The Risks of Breast Cancer Recurrence

Understanding the symptoms, causes, treatment, and prognosis

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The return of breast cancer after a period of remission, referred to as a recurrence, can be extremely distressing—some argue even more distressing than the first diagnosis. After beating the disease the first time around, it is normal to feel sad, anxious, and even angry about what the recurrence means not only about your immediate health but your future.

Even women (and men) who are cancer-free will have moments when they wonder whether the cancer may one day return. The prospect of recurrence is ultimately something that everyone breast cancer lives with. Understanding why it happens and who is at risk can help you make the appropriate health decisions, whether you are faced with a recurrence or hoping to avoid it.

Types

Cancer recurrence, by definition, is the return of the same cancer previously diagnosed and treated. It occurs when cancer cells remain after treatment despite best efforts to eradicate them. These lingering cells can often remain dormant for years and, for reasons not entirely understood, suddenly start to multiply.

The recurrence may develop in the same area as the first malignancy, in the opposite breast, or in some other part of the body. When diagnosed, the recurrence will be categorized as:

  • Local (occurring in the vicinity of the original tumor)
  • Regional (occurring in lymph nodes near original cancer)
  • Distant (occurring in distant organs, often the liver, bone, or brain)

If cancer is discovered within three months of the initial treatment, it is generally not considered a recurrence. Instead, it is seen as cancer progression or treatment failure.

To be considered a recurrence, the malignancy must recur at least a year after the successful completion of cancer therapy.

Symptoms

As with the original breast cancer, the signs and symptoms of a recurrence can vary from one individual to the next. In some cases, the symptoms may be subtle. In others, there may be overt signs, including a lump.

Local or regional recurrence will often present with tell-tale signs, including:

  • Red, swollen, scaling, or puckering breast skin
  • Streaks of color or an "orange peel" skin texture
  • A hot area of breast skin
  • A mass, lump, or thickening of breast tissue
  • Thickening or inflamed scar tissue
  • Enlarged lymph nodes under the arm
  • Nipple changes, including flaky or retracted nipples
  • Clear or bloody nipple discharge

Local, regional, or distant recurrence may also present with more generalized or non-specific symptoms, such as:

  • Explained weight loss
  • Fever and/or chills
  • New cough or shortness of breath
  • Bone pain
  • Right-side abdominal pain under the ribs
  • Swollen lymph nodes in the neck or groin
  • Headaches
  • Vision changes
  • Yellowing of the eyes or skin

It is important to report any changes, however subtle, to your oncologist when they occur rather than waiting until your next appointment which may be months away.

Causes

Because there are so many factors that figure into the risk of recurrence, it is difficult to cite meaningful statistics. The breast cancer type can certainly influence the risk as can the stage and the extent of the initial malignancy. The same applies to the treatment choices, including the use of a breast-conserving lumpectomy versus a total or partial mastectomy.

Other treatment choices, including chemotherapy, radiation therapy, hormone therapy, or targeted therapy, also play a role. Age and family history also factor in.

Less certain is the role that lifestyle factors (such as diet and weight) play in recurrence, although some studies suggest that obesity is associated with the survival and persistence of cancer cells after treatment.

From a statistical viewpoint, there are certain key factors associated with breast cancer recurrence:

Generally speaking, the risk of recurrence is low if lymph nodes are unaffected and the tumor margins (the tissues surrounding a tumor) are cancer-free.

Treatment

The type of treatment used for a local or regional recurrence will vary by the type of treatment you were initially prescribed:

  • If you had a lumpectomy, would most be given a mastectomy since radiation therapy cannot be delivered twice in the same area.
  • If you had a mastectomy, you would undergo surgery to remove the tumor, followed by radiation therapy to kill any remaining cancer cells.
  • If a tumor is found in the opposite breast, a tissue sample would be obtained to determine whether it is the same or different type of cancer. Based on the results, you may undergo a mastectomy or a lumpectomy with radiation.

In any circumstance, chemotherapy and/or hormone therapy may be explored. Immunotherapy with Herceptin (trastuzumab) may be used with or without chemotherapy for women with HER2+ breast cancer to prevent future recurrence.

Women with a distant recurrence are treated with systemic therapies (and less commonly with surgery and radiation) to control the growth of the tumor. Cancers like these are categorized as stage 4, meaning that they cannot be cured. Instead, the focus would be placed on managing pain and maintaining the optimal quality of life.

Prevention

There is no clear way to prevent cancer recurrence. Even if you do everything "right," breast cancer can still return. Arguably the best strategy is to identify a recurrence early when treatment is most effective. This involves keeping your appointments, having routine mammograms, and staying linked to care with a medical team that knows your history.

You would also be well served to maintain a healthy lifestyle by eating right, exercising regularly, cutting back on alcohol, and losing weight if needed.

Prognosis

The likely outcome of a breast cancer recurrence, known as the prognosis, is largely dependant on whether the recurrent is local, regional, or distant. Generally speaking, the more advanced the malignancy is, the greater the impact on survival

For example, in the same way that lymph node involvement increases the risk of a recurrence, it also increases the risk of breast cancer-related death. A 2019 study in PLoS One reported that women with triple-negative breast cancer (an especially aggressive form of the disease) have no less than a five-fold increased risk of recurrence and death if regional lymph nodes are involved.

None of this should suggest that breast cancer recurrence will inherently shorten your life span. Some women are successfully treated following the diagnosis and go on to live long, healthy lives.

A 2016 study from the University of Texas reported that, among 881 women with triple-negative breast cancer, only 16 deaths occurred in the five years following recurrence. Of these, most occurred within a year due to an advanced malignancy.

Coping

If you have been diagnosed with breast cancer recurrence, the emotional impact can be just as profound as the physical impact. More than ever, it is important to reach out to your support network of friends, family, and health professionals. You should also seek a support group of breast cancer survivors who understand first-hand what you are going through.

While you may feel like hiding under the bed covers, make every effort not to isolate yourself or numb your grief with pills or alcohol. Start by accepting that whatever you are feeling—whether it be anger, fear, sadness, or depression—is perfectly normal, and share those feelings with others you trust.

Even if you are not faced with breast cancer recurrence, it is not unusual to feel on edge at times, wondering if a certain pain or redness is a sign that the cancer is returning. It's important not to swallow these feelings, but, at the same time, don't allow them to control your life.

If you are unable to cope, seek professional help from a qualified therapist or psychiatrist. Going through the experience of breast cancer is invariably traumatic, often manifesting with anxiety and depression for months and years after treatment. By reaching out and asking or help, you can work through these emotions and be better equipped to face whatever challenges lie ahead.

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