The aim of the study was to analyze clinicopathological features in breast cancer patients with local recurrence (LR). Material and methods. A retrospective analysis of database of breast cancer patients operated on in the Department of Surgical Oncology in Łódź from 2 January 2009 to 30 June 2013, identified 1080 women with primary breast cancer and 11 patients with LR. Results. LR rate was 0.23% per year. True recurrence (TR) occurred more frequently in patients with luminal B molecular subtype, in HER-2 positive and in triple-negative subgroups. In one patient with luminal -A subtype new primary (triple negative) occurred. TR were noted predominantly in patients with axillary lymph nodes metastases and with luminal B subtype who did not receive adjuvant chemotherapy but were given only endocrine therapy. LR were observed more frequently in patients who did not receive adjuvant radiotherapy or this treatment was delayed. Minimal surgical margins in postoperative specimens measured by pathologist were 4-25 mm, mean 9.5 mm. Conclusions. The LR rate in patients operated on breast cancer in the Department of Surgical Oncology between 2009 and 2013 was low. TR was diagnosed in patients with non- luminal A breast cancer despite wide surgical margins, especially if the patients did not receive optimal adjuvant systemic treatment or radiotherapy was delayed or omitted. Complete cancer excision followed by an immediate implementation of optimal adjuvant treatment seems to be crucial especially in patients with poor tumor biology.
Breast cancer is one of the most frequently diagnosed cancers among women in the western world. Due to the aggressive behaviour of some specific types and the possibility of an early diagnosis, breast cancer has been constantly studied. Tumour size, histological type, cellular and nuclear characteristics, mitotic index, vascular invasion, hormonal receptors and axillary lymph node status are biomarkers routinely used. However, these parameters are not enough to predict the course of this disease. Molecular biology advances have made it possible to find new markers, which have already been incorporated to the clinical practice. Their ultimate goal is to reduce mortality by identifying women at risk for the development of this disease, help diagnosis, determine prognosis, detect recurrences, monitor and guide treatment, and in particular cancers they are suited for general screening. Tumour markers in breast cancer were ranked in categories reflecting their clinical utility, according to the American College of Pathologists. This article focuses on traditional and new molecular markers stratifying them into categories and emphasizing their relevance in the routine evaluation of patients with breast cancer.
In order to present a reliable picture of hormone-dependent breast cancer treatment in Poland, an on-line survey has been conducted in 19 oncology centres. As a result, data on the treatment of 486 patients have been obtained (405 of them initially presenting with stage I–III of disease advancement, and 81 representing stage IV). It has been concluded that in the majority of cases the treatment in question involves combined therapy, including chemotherapy, hormonal therapy, targeted molecular therapy, radiotherapy, and surgical methods with reference to the group of patients subjected to radical treatment.
We report a rare case of metastatic gastric cancer from invasive carcinoma of the breast (BC) as the first symptom of disease-mimicking primary gastric linitis plastica.
Breast cancer is the most frequent malignancy in women. The diagnosis of neoplastic disease produces or deepens anxiety and depression in a patient.The aim of the study was to assess the influence of surgery and socio-demographic factors on the level of anxiety and depression in women suffering from breast cancer.Material and methods. 50 women (30-71 years old, mean age 54.7 years) with breast cancer were enrolled into the study. They were assessed two times - before and after surgery. To evaluate the level of depression BECK scale was used. It consists of 21 points that determine the level of depression. HAD scale containing seven descriptions of a patient's status was used to assess the level of anxiety.Results. Most of patients (17(34%) women had vocational education. More than half of the analyzed women were free of depression both before and after surgery, 50 % and 60% respectively. 2% of all women had extremely deep depression preoperatively. A normal and high level of anxiety before surgery was felt by 21 (42%) and 21 (42%) women respectively.A high level of anxiety was found in 15 patients (30%) postoperatively. The level of depression after surgery decreased in 32 women and psychological status was deteriorated in 9 patients according to BECK scale. The level of anxiety after surgery decreased in 30 patients and deteriorated in 8 cases according to HAD scale. The intensity of anxiety decreased after surgical treatment. The most intensive increase in depression was observed in women with secondary education (51 points) before surgery and 35 points in women with vocational education after surgery. The highest level of anxiety before surgical treatment was found in women with secondary as well as vocational education (21 points). Whereas the highest level of anxiety after surgery was observed in patients with secondary education. (21 points). The hardest depression was observed in working patients (51 points) preoperatively and they still had the hardest depression (35 points) postoperatively, too. The level of anxiety was highest in working women both preoperatively and postoperatively (21 points). The most intensive depression before surgery was observed in women at middle social status (35 points) and this tendency was observed also after surgery. The level of anxiety before surgery was the highest in women with good and middle social status (21 points). After surgery it was the highest in patients with middle social status (21 points). The most intensive depression before surgical treatment was found in patients between 51 and 60 years old (51 points). The hardest depression after surgery was observed in women between 41 and 50 years old (35 points). The highest level of anxiety was felt by patients between 41 and 50 and between 51 and 60 years old (21 points) preoperatively and in women between 51 and 60 years old (21 points) postoperatively.Conclusions. The intensity of depression and anxiety in women with breast cancer decreased significantly after mastectomy. Patients with university education had lower levels of anxiety and depression both before and after surgery. Working women with average social status had the highest levels of anxiety and depression both before and after surgical treatment. The age of a patient did not influence significantly on the levels of anxiety and depression both before and after surgery.
Introduction The World Health Organization as the main task, set himself to care about the good quality of life in patients after anti¬cancer treatment. Aim The aim of the study is the analysis of specific symptoms in patients after removal of breast cancer with the use of questionnaire QLQ-BR23. Material and methods The study was conducted among 100 patients. The study uses a questionnaire QLQ-C23. Results The discomfort of the patient concerned to taste the food, feel sick/bad, feels pain in the arm or shoulder, swelling of shoulder or arm, difficulty lifting up the arm, swelling of the affected mammary gland responses remained at the average level. Conclusions These problems clearly decreased in the patients satisfaction from life.
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Wstęp Światowa Organizacja Zdrowia jako naczelne zadanie stawia sobie dbałość o dobrą jakość życia chorych po leczeniu przeciwnowotworowym . Cel Celem pracy jest analiza specyficznych objawów u pacjentek po usunięciu piersi z powodu raka z wykorzystaniem kwestionariusza QLQ-BR23. Materiał i metody Badania zostały przeprowadzone pośród 100 chorych. W badaniach wykorzystano kwestionariusz QLQ-C23. Wyniki Dyskomfort u pacjentek dotyczył odczuwania smaku potraw, czucia się chorym/niedobrze, odczuwania bólu w ramieniu lub barku, obrzęku ramienia lub ręki, trudności z podnoszeniem ramienia, obrzęku chorej piersi -odpowiedzi utrzymywały się na poziomie średnim. Wnioski Wskazane problemy, niewątpliwie pogarszały u pacjentek satysfakcję z życia.
Bax protein, the proapoptotic member of Bcl-2 protein family, plays the key role in apoptosis pathway.The aim of the study was to assess the expression of Bax protein in breast cancer cells.Material and methods. Sixty-two breast cancer patients were included in the study. The control group encompassed 11 fibroadenoma patients. Single cells were isolated from defrosted samples and prepared for flow cytometry measurement.Results. Median expression of Bax protein in study group was 7.9% (range: 0-49.4%) and was significantly lower than in control (median expression 15.8%; range 4.9-30.9%; p=0.034). Expression of Bax correlated with expression of p53 and caspase-3 proteins (p<0,01, rank Spearman test). In patients under 70 years old and with positive estrogen receptors status the expression of Bax protein was significantly higher (p=0.03 and p=0.01 respectively).Conclusions. Lower expression of Bax protein in breast cancer cells may suggest the potential way of apoptosis avoidance of tumor cells. Correlations among Bax protein, p53 and caspase-3 are likely associated with active apoptotic mechanism in breast cancer cells expressing Bax protein. Further investigation with long time follow-up should be performed to establish the prognostic role of Bax protein expression in breast cancer patients.
The achieve pathologic complete response is proven to be the most important parameter of prognosis. Thereports evaluating the impact of obesity on the obtained pathologic response to chemotherapy are unequal. The aim of the study was to evaluate in locally advanced breast cancer patients, treated with AT(doxorubicin plus docetaxel) neoadjuvant chemotherapy: 1. The relationship of obesity with obtaining pathological response. 2. The relationship of obesity and free of disease recurrence survival (DFS) and overall survival (OS) associated with the tumour. Material and methods. A retrospective study was carried out in a group of 105 patients with locally advanced breast cancer, treated with AT neoadjuvant chemotherapy and then treated with radical surgery. Two variants of pathological response have been adopted: a pCR (T0N0) and pCR1 (TisN0, TxN1, T1N0, T1N1, T0N1). The relationship of obesity with pathological response and survival was investigated. Results. In univariate analysis the pCR1 was obtained with its arising from the borderline of statistical significance with lower incidence of obesity. In pCR1 multivariate analysis, negative pCR1 relationship with obesity was on the borderline of the statistical significance. The multivariate analysis showed a significant negative association OS with obesity (p=0.047) and positive with the occurrence of menopause (p = 0.029). Conclusions. In patients with locally advanced breast cancer treated with AT neoadjuvant chemotherapy. 1. Obesity seems to be an independent and unfavourable predictor of the lack of obtaining pCR1 pathological response 2. In the multivariate analysis, the obesity was a significant independent factor related to shorter OS.
Selection of the treatment method in breast cancer patients and its consequences may affect their quality of life through somatic, psychical, and social factors. The aim of the study was early evaluation of the quality of life of women after mastectomy vs. breast conserving surgery. Material and methods. The study included 100 women aged 31 to 79 years (mean: 57) who underwent surgery due to breast cancer (amputation: 52; breast conserving surgery: 48 women) at the Cancer Centre in Bydgoszcz in 2014. The QLQ C-30 and QLQ BR-23 questionnaires were used to evaluate the quality of life of the patients 3 months after surgery. Results. In the Global Health Status/QoL domain, the mean score for women after amputation and breast conserving surgery was 49 and 53, respectively; for Physical Functioning, the scores were 70 and 75, and for Role Functioning, 62 and 68, respectively. For Cognitive Functioning, the mean score was 74 and 73; for Emotional Functioning - 62 and 68, and for Social Functioning 64 and 60, respectively. The difference in the arm symptoms domain was significant at 46 and 33 points, respectively (p = 0.004). The patients treated with breast conserving surgery had a better body image than women after amputation - the mean score was 52 and 66, respectively (p = 0.01). Conclusions. With respect to Global Health Status/QoL and Physical Functioning, the quality of life of women in the early postoperative period was similar in women after breast amputation and those who underwent breast conserving surgery. Patients treated with breast conserving surgery had a better score for body image, while those who underwent amputation more often suffered from arm symptoms, such as pain, oedema, and problems with raising of the limb.
Primary tumor size, an essential clinical parameter, is assessed by oncologist during the physical examination of a patient with breast cancer. The results of such assessment constitutes a basis for classification of breast cancer staging, selection of proper primary treatment, selection of type of surgical treatment and initial evaluation of patient prognosis.The aim of the study was to describe changes in biological characteristics of breast cancers relative to increases in primary tumor size.Material and methods. All women treated surgically for breast cancer in the Department of Surgical Oncology, Medical University in Łódź, from 1999 to 2004, were included in our study. We confined our analysis to primary operable, invasive, primary tumors less than 3 cm. 639 cases comprised the study group. We analyzed the associations between primary tumor size and other routinely assessed clinical and pathological parameters.Results. We found statistical associations between primary tumor size and the presence of metastases in axillary lymph nodes (p<0.0001), presence of extracapsular extension of lymph nodes metastases (p<0.0001), presence of tumor cells emboli (p<0.0001), absence of expression of estrogen receptor (p=0043) and absence of progesterone receptor (p=0.0196) in cancer cells. No association was found between tumor size and histologic tumor type (p=0.205). In a subgroup of ductal carcinomas, tumor size was associated with the grade of cancer (p=0.0002).Conclusions. Increases in tumor size are accompanied by increasing incidence of unfavorable prognostic factors and decreasing incidence of favorable prognostic factors. Tumor size constitutes the source of direct and indirect prognostic information.
Matrix metalloproteinase-2 (MMP-2) is an enzyme with proteolytic activity against matrix proteins, particularly basement membrane constituents. A single nucleotide polymorphism (SNP) at -1306, which disrupts a Sp1-type promoter site (CCACC box), displayed a strikingly lower promoter activity with the T allele. In the present study, we investigate whether this MMP-2 SNP is associated with susceptibility to breast cancer in the Saudi population. Ninety breast cancer patients and 92 age matched controls were included in this study. TaqMan Allele Discrimination assay and DNA sequencing techniques were used for genotyping. The results showed that, the frequency of MMP-2 CC wild genotype was lower in breast cancer patients when compared with healthy controls (0.65 versus 0.79). The homozygous CC (OR=2, χ2=5.36, p=0.02) and heterozygous CT (OR=1.98, χ2=4.1, p=0.04) showing significantly high risk of breast cancer in the investigated group. In conclusion our data suggest that the MMP-2 C-1306T polymorphism may be associated with increased breast cancer risk in the Saudi population.
Purpose: To determine the toxicity and efficacy profile of non-pegylated doxorubicin in combination with capecitabine administered according to LipAX regimen. Materials and methods: The analysis included 5 female patients undergoing first-line treatment for metastatic breast cancer. Patients received non-pegylated doxorubicin intravenously and oral capecitabine at usual doses used for monotherapy, until disease progression or unacceptable toxicity. Results: Patients received a total of 26 complete treatment cycles according to LipAX regimen. During treatment, 15 toxicities occurred, including 7 adverse events with grade 3 severity. Only two haematological toxicities were observed, and the other 13 were of a non-haematological nature. Only one patient experienced no adverse events. Apart from symptomatic treatment, the capecitabine dose was reduced twice and the non-pegylated doxorubicin once. Positive clinical outcomes were observed in 4 patients, and disease progression was reported in the case of 1 patient in the course of the treatment. The median time to disease progression was 10.4 months, and the median overall survival was 34.2 months. During the 54-month follow-up, 4 of the patients died. The surviving patient continues treatment. Conclusions: Therapy according to the LipAX regimen was relatively well tolerated, however, since the majority of patients discontinued treatment due to adverse events, and not disease progression, an adequate reduction in the cytostatic doses should be considered. The use of the LipAX regimen may contribute to the achievement of long-term remission in some patients, a fact that encourages further studies on this form of therapy.
Breast cancer is the most prevalent female neoplasm in Poland as well as in the rest of the world, accounting for 25% of all cancers. Lapatinib is a reversible inhibitor of the HER-1 and HER-2 tyrosine kinase receptors. Combined with capecitabine, it is administered in patients suffering from advanced breast cancer with HER-2 receptor overexpression. The present article analyses data obtained from medical records of 24 breast cancer patients treated with lapatinib and capecitabine in the years 2010–2015, in order to examine the treatment-related toxicity. The major adverse effects observed under treatment included diarrhoea, nausea, emesis, skin toxicity, and elevated transaminases. In 3 patients, grade 3 adverse events were reported, as assessed in accordance with CTCAE. The most frequent cause behind the cessation of treatment was disease progression. The analysis has indicated that lapatinib plus capecitabine is a well-tolerated treatment regimen.
Women with breast cancer are affected by deep venous thrombosis and/or pulmonary embolism 3 times more often than the group of healthy women in the same age. Thrombosis can be the first manifestation of a malignant disease, but it can also result from hormonal therapy with aromatase inhibitors or tamoxifen which is used in cancer treatment. The necessary clinical problem to solve in this population is the issue of prophylactic antithrombotic treatment. In this paper we present a case of pulmonary embolism in the course of the breast cancer, which was associated with tamoxifen hormone therapy and inadequate thromboprophylaxis.
Liposomal doxorubicin is a newer form of chemotherapeutic agents that, due to its own special properties, preferably accumulates in cancer tissue. On the other hand, it shows lower affinity to cardiomyocytes and in this way is less cardiotoxic. As a result of that, there is the possibility to use liposomal form of doxorubicin until disease progression or chemotherapy intolerance in palliative setting, without treatment cessation after reaching the maximum cumulative dose of conventional doxorubicin. In this article we describe the case of a female patient diagnosed with breast cancer who was primary treated with adjuvant treatment, including chemotherapy and in whom a disease recurrence occurred after seven years of observation. As a primary palliative treatment the patient received chemotherapy based on liposomal doxorubicin and cyclofosphamide with a very good tolerance. The initial response was partial remission in lungs and in mediastinal lymph nodes. During the whole course of therapy there were no pathological changes in electrocardiogram, no signs and no symptoms of congestive heart failure, and the left ventricular ejection fraction was within normal limits.
INTRODUCTION Breast cancer is the most frequent malignancy in women in Poland. Overexpression of the HER2 receptor positively correlates with the aggressiveness of the disease. Trastuzumab, a humanized monoclonal antibody against HER2, radically improves the prognosis in such patients. However, its main side effect is cardiotoxicity. The aim of this study is to evaluate the cardiotoxicity in trastuzumab-treated patients. MATERIALS AND METHODS The cases of 19 women treated in the Department of Internal Medicine and Oncologic Chemotherapy Medical University of Silesia in Katowice in the period of 2010–2011 were retrospectively analyzed. RESULTS The median age at the time of diagnosis – 57 years, pathology: invasive ductal carcinoma in 17, invasive lobular carcinoma in 2 patients. Overexpression of HER2 was observed in all the cases. Trastuzumab was administered to 16 of them after previous therapy with antracyclines and/or taxan; the median total antracycline dose was 680 mg. Moreover, 13 patients were subjected to radiotherapy; the median total dose was 50 Gy. In 3 patients, trastuzumab and chemotherapy was used in the management of metastasized disease. The median time between the administration of trastuzumab and anthracyclines was 3 months. The median number of cycles was 10. Before administration of the drug, ECG and echocardiography were performed along with ejection fraction (EF) assessment. Before and after therapy the median EF was 65% and 61%, respectively. The therapy was withheld in 1 patient because of a decrease in EF to 40%. CONCLUSIONS The treatment with trastuzumab was well tolerated. In most patients, we did not observe a significant decrease in EF. However, the cases should be followed up to detect delayed cardiotoxicity.
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WSTĘP Rak piersi to najczęstszy nowotwór złośliwy u kobiet w Polsce. W praktyce klinicznej ważne jest określenie ekspresji receptorów, w tym dla naskórkowego czynnika wzrostu typu 2 (HER2) na komórkach nowotworowych. Gdy komórki te wykazują wzmożoną ekspresję HER2, przebieg choroby jest agresywniejszy. Trastuzumab, humanizowane przeciwciało monoklonalne przeciw HER2, znacząco poprawia rokowanie. Jednak terapia taka nie jest pozbawiona działań niepożądanych, w tym kardiotoksyczności. Celem pracy była ocena kardiotoksyczności leczenia trastuzumabem u pacjentek z rakiem piersi. MATERIAŁ I METODY Dokonano retrospektywnej analizy historii chorób 19 kobiet leczonych w Klinice Chorób Wewnętrznych i Chemioterapii Onkologicznej Śląskiego Uniwersytetu Medycznego w Katowicach w latach 2010–2011. WYNIKI Mediana wieku w chwili rozpoznania – 57 lat, typ histologiczny: rak przewodowy naciekający u 17, rak zrazikowy naciekający u 2 pacjentek. Nadekspresję HER2 stwierdzono u wszystkich 19 kobiet, u 16 z nich zastosowano trastuzumab po wcześniejszym leczeniu upełniającym antracyklinami i/lub taksanami – mediana sumarycznej dawki antracyklin 680 mg. U 13 pacjentek dodatkowo przeprowadzono radioterapię – mediana dawki sumarycznej 50 Gy. U 3 pacjentek podano trastuzumab oraz chemioterapię w leczeniu rozsianej choroby nowotworowej. Mediana czasu włączenia trastuzumabu po antracyklinach wyniosła 3 miesiące. Liczba cykli: mediana 10. Przed włączeniem leku wykonano badanie EKG i czynnościowe serca z oceną frakcji wyrzutowej (EF). Mediana EF przed rozpoczęciem leczenia: 65%, po leczeniu: EF 61%. U jednej pacjentki przerwano leczenie z powodu obniżenia EF do 40%. WNIOSKI Leczenie trastuzumabem było dobrze tolerowane. U większości pacjentek nie obserwowano znamiennego obniżenia EF wymagającego odstawienia leku. Badana grupa wymaga jednak badań czynnościowych serca również po odstawienia trastuzumabu w celu wykrycia późnych powikłań kardiotoksycznych.
At present, sentinel lymph node biopsy is a standard procedure to assess the advancement of breast cancer and cutaneous melanoma. The aim of the study was to assess the role of the sentinel lymph node biopsy in the treatment of patients with breast cancer in our own material. Material and methods. Analyzed was medical documentation of 258 patients with initially operable breast cancer, qualified for operation with sentinel lymph node biopsy in 2004-2014 in the Department of Surgery of the 4th Military Teaching Hospital. A few hours prior to the planned surgery, radioisotope (technitium-99 sulfur colloid) was applied in the area of tumor or under the areola. 1-2 hours after administering the tracer, the lymphoscintigraphy with the labelling of the sentinel lymph node on the skin was performed. Results. On the basis of the gathered material, obtained were the following parameters: sensitivity – 100%, and specificity – 94.6%. Four cases were false negative (5.5%). Conclusions. 1. Marking the sentinel lymph node in breast cancer, based on the single visualisation method with the use of radioisotope, is a useful and effective technique. 2. The factor influencing the results of the sentinel lymph node biopsy (true positive and negative results and false negative result) was the number of the excised lymph nodes except for the sentinel lymph node. 3. Patients with estrogen receptor expression had often metastases to sentinel lymph node (145 cases – 56%). 4. The false negative rate, i.e. 5.5% in our material, is within the limits of acceptability given in the literature. 5. The sentinel lymph node biopsy performed by the experienced surgical team is a reliable diagnostic tool with a low complication rate.
Introduction: General quality of life, health, and sensation of pain caused by cancer are connected with the physical, mental and social state of a human being. Aim of the study: The aim of the study is self-assessment of life quality, general health, and pain sensations in breast cancer patients after adjuvant therapy with chemo- and radiotherapy. Material and methods: The study was carried out in 2016 at the Professor Franciszek Łukaszczyk Oncology Clinic in Bydgoszcz. 56 women with breast cancer were qualified for the study, upon completion of treatment. Socio-demographic and clinical data was used, questions 29 and 30 from the QLQ C30 questionnaire, and the Memorial Pain Assessment Card. Results: Generally, the average self-assessment of health and life quality was 4.98 and 5.18 points, respectively. Age, education, marital status and the place of residence did not have any influence on the self-assessment of health and life quality (p > 0.05). 46 women (82.1%) did not take analgesics. Those patients who did not take analgesics assessed their health and life quality better, with the average scores of 5.3 and 5.63 points, respectively. The average for pain intensity was 2.05 on a 0–11 scale. Most women – 14 (25%) – assessed their mood as very good. The mood average was 2.91 points. Only the administration of analgesics influenced the mood score (p = 0.001). Conclusions: Women with breast cancer after radical treatment assess their health and life quality as good. Those not taking analgesics assess their health and life quality better and are decidedly in a better mood than those taking such medications. Socio-demographic factors do not influence self-assessment of health, life quality, or pain intensity.
Mitochondria are cell energetic centers where ATP is produced. They also play a very important role in the PDT as intracellular sites of photosensitizer localization. Photosensitizers gathering in mitochondria (like porphyrin derivatives used in this work) are more effective in tumor cell destruction. Moreover, it was assumed that di-amino acid substituents attached to porphyrin ring will strengthen the effectivity of interaction with membrane receptors of examined cells. MTT assay was performed to investigate the influence of PP(Arg)2 and PP(Ala)2(Arg)2-based PDT on breast cancer cell viability for 24 h, 48 h and 120 h after cell irradiation. Then the influence of PP(Ala)2(Arg)2- and PP(Arg)2-mediated PDT on early mitochondrial apoptosis induction via measurements of the transmembrane mitochondrial potential changes was examined. Results showed that lower energy doses and maximal nontoxic photosensitizer doses of PP(Ala)2(Arg)2 and PP(Arg)2 applied in PDT can imply apoptotic cell death. It was confirmed that modification of the protoporphyrin IX by attaching two alanine substituents raised the efficiency of photodynamic therapy.
A follow-up assessment plan after radical treatment is a part of a comprehensive approach to treating patients with breast cancer. Because breast cancer is the most frequent cancer both worldwide and in Poland, adequate follow-up is important not only for patients but also for economic reasons. Herein, we review current recommendations for follow-up assessments in patients with breast cancer. The main aim of such assessment is detection of early recurrence or tumor presence in the other breast, observation of long-term treatment complications, and creation of multidisciplinary infrastructure that will allow to reduce the risk of recurrence and alleviate physical, mental, and social consequences of treatment.
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