The opening line of the first book in Lemony Snicket’s children’s book series A Series of Unfortunate Events is “If you are interested in stories with happy endings, you would be better off reading some other book”. I can’t remember what age our was older son was when he first started reading that book, but he stopped right there, after that first sentence.
That’s my way of warning you that this post – about breast cancer recurrence – is not an easy read. As someone who’s only very recently finished treatment for primary breast cancer, I can tell you that secondary breast cancer is not an easy subject. But as you’ll know if you’ve been following my blog since I was diagnosed last summer, I’m a firm believer in the whole “knowledge is power” thing. Here’s another warning… this is the first in a series of posts about recurrence. There’s lots to say.
If you’ve had breast cancer once, your risk of recurrence is essentially never zero. Having primary breast cancer is bad, but getting a secondary breast cancer diagnosis must be a whole lot worse. Primary or early-stage breast cancer is curable; secondary or late-stage breast cancer is not. I suspect a lot of people don’t know that, despite the fact that breast cancer has such a high public profile. You can live with secondary breast cancer, productively, and sometimes for many years , but it seems that median survival once you have it is just two to three years, and that hasn’t changed in decades. In England, only 15 out of 100 women will survive for five years or more after they are diagnosed with secondary breast cancer. In the UK alone, almost 12,000 women die of breast cancer each year.
When you finish your hospital treatment of chemotherapy, surgery and radiotherapy, you’re relieved and happy that it’s over. At the same time, though, you know you can never be sure your cancer has gone completely. As the US organization breastcancer.org helpfully points out, “even a single cell that escaped treatment” may be able to spread and grow into a tumour. In addition, women who’ve had one breast cancer have an increased risk of developing cancer in the other breast (known as second primary breast cancer) for at least 20 years compared with the general population.
Breast cancer can come back in or around the area you had it originally. That’s known as local or regional recurrence. Worse, breast cancer cells can spread from your first tumour in the breast through the lymphatic or blood system to other parts of your body, most commonly with breast cancer to your bones, or to your lungs, liver or brain. This can become apparent soon after diagnosis or many years later. The tiny “micrometastatic” cells leave the primary tumour early on, but the secondary spread they cause can lie dormant for years. When this “distant recurrence” happens, it’s called secondary, late-stage, Stage 4, advanced or metastatic breast cancer. It can be managed but it is not curable. You don’t die of primary or early-stage breast cancer, where the cancer hasn’t spread beyond the breast and the axillary lymph nodes; breast cancer kills when it spreads to other parts of the body.
Everyone knows that one in eight women will develop breast cancer over the course of their lifetime. Thus the name of this blog. But how many women who’ve had a primary breast cancer diagnosis go on to develop secondary breast cancer? It’s seemingly not known with any real certainty but a commonly cited figure – in the US – is 20-30%. There appears to be no figure specifically for the UK, although I’ve seen one in five, “up to a third” and “roughly 35%” all cited. It is known, though, that the earlier breast cancer is caught the less chance there is of it recurring. Most breast cancers are diagnosed at Stage 1 and women in this category have negligible risk of metastatic disease, even though they may have received radiotherapy and even chemotherapy. Some 5% of breast cancers are already Stage 4 at diagnosis.
It is also not known with any great certainty how many of the estimated more than half a million people in the UK who’ve had primary breast cancer are living with recurrent or metastatic disease. I’ve seen just one estimate, of 35,000, and I’ve only seen it used by one organisation, Breast Cancer Now. There’s no firm data in the US, but there’s an estimate of more than 150,000.
A big new report on secondary breast cancer notes that while there has been progress in the scientific understanding of the disease, there have been just modest improvements in outcomes. There have been incremental advances in survival and quality of life during survival but these advances are not realised by all women. The pace of innovation in this field, says the report, appears to have slowed in recent years in terms of treatment advances and clinical research. This is clearly an area where more attention is needed.
I decided to ask my oncologist for her thoughts on all this. She commented that part of the challenge is that there is no one-size-fits-all treatment for secondary breast cancer. Treatment depends among other things on the burden of the cancer in each patient. This, though, she said, is leading to there being a push towards individualising therapy for each patient with the disease in an effort to enable women to, as it were, “live alongside” their cancer. She also highlighted the fact that there is more focus on aggressive treatment for small amounts of secondary breast cancer that might be curable; perhaps small individual metastatic – “oligometastatic” – spots that can be removed by surgery or fixed with local radiotherapy. Lastly, she pointed to the existence or development of “exciting new therapeutic strategies” in fields such as immunotherapy, harnessing the patient’s own immune system to fight cancer.
So things are happening. Immunotherapy and targeted therapies – treatments that target specific characteristics of cancer cells – are the big hopes for the future. Potential new drugs are in clinical trials and research is under way into how and why metastasis happens and what it might take to stop it. But this all takes time.
In the meantime, breast cancer is the second most common cause of cancer death among women in the UK, killing around 1,000 every month. That’s around 12,000 a year (to be precise, 11,643 in 2012, along with 73 men). You might be wondering whether that’s a lot. Well it’s all relative, I guess. Lung cancer, the most common cause of cancer death in women in the UK, was responsible for 16,067 female deaths in 2012. But compare it with, say, the number of deaths there have ever been in the UK of people with HIV/AIDS. The total number between 1980 and 2013 was 21,718. That’s less than the number of breast cancer deaths in two years. Makes you think, doesn’t it? In the early days, as everyone knows, HIV/AIDS was almost always fatal but thanks to advances in treatment it’s now treated as a long-term chronic condition. It would be good to think this might one day be the same for secondary breast cancer.
I bet much of this will come as a surprise to a lot of people reading this. Breast cancer in the public’s eye has gone from being a disease that was a sure death sentence to one that can be treated and cured and survived, with surviving meaning you’re free of the disease for ever after. That clearly couldn’t further from the truth for many women, and some men too. This quote (taken from an article on the report referred to above) illustrates perfectly the shift that has taken place: “In the 1970s, we had to fight the taboo against talking about breast cancer; now we have to fight the taboo against talking about how breast cancer can kill.”
In very broad terms, risk of breast cancer recurrence reduces over time, but it never completely goes away*. I think it’s important people know that. I think plenty don’t. I’ve heard it said that you only really “beat” or survive breast cancer if you die of something else. That sounds a bit melodramatic but at this precise moment, at just two-and-a-half months out of treatment, I can relate to that.
*April 2019 update: Since I wrote this, further evidence has emerged that with the type of breast cancer I had, ie estrogen-receptor positive, the risk of recurrence essentially stays constant for as much as 20 years.