Recurrence in Early Stage Breast Cancer: Key Insights and Concerns

Breast cancer stage I relapsed one year after treatment without chemotherapy?

Hello, Doctor! I was diagnosed with breast cancer in November 2021 and underwent a right mastectomy with reconstruction.
Post-surgery, it was found that there was a 0.1 cm invasive cancer in the lymph nodes with no metastasis, and the subtype was hormone receptor-positive.
The doctor assessed the malignancy as low-grade, and I was advised to take Tamoxifen.
During this year's annual check-up, all blood indices were normal, and both the liver ultrasound and chest X-ray were clear.
However, the breast ultrasound showed abnormalities in the axillary lymph nodes on the affected side.
A core needle biopsy revealed new breast cancer cells with the subtype being HER2 overexpressed.
The doctor did not specify the number of HER2 positivity but mentioned that both ER and PR were negative, indicating that this is not the same as the primary breast cancer from last year.
The current treatment plan from the doctor is chemotherapy combined with dual-targeted therapy, followed by surgical removal of the axillary lymph nodes.
Since I do not have personal insurance, the medical burden is quite heavy, and I am also worried about the prognosis...
Currently, I have no discomfort, but I have requested the doctor to arrange for a bone scan and a CT scan.
The doctor said that treatment must start first, and then we can conduct examinations during the treatment.
I asked the doctor if the recurrence was due to not receiving adjuvant therapy last year, but the doctor indicated that there were no conditions for adjuvant therapy last year...
I would like to ask the doctor: 1.
Is it possible for the cancer cells to remain in the lymph nodes without distant metastasis in the case of lymph node recurrence? 2.
If metastasis is discovered, is there a chance that the cancer cells could disappear with treatment? If they disappear, will the stage be reduced? 3.
The doctor mentioned that the change in subtype could likely be due to the vaccine causing an immune system disruption, allowing the previously dormant HER2 to become active and grow rapidly.
Is this possible? 4.
The doctor said to complete 6 cycles of chemotherapy combined with dual-targeted therapy before removing the lymph nodes, and will I need to continue targeted therapy afterward? The doctor has only mentioned looking at the examination report after the surgery...
My doctor has many patients, and he hopes that patients can fully trust his diagnosis, so he tends to be very brief during consultations, only elaborating when asked.
I have suggested transferring to another hospital because the current treatment facility is far from home, and I am concerned about the fatigue from travel for subsequent treatments, but the doctor strongly advised against transferring.
However, the recurrence after just one year has shaken my confidence in the doctor.
Am I really one of those patients with less than a 5% chance of recurrence at stage I...?

Evans, 40~49 year old female. Ask Date: 2022/12/10

Dr. Chen Sirong reply Oncology

Evans, 43 years old, female.
Due to the lack of personal insurance, the medical burden is really heavy.
A: It is possible to choose treatment options covered by the National Health Insurance, but the general public tends to want to follow the doctor's advice if they can afford it.
For example, using National Health Insurance: first surgery, then chemotherapy plus targeted therapy.
Of course, the success rates may vary.
There is also concern about whether the prognosis will be poor.
A: You are worried that it has already metastasized; this concern can only be alleviated once tests confirm that it has not.
You asked the doctor whether the recurrence was due to not receiving adjuvant therapy last year, but the doctor indicated that there were no conditions for adjuvant therapy last year.
A: What he said is correct.
In stage I, with only 0.1 cm, hormonal therapy is sufficient to prevent recurrence.
I would like to ask the doctor: 1.
Is it possible for cancer cells to still be present in the lymph nodes without distant metastasis? A: Most patients with lymphatic involvement have not yet experienced distant metastasis, but it must be confirmed through testing.
2.
If metastasis is discovered, is there a chance that the cancer cells could disappear with treatment? If they disappear, will the stage be reduced? A: If there is distant metastasis, it is stage IV.
Currently, there is no chemotherapy or immunotherapy that can cure it.
This means that even if treatment is completely effective and the cancer disappears, it may still recur later.
In the past, most people could not survive beyond five years, but with advancements in medicine, the five-year survival rate can now exceed 20%.
To directly answer your question: 2.1 Treatment after metastasis still has a chance of making the cancer disappear, but generally, stage IV patients will experience recurrence after a period of stability and will require further treatment.
2.2 The initial stage is your actual stage; any reduction in stage after treatment is merely a comforting statement.
3.
The doctor mentioned that subtype changes are likely due to the vaccine causing immune system disruption, allowing previously dormant HER2 to become active and grow rapidly.
Is this possible? A: Yes, it is possible.
4.
The doctor said to complete six cycles of chemotherapy plus dual targeted therapy before removing the lymph nodes, and whether further targeted therapy is needed will be determined after the surgery based on the pathology report.
A: What he said is correct; currently, it is not possible to decide what to do after surgery.
The need for additional treatment will depend on the pathology report.
*I believe that Western medicine treatments are quite similar.
You mentioned: 1.
Proximity to home 2.
Confidence in the doctor.
I think transferring hospitals is feasible, but you are (in that less than 5% risk of stage I recurrence).
I believe your original attending physician genuinely wants to care for you until you recover.
*Am I really that less than 5% risk of stage I recurrence? A: This is your self-awareness.
(The doctor may say it lightly, but it must be painful for you to hear.) In any case, you must gather your spirits to face the challenge.
Wishing you: Merry Christmas.
Taoyuan Hospital, Chen Si-Rong.

Reply Date: 2022/12/10

More Info

Understanding the recurrence of breast cancer, especially in early-stage cases, is a complex and multifaceted issue that raises many concerns for patients and their families. Your situation, having been diagnosed with hormone receptor-positive breast cancer and subsequently experiencing a recurrence, is understandably distressing. Let's address your questions and provide some insights into the factors influencing recurrence and treatment options.

1. Can lymph node recurrence indicate that cancer cells are still localized without distant metastasis?
Yes, it is possible for cancer cells to recur in the lymph nodes without having spread to distant sites. Lymph nodes are often the first place cancer spreads from the primary tumor, and if cancer is detected in the lymph nodes, it may not necessarily mean that it has metastasized to other organs. However, further imaging and tests are essential to determine the extent of the disease. Your medical team will likely conduct additional evaluations, such as CT scans or bone scans, to assess for any distant spread.

2. If metastasis is found, is there a chance that treatment can eliminate the cancer cells?
If metastasis is confirmed, treatment can still be effective in managing the disease. Chemotherapy and targeted therapies can lead to significant reductions in tumor burden, and in some cases, cancer cells may become undetectable. However, it is important to understand that even if the cancer is eliminated from the current sites, there is still a risk of recurrence in the future. The stage of cancer at diagnosis is crucial; while treatment may lead to a complete response, the original stage of the cancer remains a factor in long-term prognosis.

3. Is it possible that changes in cancer subtype are due to immune system alterations from vaccination?
Changes in cancer subtype, such as the emergence of HER2-positive characteristics, can occur due to various biological factors, including tumor evolution and genetic changes. While there is ongoing research into the effects of vaccines on cancer, it is not definitively established that vaccination directly causes such changes. It is essential to discuss these concerns with your oncologist, who can provide insights based on the latest research and your specific case.

4. Will further treatment be necessary after the initial chemotherapy and targeted therapy?
After completing the initial six cycles of chemotherapy and targeted therapy, your oncologist will assess the response to treatment through imaging and possibly further biopsies. Depending on the results, additional treatments may be recommended, which could include continued targeted therapy or other systemic treatments. The decision will be based on the tumor's response and any residual disease.

Your concerns about the financial burden of treatment and the distance to your treatment facility are valid. It is essential to communicate openly with your healthcare team about these issues. They may be able to provide resources or referrals to support services that can help alleviate some of the financial stress. Additionally, if you feel that transferring to a closer facility would improve your comfort and access to care, it is worth discussing with your doctor.
Lastly, regarding your feelings of doubt about your prognosis, it is crucial to remember that statistics are based on large populations and may not reflect individual outcomes. Many factors influence prognosis, including the specific characteristics of your cancer, your overall health, and how well you respond to treatment. It is essential to maintain open communication with your healthcare team, ask questions, and express your concerns. They are there to support you through this challenging time.
In conclusion, while the recurrence of breast cancer can be daunting, advancements in treatment options and ongoing research provide hope for many patients. Stay engaged with your treatment plan, seek support from loved ones, and consider connecting with support groups for additional emotional and informational resources.

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