Breast cancer is one of the most feared diseases, especially among women in North America, yet it has become an exemplar of success in the war against cancer.¹ Not too long ago, most breast cancers were detected by the woman herself (substantially larger than 2 cm) and had already spread to the axillary lymph nodes. Just 40 years ago we were still using radical surgical approaches for the treatment of breast cancer, declaring that we had “got it all” surgically, even though metastatic disease would appear within a few years after surgery. The concept of adjuvant chemotherapy and endocrine therapy slowly evolved over several decades of systematic investigation through clinical trials, and we even experimented with high dose chemotherapy as adjuvant therapy.

Today, there has been a significant shift in the stage of newly-diagnosed breast cancer to negative node disease, and we have refined our knowledge of the disease biology, such that risk stratification by molecular subtypes allows us to define more tailored and often less toxic therapies. The multidisciplinary clinical approach to the management of breast cancer (surgery, radiology, pathology, medical oncology, radiation therapy, and reconstructive surgery), as well as the translational approach to breast cancer research, are now the models for other cancer sites. While we can argue about whether or not intensive mammographic screening has led to overdiagnosis, identifying low risk conditions that may cause no harm, there is no question that the overall outcomes for women with breast cancer diagnosed today are substantially better than when many of us started our oncology training several decades ago.

As a consequence of the advances, there has been a striking decline in breast cancer mortality over the past two decades (Siegel et al. 2014). A secondary outcome is the growing number of breast cancer survivors who now number nearly 3 million in the US and represent 41 % of female cancer survivors (Desantis et al. 2014). These women live in our communities, share our workplaces, teach our children, and may be a spouse or loved one. Almost everyone has acquaintances who have had breast cancer, and most of those affected are no longer hiding their experience from others, unlike the situation 50 years ago when the first women with breast cancer could not talk about it in public and had trouble finding support for each other. On the other hand, there are still many women living with metastatic breast cancer who are being maintained on treatment for long periods of time and who are hoping for the next therapeutic breakthrough. In the United States, nearly 40,000 women are lost to breast cancer each year, and we clearly need to do a better job eliminating premature death and suffering from this disease.

As survival outcomes improve, many survivors are at risk for non-breast cancer related diseases. One recent study that examined deaths in postmenopausal women with hormone receptor positive breast cancer participating in a trial of extended adjuvant endocrine therapy found that non-breast cancer deaths accounted for 60 % of all deaths; this proportion was higher in women over 70 years of age (72 %) and lower in younger women (48 %) (Chapman et al. 2008). Second cancers and cardiovascular disease were the commonest non-breast cancer causes of death. Because obesity is associated with increased postmenopausal breast cancer risk, survivors may be at increased risk of obesity associated conditions such as diabetes. These observations underscore the importance of maintaining overall health in breast cancer survivors, and suggest that secondary prevention strategies, including adoption of a healthy lifestyle and appropriate management of non-breast cancer related health issues, such as hypertension and lipid disorders, should be considered high priorities. The diagnosis of cancer has been considered a “teachable moment” (Demark-Wahnefried et al. 2005), a time when many women re-evaluate their priorities and may be more amenable to making lifestyle and other changes (including smoking cessation, weight loss, enhanced physical activity, and adoption of a healthy diet) that will lead to improved health. Exploitation of this teachable moment may yield important benefits.

In this volume, we have been given an opportunity to focus on a wide range of outcomes associated with the diagnosis and treatment of breast cancer. This work is the product of an innovative collaboration between the Breast Cancer Research Foundation (BCRF) and Springer, as part of its Advances in Experimental Medicine and Biology series. The charge to the authors was to produce a work that provides perspective and commentary, and not the traditional review article that so often is found in multi-authored edited volumes. All of the authors are BCRF funded researchers who are working in the topic areas that they are writing about. Many of the author teams are active research collaborators, but several of the chapters have brought together scientists who have not previously worked together and were asked to do so for the purpose of this effort. For those of you who may know some of the authors, you will likely hear their personal voice come through—something we encouraged to make this book different and to emphasize the goal of providing a perspective on the field and where the research is today and where it needs to be going. As such, those of you who read this volume will be disappointed if you are expecting a thorough review of a chapter topic—this was not our goal.

The title of this volume—Improving Outcomes for Breast Cancer Survivors—actually has two meanings: the word “improving” is both an adjective and a verb as used to describe the book’s content. We are faced with a large and growing population of breast cancer survivors whose outcomes are much improved over a generation ago. In the long term, many of these survivors experience quality of life that is comparable to that of women without breast cancer (Hsu et al. 2013), but this experience is not universal. We need to work on improving outcomes for those survivors who suffer from persistent symptoms and side effects after treatment ends, and for those with recurrent or persistent disease who remain on long term therapy. In the section that follows, we briefly highlight how the BCRF authors address specific content areas, so as to direct your attention to the expert opinion this volume contains.

In three early chapters in the book, we have chosen to highlight the needs of several special populations among breast cancer patients and survivors. While the average age of breast cancer diagnosis is 61 years in the United States, and it is still largely a disease of women of European origin in the US and Canada, it affects women of all ages and all ethnic and racial subgroups. In fact, it is the leading cause of cancer in women worldwide. Age at diagnosis can have a tremendous effect on how women cope and adjust to a breast cancer diagnosis, as well as to the toxicities they experience from treatments. In a chapter devoted to younger women (Chap. 2, Ganz et al.) the unique needs and concerns of this population are addressed, including life stage, premature menopause, reproductive and fertility concerns, risk of hereditary cancers, as well as the unique emotional needs of younger women. Importantly, because of the long life span these women face after breast cancer treatment, preventing and reducing the risk for late effects of cancer treatment is critical. In parallel, the older woman with breast cancer may be extremely vigorous or, at the other extreme, burdened with comorbid conditions when cancer is diagnosed. In Chap. 3, Hurria and Muss, highlight the unique needs of older women with breast cancer and how we need more research to better understand how to manage treatment and potential toxicities in this population. The importance of maintaining functional independence in this population is a central goal. For both older and younger patients with breast cancer, there is a paucity of research targeting their specific needs and concerns, and the authors highlight areas that need our attention. Lastly, in Chap. 4 on Disparities in Care Across the Cancer Control Continuum, Paskett alerts us to the many gaps in knowledge related to the experience of vulnerable populations (racial/ethnic groups, older women, women from rural and urban areas) who are most likely to experience disparities in care related to breast cancer. In some settings it is a lack of institutional (health system) resources for early detection and prompt treatment, in others there are patient level factors that lead to poorer outcomes including attitudes, behaviors, culture and limited financial resources/access to care. There is much to be done, and there are important US national efforts that are now focusing on many of these problems.