The natural history of operable breast cancer after primary treatment

Early Detection of Recurrences in the Follow-up of Primary Breast Cancer in an Asymptomatic or Symptomatic Phase

Aims and background

Periodic follow-up after primary treatment for breast cancer is a common procedure for the early detection of recurrent disease in the asymptomatic state. Anyway, there is no clinical evidence that treatment of metastases may improve the prognosis if applied in the asymptomatic state. The aim of the present study was to investigate the modality of detection of the first relapse in the asymptomatic vs the symptomatic state.

Methods

We retrospectively analyzed 717 breast cancer patients who had been consecutively referred to the Parma Oncology Division during the period 1986 to December 1988. Recurrences were detected in the course of periodic follow-up.

Results

A total of 211 of the 408 patients evaluated had a first relapse with a median follow-up of 94.7 months. Local and distant recurrences were 49% and 47%, respectively. Bone recurrences represented 24% of the total first recurrences, then chest wall recurrences in 23%, local regional nodes in 13%, lung in 7%, liver in 4%, and brain in 2%. The distribution of the studied patients according to recurrence site and asymptomatic or symptomatic state was different: 69% of asymptomatic patiens (110) had a local recurrence vs 31% of symptomatic patients (101). A difference in survival was recorded in favor of cases detected in the asymptomatic state (P <0.001).

Conclusions

The present study suggests that an early detection of local recurrence might have a favorable impact on the prognosis of patients followed after primary treatment for breast cancer. It should be considered that any difference in survival could also be explained by several “biases” and that breast cancer follow-up is still an area of investigation open to discussion in which many questions remain to be clarified.

Forequarter amputation for recurrent breast cancer: A case report and review of the literature

Axillary recurrence of breast cancer is an uncommon event that can lead to debilitating pain, lymphedema, and paralysis of the upper extremity. Multimodality therapy including surgery is usually used to control local recurrence. In a subset of patients, the extent of disease is such that local excision of the recurrence is not possible. In the absence of metastatic disease, forequarter amputation may be used as an effective means of surgical salvage and palliation for locally recurrent breast cancer. In this report, we describe management of a patient with advanced axillary recurrence treated with forequarter amputation and review the current literature on the use of this operation in breast cancer patients.

The value of follow-up of patients with early breast cancer treated with conservative surgery and radiation therapy

A retrospective study of 438 women with Stage I or II breast cancer who were treated with conservation therapy and followed in accordance with a 'minimal' follow-up programme was conducted to identify a follow-up schedule to optimize detection of salvageable recurrence and/or contralateral new primary breast cancer, and to rationalize cost. Data from 104 women were used to establish the cost of detecting a salvageable event and to model the efficacy of 13 theoretical follow-up schedules. Among women followed for 5 years, 21% relapsed, and 19% of recurrences were salvageable. Only 0.1% of 1294 follow-up visits resulted in the detection of a salvageable event, at an average cost per woman of A $802. A simulated follow-up programme involving monthly visits for 5 years, costing A $3870 per woman, was the most successful in facilitating the detection of a salvageable recurrence but was also prohibitively expensive. Three-monthly visits for 4 years and 12-monthly for 1 year was more efficacious, but a better understanding of the psychosocial impact and patients' preferences for follow-up is required before any programme is implemented.

Double-Peaked Time Distribution of Mortality for Breast Cancer Patients Undergoing Mastectomy

PURPOSE

To gather information on the natural history of breast cancer from the time-distribution of deaths of patients undergoing mastectomy alone.

PATIENTS AND METHODS

A total of 1173 patients, who entered controlled clinical trials carried out at the Milan Cancer Institute and underwent radical or modified radical mastectomy without any adjuvant therapy for operable breast cancer, were examined. The risk of death at a given time after surgery was studied utilizing the death-specific hazard rate. The risk distribution was assessed relative to tumor size, axillary lymph node involvement, and menopausal status.

RESULTS

The hazard rate for death presented an early peak at about the 3rd-4th year after surgery and a second late peak near the 8th year. The double-peaked pattern was almost completely generated by N+ patients, while N- patients did not show relevant structures. Pre-menopausal patients showed an initial mortality wave covering about 6 years, with maximum height at the 4th year, followed by a peak 8 years after surgery, while post-menopausal patients showed an early high mortality surge peaking at the 3rd year, followed by a modest increase at the 8th year. Detailed analysis revealed that post-menopausal patients with early mortality had significantly larger tumors and higher nodal involvement, while no special trait characterized the corresponding pre-menopausal patients. Moreover, patients of the late mortality peak were more likely to have suffered early local-regional or contra-lateral recurrence or to be pre-menopausal patients recurring anywhere at the second recurrence peak.

CONCLUSION

The double-peaked hazard curve confirmed the occurrence of discontinuous features in the natural history of breast cancer for patients undergoing mastectomy. Indeed, the mortality pattern maintained definite signs of the previous double-peaked structure of recurrences. However, death events did not parallel the corresponding recurrence events and, moreover, pre and post-menopausal patients revealed dissimilar survival after recurrence, at least for early deaths. These findings, showing disconnection of mortality pattern from recurrence pattern for subsets of patients, suggest that parameters other than those influencing the recurrence risk may determine the survival of recurred patients.

Microsatellite alterations detected in the serum of early stage breast cancer patients

Breast cancer is the most common malignancy affecting women. Advances in screening have resulted in an increasing trend towards detecting earlier stage tumors associated with a longer disease-free survival. Because of this prolonged latency period, it is critical to identify patients early in their disease course who are at increased risk for recurrence, whereby treatment decisions may be altered accordingly based on more precise information. Molecular markers that demonstrate prognostic importance as well as utility for assessing subclinical disease progression offer one such approach. Specifically, circulating microsatellite alterations that reflect those genetic events occurring in tumors and that can be serially assessed through a minimally invasive procedure are a logistically practical method. In this study, serum was collected preoperatively from 56 patients with early stage breast cancer (AJCC stages I/II) and assessed for loss of heterozygosity (LOH) using 8 microsatellite markers. Twelve (21%) of 56 patients demonstrated LOH in their serum for at least one marker. Histopathologic correlation revealed an association between the presence of circulating LOH in serum and those tumors with increased proliferation indices as characterized by an increased diploid index, elevated MIB-1 fraction, and abnormal ploidy. These findings demonstrate the presence of circulating microsatellite alterations in the serum from patients with early stage breast cancer. The association of known poor prognostic features found in tumors with increased nuclear activity not only suggests a possible etiology for their presence, but also offers a potential blood-based surrogate marker for this disease that may demonstrate clinical utility in long-term follow-up studies.