Breast Cancer Recurrence: Symptoms, Causes, and Prognosis

The return of breast cancer after a period of remission, referred to as a recurrence, occurs when cancer returns after treatment, despite best efforts to eradicate it. Lingering cancer cells can often remain dormant for years and, for reasons not entirely understood, they may suddenly start to multiply. A recurrence may develop in the same area where cancer first appeared, in the opposite breast, or in another part of the body.

The prospect of recurrence is ultimately something that everyone with 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.

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Types

When diagnosed, a recurrence will be categorized as:

Local: Occurring in the same place or near the original tumor
Regional: Occurring in lymph nodes near the original cancer
Distant: Occurring in distant organs, often the liver, bone, or brain.

If cancer grows or spreads during your treatment, this would be defined as cancer progression or treatment failure.

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

Smiling patient talking with doctor while sitting on bed at hospital — Cavan Images / Getty Images

Symptoms

As with the original breast cancer, the signs and symptoms of a recurrence can vary. 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 cause non-specific symptoms, such as:

Unexplained 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.

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Causes

There are many factors that figure into the risk of recurrence. The breast cancer type, the stage, the extent of the initial malignancy, and treatment choices can all influence the risk of recurrence. Treatments can include a combination of breast-conserving lumpectomy, total or partial mastectomy. chemotherapy, radiation therapy, hormone therapy, targeted therapy, or immunotherapy. Age and family history factor in as well.

It's not clear whether lifestyle factors (such as diet and weight) play a role in recurrence, although some studies suggest that obesity can worsen outcomes.

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 is associated with a 6% risk of recurrence within five years if cancer has not spread to lymph nodes. If cancer has spread to lymph nodes, the risk increases to 23% if there's no radiation treatment.
Women with hormone-receptor-positive (ER+) and HER2-positive (HER2+) cancer were less likely to experience the first recurrence in bone and more likely to have a recurrence in the brain than women with hormone-receptor-positive and Her2-positive (HER2+) 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 (20% 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 surgical tumor margins (the tissues surrounding a tumor) are cancer-free. That said, even small stage 1A breast cancers may sometimes recur.

Late Recurrence

Breast cancers may recur at any time. In fact, estrogen-receptor-positive breast cancers are more likely to recur after 5 years than in the first 5 years.

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 14 years after treatment as three years after treatment.

Treatment

Treatment of a recurrence will depend on whether it is local, regional, or distant.

Local/Regional Recurrence

The type of treatment used for treating a local or regional recurrence can vary based on the type of treatment you initially had:

If you had a lumpectomy, a mastectomy will be recommended, since radiation therapy cannot be delivered twice in the same area.
If you had a mastectomy, you might undergo surgery to remove the recurrent 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 a different type of cancer. You may then undergo a mastectomy or a lumpectomy with radiation.

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

Distant Recurrence

If you have a distant recurrence, you might be prescribed systemic therapies (and less commonly, surgery and radiation) to control tumor growth. Cancers like these are categorized as stage 4, and that cannot be cured. Your treatment would be focused on extending your life and maintaining your 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. There are many clinical trials currently in place looking for better treatments for metastatic breast cancer.

Prevention

Tamoxifen, a drug approved for breast cancer risk reduction, can lower the incidence of invasive, ER-positive breast cancer in high-risk women. Aromatase inhibitors have also been proven to help prevent breast 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 expected to be 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.

Prognosis

The prognosis after a recurrence depends on whether the recurrent is local, regional, or distant. Generally speaking, more advanced malignancy is associated with shorter anticipated survival.

A 2019 study in PLoS One reported that women with triple-negative breast cancer (an especially aggressive form of the disease) have a higher 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 for recurrence and go on to live long, healthy lives.

A 2016 study from MD Anderson reported that, among 881 women with triple-negative breast cancer who were disease-free after five years, only 16 deaths occurred in the subsequent five years. Of these, most occurred within a year due to an advanced malignancy. This indicates a low probability of recurrence after five years disease-free.

Coping

If you have been diagnosed with breast cancer recurrence, the emotional impact can be just as profound as the physical impact. In fact, some people say 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 for your immediate health and 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, and, at the same time, not to 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 traumatic, and it can manifest 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.