Jennifer Schmid has just learned that she has pancreatic cancer and that she will need surgery to remove part of her pancreas, stomach and intestines. Schmid’s oncologist recommended a CT scan to check for cancer elsewhere in her body.
This is how doctors found the spot in her lung.
For Schmid, 61, of Newhall, California, this news sounded as bad as it could get. She thought the pancreatic cancer was so advanced that it had already spread to her lungs. But this was not the case.
Schmid’s oncologist ordered genetic sequencing of both the lung tumor and the pancreatic tumor. This is a test to read the unique DNA of each tumor. She revealed that the two tumors are completely different from each other. Schmid did not have a single advanced cancer that had spread from her pancreas to her lungs. She had two separate types of cancer in their early stages: lung cancer and pancreatic cancer. This made all the difference to Schmid’s treatment and long-term prognosis.
“It was a stroke of luck because they found that spot on my lung and they figured it wasn’t a malignancy,” Schmid says.
Two separate primary cancers, as opposed to one that has spread to multiple parts of the body, require different treatment and, in many cases, can have a much better outlook than one metastatic cancer. And it happens more often than people think.
How common is it?
Although it may seem like a rare case of lightning striking twice, it is not uncommon for a person to develop two primary cancers — even at the same time.
Researchers estimate that about 1 in 20 people with cancer will have another separate cancer at the same time. They define ‘at the same time’ as two tumors that occur less than 6 months apart. It’s even more common to have two different types of cancer at separate times – a second cancer more than 6 months after the first. This occurs in up to 1 in 5 people who have cancer.
Lauren Stevens of Louisville, Ohio, was one of those 1 out of 5. She lived with a brain tumor from 2004 to 2019. Her doctor monitored it with routine checkups and as long as it wasn’t growing, they chose not to have the operation. However, screening in 2019 showed that it was starting to grow — and fast.
Stevens, now 50, underwent surgery to remove most of the tumor followed by radiotherapy and chemotherapy. She then resumed routine checkups to monitor the remaining tumor that the surgeon could not remove.
Stevens continued to live with an inoperable brain tumor, and began seeing blood in her stool. A colonoscopy and biopsy revealed that she had colon cancer. Stevens soon returned to chemotherapy and radiation followed by surgery to treat this second cancer while he was still living with the first.
Understandably, living with cancer since she was 32 has been tough for Stevens. There were times when she wanted to give up and no longer sought the recommended care. But 7 years ago, I got a new reason to live.
“I have a grandson now,” she says. “He just turned seven. I didn’t know my grandparents were growing up. I want my grandson to remember me. She was so close. I think the sun rises and sets for him.”
Who gets cancer twice?
Anyone with any type of cancer can develop a second cancer of any type. But research shows that those who have had bladder cancer or non-Hodgkin’s lymphoma are at an increased risk of developing a second cancer. Lung cancer appears to be the most common type of primary cancer.
There are a number of reasons why a person may develop two separate primary cancers in their lifetime.
Coincidence. Anyone is at risk of developing cancer at any time. You have a lifetime risk, for example, for lung cancer and a separate risk for colorectal cancer, for example. So, while it’s less common than getting one of those cancers, it’s possible to get both.
Genetics. You can inherit genes from your parents that increase your risk of developing certain cancers. Mutations in the BRCA1 and BRCA2 genes, for example, that you inherit from one parent increase the risk of breast cancer (as well as ovarian and pancreatic cancer). You can also inherit a gene that increases your risk of colorectal cancer. This genetic predisposition is called Lynch syndrome.
“That’s why it’s important to have genetic testing to look for one of these syndromes if you have both primary cancers,” says Joleen Hubbard, MD, an oncologist at the Mayo Clinic. “There is a lot that we can test, but there are also likely many cancer syndromes that we are not aware of yet.”
Common risk factors. Many of the factors that increase your risk of developing one cancer also increase your risk of developing others. Smoking and tobacco use, for example, cause at least 14 different types of cancer. Obesity, alcohol use, and an unhealthy diet are other risk factors for many different types of cancer. Exposure to harmful substances in the environment can also increase the risk of more than one type of cancer.
Previous cancer treatment. Radiation and chemotherapy for one cancer can increase the risk of developing another cancer. But doctors don’t usually call these cancers second primary cancers. These are secondary cancers caused by radiation or chemotherapy.
How do doctors diagnose two separate types of cancer?
With many types of cancer, when you get a diagnosis, your doctor will order imaging of your chest, abdomen, and pelvis to see if the cancer has spread beyond where it started. For cancers that usually spread to the brain, such as lung cancer, the test may include imaging of the brain as well.
If additional tumors appear in these images, they may contain clues about whether they originated from the same cancer or from a different cancer.
“If you have a patient who has two separate masses and they appear to be different on the PET scan — one shines more than the other — that raises our suspicion that they may not be the same malignancy, which would require us to sample from both areas,” says Arsen Osipov, MD. Oncologist who managed Schmid’s care at Cedars-Sinai Cancer in Los Angeles He directs a multidisciplinary pancreatic cancer clinic.
A biopsy and genetic sequencing of both tumors, such as Schmid, can tell doctors definitively whether they are looking at one or two cancers.
“Knowing whether a person has two primary cancers versus one metastatic cancer is critical,” Osipov says. “She was supposed to have had metastatic pancreatic cancer, but in reality she had two separate cancers that could be treated definitively with the goal of being cured. You take care of one, then the other, and these cancers are not as advanced as one cancer with metastasis would have been” .
What is the treatment for two separate cancers?
When two different types of cancer appear at the same time, doctors have to make a decision: Which type of cancer should they treat first?
In unusual cases, the two types of cancer may share characteristics that cause them to respond to the same chemotherapy regimen or targeted drug.
“This would be an ideal scenario, but it is very rare,” Osipov says.
When two types of simultaneous primary cancers require two different treatments, “either you treat the most life-threatening cancer first or sometimes it may be best to treat the easier-to-treat type first,” Hubbard says.
Schmid had abdominal surgery first for pancreatic cancer and then radiotherapy and chemotherapy for lung cancer. Chemotherapy is still in progress.
What if that happened to you?
If you are diagnosed with metastatic cancer, be sure to get a biopsy of the metastases to make sure there are no two separate types of cancer.
“Most centers already do this, which is why your doctor needs to take a biopsy from a metastatic site,” Hubbard says.
Osipov recommends that people with two concurrent primary cancers receive care in a cancer center where they can work with a multidisciplinary team that includes oncologists, surgeons, radiologists and pathologists who can work together in your case. Keep in mind that oncologists tend to specialize in certain types of cancer, so if you have more than one type of cancer, you’ll want a team of oncologists at a cancer center to determine which cancer to treat first.
At the very least, Hubbard adds, patients with two cancers should get a second opinion about their diagnosis and care.
“Not only does this help the patient, but the primary oncologist gets a better idea of the tumors they’re dealing with, the treatment options available, and the best arrangement for treating the cancers.”