Contralateral Breast Carcinoma Surveillance - PowerPoint Presentation

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Contralateral Breast Carcinoma Surveillance

Scott D. Hamling, MD,

FACS

The Iowa Clinic Surgical Breast Clinic

JSCC Breast Program Leadership Committee Chair

Contralateral Breast Cancer

Overview

Review

contralateral breast cancer statistics

Discuss the occurrence patterns of CBC

Emphasize the effect CBC has on survival

Identify patients at high risk for CBC development

Implement a high risk surveillance program

Breast Cancer Statistics

Breast cancer is the most common cancer in American women, excluding skin cancers

The

average risk of a woman in the United States developing breast cancer approaches 13%

Incidence rates have increased in recent years by 0.3%

Breast cancer is the second leading cause of cancer deaths in women after lung cancer

Contralateral Breast Cancer Statistics

CBC is

the most common second primary cancer in patients treated for a first BC, accounting for approximately 50% of all second cancers

Reported incidence rates range from 1.2% to 14% depending upon patient demographics, stage of first BC diagnosis, original treatment administered and reporting periods

Increased incidence of BC, improved survival, and decreased patient age at diagnosis results in an increased number of BC patients at risk of developing a CBC

Thus, surveillance for metachronous CBC is increasingly important

CBC Unpredictable Occurrence Patterns

Risk of BC

is higher in patients with BC compared to general population risk

Stage associated mortality affects reported CBC risk

Initial treatment affects CBC risk and delays time to CBC development

Variability in study reporting periods

Variability in genetics

Initial BC tumor biology

Studies indicate survival may be worse in patients who develop CBC

Identifying CBC Occurrence and Outcome Patterns

SEER

(Surveillance, Epidemiology, and End Results) database

Standard for

quality among cancer registries

Collects cancer incidence and related data from multiple population-based registries

Represents approximately 14% of the Unites States population

Includes: demographics, description of neoplasm, first course of cancer-directed therapy, and follow-up

Occurrence Pattern of CBC Incidence in Early-Stage BC (stage I/II)

The

5-, 10-, 15-, and 20-year cumulative incidences of CBC were 1.9, 4.6, 7.6, and 10.5%, respectively (

Xiong

et al, 2018)

Gao et al (2003) reported 3, 6.1, 9.1, and 12% incidence rate at 5-, 10-, 15-, and 20-years

Overall, we see an approximate 0.5% per year CBC risk

Age<40 years, African American ethnicity, receiving radiotherapy for the first BC, and having hormone receptor-negative BC were significantly correlated with a higher risk of CBC

Cumulative Incidence Over Time

Occurrence Pattern of CBC

Three phases of CBC incidence

Increases

continuously in the first 11 years (trend 1)

Slowing of the upward trend years 11-21 (trend 2)

Declining incidence years 21-24 (trend 3)

Age variance

Incidence increases more rapidly in younger patients

Declining trend in CBC risk in patients >70 years between year 9 and 23

Occurrence Pattern of CBC

Hormone

receptor status

CBC

incidence in i

nitial hormone receptor-positive BC was delayed compared to initial hormone receptor-negative BC

Radiotherapy

Incidence of CBC increased continuously during follow-up, whereas no significant

trend was seen in patients who had not undergone radiotherapy

Temporal trend

The risk of CBC was significantly higher

than general population BC risk for the first 23 years

At year 24, no significant excess risk was observed

CBC Survival

Overall survival

Patients with CBC had significantly shorter OS than first BC

Stage subgroup analysis

showed patients with first BC had better OS compared to patients with CBC

Cancer-specific

survival

CBC appears to be correlated with worse breast cancer-specific

survival regardless of tumor stage

OS

BCSS

CBC Occurrence Pattern Summary

As BC

mortality is decreasing and life expectancy is increasing, BC patients have an increased probability of developing CBC

The risk of CBC is greater than general population BC risk

CBC risk remains significant for over 21 years

Age and tumor biology predict CBC incidence trends

Adjuvant treatments modify CBC incidence trends

CBC development adversely affects survival

CBC Risk Appropriate Surveillance

CBC

risk identification and assessment

Genetic

susceptibility

Prior therapeutic chest wall radiation age 10-30 years

Predictive model lifetime breast cancer risk > 20%

Age of first breast cancer diagnosis

Patients with a CBC risk exceeding 20%- consider more intensive surveillance

Frequency

Supplemental imaging modalities

Standard Surveillance

Patients who have undergone unilateral mastectomy: the contralateral breast should be followed with yearly screening mammography

Patients who have undergone breast-conserving therapy: annual bilateral mammography with the ipsilateral breast imaged 6 months post-therapy

Clinical exam 1-4 times per year as clinically appropriate for 5 years, then annually

High Risk Surveillance

Patients

with a second BC/CBC risk exceeding 20%

Genetic susceptibility

Prior therapeutic chest wall radiation age 10-30 years

Predictive model lifetime breast cancer risk > 20%

Initial

breast cancer age of diagnosis < 50 years

Prior history of breast cancer with continued increased breast density

Standard Surveillance schedule and access to annual supplemental imaging (MRI preferred

modality)

Intensive surveillance continues as long as patient has an elevated risk of second cancer and a life expectancy of 10 years, but not beyond age 74

CBC Surveillance Summary

CBC is

the most common second primary cancer in patients treated for a first BC, accounting for approximately 50% of all second cancers

Overall, we see an approximate 0.5% per year CBC risk

Three phases of CBC incidence

Increases

continuously in the first 11 years (trend 1)

Slowing of the upward trend years 11-21 (trend 2)

Declining incidence years 21-24 (trend 3)

Overall

survival and cancer-specific survival decreases with CBC

Patients with a second BC/CBC risk exceeding 20% should be offered high risk surveillance

Surveillance Summary