Local Breast Cancer Recurrence
Local breast cancer recurrence is when the cancer has reoccurred close to or in the same place the first tumor was found within the breast. If you were treated with lumpectomy and radiation for your first occurrence, the breast tissue cannot be treated with radiation again. In that case, the standard of care for surgical treatment is mastectomy.
If radiation was not part of your original treatment when lumpectomy was performed, then another lumpectomy followed by radiation may be recommended. If there is not adequate breast volume remaining for lumpectomy, mastectomy may be recommended. Depending on the medical oncologists evaluation, which is based on the prognostic factors of the tumor, he or she may recommend chemotherapy and/or hormonal therapy.
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Breast Cancer Subtypes Hormonal And Her2 Status And Survival Rates
Many research studies over the years have shown that Estrogen-positive breast cancers have better survival rates than all of the Estrogen-negative subtypes.
Progesterone-positive breast cancer also appears to have improved survival rates in comparison to progesterone-negative cases.
A recent research study combines hormone receptivity, HER2 status and stage and found some interesting results:-
For ER+ sub-types survival rates were significantly better than all other subtypes. For example, at stage 1b,
ER+ PR+ HER2- 5-year survival rates were 98.6%ER+ PR- HER2+ 5-year survival rates were 97.3%
The subtype triple negative breast cancer had the worst survival rates over all three stages. At stage I the 5-year survival rate was 92.9% and at stage III 48.9%.
What I Wish People Knew About Metastatic Breast Cancer
Women with metastatic breast cancer think about fighting cancer very differently than women who don’t have a stage 4 diagnosis. If you have advanced cancer, these women understand what youre going through.
The term metastatic breast cancer describes breast cancer that has spread beyond the breast to the bones, liver, brain, or another organ. Even if the cancer is found in another organ, its still referred to as breast cancer and is treated as such.
While metastatic breast cancer is terminal and cannot be cured, because of improved treatments more women are living longer than ever with it. Even so, a lack of information and many misconceptions about this diagnosis persist.
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Types Of Breast Cancer
There are several different types of breast cancer, which develop in different parts of the breast.
Breast cancer is often divided into either:
- non-invasive breast cancer found in the ducts of the breast which has not spread into the breast tissue surrounding the ducts. Non-invasive breast cancer is usually found during a mammogram and rarely shows as a breast lump.
- invasive breast cancer where the cancer cells have spread through the lining of the ducts into the surrounding breast tissue. This is the most common type of breast cancer.
Other, less common types of breast cancer include:
- invasive lobular breast cancer
- inflammatory breast cancer
It’s possible for breast cancer to spread to other parts of the body, usually through the blood or the axillary lymph nodes. These are small lymphatic glands that filter bacteria and cells from the mammary gland.
If this happens, it’s known as secondary, or metastatic, breast cancer.
Treatment Of Hormone Receptorpositive Metastatic Breast Cancer
Metastatic breast cancer expressing ER and/or PR should be treated with hormonal agents. The only indication for chemotherapy as first-line treatment in this setting is a life-threatening visceral disease such as diffuse liver metastasis. Tamoxifen continues to be widely used in the treatment of hormone-responsive metastatic breast cancer, and the likelihood of responding can be predicted by the hormone receptor status of a patient’s tumor. Patients are most likely to respond if their tumor expresses both ER and PR, but patients with tumor expressing one or other of the receptors benefit from hormonal therapy in 30% to 40% of cases.83 A patient who benefits from one hormonal therapy can benefit from second-, third-, and even fourth-line hormonal therapy.
Recent trials have demonstrated that aromatase inhibitors are at least as effective as tamoxifen as first-line therapies for hormone-responsive metastatic breast cancer.8488 Newer agents, such as fulvestrant, which down-regulates ER and PR, are effective in patients whose cancer has progressed on tamoxifen.89 Progestins, such as megestrol acetate, estrogens, and androgens can be used as third- and fourth-line agents in patients who continue to benefit from hormonal therapy.
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Symptoms Of Skin Metastases
Symptoms of skin metastases include:
- a change in the colour of the skin
- a lasting rash
- a firm, painless nodule or a number of nodules of different sizes
Sometimes the symptoms of skin metastases, such as redness and inflammation, may look like an infection of the skin called cellulitis.
Skin metastases can also cause lymphoedema, which is swelling of the arm, hand or breast area.
Other possible symptoms include:
- odour
Aggressive And Advanced Metastatic Breast Cancer
Habibi says the most extreme situations involve patients who are diagnosed with a very fast, aggressive breast cancer that has already spread to multiple organs and begins to overwhelm the body. For those patients, palliative care is important, concentrating on local control, pain management and avoiding bleeding and infection.
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Mechanisms Of Breast Cancer Metastasis
No one really knows what factors will make a certain patient more or less susceptible to breast cancer metastasis.
There is growing awareness that part of that susceptibility is due to host factors. The host factors are the characteristics of the non-malignant cells and the general biological environment surrounding the malignant breast tumor.
Sometimes the host factors are referred to as the pre-metastatic niche and it is thought that bone-marrow-derived progenitor cells may directly influence the dissemination of malignant cells to distant areas.
Non-neoplastichost cells within the tumor may also play a key role in the regulation of breast cancer metastasis.
Clinical Data Of Patients Who Underwent Early Treatment
The baseline tumor characteristics are listed and compared between the luminal B group and the non-luminal group .1). The median age at diagnosis of the patients with luminal B breast cancer was 48 years , and the median age at diagnosis of patients with non-luminal breast cancer was 42 . Compared with non-luminal breast cancer patients with postoperative recurrence and metastasis, the average age at diagnosis of patients in the luminal group was greater, and the proportion of patients with postmenopausal status was higher. The difference between the groups was statistically significant . However, in regards to family history of breast cancer, pathological type, clinical stage, and axillary lymph node status, no differences were observed between the groups. An analysis of individuals with luminal B breast cancer showed that patients in this subgroup did not differ in terms of any of the clinical characteristics under investigation .
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Preventing Metastatic Breast Cancer
Habibi advises: Having a routine evaluation by your PCP and or cancer specialist would assist in diagnosing any cancer recurrence taking the hormone therapy medications also can decrease the chance of cancer recurrence.
Maintaining a healthy lifestyle, including staying at a healthy weight and avoiding alcohol, can help in reducing the chance of recurrence.
Scenario : The Progression Model
We now consider a drug that does not cure patients but doubles the time to death for each patient. We have given the drug to a cohort of 45,647 women with the same inherent mortality risk as the untreated cohort in scenario 1. The net benefit in terms of survival at 20 years is from 72.4 to 79% . The three curves are presented in Fig. ac. The intervention doubled the time to death for individual patients this resulted in an increase in the mean time to death from 6.3 to 9.2 years . These curves are notable in that a profound impact on delaying the time to death has a relatively modest impact on mortality i.e. if we double the life expectancy of each patient in the study, we improve actuarial survival at 20 years from 72.4 to 79.9%. This is equivalent to curing 30% of the patients.
a Impact of doubling time to death on annual hazard rates, ER-positive patients in SEER. b Impact of doubling time to death on actuarial survival, ER-positive patients in SEER. c Impact of doubling time to death on time to death, ER-positive patients in SEER
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Treatment Of Stage Iv Breast Cancer
Stage IV cancers have spread beyond the breast and nearby lymph nodes to other parts of the body. When breast cancer spreads, it most commonly goes to the bones, liver, and lungs. It may also spread to the brain or other organs.
For women with stage IV breast cancer, systemic drug therapies are the main treatments. These may include:
- Some combination of these
Surgery and/or radiation therapy may be useful in certain situations .
Treatment can often shrink tumors , improve symptoms, and help some women live longer. These cancers are considered incurable.
Living With Secondary Breast Cancer
Everyones experience of being diagnosed with secondary breast cancer is different, and people cope in their own way.
For many people, uncertainty can be the hardest part of living with secondary breast cancer.
Our information on living with secondary breast cancer addresses the emotional, practical and physical effects of a diagnosis.
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Disseminated Tumour Cells As Culprits For Metastatic Recurrence
Metastatic relapse is attributed to the outgrowth of cancer cells that have escaped from the primary tumour and take up residence in secondary sites. Cancer cells that physically detach from a primary source and seed distant sites are known as disseminated tumour cells . The process whereby DTCs transform a localised cancer into a systemic disease is called the metastatic cascade . In the next few sections, the seven key steps comprising this complex biological process are discussed with the goal to shed light on the when and how of DTC dissemination. Importantly, while depicting the metastatic cascade as an orderly series of sequential eventsstarting from the primary tumour and ending in a distant metastatic siteit should be noted that DTC spread can take place through multiple routes and different directions. Accordingly, clinical evidence of self-seedingwhereby a metastatic cell re-infiltrates its primary tumourand of metastasis-to-metastasis spread, has been documented, with one such study in HR+ breast cancer patients reporting a common origin between lymph node and distant metastases in up to 25% of cases.
Fig. 2: Tumour cell dissemination: the route to metastatic success or failure.
Basic Information About Breast Cancer
Cancer is a disease in which cells in the body grow out of control. Except for skin cancer, breast cancer is the most common cancer in women in the United States. Deaths from breast cancer have declined over time, but breast cancer remains the second leading cause of cancer death among women overall and the leading cause of cancer death among Hispanic women.
Each year in the United States, about 255,000 cases of breast cancer are diagnosed in women and about 2,300 in men. About 42,000 women and 500 men in the U.S. die each year from breast cancer. Black women have a higher rate of death from breast cancer than White women.
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Disease Free Intervals And Prognosis In Metastasis
The time that passes between the primary diagnosis and treatment of breast cancer and a diagnosis of metastasis is also of prognostic significance.
A 2015 medical study from the Netherlands looked at 815 patients with metastatic breast cancer between 2007 and 2009 in eight hospitals.
Of these 815 patients, 154 had metastatic spread at diagnosis. 176 patients had a metastatic free interval of less than 2 years and 485 patients had been metastasis-free for longer than 2 years.
The ladies presenting with metastatic breast cancer at diagnosis had a longer survival rate than those who experienced a recurrence at distant sites in under 2 years from the initial diagnosis of breast cancer.
However, there were no differences in survival rates between those diagnosed at Stage IV and those women who had metastatic spread over 2 years after an original breast cancer diagnosis and treatment.
Furthermore, some medical studies show that survival rates vary for different types and subtypes of breast tumors according to the time intervals of recurrence. So, for example, breast cancer survival rates comparing two cancers may be better at a 5-year interval for some cancers but even out over 15 years.
What Is Secondary Breast Cancer
Secondary breast cancer is when cancer cells from a cancer that started in the breast spread to other parts of the body. The cancer that started in the breast is called primary breast cancer.Secondary breast cancer is also called advanced breast cancer or metastatic breast cancer. The most common places for breast cancer to spread to are the:
Rarely, breast cancer may spread to other parts of the body, such as the bone marrow, ovaries or lining of the tummy which is called the peritoneum.
Breast cancer can spread to different parts of the body. This does not mean it will go to all these places.
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Advanced Metastatic Disease Management
Metastatic breast cancer is still considered an incurable process, but the division into molecular subtypes has led to improvements in care and facilitated a personalized management approach. The conventional markers of HER-2, ER, and PR also guide management in the metastatic setting. The identification of HER-2 positive breast cancer has led to the most dramatic change, with prolonged disease control in many patients either presenting with or developing metastatic HER-2 positive breast cancer. Consensus guidelines recommend repeating these conventional markers on a biopsy of suspected metastatic disease, since numerous studies have documented the potential for changes in the conventional markers on metastasis. Meta-analyses of these studies suggest that ER status can change from positive to negative in 5.7% to 9.5% of cases, and negative to positive in 3% to 8.8% of cases. HER-2 can change in either direction in approximately 5.5% of cases. While the benefit of reassessing markers is unproven, the consensus recommendation is to guide treatment based on the metastatic cancer . The broader point is that assessment of metastatic biology is much more complex, but important for optimal personalized disease management.
Juan Garona, … Daniel F. Alonso, in, 2020
Encouraging Statistics On Prognosis Of Metastatic Breast Cancer
In recent years, there have been some encouraging new statistics on the prognosis of metastatic breast cancer, these include:
- The statistics on survival rates show that women with breast cancer live longer today than ever before.
- In the past decade, the survival rate has substantially increased, due to an improvement in early diagnosis and screening, as well as improved targeted treatment.
- Survival rates are higher for women in higher economic groups
- The stage of cancer at the time of diagnosis plays an impactful role in prognosis, the highest survival rate begins for those who are five years post-treatment.
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Metastatic Breast Cancer Treatment
Metastatic breast cancer can have different presentations for each patient, and can behave differently from one person to the next. But for most, individualized treatment can slow the spread of cancer, lessen the impact of symptoms or both.
We see patients with a whole host of presentations and degrees of aggressiveness. Were not looking at all metastatic diagnoses with the same lens. When planning treatment and supportive care, we look at each individual patient and consider all aspects of their health and well-being.
The mainstay of therapy in the setting of metastatic disease is systemic therapy, Habibi explains.
Systemic therapies use medicines, and may include:
Local therapy: Examples of this approach include surgery and radiation directed at one or more specific spots where breast cancer has spread. Local therapy can be used to address oligometastatic breast cancer, which is breast cancer that has spread to just one spot or to a limited number of areas.
If a metastatic area remains stable with treatment, it can be treated as a chronic disease, Habibi says, noting that in these situations, the strategy is preventing the cancer from advancing. For oligometastatic breast cancer, he says that a combination of chemotherapy, radiation treatments or surgery to remove cancerous areas can address symptoms and extend life.
Regional therapy includes surgery or radiation to treat metastatic cancer in nearby affected lymph nodes.
What Is The Staging For Invasive Ductal Carcinoma
Staging refers to the extent of a cancer. A cancer is always referred to by the stage it was determined to be at diagnosis, even if it spreads.
Stages of invasive ductal carcinoma include:
- Stage I: Breast tumor is smaller than 2 centimeters in diameter and the cancer has not spread beyond the breast
- Stage II: Breast tumor measures 2 to 4 centimeters in diameter or cancerous cells have spread to the lymph nodes in the underarm area
- Stage III: Cancer is more extensive but it is confined to the breast, surrounding tissues, and lymph nodes
- Stage IV: Breast cancer has spread to lymph nodes beyond the underarm area or to distant sites, such as the lungs, liver, bones, or brain
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Why Does My Provider Need To Test The Metastatic Tumor
Your care team will test the metastases to figure out the biology of the tumor, which can help guide your treatment plan. Providers may test tumors for:
- Hormone receptor status: If the cancer is hormone receptor-positive, hormonal therapy may be your first treatment.
- HER2 status: Human epidermal growth factor receptor 2 is a protein that is overexpressed on some breast cancer cells. HER2-positive cancer responds to specific HER2-targeted therapies.
- PIK3CA gene mutation: If a tumor is hormone receptor-positive and HER2-negative, your provider may test for this gene mutation. Specific targeted therapies can be used to treat tumors with this mutation.
- PD-L1 status: Tumors that are hormone receptive-negative and HER2-negative may be tested for PD-L1 status. If the PD-L1 test is positive, you may be recommended to receive a combination of immunotherapy and chemotherapy.