breast cancer survival (includes breast cancer prognosis)
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Introduction
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]
- 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]
- 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
- guidelines from the American Cancer Society, the American College of Physicians & the American Society of Clinical Oncology[20]
- 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
- 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
- counsel patients on maintaining good health
- care coordination with the patient's oncologists & caregivers to implement a survivorship care plan
- surveillance for recurrence:
- comprehensive & multidisciplinary management
- 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
- maintenence of overall health
- treatment of distressing menopausal symptoms
- healthy lifestyle changes
- exercise reduces risk of cardiovascular events in survivors of non-metastatic breast cancer[23]
- referrals to mental health practitioners & support groups as indicated
- 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
- surveillance of recurrence
- psychological intervention
- stress reduction, smoking cessation, mood improvement, & attention to diet & exercise) may sustantially diminish the risk of recurrent breast cancer & diminish mortality
- daily self-administered acupressure may improve fatigue, sleep, & quality of life[24]
- telephone follow-up appears to satisfy breast cancer patients' informational needs as effectively as do clinic visits, with no adverse psychosocial effects[13]
- hot flashes[27]
- estrogen replacement
- contraindicated per FDA
- risk of breast cancer recurrence controversial
- selective serotonin reuptake inhibitors (SSRIs)
- safe & for treatment of breast cancer patients with hot flashes
- use caution when combined with tamoxifen[2] (SSRIs inhibit cyt-P450s that metabolize tamoxifen)
- serotonin-norepinephrine reuptake inhibitors (SNRIs) may be modestly effective
- gabapentin (900 mg daily in 3 divided doses) is an alternative
- avoid stronp CYP2D6 inhibitors that can inhibit tamoxifen activation[15]
- cognitive behavioral therapy used with variable success[27]
- estrogen replacement
- urogenital symptoms including sexual dysfunction
- over-the-counter water-based vaginal lubricants for symptomatic relief (1st line)
- 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
- osteoporosis
- bisphosphonate therapy
- avoid excessive alcohol use
- smoking cessation
- weight-bearing exercise
- dietary calcium, 1200-1500 mg QD
- vitamin D, 800 IU QD
- bone mineral density every other year for patients on aromatase inhibitor[15]
- 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]
- diet
- breast cancer recurrence & overall mortality are lower among women who eat soy foods after their initial diagnosis[14]
- exercise:
- weight-lifting does not increase lymphedema among breast cancer survivors
- exercise improves physical function & quality of life[17]
- 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
- 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]
More general terms
Additional terms
References
- ↑ Andersen BL et al Psychologic intervention improves survival for breast cancer patients: A randomized clinical trial. Cancer 2008 Dec 15; 113:3450. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19016270
- ↑ 2.0 2.1 Carpenter JS et al Hot flashes and related outcomes in breast cancer survivors and matched comparison women. Oncol Nurs Forum 2002 Apr; 29:E16. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/11979290 <Internet> http://ons.metapress.com/content/6616786818742847/fulltext.pdf
- ↑ Loprinzi CL et al Venlafaxine in management of hot flashes in survivors of breast cancer: A randomised controlled trial. Lancet 2000 Dec 16; 356:2059. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11145492
- ↑ Carpenter JS et al Randomized, double-blind, placebo-controlled crossover trials of venlafaxine for hot flashes after breast cancer. Oncologist 2007 Jan; 12:124. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17227907
- ↑ Hickey M et al Practical clinical guidelines for assessing and managing menopausal symptoms after breast cancer. Ann Oncol 2008 Oct; 19:1669. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18522932
- ↑ Jin Y et al CYP2D6 genotype, antidepressant use, and tamoxifen metabolism during adjuvant breast cancer treatment. J Natl Cancer Inst 2005 Jan 5; 97:30. PMID: https://www.ncbi.nlm.nih.gov/pubmed/15632378
- ↑ Walker EM et al. Acupuncture for the treatment of vasomotor symptoms in breast cancer patients receiving hormone suppression treatment. American Society for Therapeutic Radiology and Oncology 50th Annual Meeting , Boston , Sep 22; 2008. 72:S103.
- ↑ Barentsen R et al Continuous low dose estradiol released from a vaginal ring versus estriol vaginal cream for urogenital atrophy. Eur J Obstet Gynecol Reprod Biol 1997 Jan; 71:73. PMID: https://www.ncbi.nlm.nih.gov/pubmed/9031963
- ↑ Barton DL et al Randomized controlled trial to evaluate transdermal testosterone in female cancer survivors with decreased libido; North Central Cancer Treatment Group protocol N02C3. J Natl Cancer Inst 2007 May 2; 99:672. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17470735
- ↑ Shapiro CL et al Ovarian failure after adjuvant chemotherapy is associated with rapid bone loss in women with early-stage breast cancer. J Clin Oncol 2001 Jul 15; 19:3306. PMID: https://www.ncbi.nlm.nih.gov/pubmed/11454877
- ↑ Eastell R et ak for the ATAC Trialists' Group. Effect of anastrozole on bone mineral density: 5-year results from the anastrozole, tamoxifen, alone or in combination trial 18233230. J Clin Oncol. 2008 Mar 1;26(7):1051-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/18309940
- ↑ Mao JJ et al. Delivery of survivorship care by primary care physicians: The perspective of breast cancer patients. J Clin Oncol 2009 Feb 20; 27:933. PMID: https://www.ncbi.nlm.nih.gov/pubmed/19139437
- ↑ 13.0 13.1 Beaver K et al Comparing hospital and telephone follow-up after treatment for breast cancer: Randomised equivalence trial. BMJ 2009 Jan 14; 338:a3147. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19147478 <Internet> http://dx.doi.org/10.1136/bmj.a3147
- ↑ 14.0 14.1 Shu XO et al, Soy Food Intake and Breast Cancer Survival JAMA. 2009;302(22):2437-2443 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/19996398 <Internet> http://jama.ama-assn.org/cgi/content/full/302/22/2437?home
- ↑ 15.00 15.01 15.02 15.03 15.04 15.05 15.06 15.07 15.08 15.09 15.10 15.11 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
- ↑ Schmitz KH et al Weight Lifting for Women at Risk for Breast Cancer- Related Lymphedema JAMA. 2010 Dec 22;304(24):2699-705. Epub 2010 Dec 8. PMID: https://www.ncbi.nlm.nih.gov/pubmed/21148134 doi:http://dx.doi.org/ 10.1001/jama.2010.1837
- ↑ 17.0 17.1 Fong DYT et al. Physical activity for cancer survivors: Meta-analysis of randomised controlled trials. BMJ 2012 Jan 31; 344:e70 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22294757
- ↑ 18.0 18.1 Davis SR et al. Menopausal symptoms in breast cancer survivors nearly 6 years after diagnosis. Menopause 2014 Oct; 21:1075. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24618765
Carpenter JS and Milata JL. Do menopausal symptoms continue after oral endocrine therapy for breast cancer? Menopause 2014 Oct; 21:1035. PMID: https://www.ncbi.nlm.nih.gov/pubmed/25026115 - ↑ Hayes DF Clinical practice. Follow-up of patients with early breast cancer. N Engl J Med. 2007 Jun 14;356(24):2505-13. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17568031
- ↑ 20.0 20.1 Runowicz CD et al American Cancer Society/American Society of Clinical Oncology Breast Cancer Survivorship Care Guideline. J Clin Oncol. Dec 7, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26644543 <Internet> http://jco.ascopubs.org/content/early/2015/12/07/JCO.2015.64.3809.full
- ↑ Orciari Herman A, Fairchild DG, Hefner JE ACOG: Vaginal Estrogen an Option for Urogenital Symptoms in Breast Cancer Survivors. Physician's First Watch, Feb 23, 2016 David G. Fairchild, MD, MPH, Editor-in-Chief Massachusetts Medical Society http://www.jwatch.org reference to Obstetrics and Gynecology article
- ↑ 22.0 22.1 Ferguson CM et al. Impact of ipsilateral blood draws, injections, blood pressure measurements, and air travel on the risk of lymphedema for patients treated for breast cancer. J Clin Oncol 2016 Mar 1; 34:691. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26644530 <Internet> http://jco.ascopubs.org/content/34/7/691
- ↑ 23.0 23.1 23.2 Jones LW, Habel LA, Weltzien E et al. Exercise and risk of cardiovascular events in women with nonmetastatic breast cancer. J Clin Oncol 2016 May 23 PMID: https://www.ncbi.nlm.nih.gov/pubmed/27217451
- ↑ 24.0 24.1 Zick SM, Sen A, Wyatt GK et al Investigation of 2 Types of Self-administered Acupressure for Persistent Cancer-Related Fatigue in Breast Cancer Survivors. A Randomized Clinical Trial. JAMA Oncol. Published online July 07, 2016 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/27388752 <Internet> http://oncology.jamanetwork.com/article.aspx?articleid=2532352
Zick SM, Wyatt GK, Murphy SL et al Acupressure for persistent cancer-related fatigue in breast cancer survivors (AcuCrft): a study protocol for a randomized controlled trial. BMC Complement Altern Med. 2012 Aug 21;12:132. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22909076 Free PMC Article - ↑ 25.0 25.1 Samiian L When to Stop Surveillance Mammography in Older Breast Cancer Survivors? NEJM Journal Watch. Dec 13, 2016, Women's Health, Oncology & Hematology Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Freedman RA et al. Surveillance mammography in older patients with breast cancer
can we ever stop? A review. JAMA Oncol 2016 Nov 17; PMID: https://www.ncbi.nlm.nih.gov/pubmed/27892991 - ↑ 26.0 26.1 26.2 Lai JH, Park G, Gerson LB. Association between breast cancer and the risk of colorectal cancer: Systematic review and meta-analysis. Gastrointest Endosc. 2017 Apr 19. <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28433614 <Internet> http://www.giejournal.org/article/S0016-5107(17)31810-2/pdf
- ↑ 27.0 27.1 27.2 Santen RJ, Stuenkel CA, Davis SR et al Managing menopausal symptoms and associated clinical issues in breast cancer survivors. Journal Clin Endocrinol Metab (JCEM) jc.2017-01138 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26444994 https://academic.oup.com/jcem/article/doi/10.1210/jc.2017-01138/4058051/Managing-menopausal-symptoms-and-associated
- ↑ 28.0 28.1 Childers CP, Childers KK, Maggard-Gibbons M, Macinko J National Estimates of Genetic Testing in Women With a History of Breast or Ovarian Cancer. J Clin Oncol. 2017 Aug 18:JCO2017736314 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/28820644 <Internet> http://ascopubs.org/doi/abs/10.1200/JCO.2017.73.6314
Jenkins K Huge Underuse of Genetic Testing Among Cancer Survivors. Medscape - Aug 24, 2017. http://www.medscape.com/viewarticle/884645 - ↑ 29.0 29.1 29.2 Davenport L Neuropathy After Breast Cancer Chemo Can Last for Years. Medscape - Sep 01, 2017. http://www.medscape.com/viewarticle/885106
Bandos H, Melnikow J, Rivera DR et al Long-term Peripheral Neuropathy in Breast Cancer Patients Treated With Adjuvant Chemotherapy: NRG Oncology/NSABP B-30. JNCI: , Vol 110, Issue 2, 1 Feb 2018; Online Aug 24, 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28954297 https://academic.oup.com/jnci/article-abstract/110/2/djx162/4093779/Long-term-Peripheral-Neuropathy-in-Breast-Cancer
Rivera DR, Ganz PA, Weyrich MS, Bandos H, Melnikow J Chemotherapy-Associated Peripheral Neuropathy in Patients With Early-Stage Breast Cancer: A Systematic Review. JNCI: Vol 110, Issue 2, 1 Feb 2018. Online Aug 25, 2017 PMID: https://www.ncbi.nlm.nih.gov/pubmed/28954296 https://academic.oup.com/jnci/article-abstract/110/2/djx140/4093778/Chemotherapy-Associated-Peripheral-Neuropathy-in - ↑ 30.0 30.1 Pan H, Gray R, Braybrooke J et al 20-Year Risks of Breast-Cancer Recurrence after Stopping Endocrine Therapy at 5 Years. N Engl J Med 2017; 377:1836-1846. November 9, 2017 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/29117498 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMoa1701830
- ↑ 31.0 31.1 31.2 Freedman RA, Minami CA, Winer EP et al Individualizing Surveillance Mammography for Older Patients After Treatment for Early-Stage Breast Cancer. Multidisciplinary Expert Panel and International Society of Geriatric Oncology Consensus Statement. JAMA Oncol. Published online January 28, 2021 PMID: https://www.ncbi.nlm.nih.gov/pubmed/33507222 https://jamanetwork.com/journals/jamaoncology/fullarticle/2775244