Breast Cancer: Follow up and Management of recurrence

Carol Marquez, M.D.

Associate Professor Department of Radiation Medicine OHSU

Goals of discussion

 Review data on management of primary tumor in setting of metastatic disease.

 Present guidelines for follow up of patients in the years following therapy.

 Discuss management of local recurrence in the intact breast.

 Discuss role of SRS/ SBRT in the management of distant metastases.

Presenting with Stage IV disease

 A small proportion of patients will present with metastatic disease (~<5%).  Certain patients will have resectable primary disease either by lumpectomy or mastectomy.

 Recent literature has supported the use of surgery in this group for both improved control of the primary mass and possibly to improve survival.

Retrospective review from Washington University     N=409 pts of whom 187 had surgical resection of primary tumor.

One third of those had lumpectomy; no statement re: use of XRT.

Showed improved median and 5 year survival.

Patients with bone only disease had a reduced risk of dying when compared to other met sites. Annals of Surgical Oncology 14:3345-3351, 2007

Follow up of Rapiti study

  Initial study (JCO 18:2743, 2006) showed importance of obtaining negative margins; those with negative margins had a 50% reduction in breast cancer mortality.

Abstract presented at SABCS suggested that giving adjuvant local XRT also improved breast cancer mortality.

Unanswered questions in this setting  What are the important selection criteria? Age? Type or use of adjuvant therapy? Sites of metastases? Number of metastases?

 If you chose to radiate the primary site, should the metastatic sites also be radiated?

 If you radiate the breast or chest wall, what should your treatment schedule be?

     How should we be following our patients?

NCCN and ASCO guidelines recommend history and physical exam every 3-6 months for the first 5 years and then every 12 months.

Mammogram every 12 months Bone density should be monitored if on aromatase inhibitor Annual gyn exam if uterus present while on tamoxifen No role for routine marker evaluation

Which patients are not getting followup mammograms?

 Patients who didn’t get XRT after breast conserving surgery.

 Older women.

 Women who are more than 3 years out from their initial treatment.

 Women who do not see an oncologist or breast cancer surgeon. (J Gen Intern Med 2007)

Management of local recurrence (IBTR)    NCCN guidelines recommends mastectomy for those patients who recur after breast preservation therapy.

Several reports now available discussing salvage lumpectomy with or without additional radiation therapy.

Methods of delivery vary from brachytherapy to fractionated external beam to IORT but all usually involve partial breast irradiation.

Distinction of new primary from true recurrence  Work from Yale showed that new primary tumors are in a different location from the original primary and may have a different histologic type.

 New primary tumors appear later than recurrences and had better overall and distant disease free survival than true recurrences.

IJROBP 48:1281-1289, 2000

New Primary vs. True Recurrence