Breast Cancer: Follow up and Management of recurrence

1. Breast Cancer: Follow up and Management of recurrence Carol Marquez, M.D. Associate Professor Department of Radiation Medicine OHSU

2. 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.

3. 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.

4. 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

5. 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.

6. 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?

8. 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

9. 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)

10. 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.

11. 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

12. New Primary vs. True Recurrence