The remission is over. The cure did not hold. A familiar, unwelcome fight is on.

By Todd C. Frankel and Tina Hesman Saey, St. Louis Post-Dispatch, April 1, 2007

Each time the cancer returned, she renegotiated with God.

Ellen Mannoia of Greenville, Ill., discovered she had breast cancer in 1988. Her children were just 8 and 11 years old. She prayed to see them grow up. After the cancer came back in 1999 - this time in her bones - she struck a new deal. She wanted to see her younger child graduate from college. And she did. Two months ago she learned the cancer was in her liver. Her children have grown up, graduated from college and married.

"I now want to see grandchildren," Mannoia, 56, said from her room at Barnes-Jewish Hospital.

Cancer usually is thought of as a singular disease. You fight it - win or lose - and move on.

But the recent announcements that Elizabeth Edwards'' and Tony Snow''s cancers have recurred highlight how patients deal with the troubling news that the cancer is back.

The remission is over. The cure did not hold. A familiar, unwelcome fight is on.

Patients tend to see cancer in a new light the second time around.

"It was difficult in a different way," Mannoia said.

The return of cancer can be more frightening than the initial diagnosis, said Teresa DeShields, a psychologist at the Siteman Cancer Center in St. Louis. "The first time there is the thought of, ''That''s over. It''s done. Close that door. It''s behind me.'' But when the cancer returns, there is serious doubt. There''s a worry of maybe this isn''t ever going to be over."

DeShields said her patients had grown more interested in discussing this sensitive topic since Edwards, 57, wife of Democratic presidential hopeful John Edwards, said recently that her breast cancer had returned in her bones. Edwards, who was treated for breast cancer in 2004, has said she expects to treat this cancer as a chronic condition.

Last Tuesday came the news that Snow, 51, the White House press secretary, was sick. The colon cancer for which he was treated in 2005 had spread to his liver.

Some of DeShields'' patients were rattled by the developments with Edwards and Snow. Although cancer is no longer a subject whispered about - no longer "the Big C" - "I think the idea that it comes back is a little more scary than we can talk about easily," DeShields said.

Debbie Davis of Kirkwood was floored when she found out her breast cancer had returned in her bones after a long remission.

"I was just so convinced that I was done with it," Davis, 48, said.

After her first diagnosis and treatment in 1993, Davis gave birth to a son. So with her second cancer bout, she had a family to worry about. The stakes seemed higher. Her cancer is now considered a chronic condition. She gets regular treatment. Last month she had radiation. Sometimes she forgets she has cancer.

"Having a recurrence is not the end of the world," Davis said.

Whether a patient''s cancer will reappear is a numbers game. It depends on the type of tumor, how big it was, whether the cancer had spread to lymph nodes, the person''s health and other, unpredictable factors.

If a woman is past menopause, caught her tumor early and her breast cancer responds to hormones, "that patient has an outstanding chance of never being bothered by cancer again," said Dr. Katherine Weilbaecher, a breast cancer oncologist at Siteman Cancer Center and Washington University.

But the risk of recurrence is always present. "We can never say zero," Weilbaecher said. "We wish we could."

Doctors know that cancer can come back. It happens when a few cancer cells survive surgery, radiation and chemotherapy. Doctors and patients don''t know the cells are there until symptoms appear or the tumor has grown large enough to be seen on scans.

Like tropical plants that won''t grow in the desert, tumors won''t grow in just any part of the body, Weilbaecher said. Breast cancer cells are often drawn to bone. They can also spread to the lungs, liver and brain. Colon cancer often moves to the liver and sometimes to the lungs, but rarely the bones, said Dr. Paul Petruska, director of the division of hematology and oncology at St. Louis University.

Metastatic cancer - one that has spread - is hard to cure.

"If a patient appears in my office with metastatic disease, I know I only have a 1 to 3 percent chance of curing the patient," Petruska said. A cure means getting rid of the cancer cells so the cancer never comes back.

New drugs are helping keep cancer at bay longer, said Dr. Eddy Hsueh, a surgical oncologist at St. Louis University. Now, people with colon cancer that has spread to the liver can expect to live 25 to 30 months on average. That''s double the life span - 13 months - people with metastatic colon cancer could expect only four years ago, he said.

Patients often struggle in adjusting to cancer as a potentially lifelong battle.

The idea of cancer''s recurring can color the traditional milestones of cancer treatment.

When Mannoia was diagnosed in 1988, her husband, Jim, who is now president of Greenville College, quietly conducted his own research. He dug up the then-dour statistics on the chances his wife would live five years or even 10 years. He did not want to worry her. So he wrote down the numbers on a piece of paper and tucked it in his Bible. The note was hidden next to Psalms 40, the one that begins, "I waited patiently for the Lord; and he inclined unto me, and heard my cry... "

On the 10-year anniversary of her diagnosis, he pulled out the paper and finally showed it to his wife. After a night out on the town, they celebrated by setting the note on fire.

The following year, she was diagnosed with cancer again.

"There really has not been a point where I have given up," Mannoia said. "Even now."