The Risks of Breast Cancer Recurrence

The return of breast cancer after a period of remission, referred to as a recurrence, 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. A recurrence may develop in the same area as the first malignancy, in the opposite breast, or in some other part of the body.

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 working to avoid one.

When diagnosed, a recurrence will be categorized as:

• Local: Occurring in the vicinity of the original tumor
• Regional: Occurring in lymph nodes near the original cancer
• Distant: Occurring in distant organs, often the liver, bone, or brain. Most people who have metastatic breast cancer first had an early stage breast cancer that was followed by a distant recurrence.

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.

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, as is the case with a lump.

Local or regional recurrence will often present with telltale 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

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 factor in as well.

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:

• Lumpectomy followed by radiation is associated with a 3% to 15% risk of a local recurrence within 10 years, according to a 2017 study from the Dana-Farber Cancer Institute.
• Mastectomy without lymph node involvement is associated with a 6% risk of recurrence within five years. If lymph nodes are involved, the risk increases to 23% if radiation is not pursued.
• Women with hormone-receptor-positive (ER+) and HER2-positive (HER2+) cancer are 35% and 110% more likely to have a recurrence in the brain and bone, respectively, than women with HER-/HER+ cancer, according to a 2012 study in Breast Cancer Research.
• Younger age is also a key risk factor. A 2015 study from Emory University reported that women under 40 had higher rates of local or regional recurrence (24% vs. 7%) and distant metastases (18% vs. 5%) than women 75 or older.

The risk of recurrence is generally low if lymph nodes are unaffected and the tumor margins (the tissues surrounding a tumor) are cancer-free. That said, even small stage IA breast cancers may sometimes recur.

While public opinion often equates surviving 5 years with breast cancer to a cure, breast cancers may recur at a later time. In fact, estrogen-receptor positive breast cancers are more likely to recur after 5 years than in the first 5 years following diagnosis. A 2018 study looking at recurrence after 5-years of hormonal therapy (tamoxifen or an aromatase inhibitor) found that the risk of recurrence remains constant for at least 20 years. In other words, an estrogen receptor positive breast cancer is just as likely to recur in the period 13 years to 14 years after diagnosis as it is between the third and fourth year out.

Treatment of a recurrence will depend on whether it is local/regional or distant (metastatic).

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, a mastectomy is likely, 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 extending life and maintaining the optimal quality of life.

Treatment options for metastatic breast cancer can include chemotherapy, targeted therapies, and immunotherapy (for metastatic triple negative breast cancer). Some drugs are used primarily for people who have BRCA mutations, and others are used for anyone. There are many clinical trials currently in place looking for better treatments for metastatic breast cancer.

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.

Maintain a healthy lifestyle by eating right, exercising regularly, cutting back on alcohol, and losing weight, if needed, to help lower your overall risk.

Clinical trials are currently in place looking at therapies such as daily low dose aspirin and melatonin to reduce recurrence risk, but it's not known if these treatments will be effective at the current time.

The likely outcome of a breast cancer recurrence, known as the prognosis, is largely dependent 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 nearly a three-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.

If you have been diagnosed with breast cancer recurrence, the emotional impact can be just as profound as the physical impact. In fact, some argue that this news is even more distressing than receiving their first diagnosis. It is normal to feel sad, anxious, and even angry about what the recurrence means not only for your immediate health but your future.

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 firsthand 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 for help, you can work through these emotions and be better equipped to face whatever challenges lie ahead.