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Recurrence: When Cancer Returns

When breast cancer comes back, it is known as recurrence because it is not a new cancer. A recurrence can occur in the same breast where the cancer first appeared, in the neighbouring lymph nodesLymph nodes:
Small structures that filter lymph fluid for harmful substances. They contain immune cells that can help fight infection by attacking and destroying germs. Cancer can travel through the lymphatic system spread to the lymph nodes.
, on the chest wall after a mastectomyMastectomy:
Surgery to remove all or part of the breast and sometimes other tissue.
, or at a distant site in the body.

Risk of Recurrence

The risk that breast cancer will return is estimated by your health care team when you are first diagnosed with breast cancer and depends on several factors – the stageStage:
A way of classifying breast cancer that describes how far a cancer has spread. It identifies whether breast cancer is at an early, locally advanced or metastatic stage. The stage of breast cancer can sometimes be represented as a number (e.g. between 0 and 4).
and gradeGrade:
A way of classifying cancer that describes how aggressive the cancer is likely to be (i.e., how fast it will grow and spread).
of the cancer, its receptorReceptor:
Cells have many different proteins on their surface called receptors. Her-2 is one kind of receptor. In normal cells, HER-2 receptors are thought to be involved in cell growth and reproduction. In some breast cancers, there are too many HER-2 receptors and they speed up cancer cell growth.
status, if any lymph nodes were affected and how many. The treatment that your health care team recommends takes into consideration the risk of breast cancer recurrence.

Some of the medications used to treat hormone receptor and HER-2HER-2-neu:
Cells have many different proteins on their surface called receptors. HER-2 is a type of naturally occurring receptor. In normal cells, HER-2 receptors are thought to be involved in cell growth and reproduction. In some breast cancers, there are too many HER-2 receptors and they speed up cancer cell growth. HER-2 therapy is used to treat some breast cancers by targeting receptors that stimulate breast cancer growth.
positive breast cancers may also be used to help reduce the risk of recurrence. Your health care team may recommend that you take hormone therapyHormone therapy:
A treatment method for breast cancer that uses medication to block the production of the hormone estrogen, or the way that it works in the body.
(e.g., tamoxifen) or HER-2 therapyHER-2 targeted therapy:
A treatment method that uses medication to target HER-2 receptors that stimulate breast cancer growth.
(e.g. herceptin) for a number of years after your active breast cancer treatment is complete.

If breast cancer does recur, the prognosisPrognosis:
A prediction of the likely outcome and chance of recovery from a disease. A doctor makes a prognosis based on statistics and other information gathered from studies of a large number of people with the same disease. Prognosis affected by the type and severity of the disease, treatments available and other factors such as the age and overall general health of the person affected.
(the likely outcome of your condition and chance of recovery) depends on the location and the extent of the recurrence, the original treatment that you received, and the time that has passed since your initial diagnosis and treatment.

There are no special diets, vitamin supplements or physical activities that have been definitely proven to prevent the recurrence of breast cancer. However, living well— by having a healthier body weight, being physically active, limiting alcohol use and quitting smoking —promotes overall health and wellness and reduces your risk of many diseases.

While there is still much more to learn, research is beginning to provide more information on how lifestyle factors may affect the risk of breast cancer recurrence. For example, a recent study showed that women who exercised while receiving chemotherapyChemotherapy:
A treatment method that uses medication to destroy cancer cells.
had a lower risk of breast cancer recurrence and a lower overall mortality rateMortality (rate):
The number of people that die from a disease in a population over a period of time.
eight years after their initial chemotherapy treatments began, compared to women who did not exercise during treatment.

If you are concerned about your risk of recurrence, speak to your health care provider, health care team or oncologistOncologist:
A doctor or surgeon who specializes in treating cancer. A medical oncologist specializes in drug therapy (chemotherapy) for cancer. A radiation oncologist specializes in treating cancer with radiation.
about your concerns and ways to help reduce the risk.

Diagnosis

After making it through your first diagnosis and treatment, a diagnosis of recurrence can be discouraging. Recurrence may be even more daunting than your first diagnosis because you now know the kinds of changes and adjustments you will have to make if the recurrence is to be treated. However, it is also possible that recurrence may feel less daunting because you have the experience of your original diagnosis to draw upon this time.

Recurrence is often classified by the location where cancer is detected:

Diagnosing Recurrence

Your follow up care will include regular check-ups with your specialist, family doctor or nurse practitioner, regular mammogramsMammogram (also called mammography):
A low-dose X-ray of the breast. It is used to take images of the breasts and is an important screening tool for the earlier detection of breast cancer.
and clinical breast examinationClinical breast exam (CBE):
A physical examination of the breasts by a health-care provider.
.

There are no special tests that are useful in detecting breast cancer recurrence. Breast cancer recurrence that occurs within the breast may be found by mammography, clinical breast examination, or a combination of the two. Often, recurrences are found between follow-up visits with a health care provider, either by chance, or because a new symptom develops. If you find a lumpLump:
A mass that can be found in the breast or elsewhere in the body. This can also be called a nodule.
in your breast, at the location of the original tumour or elsewhere, it does not necessarily mean that your breast cancer has returned. There may be scar tissue or other tissue changes that have occurred in the area where you had treatment. If you notice any changes in your breast tissue, it is important to get them checked by a health care provider.

Some people think that if you have had a mastectomy, you cannot get breast cancer in the area where the breast was removed. However, breast cancer can come back in the skin where the breast used to be, in any tissue that remains (e.g., muscle on the chest wall), or even in a reconstructed breast.

The process of diagnosing breast cancer when it returns is similar to when it occurs for the first time. Your health care provider may order imaging tests and a biopsyBiopsy:
A procedure in which tissue samples are removed from the body for examination under a microscope to determine if cancer or other abnormal cells are present.
to confirm a diagnosis. Tissue that is collected during a biopsy will be sent to a lab to be examined by a pathologistPathologist:
A doctor who specializes in the diagnosis of disease by examining cells, body fluids and tissue.
under a microscope. The pathologist will also check for hormone and HER-2 receptor status. When breast cancer returns, it can have different properties than the original cancer. For example, a hormone receptor positive breast cancer may be hormone receptor negative when it returns. This means that the treatment you receive may be different than the first time.

Metastasis – when cancer spreads

Metastatic breast cancer (also known as secondary cancer) has spread from the breast to distant tissues or organs in the body. When breast cancer spreads, or metastasizes, the most common sites include the bone, liver, brain and lungs. Once it has spread to distant parts of the body, breast cancer is no longer considered curable. However it can still be treated, and many people live with metastatic breast cancer for a long time.

Treatment Options

The location and other characteristics of the recurrence will help you and your health care team decide how to proceed.

The treatment options available are the same for recurrence as for the primary cancer: surgery, radiation therapyRadiation therapy (Sometimes called radiotherapy):
A treatment method that uses a high energy beam to destroy cancer cells by damaging the DNA of cancer cells so that they can’t continue to grow.
, chemotherapy, hormone therapy and HER-2 therapy. However, the treatment choices for your recurrence may be different from your previous treatment plan. For example, if you had radiation therapy previously, you may not be able to have it again, or the receptor status of the breast cancer may have changed. Remind yourself that you got through treatment before and the experience you gained may help you cope as you deal with the recurrence.


Sources:

Breastcancer.org. Recurrent and Metastatic Breast Cancer. Accessed January 21, 2014

Canadian Breast Cancer Foundation-Ontario Region & Princess Margaret Hospital. (2010). Getting Back on Track. Life after breast cancer treatment. Toronto, ON: Canadian Breast Cancer Foundation.

Courneya, K.S., Segal, R.J., McKenzie, D., et al. (2014). Effects of Exercise during Adjuvant Chemotherapy on Breast Cancer Outcomes. Medicine and Science in Sports and Exercise. Published ahead of print.