Pharmacologic Therapy

® For patients with inoperable breast cancer, including inflammatory breast cancer, the initial approach to therapy should be chemotherapy with the goal of achieving re-sectability. After neoadjuvant chemotherapy, most tumors respond with more than a 50% decrease in tumor size; about 70% of patients experience downstaging. Chemotherapy regimens used in this setting are similar to those used in the adjuvant setting. Supporting evidence for each individual regimen differs, but most of the available data support the use of anthracycline-containing regimens, incorporation of the tax-anes in some manner, and other approaches to improve dose density or dose intensity. For more details regarding the specific regimens, the reader is referred to a recently published review.6 Neoadjuvant endocrine therapy may be an option for patients who have unresectable hormone-receptor-positive tumors who are unable to receive chemotherapy (e.g., multiple comorbid conditions). In terms of local therapy, this usually follows chemotherapy, and the extent of surgery will be determined by response to chemotherapy, the wishes of the patient, and the cosmetic results likely to be achieved. Many patients may be able to have breast-conserving surgery if an acceptable response to chemotherapy is achieved. Adjuvant radiation therapy should be administered to all locally advanced breast cancer patients to minimize local recurrences regardless of the type of surgery used for that individual patient (e.g., mastectomy or segmental mastectomy). Inoperable tumors that are unresponsive to systemic chemotherapy may require radiation therapy for local management and may or may not be eligible for surgical resection after that radiation. Such patients are not seen commonly, but they have a very poor prognosis. For most patients in this category, cure is still the primary goal of therapy and can be achieved in a large number of patients when all treatment modalities are employed.

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