Triple-Negative Breast Cancer Recurrence After Mastectomy

Triple-negative breast cancer (TNBC) is harder to treat than other types of breast cancer because it lacks the three most common proteins—estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 (HER2/neu)—that targeted medications act upon to reduce tumor growth.

Most breast cancers, especially when detected early, are treated successfully with different approaches to therapy, including surgery (lumpectomy or mastectomy), chemotherapy, and radiation.

Even when initial treatment leads to remission, the chance of TNBC recurrence remains higher than in other breast cancers. Recurrence rates after standard conventional therapy (surgery, chemotherapy, and radiation therapy) are around 25%.

This article will discuss recurrence rates for triple-negative breast cancer with and without mastectomy and by stage. It will also review symptoms of recurrence and preventative measures.

Recurrence Rates in Triple-Negative Breast Cancer Patients

Surgical removal of breast cancer may be done with lumpectomy (breast-conserving surgery), which is usually followed by radiation therapy, or with mastectomy (removal of the entire breast, sometimes with lymph node dissection-removal of the lymph nodes in the armpit). Mastectomy may or may not be followed by radiation therapy.

Chemotherapy is also given for TNBC. It may be given before surgery (neoadjuvant chemotherapy), after surgery, or both.

As TNBC is known to have a higher rate of recurrence, more aggressive surgical treatment (mastectomy instead of lumpectomy) might be preferred by some healthcare providers.

Without Mastectomy

Some studies have found that the type of surgery is not a significant factor in recurrence. For example, a study of lumpectomy found no more local recurrence of cancer in TNBC than in other subtypes.

With such studies in hand, healthcare providers can consider the individual case and decide whether it can be treated with breast-conserving surgery or lumpectomy, plus radiation and systemic treatments like chemotherapy.

After Mastectomy

Mastectomy, and sometimes lymph node dissection, is often recommended for people with TNBC due to its aggressive nature.

By the time TNBC is found, many people have large tumor size, lymphovascular invasion (tumor cells in the blood vessels or lymph vessels), and lymph node lesions, indicating that cancer has begun to spread outside of the breast cavity.

Recurrence after mastectomy is highly dependent on the stage (determined by whether and how far the cancer has spread) and the extent of lymphovascular infiltration when surgery is performed.

An analysis of 390 cases found that the risk of local TNBC recurrence was higher in people under 50, those with lymphovascular infiltration, those with a higher degree of lymph node involvement (presence of cancer in three or more lymph nodes), and those with stage 3 disease (advanced but without spread to other organs).

Even more, the risk was highest in those with two or more of these factors, with the five-year frequency of regional recurrence in the presence of one factor being 4.2% compared to 25.2% for two factors and 81% in the presence of three or more factors.

Recurrence Rate by Stage

The stage at diagnosis is a key factor in the recurrence rate for triple-negative breast cancer. The stage denotes how far cancer has spread at the time of diagnosis.

The high recurrence rate generally reported for TNBC reflects that this cancer is often discovered when it is more advanced. The numbers are better for cancer found in the early stages.

For early-stage triple-negative breast cancer (stages 1 and 2 without spread to the lymph nodes), the recurrence rate is far lower than for more advanced TNBC. A 2013 study found the five-year cumulative incidence rate of locoregional recurrence (in tissues near the original site or nearby lymph nodes) in early-stage TNBC was 4.2% with lumpectomy and 5.4% with mastectomy.

Unfortunately, reporting local or locoregional recurrence numbers does not reflect that the vast majority of recurrence is distant metastasis. A New Zealand study of people with TNBC but without distant metastasis at diagnosis reported that 74% of first recurrences were distant metastases (often to the lung or multiple sites).

A study of people treated with stages 2 or 3 triple-negative breast cancer treated with preoperative chemotherapy and breast-conserving surgery showed locoregional recurrences in 21.3% (mostly in lymph nodes in the breast and armpit), local recurrence in 14.8%, and distant metastases in 29.5%.

These numbers continue to change based on the development of new therapies and treatment strategies. By definition, five-year statistics cannot show the effects of treatments introduced in less than five years.

Symptoms of Recurrence

Symptoms associated with recurrence vary depending on their location in the body. Local recurrence symptoms mimic the symptoms people living with TNBC originally experienced before treatment. Local symptoms include:

• New lumps
• Skin discoloration
• Skin irritation or swelling
• Skin changes such as thickening or dimpling of the skin 
• Nipple changes such as flattening, inversion, or dimpling
• Bumps on the chest wall, either under or on the skin

More regional TNBC recurrence is characterized by lymph node involvement and metastasis to nearby organs such as the breastbone or throat. Regional recurrence symptoms include: 

• Trouble breathing
• Trouble swallowing
• Lumps under the arm, along the collarbone, or near the breastbone
• Loss of feeling (or pain) in the arm or shoulder 
• Swelling on the affected side (often where mastectomy was performed)

More distant recurrence symptoms usually manifest as a combination of generalized and organ-specific symptoms. Metastatic symptoms include:

• New, unexplained weight loss
• Severe and sudden headaches
• Bone pain
• Sudden falls/difficulty with balance 
• Numbness
• Weakness
• Loss of appetite 

Prevention Measures  

Taking a low dose of Xeloda (capecitabine)—a chemotherapy drug—for one year after surgery to remove early-stage triple-negative breast cancer plus standard postsurgical chemotherapy may reduce your risk of TNBC recurrence. In a study, the five-year recurrence rate after this treatment was 17.2%, compared with 27% in those who did not receive this maintenance treatment.

Lifestyle modifications also decrease your general risk. These include: 

• Eating healthy
• Limiting stress
• Exercising regularly
• Maintaining a healthy weight
• Quitting smoking
• Limiting alcohol consumption
• Seeing your healthcare provider regularly and attending screenings 
• Managing other comorbidities (co-occurring medical conditions)

Summary

Few breast cancers are more aggressive and harder to treat than triple-negative breast cancer (TNBC). Even after initial success with conventional treatment such as mastectomy, recurrence rates remain high. Breast-conserving surgery (lumpectomy) may be an option as recurrence rates are similar to those of mastectomy.

The treatment chosen will depend on the size of the tumor, stage, and other factors. Early-stage TNBC has a lower rate of recurrence than advanced stages.

A Word From Verywell 

TNBC’s disease course can be unpredictable whether people have had a mastectomy or not. Although it is unclear why one person experiences recurrence but another does not, engaging with supportive family and friends who encourage you to live your healthiest possible life can greatly improve your quality of life.