Diseases & Conditions

Recurrent breast cancer

Recurrent breast cancer is cancer that comes back following initial treatment. Although treatment is aimed at eliminating all cancer cells, a few may survive. 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 tumor, known as local recurrence, or it may spread to other areas, typically your bones, liver or lungs.

Learning you have recurrent breast cancer may be harder than dealing with the initial diagnosis. But recurrent breast cancer is far from hopeless. Treatment may eliminate locally recurrent breast cancer. Even if a cure isn't possible, treatment may control the disease.

Signs and symptoms of recurrent breast cancer vary depending on where the cancer comes back. It may show up as a lump in the breast, thickening of the surgical scar or lump on the chest wall near where your original cancer was. It may be detected in an abnormal finding on a mammogram of the breast where you had a lump removed (lumpectomy), or show up in a distant place in your body such as a bone, your liver or your lungs.

Local recurrence
In a local recurrence, cancer reappears in the same area as your original, or "primary," tumor. This could be in the remaining breast in women who have had a lumpectomy, or it may be in the chest wall or skin in women who have had a mastectomy.

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

• A new lump in your breast or irregular area of firmness
• A new thickening in your breast area
• A new pulling back of the skin at the lumpectomy site
• Skin inflammation or area of redness
• Flattening or indentation of your nipple or other nipple changes

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 lymph nodes in your armpit or collarbone area. Signs and symptoms of regional recurrence may include:

• A lump or swelling in the lymph nodes under your arm, in the groove above your collarbone or around your breastbone
• Swelling of your arm
• Persistent pain in your arm and shoulder
• Increasing loss of sensation in your arm and hand
• Persistent chest pain
• Difficulty swallowing

Distant (metastatic) recurrence
A distant or metastatic recurrence means the cancer has traveled to distant parts of the body, most commonly the bones, liver and lungs. The signs and symptoms may include:

• Bone pain
• Persistent, dry cough
• Difficulty breathing
• Shortness of breath
• Chest pain
• Loss of appetite
• Abdominal tenderness or discomfort
• Persistent nausea, vomiting or weight loss
• Jaundice
• Severe headaches
• Visual disturbances
• Seizures, numbness or imbalance

When to see a doctor
After you've been treated for breast cancer, you should continue to see your doctor regularly for follow-up exams. Your doctor will check for any signs of cancer recurrence. You'll also have an annual mammogram if you had a lumpectomy. Still, many women discover recurrent breast cancer on their own. You know your body best — what feels normal and what doesn't. Check your breasts monthly to look for changes.

It's important to be aware of the signs and symptoms of recurrent breast cancer, such as new pain, changes or new lumps in your breast or surgical scar, weight loss, and shortness of breath. If you experience any signs and symptoms that might suggest a recurrence, talk to your doctor.

Recurrent breast cancer develops from cells that originally came from the primary breast tumor. The cancer returns after the initial treatment and a period of time when no cancer was detected. This can happen because treatment did not fully destroy or remove all the cancer cells. Even with surgery, small clusters of cancer cells may have been left behind that were too small to be detected with any test.

If the cancer is aggressive, isolated cells may survive the rounds of chemotherapy and radiation meant to stop recurrence. Occasionally, cancer cells may be resistant to these treatments or develop the ability to spread (metastasize).

Sometimes a single cancer cell may be dormant for years without causing harm. Then something happens that activates the cell, so it grows and makes other cells. Not all of the growth factors for cancer have been found.

It's also possible to develop a new tumor, called a second or new primary tumor, in the same breast as the first tumor or in the other (contralateral) breast. Doctors make a distinction between recurrent breast cancer and a second primary cancer in the breast. Women who have had breast cancer are at higher risk of cancer in the other breast, when compared with women who've never had breast cancer. The risk is higher if you have a strong genetic predisposition or hereditary breast cancer. Fortunately, the vast majority of women who have cancer in one breast never develop cancer in the opposite breast.

If your doctor suspects recurrent breast cancer based on results of a mammogram or physical exam, or because of signs and symptoms, you'll likely need further imaging tests and a biopsy.

The following tests may be used to help diagnose recurrent breast cancer:

• Breast ultrasound. Ultrasound uses sound waves to produce images of the inside of the body. For women who've had lumpectomy, breast ultrasound may be used to evaluate an abnormality seen on a mammogram or found during a physical exam of your breast.
• Magnetic resonance imaging (MRI). MRI uses a magnet and radio waves to make images of the inside of your body. MRI may be able to detect abnormal areas within the breast, chest wall, lymph node areas, and blood vessels and nerves around the breast and armpit. The MRI by itself can't tell the difference between cancer and a benign process, but it can help your doctor determine the best areas for a biopsy or further testing. Not all women with a local recurrence benefit from having an MRI. Discuss your specific situation with your doctor.
• Computerized tomography (CT). A CT scan is a type of computerized X-ray that provides more-detailed pictures than do ordinary X-rays. CT scans of your chest, abdomen, pelvis, bones and head can help look for evidence of cancer that's spread to your internal mammary lymph nodes or to distant sites, such as the bones, lung or liver.
• X-rays. Chest X-rays may detect a recurrence in your lungs, while bone X-rays may be able to detect cancer in your bones.
• Bone scan. A bone scan can provide an image of your whole skeleton and may detect cancer recurrence in your bones. During a bone scan, a small, safe amount of radioactive material (tracer) is injected into your bloodstream. The tracer binds to your bone cells. Areas with cancer absorb more of the tracer and "light up" on the scan.
• Positron emission tomography (PET). A PET scan also uses radioactive material injected into your body to produce an image. Tumors often absorb greater amounts of the material and show up more prominently on the scan. A PET scan or hybrid PET/CT scan of your whole body may be used to look for areas of cancer recurrence.

Biopsy
A biopsy — a small sample of tissue removed for analysis in the laboratory — is needed to confirm the diagnosis of recurrent breast cancer. The tissue specimen will be tested for the presence of estrogen and progesterone receptors. A breast cancer that makes receptors for the female hormones estrogen and progesterone (hormone receptor positive cancer) can be treated with hormone therapy. The hormone receptor status of your cancer may change with a recurrence.

The tissue is also tested for extra amounts of the HER2 protein, which some breast cancers overproduce. Cancers that are HER2 positive can be treated with biotherapies that target this protein.

Blood tests
A complete blood count and liver function tests can help evaluate how your body is doing and may help guide future treatments. Doctors often use blood tests that measure breast cancer tumor markers to follow the course of cancer. But tumor markers aren't specific for a cancer recurrence. These tests aren't recommended for looking for a recurrence, as they aren't always reliable.

Local cancer recurrences can cause pain, swelling and discomfort in the area of the recurrence. Local recurrences can often be cured, but in about one-fourth to one-third of people who have a local recurrence, the disease later appears in a distant site in the body, such as a bone, the liver or a lung. Once a cancer has spread beyond the breast and nearby areas, the disease isn't usually curable.

To plan treatment for recurrent breast cancer, your doctor considers many factors, including the extent of the disease, its hormone receptor status and the type of treatment you received for your first breast cancer. Most women receive a combination of treatments that may include surgery, radiation, drugs to destroy cancer cells (chemotherapy) and hormone therapy. Breast cancers that make extra amounts of the HER2 protein may be treated with a biotherapy such as trastuzumab (Herceptin).

Treatment decisions for recurrent breast cancer are complex and individualized. Talk with your health care team to learn as much as you can about your treatment options.

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.

• Surgery. For recurrent breast cancer that's confined to the breast, the usual treatment is mastectomy. During a mastectomy, your surgeon removes all your breast tissue — lobules, ducts, fatty tissue, skin and nipple. If your first breast cancer was treated with 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 lymph nodes under your arm (axillary dissection) during surgery if they weren't removed during your initial treatment.

• Radiation therapy. Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. If you did not 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 recommended because of the risk of side effects.
• Drug therapy (chemotherapy). If your recurrent breast cancer is the inflammatory type or involves the skin, your doctor may recommend chemotherapy before surgery. Chemotherapy may also be recommended if your recurrent cancer is so extensive that surgery isn't an option.
• Hormone therapy. Medications that block the growth-promoting effects of estrogen and progesterone may be recommended if your cancer is hormone receptor positive. Hormone therapy may shrink and control recurrent breast cancer. Hormone therapy may include tamoxifen (Nolvadex) or an aromatase inhibitor, such as anastrozole (Arimidex), letrozole (Femara) or exemestane (Aromasin).

Treating a regional recurrence
If it's possible, surgery to remove the recurrence is the recommended treatment for a regional recurrence. Your surgeon may also remove the lymph nodes under your arm (axillary dissection) if they're still present. Sometimes radiation therapy may be used after surgery.

If surgical removal isn't possible, radiation therapy may be used as the main treatment. Chemotherapy or hormone therapy may be recommended as the main treatment or may follow surgery or radiation.

Treating a metastatic recurrence
Treatment for recurrent breast cancer that's spread beyond the breast region involves many different options. It's important to work with your doctor to understand what's most appropriate for your particular situation. If one treatment doesn't work or stops working, you may be able to try other treatments.

In general, the goal of treatment for a metastatic recurrence isn't to cure the disease. Treatment may allow you to live longer and can help relieve symptoms the cancer is causing. Your doctor will try 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.

If the cancer has spread to other parts of the body, treatment for a metastatic recurrence usually involves whole body (systemic) therapy rather than local therapy such as surgery or radiation. Options for systemic therapy include hormone therapy, chemotherapy and biotherapy. Because hormone therapy is less toxic than chemotherapy, your doctor might start with tamoxifen or an aromatase inhibitor. But if your cancer is fast-growing or has already spread to organs such as the lungs and liver, your doctor might recommend starting with chemotherapy.

If your cancer is HER2 positive, you may also be given a biotherapy to attack the protein that's overproduced in these cancers. Biotherapies include trastuzumab (Herceptin), bevacizumab (Avastin) or lapatinib (Tykerb).

Depending on where the cancer has spread and what symptoms it's causing, you may also have localized treatments, such as medications or radiation to treat the disease in your bones.

Eating well, managing stress and exercising are ways to promote your overall health and cope with cancer and treatment.

Eat well
Good nutrition during cancer treatment can help you keep up your stamina and your ability to cope with the side effects of treatments. But eating well can be difficult if your treatment includes chemotherapy or radiation therapy. For times when you don't feel well, try these strategies:

• Eat protein-rich foods. Foods high in protein can help build and repair body tissues. Choices include eggs, yogurt, cottage cheese, peanut butter, poultry and fish. Kidney beans, chickpeas and black-eyed peas also are good sources of protein, especially when combined with rice, corn or bread.
• Keep an open mind about the foods you eat. Something that doesn't appeal today might taste better next week.
• When you do feel well, make the most of it. Eat as many healthy foods as you can. Prepare meals that you can easily freeze and reheat. Also look for low-fat frozen dinners and other prepared foods.
• Eat smaller amounts of food more frequently. If you can't face the thought of a large meal, try eating small amounts of food more often. Keep fruits and vegetables handy for snacking.

Stay active
Regular physical activity can help relieve anxiety and depression, improve your mood, and reduce signs and symptoms of fatigue, nausea, pain and diarrhea. The activity doesn't have to be strenuous — moderate activities such as walking, biking, swimming and yardwork bring benefits. A little bit of physical movement is better than none.

Manage stress
Methods for reducing muscle tension can help you manage stress. One simple and powerful technique is to close your eyes and notice your breathing. Pay attention to each inhalation and exhalation. Your breathing will become slower and deeper, promoting relaxation. Another technique is to lie down, close your eyes and mentally scan your entire body for any points of tension.

In addition, activities that require repetitive movement, such as swimming, can produce a mental state similar to that achieved with meditation. The same is true of yoga and other stretching exercises.