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breast cancer survival (includes breast cancer prognosis)

Clinical features associated with favorable survival/prognosis: - hormone receptor positive - small size - low tumor grade - negative lymph nodes [15] Epidemiology: - 10-year survival rate for patients with all stages of breast cancer combined is 80% - metastatic breast cancer is not curable, but systemic therapy can improve survival, alleviate symptoms, & improve quality of life Clinical manifestations: - menopausal symptoms are common [18] Laboratory: - BRCA1/BRCA2 genotyping [28] - no routine laboratory testing recommended [15] Radiology: - shared decision-making between patients & clinicians is encouraged for all age groups [31] - continue breast cancer screening (biennial) by mammography until age 80-85 if expected survival is > 5 years [25,31] - no routine imaging (except annual mammography) recommended [15] - MRI reserved for women at high risk for recurrence [15] - annual bone mineral density (Dexa) for women at high risk for developing osteoporosis (treated with aromatase inhibitor) Staging: 5 year survival - stage 0: ductal carcinoma in situ, negative lymph nodes = 99% - stage 1A: < 2 cm, negative lymph nodes = 95% - stage 1B: < 2 cm, 1-3 micrometastatic (< 2 mm) lymph nodes = 95% - stage 2A: < 2 cm, 1-3 positive lymph nodes* = 85% - stage 2B: 2-5 cm, 1-3 positive lymph nodes* = 70% - stage 2B: > 5 cm with negative lymph nodes = 70% (alternative) - stage 3A: any size, 1-9 positive axillary lymph nodes* = 52% - stage 3B: skin or chest wall, < 10 positive axillary lymph nodes* = 52% - stage 3C: any size, >9 positive axillary lymph nodes* = 52% - stage 4: distant metastases = 18% [15] * one example of stage criteria; see staging of breast cancer [15] Complications: - leading cause of death among survivors on non-metastatic breast cancer is cardiovascular disease [23] - adjuvant chemotherapy may result in peripheral neuropathy persisting years after completion of therapy [29] - cumulative docetaxel seems to be implicated [29] - women with ER-positive, early-stage breast cancer with 5 years of adjuvant endocrine therapy are still at risk for recurrence up to 20 years later [30] Management: 1) guidelines from the American Cancer Society, the American College of Physicians & the American Society of Clinical Oncology [20] a) surveillance for recurrence: - physical exams every 3-6 months for 3 years after primary therapy, every 6-12 months for the next 2 years, & then annually - annual mammography for all survivors - breast MRI for women at high-risk of recurrence - screening for other primary cancers as per the general population b) management of late effects of cancer & cancer treatment - assess patients for body image concerns & for symptoms including fatigue, depression, & pain after treatment - counsel patients on how to prevent lymphedema c) counsel patients on maintaining good health - exercise, nutrition, smoking cessation d) care coordination with the patient's oncologists & caregivers to implement a survivorship care plan 2) comprehensive & multidisciplinary management a) surveillance of recurrence - in the absence of symptoms, laboratory testing & imaging studies do not improve survival or quality of life - history & physical exam every 6 months for 5 years, then annually - monthly breast self examination b) maintenence of overall health c) treatment of distressing menopausal symptoms d) healthy lifestyle changes - exercise reduces risk of cardiovascular events in survivors of non-metastatic breast cancer [23] e) referrals to mental health practitioners & support groups as indicated f) monitor for adverse effects of treatment - adverse effects of thoracic radiation therapy - upper extremity lymphedema if axillary node dissection - gynecologic examination yearly for women taking tamoxifen due to increased risk of endometrial cancer [15] - bone mineral density every other year for women taking aromatase inhibitor 3) psychological intervention a) stress reduction, smoking cessation, mood improvement, & attention to diet & exercise) may sustantially diminish the risk of recurrent breast cancer & diminish mortality b) daily self-administered acupressure may improve fatigue, sleep, & quality of life [24] c) telephone follow-up appears to satisfy breast cancer patients' informational needs as effectively as do clinic visits, with no adverse psychosocial effects [13] 4) hot flashes [27] a) estrogen replacement 1] contraindicated per FDA 2] risk of breast cancer recurrence controversial b) selective serotonin reuptake inhibitors (SSRIs) 1] safe & for treatment of breast cancer patients with hot flashes 2] use caution when combined with tamoxifen [2] (SSRIs inhibit cyt-P450s that metabolize tamoxifen) c) serotonin-norepinephrine reuptake inhibitors (SNRIs) may be modestly effective d) gabapentin (900 mg daily in 3 divided doses) is an alternative e) avoid stronp CYP2D6 inhibitors that can inhibit tamoxifen activation [15] f) cognitive behavioral therapy used with variable success [27] 5) urogenital symptoms including sexual dysfunction a) over-the-counter water-based vaginal lubricants for symptomatic relief (1st line) a) vaginal estrogen preparations controversial - low-dose vaginal estrogen may be considered, even among women with a history of estrogen-dependent breast cancer if 1st line therapy unsuccessful 6) osteoporosis a) bisphosphonate therapy b) avoid excessive alcohol use c) smoking cessation d) weight-bearing exercise e) dietary calcium, 1200-1500 mg QD f) vitamin D, 800 IU QD g) bone mineral density every other year for patients on aromatase inhibitor [15] 7) blood draws, injections, & BP measurements in potentially affected arm & air travel do not increase risk for lymphedema in women who underwent sentinel node biopsy [22] 8) diet - breast cancer recurrence & overall mortality are lower among women who eat soy foods after their initial diagnosis [14] 9) exercise: - weight-lifting does not increase lymphedema among breast cancer survivors - exercise improves physical function & quality of life [17] 10) screening for cancer - women with a history of breast cancer before age 50 are at higher risk for colorectal cancer [26] - breast cancer in women > 50 years of age not associated with increased risk for colon cancer [26] - no need to alter colon cancer screening frequencies 11) pregnancy after 5 years of tamoxifen therapy - no increased risk of breast cancer or congenital malformations [15] - decreased fertility - refer to reproductive endocrinologist for embryo/oocyte cryopreservation [15]

Related

breast cancer staging of breast cancer

General

cancer survivor

References

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