Patterns of relapse and long-term complications of therapy in breast cancer survivors
- Arti Hurria, MD
Arti Hurria, MD
- Associate Professor of Medicine
- Director of Cancer and Aging Research Program
- Medical Oncology and Therapeutics Research
- City of Hope
- Steven E Come, MD
Steven E Come, MD
- Associate Professor of Medicine
- Harvard Medical School
- Director of Breast Medical Oncology Program
- Beth Israel Deaconess Medical Center
- Lori J Pierce, MD
Lori J Pierce, MD
- Section Editor — Radiation Therapy
- Professor of Radiation Oncology
- University of Michigan School of Medicine
Breast cancer is the most frequently diagnosed cancer and the leading cause of cancer death in females worldwide. In the United States, breast cancer is second to lung cancer as the most common cause of cancer death in women, and the main cause of death in women ages 40 to 49 years . However, there has been a decline in breast cancer mortality rates in the United States and elsewhere in the Western world, attributable to the increased use of screening mammography and advances in adjuvant therapies. As a result of improved survival and the aging of the population, there are over three million women living with a history of breast cancer in the United States alone, accounting for 41 percent of all female cancer survivors . Breast cancer survivors are the largest constituent of all cancer survivors, representing 3.6 percent of the United States population [3,4].
The majority of breast cancer recurrences occur within the first five years of diagnosis, particularly with hormone receptor-negative or human epidermal growth factor receptor 2 (HER2)-positive disease. However, some recurrences occur much later, particularly in the setting of hormone receptor-positive, HER2-negative tumors, which tend to behave more indolently . This was shown in a study of 2838 patients with stage I/II or III breast cancer (table 1) who had not recurred within five years of completing initial therapy; recurrence risks in the subsequent 5 and 10 years were still 11 and 19 percent, respectively .
Relapse patterns and long-term complications of therapy for invasive breast cancer in women who are at least five years out from their initial diagnosis will be reviewed here. Recommendations for surveillance strategies in breast cancer survivors and an overview of the approach to breast cancer survivors are discussed separately. (See "Approach to the patient following treatment for breast cancer".)
OVERVIEW OF BREAST CANCER
Treatment overview — All patients with early-stage and locally advanced breast cancer require a multidisciplinary treatment approach that may include surgery, radiation therapy (RT), and systemic therapy. The following provides a broad overview of contemporary breast cancer treatment (see "Overview of the treatment of newly diagnosed, non-metastatic breast cancer" and "Breast cancer in men"):
Surgery — For women with newly diagnosed breast cancer, the surgical approach depends on extent of disease and patient preference, with consideration given if the patient has a known genetic mutation. In general, women with limited breast ductal carcinoma in situ (DCIS) undergo breast-conserving surgery. Axillary node evaluation is not routinely indicated for these women as long as an invasive component is not present in the excised breast tissue. However, for more extensive disease (ie, tumor extent >3 cm) or if there was evidence of microinvasive disease, a sentinel node biopsy is generally performed. (See "Ductal carcinoma in situ: Treatment and prognosis".)
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- OVERVIEW OF BREAST CANCER
- Treatment overview
- - Surgery
- - Radiation therapy
- - Endocrine therapy
- - Chemotherapy
- - Anti-HER2 directed treatment
- RELAPSE PATTERNS
- Locoregional recurrence
- Metastatic disease
- SECOND PRIMARY BREAST TUMORS
- LONG-TERM ADVERSE EFFECTS OF PRIMARY THERAPY
- Chest wall and breast complications
- Cardiovascular morbidity
- - Radiation therapy
- - Systemic treatment
- - Endocrine therapy
- Second cancers
- - Radiation therapy
- - Chemotherapy
- Cognitive dysfunction
- Ovarian failure
- Psychological effects
- APPROACH TO THE LONG-TERM SURVIVOR