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