Recurrent breast cancer

Recurrent breast cancer is breast cancer that comes back after initial treatment. Although the initial treatment is aimed at eliminating all cancer cells, a few may have evaded treatment and survived. These undetected cancer cells multiply, becoming recurrent breast cancer.

Recurrent breast cancer may occur months or years after your initial treatment. The cancer may come back in the same place as the original cancer (local recurrence), or it may spread to other areas of your body (distant recurrence).

Learning you have recurrent breast cancer may be harder than dealing with the initial diagnosis. But having recurrent breast cancer is far from hopeless. Treatment may eliminate local, regional or distant recurrent breast cancer. Even if a cure isn't possible, treatment may control the disease for long periods of time.

Symptoms

Signs and symptoms of recurrent breast cancer vary depending on where the cancer comes back.

Local recurrence

In a local recurrence, cancer reappears in the same area as your original cancer.

If you've undergone a lumpectomy, the cancer could recur in the remaining breast tissue. If you've undergone a mastectomy, the cancer could recur in the tissue that lines the chest wall or in the skin.

Signs and symptoms of local recurrence within the same breast may include:

• A new lump in your breast or irregular area of firmness
• Changes to the skin of your breast
• Skin inflammation or area of redness
• Nipple discharge

Signs and symptoms of local recurrence on the chest wall after a mastectomy may include:

• One or more painless nodules on or under the skin of your chest wall
• A new area of thickening along or near the mastectomy scar

Regional recurrence

A regional breast cancer recurrence means the cancer has come back in the nearby lymph nodes.

Signs and symptoms of regional recurrence may include a lump or swelling in the lymph nodes located:

• Under your arm
• Near your collarbone
• In the groove above your collarbone
• In your neck

Distant recurrence

A distant (metastatic) recurrence means the cancer has traveled to distant parts of the body, most commonly the bones, liver and lungs.

Signs and symptoms include:

• Persistent and worsening pain, such as chest, back or hip pain
• Persistent cough
• Difficulty breathing
• Loss of appetite
• Weight loss without trying
• Severe headaches
• Seizures

When to see a doctor

After your breast cancer treatment ends, your doctor will likely create a schedule of follow-up exams for you. During follow-up exams, your doctor checks for any symptoms or signs of cancer recurrence.

You can also report any new signs or symptoms to your doctor. Make an appointment with your doctor if you notice any persistent signs and symptoms that worry you.

Causes

Recurrent breast cancer occurs when cells that were part of your original breast cancer break away from the original tumor and hide nearby in the breast or in another part of your body. Later, these cells begin growing again.

The chemotherapy, radiation, hormone therapy or other treatment you may have received after your first breast cancer diagnosis was intended to kill any cancer cells that may have remained after surgery. But sometimes these treatments aren't able to kill all of the cancer cells.

Sometimes cancer cells may be dormant for years without causing harm. Then something happens that activates the cells, so they grow and spread to other parts of the body. It's not clear why this occurs.

Risk factors

For breast cancer survivors, factors that increase the risk of a recurrence include:

• Lymph node involvement. Finding cancer in nearby lymph nodes at the time of your original diagnosis increases your risk of the cancer coming back.
• Larger tumor size. People with larger tumors have a greater risk of recurrent breast cancer.

• Positive or close tumor margins. During breast cancer surgery, the surgeon tries to remove the cancer along with a small amount of the normal tissue that surrounds it. A pathologist examines the edges of the tissue to look for cancer cells.

  If the borders are free of cancer when examined under a microscope, that's considered a negative margin. If any part of the border has cancer cells (positive margin), or the margin between the tumor and normal tissue is close, the risk of breast cancer recurrence is increased.

• Lack of radiation treatment following a lumpectomy. Most people who choose a lumpectomy (wide local excision) for breast cancer undergo breast radiation therapy to reduce the risk of recurrence. Those who don't undergo the radiation therapy have an increased risk of local breast cancer recurrence.
• Younger age. Younger people, particularly those under age 35 at the time of their original breast cancer diagnosis, face a higher risk of recurrent breast cancer.
• Inflammatory breast cancer. People with inflammatory breast cancer have a higher risk of local recurrence.
• Lack of endocrine therapy for hormone receptor-positive breast cancer. In people who have a certain type of breast cancer, not receiving endocrine therapy can raise their risk of recurrence.
• Cancer cells with certain characteristics. If you had triple negative breast cancer, you may have an increased risk of breast cancer recurrence. Triple negative breast cancer cells don't have receptors for estrogen or progesterone, and they don't make too much of a protein called HER2.
• Obesity. Having a higher body mass index increases your risk of recurrence.

Prevention

Strategies that have been linked to a reduced risk of breast cancer recurrence include:

• Hormone therapy. Taking hormone therapy after your initial treatment may reduce the risk of recurrence if you have hormone receptor positive breast cancer. Hormone therapy may continue for at least five years.
• Chemotherapy. For people with breast cancer who have an increased risk of cancer recurrence, chemotherapy has been shown to decrease the chance that cancer will recur, and those who receive chemotherapy live longer.
• Radiation therapy. People who've had a breast-sparing operation to treat their breast cancer and those who had a large tumor or inflammatory breast cancer have a lower chance of the cancer recurring if they're treated with radiation therapy.
• Targeted therapy. If your cancer makes extra HER2 protein, drugs that target that protein can help decrease the chance of the cancer recurring.
• Bone-building drugs. Taking bone-building drugs reduces the risk of cancer recurring in the bones (bone metastasis) in people with an increased risk for breast cancer recurrence.
• Maintaining a healthy weight. Maintaining a healthy weight may help decrease the risk of recurrent breast cancer.
• Exercising. Regular exercise may reduce your risk of breast cancer recurrence.
• Choosing a healthy diet. Focus on including lots of vegetables, fruits and whole grains in your diet. If you choose to drink alcohol, limit yourself to one drink a day.

Diagnosis

If your doctor suspects you may have recurrent breast cancer based on results of a mammogram or physical exam, or because of signs and symptoms, he or she may recommend additional tests to confirm the diagnosis.

Tests and procedures may include:

• Imaging tests. What imaging tests you'll undergo will depend on your specific situation. Imaging tests may include magnetic resonance imaging (MRI), computerized tomography (CT), X-ray, bone scan or positron emission tomography (PET).

  Not every person needs every test. Your doctor will determine which tests are most helpful in your particular situation.

• Removing a sample of tissue for lab testing (biopsy). Your doctor may recommend a biopsy procedure to collect suspicious cells for testing, as this is the only way to confirm whether your cancer has returned. Working in a laboratory, a pathologist examines the cells and determines the types of cells involved.

  A pathologist can determine if the cancer is a recurrence of cancer or a new type of cancer. Tests also show whether the cancer is sensitive to hormone treatment or targeted therapy, since these may have changed since your original cancer diagnosis.

Treatment

Your treatment options will depend on several factors, including the extent of the disease, its hormone receptor status, the type of treatment you received for your first breast cancer and your overall health. Your doctor also considers your goals and your preferences for treatment.

Treating a local recurrence

Treatment for a local recurrence typically starts with an operation and may include radiation if you haven't had it before. Chemotherapy and hormone therapy also may be recommended.

• Surgery. For recurrent breast cancer that's confined to the breast, treatment usually involves removing any remaining breast tissue.

  If your first cancer was treated with a lumpectomy, your doctor may recommend a mastectomy to remove all of your breast tissue — lobules, ducts, fatty tissue, skin and nipple.

  If your first breast cancer was treated with a mastectomy and the cancer comes back in the chest wall, you may have surgery to remove the new cancer along with a margin of normal tissue.

  A local recurrence may be accompanied by hidden cancer in nearby lymph nodes. For this reason, the surgeon may remove some or all of the nearby lymph nodes if they weren't removed during your initial treatment.

• Radiation therapy. Radiation therapy uses high-energy beams, such as X-rays or protons, to kill cancer cells. If you didn't have radiation therapy for your first breast cancer, your doctor may recommend it now. But if you had radiation after a lumpectomy, radiation to treat the recurrence isn't usually recommended because of the risk of side effects.
• Chemotherapy. Chemotherapy uses drugs to kill cancer cells. Your doctor may recommend chemotherapy after surgery to reduce your risk of another cancer recurrence.
• Hormone therapy. Medications that block the growth-promoting effects of the hormones estrogen and progesterone may be recommended if your cancer is hormone receptor positive.
• Targeted therapy. If testing shows your cancer cells produce excess HER2 protein, medications that target that protein will likely be recommended.

Treating a regional recurrence

Treatments for a regional breast cancer recurrence include:

• Surgery. If it's possible, surgery to remove the cancer is the recommended treatment for a regional recurrence. Your surgeon may also remove the lymph nodes under your arm if they're still present.
• Radiation therapy. Sometimes radiation therapy may be used after surgery. If surgery isn't possible, radiation therapy may be used as the main treatment for a regional breast cancer recurrence.
• Drug treatments. Chemotherapy, targeted therapy or hormone therapy also may be recommended as the main treatment or may follow surgery or radiation.

Treating a metastatic recurrence

Many treatments exist for metastatic breast cancer. Your options will depend on where your cancer has spread. If one treatment doesn't work or stops working, you may be able to try other treatments.

In general, the goal of treatment for metastatic breast cancer isn't to cure the disease. Treatment may allow you to live longer and can help relieve symptoms the cancer is causing. Your doctor works to achieve a balance between controlling your symptoms while minimizing toxic effects from treatment. The aim is to help you live as well as possible for as long as possible.

Treatments may include:

• Hormone therapy. If your cancer is hormone receptor positive, you may benefit from hormone therapy. In general, hormone therapy has fewer side effects than chemotherapy, so in many cases it's the first treatment used for metastatic breast cancer.
• Chemotherapy. Your doctor may recommend chemotherapy if your cancer is hormone receptor negative or if hormone therapy is no longer working.
• Targeted therapy. If your cancer cells have certain characteristics that make them vulnerable to targeted therapy, your doctor may recommend these medications.

• Immunotherapy. Immunotherapy uses your immune system to fight cancer. Your body's disease-fighting immune system may not attack your cancer because the cancer cells produce proteins that help them hide from the immune system cells. Immunotherapy works by interfering with that process.

  Immunotherapy might be an option if you have triple-negative breast cancer, which means that the cancer cells don't have receptors for estrogen, progesterone or HER2. For triple-negative breast cancer, immunotherapy is combined with chemotherapy to treat advanced cancer that's spread to other parts of the body.

• Bone-building drugs. If cancer has spread to your bones, your doctor may recommend a bone-building drug to reduce your risk of broken bones or reduce bone pain you may experience.
• Other treatments. Radiation therapy and surgery may be used in certain situations to control signs and symptoms of advanced breast cancer.

Alternative medicine

No alternative medicine treatments have been found to cure breast cancer. But complementary and alternative medicine therapies may help you cope with side effects of treatment when combined with your doctor's care.

For instance, many people diagnosed with cancer experience distress. If you're distressed, you may feel sad or worried. You may find it difficult to sleep, eat or concentrate on your usual activities.

Complementary and alternative treatments that can help you cope with distress include:

• Art therapy
• Dance or movement therapy
• Exercise
• Meditation
• Music therapy
• Relaxation exercises
• Yoga

Your doctor can refer you to professionals who can help you learn about and try these alternative treatments. Tell your doctor if you're experiencing distress.

Coping and support

Finding out your breast cancer has returned can be equally or more upsetting than your initial diagnosis. As you sort through your emotions and make decisions about treatment, the following suggestions might help you cope:

• Learn enough about recurrent breast cancer to make decisions about your care. Ask your doctor about your recurrent breast cancer, including your treatment options and, if you like, your prognosis. As you learn more about recurrent breast cancer, you may become more confident in making treatment decisions.
• Keep friends and family close. Keeping your close relationships strong will help you deal with your recurrent breast cancer. Friends and family can provide the practical support you'll need, such as helping take care of your house if you're in the hospital. And they can serve as emotional support when you feel overwhelmed by cancer.

• Find someone to talk with. Find a good listener who is willing to listen to you talk about your hopes and fears. This may be a friend or family member. The concern and understanding of a counselor, medical social worker, clergy member or cancer support group also may be helpful.

  Ask your doctor about support groups in your area. Or check your phone book, library or a cancer organization, such as the National Cancer Institute or the American Cancer Society.

• Look for a connection to something beyond yourself. Having a strong faith or a sense of something greater than themselves helps many people cope with cancer.

Preparing for an appointment

If you have any signs or symptoms that worry you, make an appointment with your primary care doctor or family doctor.

Your doctor can recommend the necessary tests and procedures to confirm a diagnosis of recurrent cancer. Then you'll likely be referred to a doctor who specializes in diagnosing and treating cancer (oncologist).

What you can do

• Be prepared to discuss your new symptoms and any other health problems you've had since your first cancer diagnosis.
• If you're seeing a new doctor, request your medical records from your former doctor. If you already have these, be sure to bring your medical records and any imaging tests you have with you. Otherwise, you'll need to sign an information release form so that your new provider's office can acquire the records.
• Make a list of all medications, vitamins or supplements that you're taking. Let your doctor know if you have tried any alternative treatments for your cancer.
• Consider asking a family member or friend to come with you. It may be hard to remember all of the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
• Write down questions to ask your doctor.

If you might have recurrent breast cancer, some basic questions to ask your doctor include:

• Has my cancer returned?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• What are the hormone receptor status and the HER2 status of the cancer recurrence?
• What treatments are available to me at this stage, and which do you recommend?
• What types of side effects can I expect from treatment?
• Are there any alternatives to the approach that you're suggesting?
• Are there any clinical trials open to me?
• What's my prognosis?

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over points you want to spend more time on. Your doctor may ask:

• When did you first begin experiencing symptoms again?
• Has there been a change in the symptoms over time?
• Do these symptoms feel different from when you were first diagnosed with cancer?
• How do you feel overall?
• Have you had any unexpected weight loss? Have you lost your appetite?
• Are you experiencing any pain?

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