What to Do When Breast Cancer Reappears

Even years after the initial treatment, breast cancer can reappear either locally or in other regions of the body.   

If cancer is detected in the same location as a previous cancer, pathologists can examine some cells from it, compare them with samples from the original cancer, and decide if this is a new cancer or a recurrence of the original. Recurrence means the cancer is not a new cancer; it is the same cancer the person originally had.

The original cancer can also reappear in a new location. Any cancer can spread and invade other organs and body parts. This is called "metastatic cancer."  "Metastasize" means to spread; cancer that has "metastasized" has spread to other parts of the body.  For example, if breast cancer cells invade the liver, the disease in the liver is not called "liver cancer," but "metastasized breast cancer."

Therefore, breast cancer recurrence can be:

• Local: the cancer returns to the breast where it started, or to the skin and tissues where the breast was.
• Regional: the cancer returns to lymph nodes near the breast.
• Metastatic or distant: the cancer returns to some other part of the body which may not be near the breast, such as bones, the brain, liver, or lungs.

When a woman first has breast cancer, the doctors can look for certain things that increase or decrease the risk of recurrence, like:

• Stage and grade.  Stage denotes size.  The larger the original cancer, the greater the risk of recurrence.  The grade denotes how aggressive the cancer is; that is, how fast it is likely to grow and spread in the future.

    ◦    Histologic grade refers to how similar the cancer cells are to normal cells. The more the cancer cells resemble normal cells, the lower the grade, and the lower the risk of recurrence.
    ◦    Nuclear grade refers to how fast the cancer cells divide to form more cells.  The slower the rate, the lower the grade, and the lower the risk of recurrence.

• Cancer in the lymph node.  The risk of recurrence is greater if the original cancer spread to nearby lymph nodes.
• How well the patient responded to treatment for the original cancer.
• Hereditary mutations in BRCA1 and BRCA2 tumor suppressor genes.
• Acquired mutations in certain genes:

    ◦    Genes responsible for the division process of the cells are called proto-oncogenes.  When a proto-oncogene mutates it's called an oncogene.
    ◦    Genes that decrease the cell division process or cause cells to die are called tumor suppressor genes.
When either type of gene does not function properly, cells can grow out of control, which can lead to cancer.

• ER+ (estrogen receptor positive):  ER+ means the cancer contains (is positive for) receptors for the hormone estrogen. ER+ cancers generally are more receptive to treatment with hormones and grow more slowly; therefore the risk of recurrence is reduced.

The symptoms of a local recurrence are somewhat similar to those of breast cancer in general:

• A lump in the breast that persists and seems to grow
• A lump on or under the skin that seems irregular in shape, pink to red in color, firm or hard to the touch
• A thickening in or near the breast or in the underarm
• A part of the breast that seems unusual or different from any other part of either breast
• A change in the breast's shape, contour, or size
• Redness or a rash on the skin of the breast or nipple
• Other changes in the look or feel of the skin of the breast or nipple
• Fluid coming from the nipples

However, some of these symptoms can also result from harmless causes.  The important thing is to continue your regularly scheduled follow-up appointments with your doctor and to be extra vigilant in performing monthly breast self-exams.  Note that:

• Breast self-exam or a doctor's physical exam detects about one third of local breast cancer recurrences
• Mammography alone detects another third of local breast cancer recurrences
• Mammography and physical exam together detect the final third of local breast cancer recurrences

About forty percent of cases of recurrence are regional; they have spread to the lymph nodes in one or more of these places:

• Under the arm next to the breast that had the original cancer
• Under the other arm
• At the base of the neck
• Below the collarbone
• Under the chest wall
• Along the breastbone

The basic symptom for this is the presence of hard, round lumps in any of these areas. But again, there are harmless causes for this as well.  Be sure to report any concerns to your doctor.
In cases of distant or metastatic recurrence, the cancer spreads most often to the bones, brain, liver, or lungs.  Naturally, the symptoms depend on the area affected.  You can find a detailed description of them at Breastcancer.org.
   

Manging a Recurrence

Breast cancer recurrence is a chronic disease that has to be managed. The goal of treatment is control, not necessarily cure.  Many people live full, long lives with breast cancer.

Thinking of recurrent breast cancer as a chronic disease means understanding that there will be times when it is active, other times when it is not.  In short, it means understanding that it is a disease you live with.  The key word is "live."   No one knows how long you will live with it, but no one knows how long anyone will live.  We do know that new, very effective treatments are being developed constantly.

Treatments for breast cancer recurrence are considered either local (targeted at a specific area) or systemic (affecting the entire body). Local treatments include surgery and radiation; systemic treatments include chemotherapy (drugs that kill the cancer cells), hormone therapy (drugs that stop or slow the production of the female hormone estrogen [estrogen encourages the growth of cancer cells]), and immunotherapy (drugs that act like our own disease fighting immune system and block substances that encourage the growth of cancer cells).

Naturally, the treatment chosen depends on the specifics of the case. These include not only the nature of the current cancer (its location, size, aggressiveness, etc., all of which can be determined by a variety of tests), but also on the kind of treatment you received for the original cancer.

For example, if the recurrence is completely local (within the breast) and limited to a small lump, and you had a lumpectomy (removal of a cancerous lump) without radiation originally, then removing the new lump followed by radiation therapy may be all that's needed now.

However, if you did have radiation originally, then the treatment would be a mastectomy (surgical removal of the breast), because a single area can't receive radiation therapy twice.  On the other hand, if you had a mastectomy originally, then the treatment would probably be to surgically remove the new cancer, followed by radiation therapy.   In either case, these local treatments might be followed by the systemic treatments of chemotherapy or hormone therapy.

Treatment for regional recurrence will more likely involve all three forms of treatment: surgery, to remove the affected lymph nodes, followed by radiation and then by chemotherapy. Generally, treatment for distant or metastatic recurrence concentrates on systemic methods, though radiation may also be used.

The systemic methods include:

• Hormonal therapies, such as:

    ◦    Tamoxifen, an anti-estrogen drug that has been used successfully for more than twenty years
    ◦    Arimidex (chemical name: anastrozole)
    ◦    Femara (chemical name: letrozole)
    ◦    Aromasin (chemical name: exemestane)

Tamoxifen was the "first choice" for several decades, but recent studies sugest that the next three on the above list (known as aromatase inhibitors) are more effective and have fewer side effects for post-menopausal women.

• Chemotherapy, which includes a large number of drugs
• Immunotherapy, which includes a drug called Herceptin.  Herceptin is a very effective treatment for a specific type of breast cancer: known as HER2-positive breast cancer and is currently approved by the U.S. Food and Drug Administration for:

    ◦    Women with metastatic HER2-positive cancer
    ◦    Women with earlier stages of HER2-positive cancer as "adjuvant treatment" (additional treatment that follows after a different initial treatment, such as surgery) in combination with chemotherapy

The goal of all these treatments is to prolong life and improve the quality of life with as few side effects as possible.  We talk about "quality of life" often, but its meaning differs for every individual.  Only you can decide what's most important for you. But you should make that decision with the best medical advice possible in mind.

For example, if your disease is not very aggressive, and your doctors suggest that it will not be dangerous, you may decide to "take a vacation" from medications or treatment for a while.  Under the right circumstances, it's possible to do this for a period of time (months or even years). Of course you must monitor your condition and be ready to reconsider your decision, especially if the disease spreads or becomes painful.  But having a chronic disease does not necessarily mean being on constant medication.

The Complexities of Treating a Recurrence

The treatment of recurring breast cancer can be complex. It is important to surround yourself with a medical team that can handle all the issues involved with a chronic disease, both emotional and physical.

The medical team would normally consist of your primary care physician (PCP) and a group of specialists, including a:

• Surgeon: specializes in surgical procedures, including biopsies and operations to remove cancers.
• Medical oncologist: specializes in various non-surgical cancer treatments, such as chemotherapy, hormonal (anti-estrogen) treatment, immune therapies, pain medications, and nutrition.
• Radiation oncologist: specializes in treating cancer with radiation.
• Radiologist: specializes in reading (interpreting) images produced by various imaging technologies, such as mammograms, ultrasound, bone scans, CT scans, MRIs, etc.
• Pathologist: specializes in testing and analyzing the sample tissue gathered during a biopsy.
• Palliative care: specializes in pain and symptom management, assisting with difficult decision-making, and providing additional support to patient and family.
• Psychiatrist, psychologist, clinical social worker, clergyperson, or other psychotherapist: specializes in dealing with the emotional and psychological issues that accompany cancer and cancer treatment.

You'll need to be able to meet with or at least contact each of these people on a regular, ongoing basis.  And each of them needs to be in contact with all the others, so that they can truly work together as a team and give you the care you need. You may also want a second opinion on some specific matter and will, therefore, want to talk to a second surgeon or medical oncologist or pathologist.  Your PCP should help you coordinate all this.

Note that while the "emotional and psychological doctors" are not at the top of the list above, their value on your team should not be minimized. If breast cancer becomes a chronic condition whose symptoms must be constantly monitored and treated as needed, the emotional and psychological symptoms must be included.  Breast cancer recurrence can create fear, anxiety, stress, and depression.  It can lead to a sense of uncertainty and lack of control. All this can be as debilitating as the disease's physical symptoms.

There are other important issues. For some women, the breasts are an essential source of female self-image. If you originally had a lumpectomy, but are now facing a mastectomy, you may experience feelings of decreased attractiveness and fear that your partner will abandon you.  As someone with recurrent breast cancer, you may, perhaps unconsciously, feel guilty, as if you "did something to make it come back." Or you may fear that you have passed a genetic predisposition for the disease to your daughters, or that you may become a burden to your loved ones.

How do you deal with all these issues?  First, you need to find some sort of psychotherapist or counselor you can trust and develop a good relationship with.  Perhaps you've worked with someone in the past. On the other hand, you may want to find a new person who specializes in helping people deal with life threatening situations, chronic illness, and cancer.

Besides working with a professional, there are other steps you can take:

• Confide in someone, a partner, a friend, about your feelings.  People who keep their anguish to themselves tend to develop more symptoms and suffer more pain than those who share their feelings.
• Recognize (and internalize) that even really healthy people get a recurrence of breast cancer.  You are not to blame.
• Recognize (and internalize) that your breasts do not equate to who you are.
• Allow yourself to grieve; then get up, dust yourself off, and persevere.
• Build stronger relationships with your partner, your children, and your friends through open and honest communication.
• Try to control only what you can control; let the other stuff go.

This article reprinted with permission from Second Opinion, a public television health program hosted by Dr. Peter Salgo and produced by WXXI (Rochester, NY),  West 175 and the University of Rochester Medical Center.

By Second Opinion