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Recurrent Breast Cancer

Definition


Disease: Recurrent Breast Cancer Recurrent Breast Cancer
Category: Tumors

Disease Definition:

When the breast cancer comes back following initial treatment, it is called recurrent breast cancer. A few cancer cells might survive despite the fact that treatment is aimed at eliminating all cancer cells. Recurrent breast cancer occurs when these undetected cancer cells multiply.

 

Months or even years after the initial treatment, recurrent breast cancer may occur. In the same place as the original tumor, the cancer may come back, in which case it's known as local recurrence, or it might spread to other areas, usually the liver, lungs or bones.

 

It might be harder for the patient to learn that she has recurrent breast cancer than dealing with the initial diagnosis. Locally recurrent breast cancer may be eliminated by treatment, meaning that recurrent breast cancer is not hopeless. Treatment may control the disease even if a cure isn't possible.
 

Work Group:


Symptoms, Causes

Symptoms:

Depending on where the cancer comes back, signs and symptoms of recurrent breast cancer vary. It might appear as a lump on the chest wall near where the original cancer was, a lump in the breast or a thickening of the surgical scar. It might also show up in a distant place in the body like the liver, the lungs or a bone, and it might be detected in an abnormal finding on a mammogram of the breast where the patient had a lump removed (lumpectomy).

 

LOCAL RECURRENCE:

Cancer reappears in the same area as the original or "primary" tumor in a local recurrence. It may be in the chest wall or skin of women who have had a mastectomy, or it can be in the remaining breast in women who have had a lumpectomy. 

 

In the case of a local recurrence within the same breast, signs and symptoms may include:

 

  • A new thickening in the breast area
  • Flattening or indentation of the nipple or other nipple changes
  • Skin inflammation or area of redness
  • A new pulling back of the skin at the lumpectomy site
  • A new lump in the breast or irregular area of firmness
  • In the case of a local recurrence on the chest wall after a mastectomy, signs and symptoms may be:
  • A new area of thickening along or near the mastectomy scar
  • One or more painless nodules on or under the skin of the chest wall

 

REGIONAL RECURRENCE:

When the cancer comes back in the lymph nodes in the armpit or collarbone area, it means that it's a regional breast cancer recurrence. The signs and symptoms of this regional recurrence might include:

 

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

 

DISTANT (METASTATIC) RECURRENCE: 

When the cancer has traveled to distant parts of the body, usually the liver, lungs and bones, it means that there's a distant or metastatic recurrence. Signs and symptoms for this type may include:

 

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

 

The patient should continue to see the doctor regularly for follow-up exams after being treated for breast cancer. Any signs of cancer recurrence will be checked. If the patient had a lumpectomy, she will also have an annual mammogram. But still, many women discover recurrent breast cancers on their own, because when it comes to what feels normal and what doesn't, each woman knows her body best. Additionally, to look for changes, the breasts should be checked monthly.

 

Weight loss, new pain, shortness of breath and changes or new lumps in the breast or surgical scar and such signs and symptoms of recurrent breast cancer are important to be aware of. A woman should talk to her doctor if she experiences any signs and symptoms that may suggest a recurrence.
 

Causes:

Cells that originally came from the primary breast tumor form a recurrent breast cancer. After the initial treatment and a period of time when no cancer was detected, the cancer returns. When treatment doesn’t fully destroy or remove all the cancer, this may happen. Even with surgery, small clusters of cancer cells may have been left behind that were too small to be detected with any test.

 

Isolated cells may survive the rounds of chemotherapy and radiation meant to stop recurrence if the cancer is aggressive. Cancer cells may develop the ability to spread (metastasize) or may sometimes be resistant to these treatments.

 

Without causing harm, sometimes a single cancer cell may be dormant for years. This cell grows and makes other cells if something that activates it. However, the growth factors for cancer have not all been found.

 

A second or new primary tumor is when a new tumor develops in the same breast as the first tumor or in the other (contralateral) breast.

 

There's a difference between a second primary cancer in the breast and recurrent breast cancer. The risk of developing breast cancer in the other breast for women who've had breast cancer is higher than those who've never had breast cancer. Additionally, if a woman has hereditary breast cancer or if she has a strong genetic predisposition, her risk will be even greater. However, the good thing is that most women who have breast cancer don't develop cancer in their other breast.

 

Some of the factors that may increase a woman's risk of developing a recurrent breast cancer are:

Positive or close tumor margins:

During an operation to remove a breast lump, the cancerous lump will be removed in addition to a healthy margin of normal tissue. A negative margin is when the borders of the removed tumor are free of cancer when examined under a microscope. However, if the margin between the tumor and normal tissue is close, or if the edge of the tumor has cancer cells, then it will be considered a positive margin. In this case, the woman will have an increased risk of breast cancer recurrence.

Lymph node involvement:

A woman's risk of recurrent breast cancer will be increased in case cancer is found in the nearby lymph nodes. This risk will be even greater in case multiple lymph nodes are affected.

Not enough radiation treatment after lumpectomy:

When a woman undergoes lumpectomy, also known as wide local excision, in order to preserve her breast, she should undergo radiation treatments to the remaining breast for the purpose of decreasing the chance of a local recurrence. Lumpectomy followed by radiation has shown to work just as well as mastectomy, which is the removal of the entire breast.

Larger tumor size:

Women will have a higher risk of the cancer recurring in the same area in case their tumors are very large, namely more than 5 centimeters (about 2 inches). Even if these women undergo mastectomy, they should still consider radiation therapy.

Inflammatory breast cancer:

Treatment for women with inflammatory breast cancer will involve mastectomy as well as radiation to the chest wall because these women have a higher risk of local recurrence.

Age:

Women will have a higher risk of recurrent breast cancer in case they are under the age of 60, especially those under the age of 35 at the time of their original breast cancer diagnosis.

 

In these last few years, genetic tests have been developed that are designed to predict the risk of breast cancer recurrence. In a process called gene expression profiling, these tests measure the activity of up to 70 genes that are associated with breast cancer. The results of these tests will be used in estimating the chances of breast cancer recurrence.

 

However, until now, these tests are available only for women with estrogen receptor positive tumors that don't show any sign of spread to the lymph nodes. These tests, whose roles are still limited, have been used in planning treatment for primary breast cancer in a small number of women. In order to determine if these tests can prove useful on a broader scale, more research is needed.
 

Complications

Complications:

Pain, discomfort and swelling are some of the things that local cancer recurrences may cause in that particular area. Although in about one-fourth to one-third of the cases of recurrent breast cancer the disease may appear in a distant area in the body, such as a lung, bone or the liver, but in most cases, local recurrences can be cured. The cancer is usually not curable if it spreads beyond the breast and nearby areas.
 

Treatments:

Many factors will be considered in the planning of recurrent breast cancer treatment. Some of those factors are the level of the disease, its hormone receptor status and the type of received treatment for the original breast cancer.

 

A combination of radiation, surgery, hormone therapy and chemotherapy is what the treatment for most cases of recurrent breast cancer involves. A biotherapy such as trastuzumab may be used in the case of a breast cancer that makes extra amounts of the HER2 protein.

 

The patient should talk with the doctor to learn about her treatment options, because decisions for recurrent breast cancer treatment are usually complex and individualized.

 

HOW TO TREAT A LOCAL RECURRENCE:

A local recurrence is usually treated with surgery that may include hormone therapy; chemotherapy; and radiation, in case the patient hasn't had it before.

Surgery:

A mastectomy is the standard treatment for a recurrent breast cancer that is confined to the breast. The surgeon will remove all the breast tissue during this surgery including the ducts, nipple, lobules, fatty tissue and skin. A woman may also undergo surgery to remove the new cancer as well as a margin of normal tissue in case her first breast cancer was treated with a mastectomy but then came back in the chest wall.

 

A hidden cancer in the nearby lymph nodes may accompany a local recurrence. Because of this, in case the lymph nodes under the patient's arm weren't removed during the initial treatment (axillary dissection), they will be removed during this surgery.

Radiation therapy:

High-energy X-rays are used in this therapy to kill cancer cells and shrink the tumors. The patient may be recommended radiation therapy in case she didn't have it for her first breast cancer. On the other hand, radiation won't be recommended due to the risk of side effects in case the patient had radiation after a lumpectomy.

Chemotherapy:

Chemotherapy may be recommended before surgery in case the recurrent breast cancer involves the skin or if it is the inflammatory type. Additionally, if surgery isn't an option due to the extent of the recurrent cancer, chemotherapy may also be recommended.

Hormone therapy:

Some examples of hormone therapy are tamoxifen or an aromatase inhibitor, such as exemestane, anastrozole or letrozole. In case the cancer is hormone receptor positive, the patient may be recommended medications that block the growth-promoting effects of estrogen and progesterone. Recurrent breast cancer may be shrunk and controlled with hormone therapy.

 

HOW TO TREAT REGIONAL RECURRENCES:

In the case of a regional recurrence, the recommended treatment is surgery to remove the recurrence if it is possible. Additionally, if the lymph nodes under the arms are still present, they will also be removed during this surgery (axillary dissection).

 

However, the patient's main treatment will be radiation treatment in case surgery isn't possible. Hormone therapy and chemotherapy may either follow the surgery or radiation, or they may be the main treatment.

 

HOW TO TREAT A METASTATIC RECURRENCE:

There are many different options for treating a recurrent breast cancer that has spread beyond the region of the breast. In case one of those treatments doesn't work or if it stops working, the patient might be able to try other treatments. However, in order to know the most appropriate approach for the patient's particular situation, she should talk to her doctor.

 

Curing the disease isn't the goal of treatment for a metastatic recurrence. Treatment in this case will relieve the symptoms of cancer, and it may give the patient a longer life. The objective of this treatment is to allow the patient live as well as possible for as long as possible.

 

Treatment for metastatic recurrence will involve the patient's whole body (systemic therapy) instead of local therapy such as surgery or radiation, in case the cancer has spread to other parts of the body. Hormone therapy, biotherapy and chemotherapy are some of the options of systemic therapy.
The patient's therapy may start with tamoxifen or an aromeatase inhibitor because hormone therapy is less toxic than chemotherapy. However, the patient may be recommended starting with chemotherapy in case her cancer is fast-growing or if it has already spread to other organs such as the liver and lungs.

 

The patient may also be given a biotherapy to attack the protein that is overproduced in the cancers in case her cancer is HER2 positive. Bevacizumab, lapatinib and trastuzumab are some examples of biotherapy.

 

The patient may also undergo localized treatments such as medications or radiation to treat the disease in her bones, depending on where the cancer has spread and what are its symptoms.
 

Prognosis:

Not available

Expert's opinion

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