Breast Cancer: The Risks of Recurrence

A study just released in the Journal of the National Cancer Institute is getting a lot of media attention.


 


The research, from the M.D. Anderson Cancer Center in Houston, Texas took a look at what happened to about 2800 women with breast cancer who were treated at the center from 1985 through 2001.  All of the women had primary breast cancer of various stages, and all of them had some form of adjuvant therapy.


 


The goal of the study was to find out how many women had their breast cancer recur 5 years or more after they completed their adjuvant therapy.  What it also pointed out, to me at least, was that some commonly held beliefs about the outlook for women with breast cancer aren’t always correct.


 


The women in the study represented the universe of women with primary breast cancer.  There were younger and older women, women whose breast cancers were hormone sensitive or not, pre and post menopausal women, and women with various stages of primary breast cancer, among other factors.


 


Many of the women had received tamoxifen as their adjuvant therapy.  Some of the women also received chemotherapy.


 


Since aromatase inhibitors (AIs)—which are now probably the treatment of choice for adjuvant therapy in post-menopausal breast cancer patients—had just become available during the time of the study, there were only a handful of women who received these medications.


 


For the overall group—and remember this was a large number of women covering all types of breast cancer at all stages and ages—the recurrence rate at 10 years after diagnosis was 11%, and at 15 years was 20%.


 


If you had a more advanced cancer at the time of diagnosis, your chance of recurrence 10 years after surgery was almost double that of someone with an earlier stage cancer (Stage 1: 7%; Stage 3: 13%).


 


But there was also something reported in the study that I would not have expected: the long term recurrence rate for women with hormone receptor-positive breast cancer was significantly higher than for women who were not hormone sensitive at the time of diagnosis.


 


The reason this finding is important is that most of us are of the opinion that women with hormone negative breast cancers fare worse than their hormone sensitive counterparts.  However, the fact may be that (unfortunately) women with hormone negative cancers may have had very early relapses.  Those that did not relapse within 5 years after diagnosis may have been “selected” to have a better long-term outlook, as seen in this study.


 


The study also showed that women diagnosed with lower grade breast cancers—which we would think would have a better long term outlook, since lower grade is supposed to be associated with a less aggressive cancer —actually had a higher rate of long term relapse.  Again, the same reasoning noted above may apply to this circumstance as well, namely that women with higher grade cancers experienced relapse earlier in the course of their disease, and if they made it through the first 5 years they did better in the long term.


 


What are the practical implications of this study?


 


The primary one is that we need to be aware that adjuvant therapy does not completely remove the risk of breast cancer recurrence after 5 years.  In fact, up to 20% of the women remain at risk of recurrence at 15 years, depending on the unique characteristics of their cancers and other factors such as age.


 


As the authors note in their report:


 


“The magnitudes of the residual risk of recurrence for pre- and postmenopausal patients were within the range (8%-20%) considered appropriate to recommend AST (adjuvant systemic therapy) at the time of (initial) diagnosis, indicating a need for the continued development of risk reduction strategies for these survivors.”


 


In other words, we need to revisit the question of whether we have to consider providing additional preventive therapies once women complete their initial primary adjuvant treatment.


 


But there are some important limitations to this study that must be pointed out.


 


This was a diverse group of women, with different ages, stages of breast cancers, different treatments, and so on.  The drugs used in treating these women are different today than they were back at the time the study was done.  We have newer techniques and diagnostic tests available today that help us better understand what treatment a women requires, and we have new approaches to the treatment of pre-menopausal women that may significantly improve their outlook with adjuvant hormonal therapy.


 


As to what this study means for you personally if you are a woman with breast cancer and are concerned by this report, I strongly urge you to speak to your oncologist. 


 


We have made considerable progress in the early diagnosis of breast cancer, and what we can do to prevent it from returning.  We already know that adjuvant therapies don’t completely eradicate breast cancer in some women, and this study reinforces that fact. 


 


What we need to do now is take a careful look at what we do and how we do it to determine whether there is something else we can do better to improve the outlook for all women with primary breast cancer.


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J. Leonard Lichtenfeld's Biography

Dr. Len

J. Leonard Lichtenfeld, MD, MACP: Dr. Lichtenfeld currently serves as Deputy Chief Medical Officer for the American Cancer Society in the Society's Office of the Chief Medical Officer located at the Society's Corporate Center in Atlanta. Dr. Lichtenfeld joined the Society in 2001 as a medical editor, and in 2002 assumed responsibility for managing the Society's then newly created Cancer Control Science Department which included the prevention and early detection of cancer, emerging cancer science and trends, health equity, quality of life for cancer patients, the science of cancer communications and the role of nutrition and physical activity in cancer prevention and cancer care.  In 2014, Dr. Lichtenfeld assumed his current role in the Office of the Chief Medical Officer where he provides extensive support to a number of Society colleagues and activities. As a result of his over four decades of experience in cancer care, Dr. Lichtenfeld is frequently quoted in the print and electronic media regarding the Society's positions on a number of important issues related to cancer. He has testified regularly in legislative and regulatory hearings, and participated on numerous panels regarding cancer care, research, advocacy and related topics. He has served on a number of advisory committees and boards for organizations that collaborate with the Society to reduce the burden of cancer nationally and worldwide. He is well known for his blog (www.cancer.org/drlen) which first appeared in 2005 and which continues to address many topics related to cancer research and treatment. A board certified medical oncologist and internist who was a practicing physician for over 19 years, Dr. Lichtenfeld has long been engaged in health care policy on a local, state, and national level.  He is active in several state and national medical organizations and has a long-standing interest in professional legislative and regulatory issues related to health care including physician payment, medical care delivery systems, and health information technology. Dr. Lichtenfeld is a graduate of the University of Pennsylvania and Hahnemann Medical College (now Drexel University College of Medicine) in Philadelphia.  His postgraduate training was at Temple University Hospital in Philadelphia, Johns Hopkins University School of Medicine and the National Cancer Institute in Baltimore. He is a member of Alpha Omega Alpha, the national honor medical society.  Dr. Lichtenfeld has received several awards in recognition of his efforts on behalf of his colleagues and his professional activities.  He has been designated a Master of the American College of Physicians in acknowledgement of his contributions to internal medicine.  Dr. Lichtenfeld is married, and resides in Atlanta and Thomasville, Georgia.

4 thoughts on “Breast Cancer: The Risks of Recurrence

  1. Dr. Len, I am a 53-year old negative hormone receptor survivor. My first occasion to be diagnosed was 4 days after the birth of my son, when I was 20 years old (1975). I had 17 nodes removed during a radical mastectomy, all were clean. 18 months later I had a recurrance, a tumor on my breastbone, not IN the bone, but on it. Proceeded through 33 radiation treatments. During radiation I developed another tumor under the opposite arm. December 1976 I started a 5-year protocol of 5FU, Methatrexate, and cytoxin. December 1981-treatment stopped. I was cancer free for 29 years. I had a lump August of 2004, modified radical and 17 nodes removed. All clean again. I had a round of 4 treatments of chemo. My doctor is Michael Perry, Ellis Fischel, Columbia, MO. He has been my oncologist since 1976. We have quite a history. I have been blessed to live this long, and plan to be around for quite some time.
    Regards,
    Laura Lee Klouzek

  2. HI,
    My mom had breast cancer (lumpectomy, radiation and tamoxifen) 15 years ago and was told today that it is back in the same area but closer to her armpit, She was advised to get a mastectomy and chemo. Our questions is, did it come back because they didn’t get it all out the first time OR what makes it come back to the same place. Thanks so much for your help and support on this.

  3. Elizabeth, I am not aware of any internet site that provides that information. I do know when we try to get that information it is a complicated task. Perhaps someone else has a better suggestion.

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