There was a time when both the medical community and the women and men dealing with breast cancer felt a clean bill of health had been achieved if you remained cancer free for five years. Unfortunately, this is not the case. Certainly there are breast cancers that if caught early enough or treated aggressively enough simply will not recur, but at the moment it’s impossible to definitively say which individuals have cancers that will fall into this category.

Today, although science and medicine seem to be coming closer all the time to finding, if not cures, at least ways in which breast cancer can be treated more like a chronic condition; women are still experiencing recurrences or secondary breast cancers many years after their original diagnosis. While it is important to focus on health and wellness, any woman who has experienced breast cancer needs to be sure she is cognizant of her potential for a recurrence.

The current standard of treatment for most women with an early stage breast cancer is surgery and radiation, followed by chemotherapy. This modality is used in order to reduce the risk of a recurrence by attempting to eliminate any cancer cells still present elsewhere in the body. The treatment options for women with ER/PR+ breast cancers do not end here. For these women very promising new hormonal medicines continue being developed. Tamoxifen was the hormonal medicine of choice for all women with hormone-receptor-positive breast cancer for several years.

Although early studies showed that this approach reduced the chances of a relapse and increased the odds of survival, there were still valid concerns about just how long those benefits would last since breast cancer can remain dormant in the body for years or even decades before reemerging.

This changed dramatically in 2005 when the results of several major worldwide clinical trials indicated that aromatase inhibitors (Arimidex [anastrozole], Aromasin [exemestane], and Femara [letrozole] worked better than Tamoxifen in post-menopausal women with ER/PR+ breast cancer.

Aromatase inhibitors are now considered the standard of care for post-menopausal women with ER/PR+ breast cancer. At the moment, Tamoxifen remains the hormonal treatment of choice for pre-menopausal women.

The latest data from an extensive ongoing project involving 145,000 women with early breast cancer found that chemotherapy and hormone treatment continue to protect many women from dying from the disease for at least 15 years. The study also showed that the protection frequently becomes stronger over time, increasing the likelihood that the therapy is truly eradicating cancer.

Since this research provides confirmation that these follow-up therapies are helping more women survive breast cancer and not simply keeping it at bay, it’s obvious they provide substantial benefits. Is this a cure? It’s as close as we are going to get at the moment, so it’s important for women who would benefit from these treatments to receive them.

From a purely pragmatic standpoint, even if not all women obtain 15 years cancer free, buying a substantial amount of time without active disease may mean that new discoveries will provide even further protection in the years ahead.

But what about the women who are diagnosed with ER/PR- breast cancers? It has been shown that hormonal therapies provide no benefit for women in this category. Do these women actually have the ability to believe their cancer has been “cured” at any time after diagnosis? Between five and ten percent of women with early stage breast cancer will have a recurrence. And once you’ve had breast cancer you are at an increased risk of getting a new breast cancer (called a second primary breast cancer). This risk is even higher for women with a strong family history, or a BRCA mutation.

Women who have had breast cancer are also at increased risk of certain other types of cancers as well, particularly ovarian cancer. So if hormonal therapies are not an option for ER/PR- women, exactly what can they do to increase their odds of survival? Actually, for all survivors the most important step they can take is to make sure they get regular medical care after their treatments are completed. Since the highest risk of recurrence is during the first five years after diagnosis, it’s important to be armed with knowledge.

Common factors have been identified for predicting the risk of recurrence in patients with breast cancer. These include:

Hormone Receptor Status
This status reflects whether the cancer is estrogen receptor positive (ER+) or not.

• Lymph Node Involvement
  Whether the tumor has spread to the lymph nodes at the time of diagnosis (node-positive) and, importantly, the number of lymph nodes in which cancer has been found.
• Tumor Size
  Factor in determining the stage of breast cancer
• Histological Grade
  Grade is a calculation based on how abnormal the cancer cells look under a microscope and how fast they are growing. There are 3 features when determining a cancer's grade: (1) the rate of cell division, (2) percentage of cancer composed of tubular structures, and (3) change in cell size and uniformity. If a tumor has been determined to be Grade 3 then there is a higher risk of recurrence than if the tumor was determined to be Grade 1.
• HER2/neu (a growth-promoting protein) Status
  Gene that helps the growth of cells -- how they divide and repair themselves. Positive or negative HER2/neu is important in the control of abnormal or defective cells that could become cancerous and might have implications for treatment.
• Lymphatic Vessel Invasion (LVI)
  When pathologists look directly at the cancer under a microscope they determine whether cancer cells are found in the lymphatic vessels within the cancer itself.
• Hormone Receptor Status
  This status reflects whether the cancer is estrogen receptor positive (ER+) or not.

In a meta-analysis involving seven different studies of more than 3,500 patients who had received some type of post-surgical adjuvant therapy for breast cancer, the risk of cancer recurrence was greatest during the first two years following surgery. After this period, the research showed a steady decrease in the risk of recurrence until year five, when the risk of recurrence declined slowly and averaged 4.3% per year. However, a substantial proportion of breast cancer recurrences seen in this study occurred more than five years after surgery, between years six and 12, even in patients who typically would be considered at low risk for recurrence because their cancer was node negative. What this research indicates is that through at least 12 years of follow-up, the risk of breast cancer recurrence remains appreciable and even some patients considered low risk have some risk of the cancer coming back.

Another meta-analysis of nearly 37,000 women with early breast cancer, conducted by the Early Breast Cancer Trialists' Collaborative Group, found:

• Through the first 10 years after diagnosis, the cumulative incidence of recurrence and breast cancer-related deaths continued to increase, with a substantial portion of recurrences and breast-cancer related deaths occurring beyond five years after diagnosis.
• The recurrence rate among patients who did not receive adjuvant hormonal therapy was nearly 50% in node-positive patients and 32.4% in node-negative patients throughout the first 10 years after diagnosis.

Medical care after treatment is of crucial importance. There are more than 2.3 million women in the United States who have been treated for breast cancer. These women face a three-fold increased risk of a malignancy in the other breast. Recommendations for follow-up of these women include annual mammography for early identification of subsequent cancers. For breast cancer survivors, mammography has been shown to identify tumors at early stages, when treatment is more successful.

A new study finds that the use of annual mammography among breast cancer survivors dropped off after a few years. During the five year study period, only one in three women in this high-risk population had received regular annual mammograms. The most significant factors predicting who got screened included being seen by a gynecologist or primary care physician and having been treated with breast conserving surgery.

Breast cancer survivors should continue to see their health care team regularly. This follow-up care helps to track not only the effectiveness of treatment, but further allows a woman to talk about any concerns she may be having about her health.  These regular visits help to:

• Find any cancer that has returned to the breast, chest or nearby lymph nodes.
• Find breast cancer that has spread to other parts of the body.
• Find any new breast tumors that have developed.
• Find any side effects that are a direct result of treatment (such as lymphedema, endometrial cancer or heart problems.
• Screen for other health-related risks.

It is recommended that women receive follow-up after breast cancer treatment that includes:

• Regular physical exams
• Mammograms
• Pelvic Exams
• Bone Health Assessments

Women should have their medical history charted and get a physical exam every four to six months during the first five years after a diagnosis. Once they have reached the five year mark, they should be seen for these purposes every 12 months.

Women treated with breast conserving surgery and radiation should have a mammogram six months after their radiation therapy ends, and then every six to 12 months thereafter. Women treated with mastectomy who have a remaining breast should have a mammogram every 12 months.

It’s recommended that breast cancer survivors who have not had their uterus removed and are taking Tamoxifen get a pelvic exam every 12 months.

Women who are at higher risk of osteoporosis (which can include a family history, low body weight, aromatase inhibitor use, or treatment-related menopause) should have a bone mineral density test every 12 months. Women who are at lower risk should have an office visit every year to assess their risk.

Exactly what symptoms should you report to your doctor? If you notice any of the following and the symptoms do not go away quickly, you should contact your doctor:

• Any changes in the remaining breast(s) and chest area
• Unusual pain
• Loss of appetite or weight
• Changes in your menstrual periods
• Unusual vaginal bleeding
• Blurred vision
• Dizziness
• Coughing that does not go away
• Hoarseness
• Shortness of breath
• Headaches
• Backaches
• Digestive problems that are unusual or don’t go away

Breast cancer survivors fully understand the sort of tightrope we must walk to create a balance between living a healthy, active life after a diagnosis – and arming ourselves with the knowledge necessary to recognize a recurrence. No one wants to dwell in the what if, and much study has been done about lowering anxiety and stress in order to remain healthy. So how do you live in the moment and prepare for a possible health threat? When people talk about how brave we are to have gone through breast cancer, they are usually referring to the surgeries, chemotherapy, and radiation. Perhaps the true bravery comes from living a life where you fully understand just how vulnerable we all are – and still manage to move forward with a healthy mental attitude! It is difficult to live in the limbo of being told to expect the best, but prepare for the worst.

For breast cancer survivors it’s important not to operate in the realm of myths, but to embrace the realities of this disease in order to maintain optimum health. Life saving medical discoveries occur all the time, which makes it even more important for women who have had breast cancer to pay attention to their health. A practical goal is to remain as healthy as possible in order to have the opportunity to see breast cancer become, if not a curable disease, at least a manageable chronic condition much like asthma or diabetes.