Know your recurrence score?
Submitted by Dr.Kattlove’s Cancer Blog
Many years ago, I treated a young woman with what appeared to be very early breast cancer. Her tumor was small, and had not spread to lymph nodes under her arm. The cancer contained estrogen receptors, which meant that my giving her tamoxifen, a drug that suppresses cancer growth in cells with this receptor, would keep her cancer in check. I assured her that she was not likely to see her cancer come back and spread.
Well, I was wrong. Within 2 years, the cancer had recurred, spread throughout her body and eventually killed her. I thought I had done the right thing for her for that time. She and I discussed chemotherapy and she was happy to know that the small size of her cancer, the fact that it had not spread to lymph nodes and its supposed responsiveness to tamoxifen made it unnecessary for her to take chemotherapy to lower the chance that it would recur. How could I have predicted what happened?
If I saw a patient like her today, even though I would still be optimistic, I would be able to check my optimism by measuring the recurrence score of her tumor. I’m not the only oncologist who has been burned by seemingly non-lethal breast cancers devastating their patients. But now we have a new test, called the recurrence score that can help us pick out which patients have a low chance of recurrence and don’t need chemotherapy.
The test looks at 21 genes in the breast cancer cells and comes up with a score depending on whether the genes are expressed strongly or weakly. The score is then determined to be low risk, medium risk or high risk. This scoring system is based on studies of women whose cancers were tested this way and then followed for many years to see if the cancer came back.
A recent study reported in the Journal of Clinical Oncology confirmed the value of the recurrence score. The first major study was reported in the New England Journal of Medicine. That report looked at women exactly like my patient. All the women in their study had estrogen positive breast cancer and all received only tamoxifen after surgery. Women like my patient with no spread to lymph nodes still did poorly if their recurrence score was high, with about 30 percent seeing their cancer come back within 10 years. Those with a low score and no lymph node spread had much better outcomes; only a handful developed recurrence within 10 years.
In the new study from the JCO, the results showed the same trend with higher scores leading to higher recurrence rates. I need to point out that the test isn’t foolproof. People with low scores still had recurrence, although there were many fewer of them. If I had known my patient’s recurrence score and if it were high, I certainly would have not had an open discussion about chemotherapy. Instead, I would have urged it - lots of it.
It might not have done the trick and prevent her death, but it would at least have given her a better chance than she had.
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