Breast cancer: adjuvant and neoadjuvant chemotherapy regimes, adjuvant endocrine therapy

3. Non-trastuzumab containing adjuvant regimens (NCCN)
A. Preferred
a. TAC (docetaxel/doxorubicin/cyclophosphamide)
docetaxel 75mg/m2 iv D1
doxorubicin 50mg/m2 iv D1
cyclophosphamide 500mg/m2 IV D1
cycled every 21 days for 6 cycles (all cycles with filgrastim support)

b. Dose-dense AC (doxorubicin/cyclophosphamide) followed by paclitaxel every 2 weeks
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 14 days for 4 cycles
followed by paclitaxel 175mg/m2 by 3h iv infusion day 1
cycled every 14 days for 4 cycles
all cycles with filgrastim support

c. AC (doxorubicin/cyclophosphamide) followed by weekly paclitaxel
doxorubicin 60mg/m2 iv day 1
cyclophosphamide 600mg/m2 iv day 1
cycled every 21 days for 4 cycles
followed by paclitaxel 80mg/,2 by 1h IV infusion weekly for 12 wks

d. TC (docetaxel and cyclophosphamide)
docetaxel 75mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 21 days for 4 cycles

e. AC (doxorubicin/cyclophosphamide)
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 iv D1
cycled every 21 days for 4 cycles

B. Others
a. FAC/CAF (fluorouracil/doxorubicin/cyclophosphamide)
i. FAC
5FU 500mg/m2 iv D1&8 or D1&4
Doxorubicin 50mg/m2 IV D1 or by 72h continuous infusion
Cyclophosphamide 500mg/m2 iv D1
Cycled every 21 days for 6 cycles

ii. CAF
cyclophosphamide 100mg/m2 iv D1
doxorubicin 30mg/m2 iv D1&8
5FU 500mg/m2 iv D1&8
Cycled every 28 days for 6 cycles

b. FEC/CEF (cyclophosphamide/epirubicin/fluorouracil)
i. FEC
cyclophosphamide 75mg/m2 PO D1-14
epirubicin 60mg/m2 iv D1&8
5FU 500mg/m2 iv D1&8
With cotrimoxazole support
Cycled every 28 days for 6 cycles

c. CMF (cyclophosphamide/methotrexae/fluorouracil)
Cyclophosphamide 100mg/m2 PO D1-14
Methotrexate 40mg/m2 iv D1&8
5FU 600mg/m2 IV D1&8
Cycled every 28 days for 6 cycles

d. AC followed by docetaxel every 3 weeks
doxorubicin 60mg/m2 D1
cyclophosphamide 600mg/m2 IV D1
followed by docetaxel 100mg/m2 IV on D1
cycled every 21 days for 4 cycles

e. AC followed by paclitaxel every 3 weeks
doxorubicin 60mg/m2 D1
cyclophosphamide 600mg/m2 IV D1
cycled every 21 days for 4 cycles
followed by paclitaxel 175-225 mg/m2 by 3h IV infusion on D1
cycled every 21 days for 4 cycles

f. EC (epirubicin/cyclophosphamide)
epirubicin 100mg/m2 iv D1
cyclophosphamide 830mg/m2 IV D1
cycled every 21 days for 8 cycles

g. Dose dense ATC:- A followed by T followed by C (doxorubicin followed by paclitaxel followed by cyclophosphamide) every 2 weekly regimen with filgrastim support
doxorubicin 60mg/m2 IV D1 cycled every 14 days for 4 cycles
followed by paclitaxel 175mg/m2 by 3h IV D1 cycled every 14 days for 4 cycles
followed by cyclophosphamide 600mg/m2 IV D1 cycled every 14 days for 4 cycles

h. FEC followed by T (docetaxel)
5FU 500mg/m2 IV D1
Epirubicin 100mg/m2 IV D1
Cyclophosphamide 500mg/m2 D1
Cycled every 21 days for 3 cycles
Followed by docetaxel 100mg/m2 D1 cycled every 21 days for 3 cycles

4. Trastuzumab containing regimens
A. Preferred adjuvant
a. AC followed by T + concurrent tastuzumab (doxorubicin/cyclophosphamide followed by paclitaxel plus trastuzumab, various schedules)
doxorubicin 60mg/m2 iv D1
cyclophosphamide 600mg/m2 IV D1
cycled every 21 days for 4 cycles
followed by
paclitaxel 80mg/m2 by 1h IV weekly for 12 wks OR paclitaxel 175mg/m2 by 3h IV D1 cycled every 21 days for 4 cycles
with trastuzumab 4mg/kg IV with first dose of paclitaxel
followed by
trastuzumab 2mg/kg IV weekly to complete 1y OR 6mg/kg iv every 3 wk to complete 1y
(cardiac monitoring at baseline 3,6,9 mo)

b. Dose dense AC followed by paclitaxel chemotherapy (all cycles with filgrastim support)
AC as above but cycled every 14 days for 4 cycles
Followed by paclitaxel 175mg/m2 by 3h IV infusion D1 cycled every 14 days for 4 cycles
With trastuzumab 4mg/kg IV with first dose of paclitaxel
Followed by trastuzumab 2mg/kg IV weekly to complete 1y or 6mg/kg IV every 3 wk to complete 1y
(cardiac monitoring at baseline 3,6,9 mo)

c. TCH (docetaxel, carboplatin, trastuzumab)
docetaxel 75mg/m2 IV D1
followed by carboplatin AUC 6 IV D1
cycled every 21 days for 6 cycles
with trastuzumab 4mg/kg wk 1 followed by 2mg/kg for 17 wks followed by 6mg/kg every 3 wks to complete 1 y
(cardiac monitoring at baseline,3,6,9 mo)

B. Other adjuvant
a. Docetaxel + trastuzumab followed by FEC (fluorouracil/epirubicin/cyclophosphamide)
docetaxel 100mg/m2 by 1h IV D1 cycled every 21 days for 3 cycles
with trastuzumab 4mg/kg IV with first dose of docetaxel D1 followed by 2mg/kg IV weekly to complete 9 wks
followed by
5FU 600mg/m2 D1
Epirubicin 60mg/m2 D1
Cyclophosphamide 600mg/m2 D1
Cycled every 21 days for 3 cycles
(cardiac monitoring at baseline, after last FEC cycle, at 12 and 36 mo after chemotherapy)

b. Chemotherapy followed by trastuzumab sequentially
Approved adjuvant chemotherapy regimen at least 4 cycles followed by trastuzumab 8mg/kg IV times 1 dose followed by trastuzumab 6mg/kg IV every 21days for 1 y
(cardiac monitoring at baseline,3,6,9 mo)

c. AC followed by docetaxel + trastuzumab
doxorubicin 60mg/m2 IV D1
cyclophosphamide 600mg/m2 D1
cycled every 21 days for 4 cycles
with
trastuzumab 4mg/kg IV wk one followed by 2mg/kg IV weekly for 11 weeks followed by 6mg/kg every 21 days to complete 1y of trastuzumab therapy
(cardiac monitoring at baseline,3,6,9 mo)

C. Neoadjuvant
a. T (paclitaxel) + trastuzumab followed by CEF + trastuzumab
trastuzumab 4mg/kg IV for 1 dose beginning just prior to first dose of pacitaxel
followed by trastuzumab 2mg/kg IV weekly for 23 weeks
paclitaxel 225mg/m2 by 24h IV infusion every 21 dys for 4 cycles (alternatively paclitaxel 80mg/m2 by 1h IV infusion weekly for 12 wks)
followed by
5FU 500mg/m2 on D1 and 4
Epirubicin 75mg/m2 on D1
Cyclophosphamide 500mg/m2 on D1
Cycled every 21 days for 4 cycles

7. Adjuvant endocrine therapy
a. Premenopausal
- tamoxifen for 2-3 y +/- ovarian suppression/ablation
- complete 5y tamoxifen or after postmenopausal aromatase inhibitor 5y
b. Menopause – prior bilateral oopherectomy, age >= 60y, age <60y and amenorrhoeic 12 mo in absence of chemotherapy/tamoxifen/toremifene/ovarian suppression and FSH & estradiol in postmenopausal range, if taking tamoxifen or toreifene and age<60y then FSH & oestradiol in postmenopausal range)