Cancer that comes back after treatment is called a recurrence. But some cancer survivors develop a new, unrelated cancer in later life known as second cancer [1]. The most common second cancer in breast cancer survivors is cancer in contralateral breast. The new cancer can occur in the contralateral breast, or in the same breast for women who were treated with breast-conserving surgery (such as a lumpectomy) [2]. Others include Salivary gland cancer, Oesophagus cancer, Stomach cancer, Colon cancer, Uterine cancer, Ovarian cancer, Thyroid cancer, Acute Myeloid Leukaemia (AML) [3,4].

A 50-year-old female presented with lump right breast in 2017 of size 5×6 cm involving upper outer quadrant, fixed to underlying structures with mobile, nontender axillary lymph node of size 2×2 cm. She underwent modified radical mastectomy and detailed histopathology suggestive of invasive duct carcinoma with margins free of tumour, LVSI and PNI negative. 4 lymph nodes dissected with tumour deposits in it [5,6]. On IHC ER/PR positive and Her2neu negative. Patient then received adjuvant chemotherapy (4 cycles of Epirubicin-cyclophosphamide and 4 cycles of taxanes) followed by radiotherapy to chest wall, axilla and supraclavicular area @40 Gy in 15#. Patient was then put on hormonal treatment [7].

In 2019, patient presented with postmenopausal bleeding and copious, foul-smelling vaginal discharge. On examination, P/v finding suggestive of an ulceroproliferative growth of size 4×4 cm felt at cervix extending to lower 1/3rd of vagina with fornices involved. Growth bleeds on touch. On P/R examination 4×4 cm nodule felt in centre with parametrium involved up to lateral pelvic wall. The cervical biopsy was suggestive of squamous cell carcinoma. Patient received 2 cycles of paclitaxel-carboplatin-based chemotherapy followed by CRT @ 46Gy in 23# and 3 fractions of ICBT of 7Gy each. Patient is now on close follow up.

The incidence of secondary malignancies, as with the issue of contralateral breast cancer, appears to be very low, and it is evident that the appropriate use of radiation therapy far outweighs the risk of radiation-induced malignancy. Although this may be more prevalent with older techniques, it is an important component of treatment planning to minimize dose to nontarget normal tissues. Cancer related to radiation treatment includes lung   cancer,  sarcomas  and  certain  blood   cancers. The available evidence of the risk of lung cancer in patients undergoing radiation suggests that smoking and radiation may be synergistic in contributing to the risk of lung cancer. Cancer related to genetic factors may include mutation in BRCA genes with presentation of ca ovary. Cancer related to hormonal therapy-tamoxifen a SERM is a commonly used. It commonly shows an improvement of 10 years in patients with ER positive breast cancer. However, tamoxifen is strongly associated with endometrial hyperplasia and carcinoma. The possibility of cervical cancer post tamoxifen therapy is rare. In patients with HPV infection, tamoxifen is responsible for enhanced expression of HPV16 and 18. In our patient, after 2 years of continuous use of tamoxifen, patient developed ca cervix [8]. Hence women treated for breast cancer need to be followed up for development of gynaecological cancers as second malignancy [9,10].

1. Takatori, E. et al. "Triple simultaneous primary invasive gynecological malignancies: A case report." Journal of Obstetrics and Gynaecology Research, vol. 40, 2014, pp. 627–631.

2. Watrowski, R. et al. "Papillary-serous adenocarcinoma of the uterine cervix during tamoxifen therapy after bilateral breast cancer." Anticancer Research, vol. 32, 2012, pp. 5075–5078.

3. Muss, H.B. "Role of adjuvant endocrine therapy in early-stage breast cancer." Seminars in Oncology, vol. 28, 2001, pp. 313–321.

4. De Muylder, X. et al."Endometrial lesions in patients undergoing tamoxifen therapy." International Journal of Gynecology and Obstetrics, vol. 36, 1991, pp. 127–130.

5. Bergman, L et al. "Risk and prognosis of endometrial cancer after tamoxifen for breast cancer." Lancet, vol. 356, 2000, pp. 881–887.

6. van Leeuwen, F.E. et al. "Risk of endometrial cancer after tamoxifen treatment of breast cancer." Lancet, vol. 343, 1994, pp. 448–452.

7. Hwang, J.Y. et al."Tamoxifen stimulates human papillomavirus type 16 gene expression and cell proliferation in a cervical cancer cell line." Cancer Research, vol. 52, 1992, pp. 6848–6852.

8. Kim, C.J. et al. "Regulation of cell growth and HPV genes by exogenous estrogen in cervical cancer cells." International Journal of Gynecological Cancer, vol. 10, 2000, pp. 157–164.

9. Heng, B. et al. "Human papilloma virus is associated with breast cancer." British Journal of Cancer, vol. 101, 2009, pp. 1345–1350.

10. Di Lonardo et al. "Human papillomavirus in breast cancer." Breast Cancer Research and Treatment, vol. 21, 1992, pp. 95–100.