Characteristics of Early-Stage Breast Cancer That Make It More Likely to Come Back
In this podcast, Dr. Shah talks about specific characteristics of early-stage breast cancer that make the cancer more likely to come back, which doctors call recurrence.
Listen to the podcast to hear Dr. Shah discuss:
the difference between local/regional recurrence and metastatic/distant recurrence
the characteristics of early-stage breast cancer that make the risk of recurrence higher
Editor’s Note: Please know that Dr. Shah does point out that more research is needed on how diet, alcohol use, and smoking affect recurrence risk because current data are inconsistent. His ultimate point is that a survivorship care plan, which includes monitoring, is the most important tool we have beyond following your treatment plan to reduce the risk of recurrence. A survivorship care plan includes:
monitoring for and managing long-term physical and emotional side effects
guidance about diet, exercise, and health-promoting activities
resources to help with financial and insurance issues
Dr. Chirag Shah is a radiation oncologist and director of breast radiation and clinical research in the department of radiation oncology at the Cleveland Clinic. His primary research interests are breast cancer, sarcoma, and innovative radiation treatment schedules, as well as lymphedema. He has participated in numerous clinical trials.
— Last updated on January 31, 2022, 6:36 PM
Jamie DePolo: Hello, thanks for listening! Today’s guest is Dr. Chirag Shah, a radiation oncologist and director of clinical research for the department of radiation oncology at the Cleveland Clinic. Dr. Shah received his bachelor’s degree from Youngstown State University and his medical degree from Northeast Ohio Medical University. He completed his internship and residency at William Beaumont Hospital from 2007 to 2012 and joined the Cleveland Clinic staff in 2015. Dr. Shah serves as a reviewer for various medical journals and is a member of various medical societies. His primary research interests are breast cancer, sarcoma, prostate cancer, lymphoma, and innovative radiation treatment schedules, as well as lymphedema. He has participated in numerous clinical trials.
Today he joins us to talk about specific characteristics of early-stage breast cancer that make the cancer more likely to come back, which doctors call recurrence. Dr. Shah, welcome to the podcast!
Dr. Chirag Shah: Good morning! Thank you for having me.
Jamie DePolo: Let’s start by talking about types of breast cancer recurrence. I know recurrence can be local or it can be distant, or metastatic. Can you explain the difference between those two types of recurrence?
Dr. Chirag Shah: Sure, absolutely. In terms of recurrence, when we talk about local recurrences, or what are sometimes called locoregional recurrences, these are recurrences that happen inside the breast or in the lymph nodes in close proximity to the breast. And so when we look at these types of cases, we want to make sure that the cancer, if it has returned, has only returned in the breast, the chest, or in the lymph nodes, and we call that a limited locoregional or local recurrence.
On the other hand, a distant recurrence is cancer that has spread beyond the breast or chest wall in the lymph nodes in close proximity and gone elsewhere, most commonly to the bone but sometimes to organs such as the lungs, the brain, or the liver.
It’s also important to recognize that these recurrences can happen together sometimes, such that a patient that has a local or locoregional recurrence can also have a distant recurrence, which is why when patients develop a local recurrence we’ll often check and make sure there’s not cancer elsewhere.
Jamie DePolo: Ok, thank you. Now, are there statistics on each type of recurrence per year, at least in the United States?
Dr. Chirag Shah: You know, unfortunately there’s not a great, perfect set of numbers. The risk is very much dependent on the type of breast cancer and the stage. So for example, when we talk about local recurrences, if you take a patient who has an early-stage breast cancer with favorable features such as estrogen positivity, small size, the risk of recurrence after a lumpectomy and radiation therapy at 10 years is often less than 5% within the breast or in the lymph nodes.
On the other hand, if you take a breast cancer that’s maybe a more aggressive breast cancer, say one that doesn’t respond to estrogen and a larger tumor size, maybe even inflammatory breast cancer, even after surgery, radiation therapy, and chemotherapy, the risk of recurrence still may exceed 15-20%.
With respect to distant recurrences, again, it’s very much based on the type of cancer and the stage, with early-stage cancers having risk of distant recurrence of less than 5% and more aggressive cancers having risk of recurrence of more than 15 or 20%.
Jamie DePolo: Well that’s a perfect lead-in to my next question, which is these characteristics that you spoke about that make the risk of recurrence higher for certain cancers. So can you talk in more detail about each one of those and kind of what they are?
Dr. Chirag Shah: Of course. So when I talk about risk factors for recurrence, I tend to break them up into clinical risk factors, meaning things that are inherent to the patient, as well potentially what we call tumor-related risk factors.
So in terms of patient-related risk factors, the most well-known and well-studied is young age. Typically, younger patients tend to have higher risk of recurrence both locally as well as distantly regardless of the same type of tumor stats. So that’s always one we look at and one we counsel patients on.
In terms of tumor factors, some of the most important ones we look for recurrence include estrogen-receptor-negative status, tumor size, and then some study things like tumor grade, meaning how aggressive the tumor looks under the microscope, or the presence of lymphovascular space invasion, which is a fancy word for tumor cells being seen in the blood channels as well as the lymph channels. Also, the presence of having cancer in the lymph nodes can be a risk factor for recurrence both in the chest/breast/lymph node area as well as distantly.
Jamie DePolo: And when you said that a patient’s young age confers a higher risk of recurrence, is that just because the person is expected to live longer as opposed to... say, somebody who’s diagnosed at 40 versus somebody who’s diagnosed at 75?
Dr. Chirag Shah: So that’s an interesting question, and for the most part we think it’s probably independent of how long they’re going to live. If we look at the rates of recurrence at 5 years or at 10 years, you know, they’re still higher for a 40 year old than, say, a 70 year old with similar cancer, so it seems to be irrespective of longevity phenomenon. It may mean a tumor genetics phenomenon, and a lot of these risk factors we just talked about may actually be linked to the genetics of the tumor, which is why you’re seeing more and more testing looking at tumor genetics and its impact on recurrence for patients.
Jamie DePolo: Oh, interesting. So do we know yet, does, say, somebody who has a mutation in a BRCA1 or BRCA2 gene, does that make the cancer more likely to recur?
Dr. Chirag Shah: Those are a bit of a different type of mutation. BRCA mutations are simply thought of as mutations within the patient’s own genetics. What we’re looking at now are the genetics of the cancer and saying… for example, the cancer that the genetics may represent, say it’s a higher-risk cancer and therefore may derive more benefit from chemotherapy, whereas it may have a genetic signature that doesn’t suggest a strong benefit to chemotherapy and therefore the patient may not require chemotherapy. In the past a lot of the patients had very pragmatic decisions on chemotherapy based on tumor size and things of that nature. Now we’re able to actually look at patients’ individual cancers through these tests and give them a better idea of what the risk and benefit of, for example, chemotherapy [are].
Jamie DePolo: I see, I see. Ok. Are there other factors, I’m thinking more specific to an individual person? I know we talked about age, but do other medical conditions, or diet, alcohol use, smoking, weight — do any of those things affect the risk of recurrence?
Dr. Chirag Shah: You know, it’s a question we’re being faced with more and more in light of different studies being published. Unfortunately there’s no consistent data that really supports, for example, a certain diet that has an impact on recurrence. You know, there have been suggestions of alcohol use, but it’s not a consistently demonstrated phenomenon. So I think it’s something that bears further study to really understand the effects of health, diet, wellness on cancer outcomes and the potential therefore for patients to modify those factors to improve their outcomes.
Jamie DePolo: Ok. And I know you talked about, earlier, risk of recurrence within 5 years after diagnosis. I’ve read some studies that talk about hormone-receptor-positive breast cancer maybe has a higher risk of recurrence, say, 10 to 15 years after diagnosis. Are studies looking at that? Is that an accurate statement?
Dr. Chirag Shah: Yes, absolutely. One of the things that we’ve seen is that patients who have estrogen-positive breast cancers who are getting anti-estrogen therapy, whether that be a tamoxifen or an aromatase inhibitor, may actually have delayed recurrences. What that means is that clinicians as well as researchers, these patients, when they’re studied, need to have longer-term follow-up to make sure that we are accounting for any potential late recurrences. So not only will this impact future studies, but it also impacts current studies and making sure we’re following these patients who are estrogen-positive for a longer period of time.
Jamie DePolo: Are there steps people can take to reduce the risk of recurrence? I know obviously there are medicines. That’s why people are prescribed tamoxifen, an aromatase inhibitor if the cancer is hormone-receptor-positive. That’s why people have chemotherapy after surgery. Could you kind of go over those treatments, but as well, are there any things people can just do on their own?
Dr. Chirag Shah: Sure, absolutely. I’ll break that up into those two areas.
So in terms of treatment itself, the number one thing I tell patients is compliance. Endocrine therapy, for example — whether that be tamoxifen or an aromatase inhibitor — is something that is not easy for patients to take, and it certainly can be associated with side effects. And we have studies showing noncompliance with those treatments. So first and foremost, being compliant with the endocrine therapy.
You know, when it comes to chemotherapy, having a discussion with the oncologist about the pros and cons and understanding. From a radiation standpoint, understanding that radiation can lead to reductions in the risk of recurrence on the chest and in the lymph nodes, and even some data suggesting that radiation therapy can reduce the risk of the cancer spreading distantly, and so following recommendations with respect to that.
In terms of long-term for the patient, I would say the most important thing is really what we call survivorship or follow-up care. You know, most recurrences, if they’re local or locoregional, can often be detected by follow-up imaging, follow-up physical exam. Also, if any new symptoms arise that may suggest cancer has spread elsewhere, letting physicians know right away so that imaging and potential biopsies can be arranged expediently. Those are the biggest things patients can do — being aware, watching, being engaged in the follow up of their breast cancer and letting their clinicians know if anything doesn’t seem right.
Jamie DePolo: Ok. I did read a study — you mentioned survivorship plans. The majority of people diagnosed with breast cancer do not have a survivorship plan to sort of follow, “Ok, I had radiation, now I need to follow any side effects of that. I was on chemotherapy, now I have to look for side effects, like maybe if I had been given Herceptin, I need to have my heart monitored because of that.” In your mind, where should a person start if they’ve been treated for breast cancer — is it their oncologist that helps them with that follow-up plan? Is it their general practitioner? If they don’t have one, where should they start?
Dr. Chirag Shah: That’s a great question, and survivorship is going more and more into the mainstream fold. I agree with you. Unfortunately, not all patients are getting survivorship plans, but it’s something that’s becoming a focus.
So from my standpoint, it should start with one of the patient’s oncologists. There are some patients, for example, who get chemotherapy and not radiation therapy, and some that get radiation and not chemotherapy, but someone on the oncology team — and in some institutions, that may even be the breast surgeon or surgical oncologist — but one of those oncologists, depending on the patient’s treatment paradigm, needs to take responsibility. And usually programs involved with that will provide the patient with what’s called a treatment summary, so they understand the treatments that they have received, and they understand that subsequently the survivorship visits that are followed with that. So a patient who may, for example, have a left breast cancer that got left-sided radiation and chemotherapy that may have cardiac complications may need to follow up with cardiology or cardiac oncology. On the flip side, someone who’s taking an endocrine therapy may need to continue to follow up for years and make sure we’re managing any side effects associated with that.
So I think first and foremost, it starts with one of the members of the oncology team coming up with a summary and then having a detailed follow-up plan. As the years go on, many of these things can be addressed by primary care physicians, but some things may require specialized follow-up long term.
Jamie DePolo: And does the survivorship care plan… that does include monitoring for recurrence of breast cancer?
Dr. Chirag Shah: Absolutely, absolutely. So whether that’s mammograms if the patient underwent lumpectomy, physical examination if the patient underwent mastectomy or reconstruction, it would be tailored to the patient’s individual treatment.
Jamie DePolo: That’s an excellent point you bring up. I want to sort of focus on that before we finish up. Sometimes people — women mostly — who had mastectomy think they don’t need any monitoring of the breast area because they had mastectomy, the breast is gone, how could anything be there again. But it is a possibility, however small, that there could be some cells in that area, correct?
Dr. Chirag Shah: Correct. So we know that even after mastectomy there is a risk of recurrence on the chest or the reconstructed chest wall. Unfortunately, yeah, many patients can have the expectation there’s no risk of recurrence, and then we see those recurrences. So they are uncommon, but it is something where if you had a mastectomy with reconstruction, making sure you undergo examination on a routine basis to rule out any recurrences on the chest wall or in the lymph nodes is vital.
Jamie DePolo: Ok, and it sounds like, from what you said, having a survivorship plan that includes monitoring of breast cancer recurrence is really the most important thing to reduce the risk of recurrence? Is that fair to say?
Dr. Chirag Shah: I would say absolutely, yeah. Being vigilant and making sure you’re following up and being surveilled for any recurrence is very important in my opinion.
Jamie DePolo: Dr. Shah, thank you so much.
Dr. Chirag Shah: Thank you for your time.