Monitoring disease progression Some additional tumor markers that may be followed during the course of treatment are CA 27.29 and CA 15-3. These tumor markers are valuable only for monitoring metastatic disease. The increase or decrease in tumor markers can track both the course of the disease and the response of the disease to treatment. While markers are ineffective in diagnosing initial disease because they lack specificity and sensitivity, for a patient in remission, they can serve as an early indicator of disease recurrence. Markers are most effectively used when serial measurements are obtained.4
Therapeutic modalities Many women will undergo some form of surgery to excise the cancer. Additional treatment may include chemotherapy or radiation. The more advanced the stage of the cancer, the more likely the patient will receive chemotherapy to prevent metastasis and reduce the risk of recurrence. Radiation therapy is used to reduce the risk of local recurrence especially in those patients with large tumors, lymph-node involvement, or close or positive margins during surgery. Patients presenting with metastatic disease are not candidates for surgery, and neoadjuvant therapy may be necessary before surgery can be considered as an option.
The woman in this case did not exhibit any of the classic symptoms of breast cancer. Instead, her disease was discovered only after she became symptomatic secondary to her metastatic disease. Further investigation into her initial symptoms led to the eventual discovery of her primary disease.
Because her disease had already metastasized at presentation, the patient was not initially a candidate for surgical resection. She underwent chemotherapy followed by trastuzumab to address her positive HER2 status. The primary and metastatic disease was effectively treated, resulting in a disease-free interval. This, along with the lack of evidence of metastasis at the time of her recurrences, allowed her to be restaged and become a candidate for surgical resection. At her first recurrence, the tumor was estrogen receptor-positive, and anastrozole was prescribed in consideration of the patient's postmenopausal state. At the time of her second recurrence, she was switched to tamoxifen because of cardiotoxic effects she experienced while taking anastrozole. Trastuzumab was also abandoned, as it was clearly ineffective in preventing recurrences.
Even though this woman followed established screening guidelines, her breast cancer went undetected by conventional methods and presented in an advanced stage. Had she heeded the advice of her oncologist, she would not be here today. In this case, the accurate diagnosis came only after one of the basic principles of medicine was considered. Had the specialist physician responsible for administering her chemoembolization not done a complete physical examination and reviewed her studies in detail, he likely would have continued treating her for the incorrect diagnosis of primary cholangiocarcinoma. Fortunately for the patient, the combination of diligence in searching for a treatment, her resiliency to the disease with which she was faced, and the excellent professionals she encountered through her own research resulted in an outcome that has surpassed everyone's expectations. JAAPA
Holly Johnson practices in thoracic surgery at The Arthur G. James Cancer Hospital, Ohio State University Medical Center, Columbus. She has indicated no relationships to disclose relating to the content of this article.
DRUGS MENTIONED
Anastrozole (Arimidex)
Cisplatin (Platinol-AQ, generics)
Docetaxel (Taxotere)
Doxorubicin (Adriamycin, Doxil, Rubex, generics)
Mitomycin (Mutamycin, generics)
Tamoxifen (Nolvadex, Soltamox, generics)
Trastuzumab (Herceptin)
REFERENCES
1. Poggi MM, Harney KF. The breast. In: DeCherney AH, Nathan L, eds. Current Obstetric & Gynecologic Diagnosis & Treatment. 9th ed. New York, NY: Lange Medical Books/McGraw-Hill; 2003:1094-1116.
2. Ward BA, Reiss M. Breast diseases. In: Noble J, Greene HL II, Levinson W, et al, eds. Textbook of Primary Care Medicine. 3rd ed. St Louis, MO: Mosby, Inc; 2001:364-377.
3. Yamauchi H, Hayes D. HER2 and predicting response to therapy in breast cancer. UpToDate Web site. Version 17.3. http://www.uptodateonline.com. Updated May 6, 2009. Accessed February 2, 2010.
4. Esserman L, Joe B. Initial staging work-up for women with a diagnosis of breast cancer.
UpToDate Web site. Version 17.3. http://www.uptodateonline.com. Updated August 20, 2009. Accessed February 2, 2010.