When Is Breast Cancer Recurrence Most Likely

Signs Of Breast Cancer Recurrence

The signs of cancer recurrence depend on where the cancer resurfaces. You might not see or feel any signs of a local recurrence, and, if you do, it will probably be a slight change in or around your breast or underarm area. More often than not, your provider might find evidence of a local recurrence during a physical exam or mammogram.

A distant recurrence will typically produce some symptoms, but because many of those breast cancer symptoms are common to other health problems, it can be hard to tell if theyre due to a distant recurrence or something else. Have an open conversation with your cancer care team about any symptoms youre having, especially if they last more than two weeks.

Pay special attention to these symptoms, which could signal a cancer recurrence:

• Blood in your urine or stools
• Any new lumps or areas of swelling

Tumor Size And Lymph Node Status

The risk of recurrence is linked to the size of the original tumor as well as the number of positive lymph nodes, although these factors alone can’t explain all recurrences. In the 2017 study noted earlier, for women who were cancer-free after five years of hormonal therapy, the risk of recurrence was highest for those who had large tumors that had spread to four or more lymph nodes , and lowest with small, node-negative tumors.

The risk of recurrence of these small, node-negative tumors, however, remains significant at roughly 1% per year until at least 20 years post-diagnosis. Due to the life expectancy of metastatic breast cancer , the risk of death lags somewhat behind recurrence.

Within these ranges, the risk of recurrence was greater in women who had larger tumors than smaller tumors . Tumor grade and Ki-67 had only moderate predictive value, and progesterone receptor status and HER2 status had no predictive value in this study.

It’s noteworthy that women who had one to three positive lymph nodes were twice as likely to have their cancer recur at distant locations between five years and 20 years post-diagnosis than in the first five years, and those who have node-negative tumors were roughly four times more likely to have a late than an early recurrence.

How Does Distant Recurrence Occur

Many patients find it hard to understand how they can be apparently cancer free one day and be diagnosed with recurrent cancer the next. If surgery got all of the cancer out and chemotherapy and radiation were supposed to have mopped up the rest, how can recurrence even happen?

In most cases, even the smallest breast cancer detected has been growing for some time before it was caught. During this period of growth, the cancer cells multiplied and divided over and over again, and some cancer cells may splinter off from the main tumour and escaped into the surrounding blood and lymphatic vessels. Cells that spread to lymph nodes can certainly be trapped in those lymph nodes and removed at the time of surgery, but cells can also go into the circulatory system. Even early-stage cancers that originally had no lymph node involvement can recur and develop metastatic disease.

While its less common, cancer cells can bypass lymphatics and lymph nodes and travel via surrounding blood vessels. Cancer cells can continue to circulate and go anywhere the blood vessels will take them, or they can home in on other organs in the body, where they take up residence and continue to grow and divide in that one particular spot.

If and when cancer comes back, the cancer cells that escaped the breast are to blame. Obviously if your recurrence is ten years after your diagnosis, we assume that the cells have been dormant all that time and missed the treatments aimed at dividing cells.

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Second Cancers After Breast Cancer

Breast cancer survivors can be affected by a number of health problems, but often a major concern is facing cancer again. Cancer that comes back after treatment is called a recurrence. But some cancer survivors develop a new, unrelated cancer later. This is called a second cancer.

Women whove had breast cancer can still get other cancers. Although most breast cancer survivors dont get cancer again, they are at higher risk for getting some types of cancer, including:

• A second breast cancer
• Salivary gland cancer
• Melanoma of the skin
• Acute myeloid leukemia

The most common second cancer in breast cancer survivors is another breast cancer. The new cancer can occur in the opposite breast, or in the same breast for women who were treated with breast-conserving surgery .

Treatment For Breast Cancer Recurrence

If your care team thinks you might have a cancer recurrence, theyll recommend diagnostic tests, like lab tests, imaging or biopsies, both to be sure the cancer has come back and to get more information to guide your treatment.

Treatment options depend on where the cancer has recurred and what breast cancer treatment youve had before:

• Local recurrence is likely to be treated surgically first with a mastectomy if you didnt have one already or a surgical removal of the tumor if you did. After surgery, breast cancer chemotherapy and radiation are commonly used, as well as hormone therapy or targeted therapy if your kind of cancer will respond to one or both of them.
• Regional recurrence is also typically treated first with surgery to remove affected lymph nodes. After the surgery, youll likely have radiation and possibly chemotherapy, hormone therapy and/or targeted therapy, too.
• Distant recurrence is mainly treated with drug therapychemotherapy, hormone therapy, targeted therapy for breast cancer or a combination of these. Breast cancer surgery and/or radiation might be used, too, but only in cases where the aim is relieving symptoms.

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If Cancer Comes Back In The Same Breast

If the breast cancer comes back in the same breast it’s called local recurrence. The cancer might be picked up at one of your follow up scans or appointments. Or you might notice your breast or scar looks or feels different.

Symptoms of local recurrence can include:

• a small pink or red lump called a nodule on the breast or scar
• change in shape or size of the breast
• a swelling in your arm or hand on the side of your breast surgery
• changes in the shape or position of the nipple
• redness or a rash on the skin on or around the breast area
• a lump or thickening in the breast

Let your doctor know as soon as you can if you notice any changes. You usually have tests to check if the cancer has come back.

Am I Still At Risk Of Local Recurrence If I Have Had A Mastectomy

Yes. Local recurrence can also happen after a mastectomy, although the likelihood is usually low.

Some of the signs of local recurrence after mastectomy include

• A lump or raised bump in or under the skin, especially near the previous mastectomy scar
• Changes to the skin, including redness or thickening

After reconstruction a local recurrence can appear at the suture line of the flap or in front of the implant. When its in the skin itself, it is red and raised. Reconstruction rarely if ever hides a recurrence. With implants, the recurrences are in front of the implant. With a flap, the recurrences are not in the flap itself but along the edge of the breast skin.

Local recurrence after mastectomy is often described as a chest wall recurrence, which isnt entirely accurate because it implies that the cancer is in the muscle or bone. But usually such a recurrence appears in the skin and fat where the breast was before, and only rarely does it include the muscle.

Ninety percent of local recurrences following mastectomy happen within the first five years after the mastectomy. Approximately 20 to 30 percent of women with local recurrences after mastectomy have already been diagnosed with metastatic disease, and another 20 to 30 percent will develop it within a few months of diagnosis. Therefore, just as with local recurrences after breast conservation, tests should be done to look for distant disease.

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Recurrence Ebook: Volume 2

The most frequently asked question for women who have had breast cancer is: What are the chances it will recur?

With the aim of answering a wide range of questions while providing support, empowerment, and education, a free Q& A follow-up to our first Recurrence eBook delves deeper into breast cancer recurrence and related issues.

Type Of Breast Cancer

The type of breast cancer can affect the recurrence rate.

In a 2017 study, researchers found that people with estrogen-receptor positive breast cancer had a persistent risk of recurrence for at least 20 years after their original diagnosis.

According to Susan G. Komen, factors that influence recurrence can include:

• biology of the tumor
• treatment of the original tumor
• stage of the cancer at diagnosis

, treatment for recurrent local breast cancer depends on what treatment the person originally had.

If a person originally had a lumpectomy, a doctor may recommend a mastectomy.

If a person originally had a mastectomy, a doctor may try to remove the tumor and recommend radiation.

For either scenario, a doctor may also suggest hormone therapy, chemotherapy, or targeted therapy in addition to removing the tumor and using radiation therapy.

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Should I Have Regular Routine Scans Or Blood Tests To Check For Distant Breast Cancer Recurrence

No. Routine scans to check for the presence of distant disease recurrence are not recommended in the absence of symptoms

Given the ominous nature of stage 4 disease, the obvious question is, why dont we scan for spread regularly after a first diagnosis, so that we can detect it early if it does return? The reason we dont scan or test for metastasis is that there really is no early stage 4 disease, and thus no real opportunity to intervene earlier and increase the chance of cure. Its also important to know that with recurrence, one does not progress from one stage to the next: a woman who was originally diagnosed with stage 1 breast cancer does not recur as stage 2, because once cells have taken up residence elsewhere, she is immediately considered to have stage 4 disease. And with stage 4 disease, either you respond well to treatment and the disease regresses, or you dont and it doesnt. Studies have shown that getting frequent scans after a first cancer diagnosis does not lead to improved survival, which is why we dont scan for stage 4even if we wish we could.

Current guidelines and evidence therefore recommend against routine CT or bone scans, or blood tests, to look for recurrence of cancer in patients who do not have any symptoms or other concerns that need to be followed up on.

If you do have concerning symptoms , then you should bring them to the attention of your healthcare team to be checked out.

Expert Review And References

• American Cancer Society. Breast Cancer. 2015: .
• de Boer M, van Dijck JA, Bult P, Borm GF, Tjan-Heijnen VC. Breast cancer prognosis and occult lymph node metastases, isolated tumor cells, and micrometastases. Journal of the National Cancer Institute. Oxford University Press 2010.
• Lonning PE. Breast cancer prognostication and prediction: are we making progress?. Annals of Oncology. Oxford: Oxford University Press 2007.
• Morrow M, Burstein HJ, and Harris JR. Malignant tumors of the breast. DeVita VT Jr, Lawrence TS, & Rosenberg SA. Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins 2015: 79: 1117-1156.
• Tripathy D, Eskenazi LB, Goodson, WH, et al. Breast. Ko, A. H., Dollinger, M., & Rosenbaum, E. Everyone’s Guide to Cancer Therapy: How Cancer is Diagnosed, Treated and Managed Day to Day. 5th ed. Kansas City: Andrews McMeel Publishing 2008: pp. 473-514.

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Treating A Metastatic Recurrence

Many treatments exist for metastatic breast cancer. Your options will depend on where your cancer has spread. If one treatment doesnt work or stops working, you may be able to try other treatments.

In general, the goal of treatment for metastatic breast cancer isnt 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:

How Long After Breast Cancer Treatment Do Recurrences Occur

The risk of recurrence for all breast cancers was highest in the first five years from the initial cancer diagnosis at 10.4%. This was highest between the first and second years after the initial diagnosis. During the first five years after the initial diagnosis, patients with oestrogen receptor positive breast cancer had lower rates of recurrence compared with those with ER negative disease. However, beyond five years, patients with ER positive disease had higher rates of recurrence.

The late recurrence or relapse of breast cancer refers to cancers that come back after five years, but may not return for 10 years, 20 years, or even more. For people who have estrogen receptor-positive tumours, the cancer is actually more likely to recur after five years than in the first five years.

In contrast to the common belief that surviving for five years after cancer treatment is equivalent to a cure, with hormone-sensitive breast tumours there is a steady rate of recurrence risk for at least 20 years after the original diagnosis, even with very small node-negative tumours.

An awareness of the risk of late recurrence is important for a number of reasons. People are often shocked to learn that their breast cancer has come back after say, 15 years, and loved ones who dont understand this risk are often less likely to be supportive as you cope with the fear of recurrence.

Bone Metastases

• Spine
• Pelvis
• The long bones of the arms and legs

Symptoms and Detection

Treatment

Liver Metastases

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Can I Lower My Risk Of Getting A Second Cancer

There’s no sure way to prevent all cancers, but there are steps you can take to lower your risk and stay as healthy as possible. Getting the recommended early detection tests, as mentioned above, is one way to do this.

Its also important to stay away from tobacco products. Smoking increases the risk of many cancers, including some of the second cancers seen after breast cancer.

To help maintain good health, breast cancer survivors should also:

Cancers Linked To Radiation Treatment

Lung cancer: The risk of lung cancer is higher in women who had radiation therapy after a mastectomy as part of their treatment. The risk is even higher in women who smoke. The risk does not seem to be increased in women who have radiation therapy to the breast after a lumpectomy.

Sarcoma: Radiation therapy to the breast also increases the risk of sarcomas of blood vessels , bone , and other connective tissues in areas that were treated. Overall, this risk is low.

Certain blood cancers: Breast radiation is linked to a higher risk of leukemia and myelodysplastic syndrome . Overall, though, this risk is low.

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Limit Or Avoid Alcohol

Studies show that there is a link between moderate and heavy alcohol use and breast cancer. Alcohol is known to raise estrogen levels in your blood. This makes it more likely for you to get cancer again. If youâre a cancer survivor, itâs best to avoid alcohol altogether.

If you do choose to drink, make sure to limit it to only one drink a day to lower your chances of your cancer coming back.

Integrative Subtypes And Late Recurrence

Researchers recently developed a model to identify 11 integrative subtypes of breast cancer with different risks and timing of recurrence, according to the findings of a 2019 study published online in Nature.

Four integrative subtypes were identified that were associated with a high risk of late recurrence . Altogether, these four subtypes accounted for roughly 26% of breast cancers that were estrogen receptor-positive and HER2 negative.

These subtypes included tumors that had an enriched copy number alterations in genes that are thought to drive the growth of cancer , including:

• CCND1
• RPS6KB1
• MYC

They were also able to identify a subgroup of triple-negative tumors that were unlikely to recur after five years as well as a subgroup in which people continue to be at risk of late recurrence. A Breast Cancer Recurrence Calculator including integrative subtypes has been developed but, at the current time, this is meant for research purposes alone.

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Take Care Of Your Emotional Needs

A breast cancer diagnosis can take quite a toll on your body, both physically and mentally. The treatments can affect each person differently. And the uncertainty that comes along with breast cancer may also affect your self-worth, identity, and your confidence.

After treatment, managing your new normal and coming to terms with all that has happened may feel challenging. Itâs important to take the time to heal and prioritize your overall emotional and mental health, in addition to your physical health.

• Make some time for self-care and put your needs first.
• Talk to a professional counselor or therapist if fears of breast cancer coming back start to interfere with your daily life.
• Connect with other people whoâve had breast cancer to gain a sense of community.
• Follow news on new treatments or findings.
• Practice mindfulness to reduce stress. Yoga, meditation, and other relaxation techniques can help you center yourself.
• Pick up a hobby that youâve enjoyed before, or explore new ones.
• Journal your feelings.

Keep in mind that if breast cancer does come back, it is not your fault and it can often be treated.

Show Sources

Johns Hopkins Medicine: âReducing Risk of Recurrence,â âEndocrine Therapy for Premenopausal Women,â âEndocrine Therapy for Postmenopausal Women,â âBreast Cancer Recurrence.â

Cleveland Clinic: â3 Reasons to Quit Smoking After a Cancer Diagnosis.â

American Lung Association: âTop Tips for Quitting Smoking.â