Breast Cancer Recurrence

Introduction to Breast Cancer Recurrence

Breast cancer can recur at any time, but most recurrences occur in the first three to five years after initial treatment. Breast cancer can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body. The most common sites of recurrence include the lymph nodes, the bones, liver, or lungs.
How Do I Know There Is A Recurrence?
If you've been treated for breast cancer, you should continue to practice breast self-examination, checking both the treated area and your other breast each month. You should report any changes to your doctor right away. Breast changes that might indicate a recurrence include:

• An area that is distinctly different from any other area on either breast
• Lump or thickening in or near the breast or in the underarm that persists through the menstrual cycle
• A change in the size, shape, or contour of the breast
• A mass or lump, which may feel as small as a pea
• A marble-like area under the skin
• A change in the feel or appearance of the skin on the breast or nipple, including skin that is dimpled, puckered, scaly, or inflamed (red, warm or swollen)
• Bloody or clear fluid discharge from the nipples
• Redness of the skin on the breast or nipple

In addition to performing monthly breast self-exams, keep your scheduled follow-up appointments with your healthcare provider. During these appointments, your healthcare provider will perform a breast exam, order lab or imaging tests as needed, and ask you about any symptoms you might have. Initially, these follow-up appointments may be scheduled every three to four months. The longer you are cancer-free, the less often you will need to see your healthcare provider. Continue to follow your healthcare provider's recommendations on screening mammograms (usually recommended once a year).
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Breast Cancer Recurrence

When and where do recurrences occur?

Breast cancer can recur at any time, but most recurrences occur in the first three to five years after initial treatment. Breast cancer can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body. The most common sites of recurrence include the lymph nodes, the bones, liver, or lungs.

How do I know there is a recurrence?

Women who have been treated for breast cancer should continue to practice breast self-examination, checking both the treated area and the other breast each month. A woman should report any changes to her doctor right away. Breast changes that might indicate a recurrence include:

• An area that is distinctly different from any other area on either breast
• A lump or thickening, in or near the breast or in the underarm, that persists through the menstrual cycle
• A change in the size, shape, or contour of the breast
• A mass or lump, which may feel as small as a pea
• A marble-like area under the skin
• A change in the feel or appearance of the skin on the breast or nipple [dimpled, puckered, scaly, or inflamed (red, warm, or swollen)]
• Bloody or clear fluid discharge from the nipples
• Redness of the skin on the breast or nipple

In addition to performing monthly breast self-exams, keep your scheduled follow-up appointments with your health care provider. During these appointments, your health care provider will perform a breast exam, order lab or imaging tests as needed, and ask you about any symptoms you might have. Initially, these follow-up appointments may be scheduled every three to four months. The longer you are cancer-free, the less often you will need to see your health care provider. Continue to follow your health care provider’s recommendations on screening mammograms (usually recommended once a year).

Prognostic indicators

Prognostic indicators are characteristics of a patient and her tumor that may help a physician predict a cancer recurrence. These are some common indicators:
Lymph node involvement — Women who have lymph node involvement are more likely to have a recurrence.
Tumor size — In general, the larger the tumor, the greater the chance of recurrence.
Hormone receptors — About two-thirds of all breast cancers contain significant levels of estrogen receptors, which means the tumors are estrogen receptor positive (ER+). ER+ tumors tend to grow less aggressively and may respond favorably to treatment with hormones.
Histologic grade — This refers to how much the tumor cells resemble normal cells when viewed under the microscope. The grading scale is 1 to 4. Grade 4 tumors contain very abnormal and rapidly growing cancer cells. There is a greater chance of recurrence the higher the histologic grade.
Nuclear grade — This is the rate at which cancer cells in the tumor divide to form more cells. Cancer cells with a high nuclear grade (also called proliferative capacity) are usually more aggressive (faster growing).
Oncogene expression — An oncogene is a gene that causes or promotes cancerous changes within the cell. Tumors that contain certain oncogenes may increase a patient’s chance of recurrence.

Treatment team

Following local breast cancer treatment, the treatment team will determine the likelihood that the cancer will recur outside the breast. This team usually includes a medical oncologist, a specialist trained in using medicines to treat breast cancer. The medical oncologist, who works with the surgeon, may advise the use of tamoxifen (tamoxifen citrate, Nolvadex) or possibly chemotherapy. These treatments are used in addition to, but not in place of, local breast cancer treatment with surgery and/or radiation therapy.

Treatment of breast cancer recurrence

The type of treatment for local breast cancer recurrences depends on the woman’s initial treatment. If she had a lumpectomy, local recurrence is usually treated with mastectomy, since radiation therapy cannot be delivered twice to the same area. If the initial treatment was mastectomy, recurrence near the mastectomy site is treated by removing the tumor whenever possible, usually followed by radiation therapy. In either case, hormone therapy and/or chemotherapy may be used after surgery and/or radiation therapy. If breast cancer is found in the other breast, it may be a new tumor unrelated to the first breast cancer. Treatment would include a lumpectomy or mastectomy and, sometimes, systemic therapy.
Women with distant recurrence involving organs such as the bones, lungs, brain, or other organs, are treated with systemic therapy using chemotherapy, hormonal therapy, or both. Radiation therapy or surgery also may be recommended to relieve certain symptoms.
Immunotherapy with trastuzumab (Herceptin) alone or with chemotherapy may be recommended for women whose cancer cells have high levels of the HER2/neu protein. Immunotherapy is generally started after hormonal or chemotherapy is no longer effective.