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Who is At Risk For Metastatic Breast Cancer?

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Published on June 22, 2020

Is breast cancer genetic or environmental? How do experts define the risk? And who is most at risk for metastatic breast cancer? Watch as an expert explains.
In this segment from the second episode of our eight-part Let's Talk: Metastatic Breast Cancer series, host and MBC patient advocate Pam Kohl talks to her own oncologist, Dr. Jeremy Force of Duke Cancer Institute, about this important topic. Watch as Dr. Force gives an illustrative analogy and answers questions from our community.
This program is sponsored by Seattle Genetics. This organizations have no editorial control. It is produced by Patient Power and is solely responsible for program content. 


Transcript | Who is At Risk For Metastatic Breast Cancer?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Pam Kohl:

Hi, I'm Pam Kohl. And welcome to episode two in our Let's Talk About Metastatic Breast Cancer series. I first of all, want to thank our generous sponsor, Seattle Genetics for their support of this series. And as always throughout the series, Patient Power does maintain all editorial control. In our last show, we talked about the shock of diagnosis. That moment when you are first told that you have stage four metastatic breast cancer and the shock, and when you realize that your life has changed forever. I was diagnosed with stage I estrogen positive breast cancer early in 2010. And was told that I was really lucky because I was estrogen positive.

And that if you get the breast cancer card, that was the one you wanted to be dealt. And I had less than a centimeter tumor, I had no lymph node involvement, and Oncotype, which is a test that evaluates your risk factors for recurrence if you're estrogen positive. My risk factor was a number six, which was one of the lowest numbers you can get. So I was told that I had a very little risk of recurrence and I did everything I was supposed to do. I did all the treatment, et cetera, stayed on my endocrine therapy for five years. And was told I was cancer free. And that breast cancer was behind me. That I could look at it through my rear view mirror. And so I went about my life. I did work at Komen, so I had heard a rumor that maybe we needed to stay on our endocrine therapy longer than five years, but that study had not come out yet.

So my oncologist at the time said, "No, you're fine with your five years." And I celebrated that. Like you saw in our opening video, metastatic breast cancer, or MBC, can sneak up on you. And even when you're told that you're cured and that your breast cancer's behind you, it can sneak back in at any point.

So, I'm here today, I'm delighted to be here today with Dr. Jeremy Force, who is my doctor. It's great to see you when I'm dressed and in my own home, and not in a hospital gown. So Dr. Force is with Duke Cancer Institute and he's been my oncologist, I guess, for the last two and a half years. And we have a great partnership. So welcome, Dr. Force.

Dr. Force:

Thank you so much for having me. I'm very excited to be involved in this and participate in this really unique and innovative platform to spread the word across the nation, and hopefully beyond that, about metastatic breast cancer. And I look forward to this conversation.

Pam Kohl:

Me too. So let's just dive right in. How do we define what the risk of metastatic breast cancer is? Is it genetic, is it environmental? Tell us your thoughts and what you know about this.

Dr. Force:

Yeah, of course. I'm happy to share what I know and learn from you and others as part of this conversation. I have an analogy about sort of what really cancer risk in general and the fact that it's sort of... You can imagine like a symphony orchestra. And you have the strings, you have the woodwinds, the brass or horns, the percussion and the conductor. And that's kind of your majority of what would make up a symphony. And each part plays a role in terms of the potential for cancer development. And then I'll go into a little bit about how our risks of metastatic breast cancer. If you were to look at say, the strings being more of an environmental theme, the benzene's, tobacco, radiation exposure, for instance. Those would be more of the environmental component. And then woodwinds, maybe the dietary component, and alcohol, obesity or things that are not healthy for you necessarily.

The brass or horns, I think of the hormones. So what increases hormones in women, or it can decrease them. And so sometimes women will take hormone replacement therapy and oral contraceptive pills, nulliparity, or if they have a child or not during their life, and what time is their first menstrual cycle, et cetera. And then maybe the percussion's are sort of like the racial and socioeconomic factor. And those are equally important because we know that some ethnicities have higher rates of developing breast cancer. And then, if you have lack of care, lack of access to healthcare through various socioeconomic factors, is a well known component of having this decreased access to care, can increase your risk of developing breast cancer.

And I look at the conductor as sort of the hereditary component. Where it's this solitary figure in which there's something like a BRCA 1-2 mutation, or PALB2 mutation, and these are things that you would have inherited from your mom or dad that sort of set you up to develop cancer many times at a younger age, but not always the case. And so taking this sort of... That thought process of the orchestra as I like to talk about it with some of my patients in terms of overall risk. That's kind of what we know about breast cancer risk specifically. What has really tied in of late is sort of some of these genomic biomarkers, the subtype of the cancer.

So is it estrogen receptor negative? Is it HER2 positive? Is it triple negative? And those are certainly things that will increase risks of developing metastatic cancer. So that I look at sort of the symphony as being something that is just, what's your risk of potentially developing cancer? And we even have risk calculators, like the Gail Risk Model. There's several through the NIH websites that are publicly available. People can look at their risk compared to that of the general population. But it's an important question about metastatic cancer and what are the risk factors? Because we're getting so much better at treating this disease, that it is in some folks becoming almost a chronic issue. With treatment, of course.

And so it's important to identify those who might end up developing it in the first place. Some key things that we still know about are the stage. That's still one of the highest or best prognostic features that we have. So if a woman had their surgery and they have a lot of lymph nodes involved, they would be higher risk compared to somebody who didn't have lymph nodes involved of developing metastatic cancer. Another component is the Oncotype. And while in your case, it was low. It still isn't an end all be all to developing metastatic cancer. But we do know Oncotypes that are higher are obviously higher risk of developing metastatic disease.

Patients who have residual disease. Let's say they got treatment before surgery, and they have something left over. We only know that because while they had surgery and you actually see that cancer remaining, we know that those folks, those women and men, are also at higher risk of developing metastatic disease. I wish I had a solitary one size fits all answer for you, but it truly is a culmination of multiple factors that need to go into the thought process of what I would just state is just the prognosis of developing that metastatic cancer. And it's not really all one - I wish we could add one biomarker that would tell you what the risks would be.

Pam Kohl:

Is there a higher risk if you're ER positive, or HER2 positive, or triple negative? I know people are asking you that. Of those three types, is there more risk in either one?

Dr. Force:

So of the three types, triple negative disease would have a higher risk compared to the others. And that's in part because we don't have as many good treatments. Now, many new therapies are on the way and are quite literally revolutionizing the face of triple negative disease, for instance, immunotherapy. And using your own immune system to essentially start attacking the cancer, which we're all universally excited about.

Pam Kohl:

Yeah. We're going to have some conversation about that in future topics. Well, so let's talk about... I mentioned that I did everything right. A lot of these pay people who are on this call, they eat right, they exercise, they did their chemo, they did their surgery, they did their radiation. And they still come up later with metastatic breast cancer. So how does that happen?

Dr. Force:

Yeah. We wish we knew. And that is certainly is a $64,000 question. Some of it is genes that the cells are turned on. The accelerator is on, or the brakes are off. And those cells somehow break off from the primary cancer. And they move along in the lymph system, or in the bloodstream, and they set up shop in bones or other visceral organs. And they start to grow. They start to get the nutrients that are necessary to set up growth and they start to grow. And we see symptoms in patients. But we don't truly know exactly why. And we certainly don't know how to capture that early to prevent it from happening.

Pam Kohl:

Believe me, a lot of us wish that we knew the answer to that and knew the answer of course, to the question of once you are metastatic, why do we develop resistance to different drugs? So we talked a lot about, or earlier about how we as patients feel after we have been diagnosed and been told that we were cancer free. And then we come up later with metastatic breast cancer. When we've done everything you all have told us to do. And some of us feel guilty, and some of us feel like, well, what did I do to make this happen? Was I under too much stress? Did I drink too much wine with dinner? Is it our fault? What did we do wrong? How do you talk to your patients about that?

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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