Friday, March 31, 2017

Can My Breast Cancer Come Back?

As you come to the completion of your breast cancer treatments, it seems unfair to think you might have to deal with it again in the future. For many patients, treating breast cancer can be a painful, unpleasant experience, and once your doctor says you're clear of it, it seems like you should be able to carry on without ever having to worry about getting cancer again. But unfortunately, cancer can recur, and some breast cancer survivors struggle with anxiety for the rest of their lives over whether their cancer will come back. Upon completing surgery, radiation or chemotherapy, many patients assume that they're done with treatment and can move on. Some may even assume that simply finishing chemo means they're cured.

But Dr. Melissa Pilewskie, a surgical breast oncologist at Memorial Sloan Kettering Cancer Center in New York, says, "we tend to think of completing treatment as finishing surgery, chemotherapy and radiation. But a lot of women still have treatment going on for years." In the first year after the initial treatments have concluded, "many women will be on some kind of pill," often an anti-estrogen pill or other drug therapy to help prevent cancer cells from regenerating. Dr. Maggie DiNome , associate professor of surgery at the UCLA Santa Monica Breast Center at the David Geffen School of Medicine at UCLA, says that some women with hormone-positive breast cancer will be on drug therapy for upwards of five years.

And only after they complete that treatment can they be considered "cured." Still, even after being cancer-free for any length of time, it's possible your cancer could come back, although DiNome says the risk isn't as high as many women fear. For most women with breast cancer – those who developed the disease without a genetic mutation to aid it – the risk for recurrence is about 6 percent over 15 years, she says. And it's critical to put the fear of recurrence in an appropriate context for patients, she says. "You don't want patients to live a lifetime of anxiety that it's going to recur." At the same time, finally reaching the point where they can be considered cancer-free can create a strange feeling for some women. "When they're in active treatment and they're doing everything you ask them to do, they're comfortable being watched and tested. But then they reach their five-year mark off treatment and you're just monitoring them. That's a tricky scenario for some women – they almost feel like all of the sudden the net's been pulled out from under them," DiNome says. Pilewskie agrees.

"During treatment, most patients feel empowered, that they're doing something to deal with the disease. But once that stops, there can be a fear of what happens next. It's a waiting game of wondering whether something is going to happen. It can be hard emotionally to get back to a healthy lifestyle from that standpoint, and I'll often refer patients struggling with this for counseling and support groups." Recurrence can happen after a period of remission. Pilewskie refers to remission as "no evidence of disease," and this is when treatment will shift from actively battling the cancer to monitoring your body going forward.

 According to the American Cancer Society,"if cancer is found after treatment, and after a period of time when the cancer couldn't be detected, it's called a cancer recurrence." The ACS classifies the different types of recurrence you may experience as local recurrence, regional recurrence or distant recurrence. With a local recurrence, the cancer comes back in the original place it started. In regional recurrence, it returns to the lymph nodes near where it started. And in distant recurrence, the cancer comes back in another part of the body. The ACS reports that "the less time between when the cancer was thought to be gone and the time it came back, the more serious the situation. There's no standard length of time to decide if it's recurrence or progression. But most doctors consider recurrence to be cancer that comes back after you've had no signs of it for at least a year."

Progression, on the other hand, refers to cancer that never fully disappeared and continues to grow and change in the body. For example, if you're diagnosed with Stage 2 cancer and the disease progresses, you could be reclassified as having Stage 3 or 4 cancer. Also, if the cancer metastasizes, or invades a new organ, that would be considered a progression. In some cases, patients can be thought to have been in remission and then the cancer progresses, indicating that the first treatment protocol did not kill all of the cancer and additional treatment is needed. If it's determined that your cancer was in remission and at some point thereafter, cancer is again detected in your body, your doctor will run diagnostic tests to determine whether it's a recurrence or a new cancer altogether (called a second primary cancer); if it's the same type as you originally battled, chances are it's a recurrence. If it's a different type or has a different progression, then it's probably a second cancer.

The ACS reports that developing a second cancer "is much rarer than cancer recurrence, but it does happen. Having cancer once does not mean you cannot get another type of cancer in the future." Pilewskie says that having had breast cancer "does slightly increase the risk for a subsequent case." She also says that there are some second cancers that can be associated with breast cancer, but it's not necessarily the breast cancer itself that's caused this second illness; often there's an underlying genetic reason a person battles cancer more than once. The BRCA1 and BRCA2 genes are perhaps the most widely known genetic mutations associated with breast cancer, though there are other genetic factors that can predispose a person to cancer or elevate your risk for developing a second type of cancer. "Depending on the family history and genetics, breast and ovarian cancer are the two most commonly associated cancers, but in people with these genetic mutations, we also see an increase in pancreatic cancer. For men with these genes, breast cancer, prostate cancer, and some carcinomas may be associated." And what's more, simply surviving cancer – and living longer – can be its own risk factor for recurrence or developing a second cancer. According to, "the aging process is the biggest risk factor for breast cancer. That's because the longer we live, there are more opportunities for genetic damage (mutations) in the body. And as we age, our bodies are less capable of repairing genetic damage."

 Although as a whole, any kind of cancer can come back, Pilewskie says your chances of it returning can vary depending on the type of cancer you've had. "The more aggressive cancers may recur faster." With more aggressive forms of breast cancer, if it doesn't recur within the first two years, most likely you can be considered "cured." With slower-growing cancers, the cancer can return much later. Although many breast cancer survivors worry about their cancer coming back "sometimes I think that women overestimate their risk," Pilewskie says. She encourages anyone who's completed breast cancer treatment to have "a good conversation with their doctor about their actual risk of recurrence." Although there's no surefire way to prevent your cancer from coming back, there are a few lifestyle choices you can make to help reduce the chances. These are virtually the same things you're advised to do to help reduce your risk of developing breast cancer in the first place: eating right, controlling stress, getting enough sleep, managing your weight, participating in routine screening and exercising. It's this last item – exercise – that Pilewskie says she thinks holds the most promise for the future of cancer recurrence prevention.

"I just got back from a surgical oncology meeting and exercise is a hot topic. It's going to really come out in the research over the next few years what the specific links are" between breast cancer and exercise. She says she's hopeful that research will pinpoint a specific dose of exercise that's beneficial that doctors can prescribe their patients to reduce recurrence. "There's a lot of data looking at the impact of exercise on women to improve survival and lower recurrence rates. I think it's a complicated relationship in the effect of exercise and dietary factors," but she says breast cancer patients and survivors should strive to get back to a normal exercise routine as soon as possible. And be sure to keep all your follow-up appointments.

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