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Breast Cancer Recurrence (transcript)
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(Dr. Peter Salgo) 
Welcome to Second Opinion, where each week we solve a real medical mystery.  When we close this file about a half an hour from now, you'll not only know the outcome of this week's case, but you'll be better able to take care of your own healthcare.  I'm your host, Dr. Peter Salgo, and you've already met our special guests, who are joining our cast of regulars, primary care physician Dr. Lisa Harris, and Bioethicist Glenn McGee.  No one on this team has ever seen this case except me.  I've got it right here, so let's get right to work.  Let me tell you a little bit about our patient today.  We're going to be talking about Sarah.  Sarah is 56 years young.  She is in her primary care physician's office.  She's been having recurrent headaches, not too bad, but bad enough and consistent enough that she wants to have these headaches checked out.  Lisa? 

(Dr. Lisa Harris)  
So she's - really it's more history.  Has she ever had headaches in the past?  Is this a brand-new thing for her?

(Peter) 
It looks like, from what I see in the chart, based on her private physician's records, nothing like this before.  I mean, clearly, she's had headaches before.

(Lisa)   
You really need to know a little bit more about red flags.  Are these headaches that wake her up out of the middle of the night?  Does she have any blurred vision?  Any other associated symptoms?

(Peter)  
Well, I could tell you that she had a neurologic exam, and there were no gross focal signs or symptoms and no field cut.  Her vision was normal.  Pressure is 120 over 80.  Looks like she's afeveral, no fever.  She's five foot seven, 150.  Her LDL cholesterol is up a little bit.  She doesn't smoke.  Any other history you want, anything else?

(Lisa) 
Yeah, what is her past medical history?  I mean you said -

(Peter)  
Well, she has - 

(Lisa) 
- she has some headaches.

(Peter) 
Very little in terms of past medical history other than a ductal carcinoma on the left breast.  She had this lumpectomy.  She had some radiation.  She had Tamoxifen.  It was a ductal carcinoma.  What are you thinking now?

(Lisa) 
Well, I'm concerned because this is a patient who, although has had some headaches in the past, has any change in the frequency, and that's always a red flag when you have a patient that has stable headaches that have changed.  Even though her exam is relatively benign, that doesn't give me much reassurance.  And at this point, she would go for an imaging study of her head.

(Peter) 
Let me open this up.  Is it reasonable here to be worrying about something that happened from a breast cancer, which, now that I looked, was over six years ago, six and a half years ago?

(Jennifer) 
Well, just extrapolating from what we know about the patient, it sounds as though she probably did not have positive nodes or even six years ago she would've been offered chemotherapy. 
 
(Dr. Peter Salgo) 
Mm-hmm.

(Dr. Jennifer Griggs) 
So my guess was that she had a Stage I cancer.  It was estrogen-receptor positive because she was given Tamoxifen.  We don't use Tamoxifen in tumors that don't have the estrogen receptor.  She, like I said, did not get chemotherapy, so her disease was not particularly high-risk, but unfortunately even lower risk Stage I cancers can recur.

(Dr. Lisa Harris) 
That's one of the things.  You're worrying about recurrent breast cancer.  You're worrying about a new primary tumor.  You're worrying about aneurysms.  You're worrying - there's a lot of things you're worrying about.

(Peter) 
Again, just to be clear, a new primary tumor would be not breast cancer, which has spread -

(Lisa) 
Right.

(Peter) 
- but something else going on.

(Lisa) 
Absolutely.

(Peter) 
A brain cancer.

(Lisa) 
Absolutely.

(Peter)
A brain tumor of some sort.

(Jennifer) 
That's right.

(Dr. Gail Rousseau) 
Certainly that's what I'd be worried about.  If a patient were seeing a neurosurgeon with a complaint of changing headaches, we'd be looking at an imaging study promptly for just those reasons.  
 
(Dr. Timothy Quill) 
But you can see just how different life is for somebody who has had breast cancer.  Think about how the tone of our conversation has changed once that bit of history was taken.

(Lisa) 
Right.

(Timothy) 
So that if you haven't had such a history, headaches are generally pretty benign.

(Dr. Peter Salgo)  
What kind of a brain scan do you want for her?

(Dr. Lisa Harris) 
I want an MRI.

(Peter) 
She got an MRI, and the result is that she had a solitary lesion with a, quote, halo, unquote.  They did a biopsy in the operating room.  They determined that, indeed, she had cancer.  Now, could this be related to her initial tumor, as we were discussing, could this be a primary brain cancer?  What are the odds here?  What's going on?

(Gail) 
In a 56-year-old woman with a history of breast cancer, the first thing that's it's likely to be is a metastatic breast cancer to the brain, but a primary cancer, such as a glioma, a tumor that starts from the brain cells itself, could also be at work.

(Peter) 
When people talk about cancer which has spread from a primary tumor somewhere else, it's still the primary cancer.  In other words, she doesn't have brain cancer; she has breast cancer, which has traveled.  It has gone to...

(Lisa) 
That's correct, mm-hmm.

(Peter) 
Is that a fair statement?

(Peter) 
All right.  I mean, we hear this a lot, and I think it confuses people.

(Gail) 
Yes, mm-hmm.

(Peter) 
So she has breast cancer, and she has breast cancer in her brain.  It has traveled, is metastatic.  How did this happen?

(Jennifer) 
Well, her cancer, actually, those cells have been there in the brain since her primary was diagnosed.  Where -

(Dr. Peter Salgo) 
But could they have missed that?  I mean, shouldn't they have seen that?

(Jennifer)  
Well, only 7% of women with breast cancer are found to have metastases at diagnosis.  It's actually quite rare, and it tends to be a different kind of cancer.  It's more aggressive.  It's higher grade.  It's more advanced within the breast and the lymph nodes.  So, no, I don't believe that they missed it.  We also don't recommend, in the asymptomatic patient with especially a relatively low-risk tumor, doing imaging in somebody with no symptoms because of lots of reasons.  There's the inconvenience and the worry, and you'll find things that have nothing to do with it that lead to unnecessary procedures.  And there's even the case where you can do an imaging study in a asymptomatic patient for surveillance, then six months later they have symptoms, and everybody said, "Well, your scan was fine six months ago" or the patient does.

(Lisa) 
Right.

(Jennifer) 
She said, "My scan was fine.  I've been having headaches for four months, but my scan had just been fine, so I didn't call anybody." 


(Dr. Jennifer Griggs) 
So there's even the possibility of delaying a diagnosis.

(Peter) 
But I can hear the patient saying, "Low-risk?  What are you talking about?  I've had breast cancer.  They took it out, and they gave me radiotherapy.  I'm on Tamoxifen.  How much higher would you like my risk to be before you're going to get a scan?"

(Jennifer)  
Well, it's important to realize that most women with breast cancer are cured of their disease, and when anybody has a recurrence we want to make sense of it.  We want to put the story together, "Well, this is why it happened," or "This is what we could've done differently."  But, statistically, most likely she should have been cured.  Everything was done right, even if...
 
(Lisa) 
And it's this thought process that if you had scanned her initially, as we already said, that you would've been able to prevent this from happening, and that's not true.

(Jennifer) 
That's a really good point.

(Timothy) 
But even if you're in the 95% likelihood of cure group, there's 5% who are not going to be cured, and she might have fallen into that 5%.

(Jennifer) 
That's right.

(Timothy) 
And for of those people, they have that worry always on their mind.  So they should have that conversation with their doctor.

(Peter) 
If I hear what you're saying, epidemiology is a statistical study of tens of thousands of patients over many, many years.  She's one patient.

(Jennifer) 
Mm-hmm.

(Dr. Gail Rousseau) 
And, after all, that's what any one patient really cares about most -

(Peter) 
Her right now..

(Gail) 
- and - is her problem or his - her problem now, and that conversation needs to happen with those treating physicians. Now, in this case, one has to frame that conversation with the epidemiologic data.

(Peter) 
By the way, what are you going to do about this?  Are you going to go in after it, take this thing out?  Surgeon, you going to surg?

(Gail) 
Depends where it is.  If it's a single, accessible lesion, and it's causing symptoms, we know that the primary treatment is surgery.  If it's an inaccessible lesion or there are - in a case of multiple lesions, then there are other options such as radiosurgery.

(Peter)  
Now, you've been sitting her nodding.  Tell us a little bit about your experience.
 
(Nancy Scannell)  
Well, I was - 1986 I was first diagnosed with breast cancer.  Found through the - was doing my self-exam and found the lump myself and had the lumpectomy and radiation.

(Dr. Peter Salgo) 
Then what happened?

(Nancy Scannell)  
I thought I was doing just fine and was waiting for the five-year mark, the golden mark, the five-year, and about four years into my recovery, I went back for an appointment, and it was diagnosed in the opposite breast.

(Peter) 
Okay.

(Nancy Scannell)  
And that's where the journey began, that was rather difficult.

(Peter) 
What were you feeling?  And what do you think Sarah's feeling right this second?  She's been told, "Your breast cancer has reappeared and it's in your brain."

(Nancy)  
Devastation.  Absolute devastation thinking that you've taken care of it, and you are on the move to recovery, you can get your life back together, and all of a sudden there it is again and it's very difficult.

(Peter) 
Did it paralyze you?

(Nancy)  
For a time.  And the process of trying to find out what to do with that, with this other cancer that has - the metastatic disease, was very, very difficult and had to do with doctors not having enough time to talk...

(Peter) 
Let me just pause for just a moment over here and sum up where we are.  We've discovered a lot about Sarah, and we've covered some ground here.  Even years, I think, after the initial treatment, breast cancer can reappear.  It can either reappear locally or in another region of the body.  For example, in Sarah's case, it reappeared this time in her brain.  Tim, now, if you were one of Sarah's doctors, how would you go about explaining her diagnosis at this point to her?

(Dr. Timothy Quill)  
Well, I think I would talk about the fact that breast cancer spreads.  It was - and it probably spread at the time of the original diagnosis.  And now what we have to do is figure out how to approach this next.  And it's going to be a complicated process because we're going to have to talk to a neurosurgeon, we're going to have to talk to the breast oncologist, we're going to have to, perhaps, talk to radiation, and then we're going to have to try to put this all together and make a plan.

(Peter) 
What are Sarah's treatment options right now?  She's about almost five years out from her first diagnosis of breast cancer.  It has recurred.  The breast cancer has spread to her brain.  They've got biopsy-proven diagnosis here.  What now, just technically, are her options?

(Dr. Gail Rousseau) 
Is that visible lesion removed?  Did they biopsy it? 

(Dr. Peter Salgo) 
They biopsied...

(Gail) 
If just a few cells were taken to diagnosis what it is, and there truly was a biopsy leaving a mass behind, then she needs radiation therapy, perhaps focal radiation to that area as well as whole brain radiation.

(Peter) 
It sounds to me as if she doesn't have a disease capable of cure necessarily, but it's now a chronic disease that needs ongoing treatment.

(Jennifer)  
For the most part, when people have metastatic disease, although we hope for a cure, and we're sort of all sitting waiting for advances in breast cancer that happen, by the way, with rapid drug development and new discoveries, we are treating this as a treatable but generally not curable disease. 

(Peter) 
Go ahead.

(Timothy)  
We're talking those odds, though, on their head -

(Dr. Jennifer Griggs) 
Yes.

(Timothy) 
- that she was looking at before.  So maybe she had a 95% chance of cure.  If this even were an isolated -

(Jennifer) 
Yes.

(Timothy) 
lesion in her brain, she maybe has a 1% chance of cure, if that's successfully removed, because it's so likely that there's going to be disease elsewhere at some point in the future.


(Lisa) 
We have to be absolutely certain that we're clear about the terms that we're using because we all know what those terms mean, and I'm not sure the patients know what those terms mean.

(Glenn)  
I agree with you, but I think we have to be more aggressive at this point in a way that aggression isn't usually used.  A patient, at this point, as Tim points out, has turned the odds upside down.  Now, people go to casinos, and they buy lottery tickets in this country.  They believe that they might make it on the strength of a piece of paper that they throw money at.  They buy bad stocks.  Cancer is a special case in that way.  People will take chances they wouldn't take in any other therapy I can think of.  We've got this very complicated conversation, and you're thinking about living and yet your body is attacking you.

(Nancy)  
Mm-hmm.

(Glenn) 
And, at the same time, you've got language going on where there's a 1 or 5% chance, and it's a war.  So we're talking about a war against cancer, a war that involves attacking yourself and taking chances that sound like a lottery.

(Peter) 
Let me explore this chronic disease versus cure dichotomy for just a few moments.  You went up to five years, almost.

(Nancy)  
Almost up to five.

(Peter) 
Were you looking at the clock saying, "If I just get to five years, I'm out of here for good"?

(Nancy)  
Yes.

(Peter) 
Have we perpetrated, as a medical community, what amounts to a fraud on the American public?  We like five-year survival.  We like eight-year, ten-year survival.  They're sitting out there waiting for the clock to go ding, "I'm free."

(Nancy)   
Well, I think I was hearing that from a lot of different people, just five years, "You just have to wait for five years."

(Jennifer) 
In breast.  Now, there are other cancers where -

(Nancy)  
Mm-hmm.

(Jennifer) 
- if you make it to five years, the likelihood of a recurrence is very - much, much lower than with breast, but so few people -

(Nancy)  
Mm-hmm.

(Dr. Jennifer Griggs) 
- are alive at five years.

(Dr. Peter Salgo) 
Let me reframe the discussion again.  We were discussing cure -
– early on with the first tumor.Now we hear the word, well, it's a chronic disease, and we're going to go forward and treat it. 
Does the - does that transition from cure to chronic disease scare you?

(Nancy)   
This is another disease that I have to be vigilant about, and with me it was a choice and I had the radical mastectomy and reconstruction surgery followed by chemotherapy, and then I was put on Tamoxifen.

(Peter)  
So you rolled the big dice.

(Nancy)  
Yes, I did.

(Peter)  
You said, "Let's go for it."

(Nancy)  
Yep.

(Dr. Peter Salgo)  
"Get - tumors belong in bottles."

(Nancy Scannell)  
Mm-hmm.

(Peter) 
"Let's go."

(Nancy)  
Yep.

(Peter) 
What happened next?

(Nancy)  
I had another recurrence, and that's when I decided to do the mastectomy and the...

(Peter) 
Okay.  Just to be clear, I want to be sure I understand you.  You had breast cancer on one side.

(Nancy)  
Mm-hmm.

(Peter) 
You had lumpectomy.

(Nancy)  
Right.

(Peter)
Breast cancer on the other side.

(Nancy)  
Right.

(Dr. Peter Salgo) 
Lumpectomy.

(Nancy)  
Mm-hmm.

(Peter) 
And then a third recurrence.

(Nancy)  
Yes.

(Peter) 
And that was on the side of the second cancer.

(Nancy)  
Yes, it was, mm-hmm.

(Peter) 
Okay.  And so after that third recurrence -

(Nancy)  
Mm-hmm.

(Peter) 
you were on Tamoxifen?

(Nancy)  
I was - I had the radical mastectomy -

(Peter) 
Right.

(Nancy Scannell) 
reconstruction, and Tamoxifen.

(Dr. Peter Salgo) 
So you were still pushing forward.

(Nancy)  
Yes, I was.

(Peter) 
But, again, this is an example, I think, on what everybody was talking about; it's a chronic disease.

(Nancy)  
Mm-hmm.

(Peter) 
You're dealing with it as it comes up.  Did this consume your life, or was it just episodes along the way?

(Nancy)  
No, it was episodes along the way.

(Peter) 
I think that's what everybody is thinking about -

(Gail) 
It's what we hope for.

(Lisa)  
That's what we hope for, yeah.

(Peter) 
Let's pause for a moment and sum up where we are.  Breast cancer recurrence is a chronic disease.  Once you've had that first tumor, then it comes back.  I think you've entered a new phase, the chronic disease phase.  It has to be managed.  The goal of treatment is control, not necessarily cure.  Many people live long, full lives with breast cancer coming back occasionally at points in time, and you have to deal with it.

So let me give you a little bit more information about Sarah.  Sarah decided that what she was going to have was something called the Gamma Knife after discussing this with her doctors. I'll ask a neurosurgeon, but it's not really surgery or is it?

(Gail) 
Well, it is surgery in the sense that you are obliterating the DNA and the target volume, which is the tumor.  It's not surgery in that there's no knife.  Gamma Knife is a trade name.  The real procedure is radiosurgery, and there's several trade names for machines that deliver that.  And it's typically a treatment that is designed and delivered by a team of three doctors, actually, for the fourth partner, who is the patient, and that's a neurosurgeon, who applies a frame and helps identify a target and...

(Peter)          
A frame is literally a piece of metal you put around the head?

(Dr. Gail Rousseau)  
It's a piece of metal that's attached to the head under a local anesthesia followed by an MRI, which designs - is designed to identify where that lesion or target is in 3D space, and a medical physicist, who helps make sure that everything is done as accurately as it must be in order to give basically six weeks of radiation in a part of the day.  It's an outpatient procedure, and it's very attractive to patients for that reason.

(Peter) 
And the option here, the intent of all of this is to obliterate the cancer.

(Gail) 
Is to obliterate it with very good tumor control rates.  Depending on what that metastatic tumor is, it's usually above 90%.

(Peter) 
Obliterated?

(Gail) 
Yeah.

(Peter) 
Now, does this all fit in with the concept of chronic disease?  I mean, this sounds like it's going in there and pounding away at it.  Jennifer?

(Jennifer) 
No, it's - what's chronic about this is that just knowing what we know about this disease most likely other areas in her body will be shown to be affected, whether it's the brain or the bone or the liver or the lung, but her team and the patient herself need to be prepared for ongoing surveillance.  The thing that I can't stand about the disease at this point is that it does start to structure the patient's life.  She now has to have scans every three to four months and doctor visits and blood tests, where we're poking the body, and it - this is what bothers me about metastatic diseases.  Now, your time is mine.  I take over the patient's time in so many ways.  I wish I didn't, and this is where an organized patient, who can say to her doctor, "Look, I love you, but I don't want to see you for six months.  Can we postpone the" - I know patients who will say "I canceled a trip because you scheduled the scan on that day."
 
(Nancy)  
Mm-hmm.

(Dr. Jennifer Griggs) 
And you really want the patient to say, "You reschedule your scan.  I'm off to Alaska."  And I hope that our patients know that we put them first.

(Peter)  
Nancy, let me just ask you.  You're the one here who has the most personal experience with this disease.

(Nancy)  
Yes.

(Dr. Peter Salgo) 
How have you dealt with that?  How have you dealt with this life and death in the balance issue?

(Nancy)  
I haven't allowed the disease to control me.  I want to live.  I have things to live for.  I have a wonderful family.  I now have two wonderful grandchildren.  I'm looking at that, and everyone is going to die.

(Gail) 
Mm-hmm.

(Nancy)  
And we don't know when.  So you've got to live your life.  You -

(Peter) 
Who's on this team?  Who's on your team?

(Nancy Scannell)  
Let's see.  My radiation oncologist, my primary care physician, my family, good friends, and my medical oncologist.

(Peter) 
Does anybody else need to be on her team, or has she got a pretty good set?  Who else should be there?

(Lisa) 
Did you ever have a social worker on the team?

(Nancy)  
No.  No, I never -

(Jennifer) 
I would have to say a palliative care specialist.  I've been referring my patients with metastatic disease to palliative care to discuss things that patients may not actually want to talk about with me.  With me they've got their armor on, and sometimes they don't want to start talking about if things don't work.  Maybe they think that they'll hurt my feelings or that I'll start to think they don't want to get treatment.

(Peter) 
Now, you've written about palliative care?

(Timothy)  
Yeah, having a safe - yeah, there used to be a belief that you save palliative care until the very end -

(Jennifer) 
Yes.

(Timothy) 
- and when you really need it and when you're transitioning to hospice.  But, in fact, we've learned that the same kinds of skills, this pain and symptom management, and a safe place to talk is very important on the early end.

(Peter) 
Nancy, advance your story for us a little bit.  What happened?  Now, we're three surgeries in.

(Nancy)  
Right.

(Peter) 
What happened next?

(Nancy)  
And two years later, I was having headaches and -

(Dr. Peter Salgo) 
The story of Sarah sounds a bit familiar.

(Nancy)  
Mm-hmm, it sounds familiar.  And I went through a series of tests and nothing appeared.  And, finally, I was sent for an MRI, and they found a metastasis in my skull in the hypoglossal canal area, which was not operative at that point.  And the advances of cancer treatment, I was very fortunate that my radiation oncologist had new information, new equipment, and I had radiosurgery.  And it's been five years now since -

(Peter)
Again.

(Glenn McGee) 
That's who's new on the team, the search engine.

(Jennifer) 
Mm-hmm.

(Glenn) 
That's who's new on the-

(Peter) 
The search engine-

(Jennifer) 
Mm-hmm.

(Glenn) 
The search engine is on the team, right?

(Dr. Jennifer Griggs) 
Yeah.

(Glenn) 
That search for new information from clinical trials, a way of talking.  People are - you talked about being frantic in your early time, and then the story, as it evolved, you were understanding cycles of your illness.  Incredibly compelling to me.  As an ethicist in the hospital, the case I see most frequently is of the patient or nursing staff who say, "These doctors will not talk about hope.  They'll only talk about the regimen, 'You have to have X, Y, and Z.'"  They almost have no chance to do anything else.  They've got no time, but what people in the ethics business do, I think a lot of the time, is to talk with physicians who really weren't trained ever to say, "Something might happen that won't be what you wanted, and your whole family's telling you, 'Fight, fight, fight.'"

(Nancy)  
Absolutely.

(Glenn McGee) 
But you may lose it, if you think it's a fight and -

(Peter)
Well, let's pause right there - because there's another whole chapter we need to open up, but before we do that I want to put a button on what we've been discussing so far.  The treatment of recurring breast cancer can be complex.  I think that's become clear.  It's important to surround yourself with a medical team that can handle all the issues involved with a chronic disease, and these are both emotional issues and physical issues.  It's an entire package.  Now, I think it's important to realize Sarah was 50 years old - or so when she had her first surgery.  How old were you when you had your first surgery?

(Nancy)  
I was 38.

(Dr. Peter Salgo) 
Thirty-eight, very, very young woman. Let me bring it right here in the present day.  Instead of having a 30-some-odd-year-old patient, Jennifer, or a 50-year-old patient presenting now, you had a 75-year-old patient presenting like this, perhaps with the first instance of metastatic disease.  Would your advice to this person be different than if the person were 50?

(Jennifer) 
Well, obviously, we take into account what the patient wants, and that can vary by age, though most recent research has shown that age does not influence people's desire to be aggressive or to not be aggressive.  So assuming that she's a healthy, older woman and doesn't have other medical problems, I actually would not really change my advice very much at all.

(Dr. Gail Rousseau) 
It's really their physiologic age -

(Jennifer) 
Right.

(Gail) 
and their spirit -

(Lisa) 
Right.

(Gail) 
- that determines what the options are, but there's nothing about advanced age in and of itself that should change the options that are open.

(Peter)  
So you might take a 75-year-old woman to brain surgery -

(Gail) 
I've done it on many occasions.

(Peter) 
and shell out a tumor?

(Dr. Gail Rousseau) 
And they can do very well for a very long period of time.  So age in and of itself is not the issue here.

(Lisa) 
But again, as Tim, I'm sure, would point out, we have to be prepared for the other things.  They're not 25, and their recovery may not be as rapid and as quick.

(Timothy) 
The amount of risk that a 35-year-old, a 50-year-old, and a 75-year-old might be willing to take may be different, but everybody's unique.

(Lisa) 
Mm-hmm.

(Dr. Timothy Quill) 
But - and the benefit for taking risk also may be different.

(Peter) 
Just as an example, you had three recurrences.

(Nancy)  
Yes, mm-hmm.

(Peter) 
And yet, even after the third, as - since I understand what you did, that was an experimental therapy.  You were enrolled in a protocol.

(Nancy Scannell)  
I was in a study.  Yes, mm-hmm.

(Dr. Peter Salgo) 
What else were they doing, by the way?  As opposed - in addition to the radiotherapy, you're on a new medication?

(Nancy)  
Right, I was on Ariminex.

(Peter) 
Okay.

(Nancy)  
And saw they've changed - that they changed that, and I'm here.

(LAUGHTER)

(Peter) 
I don't want to leave today without letting you know a little bit about Sarah.  Sarah, actually, did very well.  I should tell you that this history was from over 15 years ago, but as she got into her 70's, Sarah's tumor had recurred and recurred, and she just wasn't feeling as well.  And she decided on palliative care at the end of her life, and that was her choice and the choice with which her team agreed.  And that's what she did.  I don't want to leave, also, Nancy, without asking you just how you're doing right now.  What's your life like?

(Nancy)  
Very, very busy taking care of my two grandchildren while my daughter is working.  So, uh-huh, a 3-year-old and a 6-week-old.

(Peter) 
So, yeah - six weeks.  Congratulations and best of luck.  Thanks again.

(Nancy)  
Thank you.

(Peter) 
You know, we covered a lot of ground today.  So let me just sum up the key things to remember.  Even years after the initial treatment, breast cancer can reappear either locally or in other regions of the body.  Breast cancer recurrence is a chronic disease.  That means it has to be managed.  The goal of treatment is control, not necessarily cure.  Many people with breast cancer live full, long lives.  The treatment of recurring breast cancer can be complex, so it's important to surround yourself with a medical team that can handle all the issues involved with a chronic disease, both emotional and physical.  And our final message is this; taking charge of your health means being informed and having quality communication with your doctor and your team.  I'm Dr. Peter Salgo and I'll see you next time for another Second Opinion.

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