Discussing Recurrence Risk and Survivorship in Breast Cancer

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In “Beyond Diagnosis: Breast Cancer,” Cleveland Clinic oncologist Tiffany Onger, MD, and host John Mangels continue their conversations on communicating effectively and empathetically with patients across the breast cancer care journey.

Each monthly installment examines an individual aspect of these crucial discussions, including establishing trust, reviewing treatment options, and supporting patients through complex or emotionally charged decisions.

This fifth of six episodes focuses on how clinicians discuss recurrence risk, explain the difference between cure and remission, and guide patients through the transition to survivorship and long-term monitoring.

The following is a transcript of their remarks:

Mangels: Welcome to “Beyond Diagnosis.” I’m your host, John Mangels. Newly diagnosed breast cancer patients need information and support. As a physician, how should you prepare for that conversation? For expert advice, I’m joined by Cleveland Clinic oncologist and breast cancer specialist, Dr. Tiffany Onger. Dr. Onger, thanks so much for your time today.

Onger: Thank you for having me.

Mangels: We’re talking about issues that arise after initial treatment ends. How do you approach discussing the issue of cure versus remission?

Onger: I help patients understand that we’re using medicines to prevent the cancer from coming back. Most patients have some understanding that the cancer can come back, and so I explain to them that sometimes there is a cancer cell that might’ve escaped the breast before you had time for surgery. It might not have spent any time in the lymph node, and so the lymph nodes were negative at the time of pathology report.

However, that cancer cell, because it was connected to the blood system, it might be hiding someplace else, for example, in a leg bone. And so I help them understand that while surgery addresses the cancer that we know about and radiation addresses any microscopic activity that might be in the lymph nodes, it doesn’t address what might be hiding in a leg bone, and that’s the role of the medicine.

Mangels: So you really have to take some time to help them understand that just because treatment has ended, it doesn’t necessarily mean recurrence is off the table.

Onger: Correct. Because I also want them to be aware of their bodies. A common question will be, “How will I know if the cancer has come back?” And I’ll let them know that it’s based primarily upon symptoms. And that if there’s any symptom that they’re experiencing for 2 weeks or longer, I want to know about it so I can initiate the appropriate workup.

Mangels: So when your patient says, “Dr. Onger, will my cancer return?” What do you say?

Onger: Well, in that case, I have to rely upon the available data that might’ve guided the treatment plan for them. I also might have some genomic data, for example, from MammaPrint or Oncotype to help guide that conversation about what we can expect for the future in terms of recurrence risk and what we can use to reduce that recurrence risk.

Mangels: So I’m sure that leads to a question about odds. “What are the odds my cancer is going to come back?” Do you find that patients understand odds in the way that a physician thinks about odds?

Onger: I like to position the conversation about odds more so around what might we anticipate within 5 years. Within 5 years, how many patients with cancer characteristics just like them had the cancer come back? And I think that gives them a little bit of a more practical appreciation for what they might anticipate going forward.

Mangels: So initial treatment is over. Do you recommend survivorship groups or other kinds of support to your patients?

Onger: Yes. I’m glad that you bring this up. Survivorship is an important part of cancer care and is recommended by the National Comprehensive Cancer Network. So I do recommend it for patients. Sometimes they’re not sure if they want to go to an hour long visit. They’ve been to a lot of visits already.

And so I encourage them by saying, “You are graduating out of active cancer care and your survivorship visit is really kind of the capstone where they will review everything that you’ve been through.” I let them know that the nurse practitioner will have this one document available for them so that if you ever move or I ever move, your new oncologist will have one document to review in terms of their treatment course. And so that usually encourages them that this is an important thing to do.

Mangels: So I’m guessing there’s a little bit of separation anxiety going on. On the one hand, they’re relieved not to have to see you as often as they had been because they’re not being treated. But on the other hand, that support, that relationship is going to be dialed back a bit. So you’re kind of helping them bridge that a little, it sounds like.

Onger: I am. And a lot of times patients get worried about who’s going to know if something’s going wrong. And so I let them know that the main thing is I want them to be aware of their body. I want them to let me know if anything is going on in their body for 2 weeks or longer so that I can initiate the appropriate workup. And that usually is pretty reassuring to our patients.

Mangels: You’re there if they need them.

Onger: Absolutely.

Mangels: Thank you so much for your insights.

Onger: Glad to be here. Thank you.

Mangels: And thank you for watching. Please join us again for another episode of “Beyond Diagnosis.”