Recurrent local-regional breast cancer
Patients with local-regional breast cancer recurrence may become long-term survivors with appropriate therapy. A clinical trial indicated that between 10% and 20% of patients will have locally recurrent disease in the breast between 1 and 9 years after breast-conserving surgery plus radiation therapy. Nine percent to 25% of these patients will have distant metastases or locally extensive disease at the time of recurrence.[7,8,9] Patients with local-regional recurrence should be considered for further local treatment (e.g., mastectomy). In one series, the 5-year actuarial rate of relapse for patients treated for invasive recurrence after initial breast conservation and radiation therapy was 52%. A phase III, randomized study showed that local control of cutaneous metastases could be achieved with the application of topical miltefosine; however, the drug is not currently available in the United States.[Level of evidence: 1iiDiii]
Local chest wall recurrence following mastectomy is usually the harbinger of widespread disease, but, in a subset of patients, it may be the only site of recurrence. For patients in this subset, surgery and/or radiation therapy may be curative.[11,12] Patients with chest wall recurrences of less than 3 cm, axillary and internal mammary node recurrence (not supraclavicular, which has a poorer survival), and a greater than 2-year disease-free interval prior to recurrence have the best chance for prolonged survival. The 5-year disease-free survival DFS rate in one series of such patients was 25%, with a 10-year rate of 15%. The local-regional control rate was 57% at 10 years. Systemic therapy should be considered in patients with local regional recurrence because of the high risk of subsequent metastases. No randomized controlled studies are available to guide patient care in this situation.
Stage IV and metastatic disease
Treatment for systemic disease is palliative in intent. Goals of treatment include improving quality of life and prolongation of life. Although median survival has been reported to be 18 to 24 months, some patients experience long-term survival. Among patients treated with systemic chemotherapy at a single institution between 1973 and 1982, 263 patients (16.6%) achieved complete responses. Of those, 49 patients (3.1% of the total group) remained in complete remission for more than 5 years, and 26 patients (1.5%) were still in complete remission at 16 years.[Level of evidence: 3iiDiii]