A million dollar qiestion

Dear Anotherone,

This article helped me understand metastatic breast cancer.

I am de novo stage 4, so I had the same question:

https://www.fredhutch.org/en/news/center-news/2014...

I wonder if complete pathological response in early stage BC neoadjuvant treatment, is the same as no evidence of disease (NED) which is achieved in some cases of stage IV? Just as the cancer can flare back up from undetectable NED in Stage IV, likewise there is a need to remove the tumor site following the neoadjuvant treatment.

pCR is a dead tumor, no micro or macro mets, no live cancer in breast or axilla. But a stray stem cell can already have left the breast and be somewhere else in the body. The stem cells are the "seeds" of new tumors and the cells that may not succumb to chemo.

I might be misunderstanding the question, so please enlighten me I had a complete PCR to Neoadjuvant chemo. To the point where they are going for curative intent/throwing everything at it. My last pet scan also said "assess for re staging". I know this is rare and it guarentees nothing, but there is hope that it is possible. I am considered oligometastatic so I don't know if it's the belief that perhaps it behaves differently than typical metastatic BC or what. It is an interesting question!

Anotherone- I am not sure I understand your question properly, but one "answer" is that once you have metastasis the cancer has spread and can hang out for years outside of the liver or lung, waiting for the right mutation to appear that allows it to grow and invade that tissue (different mutations are needed to metastasize to different tissues). By the time a met is detected, whether in bone or organ, it is likely that micromets, too small to see, also exist at other sites and are growing or waiting their turn to grow. They can be senescent (asleep) and wake up days or decades later and start growing. If they are not actively growing when the chemo is administered, they will not get killed.

Another "answer" is the idea that no breast cancer is ever "cured"; in the cases where treatment works and the cancer does not every return, the patients immune cells have been able to keep eating up all the stray transformed cells and cancer stem cells before they are able to form detectable mets of any consequence. Some argue that cancer is a failure of the immune system to take out wonky cells, and that transformation is actually rather common.

Another "answer" is that metastatic cancers can be cured. Some years ago, MD Anderson reported they were able to cure about 25% of oligometastatic cancer cases, where the mets were in one organ and fewer than five of them. And we do have examples of people with immunotherapy, etc, who ended up cured. The argument here is that there is no reason why the immune system cannot take out metastatic cancers, we just need to figure out why they are not being killed and find the right combination of drugs that can do that. Cancer is not "contagious" because the immune system of another host recognizes it as foreign and takes it out. The trick is to figure how to make our own immune system see our own cancer cells.

I think the logic behind adding chemo (taxane)to Herceptin and Perjeta is this - not all the cells will have HER2 receptors even if you are strongly HER2 positive. So, the chemo will attack ALL rapidly dividing cells while the H&P goes to work on targeting those with HER2 receptors.

This my understanding, anyone with more knowledge feel free to correct or add to this.

And heidihill’s comment speaks to another area of metastatic disease that is still a bit of a black hole. Why is disease progression so different, and in many cases, so unpredictable even among people who start out with similar dx and follow similar tx? It seems so random, sofrustrating. I know advances are being made, as I have seen it in the years since I was dx’ed, but where is the cure?