I recently gone through the NCCN recommendations for adjuvant chemotherapy for early breast cancer (non metastatic disease).
The adjuvant chemotherapy regimens mentioned for early breast cancer (non metastatic disease) are divided into “preferred” and “other regimens”, but the guidelines says that these chemotherapy regimes are not stratified as per lymph node criteria. Hence lymph node criteria has not been taken into account while mentioning the regimens. Additionally if you read the regimen description in the discussion section, you will find that most regimens are outcome of clinical trials involving node positive or high risk node negative disease (most regimens are outcome of node positive disease only). What is the criteria to define high risk node negative disease ?
If we use St Gallens criteria, the patients can be divided as low risk, intermediate risk and high risk group depending upon parameters like lymph nodes, ER/PR status, Her2 status, tumor size, grade, age etc.
I guess low risk patients can safely avoid chemotherapy and for high risk patients, chemotherapy is highly indicated.
But how to consider a patient with intermediate risk (given lymph nodes are negative- with non metastatic disease) ?
Anthracyclins are highly indicated in node positive patients as per NCCN guidelines. Can node negative patients safely omit anthracyclins (considering their long term and short term toxicity) ?
Can intermediate risk, node negative patients be managed just by taxanes only ? (obviously Herceptin will be added with taxane if tumor is Her2 positive)
Or should intermediate risk node negative patients receive full blown chemotherapy (AC-TH) or TCH [both of the regimens are mentioned as “preferred” as per NCCN] ?
Is there any other guideline which stratify chemo regimens as per lymph node criteria (for early stage breast cancer - non metastatic disease) ?