Relapse. Metastasis. Breast cancer. They are words associated with each other that often create confusion, not only among the patients with the disease themselves, but also among the society that surrounds us. Very few people know what metastatic breast cancer is. Many questions then arise. Are relapses and metastases the same thing? What differentiates them? Furthermore: Are all relapses metastases? Or the other way around: are all metastases relapses?
Shedding light is what the Spanish Breast Cancer Federation (FECMA), the Spanish Metastatic Breast Cancer Association (AECMM) and the pharmaceutical company Lilly have proposed, with the collaboration of the Spanish Society of Medical Oncology (SEOM), the Spanish Breast Cancer Research Group Foundation (GEICAM) and the SOLTI research group. As? Launching the campaign Between them: Two realities of breast cancer. The same care. An initiative that was born with the aim of improving the quality of life of patients who are between these two different realities of breast cancer, but who require the same care. And also a project that becomes even more necessary if we take into account that, according to the latest data from SEOM, in 2024 more than 36,000 cases of breast cancer will be diagnosed. Therefore, it is essential for all types of patients to resolve all their doubts and know the main differences that exist between a possible relapse and a metastasis.
Doctor-patient communication must be effective to resolve these doubts and promote the emotional well-being of patients and their environment.
“Generally, relapse contemplates two areas: one could be exclusive local relapse, that is, the tumor has reappeared in the same place, without evidence of distant extension (metastasis); and the other is relapse in the form of metastasis or systemic disease. We can say that the concept of relapse encompasses both local and metastatic relapse. It is true that local relapse can herald a relapse in the form of metastasis, after a long time. [alrededor del 30-40% de las pacientes con cáncer de mama, aunque sea operable, desarrollará metástasis con el tiempo]but the prognoses of both realities are radically different”, explains Dr. Agustí Barnadas, director of the Medical Oncology Service at the Hospital de la Santa Creu i Sant Pau in Barcelona
The most difficult debate
This difference between relapse and metastasis is known very well by Pilar Fernández Pascual, president of the Spanish Metastatic Breast Cancer Association (AECMM) and oncology patient for 31 years; for seven years, of metastatic breast cancer. “In the event of a relapse, you undergo treatments with very harsh side effects, but, once you have overcome the cancer, you return to your social and work life, you achieve or try to normalize family life again… When You are diagnosed with metastasis, the cancer has no return. Although many advances have been achieved with targeted therapies, precision oncology and new diagnostic methods that can prolong survival and improve quality of life, metastasis today remains an incurable disease, although we hope that it will arrive soon. to be a chronic disease,” shares the president of AECMM, who details the main complications: chronic treatments with devastating effects, continuous check-ups, tremendously affected family environments and giving up things, even work. “You debate all day between life and death. The emotional breakdown is tremendous,” he says.
It is essential that patients are informed about the different types of relapse, the likelihood of their occurrence, and the treatment options available.
The answer is, therefore, one: although all metastases in breast cancer are relapses (except when they appear from the first moment of diagnosis), not all relapses in breast cancer are metastases. That is why it is important for patients to know the different types of relapse that can occur, as well as the probabilities of their occurrence and treatment opportunities. We can differentiate between local relapse of the tumor, which occurs in the same breast as the original tumor, in the same site or in an area close to the place where the primary cancer was; and regional relapse, such as involvement of the axillary lymph nodes or the clavicle area.
On the other hand, new tumors may appear, such as second contralateral breast cancer, which refers to a new cancer in the opposite (contralateral) breast to the original tumor and is not a metastasis of the primary cancer, but a new independent cancer; or second primary cancer, which refers to the development of a new cancer in a different location than the original cancer. In all these types of tumors, the strategy will be to apply treatments as if it were a new tumor to try to cure the cancer and eliminate it forever.
All metastases in breast cancer are relapses (except when they appear at the time of diagnosis), but not all relapses have to involve a metastasis.
A very different reality
A very different reality from the previous ones is distant relapse or metastasis, which occurs when breast cancer returns during or after treatment and spreads to organs or tissues distant from the original site. This indicates that cancer cells have traveled from the breast through the bloodstream or lymphatic system and have formed new tumors in other parts of the body, beyond the area considered local or regional. In this situation, the main focus of treatment will be to control symptoms and prolong life by preventing progression and growth of the tumor.
Not all breast cancers have the same chance of relapse. For example, among patients with hormone receptor-positive (HR+) and human epidermal growth factor receptor 2 (HER2)-negative breast cancer, also called luminal or hormone-sensitive tumor – it is the most common type of cancer since it affects 70 % of women with breast cancer – approximately 15% have a high risk of relapse, and around 25% of these patients relapse in the first five years. About half of these relapses occur in the first two years, after surgery and/or radiotherapy or chemotherapy. In other cases, relapses may appear many years after the surgical intervention (sometimes more than 10 years).
If you have any questions, it is advisable to speak with an oncology specialist.
The second most common type of breast tumor is called HER2+, which affects between 15-20% of all patients, where the risk of relapse is higher, but thanks to treatments directed at this target, its prognosis has radically changed. in the last 15 years. The third type of breast cancer is the so-called triple negative, which represents approximately 10-15% of all patients. It is so called because it does not have either of the two hormone receptors (progesterone or estrogen) and is also HER2 negative. In this type of cancer, up to 30% of patients diagnosed in early stages can develop metastatic disease in the few years following diagnosis.
The importance of support
When facing a relapse of breast cancer, emotional and psychological support is just as important as rigorously following the steps recommended by the oncologist so that the therapy is effective throughout the process. “It has been proven that good support facilitates better adherence to treatment. Not only is the doctor here, but there are other professionals who participate in this environment. Nursing professionals play a primary role in this process by helping all women understand the objectives of a treatment and its possible side effects, as well as how to control them.
Almost half of cancer patients in Spain keep their doubts to themselves in consultation due to fear, shame, blockage or mistrust
Psycho-oncologists, who do not always have a large representation in most centers, also help to provide this support in order to face the challenge posed by the impact of the disease and, obviously, of being adherent to the treatment. We all add up, it is not an exclusive patrimony of the doctor. It is like a choir that has several voices, in which at times there are soloists but there is also a director,” says Dr. Agustí Barnadas. Equally necessary for patients is to exercise and take care of their diet, avoid harmful habits, tobacco and alcohol, or resolve any questions during the process with the healthcare professional. And, according to the social study ‘In cancer, no doubt is stupid’, almost half of cancer patients in Spain keep silent about their doubts in consultation due to fear, shame, blockage or distrust.
Listen and be heard
“The information must be given clearly and without technicalities, it must be reported in simple words so that the patient does not leave without knowing what they have been told. And communication must be bidirectional: we want to listen, but we also want to be heard,” shares Pilar Fernández Pascual. “We have published an article these days about various research that shows that doctors who put themselves more in their patients’ shoes obtain better clinical results. Humanizing is putting the patient at the center, knowing that behind them there is a person who has needs, a different family, economic, social situation and who has to receive personalized treatment,” claims the president of AECMM.
Early detection and innovative treatments play a fundamental role in life expectancy in metastatic breast cancer or those with a high risk of relapse. In recent decades, advances in research are allowing an improvement in the quality of life and a better survival rate thanks to precision medicine, which represents a paradigm shift in the diagnosis and treatment of this disease that affects a large number of people. number of women in Spain.
Almost half of cancer patients in Spain keep their doubts to themselves in consultation due to fear, shame, blockage or mistrust
The power of science
“Metastatic cancer continues to be an important challenge due to its management. The first message for a woman who finds herself faced with a diagnosis of this situation is that there are many things to do, nothing is lost. It does not mean that death will come the next day due to metastatic cancer, but rather that the message is one of trust and hope,” says the director of the Medical Oncology Service at the Hospital de la Santa Creu i Sant Pau in Barcelona.
Patients who suffer from this disease have shared doubts and concerns.
In 2022, more than 34,000 new cases of breast cancer were diagnosed in Spain and, although these cases have increased, survival has also increased, up to 86%. The treatments available are increasingly more specific, attacking cancer cells without damaging healthy cells, improving quality of life. Science is allowing a change in everyone’s lives and will continue to do so. Being in treatment is buying time for the tumor. “We hope that over time and not too late, it can become a chronic disease, that we will be cancer patients for life,” says the president of AECMM.
