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Does it Help to Find a Recurrence Early

Posted 7/27/2016

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  This is a difficult and very emotionally-charged topic. The answer is complicated and varies a great deal among different kinds of cancer. Even more specifically, the specific cell biology matters a great deal. For breast cancer, and I know that many readers of this blog have that diagnosis, the dogma is that survival is not extended by finding a recurrence early. That is, you will live just as long if the recurrence is identified because of a symptom in March than you will if the recurrence is identified by a test the previous November. There are no very reliable blood markers for breast cancer recurrence, although there are markers (e.g. CEA and CA 25.27) that can he helpful in tracking the value of ongoing treatment for known metastatic disease--in some women. In some other women, the markers are not ever useful.

  There are some cancers with reliable blood tests to check for recurrence; certainly relapses of leukemia may be picked up that way, and ovarian cancer is generally followed with blood tests at follow up appointments as the Ca 127 marker is usually reliable.

  This is a rather dense article from the Journal of Surgical Oncology that discusses this complicated issue. Be aware that the bottom line is that there is no accurate surveillance for all cancers, and, for many, it really does not extend survival. Discouraging, no?

Does finding early recurrence improve outcomes, and at what cost?

Anh-Thu Le MD and
Ching-Wei D. Tzeng MD, FACS

Conclusions and Our View
The putative goal of surveillance is the early detection of recurrence
while both the cancer and the patient are still treatable. To be cost and
clinically effective, this requires a tailored approach that is based on
each patient’s stage, tumor biology, conditional survival, and available
treatment options. With favorable tumor biology and many treatment
options, intensive surveillance seemingly would be cost-effective.
Potentially curative resection of metachronous colorectal liver
metastases would be a good example of that paradigm. In contrast,
unfavorable tumor biology and lack of systemic treatment options
would make every 3-months CT scan less cost effective in PDAC.
However, that paradigm is shifting as more options become available
for salvage therapy for Stage IV PDAC.
In total, this review did not find enough evidence that intensive
surveillance universally led to improved post-recurrence OS. However,
some retrospective studies have suggested that patients with recurrence
while asymptomatic are more likely to have treatment and also more
likely to live longer than symptomatic counterparts. To be fair, the
extent to which improved OS in asymptomatic patients is due to
treatment versus just better tumor biology is unclear
. The two clearly
beneficial salvage therapy paradigms include resection of resectable
liver and lung metastases in colorectal cancer and repeat hepatectomy or
transplantation for recurrent HCC limited to the liver. Additionally, for
oncologic outcomes to progress, clinical trial participation is highly
encouraged and is most probable when patients are still asymptomatic.
Finally, the issue of cost-effectiveness involves a sliding scale of
society’s desire for longer life. 

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