Jamie Chung for Reader's Digest
Just two weeks after completing the New York City marathon, Nebraska teacher and track coach Andrea Kabourek, 32, learned she had breast cancer. Irreverent, tough, and optimistic, she sailed through her double mastectomy and chemotherapy, missing only six days of teaching while she received eight rounds of powerful, cancer-killing drugs. The chemotherapy was successful, and Kabourek thought she had beaten cancer. She went back to her two loves: teaching and travel.
But just about a year later, in 2011, Kabourek found herself winded after running halfway around the track and then walking up a single flight of stairs. This time, she was diagnosed with leukemia, which most likely developed as a “side effect” of her original chemotherapy treatment. “It’s like the small print on the back of the bottle,” says Kabourek, who was stunned by the development.
After more chemotherapy and a bone marrow transplant, Kabourek is back at Lincoln East High School. But she’s disturbed that some of the same drugs that led to her leukemia were deployed again to destroy her bone marrow’s abnormal (along with normal) cells before her transplant.
A ‘secondary cancer’ diagnosis
Kabourek joined the growing ranks of cancer survivors who are confronting second, new malignancies—not a recurrence or spread of their original disease. Sometimes, as with Kabourek, the new cancer is an aftereffect of powerful radiation or chemotherapy treatments. Other times, genetic or familial risks play a role. And sometimes, lifestyle—diet or exposure to toxins—is to blame. The numbers are surging: An astonishing one in six people with a new cancer diagnosis had previously been diagnosed with a different cancer. “If you lump together all second cancers, it’s a very common diagnosis,” says Marie Wood, MD, professor of medicine at the University of Vermont College of Medicine. Only initial breast, prostate, and lung cancers affect more people.
Second cancers entered the breakfast-table consciousness of millions a few years ago, when Good Morning America anchor Robin Roberts, a breast cancer survivor, revealed that she had a form of bone marrow cancer called myelodysplastic syndrome (MDS). As with about one in five MDS patients, previous chemotherapy and/or radiation likely caused Roberts’s new life-threatening condition (she’d received both types of cancer treatment five years earlier).
Not long after, Kathy Bates revealed she had completed breast cancer treatment, nine years after first being treated for ovarian cancer. And Sharon Osbourne, a colon cancer survivor, announced that after testing positive for a breast cancer gene, she had undergone prophylactic mastectomy to avoid developing a new cancer.
Second cancers may be an unavoidable risk of lifesaving cancer treatment. But there are ways for people to minimize that risk. Here’s what doctors should be telling their cancer patients … and what all of us should know about the new front in the war against cancer.
“Many chemotherapy drugs are themselves cancer-causing agents.”
The chemo that’s eliminating a first cancer may cause another later; while targeting the DNA of cancer cells, the drugs also affect normal cells. Among the cells affected are the stem cells in bone marrow that go on to create red and white blood cells, making leukemia—blood cancer—a later risk. According to the American Cancer Society, several types of chemotherapy have been linked to leukemia, usually two to ten years after initial treatment. Johns Hopkins researchers reported that about one in every 200 women—one half of one percent—receiving chemo for breast cancer develops leukemia within ten years. It’s a relatively small number, but it’s five times higher than women treated with surgery alone.
What you can do: Make sure the benefit of the chemotherapy you receive is worth the risk. Various genetic tests are helping doctors tailor treatments for individual patients. These tests aim to maximize the chance of a cure and avoid toxicity—including the risk of second cancers—whenever possible by treating only those most likely to benefit.
Sharon Hayden, 62, of Niuli’i, Hawaii, was able to avoid chemotherapy this way. When she developed stage 2 breast cancer in 2012, she was offered a test of gene activity in the tumor. The analysis revealed she had a low risk of recurrence and would receive little added benefit from chemo.
The test Hayden benefited from, called Oncotype DX, became available in 2004; since then, about 300,000 women have had their tumors analyzed. “In about 37 percent of the women, the results changed decisions about treatment, and there has been about a 20 percent decrease in the use of chemotherapy, usually in favor of hormonal treatment alone,” says Steven Shak, MD, chief medical officer at Genomic Health. The company has a similar test available for colon cancer and prostate cancer.
“Even targeted radiation treatment can lead to second cancer decades later.”
For many cancer patients, radiation treatment controls tumor growth, decreases recurrences, and improves survival. Like chemotherapy, though, radiation itself is a cancer risk. As patients live longer after treatment, the possibility of a radiation-induced tumor rises. At the National Cancer Institute (NCI), researcher Amy Berrington de Gonzalez, PhD, analyzed what happened to adult patients in the decade after they reached the five-year survival mark for 15 different types of radiation-treated cancers: About 8 percent of the second cancers that occurred were related to the initial radiation. In absolute numbers, that translates to five extra cancers for every 1,000 patients treated.
While the overall rate was fairly low, greater second-cancer risks were found among those who received higher doses of radiation and those who were younger at initial treatment. Testicular and cervical cancer patients, who tend to be young adults, had higher rates of second cancers attributed to their radiation treatment than prostate and endometrial cancer patients, who tend to be older when treated.
What you can do: Ask your radiologist if she’s doing everything possible to shield your healthy tissue; the more targeted the treatment, the better. Hayden, for example, was treated for her breast cancer in a facedown position with her breast hanging through a special opening, keeping vital organs out of harm’s way. Protective measures are also available for prostate cancer by using 3-D imaging to map the prostate’s location and minimize radiation to surrounding organs.
“Your daughter will always have to be closely monitored.”
Twenty years ago, when she was 15, Ruth Rechis, PhD, was diagnosed with Hodgkin’s lymphoma and received that era’s state-of-the-art chemotherapy and radiation at St. Jude Children’s Research Hospital in Memphis. Called mantle field therapy, the treatment exposed a wide area of her neck and chest to radiation. Now 35, Rechis and others like her find themselves at far higher risk of early breast cancer—up to 30 percent by age 50, compared with 4 percent in other women—as well as heart damage and other radiation aftereffects. “It can be a burden to keep explaining why I need a mammogram and an EKG that other women my age don’t,” says Rechis, director of research at the Livestrong Foundation.
When cancer occurs in children and teens, they face a lifetime risk of a second malignancy more than five times greater than their peers who had cancer-free childhoods. Part of the reason is simply time; once cured, childhood survivors have many more years to develop a second cancer than someone first diagnosed at age 50 or 60. But cancer treatment is also harsher on children’s developing bodies. Aggressive chemotherapy and radiation can damage growing tissues, so childhood survivors need special monitoring throughout their lives.
What you can do: Make sure your child gets a post-cancer treatment plan, and share it with all her physicians. If you’re a childhood cancer survivor yourself, make sure you’re up-to-date on all recommended screenings. “If you were treated at a young age and aren’t sure of your risks, ask your doctor for recommendations, and find out whether you can do anything to prevent a second cancer or have it diagnosed earlier,” says Elizabeth Ward, PhD, vice president for intramural research at the American Cancer Society.
If you don’t know the details of your treatment history, contact the hospital where you were initially treated. Or seek help from one of the NCI-designated centers with survivorship programs. Download a guide (written for health professionals but available to the public) created by the Children’s Oncology Group at survivorshipguidelines.org.
“The lifestyle factors that contributed to your first cancer can raise your risk of a second.”
There is a strong connection between many lifestyle factors and the development of primary cancer,” says Jennifer Ligibel, MD, assistant professor of medicine at Harvard Medical School and senior physician at the Dana Farber Cancer Institute in Boston. But changing these habits isn’t always easy. The leading culprit: tobacco. A smoker who has survived lung cancer, for example, is at a fivefold higher risk of developing laryngeal cancer. Other exposures that may increase second-cancer risk: heavy alcohol use (especially in smokers) and certain hormones, chemicals, and infections.
What you can do: You can’t change your genetics or your medical history, but you can control health habits—diet, exercise, smoking, and alcohol consumption.
“Consider genetic testing.”
Some inherited genetic mutations increase cancer risk by inhibiting the ability of other genes—cancer-protective ones—to do their jobs. These mutations, dubbed cancer genes, can dramatically raise the risk of first and subsequent cancers. The most common cancers with a genetic component include breast, ovarian, prostate, and colon cancers. In recent years, doctors have tested people suspected of having cancer genes so they could take steps to avoid future malignancies or detect them at their earliest, most treatable stages. Sharon Osbourne was tested before she opted for a prophylactic double mastectomy.
Andrea Kabourek, the track coach, was young when she was diagnosed with breast cancer. Her grandmother had died of ovarian cancer. Based on those facts, she was tested for a common genetic mutation associated with both cancers, called BRCA1, and was found positive. She plans to have her ovaries removed after age 35, which will drastically reduce her risk.
What you can do: If you developed a cancer at an age considered young for developing it, or if you have a strong family history of certain cancers, talk to a genetic counselor. She can help you decide whether you should have one of the dozens of cancer genetic tests now available and help you interpret the results. The tests help determine what cancers you are at increased risk for, but they can’t determine with certainty whether you’ll develop any cancer.
Physicians also need to know your family history of cancer to monitor you appropriately. “Say you had breast cancer at 40, and your dad had colon cancer. That might be enough of a concern to start your colon cancer screening earlier than the standard guidelines,” says Dr. Wood.
“Try not to focus only on the cancer you’ve already had. You’re going to need to get tested for other cancers too.”
“First-cancer survivors may not realize they are at higher risk for some seemingly unrelated cancers. For example, in October, the Mayo Clinic reported that non-Hodgkin’s lymphoma survivors have around a 2.5 times greater risk of melanoma than other people. The earlier cancer in the bone marrow crowds out the forming immune system cells, creating the higher second-cancer risk, explains Jerry Brewer, MD, associate professor of dermatology at the Mayo Clinic in Rochester, Minnesota.
With age, the risk of developing many cancers rises, whether or not you’ve been diagnosed before. Unfortunately, many cancer survivors are not as vigilant as they should be about screenings. Surprisingly, their oncologists may not be urging the right tests either. “Health-care professionals can get so focused on the one cancer that they forget about all the others,” says Christine Hill-Kayser, MD, radiation oncologist at the University of Pennsylvania. The University of Florida reported in July that 20 to 30 percent of well-insured survivors don’t get even the standard tests recommended by the U.S. Preventive Services Task Force.
What you can do: Develop a survivorship plan with your physicians; the plan should outline your risks, recommend preventive measures, and include a schedule for medical screenings so that if you do develop another cancer, it can be treated early. For anyone who finished treatment without a written plan, a do-it-yourself version is available at livestrongcareplan.org, created by Dr. Hill-Kayser and colleagues for the University of Pennsylvania’s oncolink.org. The site will prompt you for information (type of cancer, treatment details) and then provide recommendations from professional organizations for second-cancer monitoring.
“Second cancers may be on the upswing, but the news isn’t all bad.”
More than 12 million Americans are cancer survivors—four times the number from the early 1970s. “It’s really important to understand the tremendous advances that have been made. Second cancers are a substantial clinical and public health problem now because people are living so much longer after first cancers. It’s an adverse consequence of a real success story,” says Lindsay Morton, PhD, investigator in the division of cancer epidemiology and statistics at the National Cancer Institute.