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Recurrent breast cancer with distant metastases is not curable, and the goals of treatment in such patients are to improve survival, palliate symptoms, and minimize treatment toxicity.
Screening improves disease specific survival.
Canadian National brast screening study 2014: 10 year follow up 70.6% vs 62.8% p=0.02
22% of all screen detected cancers were cancers of overdiagnosis
Medical Risk Reduction
For women at high risk of developing breast cancer, endocrine therapy (oral anti-estrogen) may be prescribed to lower the risk of a future breast cancer
For pre-menopausal women – SERM
For post-menopausal women – SERM or aromatase inhibitor
Toxicities are an important concept for the ABIM:
Chemotherapy: Cardiomyopathy (doxorubicin – dose dependent, rare, occurs 3-5 years after treatment), hair loss, fatigue, nausea, mout sores, constipation, diarrhea, skin rash, neuropathy
Tamoxifen – Tamoxifen is a SERM that blocks estrogen in breast tissue but not in other tissues. Patients on tamoxifen should not take certain SSRIs because the inhibit CYP2D6 activity and decrease metabolism of tamoxifen. Side effects include hot flashes, venous thromboembolism and endometrial carcinoma (post-menopausal women)
Aromatase inhibitors – joint aches, loss of bone density over time, hot flashes, vaginal dryness, low libido
Immunotherapy -Newer therapies PDL1 atezolizumab approved for TNBC in combination with nab-paclitaxel. Likely will see pembrolizumab for TNBC in the future: Side effects: all the “itis”, colitis, skin rash, pneumonitis, etc.
Patients with a history of early-stage breast cancer who develop findings suspicious for metastatic disease should undergo biopsy of suspected metastatic lesion, if possible, to confirm the diagnosis and facilitate repeat assessment of hormone receptor status and HER2 overexpression.
Recurrent metastatic hormone receptor-positive breast cancer is usually treated with initial antiestrogen therapy, which works best in patients with bone and soft tissue metastases and in those with a longer disease-free interval since the initial breast cancer diagnosis.
Post by Roger D. Struble MD MPH