Image Source: Image by Drazen Zigic on Freepik

It was early morning in 2020, and I was an intern sitting on the spare chair at the oncologist’s office. My biggest concern was that the doctor I would be working with would ask me a question I couldn’t answer. Yet, I instantly forgot the fear when the first patient arrived.

The patient greeted us. She sat down on the opposite side of the table and looked tense. The doctor and I skimmed through the data on her computer. “The surgery was a success,” the doctor informed her. “There is no evidence of breast cancer.” Immediately, a wave of relief washed over the patient, and I also felt calm. “Our next step is to take hormone therapy for five to ten years,” the doctor continued.

“Why should I take these medications for five years after my tests and surgery went well?” the patient asked. The patient appeared confused, and so was I. I felt confronted by the cold logic of this question. As a trainee, I held my breath, contemplating my response. But none of the answers that came to my mind satisfied me. I hate not knowing what to say.

“This treatment would prevent the cancer from returning,” the doctor replied. It was an acceptable answer, but I was dissatisfied since the risk of cancer returning seemed more like a possibility than a threat. It made me feel worse to remember that compliance with long-term therapy is low [1]. In particular, if a patient experiences side effects like joint pain. Knowing all this made me feel worse. As I drove home, these concerns plagued my thoughts, wondering whether the patient would adhere to her hormone regimen.

Years of research and my Ph.D. led me to the answer I sought. It is now clear why hormone treatment is so vital after successful surgery. This is due to disseminated tumor cells (DTCs) posing a considerable challenge. These cells spread from a patient’s tumor, even in the cancer’s early stages [2]. In some cases, before resection. Thus, DTCs are already there, waiting for favorable signals to multiply unrestrictedly. Hormonal therapy, however, can prevent cancer recurrence by controlling these signals [3]. This realization motivates us to take action daily since it is not based on vague threats from the future.
Using hormone therapy, we can suppress the growth of these dormant tumor cells, which are undetectable by imaging. While the therapy does not eliminate disseminated tumor cells, it prevents cancer relapse. Thus, ensuring high levels of compliance is very crucial for long-term success.

Dear patient,

I hope you have the strength to stick with your therapy. It is a challenging task over the long haul. Your therapy doesn’t focus solely on preventing what may or may not happen after successful surgery. Your medications empower you to keep disseminated tumor cells in check today and every day. And it will be worth it as long as it outweighs the risks.

Literature Resources:

1. Hershman DL, Kushi LH, Shao T, Buono D, Kershenbaum A, Tsai WY, Fehrenbacher L, Gomez SL, Miles S, Neugut AI. Early discontinuation and nonadherence to adjuvant hormonal therapy in a cohort of 8,769 early-stage breast cancer patients. J Clin Oncol. 2010 Sep 20;28(27):4120-8. doi: 10.1200/JCO.2009.25.9655. Epub 2010 Jun 28. PMID: 20585090; PMCID: PMC2953970. Accessed via Internet: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953970/ [2/6/2023]
2. Braun S, Pantel K, Müller P, Janni W, Hepp F, Kentenich CR, Gastroph S, Wischnik A, Dimpfl T, Kindermann G, Riethmüller G, Schlimok G. Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer. N Engl J Med. 2000 Feb 24;342(8):525-33. doi: 10.1056/NEJM200002243420801. Erratum in: N Engl J Med 2000 Jul 27;343(4):308. PMID: 10684910. Accessed via Internet: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2953970/ [2/6/2023]
3. Buschhaus JM, Humphries BA, Eckley SS, Robison TH, Cutter AC, Rajendran S, Haley HR, Bevoor AS, Luker KE, Luker GD. Targeting disseminated estrogen-receptor-positive breast cancer cells in bone marrow. Oncogene. 2020 Aug;39(34):5649-5662. doi: 10.1038/s41388-020-01391-z. Epub 2020 Jul 16. PMID: 32678295; PMCID: PMC7442734. Accessed via Internet: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7442734/ [2/6/2023]