[00:00:00] Adam Walker: From Susan G Komen, this is Real Pink, a podcast exploring real stories, struggles, and triumphs related to breast cancer. We’re taking the conversation from the doctor’s office to your living room.
Natera is a global leader in cell free DNA testing, dedicated to oncology and women’s health. At Natera, we strive to transform the management of cancer with personalized monitoring of circulating tumor DNA. Learn more at natera.com.
The goal of treating early breast cancer is to remove the cancer and keep it from coming back. When breast cancer returns after treatment, this is called a breast cancer recurrence. Most people diagnosed with breast cancer will never have a recurrence. However, everyone who’s had breast cancer is at risk of recurrence, though that risk varies greatly from person to person. Your healthcare provider cannot tell whether or not you might have a recurrence, but they can give you some information about your risk. Joining us today to talk about breast cancer recurrence and the tools available for surveillance monitoring post treatment is medical oncologist, Angel Rodriguez. Dr Rodriguez is a Komen for the Cure, multidisciplinary fellowship grant recipient. Dr. Rodriguez, welcome to the show!
[00:01:27] Angel Rodriguez: Hi Adam. Thank you for having me. It’s nice to meet you.
[00:01:31] Adam Walker: I’m glad to talk about this, I feel like recurrence is at the back of every, person I interviewed at the back of their minds. And I feel like getting, shedding more light on this is really important. So, it’s such an important topic people don’t want to talk about because they’re eager and relieved to move on and be in post treatment mode and not think about the what ifs. But I know it’s really important to arm women with this information. So first, what percentage of women have a breast cancer recurrence?
[00:02:06] Angel Rodriguez: Yeah, no, that’s a great comment. yeah, I think when one’s diagnosed with cancer, in general, their life can sometimes revolve around, this particular problem. And, it’s certainly very important to compartmentalize one’s life and thinking about this disease. And in breast cancer, the good news is that recurrences have improved significantly over time. And if we were to put a sort of average number on all of breast cancers, we typically see about maybe 10 to 15 percent of, patients having recurrences, but, it’s obviously super important to, to keep in mind that, this largely depends on the type of breast cancer that one is diagnosed with, as well as the stage and multiple other factors. But, again, going back to the point of the reduction in the risk of recurrence. Breast cancer death rates have been steadily decreasing since, 1989 where, the risk of dying of breast cancer has dropped by 43%, between 1989 and 2020. Although we’ve done significantly better, there’s certainly room to improve.
[00:03:32] Adam Walker: So I just want to make sure I heard you. You said breast cancer recurrence typically happens 10 to 15 percent of the time. Is that right?
[00:03:39] Angel Rodriguez: Yeah. Again, roughly depends on the type of disease, right? The lower risk, cancer it’ll be less than 5 percent of the time. but for the higher risk cancers, it can be higher.
[00:03:55] Adam Walker: So that’s actually lower than I would have anticipated. And having been in this community and hosted this show for years, I did not realize it was that low. So that’s encouraging. So how often can a survivor expect to see their doctor after they’re done with the breast cancer treatment and like what type of surveillance can they expect from an imaging standpoint?
[00:04:15] Angel Rodriguez: It can also depend on the type of breast cancer that one is diagnosed with because they may be treated with different therapies. One of the most important, reasons at the onset after completing curative intent treatment, one of the most important reasons to go back to the doctor is to, assess first, some of the residual side effects of the treatments that they may have experienced and that may still linger. But also more importantly for the patients who need to continue to be on treatment, whether it be oral medications or sometimes intravenous treatments. It is to ensure that the patients are, tolerating, the medications as well as they can because there are a lot of sort of tricks and a lot of opportunities that one can take advantage to try and mitigate and reduce, side effects that may happen.
And really these recurrence rates are as low as they are now, because of these treatments that exist. In the event that patients sometimes are not tolerating them, they may stop taking treatment. And so that risk can then go up, but in regards to monitoring for recurrence, how do we know if a patient has recurrence? Let’s say, the patient is cruising along and may have completed their period of intent treatment. In general every 3 to 6 month, is how patients are seen in the clinic. Initially, every 3 and then as time goes by those space out those visits. and in the clinic, it’s again, largely to see that the patients are feeling well and that nothing is lingering from previous treatment. And also, if no new concerns or symptoms have arisen.
[00:06:24] Adam Walker: And I know like when they’re being monitored, obviously there’s some imaging done as part of that process. Are there any other types of assessments that are done to monitor for recurrence?
[00:06:35] Angel Rodriguez: Yeah, so obviously yeah, the most important one really is symptoms and no, the problem when we monitor with symptoms is that they can be sometimes so vague, right? They can be very non specific. Who in their life doesn’t eventually develop some, joint pain or bone pain here and there, a headache, for example, or just even lungs, right? and just because you develop some of these symptoms, it doesn’t mean that it actually is a cancer, but it can be.
So we monitor for those. We also, occasionally, depending on what treatment patient’s on, they may be on blood work, to monitor side effects of medications that we sometimes inadvertently find abnormal results that could be suspicious signs for recurrence, such as liver function tests. And there are some tests that exist out there, we call them tumor markers, and these tumor markers are blood tests that have existed for quite a while. And these blood tests, they, can be elevated and detected in the blood, in patients who have recurrence. But, unfortunately, sometimes those tests can also be elevated, and detected in patients that do not have recurrence of cancer.
So they can create sometimes more problems that they can, solve. And then sometimes, recurrences can happen when some of these older blood tests. Tumor markers do not show their presence in the blood.
[00:08:23] Adam Walker: Okay. so you mentioned earlier that everyone’s risk of recurrence is different.
It depends on, perhaps the type of cancer, the degree of the cancer. So can you walk through what are those factors like stage of cancer that recurrence?
[00:08:40] Angel Rodriguez: Yeah, and this Adam, this is very important, because we have to understand it. What might our problem be? What might our recurrence or recurrence, risk of recurrence is so that we can then, determine how concerned might we be of a possible recurrence. And simply stated, a tumor that is very small, the size of a grain of rice, which can sometimes be that small. Aad when the tumor has not spread anywhere, not even to nearby lymph nodes and sometimes, you can look under the microscope and you can assess. How a cancer might behave based on the there. We call it grade, right? How it looks under the microscope. Those might point towards a low risk of recurrence. Then again, the smaller and whether it’s not in lymph nodes, the subtype of the cancer can also be very important. there are cancers that can be small, but the risk of recurrence may not be as low as other subtypes of cancer. So for example, we, when we hear about triple negative breast cancer and a HER2 positive breast cancer compared to it’s a hormone receptor positive breast cancer. Those risk of recurrence are generally, higher than the subtype that’s driven by hormones. so those are some of the, considerations.
[00:10:27] Adam Walker: So tell me a little bit about timing, like at what point is the risk of recurrence, at its lowest? at what point is it typically higher? Walk me through that a little bit.
[00:10:39] Angel Rodriguez: Yeah. And then that also is, not all cancers behave the same, right? You can have some cancers that you know, their biology is, we use the word aggressive, right? And they tend to grow a bit faster than others. And so those types of cancers that have that type of biology, they tend to relapse. Sooner than other tumor types that have slower growing cancers, and especially in breast cancer, there’s this biological aspect that we call a dormancy where, cells can escape where it started and find a nest in a different part of the body and most commonly the bone.
For example, and then it can lay there dormant for many years and even decades. and of course, as long as it doesn’t wake up and come recurring cause problems, it’s, it’s not a problem, right? If it never comes back, but sometimes they do wake up and sometimes they do, start growing again and they recur. And so these recurrences can happen again, as I mentioned, as late as decades later, but for diseases like, for example, triple negative breast cancer, that generally doesn’t happen. Those are the types of cancers where the recurrences, most of them happen early on, like in the first two to three years. When I talk to patients with triple negative breast cancer, the positive side of things is that although the risk of recurrence is higher early on, when they reach that three, four year mark, the risk of recurrence now becomes very low, compared to the most common type of breast cancer, the hormone receptor positive, where it’s interesting that it’s almost like a linear risk of recurrence and it’s steady throughout after diagnosis.
And it can be as little as less than half a percent or two, 1 percent per year, but it can be up to five to 6 percent per year, . and that can go on up to decades later.
[00:13:08] Adam Walker: So I’ve heard guests on this show, use the term scan anxiety, it’s a real thing. They’re anxious about getting their scan. Do you have any advice for listeners for how they can help manage their feelings of anxiety as they, approach their next scan?
[00:13:24] Angel Rodriguez: Yeah. And I have to admit, obviously easier said than done, right? Coping with scanxiety, I have to admit, I haven’t been diagnosed with cancer and I don’t have to go through these processes. However, yes, I’ve treated many patients, in the scenario where the truth is on the one hand, when we do scans, you got to admit we’re looking for trouble, right? We’re looking for a recurrence. And so that’s one way to look at it. And that’s what causes the anxiety, the fact that we’re looking for that trouble for that recurrence.
But on another note, what we’re also doing is uncovering biology, which there are things that we can control and things that we cannot control. And so if a recurrence is to happen, it’s not because the scan did it. It’s not because the scan caused the recurrence. So in a way, this anxiety can be also mitigated by the fact that I’m doing a good thing for me, right? If a recurrence is going to happen, I want to find it so that I can plan ahead and learn my options and proceed accordingly. And I think in these days, we can be very fortunate to have many options, right? And by options, sure, consideration of what today’s current standard of care treatments are for treating a recurrence.
Consideration for recurrences that can sometimes be cured again, or be, I don’t want to use that word lightly, actually. But we can be rendered no evidence of disease again if it’s a local recurrence, if it’s an isolated recurrence. But more importantly, in terms of planning ahead and having a scan find something, it’s also about consideration of clinical trial options, right? As I mentioned, the recurrence rates are not where we want them to be yet, and we can always get better and we can only improve upon that through clinical trial enrollment. And I think being aware of that and having the time to ponder the options of do I want to go here, do I want to go there, for a conservational criminal trial. I think it’s an added value of, detecting recurrence early.
[00:16:07] Adam Walker: Yeah, that’s great. That’s great advice. So, what are some signs and symptoms to be looking for? And at what point should someone see a doctor if they’re concerned about the possibility of recurrence?
[00:16:18] Angel Rodriguez: Yeah, so many of the signs and symptoms that can be associated with a cancer recurrence can be very nonspecific. Meaning that, just because you have that sign or that symptom, it doesn’t necessarily mean that cancer has recurred. And a symptom like a cough, a shortness of breath, a fatigue, a pain of anywhere in the body, a bone pain, a joint pain, a lump. Many of these things, again, patients who don’t have cancer can experience some of these.
But when it happens in a patient with cancer, it raises the concern, and it certainly warrants. A call to the oncologist to ensure that, that it isn’t, a cancer. And so when we, develop these symptoms and we develop a plan, to assess these symptoms, it’s done in conjunction with your doctor, right? We’re not going to do a scan every time, we have a cough episode. We’re not going to do a brain MRI every time we have a headache, but we evaluate the pattern a bit in more detail. At the end of the day, it’s, it figure out, shall we go ahead and do a scan to find recurrence or shall we wait a little longer?
[00:17:40] Adam Walker: So, Dr. Rodriguez in the intro for this episode, I read a term that I’m not familiar with it all so forgive my ignorance but in the intro it said, you transform the management of cancer with personalized monitoring of circulating tumor DNA. What is that exactly?
[00:18:01] Angel Rodriguez: Yeah. Okay. Thanks Adam for the question. Circulating tumor DNA is a technology that allows for a blood sample to be examined and evaluated for the presence of cancer in the body. And it does it at the molecular level, meaning, we’ve talked about how imaging and scans are used today to determine if a cancer has recurred and there are limitations to imaging when used to evaluate for cancer recurrence. One of them is that when you see a suspicious finding within a scan, number one, it’s not always a recurrence, right? And we have to use our judgment and expertise to determine what the likelihood is that finding might be a recurrence.
And sometimes it’s obvious and sometimes it’s not. Even healthy individuals can have, for example, small nodules in the lung that are not related to recurrence, but related to maybe past infection. But when a patient has a history of cancer, it raises suspicions for recurrence. So therefore, it can be sometimes non specific, and studies have been done in the past in breast cancer that when you do scans to periodically to detect recurrence, doesn’t affect the outcomes of patients when we do surveillance with scans or tumor markers for that matter. And largely because these are very nonspecific, tests that can sometimes lead to wrong results. And circulating tumor DNA evaluates the precedence of disease, as I mentioned at the molecular level. And with this test called Signatera, which is the test that our company, Natera offers. It is a test that, number one, the tumor of the each patient is examined, and the genomics, the DNA of the tumor is examined then compared to each patient DNA so that we can evaluate and determine what are the unique, DNAchanges that are present within the patient’s cancer.
That then allows us to adopt a technology where we can then, sample the patient’s blood, detect that the presence of that patient’s cancer in the blood in a much more specific way than our previous tests have done before. And so the presence of circulating tumor DNA may be informative in making decisions in some cases, when to treat, give treatment to reduce the risk of recurrence is being considered, but the risk of recurrence that again, we’ve also, talked about, it’s sometimes indeterminate or questionable whether the risk of recurrence is high enough to warrant intensive therapies. But knowing that if there is presence of disease in the blood may then be able to inform that type of decision.
Now, it’s important to note that this test, technology isn’t perfect to determine which patients have disease because there’s also biological factors that play into it. And so a negative test result should be interpreted with caution and treatment should not be avoided solely because the blood test did not find the disease in the blood. So regardless, this is a test that should be discussed with a with oncologist if a patient’s interested in, knowing.
[00:22:28] Adam Walker: Okay. I appreciate you sharing that. It’s a fascinating piece of technology there. Alright, so there are people listening right now that have just finished treatment. I wonder if you have any final advice you’d like to give them as they’re learning to adjust to their new normal?
[00:22:50] Angel Rodriguez: Yeah, absolutely. Again, as I mentioned at the beginning of the podcast, cancer can definitely change one’s life. And, one should be aware that change in life, can be for the better. We all seek to be happier and to be you know, at peace with where we are in life and having a diagnosis of cancer can challenge that. And so one of the most important things that I discuss with patients is: compartmentalize your life, right?
And by that yes, the diagnosis of cancer is real and the risk of recurrence is real. And if you compartmentalize, how you address that, whether it be within the doctor’s office, right? That’s all you’re going to talk about. And then when you step out of the office, maybe, at home, we also want to sometimes think about this, but compartmentalize it right now. I want to sit down, maybe talk to my loved ones, talk to somebody about maybe appear, who’s also been diagnosed. You address some of your concerns and anxiety in that way, but having a cancer diagnosis doesn’t define who you are or what you are. It is just a part of what has happened in your life, but there’s still life to live.
And I think that it’s very important, to continue, to seek, being happier and doing the things that one enjoys in life. And number one, I think being keen and knowing that you’ve done everything you could that’s been proven in 2023 to prevent that recurrence should also allow you to live in peace with the fact that you’ve done everything you could. But again, also knowing that recurrences can happen in that, there are trials out there, clinical studies out there that are trying to further reduce the risk of recurrence is a part of leaving no stones unturned in terms of everything that you could do. And so seeking some of these studies that are evaluating, whether finding molecular recurrence circulating through my DNA and the blood and treating that before that turns into a clinical recurrence or a recurrence is an option for patients these days. And so talk to your doctor about possibly participating in some of those studies.
[00:25:51] Adam Walker: That’s great advice. That’s great advice. Dr. Rodriguez, such a good thing to have you on the show today. I really appreciate your time today and really appreciate the work that you’re doing, for this community.
[00:26:01] Angel Rodriguez: Thank you. Thank you so much, Adam. Thank you for having me.
[00:26:05] Adam Walker: Natera is a global leader in cell free DNA testing, dedicated to oncology and women’s health. At Natera, we strive to transform the management of cancer with personalized monitoring of circulating tumor DNA. Learn more at natera.com.
Thanks for listening to Real Pink, a weekly podcast by Susan G komen. For more episodes, visit realpink.komen.org. For more on breast cancer, visit komen.org. Make sure to check out @SusanGkomen on social media. I’m your host Adam. You can find me on Twitter @AJ Walker or on my blog adamjwalker.com