Gone for Good? Breast Cancer Recurrence Debate Rages

Aug. 13, 2008 — -- A common public misperception about cancer is that once a person beats the disease, they are forever "cured." But the unfortunate reality for cancer survivors is that the risk of relapse remains a nearly constant threat throughout one's lifetime -- though some say media coverage of the disease often glazes over this fact.

Today, new research published in the Journal of the National Cancer Institute suggests that the risk of breast cancer relapse remains present even 15 years after a woman is initially diagnosed with the disease.

Still, ABC News medical editor Dr. Timothy Johnson believes that this study should provide breast cancer survivors with a realistic sense of hope.

"This study gives women a ballpark feel for what to look forward to at the point of five-year survival; they are not totally free from the risk of recurrence, as some women would like to believe, but they aren't totally doomed either," Johnson said. "And if you take these numbers at face value, [breast cancer survivors] have a pretty good chance of escaping recurrence after five years of survival."

Lead study investigator Dr. Abenaa Brewster, assistant professor of clinical cancer prevention at M.D. Anderson Cancer Center at the University of Texas, said that the conclusions of the research, which looked at more than 2,800 breast cancer survivors, should be perceived as good news for breast cancer survivors who fear recurrence.

"The message I'd really like to get across is that these [recurrence] rates are actually pretty low, and I hope these numbers are reassuring to women because women who are five-year survivors [of breast cancer] often think they are still at high risk for recurrence," Brewster said.

But Lillie Shockney, assistant professor of breast cancer at the Johns Hopkins Avon Foundation Breast Center in Baltimore, said that boiling this figure down into a single percentage ignores the evidence that each breast cancer survivor's risk is different.

"I'm a little concerned that the data is apples and pineapples," she said. "It just doesn't focus on recurrence rates, but includes local recurrence, metastatic disease and a new primary breast cancer. These are three different things."

Shockney's primary complaint was that the study lumped all breast cancer survivors into one category and reported the average risk. Shockney believes this could mean that the recurrence rate reported in the study is actually higher than it should be for patients with less aggressive forms of breast cancer. For women who have survived more difficult battles with the disease, the figure may be too low.

But cancer experts stressed that one of the most important things for a breast cancer patient to remember is that the disease should not be considered "cured" after surviving the disease.

"Clearly, it is widely understood that the risk of cancer recurrence after breast and other cancers extends beyond the previous traditional five-year landmark," said Dr. Stephen Edge, chair of the department of breast surgery and medical director of the Breast Center at Roswell Park Cancer Institute in Buffalo, N.Y.

"The public may still have the old notion that if you are free of cancer at five years, that it can't come back. All previous data, with this study providing more underscoring, shows that this notion is simply not true," Edge said.

Dr. Harry Bear, surgical oncologist at the Virginia Commonwealth University's Massey Cancer Center in Richmond, agreed. "Some of our [breast cancer] treatments delay recurrence rather than eradicating the last remaining cancer cell," he said.

How Recurrence Fears Affect Treatment

For any breast cancer survivor, the notion of recurrence plays an important role in treatment decisions.

The typical treatment for breast cancer patients can be divided into four categories: surgery to remove the cancer, radiation therapy to kill remaining cancer cells in the breast tissue, chemotherapy to stop the growth of cancer cells and hormone therapy to cease the production of hormones that fuel cancer cell growth.

Each of these treatment options reduces a woman's risk for breast cancer recurrence by a certain percentage. But the breast cancer patient is the ultimate decider of which of these treatments to take on, and whether the small reduction in recurrence risk is worth the side effects of treatment.

But the study, Shockney said, does not delve into the individual risk factors that could increase one woman's risk for recurrence over another's. For example, she noted, women who are genetically predisposed for developing breast cancer are at higher risk for disease recurrence, yet these women were grouped together with those who do not carry this genetic risk.

Moreover, she said, the study did not account for the different kinds of breast cancer recurrence -- some of which are small and localized, and some of which are aggressive and spread rapidly to other parts of the body -- or the methods by which women choose to treat their disease.

"Someone with [early stage] breast cancer who did bilateral mastectomies would have a small risk of distant or local recurrence [compared to] someone with [advanced stage] disease doing a lumpectomy [who] would have a higher risk," Shockney said.

Getting the Most Out of Continuing Treatment

Generally, women who have hormone-responsive breast cancer are at higher risk for disease recurrence after five years of survival. Brewster hopes that this study will influence more of these patients to consider remaining on adjuvant therapy even after five years of survival.

"I would like the take-home message of this study to be if you do have a [hormone-responsive] tumor and received Tamoxifen for five years and are post-menopausal, you probably want to speak with [an] oncologist about whether or not there's a rule for taking extended adjuvant therapy by reviewing the risks and benefits of such treatment," Brewster said.

But for women who have survived breast cancer, a silver lining -- the longer you survive without disease recurrence, the less chance for recurrence you have.

"What women need to know from this is that there is a long-term recurrence, but the longer you live the smaller it is," said Dr. Susan Love, president and medical director of the Dr. Susan Love Research Foundation in Santa Monica, Calif. "If you are 10 years out, you are less likely [to have a recurrence] than if you are five [years out]."