Patients with breast cancer are concerned about whether the disease will come back. Sometimes they do and sometimes they don’t. Breast cancer can come back at any time or never, but most recurrences occur within the first 5 years of breast cancer treatment.
Breast cancer can recur locally (in the treated breast or near the mastectomy scar) or elsewhere in the body. Some of the most common sites of recurrence outside the breast are the lymph nodes, bones, liver, lungs, and brain.
How do I know?
Patients should consistently perform breast self-exams, check the treated area and the other breast monthly, and inform their doctor immediately of any changes in the breast.
In addition, insist on regular mammograms. At some screening centers, 3D mammograms are available in addition to traditional digital mammograms. If genetic testing shows a BRCA mutation, a magnetic resonance imaging (MRI) of the breast is also needed. Your doctor should be consulted about the most appropriate screening modality.
Breast changes that may indicate a recurrence of breast cancer include:
- Lumps or thickening in or around the breast or in the armpit that do not go away after the end of the menstrual cycle.
- A change in the size, shape, or contour of the breast.
- A marble-shaped area under the skin.
- Changes in the sensation or appearance of the skin of the breast or nipple, including shallow dimpling, wrinkling, scaling, redness, warmth, or swelling.
- The nipple drains blood-colored or clear fluid.
In addition to monthly breast self-examinations, you should visit your doctor for regular follow-up visits. During the visit, the doctor will examine the breast, understand the symptoms and arrange for laboratory or imaging tests as needed. Tell your doctor immediately if you have new symptoms, such as pain, headache, weight loss, loss of appetite, or other symptoms.
Follow-up visits may be every 3 or 4 months. The longer the cancer-free period, the fewer visits the patient will need.
What are the factors that contribute to an increased chance of recurrence
- Tumor size. The larger the tumor, the greater the chance of recurrence.
- Tumor size.
- Cancer spread. If the breast cancer has spread to the lymph nodes, the more lymph nodes with cancer cells, the higher the risk of recurrence. The risk is also higher if cancer cells are found in the lymphatic vessels or blood vessels in the breast.
- Hormone receptors. About two-thirds of breast cancers have receptors for estrogen (ER+) or progesterone (PR+) or both hormones.
- HER-2. This gene triggers the growth of cancer cells.
- Pathological grading. This refers to how similar the tumor cells look to normal cells when viewed under a microscope. The higher the pathologic grade, the higher the chance of recurrence.
- Nuclear grading of cells. This is the rate at which cancer cells within the tumor divide into more cells. Cancer cells with a high nuclear grade are usually more aggressive (fast growing).
Treatment
The type of treatment for localized breast cancer recurrence depends on the type of treatment received initially. If breast-conserving surgery was received, local recurrences are usually treated only with mastectomy. If a mastectomy was received, a recurrence around the mastectomy site is usually followed by removal of the tumor and then radiation therapy.
Patients may receive endocrine therapy, chemotherapy, or radiation therapy after surgery. Sometimes, a combination of treatments is given.
If a breast cancer is found in the other breast, it may be a new tumor unrelated to the first breast cancer. This tumor will be treated as a new breast cancer, and the patient may undergo breast-conserving surgery or a mastectomy, with further treatment if necessary.
If the cancer recurs elsewhere in the body, for example, in the bones, lungs, liver, or brain, patients may receive surgery, chemotherapy, radiation therapy, endocrine therapy, targeted therapy, or combination therapy, as appropriate.
Physicians may recommend immunotherapy alone or combination chemotherapy with one of the following drugs for women with high levels of HER-2 protein in their cancer:
- trastuzumab (trastuzumab)
- trastuzumab-emtansine coupling (ado-trastuzumab emtansine)
- Lenatinib (neratinib)
- Pattuzumab (pertuzumab)
- Apatinib (lapatinib)