What My Patients Are Asking: Does A Cancer’s Stage Change If It Spreads or Comes Back Years Later?
Brian Wojciechowski, M.D.
April 24, 2020

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Our guest is Dr. Brian Wojciechowski, who practices medical oncology in Delaware County, Pennsylvania at Riddle, Taylor, and Crozer hospitals and also serves as Breastcancer.org's medical adviser. A native of South Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought-after speaker on the topics of medical ethics and the biology of cancer.

In one of our Discussion Board threads, people were talking about how a breast cancer is staged, especially if an early-stage cancer spreads or comes back in a place away from the breast. Both the American Cancer Society and the National Cancer Institute websites say that the stage of a breast cancer at first diagnosis doesn’t change. So a woman who was diagnosed in 2010 with stage II disease and then had a recurrence in the bones in 2015 would technically be “stage II with metastatic recurrence to bone,” which is not how most people think and talk about metastatic disease.

Dr. Wojciechowski reached out to the American Cancer Society about this, and he joins us today to help us all understand this a little bit better.

Listen to the podcast to hear Dr. Wojciechowski each explain:

  • the technical differences between stage IV breast cancer and metastatic breast cancer
  • how prognosis differs for someone diagnosed de novo stage IV and someone who was diagnosed stage II with a metastatic recurrence 2 years later
  • how he talks to his patients about a breast cancer’s stage

Running time: 17:23

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Show Full Transcript

Jamie DePolo: Hello. As always, thanks for listening. Our guest is Dr. Brian Wojciechowski, who practices medical oncology in Delaware County, Pennsylvania, at Riddell, Taylor, and Crozer hospitals and also serves as Breastcancer.org’s medical adviser. A native of South Philadelphia, he trained at Temple University School of Medicine and Lankenau Medical Center. Dr. Wojciechowski is a sought-after speaker on the topics of medical ethics and the biology of cancer.

In one of our Discussion Board threads, people were talking about how a breast cancer is staged, especially if an early-stage cancer spreads or comes back in a place away from the breast. Both the American Cancer Society and the National Cancer Institute websites say that the stage of a breast cancer at first diagnosis doesn’t change: So a woman who is diagnosed in 2010 with stage II disease and then had a recurrence in the bones in 2015 would technically be stage II with metastatic recurrence to bone, which is not how most people think and talk about metastatic breast cancer.

Dr. Wojo reached out to the American Cancer Society about this, and he joins us today to help us all understand this a little bit better. Dr. Wojo, welcome to the podcast.

Brian Wojciechowski: Thank you, Jamie. It’s great to be with you again.

Jamie DePolo: So, I am really excited to talk about this because it was very confusing to me to read all this. So, can you tell us why the American Cancer Society and National Cancer Institute say that a cancer stage never changes? I think it has something to with statistics. Is that right?

Brian Wojciechowski: I think that’s accurate. The first thing to say is that the AJCC [American Joint Committee on Cancer] is the international organization that invented cancer staging and defines cancer staging, so the NCI and the ACS take their cues from that group. And that’s the reference point. So, the short answer is that the group that defines staging says it is so. But that’s probably not an adequate answer.

So, the reason this is true — and you know, not every cancer doctor, believe it or not, is even aware of this — but the reason that it is true is because it does have something to do with statistics. And that might sound silly. The patient might say, “Well, what do I care about statistics? I’m not a number, I’m a person.” The reason it’s important is because when doctors study cancer patients and when we want to find out prognosis and we want to give our patients good, accurate information about what is their chance of survival, what is their chance of cure, we need to start at the beginning when they’re diagnosed and follow them out over time. So, if the woman you referred to, who started out as stage II and then had a recurrence in the bone, if they changed her stage to stage IV, then she would be lost in the statistics, and we wouldn’t be able to count her survival in the statistics to give patients good numbers about prognosis.

Jamie DePolo: I see. So, people want to keep track of, say, the percentage of people diagnosed with stage II disease who then had a metastatic recurrence in the bone. So, you could look at those numbers.

Brian Wojciechowski: Yeah.

Jamie DePolo: I see. I see.

Brian Wojciechowski: Yeah, so you need to follow those patients over time from beginning to end to get accurate information. And frankly the prognosis, the life expectancy, for someone who has stage II and then developed metastatic disease is different than someone who was diagnosed with metastatic disease at the very beginning of their diagnosis. And they define stage IV disease as a patient who is diagnosed with stage IV, and that means metastatic disease, at the get-go, from the beginning, and not someone who gets it later on.

Jamie DePolo: Okay. Well, let me ask you this, then. So, on our site, on Breastcancer.org, we use the term stage IV and metastatic interchangeably, and I’ve noticed that the American Society of Clinical Oncology does the same thing. So, is there really a right and wrong here, or is it a matter of terms that researchers use for statistical purposes versus the terms that people use every day in the clinic? I mean, I really can’t believe that a person would say, “I’m stage IIB with metastatic recurrence.” They don’t say that. People say, “I’m stage IV.”

Brian Wojciechowski: That’s right, or they say metastatic.

Jamie DePolo: Right. So, is it right or wrong, or is it just different? I mean, because I know most people in the clinic, like how would you tell a patient who had a metastatic recurrence? You would consider that person stage IV, wouldn’t you?

Brian Wojciechowski: Well, I don’t think it’s wrong to call that person stage IV. Because there’s the research world, the technical world, and then there’s the real world. And it kind of reminds me of how we talk about cancer treatments, too, because we often use the term chemotherapy very loosely, for example. So, is Ibrance chemotherapy? Is Herceptin chemotherapy? Well, technically no, but colloquially, we often call it that, and I don’t think it’s wrong to call it that.

So, after I reached out to the American Cancer Society, I did an informal poll of some of my colleagues, and this included medical and radiation oncologists. And I have to be honest, I’m not going to name names, but about 50% of them did not know that the stage never changes and that you wouldn’t technically call someone stage IV who had a recurrence. But the one thing we all agree upon is that when we do say stage IV, we know what that means, we know it means metastatic disease. And I’m not going to fault anyone for calling it stage IV. From a purely technical standpoint, it’s not stage IV.

Jamie DePolo: So, one thing that occurs to me, if the American Cancer Society and the National Cancer Institute say that a breast cancer stage doesn’t change, how are they tracking the number of people living with metastatic breast cancer? Because — and tell me if this is right or wrong, if I’m reading this right or understanding it right — if we use their parameters, only people who were diagnosed de novo, as you said, metastatic or stage IV at very first diagnosis, are counted as metastatic. So, are they not tracking all these metastatic numbers? Because if I’m remembering right, I think the Metastatic Breast Cancer Alliance has been talking about this issue for a while, how we really don’t have good numbers of the actual number of people living with metastatic disease because only those who are diagnosed de novo stage IV are counted as “metastatic.” Or has that changed?

Brian Wojciechowski: Yes. Those people are metastatic. They’re just not stage IV. And this is really why the staging should be as it is, because it’s going to be hard to track those people if they’re listed as stage IV as opposed to stage II recurrent metastatic, because that’s how they will be tracked, and that’s how their survival will be counted.

Jamie DePolo: Okay, because you know each year how the American Cancer Society puts out their cancer statistics, that big book, and there’s always a little caveat in there about the numbers of metastatic disease, because they’re quite clear that those only include people diagnosed de novo. So, it’s almost like those numbers aren’t getting in there somewhere.

Brian Wojciechowski: Yeah. I think I see your point that they might miss a number of patients with metastatic disease that are not called stage IV. Is that what you’re saying?

Jamie DePolo: Yeah. Yeah.

Brian Wojciechowski: Yeah. And I don’t think the American Cancer Society looks at every single patient chart, either.

Jamie DePolo: Right. Exactly. How could they?

Brian Wojciechowski: So in a sense, they might be using sophisticated statistical and mathematical techniques to just come up with really good estimates, or perhaps they’re tracking the number of prescriptions for Ibrance or that sort of thing or insurance or Medicare claims, but there’s no perfect way to track everything.

Jamie DePolo: Okay. So my next question is, if we have this way of talking about staging and it helps epidemiologists track survival separately, as you said, for someone who’s diagnosed de novo metastatic versus people who have a metastatic recurrence, when you look at those stage IV survival statistics — help me understand this — do they apply only to people who are diagnosed de novo or do we have statistics for both groups?

Brian Wojciechowski: That I don't know the answer to. When I think about survival, I base those predictions on clinical trials. So on a clinical trial, it’s very well defined who is de novo metastatic and who developed metastatic disease after having early-stage disease earlier. So we’re not talking about large epidemiologic data. We’re talking about a controlled clinical trial, which is probably more accurate anyway.

Jamie DePolo: Okay. So in your experience, how is the prognosis — and I know you would probably need more information, but if you could perhaps help me think about this. How does prognosis differ for someone who was diagnosed, say, de novo stage IV triple-negative breast cancer and the cancer is in the bones compared to someone who was diagnosed with stage II triple-negative breast cancer and then had a metastatic recurrence in the bones 3 years later? How is that prognosis different?

Brian Wojciechowski: Well, if we’re talking about from the time they’re diagnosed with metastatic disease, I think the prognosis is better for someone who’s diagnosed de novo. Because if you think about it, the person who was diagnosed previously has already been treated with chemo and maybe radiation, so they’ve already failed, essentially, a first-line treatment. When you have a recurrence after getting chemo, you’re talking about a recurrence of the cancer cells that did not respond to chemo that were left over.

Of course, if you measure their survival from diagnosis, from the time they were stage II, for example, that person’s going to have a longer overall survival simply because they were diagnosed initially years ago. But the survival is probably worse when you start from the time point where they were diagnosed with metastatic disease.

Jamie DePolo: Okay. That’s helpful. So for the bottom line, to help me understand, how do you talk to your patients when you’re talking to them about the cancer stage? I mean, do doctors actually say, “You’ve been diagnosed with stage II, and this is never going to change, but you may have a metastatic recurrence?” I mean, how do you talk to patients about that? Because it’s really confusing to think about.

Brian Wojciechowski: Yeah. It is. I think for the purpose of individual patients and their personal journey and their personal story and how we make treatment decisions, I don't think it really matters all that much. Like I said, I don't think it’s wrong to say to someone, “You have metastatic disease,” or, “You have stage IV.” I think in practice those terms are used interchangeably. So I’m not encouraging any of our listeners to go and debate with their oncologist, “I don’t have stage IV, I still have stage II.” It’s just metastatic, because it’s really not going to make a difference in terms of your individual treatment.

You know, the other thing that I’m sensitive to is that every patient crafts a narrative and tells herself a story about her disease that helps her accept it and process it. And if your individual story includes that you have stage II metastatic and you don’t have stage IV, well, that’s okay, too. I’m not going to take that away, and I want patients to have their own story, make their own story.

Jamie DePolo: But essentially, too, there’s not a whole lot of difference treatment-wise, treatment options. There may be some difference if somebody was treated with a particular drug for early-stage and then may not be able to have that for the advanced stage, for the metastatic disease, but today there are so many new, more targeted therapies for metastatic disease. The treatment plans would be kind of similar if you were diagnosed de novo versus a metastatic recurrence, wouldn’t they?

Brian Wojciechowski: Yeah. There’s really very little difference. It really just depends on what she had before and how long ago she had it that would play into that decision, not whether we call it metastatic versus stage IV.

Jamie DePolo: Okay. Well, that’s good to know. Dr. Brian, thank you so much for helping us understand this. I know when we got told about the discussion going on on the boards, I personally couldn’t believe it. I had to go to the American Cancer Society and the NCI site, and, like, what? So I was one of those people who had no idea that that existed. I do so appreciate you helping us understand this.

Brian Wojciechowski: Jamie, you are not alone. I should add that as a result of our inquiry to the ACS that they’re going to be changing the language on their website to just make it a little bit more understandable, make it make a little more sense for patients.

Jamie DePolo: Oh, good! We’ve done something then. I feel that we’ve effected good change.

Brian Wojciechowski: I think so!

Jamie DePolo: All right. Thank you. Take care.

Brian Wojciechowski: All right. Bye!

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