Breast Cancer Can And Does
Recur After 10 Years
What factors impact the risk?
It has been many years since surgeons and oncologists ceased discussing with patients a possible cure five years after diagnosis. Most physicians, however, tend to be very encouraging when patients reach the 10-year mark. Yet, most of us have seen patients presenting with recurrence well over ten years from diagnosis in our practices. In fact, in women with estrogen receptor-positive (ER+), Her2-negative (HER2-) breast cancers, nearly half of recurrences occur after five years (Dowling et al. JNCI Cancer Spectr 2019;3(4)). In a recent study by Pedersen et al. from Denmark (JNCI 2022, 114: 391), researchers attempted to understand the risk of late recurrence (>10 years after primary diagnosis) in hopes that the information will help delineate those patients that may be a candidate for longer follow-up with the potential of additional therapies.
After appropriate exclusions, the final cohort consisted of 20,315 10-year disease-free survivors. The median follow-up was seven years (i.e., 17 years after primary diagnosis). Among these survivors, 2595 women developed late recurrence (2.9%). The cumulative incidence of late recurrence grew with increasing lymph node involvement at initial presentation. The incidence ranged from 12.7% in patients with T1N0 to 24.6% in patients with T2 with 4-9 positive nodes. The cumulative incidence decreased with increasing tumor grade. Late recurrence was highest in patients in grade I with four or more positive nodes, whereas it was lowest for patients with grade III disease and no positive nodes. Tumor size and patient age also impacted the incidence of late recurrence. Recurrence was slightly lower in patients with tumors less than or equal to 20mm than in tumors larger than 20mm. Late recurrence was also higher in younger patients with ER+ cancers. Overall, patients with ER+ tumors were more likely to suffer a late recurrence than ER- tumors. The authors noted no association between receiving endocrine therapy at the initial diagnosis and late breast cancer recurrence.
Slightly over half of women with early-stage breast cancer remain disease-free for at least ten years. Unfortunately, recurrences continue beyond the ten-year mark. The authors noted that approximately 75% of primary breast tumors have spread at the time of diagnosis, spreading micrometastases either regionally or distant. The researchers further note that tumor cells survive in a dormant state with growth balanced by apoptosis (programmed cell death). Dormancy ceases only when an alteration in the tumor microenvironment occurs, “prompting full metastatic potential.” This study demonstrated that the risk of late recurrence was highest in patients with ER+ disease and those with positive nodes. Intuitively, the risk was also higher in patients with low-grade disease. Younger patients with ER+ disease were also at higher risk of late recurrence.