I. Treatment of non-invasive breast cancer (carcinoma in situ)
Carcinoma in situ of the breast is an early cancer that occurs in the ducts or lobules of the breast, a histological concept known as intraductal carcinoma in situ and lobular carcinoma in situ, respectively. Breast carcinoma in situ is a special type of breast cancer that is relatively rare in clinical practice. Most of the patients with breast carcinoma in situ are suitable for breast preservation plus whole breast radiation therapy, but for those with multicentric foci, total mastectomy is still appropriate. Axillary lymph node dissection is not necessary. Chemotherapy is also not necessary for intraductal breast cancer. Patients who undergo breast-conserving surgery plus radiation therapy and are ER (estrogen receptor) positive may be considered to take tamoxifen for 5 years after surgery to reduce the risk of ipsilateral breast cancer.
Surgery for lobular carcinoma in situ is generally not considered necessary and can be followed only for observation, as these patients rarely develop invasive carcinoma and the invasive carcinoma that does develop from them has good histologic features and rarely dies from secondary invasive carcinoma with proper monitoring. Oral tamoxifen is recommended to reduce the risk of developing invasive carcinoma. Follow-up includes physical examinations every 6-12 months for 5 years and then once a year, with annual mammograms recommended. Prophylactic bilateral mastectomy is feasible in special cases, such as BRCA1/2 mutation, or with a clear family history of breast cancer.
II. Treatment of invasive breast cancer
1.Pre-operative examination
Pre-operative examination should include: routine blood test, liver and kidney function test, alkaline phosphatase test, mammography, ultrasound of breast and corresponding lymphatic drainage area, liver ultrasound, electrocardiogram, chest X-ray, estrogen and progesterone receptors (ER, PR) and Her-2 if histological biopsy has been performed, and bone scan if there is bone pain or elevated alkaline phosphatase.
2. Choose a reasonable breast cancer treatment strategy according to the stage of the disease
Breast cancer treatment should advocate following guidelines and standardizing treatment. For different stages of breast cancer, different treatment strategies should be adopted. Most invasive breast cancers require a comprehensive treatment based on surgery.
(1) Surgical treatment for stage I, IIA, IIB and T3N1M0 breast cancer (early and mid-stage breast cancer)
Early and mid-stage breast cancer can be treated by conventional surgery. Surgical treatment consists of two parts: treatment of breast lesions and treatment of axillary lymph nodes. The former mainly consists of total mastectomy or local excision with breast preservation, while the latter mainly consists of biopsy of anterior lymph nodes and axillary lymphatic dissection.
The surgical treatment of breast cancer has undergone the changes of local excision, Halsted classical radical mastectomy, extended radical mastectomy, modified radical mastectomy and breast-conserving surgery, and the scope of surgery has undergone the cycle of “small-large-extra-large-medium-small”. At present, modified radical mastectomy is the main treatment for breast cancer in China. With the advancement of biological and immunological research, it is gradually recognized that breast cancer is a systemic disease with the possibility of hematogenous metastasis in the early stage. This recognition led to the rise of breast-conserving (breast-preserving) surgery, and the scope of surgery returned to local excision. However, modern breast-conserving surgery is different from the previous local excisional surgery because standardized breast-conserving surgery is a combination of surgery, radiotherapy, adjuvant chemotherapy, endocrine therapy and other therapies. The main considerations of breast-conserving surgery include tumor size, tumor/breast ratio, location of tumor growth, and patient’s informed consent. In general, breast-conserving surgery is mainly indicated for cases with a tumor diameter of less than 3 cm and no metastasis in the axillary lymph nodes at a distance of more than 3 cm from the areola. It has been demonstrated that the long-term survival rate of breast-conserving surgery in these cases is the same as that of modified radical surgery, except that the local recurrence rate is slightly higher, and routine postoperative radiation therapy can reduce the local recurrence rate. The distance of the primary tumor margin from the tumor margin is very important in breast-conserving surgery, and the microscopic margin is required to be free of tumor cell infiltration. The distance between the incision margin and the tumor margin is very important, and the distance between the incision margin and the tumor margin should be further clarified by sending frozen section or imprint cytology examination during the surgery, and the strength of postoperative adjuvant therapy should be decided.
Axillary lymph node dissection has been considered as part of the standard surgery for invasive breast cancer. Its purpose is not only to remove the metastatic lymph nodes, but also to understand the status of axillary lymph nodes in order to determine the staging and choose the best adjuvant treatment plan. However, axillary lymphatic dissection may lead to complications such as axillary lymphedema, limitation of upper limb movement and abnormal sensation. Therefore, in recent years, for patients who are not found to have axillary lymph node metastasis clinically, anterior lymph node biopsy is advocated first. Sentinel lymph node is the lymph node that receives lymphatic drainage first and has lymphatic metastasis first among the lymph nodes in the drainage area of the primary tumor. The methods to mark the sentinel lymph nodes include radiotracer method and blue dye method. The accuracy of predicting whether the axillary lymph nodes are metastatic by biopsy of the sentinel lymph nodes has reached 95-98%. If the sentinel lymph nodes are negative, axillary lymph node dissection is not necessary, thus avoiding complications such as lymphedema of the affected upper limb.
(2) Neoadjuvant treatment for stage IIA, IIB and T3N1M0 breast cancer (intermediate stage breast cancer)
Preoperative neoadjuvant therapy, including neoadjuvant chemotherapy and neoadjuvant endocrine therapy, can be chosen for stage IIA, IIB and T3N1M0 breast cancers with breast-conserving intention. Radical breast-conserving surgery is feasible for patients in complete or partial remission (meeting breast-conserving criteria). For patients who are eligible to have sentinel lymph node biopsy before neoadjuvant chemotherapy, axillary lymph node dissection will be performed according to the condition of the sentinel lymph nodes.
(3) Neoadjuvant treatment for stage IIIA (excluding T3N1M0), IIIB and IIIC breast cancer (locally advanced breast cancer)
Neoadjuvant therapy, including neoadjuvant chemotherapy and neoadjuvant endocrine therapy, is preferred for patients with locally advanced breast cancer. Local surgical treatment will be performed after remission is achieved. The purpose of neoadjuvant therapy is to reduce the tumor stage, so that patients with inoperable advanced localized breast cancer can be surgically resected and have more chances for breast-conserving surgery, and also to play the role of in vivo drug sensitivity testing.
The number of cycles of neoadjuvant chemotherapy depends on different stages of disease and treatment objectives. A rigorous efficacy evaluation is important in deciding on subsequent treatment. It is generally accepted that each cycle should be followed by physical examination to understand the change of tumor size, 2 cycles followed by imaging (ultrasound and X-ray) to evaluate the clinical efficacy, and 3-4 cycles followed by efficacy evaluation to decide the next step of treatment and, if necessary, by puncture to understand the pathological changes. Patients who achieve clinical CR (complete remission) or PR (partial remission) should continue chemotherapy with the original regimen for up to 6 cycles; patients with poor outcomes should consider changing their treatment regimen, such as changing drug regimens, abandoning breast conservation and switching to radical surgery or local radiotherapy. Patients with locally advanced disease generally choose modified radical surgery after effective neoadjuvant therapy; breast preservation is possible after neoadjuvant therapy, but patients with large primary tumors or axillary lymph node metastases before treatment should choose breast-conserving surgery with caution. Post-operative adjuvant therapy after neoadjuvant therapy, it should be noted that the patient’s staging has changed at the time of surgery, so the decision of whether to adjuvant radiotherapy should be based on the staging before neoadjuvant therapy. Adjuvant therapy for hormone-responsive patients is based on endocrine therapy.
(4) Comprehensive treatment for stage IV breast cancer (distant metastasis)
Stage IV breast cancer with distant metastases is generally incurable and has a poor prognosis, but about 10% of patients can still survive for more than 5 years after active treatment. After the detection of distant organ metastasis of breast cancer, it should be treated aggressively according to different situations. Similarly, the treatment of breast cancer metastases is divided into local treatment and systemic treatment. Since distant metastasis suggests that tumor cells may exist in all parts of the body, systemic treatment is essential. Among the systemic treatments, chemotherapy and endocrine therapy are applied according to the patient’s specific situation. For metastases that appear during treatment, it is generally considered that the drugs used previously are resistant and should be replaced with second-line drugs. Some breast cancers with metastases can be treated with additional local therapy. If the metastases in the liver or lung are single and small, the patient’s systemic condition allows for resection of the metastases first to obtain pathological diagnosis on the one hand and to maximize the destruction of tumor cells on the other. For pulmonary metastases and pleural metastases, pleural fluid can be released by thoracentesis, and then chemotherapy drugs can be injected into the chest cavity. Pain arising from bone metastases can be treated with local radiotherapy, as well as bisphosphonates. Localized metastases in the chest wall can be surgically removed and localized chest wall then treated with radiotherapy.
For fairly advanced breast cancer, the limitation of medical development makes there is no good method at present. The treatment for this part of patients is mainly to reduce the pain, improve the quality of life and prolong the life.
3. The post-operative treatment (observation, chemotherapy, radiotherapy, endocrine therapy, targeted therapy) is decided according to different situations.
(1) Adjuvant chemotherapy
Most breast cancers are a systemic disease has been confirmed by numerous experimental studies and clinical observations. When breast cancer develops to a size larger than 1 cm and a lump can be palpated clinically, it is often a systemic disease and there may be distant micro-metastases, but they cannot be detected by current examination methods. The purpose of surgical treatment is to maximize local control of the primary tumor and regional lymph nodes, reduce local recurrence and improve survival rate. However, after tumor removal, residual tumor cells are still present in the body. Based on the concept that breast cancer is a systemic disease at the time of diagnosis, the purpose of systemic chemotherapy is to eradicate the residual tumor cells in the body to improve the cure rate of surgical procedures.
Indications for postoperative adjuvant chemotherapy: The European St. Gallen Consensus on the basic principles of adjuvant therapy for early-stage breast cancer suggests that the responsiveness of the tumor to endocrine therapy should be considered first, divided into Endocrine responsive, Endocrine nonresponsive, and Uncertain endocrine responsiveness; and then subdivided according to The risk of recurrence was subdivided into low risk (low risk), moderate risk (intermediate risk) and high risk (high risk) according to other factors. Low risk was defined as: negative axillary lymph nodes with all of the following characteristics: pT ≤ 2 cm, pathological grade 1, no invasion of peripheral tumor vessels, HER-2(-), and age ≥ 35 years. Definition of intermediate risk: ① Negative axillary lymph nodes with at least one of the following features: pT > 2 cm, pathological grading of grade 2-3, invasion of tumor peripheral vessels, HER-2 gene overexpression or amplification, age < 35 years. ② Axillary LNM 1-3 (1-3 metastases in axillary lymph nodes) and HER-2( - ). Definition of high risk: ① axillary LNM 1-3 and HER-2 ( + ); ② axillary LNM > 3.
Chemotherapy is not administered to low-risk patients, and chemotherapy is required for high-risk patients. Intermediate-risk patients with response to endocrine therapy can be treated with endocrine therapy alone without chemotherapy or with chemotherapy sequential to endocrine therapy first, and chemotherapy is required for no response to endocrine therapy, and chemotherapy sequential to endocrine therapy is required for uncertain response to endocrine therapy.
In contrast, the indications for chemotherapy in the US NCCN guidelines differ from the St. Gallen consensus, and chemotherapy is administered to those with positive axillary lymph nodes. Chemotherapy is required for all axillary lymph node negative, tumor larger than 1 cm, ER negative or HER-2 positive, and considered for those who are ER positive and HER-2 negative. Axillary lymph node negative, tumor size of 0.6-1.0 cm, ER negative or HER-2 positive, or tumor is moderate or low differentiation, consider chemotherapy. Patients with negative axillary lymph nodes, tumor less than 0.5 cm, or tumor size of 0.6-1.0 cm with high differentiation and no adverse prognostic factors are not treated with chemotherapy. There are special criteria for ductal carcinoma or mucinous carcinoma with positive axillary lymph nodes or tumors larger than 3 cm, such as hormone receptor negative, chemotherapy, and hormone receptor positive, endocrine therapy. If the axillary lymph nodes are negative, such as tumor less than 1cm, no treatment, if the tumor is 1-3cm, hormone receptor positive, consider endocrine therapy, if hormone receptor negative, consider chemotherapy.
Choice of chemotherapy regimen.
Low risk axillary lymph node negative: CMF x 6 or AC / EC x 4-6. specifically CMF regimen: cyclophosphamide 500 mg/m2 IV d1,d8 methotrexate 50 mg/m2 IV d1,d8, 5-FU 500 mg/m2 IV d1, d8, 1 cycle of 28 days, 6 cycles in total. AC regimen: doxorubicin 60 mg/m2 IV d1, cyclophosphamide 600 mg/m2 IV d1, 1 cycle of 21 days, 4 cycles in total. CE regimen: epirubicin 100 mg/m2 IV d1, cyclophosphamide 600 mg/m2 IV d1, 1 cycle of 21 days in total. cycle of 4-6 cycles.
Axillary lymph node negative with high-risk recurrence factors: FAC/FEC × 6 or TC × 4. Specifically, CAF regimen: cyclophosphamide 500 mg/m2 IV dl, 5-FU 500 mg/m2 IV d1,d8, doxorubicin 50 mg/m2 IV dl, 1 cycle of 28 days for 6 cycles. FEC regimen: cyclophosphamide 500 mg/m2 dl, epirubicin 100 mg/m2 d1, 5-FU 500 mg/m2 d1, d8, 1 cycle of 21 days for 6 cycles.
Positive axillary lymph nodes: AC × 4 → T × 4 ( AC sequential paclitaxel ), FEC × 3 → T × 3 ( FEC sequential doxorubicin ), TAC × 6 ( doxorubicin / doxorubicin / cyclophosphamide ). It is also possible to use biweekly dose intensive chemotherapy with G-CSF support, AC × 4 → T × 4; or A → T → C (doxorubicin sequential paclitaxel sequential cyclophosphamide).
Side effects of chemotherapy and their management.
The main side effects of chemotherapy for breast cancer are: 1) chemotherapy drugs can affect the stomach or vomiting center of the brain causing nausea and vomiting. 2) Adriamycin drugs can cause hair loss and heart damage. 3) chemotherapy can inhibit the ability of bone marrow to produce red blood cells, making patients feel weak, fatigue, dizziness or shortness of breath. 4) anti-cancer drugs affect the hematopoietic function of bone marrow, causing a decrease in white blood cells, and also easily cause infections in various parts of the body, such as the mouth, skin, lungs, intestines, etc. Such as oral cavity, skin, lung, intestine, etc. 5) Some chemotherapy drugs can affect the intestinal mucosa cells causing diarrhea. 6) Chemotherapy can directly cause constipation, which may also be caused by the patient’s reduced activity and unreasonable diet structure after chemotherapy. 7) Cyclophosphamide can stimulate the bladder causing urinary pain, urgency, frequency, fever and other symptoms.
Treatment: Injections of granulocyte colony-stimulating factor can be given to raise the number of white blood cells when the white blood cells are too low; injections of anti-vomiting agents before and after chemotherapy can prevent and treat nausea and vomiting reactions; application of adrenocorticotropic hormones can prevent and treat allergic reactions; at the same time, the toxic reactions of the heart, liver and kidneys can be appropriately reduced; in general, there is no need to worry about hair loss; wigs can be worn during treatment, and most hair can gradually grow out about 3 months after the end of chemotherapy. Most hair grows back gradually about 3 months after the end of chemotherapy. In addition, during chemotherapy, patients should strengthen nutrition, including protein, energy and vitamins, pay attention to rest, ensure sleep, appropriate physical exercise, lift the psychological burden, maintain a happy mood and family harmony is also particularly important.
(2) Radiation therapy
Radiation therapy is required to reduce the local recurrence rate in patients who have undergone local mastectomy with breast preservation.
Adjuvant radiotherapy after radical or modified radical surgery: postoperative radiotherapy can reduce the recurrence rate of local and regional lymph nodes, which is the greatest benefit of postoperative radiotherapy. Overall, postoperative radiotherapy does not increase survival, but for those with lesions in the inner quadrant and positive axillary lymph nodes, postoperative radiotherapy may improve survival. The following cases are suitable for radiotherapy: 1. lesions in each quadrant, with primary breast foci greater than 5 cm, edema, rupture, erythema or fixation with the pectoral muscle, axillary lymph node metastasis of 20%, or four or more. 2. lesions in the inner quadrant or central region, with negative axillary lymph nodes, but with recurrent metastatic high factors or adjuvant examination suspecting internal breast lymph node metastasis, irradiate the internal breast lymph nodes. 3. incomplete axillary clearing If there is extra-lymph node invasion, lymph nodes fused into a mass or fixed with surrounding tissues, the whole axillary area should be irradiated after surgery. For those with lesions in the outer quadrant less than 5 cm and no metastasis in the axillary lymph nodes, postoperative radiotherapy should not be given.
(3) Endocrine therapy
The growth of most breast cancer cells is influenced by estrogen and progesterone. For hormone-dependent breast cancer, blocking estrogen and progesterone receptors can inhibit the growth of breast cancer cells.
The choice of endocrine therapy should first be based on the hormone receptor status. Endocrine therapy significantly improves 10-year disease-free survival (DFS) and overall survival (OS) in breast cancer patients with positive estrogen (ER) and/or progesterone (PR) receptors, especially in estrogen receptor-positive patients, as sequential therapy to postoperative adjuvant chemotherapy or alone. The National Comprehensive Cancer Network (NCCN) treatment guidelines recommend that estrogen receptor (ER) and progesterone receptor (PR) status be determined for all primary invasive breast cancers in patients with common histologic types of early-stage breast cancer. Adjuvant endocrine therapy should be considered in all patients with ER- or PR-positive invasive breast cancer, regardless of age, lymph node status, or whether adjuvant chemotherapy has been applied, except for those patients with negative lymph nodes and who meet one of the following criteria: 1) microinfiltration of the primary tumor, 2) lesion diameter less than 0.5 cm, and 3) lesion diameter between 0.6 and 1.0 cm, highly differentiated and without adverse prognostic factors, because these patients have a very good prognosis and very limited benefit from endocrine therapy.
Secondly, determining whether menopause is present is the cornerstone for choosing the type of endocrine therapy for breast cancer. Adjuvant endocrine therapy after breast cancer surgery requires first determining whether or not menopause has occurred. Pre-menopause requires the use of triamcinolone acetonide, while aromatase inhibitors are more effective than triamcinolone acetonide in post-menopausal patients, and aromatase inhibitors are preferred in post-menopause. Since aromatase inhibitors are not effective in patients with functioning ovaries, they cannot be used in premenopause. The current definition of menopause is: 1. post bilateral oophorectomy; 2. age > 60 years; 3. age < 60 years, menopause > 12 months, not receiving chemotherapy, tamoxifen, toremifene or treatment to suppress ovarian function, and FSH and estradiol levels are within the postmenopausal range; 4. age < 60 years, taking tamoxifen or toremifene, FSH and estradiol levels should be within the postmenopausal range; 5. Patients who are receiving LH-RH agonists or inhibitors cannot be judged to be menopausal; 6. Premenopausal women who are receiving chemotherapy, menopause cannot be used as a basis for judging menopause; 7. Because although patients will stop ovulating or experience menopause after receiving chemotherapy, ovarian function may still be normal or have the possibility of recovery. In women with chemotherapy-induced menopause, if aromatase inhibitors are considered as endocrine therapy, ovariectomy or serial testing of FSH and/or estradiol levels is required to ensure that the patient is in menopausal status.
Postoperative adjuvant endocrine therapy in postmenopausal hormone receptor-positive patients can be chosen from: 1. 5 years of anastrozole or letrozole; 2. 2-3 years of triamcinolone followed by 2-3 years of sequential exemestane or anastrozole; 3. 5 years of triamcinolone followed by 5 years of intensive letrozole or exemestane; 4. 5 years of aromatase inhibitors for patients with contraindications or unable to receive them. inhibitors or cannot receive aromatase inhibitors, or cannot tolerate aromatase inhibitors, triamcinolone acetonide can still be used for 5 years.
Postoperative adjuvant endocrine therapy in premenopausal hormone receptor-positive patients can be chosen from: 1. triamcinolone acetonide for 5 years; 2. triamcinolone acetonide for 2-3 years first, which can be switched to aromatase inhibitors for 5 years if they enter menopause; 3. triamcinolone acetonide can be continued for up to 5 years if they remain non-menopausal after 2-3 years of triamcinolone acetonide, and if they enter postmenopausal, then follow up with intensive aromatase inhibitor therapy for 5 years. 4. For some premenopausal patients who are not suitable for treatment with triamcinolone acetonide or have high risk of recurrence and metastasis factors, they can consider using aromatase inhibitors as adjuvant therapy after effective suppression of ovarian function, with reference to the principles for postmenopausal women.
There are relatively more premenopausal breast cancers in China, and their treatment has special characteristics. Ovarian function inhibition has long been successfully experienced in the treatment of premenopausal breast cancer. Ovarian function inhibition can be surgically removed or pharmacologically inhibited (Norelide Zoladex), and pharmacological inhibition overcomes the disadvantages of surgical and radiotherapy debulking and is functionally reversible, which is more acceptable to young patients.
(4) Molecular targeted therapy
The so-called molecular targeting therapy is to design the corresponding therapeutic drugs at the cellular molecular level, targeting the defined oncogenic sites (the site can be a protein molecule or a gene fragment inside the tumor cell). Therefore, molecular targeted therapy is also called “biological missile”.
Among the factors in the development of breast cancer, an oncogene called HER2 (human epidermal growth factor receptor-2) plays a major role, and nearly one third of breast cancer patients have HER2 gene overexpression. Studies have shown that patients with HER2 overexpressed tumors have shorter disease-free survival than those without overexpression. Studies have shown that patients with HER2 overexpressing tumors have shorter disease-free survival than those without overexpression. Trastuzumab (Herceptin) is a humanized antibody that specifically binds to the protein receptor expressed by gene HER2 outside the tumor cell membrane, thus blocking the information transmission channel of tumor cells for the purpose of treating malignant tumors. In addition, Herceptin is a potential mediator of antibody-dependent cell-mediated cytotoxic response (ADCC). In in vitro studies, Herceptin-mediated ADCC was shown to be preferentially produced in HER2 over-expressing cancer cells than in HER2 non-over-expressing cancer cells.
Since molecular targeted therapy has such amazing efficacy, is it available for all breast cancer patients? Of course not, there are strict conditions for the use of molecular targeted therapy, it targets specific targets, just like a missile needs radar and satellites to help find and lock on the target before launching, it also needs some auxiliary means. Take trastuzumab, before using it, we must first determine whether there is a target in breast cancer patients that can be attacked, that is, the protein receptor expressed by HER2 gene. Clinically, detecting HER2 gene is equivalent to using radar and satellite to locate the target, once the existence of the target is clear, using trastuzumab can achieve obvious striking effect; otherwise, if the target is not clear, that is, for patients with HER2 gene is patients with negative response, blind use will only result in half the effort. Therefore, the expression of HER2 gene should be routinely detected during the pre-surgical treatment of breast cancer patients in order to create strong conditions for future molecularly targeted therapy and to achieve “precise guidance, bullet-free”.
HER-2 overexpression should be detected clinically in laboratories that meet the quality criteria for HER-2 detection by immunohistochemistry (IHC) or fluorescence in situ hybridization (FISH), and patients with positive HER-2 overexpression by FISH or HER-2 (++++) by IHC and HER-2 (+++) by IHC should be confirmed by FISH. Trastuzumab can be used as a treatment at the end of chemotherapy or can be started concomitantly with paclitaxel in the AC→T regimen and not concomitantly with anthracyclines in view of cardiotoxicity. Trastuzumab is treated according to a weekly or every-three-week regimen for one year, with close monitoring of new function.
Trastuzumab (Herceptin) is currently considered to be given to patients with HER-2 overexpression who have positive lymph nodes. Trastuzumab (Herceptin) is also recommended for lymph node negative but tumors larger than 1 cm. However, histologically well-differentiated tubular and mucinous carcinomas are not recommended for Herceptin treatment regardless of lymph node and tumor size.
Herceptin product features: 1. Herceptin can be used as a single agent, which has fewer adverse effects and is better tolerated than traditional chemotherapy regimens, and has a simpler dosing regimen, and patients can be treated on an outpatient basis. Herceptin can be used in combination with chemotherapy and has been shown to have better clinical efficacy, extending the survival of patients treated with standard chemotherapy by 45%. 3. Herceptin has significantly improved the survival and quality of life of HER2 (human epidermal growth factor receptor 2)-positive breast cancer patients with poor prognosis.
Dosage: 440mg per dose, 6 doses in a course, first dose is: 220mg and 110mg thereafter. standard dose: initial loading dose: recommended initial loading dose of Herceptin is 4mg/kg. administered intravenously over 90 minutes. Maintenance dose: The recommended weekly dose of Herceptin is 2 mg/kg, which may be administered over 30 minutes if the initial loading dose is tolerated.
Herceptin can be used until disease progression. According to foreign market research data: the average continuous use of patients receiving treatment is about 24 to 26 weeks.
4.Follow up review after surgery
For breast cancer, it is recommended to have a clinical examination of the breast every 4 months for 2 years after surgery, then every 6 months for 3 years, and then every year thereafter, with annual molybdenum palladium radiographs. Chest radiographs should be performed every year for 5 years for radiotherapy patients, and the uterus and pelvis should be examined annually for women taking triamcinolone.