java barcode reader source code Follow-up Care in Objective-C

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After primary therapy, patients with breast cancer should be monitored for life in order to detect recurrences and to
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Table 16 6 Approximate survival (%) of patients with breast cancer by TNM stage
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TNM Stage 0 I IIA IIB IIIA IIIB IV All Five Years 95 85 70 60 55 30 5 10 65 Ten Years 90 70 50 40 30 20 2 30
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Stage of breast cancer is the most reliable indicator of prognosis (Table 16 6) Patients with disease localized to the breast with no evidence of pathologic involvement of the lymph nodes have the most favorable prognosis Axillary lymph node status is the best-analyzed prognostic factor and correlates with survival at all tumor sizes In addition, increased number of axillary nodes involved correlates directly with lower survival rates Biologic marker status, such as ER, PR, grade, HER-2/neu, aides in determining the aggressiveness of a tumor and are impor-
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observe the opposite breast for a second primary carcinoma Local and distant recurrences occur most frequently within the first 2 5 years During the first 2 years, most patients should be examined every 6 months, then annually thereafter The patient should examine her own breasts monthly, and a mammogram should be obtained annually Special attention is paid to the contralateral breast because a new primary breast malignancy will develop in 20 25% of patients In some cases, metastases are dormant for long periods and may appear 10 15 years or longer after removal of the primary tumor Although studies have failed to show an adverse effect of hormonal replacement in disease-free patients, it is rarely used after breast cancer treatment, particularly if the tumor was hormone receptor positive Even pregnancy has not been clearly associated with shortened survival of patients rendered disease free yet most oncologists are reluctant to advise a young patient with breast cancer that she may become pregnant, and most are less than enthusiastic about prescribing hormone replacement for the postmenopausal breast cancer patient The use of estrogen replacement for conditions such as osteoporosis and hot flushes may be considered for a woman with a history of breast cancer after discussion of the benefits and risks, but it is not recommended
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rence may be cured with local resection and radiation After partial mastectomy, local recurrence may not have as serious a prognostic significance as after mastectomy However, those patients in whom a recurrence develops have a worse prognosis than those who do not It is speculated that the ability of a cancer to recur locally after radiotherapy is a sign of aggressiveness and resistance to therapy Completion of the mastectomy should be done for local recurrence after partial mastectomy; some of these patients will survive for prolonged periods, especially if the breast recurrence is DCIS or more than 5 years after initial treatment Systemic chemotherapy or hormonal treatment should be used for women in whom disseminated disease develops or those in whom local recurrence occurs
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B Edema of the Arm
Significant edema of the arm occurs in about 10 30% of patients after axillary dissection with or without mastectomy It occurs more commonly if radiotherapy has been given or if there was postoperative infection Partial mastectomy with radiation to the axillary lymph nodes is followed by chronic edema of the arm in 10 20% of patients In the past, it was routine to perform an axillary dissection for staging In an axillary dissection, it is recommended that at least level I and II lymph nodes (approximately 15 20 lymph nodes) be removed, in combination with partial mastectomy or as part of the mastectomy After considerable research in the last decade, sentinel lymph node dissection has proved to be a more accurate form of axillary staging with less morbidity Because a sentinel lymph node dissection usually only removes the first one to three lymph nodes that would be affected by carcinoma, it can provide accurate staging without the side effects of edema or infection It does not replace axillary dissection if the sentinel lymph nodes are involved with metastases, although this is still being studied Judicious use of radiotherapy, with treatment fields carefully planned to spare the axilla as much as possible, can greatly diminish the incidence of edema, which will occur in only 5% of patients if no radiotherapy is given to the axilla after a partial mastectomy and lymph node dissection Late or secondary edema of the arm may develop years after treatment, as a result of axillary recurrence or infection in the hand or arm, with obliteration of lymphatic channels When edema develops, a careful examination of the axilla for recurrence or infection is performed Infection in the arm or hand on the dissected side should be treated with antibiotics, rest, and elevation If there is no sign of recurrence or infection, the swollen extremity should be treated with rest and elevation A mild diuretic may be helpful If there is no improvement, a compressor pump or manual decompression decreases the swelling, and the patient is then fitted with an elastic glove or sleeve Most patients are not bothered enough by mild edema to wear an uncomfortable glove or sleeve and will treat themselves with elevation or manual decompression alone Benzopyrones have been reported to decrease lymphedema but are not approved for this use in the United States Rarely, edema may be severe enough to interfere with use of the limb
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