Occasionally breast cancer can return after primary treatment. There are three types of recurrent breast cancer:
- Local recurrence: Cancerous tumor cells remain in the original site, and over time, grow back. Most physicians do not consider local breast cancer recurrence to be the spread of breast cancer, but rather, failure of the primary treatment. Even after mastectomy (surgical removal of the affected breast), portions of the breast skin and fat remain, and local recurrence is possible (however, it is uncommon).
- Regional recurrence: A regional recurrence of breast cancer is more serious than local recurrence because it usually indicates that the cancer has spread past the breast and the axillary (underarm) lymph nodes. Regional breast cancer recurrences can occur in the pectoral (chest) muscles, in the internal mammary lymph nodes under the breastbone and between the ribs, in the supraclavicular nodes (above the collarbone), and in the nodes surrounding the neck.
- Distant recurrence: A distant breast cancer recurrence, also known as a metastasis (spread), is the most dangerous type of recurrence. Once out of the breast, cancer usually spreads first to the axillary (underarm) lymph nodes. In 25% of distant recurrences, breast cancer spreads from the lymph nodes to bone. Other sites breast cancer may spread to include the bone marrow, lungs, liver, brain, or other organs.
Often, a diagnosis of recurrent cancer is more devastating or psychologically difficult for a woman than her initial breast cancer diagnosis. Women who have recurrent breast cancer are encouraged to discuss their feelings with a counselor or therapist and consider joining a support group.
Breast cancer most commonly recurs in the same area as the original cancer had occurred. Women with ductal carcinoma in situ (DCIS) who are treated with breast-conserving therapy (lumpectomy and radiation) are at a slightly higher risk of experiencing a recurrence than those women who are treated with mastectomy (removal of the affected breast). However, several studies have shown that women treated with breast conserving therapy who have local recurrence of DCIS are not at any significantly greater risk of dying from the disease than women treated with mastectomy. DCIS is a common type of cancer that is confined to the milk ducts of the breast.
A recurrence of non-invasive breast cancer is less serious than a recurrence of invasive cancer. In general, invasive local recurrences are more aggressive since they have a second chance of spreading (metastasizing) to other areas of the body.
Once recurrent breast cancer has been detected, physicians will order additional tests to determine to what extent the cancer has spread. These tests may include: bone scan, chest X-ray, CAT scan, MRI scan, and liver blood tests. Treatment of a local recurrence often depends on how the initial treatment was performed. If lumpectomy was performed, recurrent breast cancer will usually be treated with mastectomy.
A local recurrence after mastectomy will usually present itself as a small lump in the mastectomy scar or under the skin. This type of recurrence often goes undetected for some time because it may be mistaken for a leftover stitch or scar tissue from the mastectomy operation. Once the lump grows, breast biopsy is performed to determine whether it is cancerous.
Breast reconstruction rarely hides recurrent breast cancer. Local recurrences with implants are most often in front of the implant, and recurrences with TRAM flap procedures are along the edge of the breast skin (not in the flap).
Women whose initial breast cancer was aggressive are more likely to have recurrences than other women. Inflammatory breast cancer with cancer cells in the lymphatics of the skin or breast often recurs. (Lymphatics are key components of the body’s immune system). Also, women with large tumors or several cancerous lymph nodes may experience recurrent breast cancer. Often, these types of recurrent cancers are treated with mastectomy (if it was not performed during primary treatment) followed by radiation therapy to the chest wall.
Regional breast cancer recurrences are rare, occurring in approximately 2% of all breast cancer cases. Most often, regional recurrence appears as a cancerous axillary (underarm) lymph node that was not removed during primary treatment. Treatment involves simply removing the cancerous node. Regional recurrence in the lymph nodes of the neck or above the collarbone usually indicates more aggressive cancers.
Besides local and regional recurrences, a new cancer may occasionally occur years after the initial cancer. Usually, the new cancer is in a different area of the breast and does not have the same pathology. For example, the original cancer is ductal carcinoma in situ (DCIS) and the second cancer appears invasive lobular carcinoma. Second cancers are treated as new cancers, independent of the first cancer.
A distant recurrence of breast cancer is called metastatic disease. Metastatic breast cancer (Stage IV) is serious and the survival rate is considerably lower than for women whose cancer is confined to the breast or axillary (underarm) lymph nodes. Breast cancer has the potential to spread to almost any region of the body. The most common region is bone, followed by the lung and liver.
Symptoms of metastatic breast cancer may include:
- Bone pain (possible indication of bone metastases)
- Shortness of breath (possible indication of lung metastases)
- Lack of appetite (possible indication of liver metastases)
- Weight loss (possible indication of liver metastases)
- Neurological pain or weakness, headaches (possible indication of neurological metastases)
These symptoms are sometimes but not always associated with metastatic breast cancer. Additionally, having one or more of these symptoms does not necessarily mean a woman has metastatic breast cancer. Any changes in health should be reported to a physician for further examination. Metastatic breast cancer is usually diagnosed by bone scan, CAT scan, MRI scan, or liver blood tests.
Surgery is rarely an option for metastatic breast cancer because the cancer is not usually confined to one specific spot on the given organ. Instead, treatment options include one or more of the following: chemotherapy, radiation therapy, or hormonal (drug) therapies. Patients with advanced breast cancer may wish to consider entering into a clinical trial designed to evaluate the effectiveness of newly developed treatments.
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