I am the sort who would rather know more rather than less, know early rather than late – this quest for information is not of course, always linked to any real ability to influence outcomes.
Nowhere is this more true than in cancer.
I first met Susan in August 2011. She first noticed a lump in her left breast about a year earlier but didn’t think much of it. After all, she had had history of breast cysts before and these resolved by itself.
But this time was different – the lump had persisted and had grown a little in size.
She eventually saw a doctor and a mammogram confirmed that the lump was possibly cancerous.
By the time she saw me, the needle core biopsy had already been done and the diagnosis of breast cancer confirmed.
I arranged for her to undergo a series of radiological investigations, to confirm that there was no cancer spread to distant parts of the body.
After establishing that this was indeed a localized cancer (and fairly early), I sat down with her to discuss the surgical options – to have the whole breast removed or to remove only the lump and follow-up with radiation therapy to the remaining breast tissue.
Studies have shown that the cure rates are the same for those who choose a total mastectomy compared to those who had a wide excision and radiation to the breast.
Armed with the understanding of the surgical choices, the patient went back to see her surgeon for the surgery and did not come back to see me.
Then, in April 2015, out of the blue, she turned up at my consultation room.
Since her visit in August 2011, she went on to have a mastectomy and clearance of all her axillary lymph nodes. She was staged as having Stage 2 breast cancer because one of the axillary lymph nodes contained cancer. A left breast implant was placed for cosmetic reasons.
She had 16 treatments of chemotherapy and also had radiation therapy.
She finished all her treatment in July 2012 and was given oral Tamoxifen.
She had check-ups by her medical oncologist every six months. During these visits, her doctor would carry out a clinical examination. Once a year, she would have a mammogram of her right breast.
From what she described, the reviews were quite unremarkable.
Then suddenly – Stage 4 cancer.
In February 2015, Susan noticed a hard lump over the left side of her neck, just above the collar bone. She immediately went back to see her doctor.
After a series of investigations which included an MRI (magnetic resonance imaging) of the brain and a PET-CT scan, Susan was confirmed to have very extensive Stage 4 breast cancer.
The brain MRI showed that the cancer had spread to the brain.
The PET-CT scan revealed that the cancer had recurred in the left chest, just below the breast implant. There were also metastases to the lymph nodes on both sides of the neck, inside the chest as well as in the abdomen. It was a rampage –metastases to the multiple bony sites including the skull, spine, collar bone, ribs, chest plate, pelvis and others. Multiple lung metastases were also seen.
When I checked her CEA, a tumour marker, it was raised in the 100s (normal being less than 5).
Having kept faithfully to the follow-up regime, Susan was naturally disappointed. The questions that one would ask are: what is the point of follow-up every six months if the metastatic disease is only detected when the cancer had literally spread all over?
When I refer to the ASCO (American Society of Clinical Oncology) guidelines, which were updated in 2013, the recommendation was for regular history, physical examination and annual mammogram. The guidelines were specific in stating that there was no need to carry out any blood tests (including cancer markers), or radiological investigations.
I guess the reason for these recommendations is based on the fact that once the cancer recurs, it is Stage 4 disease. Since Stage 4 disease is incurable, there is no urgency to find out early?
I must confess that I have difficulty in agreeing with the guidelines.
Other than an annual mammogram, should breast cancer patients have radiological investigations at least once a year to look for any evidence of cancer spread?
Is there any value on checking the cancer markers and could this have alerted us on the need for further evaluation?
If I were to place myself in the shoes of the patient, I would want to know if I had a cancer recurrence and I would want to know it as soon as possible. I would recommend annual scans to look at sites which have a higher risk of recurrence such as chest X-rays, ultrasound of the liver and a bone scan.
The question to ask is “What difference would it make?” The real answer is “I don’t know.” It would certainly give me more time to prepare and think of treatment options. Outside medicine, it would give me more time to put my affairs in order.
Perhaps in real times, it might not have any real impact. All I know is, I would want to know rather than be in the dark.