A pre-menopausal woman three years after mastectomy for breast cancer presents with pulmonary metastases. Which of the following statement(s) is/are true concerning her management?

b. If the patient is ER-positive, hormonal therapy should be the first line of treatment

c. The response to chemotherapy will likely be dose-dependent

d. Combination chemotherapy will likely work better in this patient than a woman who is post-menopausal

Chemotherapy for metastatic breast cancer is more likely to be employed for young women, those with ER-negative tumors, those with visceral organ involvement and those with rapidly advancing or life-threatening disease. Generally, combinations of agents are used in treating metastatic breast cancer with the response rate usually dose-dependent. All regimens are slightly less active in post-menopausal women. Response rates are highest in women who have not received prior treatment for metastatic disease. Prior adjuvant therapy is not consistently associated with a poorer response to therapy, particularly if a long interval has lapsed between adjuvant therapy and the development of metastases. Endocrine therapy is appropriate as the first-line treatment for nearly all women with ER-positive metastatic breast disease. Tamoxifen is the agent of choice for first-line hormonal therapy for metastatic breast cancer. Both premenopausal and post-menopausal patients can receive this agent and side effects are minimal.