A case of complicated survivorship care

At age 34, Ms. P., a premenopausal African American woman, was diagnosed with stage IA poorly differentiated invasive ductal carcinoma of the left breast. Her tumor was estrogen and progesterone receptor (PR) positive but HER2 negative. Ms. P.'s treatment included a partial mastectomy, radiation therapy, and 2 years of tamoxifen, although tamoxifen was discontinued due to pregnancy. She was then lost to follow-up. At age 40, Ms. P. discovered a mass in her left breast upon self- exam. There was a delay in diagnosis due to pregnancy, which was terminated. A core biopsy was performed, and the pathology was positive for poorly differentiated invasive ductal carcinoma that was ER and PR positive but HER2 negative. She was clinically stage IIIB, with the tumor fixed to the chest wall. Ms. P.'s family history included premenopausal breast cancer in her mother, three of her maternal aunts, and her maternal grandmother. Genetic testing was performed; she was found to have a BRCA2 deleterious mutation. After an intrauterine device (IUD) was placed to prevent pregnancy, Ms. P. began neoadjuvant chemotherapy consisting of doxorubicin and cyclophosphamide for 4 cycles followed by paclitaxel for 4 cycles. She then underwent a left salvage mastectomy and sentinel lymph node biopsy. After treatment, she was assessed at pathologic stage IA. Tamoxifen was reinitiated. After completing treatment, Ms. P. presented for a survivorship visit accompanied by her fiancé.