Every woman who has experienced the phase of breast cancer always wonders if it will come back. It may do for some women, and for others it may not. When breast cancer returns, it is considered as recurrence. Breast cancer may recur at any point or it may not, although the chances of breast cancer recurrence increases in the first 5 years after the diagnosis.
Breast cancer recurrence is a condition where the cancer comes back after the initial treatment. Although all cancer cells are removed, a few may have evaded treatment and survived. The undetected cells of cancer grow and become persistent breast cancer. The cancer may come back at the same site as the initial cancer (local recurrence) or can spread to other parts of the body (distant recurrence). Some of the most common sites of recurrence besides the breast are bones, lymph nodes, lungs, liver, and brain. Treatment options may help to remove local, regional or distant recurrent breast cancer. Therapeutic care will manage the disease for longer periods, even when a cure is not possible.
Recurrence symptoms vary depending on the area where the breast cancer relapse.
In a local recurrence, cancer reappears in the same region as the original cancer. If a woman has undergone lumpectomy, the cancer can recur in the remaining breast tissue and if it is a mastectomy, the cancer can recur in the tissue lining of the chest wall or in the skin.
Symptoms of local recurrence breast cancer within the same breast include:
- A new lump in the breast or irregular area of firmness
- Nipple discharge
- Changes in the skin of the breast
- Skin inflammation or a flare skin
Symptoms of local recurrence on the chest wall after a mastectomy include:
- One or more painless nodules on or under the skin of the chest wall
- A new area of thickening along or near the mastectomy scar
A regional breast cancer recurrence is the cancer that comes back nearby to the lymph nodes of the breast. Signs and symptoms can include a lump or swelling in the lymph nodes located:
- Under the arm
- In the neck
- Near the collarbone
- In the groove above the collarbone
A distant or metastatic recurrence breast cancer means the cancer has traveled to distant or other parts of the body, most commonly the bones, liver and lungs.
Signs and symptoms include:
- Persistent and worsening pain, such as chest or bone pain
- Difficulty breathing
- Persistent cough
- Severe headaches
- Loss of appetite
- Weight loss
Recurrent breast cancer occurs when cells that were part of the original breast cancer break away from the original tumor and hide nearby in the breast or another part of the body. Such cells start to develop again later. Chemotherapy, radiation therapy, hormone therapy or other treatment modalities that a patient might have received after the first diagnosis of breast cancer are meant to kill any cancer cells that have remained after the surgery. Unfortunately, these treatment options may not kill all the cancer cells as they may be dormant for years without causing any harm. Any stimulation that tend to activate these dormant cells can lead to the growth and spread of these cells to other parts of the body, the reason being unclear.
Factors that increase the risk of a recurrence in breast cancer survivors include:
- Larger tumor size: There is a greater risk of breast cancer recurrence rate in women with larger tumors.
- Lymph node involvement: The detection of cancer in surrounding lymph nodes at the time of the original diagnosis increases the risk of the cancer to recur. The more the lymph nodes are invaded with cancer cells, the more likely to have the risk of breast cancer recurrence. The chances may increase if the cancer cells are found in lymph vessels or blood vessel of breast.
- Positive or close tumor margins: During breast cancer surgery, the surgeon attempts to remove the cancer along with a small amount of the normal tissue that surrounds it. A pathologist examines for the cancer cells at the edges of the tissue. Once tested under a microscope, if the borders are free of cancer, it is referred to as the negative margin. In cases where the border has cancer cell (referred to as positive margin), or where a margin is between the tumor and normal tissues, the risk breast cancer recurrence is higher.
- Lack of radiation treatment following a lumpectomy: Most of the women who choose lumpectomy for breast cancer undergo radiation therapy to reduce the risk of recurrence. Likewise, women who do not opt for the radiation therapy treatment have increased risk of local breast cancer recurrence.
- Younger age: Young women, particularly those under the age of 35, are more likely to have recurrent breast cancer during the original diagnosis of the disease.
- Inflammatory breast cancer: Women with inflammatory breast cancer have highest probability of local breast cancer recurrence.
- Cancer cells with certain characteristics: If the breast cancer is not responsive to hormone therapy or treatments directed at the HER2 gene (gene that triggers the cancer cells growth leading to triple negative breast cancer), then they may have increased risk of breast cancer recurrence.
If a physician suspects that a person has a recurrent breast cancer based on the results of a mammogram or physical examination or on signs and symptoms, he or she may be suggested for further tests to confirm his or her diagnosis.
Tests and procedures may include:
- Imaging tests: The type of imaging tests that a patient undergo will depend on the specific situation. Imaging tests may include computerized tomography (CT) scan, magnetic resonance imaging (MRI), X-ray, positron emission tomography (PET) scan, or bone scan.
It is not necessary that every person needs every test. The doctor will decide which tests are most helpful depending on the particular situation.
- Biopsy: A biopsy procedure can be prescribed by the doctor in order to collect suspicious cells to be examined, which is the only way to confirm the presence of cancer. A pathologist determines whether the cancer is a recurrence or a new type of cancer. Tests may indicate whether the cancer is sensitive to hormone therapy or targeted therapy.
The treatment options depend on various factors, including the extent of the disease, its hormone receptor status, the type of treatment a patient received for the first breast cancer and the overall health. The doctor also considers the goals and preferences of the patient for treatment.
Treating a local recurrence
Treatment for a local recurrence typically starts with surgery and may include radiation if the patient has not undergone it before along with chemotherapy and hormone therapy.
- Surgery: Treatment typically requires removing any residual breast tissue for recurrent breast cancer that is limited to the breast. The doctor may prescribe mastectomy for removing the entire breast tissue-lobules, ducts, fatty tissue, skin and nipple-if the initial cancer was treated with a lumpectomy. When the first breast cancer was treated with mastectomy and the cancer returns to the chest wall, they can undergo surgery to remove the new cancer along with margin of normal tissue.
- A local recurrence may be accompanied by hidden cancer in the neighboring lymph nodes. Hence, the surgeon may remove some or all of the nearby lymph nodes if they were not removed during the initial treatment.
- Local recurrence may be accompanied by hidden cancers in nearby lymph nodes. For this reason, the surgeon may remove some or all of the nearby lymph nodes if they have not been removed during initial treatment.
- Radiation therapy: Radiotherapy uses high-energy beams, such as X-rays, to kill cancer cells. If a patient had not received radiation therapy during the first breast cancer, the doctor may recommend it now. But if they had radiation after a lumpectomy, then this treatment option is not recommended as it can increase the risk of side effects.
- Chemotherapy: Chemotherapy uses medications to kill cancer cells. A chemotherapy is recommended after the surgery to reduce the risk of cancer recurrence.
- Hormone therapy: Medications that inhibit the growth-promoting effects of the estrogen and progesterone hormones may be recommended if the cancer is positive to hormone receptor.
- Targeted therapy: If tests show that cancer cells produce excess HER2 protein, medications that target proteins are likely to be recommended.
Treating a regional recurrence
Treatment options for a regional breast cancer recurrence include:
- Surgery: Based on the possibility, a surgery is the recommended treatment to remove the cancer for a regional recurrence. The surgeon may also remove the lymph nodes under the arm if they are still present.
- Radiation therapy: Radiation therapy may sometimes be used after surgery. This modality may be used as the mainstay of treatment for regional recurrence of breast cancer if surgery is not possible.
- Chemotherapy: Chemotherapy, targeted therapy or hormone therapy may also be recommended as the primary treatment or may be followed by surgery or radiation.
Treating a metastatic recurrence
There are many treatments for metastatic breast cancer. The options depend on the spread of the cancer. The patient can be able to seek other therapies if one treatment does not work or stops working. The aim of metastatic breast cancer treatment, usually, is not to cure the disease. Therapy can help them live longer and relieve symptoms caused by cancer. The doctor seeks to strike a balance between controlling the symptoms while minimizing the side effects of the treatment. The goal is to help the patient to live as long as possible.
Treatments may include:
- Hormone therapy: If the cancer is positive for the hormone receptor, the patient will benefit from hormone therapy. Hormone therapy has typically fewer side effects than chemotherapy, which is why it is always the first treatment for metastatic breast cancer.
- Chemotherapy: If the cancer is negative hormone receptor, or if hormone therapy is no longer effective, the doctor may prescribe chemotherapy.
- Targeted therapy: The doctor may recommend few medications targeting the cancer cells if they have certain characteristics that make them sensitive to targeted therapy.
- Bone-building medications: The doctor may recommend bone-building medication if the cancer presence is detected in the bones to reduce the risk of broken bones or reduce pain in the bone the patient may experience.
- Other treatments: Radiation therapy and surgery can be preferred in certain situations to control the signs and symptoms of advanced breast cancer.
There are certain preventive measures that have been linked to the reduced risk and in preventing breast cancer recurrence including:
- A person receiving hormonal, targeted, radiation or chemotherapy after the breast cancer surgery can prevent or reduce the risk of breast cancer recurrence.
- Bone-building supplements: Taking supplements that aids in bone building reduces the risk of cancer recurring in the bones (bone metastasis) especially in women with an increased risk for breast cancer recurrence.
- Maintaining a healthy weight: Maintaining an ideal body weight may help decrease the risk of breast cancer recurrence.
- Exercising: Frequent exercise and physical fitness may reduce the risk of breast cancer recurrence.
- Choosing a healthy diet: The diet should focus on including lots of vegetables, fruits and whole grains. If a person chooses to drink alcohol, they should limit it to one drink per day.