Risk Of Recurrence: Early And Late
Research has shown the HER2-positive early breast cancers are two to five times more likely to recur than HER2-negative tumors. Even very small HER2-positive tumors with negative lymph nodes have a much higher risk of recurrence relative to tumors that are HER2-negative. Treatment with Herceptin can cut this risk by half.
The pattern of breast cancer recurrence may also differ. Small tumors are also more likely to have a metastatic recurrence if they are HER2-positive.
Despite the fact that HER2-positive and estrogen receptor-negative tuors are more likely to recur early on than estrogen receptor-positive and HER2-negative cancers, late recurrences are much less common.
With estrogen receptor positive breast cancers, the cancer is more likely to recur after five years than in the first five years, and the risk of recurrence remains steady each year for at least 20 years following the diagnosis. In contrast, those who have HER2 positive tumors and reach their five-year mark are much more likely to be “in the clear” and remain recurrence free.
Where Can I Get Support
Now that your breast cancer treatment is complete, youre likely experiencing a wide range of emotions. Before returning to your normal daily routine, its important to address these feelings.
Having a support group is important even after treatment. A support group can be a local group of people who meet in person or an online forum. Ask your doctor to refer you to one.
Locally Advanced Breast Cancer
If breast cancer has spread to the chest wall or skin of the breast, or the lymph nodes around the chest, neck and under the breast bone, but has not spread to other areas of the body, its called locally advanced breast cancer. Sometimes breast cancer is locally advanced when it is first diagnosed.
People who have locally advanced breast cancer are thought to have an increased risk of cancer cells spreading to other areas of the body, compared to those with stage 1 or 2 breast cancers.
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Factors That Affect Outlook
When considering your outlook, your doctor must analyze many other factors as well. Among them are:
- Stage at diagnosis. Your outlook is better when the breast cancer hasnt spread outside the breast or has spread only regionally at the start of treatment. Metastatic breast cancer, which is cancer that has spread to distant areas of the body, is harder to treat.
- Size and grade of primary tumor. This indicates how aggressive the cancer is.
- Lymph node involvement. Cancer can spread from the lymph nodes to distant organs and tissues.
- HR status and HER2 status. Targeted therapies can be used for HR-positive and HER2-positive breast cancers.
- Overall health. Other health issues you may have may complicate treatment.
- Response to therapy. Its hard to predict whether a particular therapy will be effective or produce intolerable side effects.
- Age. Younger women and those over age 75 may have a worse outlook than middle-aged women, except for those with stage 3 breast cancer, according to a .
How Does The Brca1 Or Brca2 Gene Mutation Affect My Risk Of Breast Cancer Recurrence
Women with a BRCA1 or BRCA2 gene mutation and who have already been diagnosed with breast cancer, have a higher-than-average chance of new primary breast cancers than those without this genetic mutation. The chance of local or distant recurrence depends on the type and stage of the original breast cancer, and is no different from a non-BRCA-mutated breast cancer.
For women with a BRCA1 or BRCA2 gene mutation, the chance of a contralateral breast cancer, or cancer in the opposite breast to the original cancer, 10 years after diagnosis of the first cancer is about 10-30 percent compared to about 5-10 percent for women diagnosed with breast cancer who do not have a BRCA1 or BRCA2 gene mutation.
Women who have a BRCA1 or BRCA2 gene mutation and have received a breast cancer diagnosis, should talk to their treatment team about their options to reduce the risk of breast cancer recurrence.
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Prognosis Of Late Vs Early Cancer Recurrence
Late recurrence is associated with a better prognosis than early recurrence in estrogen receptor-positive breast cancer. A 2018 study in Clinical Breast Cancer found that survival after recurrence was significantly longer in people with a late versus early recurrence . In this study, the lungs were the most common site of late distant recurrence.
Early Recurrence Vs Late Recurrence
A recurrence of breast cancer at any time can be devastating. While 6% to 10% of breast tumors are diagnosed when the disease is already metastatic , 90% to 94% of metastatic breast cancers represent a distant recurrence of previous early-stage breast cancer .
Since distant metastases are responsible for around 90% of breast cancer deaths, finding ways to reduce the risk of recurrence is critical in improving the survival rate from the disease. Overall, it’s estimated that around 30% of breast cancers will recur at distant sites.
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What Do The Test Results Mean
The results of HER2 testing will guide you and your cancer care team in making the best treatment decisions.
It is not clear if one test is more accurate than the other, but FISH is more expensive and takes longer to get the results. Often the IHC test is done first.
- If the IHC result is 0, the cancer is considered HER2-negative. These cancers do not respond to treatment with drugs that target HER2.
- If the IHC result is 1+, the cancer is considered HER2-negative. These cancers do not usually respond to treatment with drugs that target HER2, but new research shows that certain HER2 drugs might help in some cases .
- If the IHC result is 2+, the HER2 status of the tumor is not clear and is called “equivocal.” This means that the HER2 status needs to be tested with FISH to clarify the result.
- If the IHC result is 3+, the cancer is HER2-positive. These cancers are usually treated with drugs that target HER2.
Some breast cancers that have an IHC result of 1+ or an IHC result of 2+ along with a negative FISH test might be called HER2-low cancers. These breast cancers are still being studied but appear to benefit from certain HER2-targeted drugs.
Triple-negative breast tumors dont have too much HER2 and also dont have estrogen or progesterone receptors. They are HER2-, ER-, and PR-negative. Hormone therapy and drugs that target HER2 are not helpful in treating these cancers. See Triple-negative Breast Cancer to learn more.
Treatments And Recurrence: Early And Late
Treatments also play a role in both early and late recurrences. While chemotherapy can significantly reduce the risk of recurrence in the first five years, it has much less influence on the risk of late recurrence.
Hormonal therapy reduces the risk of recurrence in the first five years , but can also reduce the risk of late recurrences. It is this reduction in risk that has led to recommendations to extend hormonal therapy for people at high risk beyond five years.
Extending hormonal therapy from five years to 10 years has been shown to reduce the risk of late recurrence, but the risk of recurrence needs to be weighed against the side effects of continued therapy.
A 2019 study found that people with luminal A tumors continued to have significant benefit from tamoxifen therapy for 15 years post-diagnosis.
The addition of bisphosphonates to an aromatase inhibitor in post-menopausal women with early-stage breast cancer may improve survival, but it’s too early to determine the effect on late recurrences. Bisphosphonates reduce the risk of bone metastases, but the most common sites of distant late recurrence are the brain, liver, and lungs.
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Should I Have Scans Or Blood Tests To Check For Breast Cancer
After a diagnosis of early stage breast cancer, any remaining breast tissue should be evaluated with scans regularly. The frequency is often annually but is best discussed with your specialist.
Current guidelines and evidence 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. These tests have not been shown to improve outcomes and cause unnecessary scanxiety. If you do have concerning symptoms , then you should bring them to the attention of your healthcare team to be checked out.
Risk Factors For Distant Recurrence
There are several risk factors that raise the risk of recurrence overall . These include:
- Tumour size: Larger tumours are more likely to recur than smaller ones both early and late.
- Positive lymph nodes: Tumours that have spread to lymph nodes are more likely to recur at any time than those that have not.
- Age at diagnosis: Breast cancer recurrence is more common in younger women.
- Treatments received and response to treatments: Both chemotherapy and hormonal therapy reduce the risk of recurrence
- Tumour Characteristics: More aggressive cancers are more likely to recur than less aggressive tumours , especially in the first five years. We also take into account the receptor status and an estimate of proliferation .
There are also factors that do not appear to affect the risk of recurrence. Recurrence rates are the same for women who have a mastectomy or lumpectomy with radiation and are also the same for women who have a single vs. double mastectomy.
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How Do I Know If My Cancer Has Too Much Her2
After a breast biopsy or surgery, a sample of the tumor is tested for extra HER2. This result can be found in your pathology report. There are two tests for HER2: the immunohistochemistry test and the FISH test . The results of these 2 tests are reported differently.
- The immunohistochemistry test looks for overexpression of the HER2 protein. The result is reported as a number from 0 to +3.
- Zero and +1 are considered Her 2 negative.
- +2 is borderline and +3 is considered Her 2 positive.
IHC is faster and costs less money, so it is often the first test done. Patients with a +2 result on IHC should have the FISH test done to see if the borderline result is positive or negative.
If your breast cancer recurs, talk with your provider about re-testing your tumor. Research has shown that HER2 status can change over time. This means if you are HER2 negative, your tumor could become HER2 positive if your tumor is HER2 negative it could become HER2 positive.
How Are Her2 Positive Breast Cancers Treated
Once your provider knows that your cancer is HER2 positive, they can use targeted therapy. Targeted therapy uses medications that target genes and proteins on cancer cells. This slows down or kills the cancer cells while keeping your healthy cells as safe as possible. The targeted therapy medication attaches to HER2 receptors on the surface of breast cancer cells. This blocks the receptors from receiving signals to grow. By blocking the signals, the tumor growth can be slowed or stopped.
- There are a few targeted therapies available for the treatment of HER2+ breast cancers.
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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.
Can Stress Cause Triple Negative Breast Cancer
Social stress connected to triple-negative breast cancer via fat cells. Local chemical signals released by fat cells in the mammary gland appear to provide a crucial link between exposure to unrelenting social stressors early in life and to the subsequent development of breast cancer, according to new research.
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Her2 Positive Breast Cancer Recurrence
HER2 positive breast cancer is an aggressive disease with an elevated risk of metastatic spread if appropriate treatment or therapy is not administered. While HER2 positive breast cancer recurrence affects some patients, recent advancements in targeted therapies and long-term treatment approaches have made relapse less likely than ever before. The majority of patients with HER2 positive cancer do not experience recurrence.
Despite these odds, you may still feel nervous about your chances of cancer recurrence if you have a history of HER2 positive breast cancer. This is completely understandable. The best way to calm your fears and reduce your risk is to be proactive about your breast health, complete all recommended treatments or therapies, and maintain regular follow-up with your breast cancer clinical care team.
How Fast Does Triple Positive Breast Cancer Grow
According to the Robert W. Franz Cancer Research Center at Providence Portland Medical Center, breast cancer cells need to divide at least 30 times before they are detectable by physical exam. Each division takes about 1 to 2 months, so a detectable tumor has likely been growing in the body for 2 to 5 years.
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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.
How Can I Prevent Breast Cancer Recurrence
There is no definitive way to prevent breast cancer or breast cancer recurrence. However, treatments such as surgery, chemotherapy, radiotherapy, targeted therapy and/or hormone therapy do reduce the risk of recurrence, depending on the type and stage of the cancer. These can be discussed with your treatment team.
Understanding breast cancer risk factors and participating in regular breast screening through BreastScreen in Australia and BreastScreen Aotearoa in New Zealand can help to pick up any breast changes. Discussion with your healthcare team can help to catch any changes or abnormalities early and act on them.
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Prognostic Factors And Events
5-year BCSS was 87.4% in the cohort not treated with trastuzumab and 93.4% in the trastuzumab-treated cohort. The 5-year DRFS was 81.6% in the cohort not treated with trastuzumab and 89.7% in the trastuzumab-treated cohort. The 5-year LRFS was 87.4% in the cohort not treated with trastuzumab and 98.0% in the trastuzumab-treated cohort. Kaplan-meier curves of survival with regard to ER and nodal status are displayed in Figures 2, 3 for patients not treated with trastuzumab and Figures 4, 5 for patients treated with trastuzumab. The five-year BCSS, DRFS and LRFS are shown in Table 2.
Figure 2 ER-status in relation to BCSS , DRFS and LRFS respectively in patients that did not receive trastuzumab.
Figure 3 Nodal status in relation to BCSS , DRFS and LRFS respectively in patients that did not receive trastuzumab.
Figure 4 ER-status in relation to BCSS , DRFS and LRFS respectively in patients that was treated with trastuzumab.
Figure 5 Nodal status in relation to BCSS , DRFS and LRFS respectively in patients that was treated with trastuzumab.
Table 2 Subgroup dependent 5-year survival rates.
Table 3 Multivariable cox regression analysis.