While inoperable and incurable, her type of cancer can be treated

The Baltimore Sun

A diagnosis of Stage IV metastatic breast cancer sounds like a death sentence. And, for some, it can be. It is both inoperable and incurable.

But cancer experts say the disease is treatable, and its victims' prognoses vary as widely as their individual cancers.

Elizabeth Edwards, wife of Democratic presidential candidate John Edwards, learned Monday that her breast cancer, first diagnosed and treated in 2004, has turned up in her bones.

But chemical, hormonal and biological drug therapies can be used to keep it in check, said Dr. Michael Schultz, director of the breast center at St. Joseph Medical Center in Towson. "It's not a terminal illness, it's a chronic illness. I've seen patients live for 18 or 20 years."

John Edwards announced the diagnosis yesterday in Chapel Hill, N.C., but said neither he nor his wife would suspend campaigning.

"It's true her cancer will not be cured now. She will have this as long as she is alive," he said. "But you treat it and you take your medicine, and that is exactly what we intend to do. ... . We will be in this every step of the way together."

Most women with metastatic breast cancer are able to remain "fully functional. ... It's quite possible Mrs. Edwards should be able to achieve her goals in life," said Dr. Katherine Tkaczuk, director of the breast evaluation and treatment program at the University of Maryland Greenebaum Cancer Center.

Breast cancer death rates have been on the decline since the early 1990s, the result of advances in preventing, diagnosing and treating the disease. Also, a 7 percent year-to-year drop in new cases was seen in 2003, according to data released in December by the National Cancer Institute.

The sudden decline has been attributed to women ceasing hormone therapy to treat menopause symptoms after scientists in 2002 linked the therapy to increased cancer risk. The hormones are suspected of stimulating the growth of tiny, undetectable cancer cells.

Still, the disease is expected to strike more than 178,000 American women this year and to kill more than 41,000. Elizabeth Edwards had the most common type of breast cancer, ductal carcinoma, which invades the milk ducts.

Doctors typically treat the disease by surgically removing tumors. Surgery is often followed by radiation and chemotherapy drugs intended to kill any remaining cancer cells.

Elizabeth Edwards' breast cancer was first diagnosed in 2004, shorty after her husband's failed campaign as Sen. John Kerry's vice presidential running mate. She underwent several weeks of chemotherapy, followed by a lumpectomy and radiation.

But despite treatment, if some cancer cells remain, breast cancer can metastasize - return and spread beyond its original location. Recurrence peaks two to three years after initial diagnosis.

To monitor the disease, patients typically undergo physical exams and mammograms. The frequency depends on calculations of their ongoing risk.

Recurrence rates vary widely, from 1 percent or 2 percent in some patients whose lymph nodes were initially clear of cancer, to 50 percent for those found to be "node positive," said Dr. Deborah K. Armstrong, associate professor of oncology at the Johns Hopkins University's School of Medicine.

Elizabeth Edwards said yesterday that her new cancer was discovered Monday in X-rays performed to diagnose pain in a rib on her left side.

It turned out the rib was broken, apparently during a hug last week from her husband. Although weakened bones can be a complication of metastatic breast cancer, the fractured rib was not the one that showed the cancer. The new growth was found in a rib on her right side.

"I'm actually very lucky I cracked this rib," she said. "If I hadn't, I wouldn't have gotten a chest X-ray." With the early warning from the X-ray, "we can be reasonably optimistic."

Schultz, of St. Joseph Medical Center, said physical symptoms are the best indicator breast cancer has returned. "You look for symptoms and you teach patients to be attuned for them," he said.

Elizabeth Edwards' experience this week was "the perfect example of how it's supposed to work."

For one of Schultz's patients, the tip-off was pain in the breast where she had previously had a tumor. "My breast was bothering me terribly," said Betty Love, 75, of Owings Mills.

A biopsy performed last summer showed her cancer had returned nine years after she'd undergone surgery and radiation. This time the cancer had also spread to her lymph nodes, making it more difficult to treat.

"I think when they first saw me they were a little concerned that I might not be here too long," she said. Surgeons recently removed her breast and lymph nodes. Now she is taking an oral chemotherapy drug.

"I feel great," she said. "I'm doing all I can to enjoy my grandchildren. You make the best of it and thank God you're still alive."

Elizabeth Edwards, her husband and her doctor were similarly upbeat yesterday, encouraged by the finding that the cancer was still small and limited mostly to the bone. "As we get more and more test results, we feel incredibly optimistic," she said.

Her doctor, Dr. Lisa Carey, a medical oncologist at the University of North Carolina's Lineberger Cancer Center, said the prognosis will depend on how Mrs. Edwards responds to treatment. "I don't have a crystal ball," Carey said. "In some people none of the treatments we use work, so their survival is short. Other people can live with it for many years."

Carey said the cancer, while "primarily" in the bone, might also have spread elsewhere. X-rays hinted at cancer in other organs, including some "very small ... abnormalities" in a lung, but "not to any significant degree."

"As an oncologist you are presented with cases with varying degrees of involvement. You see a lot of cancer growth throughout the body. This is not the case here," she said.

Tkaczuk, of the Greenebaum Cancer Center, said laymen associate the spread of cancer to the bones with "a very poor prognosis. But in the case of breast cancer that frequently is not the case."

Doctors have a wide variety of drugs to choose from to treat metastatic breast cancer. Beyond an array of chemical agents, they include hormonal and "biologic" agents. The choice will depend on the microscopic nature of the patient's cancer cells.

Breast cancer cells are derived from normal breast cells, and some have surface receptors that are responsive to female hormones, such as estrogen and progesterone.

Drugs that block the production or action of those hormones can kill the cancer cells, Hopkins' Armstrong said. They're available in pill form and have few serious side effects, so they can be taken for years.

Biologic agents recently approved by the Food and Drug Administration can target a different receptor on the cancer cells, if tests show it is present. It's a "human epidermal growth factor" receptor that can be attacked by drugs containing antibodies, killing the cells.

Elizabeth Edwards' doctors are awaiting further test results to identify precisely what sort of cancer cells she has. But Carey said treatment would probably begin in "a week or two."

The frequency of her treatments, and their effect on her strength and stamina, will depend on which strategy doctors select.

Elizabeth Edwards said she believed that she would have "all the energy I need" to continue campaigning with or for her husband. She said she expects to be tired at times, but more likely the result of being a 57-year-old whose younger children are 7 and 5 years old.

Having one's first child after age 30 adds slightly to the risk of eventually developing breast cancer. Elizabeth Edwards' youngest kids are late arrivals. Her first two children were born when she was in her early 30s. One, a son, died in a car accident in 1996, at age 16.

frank.roylance@baltsun.com chris.emery@baltsun.com

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