COME HOME Breast Cancer Pathway

DCIS

Primary Therapy

  • Mastectomy +/- sentinel lymph node dissection (high grade)
  • Excisional lumpectomy +/- radiation (optional if low risk)

Adjuvant Therapy

  • ER/PR Positive ER/PR Negative
    Endocrine Therapy Surveillance

Stage I-II, pT0-2, pN0: Endocrine Therapy Only Option

First Line Therapy

  • ER/PR Positive ER/PR Negative
    Endocrine Therapy Surveillance

Stage I-III: Neoadjuvant Chemotherapy

First Line Therapy

  • Her2 Positive Her2 Negative
    Preferred:
    CH BR 10: AC followed by T + concurrent trastuzumab
    CH BR 11: TCH
    CH BR 47: AC followed by T + concurrent trastuzumab + pertuzumab
    CH BR 48: TCH + pertuzumab
    Optional:
    CH BR 49: AC followed by docetaxel plus concurrent trastuzumab + pertuzumab
    CH BR 14: AC followed by docetaxel + trastuzumab
    CH BR 40/40.1: T + H    		 Preferred:
    CH BR 1/2: DDAC followed by paclitaxel (ER negative only)
    CH BR 7: AC
    CH BR: 3: TC
    CH BR 54: Paclitaxel/carboplatin followed by DDAC

Acceptable:
CH BR 4: TAC
CH BR 6/7: AC

Optional:
CH BR 8: CMF
CH BR 9: A followed by C followed by T

 

Second Line Therapy

  • Surgery

Third Line Therapy

  • ER/PR Positive ER/PR Negative
    Endocrine Therapy Surveillance

Stage I-III: Adjuvant Chemotherapy

First Line Therapy

  • Surgery

Second Line Therapy

  • Her2 Positive Her2 Negative
    Preferred:
    CH BR 10: AC followed by T + concurrent trastuzumab
    CH BR 11: TCH
    CH BR 47: AC followed by T + concurrent trastuzumab + pertuzumab
    CH BR 48: TCH + pertuzumab
    Optional:
    CH BR 49: AC followed by docetaxel plus concurrent trastuzumab + pertuzumab
    CH BR 14: AC followed by docetaxel + trastuzumab
    CH BR 40/40.1: T + H    		 Preferred:
    CH BR 1/2: DDAC followed by paclitaxel (ER negative only)
    CH BR 7: AC
    CH BR: 3: TC
    CH BR 54: Paclitaxel/carboplatin followed by DDAC

Acceptable:
CH BR 4: TAC
CH BR 6/7: AC

Optional:
CH BR 8: CMF
CH BR 9: A followed by C followed by T

 

Third Line Therapy

  • ER/PR Positive ER/PR Negative
    Endocrine Therapy Surveillance

Stage IV/Recurrent Disease, ER/PR Positive

First Line Therapy

  • Patients with visceral disease or requiring rapid response to treatment Patients with Indolent Disease
    CH BR 16: Doxorubicin
    CH BR 17: Pegylated liposomal doxorubicin
    CH BR 18: Paclitaxel
    CH BR 19: Capecitabine
    CH BR 20: Gemcitabine
    CH BR 21: Vinorelbine
    CH BR 22: Eribulin
    CH BR 23: Cyclophosphamide
    CH BR 24: Carboplatin
    CH BR 25: Docetaxel
    CH BR 26: Albumin-bound paclitaxel
    CH BR 27: Cisplatin
    CH BR 28: Epirubicin
    CH BR 29: Ixabepilone
    CH BR 7: AC
    CH BR 8: CMF
    CH BR 33: Docetaxel/capecitabine
    CH BR 34: GT
    CH BR 35: Gemcitabine/carboplatin    		 Proceed to second line (endocrine) therapy

Second Line Therapy

  • Endocrine Therapy for Advanced Disease
    Palbociclib + letrozole
    Palbociclib + fulvestrant
    Non-steroidal AI (anastrozole, letrozole)
    Steroidal AI (exemestane)
    Fulvestrant
    Tamoxifen
    Megestrol acetate
    Fluoxymesterone
    Evirolimus (patients previously exposed to endocrine therapy, in combination with Tamoxifen or AI)

Stage IV/Recurrent Disease, ER/PR Negative

First Line Therapy

    • Her2 Positive Her2 Negative
      CH BR 16: Doxorubicin
      CH BR 37: Pertuzumab + trastuzumab + docetaxel
      CH BR 38: Pertuzumab + trastuzumab + paclitaxel
      CH BR 39: Paclitaxel + Carboplatin + trastuzumab      		 CH BR 16: Doxorubicin
      CH BR 17: Pegylated liposomal doxorubicin
      CH BR 18: Paclitaxel
      CH BR 19: Capecitabine
      CH BR 20: Gemcitabine
      CH BR 21: Vinorelbine
      CH BR 22: Eribulin
      CH BR 23: Cyclophosphamide
      CH BR 24: Carboplatin
      CH BR 25: Docetaxel
      CH BR 26: Albumin-bound paclitaxel
      CH BR 27: Cisplatin
      CH BR 28: Epirubicin
      CH BR 29: Ixabepilone
      CH BR 6/CH BR 7: AC
      CH BR 8: CMF
      CH BR 33: Docetaxel/capecitabine
      CH BR 34: GT
      CH BR 35: Gemcitabine/carboplatin

Second Line Therapy

    • Her2 Positive Her2 Negative
      CH BR 44: T-DM1 Unused option from first line

Third Line Therapy and Beyond

    • Her2 Positive Her2 Negative
      CH BR 45: Lapatinib + Capecitabine Unused option from first line
      After no response to 3 consecutive regimens or ECOG > 2, transition to palliative care After no response to 3 consecutive regimens or ECOG > 2, transition to palliative care