Recurrent breast cancer

Overview

Recurrent breast cancer is breast cancer that comes back after initial treatment. Treatments usually try to remove or destroy all the cancer cells, but some cells may survive. These surviving cancer cells multiply, becoming recurrent breast cancer.

When breast cancer comes back, it happens most often in the first few years after treatment. But it also can happen many years later. The chances of breast cancer returning after treatment depend greatly on the type of breast cancer you had and the cancer's stage.

Recurrent breast cancer can come back in different parts of the body:

• Local recurrence means the cancer comes back in the same area as the original cancer. The cancer might grow in the nearby breast tissue after lumpectomy. Or it might grow in the skin or tissue of the chest wall after mastectomy.
• Regional recurrence means the cancer comes back in the nearby lymph nodes.
• Distant recurrence means the cancer has spread to other parts of the body, such as the bone, liver or lungs. This also is called a metastatic recurrence.

Treatment for recurrent breast cancer depends on where the cancer is in the body and what treatments you had before. Treatments may be different when the cancer comes back because the cancer can change over time.

Treatments may offer a cure for a local or regional breast cancer recurrence. For a distant recurrence, a cure may not be possible. Treatments can slow the growth of the cancer and extend your life. Newer treatments and more personalized treatment approaches are helping many people live longer with recurrent breast cancer.

Learning that breast cancer has come back can bring many emotions, including shock, anger and grief. You also might feel more prepared and empowered as you face cancer again. Compared with your first diagnosis, you may know more about treatments, feel more comfortable asking questions and better understand what helps you through difficult days. Even when things feel uncertain, your experience may help you navigate the challenges ahead.

Symptoms

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

Local recurrence

In a local recurrence, cancer comes back in the same area as the original cancer.

After a lumpectomy, the cancer can come back in the remaining breast tissue. After a mastectomy, the cancer can come back in the tissue that lines the chest wall or in the skin.

Symptoms of local recurrence after lumpectomy include:

• A breast lump or thickened area of skin that feels different from the surrounding tissue.
• A nipple that looks flattened or turns inward.
• Changes in the size, shape or appearance of a breast.
• Changes to the skin over the breast, such as a rash, skin that looks dimpled or skin that looks like an orange peel.

Symptoms of local recurrence after a mastectomy may include:

• A new area of thickening along or near the mastectomy scar.
• One or more nodules on or under the skin of your chest wall.
• Skin changes, such as a rash, skin that looks dimpled or skin that looks like an orange peel.

Some people are surprised to learn that breast cancer can come back in the chest after mastectomy. While a mastectomy removes nearly all of the breast tissue, small amounts can remain. If cancer cells are present in that tissue, the cancer can return.

Regional recurrence

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

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 recurrence means the cancer has traveled to distant parts of the body, most commonly the bones, liver and lungs. It's also called a metastatic recurrence.

Symptoms include:

• Pain that won't go away or gets worse, such as chest, back or hip pain.
• Cough that won't go away.
• Difficulty breathing.
• Loss of appetite.
• Weight loss without trying.
• Severe headaches.
• Seizures.

When to see a doctor

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

You also can report any new symptoms to your healthcare professional. Make an appointment with your healthcare professional if you have any symptoms that worry you.

Causes

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

The treatment you had after your first breast cancer diagnosis was meant to kill any cancer cells that were left over after surgery. But sometimes these treatments don't kill all the cancer cells.

Sometimes cancer cells may live in your body 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

Healthcare professionals consider several factors when estimating the risk of recurrent breast cancer. These include the type of breast cancer, the size and stage of the cancer, and the treatments you've had. Tools such as genomic tests and recurrence risk calculators also may help refine that estimate. This information can help guide treatment decisions and follow-up care after treatment.

Risk factors related to the type of breast cancer that you have include:

• Cell types. Invasive ductal carcinoma forms in the milk ducts, while invasive lobular carcinoma forms in the breast lobules. Invasive lobular carcinoma is more likely to recur many years after treatment.
• Hormone receptor status. Breast cancers that use hormones to help them grow are called hormone receptor (HR) positive cancers. HR positive breast cancers can recur many years after treatment. HR negative breast cancers are more likely to recur in the first few years after treatment ends.
• HER2 status. Breast cancers that make too much HER2 protein are called HER2-positive breast cancers. HER2-positive breast cancers are more likely to recur in the first few years after treatment.
• Inflammatory breast cancer. People with inflammatory breast cancer have a higher risk of local recurrence after treatment.
• Triple-negative breast cancer. Triple-negative breast cancer (TNBC) cells are HR negative and HER2 negative. TNBC is more likely to recur in the first few years after treatment.

Risk factors related to the results of breast cancer surgery include:

• Size of the cancer in the breast. People with larger cancers have more cancer cells and a greater risk of recurrent breast cancer.

• Positive or close cancer margins. During a typical breast cancer surgery, the surgeon removes the cancer along with a small amount of the healthy tissue that surrounds it. Healthcare professionals in a lab examine the edges of the tissue to look for cancer cells.

  If the borders are free of cancer, that's considered a negative margin. If any part of the border has cancer cells, that's a positive margin. If no cancer cells are found at the border but the distance between the cancer cells and healthy tissue is small, that's a close margin. Positive and close margins can raise the risk of breast cancer recurrence.

• Lymph node involvement. Finding cancer in nearby lymph nodes at the time of your original diagnosis increases your risk of the cancer coming back.
• Genomic testing. Genomic tests, such as Oncotype DX and MammaPrint, look at patterns of genes inside cancer cells to help estimate the risk of recurrence. These tests are used for certain types of breast cancer in certain situations. The results may help guide decisions about additional treatments to lower the risk of recurrent breast cancer.
• Residual cancer burden score. For those who have treatment with medicines before surgery, the residual cancer burden (RCB) score helps the healthcare team assess the risk of recurrence. To get the RCB score, healthcare professionals measure how much cancer remains in the breast and nearby lymph nodes after treatment. If there is little or no remaining cancer, the score is low and the risk of recurrence also is low. If more cancer remains, the score is higher and so is the risk of recurrence.

Risk factors related to adjuvant therapy include:

• Lack of radiation following a lumpectomy. Many people who choose a lumpectomy for breast cancer treatment also have radiation therapy to reduce the risk of recurrence. Not everyone needs this additional treatment. But if your healthcare team recommends radiation therapy and you choose not to have it, you may have a higher risk of local breast cancer recurrence.
• Lack of estrogen blocker therapy. For people with HR positive breast cancers, using estrogen blocker therapy after surgery can lower the risk of recurrence. If your healthcare team recommends this treatment but you choose not to have it, you may have a higher risk of recurrence.
• Lack of treatment that targets HER2. For people with HER2-positive breast cancers, treatment with targeted therapy after surgery can lower the risk of recurrence. These medicines target the cells that are making extra HER2. They often are combined with chemotherapy. If your healthcare team recommends this treatment but you choose not to have it, you may have a higher risk of recurrence.

Other risk factors include:

• 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.
• Obesity. Obesity raises the risk of recurrence.

Prevention

There's no sure way to prevent recurrent breast cancer, but some treatments and lifestyle changes may help lower the risk that the cancer will come back.

After your initial treatment, your healthcare team may assess your risk of recurrence and recommend treatments to help lower that risk. Treatments used in this way are called adjuvant therapies. Your care team also may recommend healthy lifestyle choices that can support your overall health and may help lower recurrence risk.

Treatments that lower the risk of recurrence

Your healthcare professional might recommend treatments to lower the risk of breast cancer recurrence. Treatments used in this way include:

• Estrogen blocker therapy. Taking estrogen blocker therapy after surgery may lower the risk of recurrence if you have hormone receptor positive breast cancer. This typically involves taking medicines for several years after your cancer treatment.
• Surgery to remove the ovaries. In those who haven't been through menopause, estrogen blocker therapy may be combined with treatment to stop the ovaries from making hormones. Often this is done with medicines, but sometimes it can involve surgery to remove the ovaries. This surgery is called oophorectomy.
• Chemotherapy. For people who have a higher risk of breast cancer recurrence, chemotherapy can lower the chance that cancer will come back and may improve survival.
• Radiation therapy. Radiation therapy helps lower the risk of cancer coming back after lumpectomy. It also lowers the risk of recurrence in those who have a large cancer in the breast or have inflammatory breast cancer.
• Targeted therapy. If your cancer makes extra HER2 protein, medicines that target that protein can help lower the chance of the cancer coming back.
• Bone-building medicines. In some people with a higher risk of recurrence, bone-building medicines may help lower the risk of breast cancer spreading to the bones. Cancer that spreads to the bones is called bone metastasis.

Researchers continue to study ways to reduce the risk of breast cancer recurrence. One newer area of interest is glucagon-like peptide 1 (GLP-1) medicines, which are used to treat diabetes and obesity. Some studies have suggested these medicines may lower the risk of some cancers, while other studies have not found this. So far, there isn't enough evidence to prove whether GLP-1 medicines lower or raise cancer risk. This makes it hard to say for sure whether GLP-1 medicines might affect breast cancer recurrence risk. More research is needed.

Self-care to lower the risk of recurrence

To lower the risk of recurrent breast cancer, healthcare professionals generally recommend making healthy choices that support overall health. These include eating a balanced diet, exercising regularly, maintaining a healthy weight and limiting alcohol.

Try to:

• Avoid alcohol. Research links drinking alcohol to a higher risk of breast cancer, but it's not clear whether alcohol raises the risk of the cancer coming back. If you choose to drink alcohol, limit how often you drink and keep the amount small. For overall health, drink one or fewer drinks a day. Do not drink every day. The less you drink, the better.
• Follow a healthy diet. Choose a diet that's rich in fruits, vegetables and whole grains. Limit how much red meat, processed meat and sugar you eat.
• Stay active. Aim to exercise most days of the week. If you don't exercise regularly, get your healthcare professional's OK first. Start out with short sessions of an activity you enjoy and build up the amount of exercise over time.
• Strive for a healthy weight. Ask your healthcare professional what weight is healthy for you. If you are at a healthy weight, work to maintain it. If you need to lose weight, aim to do so slowly. Start by making healthy choices, such as eating fewer calories, moving more and sitting less.

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