breast cancer is the most common cancer among women and its incidence is increasing . however , its mortality decreases with better screening programs , public education , and medications . disease - free survival and overall survival depend on multiple factors , including the stage of the disease , hormone receptor status , age , and prescribed chemotherapy agents [ 2 , 3 ] . , younger premenopausal women develop recurrence sooner   and recurrence after decades is not so common . here , we report 6 cases that remained disease - free for 13 - 32 years after the primary breast cancer . the goal of this report is to show that breast cancer survivors are at risk for relapse even after years . in addition , even high risk patients can have a long period of disease- free survival . in this report , we reviewed 6 cases with a mean age of 40.1 ( 30 - 57 ) years at diagnosis ( table 1 ) . in addition , 1 patient had ductal carcinoma in situ ( dcis ) and had received radiation . besides , 2 patients had breast cancer with negative axillary lymph nodes and 1 case had 6 positive nodes . except for 1 patient who had dcis , others had received cyclophosphamide , methotrexate , and 5-fluorouracil ( cmf ) ( 3 - 6 cycles ) . the patient was a 62-year - old lady who was operated for a right breast carcinoma 32 years ago ( in 1979 ) . at that time , right side modified radical mastectomy ( mrm ) was done for her and then she received 6 cycles of combination chemotherapy ( cyclophosphamide , methotrexate , and 5- fluorouracil ) . she had no regular follow up , but was well until february 2011 when she developed lymphadenopathy in the right supraclavicular fossa . moreover , physical examination and mammography from the contralateral breast revealed no lesion and abdominal ultrasonography revealed liver metastases . the patient was a 71-year - old lady who had breast cancer and underwent left side mrm and received 3 courses of combination chemotherapy by cyclophosphamide , methotrexate , and 5-flourouracil in 1986 . she also received tamoxifen for 5 years and was well until january 2012 when she developed severe pelvic pain . whole body bone scan was performed for her and showed multiple bone metastases in the first and fifth lumbar spines , left humerus , and greater trochanter of the right femur . she received 20 gray in 5 fractions for the involved areas of lumbar spines and femur . now , she is receiving zoledronic acid and has no evidence of distance metastasis except in bones . the patient was a 70-year - old woman who was affected by left side breast cancer in october 1998 and left side mrm was done for her . she received 6 cycles of chemotherapy by cmf and then radiotherapy to the chest wall and the regional lymph nodes . her whole body bone scan showed multiple bone metastases at pelvic bones , multiple vertebrae , and skull . the patient was a 56-year - old woman who was operated ( quadrantectomy and axillary lymph node dissection ) due to the right side infiltrating ductal carcinoma in january 1991 . she had a 2 cm infiltrating ductal carcinoma ( idc ) and no lymph node involvement . then , she received chemotherapy and radiotherapy and was under regular follow up . in november 2011 , she developed some nodules on the skin of the right breast and biopsy showed the recurrence of the primary tumor . the patient was a 47-year - old woman who had right side dcis in july 1997 . the patient was operated ( quadrantectomy without axillary nodal dissection ) and afterward she only received radiotherapy to the breast . she did not have a regular follow up in spite of the history of breast cancer in her mother . twelve years later in july 2009 , she was operated ( mrm ) due to local recurrence . she had a 1.5 cm idc and 6 positive axillary lymph nodes from the total of 9 nodes . then , 8 cycles of chemotherapy ( ac and taxane ) were performed for her and she received radiotherapy to the chest wall by superficial x- ray and the regional lymph nodes by co60 . after that , letrozole was started for her estrogen receptor ( er ) , and progestrone receptor ( pr ) positive , and human epidermal growth factor receptor 2 ( her2 ) negative ( er and pr positive , her2 negative ) . one and a half years later in march 2010 , she developed bone and lung metastasis and she is receiving chemotherapy now . the last patient was a 61-year - old woman who underwent left side mrm due to a 4 cm breast cancer in march 1993 . she was treated with 6 cycles of cmf and then irradiation to the chest wall and the regional nodes . in november 2007 , she developed abdominal pain and a mass was found in the epigastric area . in ultrasonography , multiple factors , such as race and ethnicity , are effective in breast cancer survival . for instance , one study showed better survival in non- hispanic whites compared to blacks and other groups . this difference is present in cases with the same stage , er - pr status , and treatment [ 2 , 7 ] . tumor size and lymph node status are also directly related to the prognosis of breast cancer . in a study by rosen et al . , the mean recurrence time was 4.9 years in the cases with 1 involved lymph node and 3.9 years in those with 2 or more involved lymph nodes . their study also revealed the importance of the menstruation status . in that study , the perimenopausal cases had higher mortality in comparison to pre and post - menopausal women . all the cases of the current study , except for 1 , were in the pre- menopausal status . some authors suggested body weight as a negative prognostic factor which may influence the prognosis by interfering in the hormonal mechanism . some studies have shown that younger age at presentation is accompanied by a higher risk of recurrence ; however , no difference has been reported in some other studies [ 6 , 10 ] . on the other hand , chen et al . performed a retrospective study and found that younger age was accompanied by better local control . in this study , the patients were not so old and the importance of age in late relapse should be studied in prospective studies . the patients with negative tumoral tissue for er , pr , and her2 ( or triple negative ) comprise 15 - 20% of the breast cancer cases and are among the worst outcome groups . this feature is associated with other high risk factors , such as young age and high grade . the time of recurrence has been studied widely and most of the recurrences have been shown to occur in the first decade . the recurrence time and pattern has been reported to have a double peak shaped curve ; the first peak occurring in the second year and the other one in the 6th to the 9th year post - treatment . in node in other words , the recurrence rates were more constant and relatively similar in both premenopausal and postmenopausal women . nevertheless , after 8 years of treatment , the recurrence rate in hormone receptor negative cases is less than the hormone positive ones . it should be mentioned that chemotherapy lowers the recurrence rate and the second peak appears later . late failure ( more than 5 years ) is more prevalent in early stage breast cancer . in a study on patients by quadrantectomy , the rate of late recurrence was 53% for t1 lesions and 25% for t2 lesions . the first cases with prolonged dfs were reported in 1887 and recurrence occurred 25 and 19 years after mastectomy . surely , they had not used chemotherapy and radiotherapy . therefore , genetic or molecular studies may be needed to enlighten the dark horizon to us . dcis by definition is a non - invasive disease ; however , invasive components may be missed in tissue sampling or even in post - operative pathologic samples . these cases may have lymph node ( ln ) metastasis at presentation or may behave like an invasive disease [ 16 , 17 ] . in general , her2 receptor status and p53 mutation are widely checked in breast cancer cells , but their role in late relapse is not so clear . in the recent years , some biomarkers are used to realize which patient is at risk for recurrence or metastasis . in this regard , cytokeratin-19 may be the best factor which can be used to find the tumor cells in bone marrow or blood . however , it is not accurate enough yet to be used as a test for decision making or as a prognostic index in breast cancer patients . the current guidelines ( nccn 2012 ) recommend annual mammogram for long time . the question is whether this time interval is enough , more , or less than what is required . the chemotherapy agent , surgery ( especially lymph node dissection ) , hormone therapy , and trastuzumab have also their own long- term side effects . thus , more studies are needed in order to determine the effect of these factors on prolonged survival . another ethical point is whether a young woman with breast cancer should be told that she will have a short survival or not . our first case that was 30 years old on arrival delivered and grew up 5 children after diagnosis of breast carcinoma . late relapse is not so common in breast cancer but can occur in any stage . therefore , we suggest life- time follow up for every patient with breast cancer including dcis cases . late relapse is not so common in breast cancer but can occur in any stage . therefore , we suggest life- time follow up for every patient with breast cancer including dcis cases .