A New Cancer in the Other Breast: How Does it Affect Survival?
ABSTRACT & COMMENTARY
Synopsis: The appearance of second-breast cancers will become more apparent as a greater number of patients are effectively treated for their initial cancers. In this series of patients with second-breast cancers from a single institution, data are presented that indicate that younger age, initial tumor size, and nodal status are predictors of second cancers. Also, the nodal status of the initial tumor, the size and nodal status of the second tumor, and the interval between first and second tumors are indicators of the overall survival from the time of initial breast cancer diagnosis.
Source: Abdalla I, et al. Cancer J Sci Am 2000;6:
266-272.
With the implementation of effective primary and adjuvant treatments, more patients are currently cured of breast cancer than ever before. Accordingly, the appearance of cancer in the contralateral breast is now being more frequently recognized. It was the purpose of the current report to describe the rather large experience from a single institution (the University of Chicago) with regard to the effect of this second breast cancer upon survival in affected individuals.
Over a 60-year period (1927-1987), 2136 women with stage I-III breast cancer were treated by the surgical service at the University of Chicago using a consistent treatment and follow-up approach. For this report, data were obtained from hospital records, tumor registry, and contact with the patients or their families and physicians. At a median follow-up of 14.2 years, 132 patients (6.2%) had developed breast cancer in the contralateral breast. Of these, 23 (17.4%) had synchronous bilateral breast cancer (disease in both breasts recognized within 1 month of the primary diagnosis), and thus, metachronous breast cancer occurred in 109 patients. The median interval between the two primaries was 53 months (range, 0-373 months). The median age at the diagnosis of the first cancer was 51.7 years and at the second cancer 59 years. For those in the overall group that did not develop a second breast cancer, the median age at diagnosis was 54 years. Primary surgery was radical mastectomy for the majority of patients (65% as treatment of the first breast cancer and 54% as treatment for the second breast cancer). Adjuvant treatment for the first cancer included radiation (27%), chemotherapy (17%), and hormonal, including bilateral salpingo-oophorectomy (20%). After the second mastectomy, adjuvant radiation was administered to 9%, chemotherapy to 7%, and hormonal therapy to 3%.
Among the patients with bilateral breast cancer, the second cancer was smaller (2.0 cm vs 3.0 cm) and was associated with a lower incidence of axillary node involvement (29% vs 52%). The development of the contralateral breast cancer was associated with worse survival when compared to those who did not develop a second cancer (hazard ratio = 1.46, 95% confidence interval [CI] 1.09-1.95). On multivariate analysis, factors that decreased the disease specific survival in patients with bilateral breast cancer were a higher number of positive lymph nodes of the first and second cancers, a larger size of the second cancer, and a shorter interval between the two primaries.
COMMENT by William B. Ershler, MD
The findings from this single (albeit large) institution analysis were predictable, but this is a valuable report because the data are well characterized and the patients received a uniform approach over a relatively large time period. Currently, patients are much less likely to receive radical mastectomy either for their first or second episode of breast cancer and they are much more likely to receive adjuvant radiation and chemotherapy. However, the basic biology principles are no doubt the same. With regard to the appearance of second breast cancers, they are more likely to occur in women who had their first malignancy at a younger age, and in those who had greater axillary node involvement initially. This fits well with the notion that these are the same features that would predict aggressive tumor biology. Furthermore, the second tumors are smaller at diagnosis, perhaps suggesting an awareness of the risk of second cancers and an appropriate increased vigilance. Notably, there was no histological feature of the first cancer that would predict the development of a second, but there was an indication that the longer the interval between tumors, the better the survival from the second tumor. In fact, the most important prognostic factors for disease-specific survival in bilateral breast cancer patients are the nodal status of the first cancer, and the size and nodal status of the second. In this series, overall survival was worse for those women who developed a second breast cancer when compared to those that did not. This, however, has not been the experience of other series in which overall survival from the time of initial breast cancer was no different for women who did, or did not develop cancer in the contralateral breast when they were examined in the context of the stage of presentation of the original cancer.1 Furthermore, radiation therapy has been reported to increase the likelihood of second breast cancer,2 but this was not apparent in the current series.
References
1. Fisher ER, et al. Cancer 1984;54:3002-3011.
2. Harvey EB, et al. Natl Cancer Inst Monograph 1985;
68:99-112.
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