Breast Cancer Recurrence Risk

Jamie DePolo: Hello, thanks for listening. Our guest is Brian Wojciechowski, MD, 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. Wojciechoswki is a sought-after speaker on the topics of medical ethics and the biology of cancer. One of the goals of treatment for either DCIS or early-stage breast cancer, which is stage I, stage II, or stage III cancer, is to stop the cancer from coming back, and that’s called recurrence by doctors. Dr. Wojciechoswki joins us today to talk about recurrence risk and how it’s estimated.

Dr. Wojo, welcome to the podcast.

Dr. Brian Wojciechowski: Thank you very much, Jamie. Nice to be back.

Jamie DePolo: Yes! So, to start, I know that recurrence risk is really unique to each person and to each type of breast cancer, and it depends on the number of different things. So, when you’re talking to your patients that have early-stage breast cancer, can you tell us some of the factors that you take into account when you’re trying to estimate a person’s recurrence risk?

Dr. Brian Wojciechowski: Yes. I certainly can, and to start from the very beginning, many of my patients will ask me, “Doc, I've had surgery, I’ve had radiation. My surgeon told me I was cancer free, so, why are we talking about recurrence? Why are we talking about adjuvant chemotherapy or hormonal therapy?” And the fact of the matter is that even women with early-stage breast cancer, a certain number we know will have a recurrence later on somewhere in the body.

And the reason for that is that a surgeon can only take out what they can see. And resumably, there may be microscopic cells that are circulating in the bloodstream or hiding out in bones or other places in the body that are dormant, that are microscopic, and eventually, sometime in the future — could be months, years, decades later — they take hold, they take root, and they grow into tumors, and therefore you have a recurrence.

So, it’s very important to try to estimate what the risk of recurrence is for a woman with breast cancer who's been treated, so that we can tailor her therapy, and we know how aggressively to treat her.

So, your question about, what do I use to estimate the recurrence? Well, there’s a few basic fundamental things that we look at. The first thing is the stage. And what goes into the stage is the size of the tumor — so the bigger the tumor when it’s diagnosed, the higher the risk of
recurrence. Same thing if the cancer is involved in the lymph nodes or has spread elsewhere in the body.

Some other factors would be, women who are younger at their initial diagnosis — say, under 40 — have a higher risk of recurrence, and women who are very old — say, over 75 — have a higher risk for recurrence. So, that’s something we look at as well. Those are the classic risk factors that we’ve been looking at for many decades.

Jamie DePolo: Okay. And I'm curious, you said size and stage. Do the hormone-receptor
status or the HER2 status, does that play into it at all, or is it really the other factors?

Dr. Wojciechowski: Yeah, so that’s a great question as well. So, we also do look at hormone-receptor status. So, the presence of estrogen receptors and progesterone receptors generally portend a better prognosis, in terms of having a lower risk of relapse or recurrence, especially since we can decrease the risk of relapse by treating those patients with hormonal therapy.

Now, HER2 is a marker that generally means a cancer is more aggressive. So, before the days of HER2-directed therapy, like Herceptin, the risk of recurrence for women with HER2-positive cancer was much higher. But nowadays that we have Herceptin, the playing field is more even, and the prognosis is better for HER2 cancers than it was before the days of Herceptin.

Similarly, if we have a triple-negative cancer — that is, no hormone receptors, no HER2 — the risk of recurrence is much higher than if the receptors were present. So, yeah. That’s another thing we look at. It’s very important.

Jamie DePolo: Okay. I’m assuming, based on what you just said, that triple-negative has a higher risk of recurrence, basically because there aren’t any treatments that are targeted specifically to that type of cancer. Like we have hormonal therapy to treat hormone-receptor-positive disease. We have the anti-HER2 therapies, as you said, like Herceptin, Perjeta, all
those that treat HER2-positive cancers, but there isn’t really anything yet that is aimed specifically at triple-negative disease. Is that right?

Dr. Brian Wojciechowski: Not in the standard situation with early-stage, where the patients had surgery and are cancer free. There’s not really anything right now, for most women, that you can give to decrease the risk of recurrence in triple-negative. And triple-negative breast cancer, it’s not just that there aren’t good treatments, but it is a more aggressive biology, pound for pound, as well.

Jamie DePolo: Okay. Okay. Good to know. Now, are some of the factors that you just talked about, would you consider them more important when trying to figure out recurrence risk? Like is the size of the cancer more important than the number of lymph nodes involved, or are they all pretty much equal?

Dr. Brian Wojciechowski: They're all more or less equal. I think lymph node involvement is
probably more important than size, but they all play a role, and they all add up in the end.

Jamie DePolo: Okay. Now, it seems like some factors, from what I’ve read, like, say, exercising regularly, research suggests that can help lower the risk of recurrence because it keeps down inflammation, it keeps weight down. We know that being overweight is linked to a higher risk of recurrence. That’s kind of a long way of asking, when you’re talking to your patients, are there things that a person can do to help keep the risk of recurrence as low as it can be? Are some factors within a person’s control?

Dr. Brian Wojciechowski: I would say, it’s mostly outside of someone’s control, but you can make a dent by making healthy lifestyle choices, and that’s something we cover extensively at the website. We talk about diet, exercise, maintaining a healthy weight, that sort of thing. So, there’s no magic cancer diet, Jamie, but when my patients ask me, “How should I eat?” I usually say, “You should eat like we all should eat.” So, low saturated fat, avoiding fried foods, eating more lean meats and less dark meats, Mediterranean-type diet, regular exercise. And I tell my patients, “If you do that, you’re going to be ahead of the pack.”

Jamie DePolo: Okay. As you mentioned, a lot of the things, like the size of the cancer, the stage of the cancer, that’s something that’s really completely out of somebody’s control.

Dr. Brian Wojciechowski: Yeah. Those are pretty much fixed obstacles.

Jamie DePolo: Yeah. Okay. Now, I also know there seem to be some differences in the length of time after treatment ends when it seems like the cancer can come back. So, what I’ve read is hormonal-receptor-positive disease can come back in 10 years after treatment ends, whereas hormone-receptor-negative disease tends to be within the first 5 years. So, could you talk a little bit about those differences and how you talk to your patients?

Dr. Brian Wojciechowski: Yes. Of course, like anything in medicine, there’s no hard and fast
rule. There’s always exceptions to these rules. But generally speaking, with HER2-positive and triple-negative breast cancers, if the recurrence doesn’t happen in the first 3 years, it’s probably not going to happen, in my experience. And as a general rule, with the hormone-receptor-positive breast cancers, recurrence can happen early in the first few years, it can happen 5-10 years, it could happen 10-15 years, or even later. We don’t understand exactly why. What we do understand is that each of these cancers has a different biology. They
should almost be thought of as different diseases entirely.

Jamie DePolo: Okay. So, finally, I know there are tests, which are called tumor genomic assays, which is a big mouthful of words, and those help doctors estimate the risk of recurrence for certain types of early-stage breast cancer. So, one of the most commonly used is Oncotype, there’s also MammaPrint, there’s several different ones, and they all seem to have kind of a slightly different use, and they're used on slightly different cancers. So, how common is it for those tests to be used? Is that something that’s standard now? Say, if somebody’s diagnosed with early-stage hormone-receptor-positive disease, is it a given that
they’re going to get a genomic test, or is that still something that somebody might have to advocate for?

Dr. Brian Wojciechowski: Well, I think patients should always be their own advocate, no matter what, no matter if you’re being treated at the leading university center or a small community hospital, because that’s just the nature of medicine these days. So, never stop being an advocate.

But if I could use the example of the Oncotype test, that’s the most common of those tests, which we use. So, I think anyone who has an early-stage hormone-receptor-positive breast cancer that is node negative or only has a couple nodes involved should have a conversation
with their doctor about this test. Because it does two things. It provides prognosis data, and it provides predictive data. So, the prognosis means how likely is the cancer to relapse, and the predictive means, is there anything we can do, specially with chemotherapy, to decrease the chance of that relapse. And this test does both, so that’s why it’s the most commonly used test.

So, unless a woman is absolutely refusing chemotherapy, for whatever reason, or if they’re not well enough to receive chemotherapy, I think she should seriously consider getting this test done, and her doctor is probably going to recommend it.

The nice thing is, and what I can tell my patients is that, in 2021, we have these great tests and not every woman with breast cancer has to get chemo. So, if you get the Oncotype test, for example, your result could come low, middle, or high — and they're analyzing 21 cancer-related genes in the surgical specimen, so she doesn’t have to get any additional testing. If it comes up high, it’s no question that we’re going to be recommending chemotherapy. If it comes up low, then it’s no question that we’re not going to be recommending chemotherapy, and if it comes up in the middle, it really depends on the score and the woman’s age. It’s a conversation, and the doctor and the patient can decide together.

Jamie DePolo: Okay. Okay. So, it sounds like these tests have been a great thing because it gives you a little more certainty when deciding how much benefit is chemotherapy after surgery really going to add. If it’s not much, then somebody doesn’t have to go through that.

Dr. Brian Wojciechowski: That’s exactly right, Jamie. We don’t want to put someone through
chemotherapy, a potentially life-altering treatment, without being absolutely sure that it’s going to benefit her. And that’s what these tests give us, that certainty, that reassurance that we’re doing the right thing.

Jamie DePolo: Okay. I know a lot of people are just very, very afraid of recurrence. Do you have any tips for managing that fear, or you know, what do you tell your patients, because obviously it’s a reality for anybody. And I know a lot of people, too — this is kind of completely different subject — but with hormonal therapy after surgery, a lot of people get tired of taking it, like if they have to take it for 5 years or 10 years, and I guess they want to put it all behind them, but there’s always also that fear. So, how do you kind of talk to people about that?

Dr. Brian Wojciechowski: Well, Jamie, a cancer diagnosis — from beginning to end, through every stage of the journey — is an emotional rollercoaster. There’s all kinds of emotions that we go through — grief, anxiety, anger, fear, all these different things — and you can be told that you’re cancer free after surgery, and then you can be in the sort of waiting game. Is it going to come back? Am I going to get 5 years? And then every little symptom you have becomes a crisis, because it could mean that something bad is going on.

So, I tell all my cancer patients, I tell them you have to try and focus on that which you can control and not what you can’t. Easier said than done, for sure, but you can get there. And it doesn’t happen by accident, and it doesn’t happen overnight. It takes time, and it takes
effort, but it really does work. You really can get there, and that’s how I tell people to try and cope with it.

Secondly, like we talked about before, whatever medical problem you have — whether it’s cancer, heart disease, anything at all — eating right, exercising, maintaining a healthy lifestyle is going to make it better, and it’s going to improve anxiety, it’s going to improve the fear, the worry, it’s going to improve the aches and pains and the side effects of therapy, and it’s probably even going to decrease the chance of a relapse for some women with breast cancer. So, all of the above.

Jamie DePolo: Excellent. Thank you so much, Dr. Wojciechowski. This has been really, really helpful.

Dr. Brian Wojciechowski: The pleasure is all mine. Always nice talking to you.