Recurrent Breast Cancer

Podcast Transcript

Dr. Scott Steele: Butts & Guts, a Cleveland Clinic podcast exploring your digestive and surgical health from end to end.

Dr. Scott Steele: Hi again, everyone, and welcome to another episode of Butts & Guts. I'm your host, Scott Steele, the Chair of Colorectal Surgery here at the Cleveland Clinic in beautiful Cleveland, Ohio. Super excited to talk about a topic that we have not discussed yet on Butts & Guts, and that is recurrent breast cancer. So I'm very pleased to welcome Dr. Chirag Shah, who is the Director of Clinical Research and Director of Breast Radiation Oncology in the Department of Radiation Oncology here at the Cleveland Clinic. He's also the co-director of our comprehensive breast program. Dr. Shah, thanks so much for joining us on Butts & Guts.

Dr. Chirag Shah: Thank you for having me.

Dr. Scott Steele: We always like to start with a little bit about your background. So, tell us a little bit about yourself, where you're from, where did you train and how did you come to the point that you're here at the clinic?

Dr. Chirag Shah: Sure. I'm originally from the suburbs of Detroit, Michigan. I did my training at Youngstown State University for my undergraduate studies and at Northeast Ohio Medical College for my medical degree. I went back up to Michigan and trained at William Beaumont for my internship and my radiation residency. I came back with my wife, who's a physician at The Clinic as well, about eight years ago and have been on staff since then.

Dr. Scott Steele: Well, we're so glad to have you. And although you do primarily breast cancer, you do a crossover sometimes and come to the other end, and we're pleased to have that. So at a high level, what is breast cancer recurrence?

Dr. Chirag Shah: So breast cancer recurrence can be defined in many ways, and when I speak with patients, I think about breast cancer recurrence in two ways. One is what I call local regional recurrences, meaning recurrence is in the breast and the lymph nodes and the other is distant recurrences. And it's important to separate these because different therapeutic modalities have different impacts on those risks of recurrence.

Dr. Scott Steele: How common is this? Is this something that, like, I know cancer recurrence, in general, can always happen even with "cures," that's why we survey people, but how often do you get local recurrence? How often do you get recurrence to the regional and how often do you get metastatic?

Dr. Chirag Shah: You know, thankfully, it's getting less and less. So when I started training and practicing 10, 15 years ago, the risk of recurrence in the breast after lumpectomy radiation was probably somewhere around 15, 20%. The most recent data which was published in the Lancet showed at 10 years the risk of recurrence in the breast of around 3.5%. So it's getting lower and lower. In terms of regional recurrences, they're even less common, typically speaking under 5% with the exception of people who have really advanced nodal burdens where we can't get all the nodal disease out.

In terms of distant metastatic disease, a lot is based on biology. So, your risk of metastatic disease in someone who has an early-stage estrogen-positive cancer is very low, maybe even under 5% at 10 years. However, if you have a patient who has advanced triple-negative breast cancer, it may even be 20, 30%. And that's where we're really educating patients on their risk of recurrence based on their biology as well as their tumors.

Dr. Scott Steele: I know you talked a little bit about the locations of recurrence, but are there specific types of breast cancer recurrence that do occur or anything like that?

Dr. Chirag Shah: Yeah, so there are specific types. So we typically think about the specific types as, first of all, local regionals, we mentioned and distant, and then we think about even within that, breaking it down further. So local, regional, we think about options or recurrences when they're resectable versus unresectable. And now in metastatic recurrences, we've really broken them down into when patients have just a few areas which we call oligometastatic, and then those that have more widespread disease or a widespread of metastatic disease.

Dr. Scott Steele: Is there something about the tumor biology that may make it more prone to having metastatic type disease or maybe even a recurrence in general, or even something along the lines of a chest wall recurrence?

Dr. Chirag Shah: Yeah. So, when we think about factors that are associated with recurrences, the biology of it, particularly things like triple-negative, which are estrogen-negative, progesterone-negative, and HER2-negative cancers tend to be associated with higher rates of distant metastatic disease. When it comes to features locally that may pretend a higher risk of chest wall recurrence, having close edges or close margins at the time of surgery, having lymphovascular invasion in the pathology specimen, having estrogen-negative tumors are all factors that pretend a higher risk of chest wall recurrence following surgery.

Dr. Scott Steele: So truth or myth: women who develop breast cancer before age 35 are more likely to get breast cancer again. Truth or myth?

Dr. Chirag Shah: Truth. So we have data showing that if you take the same type of cancer and someone who's younger versus someone who's older, their risk of local recurrence or a recurrence of the breast is higher than someone who is older with the same type of cancer.

Dr. Scott Steele: I know you talked a little bit about risk factors for recurrence, but what is it about these cancers that if they're originally, you know, they got treated appropriately, they may have gotten the radiation or chemotherapy or they may have gotten hormonal therapy, they even got resected, and then they come back and it doesn't come back for years. Where's that cancer lying for all of those years? Can we just not detect it?

Dr. Chirag Shah: I think there's a couple of truths to that. I think first is our ability to detect microscopic disease is not always the best. We can use CAT scans, MRIs, even PET scans, but it's very hard to find microscopic disease. The other is that for estrogen-positive cancers, we often see late recurrences because those patients are on endocrine therapy. And so the endocrine therapy that they take for five to 10 years may be prohibiting a recurrence that's microscopic from blossoming. And when they stop taking the endocrine therapy, it becomes macroscopic.

Dr. Scott Steele: We have a lot of patients that listen to our podcasts and what do they feel for, how do they go about this? What are the symptoms of breast cancer recurrence? And when you detect like, "Oh, that's scar," or "That's a nodule that has nothing to do with cancer," and when should they seek medical treatment?

Dr. Chirag Shah: So I think this really starts at the time of their initial diagnosis. And I tell women that they should examine themselves because they know what their normal is. And so often, post breast treatment at their first follow-up visit, we'll do a breast exam and I'll talk to them about what they're feeling and what I'm feeling because that's their new baseline. So it's going to be different than what their original diagnosis, pre-treatment baseline was. But we want to get that understood because then we can look for what I call is the delta or the change.

And I tell patients if something feels different, if it doesn't feel right to you on exam or it's changed, that's when you call a doctor right away. If you have any symptoms of discomfort on the chest or feeling something that doesn't feel right or is it inconsistent with the previous exam or you're having pain or discomfort in an area that persists, that's something to call a doctor about and to have worked up because it's very hard otherwise to discriminate something that may be nothing versus something that is something. And I tell my patients, I'd rather have a thousand false alarms than to miss one opportunity to diagnose a recurrence early.

Dr. Scott Steele: So a lot of patients will ask all the time, "I saw a doctor, they're very, very good, but gosh, now with this recurrence or anything, should I seek a second opinion on this?" And so how important is a second opinion? Is that okay? Is that something that they should do?

Dr. Chirag Shah: Yeah, I welcome second opinions. I always tell patients at the end of the day, the only bad question is the unasked question. And I think getting a second opinion helps reassure patients, even if everything was done perfectly well, there can sometimes be that loss of a little bit of confidence when a recurrence happens. So I think second opinions are great. They can affirm treatment. Sometimes they can mean patients get clinical trials that we may not have opportunities to offer for patients that may be helpful for them. So, I always tell patients, if someone doesn't want you to get a second opinion, that's even more of a reason to get one because we welcome those opinions for our patients.

Dr. Scott Steele: So let's cross over a little bit into treatment. And so, first of all, walk me through, I'm a patient, I guess, either a primary or a recurrent, and they come to see you. What can they expect in that treatment? What type of tests would you maybe get them in follow-up? And then as we embark into treatments, specifically in relation to what we're talking about today, the recurrent breast cancer, what options are available to them?

Dr. Chirag Shah: This is where there's a nice parallel to colorectal cancers in that it's a team sport. So, when I see a patient for a primary diagnosis or a recurrence, it's multidisciplinary, it's collaborative, and it's really adapting to what we're seeing.

So, I always tell patients there is no standardized algorithm, but there's the algorithm that's best for you. And what that means is looking at the imaging, doing a physical exam, and then looking at the biopsies and the biology and then putting it together. And in the setting of a recurrence, I think the first thing we think about for local or local regional recurrences is is this a resectable recurrence? And that's really a discussion with the breast surgeon looking at things like MRIs, looking at things like CTs of the chest, seeing if we need to get thoracic surgery involved, if there's chest wall involvement, then looking at the biology and saying, can we mitigate some of those potential surgical challenges by offering systemic therapies which may offer better surgical planes for resection with negative margins? And then lastly, incorporating radiation therapy in two ways. One: Is radiation possible given previous radiation or lack thereof? And number two, is radiation going to mitigate the risk of an additional recurrence?

When I think about distant recurrences, it's very much the same way. Oftentimes we'll start with the imaging and see what that imaging looks like. Is it an isolated lesion? Is it multiple lesions?

Then we think about surgery. So in the setting of an isolated pulmonary metastasis, we may call the thoracic surgeon in, for example, and say, is this resectable? Is it going to be a wedge, a lobe, a pneumonectomy? And what would that mean for the patient?

And then lastly, with radiation, if there's one lesion or multiple, is this something we can use a blade of therapies like stereotactic radiation on or in the setting of widespread metastatic disease? Is this something we need to palliate for symptoms or to prevent downstream side effects like spinal cord compression or fracture?

Dr. Scott Steele: So just talking about radiation to you as a radiation oncologist, how prevalent or how possible is reradiation if somebody's had, for example, a lumpectomy in radiation? Is that a common thing? Is there a room there? And I get asked this even with colorectal cancers that why can't you reradiate?

Dr. Chirag Shah: So I think this is where we've made some great strides, not only as a specialty in radiation but really at The Clinic as well. And when I trained, I was told, oh, you never give radiation a second time. It's kind of like you don't do that because we always worry about side effects and the ability for the body to heal based on the tolerances of different organs in different areas.

But we've had some seminal research done both at the clinic and nationally showing that's not actually the case. So for example, in women who have undergone lumpectomy and radiation, there was a national trial done, RTOG 1014, which actually looked at repeat lumpectomy and radiation, and it was published in Gem Oncology, showed a risk of recurrence of less than 5%, and really no major side effects.

And we've actually carried that work forward here at The Clinic and actually shown in our series that when you do a lumpectomy and repeat radiation, you have similar outcomes to salvage mastectomy.

I think similarly, more advanced cases, I was always taught, well, this is going to be really challenging. How are you going to heal the skin? How are you going to make these things work? And actually, that's where having wonderful plastic surgeons, wonderful breast surgeons, and wonderful thoracic surgeons who can help with tissue rearrangements allows for us to reradiate patients where we need to treat really advanced recurrences and then have colleagues who can really help with the side effects of that type of reradiation.

Dr. Scott Steele: So what other advancements are there on the horizon for managing or treating recurrent breast cancer?

Dr. Chirag Shah: I think there's a couple. From a radiation standpoint, we're increasingly using a technology called hyperthermia, which is actually heating. And what we actually do is we heat the area that we want to treat to around 43 degrees Celsius for one hour, and this sensitizes cancer to radiation. This allows us to give lower total doses of radiation and the reradiation setting with excellent outcomes. It's used routinely in Europe, but it's only now really being incorporated more and more into practices in the United States.

The other is we're incorporating systemic therapy and immunotherapies with radiation to increase our sensitivities. So we're able to give lower doses with higher efficacy in appropriate tumors, and then use targeted therapies like stereotactic radiation where we give really high ablative doses while sparing normal tissues on the metastatic side.

I continue to be marveled by the advances in systemic therapies that are prolonging life for estrogen-positive, estrogen-negative, HER-2-directed therapies every year that it seems like there's at least a half a dozen new agents that are available for recurrences.

Dr. Scott Steele: Oh, that's fantastic stuff. So now it's time for our quick hitters, a chance to get to know you a little bit better. So, first of all, what's your favorite food?

Dr. Chirag Shah: Favorite food would be freshly made pasta.

Dr. Scott Steele: Good. Do you make it?

Dr. Chirag Shah: My wife does.

Dr. Scott Steele: And then what's your favorite sport to watch and/or play?

Dr. Chirag Shah: Tennis.

Dr. Scott Steele: And you're very good. I've been firsthand witness of that. And what is a favorite place that you've either been to or a place that you want to go to?

Dr. Chirag Shah: My wife and I spent a month in Southern France, so I would say Monaco.

Dr. Scott Steele: Oh, beautiful. And then finally, it sounds like you're from the Midwest. Spent some time in a couple of different places. What do you like about being here in Northeast Ohio?

Dr. Chirag Shah: If you've been here long enough, everyone knows your name.

Dr. Scott Steele: Well, that is absolutely fantastic. So what's a final take-home message for our listeners?

Dr. Chirag Shah: I think when patients are diagnosed with recurrent breast cancer, it's appropriate to be despondent and be saddened, but I don't think you should feel defeated. I think this is an opportunity where we use modern technologies, new advances to treat these cancers and therefore offer patients the chance of cure in some situations, even when they do have recurrent breast cancer.

Dr. Scott Steele: Great, great, great news. And so to schedule a breast cancer appointment or a second opinion, please call our cancer answer line at (866) 223-8100. That's (866) 223-8100. Dr. Shah, thanks so much for joining us on Butts & Guts.

Dr. Chirag Shah: Thank you for having me.

Dr. Scott Steele: That wraps things up here at Cleveland Clinic. Until next time, thanks for listening to Butts & Guts.