
Combined use of digital mammography (2D images) with digital breast tomosynthesis
(3D images) results in better detection of cancers and lower false-positive results; this is
the preferred technique 10 95
Contrast-enhanced breast MRI
More sensitive than mammography or ultrasonography in high-risk women; however,

higher rate of false-positive results
Preferred as supplemental screening method in women at high risk of breast cancer
Not recommended for supplemental screening in women with dense breasts, except in
those with history of prior breast cancer at young age 95 107 108
sí No
Involves use of gadolinium contrast media; there is evidence of gadolinium deposition in

brain and bone in patients who undergo multiple contrast-enhanced MRIs. The clinical
significance of this fact is uncertain, because no adverse health effects have been
identified 10 109
Whole-breast ultrasonography
Option for supplemental screening in high-risk women if MRI is contraindicated or

declined 95
May be an option for supplemental screening in women with dense breasts; however, it is
not routinely recommended 10 108
Detects additional cancers not identified on mammography, but it yields more false-
positives than MRI and mammography 10 95
Best as diagnostic technique rather than as screening method
Molecular breast imaging
Emerging techniques such as sestamibi scans, breast-specific gamma imaging, and PET
mammography may have a role in screening women with mammographically dense
breasts 10 95
Not currently in routine use
Contrast-enhanced mammography
Emerging technique; not routinely used 95
Screening recommendations vary slightly among organizations and according to risk status of
woman
Women with average risk for breast cancer
National Comprehensive Cancer Network, American College of Radiology, American

College of Obstetricians and Gynecologists, and American Society of Breast Surgeons
recommend beginning screening mammography at age 40 years in women with average
risk of breast cancer 10 95 104 110
Most organizations recommend annual screening mammography
American College of Obstetricians and Gynecologists recommends screening

mammography every 1 or 2 years 110
sí No
Screening should continue until at least age 75 years or until life expectancy is less than
107 110
10 years
American Society of Breast Surgeons suggests considering supplemental screening in

women with extremely dense or heterogeneously dense breasts
American Cancer Society recommends regular screening mammography starting at age 45

years 111
Screen annually in women aged 45 to 54 years
In women aged 55 years or older, advise to transition to biennial screening but offer
opportunity to continue annual screening (patient choice)
Women should continue screening mammography as long as their overall health is

good and they have a life expectancy of 10 years or longer
Provide opportunity to begin annual screening (patient choice) in women aged 40 to 44

years
US Preventive Services Task Force recommends biennial screening mammography for

women aged 50 to 74 years 8
Decision to start regular biennial screening mammography before age 50 years should
be individualized, taking context into account, including the patient's values regarding
specific benefits and harms 8
Beginning mammography screening at a younger age and screening more frequently

may increase the risk for overdiagnosis and subsequent overtreatment 8
Women with a parent, sibling, or child with breast cancer are at higher risk for breast
cancer and thus may benefit more than average-risk women from beginning
screening between ages 40 and 49 years
Current evidence is insufficient to assess the additional benefits and harms of

screening mammography in women aged 75 years or older 8
Available evidence does not suggest a beneficial effect of screening by breast self-
examination but does suggest increased harm in terms of increased number of benign
lesions identified and increased number of biopsies performed 112
Women at increased risk for breast cancer
Women with a lifetime risk of 15% to 20% may be considered for supplemental screening
on an individual basis (eg, patient wishes)
Encontraste
10
tu respuesta? ×
sí No

MRI screening is not recommended for women whose lifetime risk of breast cancer is
less than 15% 111
Women aged 35 years or older with a 5-year Gail model risk of invasive breast cancer of at
least 1.7% 10
Clinical assessment every 6 to 12 months beginning when identified at higher risk
Annual mammographic screening from the time identified as at high risk
Women with a lifetime risk of breast cancer greater than 20% (defined by models that
depend on family history)
National Comprehensive Cancer Network
Clinical assessment every 6 to 12 months beginning when identified at higher risk

but not before age 21 years
Annual screening mammograms starting 10 years before age at which youngest

affected family member was diagnosed, or at time of lobular carcinoma in situ
diagnosis but not before age 30 or 40 years (whichever comes first)
Also recommend annual breast MRI starting 10 years before age at which youngest
affected family member was diagnosed, or at time of lobular carcinoma in situ
diagnosis but not before age 25 or 40 years (whichever comes first)
Consider whole-breast ultrasonography or contrast-enhanced mammography if

patient cannot undergo breast MRI
American College of Radiology 104
Mammography annually beginning at age 30 years
Breast MRI annually beginning at age 25 to 30 years
Breast MRI is also recommended for women with previous breast cancer and
dense breast tissue, or diagnosis before age 50 years
Others with histories of breast cancer and those with atypia at biopsy should
consider additional surveillance with breast MRI
American Society of Breast Surgeons
Begin annual screening mammography with or without supplemental screening at

age 35 years
sí No
111
American Cancer Society 111

Perform breast MRI and a mammogram every year, typically starting at age 30 years
Women with history of lobular neoplasia or atypical ductal hyperplasia and a lifetime risk
of breast cancer greater than 20% (defined by models that depend on family history) 10
National Comprehensive Cancer Network recommends annual screening

mammograms beginning at time of diagnosis but not before age 30 years
Also consider annual breast MRI starting at time of diagnosis but not before age 25
years
Whole-breast ultrasonography or contrast-enhanced mammography is an

alternative if patient cannot undergo breast MRI
Women who are BRCA1/BRCA2-positive 26
Breast awareness (including periodic self-examination) starting at age 18 years
Clinical breast examination every 6 to 12 months starting at age 25 years
Annual breast MRI with contrast enhancement (mammogram only if MRI

unavailable) from age 25 to age 29 years
Annual mammogram and MRI with contrast enhancement from age 30 to age 75
years
Mammography annually beginning at age 30 years
Ultrasonography is an alternative option for women at high risk who cannot

undergo MRI
(also in patients with first-degree relative with a BRCA1 or BRCA2 variant if patient
not tested)

sí No

Begin annual screening mammography with or without supplemental screening at
age 35 years
Women with other breast cancer susceptibility genes 26
National Comprehensive Cancer Network recommendations are similar to those for

women who are BRCA1/2-positive
Recommendations for specific gene/syndrome may be found in National

Comprehensive Cancer Network guideline for genetic/familial high-risk assessment
(breast, ovarian, and pancreatic)
American Cancer Society recommends breast MRI and a mammogram every year,

typically starting at age 30 years in patients with Li-Fraumeni syndrome, Cowden
syndrome, or Bannayan-Riley-Ruvalcaba syndrome, and those who have first-degree
relatives with 1 of these syndromes
Women at increased risk owing to thoracic radiation therapy between ages 10 and 30 years
Clinical assessment every 6 to 12 months beginning 10 years after completion of

radiation therapy
Annual screening mammograms starting 10 years after completion of radiation

therapy but not before age 30 years
Annual breast MRI starting 10 years after completion of radiation therapy but not
before age 25 years
Consider whole-breast ultrasonography or contrast-enhanced mammography if

patient cannot undergo breast MRI
Mammography annually beginning at age 25 years or 8 years after radiation therapy,

whichever is later
Ultrasonography is an alternative option for women at high risk who cannot

undergo MRI

sí No

Begin annual screening mammography at age 30 years
Begin annual screening MRI at age 25 years
Women with extremely dense breasts on mammography 10
National Comprehensive Cancer Network recommends use of digital mammography

combined with digital breast tomosynthesis, because the combination provides
improved cancer detection
Handheld or automated breast ultrasonography may also increase detection rate
Patients should be counseled regarding benefits and risks of supplemental screening

in view of reduced sensitivity of mammography
Prevention
Surgical excision of high-risk breast lesions
Lobular carcinoma in situ and atypical ductal or lobular hyperplasia are associated with
increased risk of breast cancer 79
Typical forms do not require surgical excision unless there is evidence of a histologically
aggressive variant that has greater potential to develop into an invasive carcinoma 1
Management consists of surveillance with physical examination, ultrasonography, and/or

mammography every 6 to 12 months
Subtypes that carry higher risk for invasive carcinoma (eg, multifocal or extensive lobular
carcinoma in situ involving more than 4 terminal lobular ductal units in a single core biopsy
specimen) are treated with complete surgical excision with negative margins 10
Risk reduction systemic therapy should be strongly recommended to patients with lobular
carcinoma in situ or atypical hyperplasia; it is associated with 86% reduction in risk of breast
cancer in women with atypical hyperplasia 79
Risk reduction measures for patients with a high risk of breast cancer owing to prior high-risk
breast lesions or known genetic predisposition or strong family history 79
Lifestyle modifications
sí No

Encourage patients to get daily activity; recommend at least 150 minutes of moderate
intensity aerobic activity or 75 minutes of vigorous aerobic activity per week 79
Limit consumption of alcoholic drinks 79
Achieve and maintain healthy weight 79
Encourage breastfeeding 79
Cautions regarding hormone therapy
Oral contraceptives containing both estrogen and progesterone may be associated with a
very small increase in risk of breast cancer and are not recommended in women with
personal history of breast cancer; however, family history or genetic predisposition is not
a contraindication to use 14 113 114
Postmenopausal hormone replacement therapy appears to increase risk of breast cancer

modestly; risk increases with longer duration of use 115 116 117 118
Contraindicated in women with personal history of breast cancer
Acceptable for treatment of menopausal symptoms in women at increased risk of

breast cancer if alternatives are ineffective
Risk is greater with combined estrogen-progestin preparations compared with

estrogen-only hormone replacement therapy
Risk-reducing medical therapy
May be offered to patients with life expectancy of 10 years or longer and any of the
following: 79
Known genetic predisposition
Family history suggestive of genetic predisposition
Lifetime risk of breast cancer is 20% or more according to models based on family
history
Lobular carcinoma in situ
Atypical ductal or lobular hyperplasia
5-year Gail model risk of invasive breast cancer of 1.7% or more

sí No
Tamoxifen, raloxifene, anastrozole, and exemestane have been shown to decrease

incidence of breast cancer in high-risk women 79 119
US Preventive Services Task Force recommends that these agents be offered to

women aged 35 years or older who are at increased risk for breast cancer and have low risk
of adverse effects of the medication 120
Tamoxifen is the only agent indicated in premenopausal women; any agent may be used
in postmenopausal women 119
Optimal duration has not been established, but 5 years is recommended when drug is
used for risk reduction purposes 79
Patients require monitoring for early detection of breast cancer and for adverse effects of
medications (eg, endometrial cancer, ophthalmologic conditions, osteoporosis,
thromboembolic disease)
Prophylactic bilateral mastectomy (risk-reducing mastectomy)
For women at very high risk, prophylactic bilateral mastectomy significantly lowers risk of
breast cancer 79 121
Generally considered only for women with known genetic variant associated with high
risk for breast cancer, strong family history, or prior thoracic radiation therapy at age
younger than 30 years 79
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Common subtypes accounting for most cases

Ductal (about 75%) 3

Lobular (about 8%) 4

Mixed: ductal and lobular (about 5%) 4

Rare subtypes account for around 10% of cases altogether 1 3

Inflammatory Encontraste tu respuesta? ×

Paget disease, infiltrating

Ductal carcinoma in situ

Noninvasive neoplasm of ductal origin that can progress to invasive cancer

Variable histopathology and malignant potential

Paget disease of breast

Lobular carcinoma in situ 1

Hormone and growth receptor status 1

Estrogen receptor expression

Progesterone receptor expression

HER2 overexpression (about 15%-20% of cases 5)

Androgen receptor expression 6 7

Triple-negative (ie, estrogen receptor–negative, progesterone receptor–negative, and HER2-

Major molecular subtypes

Luminal subtypes (overlap with estrogen receptor positivity)

Basal-like (typically estrogen receptor–negative, progesterone receptor–negative, and HER2-

TX: no se puede evaluar el tumor primario

T0: sin evidencia de tumor primario

Tis: tumor in situ (carcinoma ductal in situ)

T1: tumor de hasta 20 mm en su mayor dimensión

T2: tumor mayor de 20 mm, hasta 50 mm en su mayor dimensión

T3: tumor mayor de 50 mm en su mayor dimensión

T4: tumor de cualquier tamaño con invasión regional

Nodos (cN, clínico; pN, patológico) 2

cNX: no se pueden evaluar los ganglios regionales

cN1: ganglios axilares ipsilaterales móviles

cN3: ganglios ipsolaterales además de ganglios axilares

pNX: no se pueden evaluar los ganglios regionales

pN0: sin metástasis en los ganglios regionales en el examen histológico

pN1: micrometástasis o metástasis en 1 a 3 ganglios; y / o ganglios mamarios internos no detectados

pN2: 4 a 9 ganglios axilares; o ganglios mamarios internos detectados clínicamente

pN3: cualquiera de los siguientes:

10 o más ganglios axilares

Ganglios infraclaviculares ipsolaterales

Ganglios mamarios internos detectados clínicamente con ganglios axilares

Ganglios mamarios internos no detectados clínicamente con más de 3 ganglios axilares

Ganglios supraclaviculares ipsolaterales

Metástasis (cM, clínica; pM, patológica) 2

M0: sin evidencia clínica o radiológica de metástasis

cM1: metástasis a distancia detectada por examen clínico o radiológico

pM1: metástasis a distancia probada histológicamente

Estadio IA: T1N0M0

Estadio IB: T0N1M0 o T1N1M0

Estadio IIA: T0N1M0, T1N1M0 o T2N0M0

Estadio IIB: T2N1M0 o T3N0M0

Estadio IIIA: T0N2M0, T1N2M0, T2N2M0, T3N1M0 o T3N2M0

Estadio IIIB: T4N0M0, T4N1M0 Encontraste

Estadio IIIC: cualquier T, N3, M0

Etapa IV: cualquier T, cualquier N, M1

Comúnmente asintomático y detectado durante la mamografía de detección 8

Masa firme indolora en la mama detectada por el autoexamen de la paciente

Cambios en la piel o los pezones observados por el paciente