Dealing With Recurrence

by Kathy Steligo

You did it. It wasn't easy, but you made it through your breast cancer treatment, you've been given a clean bill of health, and your life is getting back to normal. Should you be concerned about your cancer returning?

Having been through the cancer ordeal once, it's only natural to fear another diagnosis. Although there is no guarantee you won't have a recurrence, most women treated for early-stage breast cancer never again hear, "you have breast cancer." When breast cancer does return, it usually does so in the first three to five years after treatment:

A local recurrence occurs in the area of the breast where the original tumor was found. Most women who develop a local recurrence show no signs of cancer elsewhere in their bodies. About 10 percent of women develop a local recurrence in the scar or chest wall after mastectomy, most within five years after their surgery.

A regional recurrence appears in the lymph nodes under the arm or above the collarbone. Most regional recurrence also involves cancer in the remaining breast tissue or in the chest wall.

Distant recurrence returns as metastatic disease that has spread to the bones, brain, lungs or other parts of the body. A distant recurrence is more serious than one that is local or regional, because it can only be treated as a chronic disease, without cure.

Will your cancer return?

Recurrence is cancer that comes back after treatment. This happens when some microscopic cancer cells survive treatment. Initially too small to be detected in follow-up tests, these cells eventually grow into new tumors. This is different than a new primary cancer, which is a tumor distinct from the original diagnosis. Most cancers that develop in the opposite breast are new primary cancers.

The likelihood that cancer will return is influenced by many factors, including the type of cancer you had, your treatment, and how long it's been since you were treated. A woman with a small non-invasive tumor with no lymph node involvement, for example, is less likely to have a recurrence than a woman with a large invasive tumor that has spread to her lymph nodes. Most recurrences appear within five years of initial treatment. The longer you are cancer-free after this five-year milestone, the less likely you are to have a recurrence.

Your initial cancer is more likely to return if:

• Your initial cancer was found in your lymph nodes.
• Your tumor was large (the chance of recurrence increases with the size of the tumor).
• Your cancer was particularly aggressive.
• You are genetically predisposed to breast cancer.

If you have early-stage breast cancer that is node negative (not present in your lymph nodes) and estrogen receptor-positive (it needs estrogen to grow), your treatment will include surgery followed by hormonal therapy to reduce or stop the amount of estrogen your body makes. Your doctor may recommend the Oncotype DX test. By assessing a sample of your tumor tissue, this test can determine whether you will also benefit from chemotherapy and whether you have a low, medium or high risk of recurrence within 10 years. The test is also being evaluated for post-menopausal women with invasive breast cancer that has spread to the lymph nodes.

What you can do after initial treatment

If you're like most women who have battled breast cancer successfully, you’ll feel a new determination and commitment to be proactive about your health. Living a healthy lifestyle is your best insurance against recurrence. Because the same factors that increase breast cancer risk may promote a cancer's return, the American Cancer Society recommends that cancer survivors follow the same nutrition guidelines as those recommended for cancer prevention. Eat a balanced, nutritional low-fat diet that includes the recommended daily servings of fruits and vegetables. Vitamins and supplements have not been shown to help prevent cancer or recurrence. Avoid alcohol or drink it slightly: research is increasingly finding that any amount increases breast cancer risk. Maintain a healthy weight -- being overweight or obese increases cancer risk. Get 45-60 minutes of moderate physical activity at least five days a week.

As a breast cancer survivor, the importance of continuing your surveillance once your initial breast cancer treatment is completed cannot be overemphasized. One-third of local breast cancer recurrences are found by physical examination and one-third are found by mammograms, either by the patient or the physician; the rest are discovered by a combination of mammography and exam. So be sure to perform careful, thorough self-examination of your breasts each month and see your doctor as frequently as he recommends for adequate follow-up exams, lab tests and mammograms.

Notify your doctor immediately if you discover any of the following symptoms:

• A change in the size or shape of your breast.
• A lump or thickening of any size under the breast skin, or under the arm.
• Any discharge from the nipple.
• A change in the breast skin or nipple, including puckering, dimpling, redness, inflammation, warmth or scaly appearance.

It's back. Now what?

If your cancer returns, your doctor will order tests to identify the extent of the disease and determine appropriate treatment. The longer you go without a recurrence, the better your prognosis. A woman who has a recurrence after five years, for instance, can generally be addressed more effectively than a woman whose cancer returns shortly after her initial treatment.

The nature of the returning cancer also affects how well it can be treated. A recurrence of invasive breast cancer is more difficult to treat than a non-invasive cancer, because it is typically more aggressive and can spread to other areas of the body. A hormone-receptor-positive tumor is more likely to be treated more effectively than a cancer that is receptor-negative because if one hormonal therapy doesn’t work, others can be tried.

The location of the recurrence plays a role as well: a cancer that returns in the bones can be treated more effectively than recurrence in the brain or lungs. Metastatic cancer that has spread beyond the lymph nodes is the hardest to treat. We still don't know how to prevent or cure metastatic disease, but for many women, it is chronic disease. Once treated with a "one size fits all" approach, customized treatment for metastatic breast cancer focuses on providing relief from symptoms, stabilizing tumor growth and providing a good quality of life.

We still have no cure for breast cancer, and we know that anyone who develops the disease once may be diagnosed again. But our arsenal of surveillance, diagnosis and treatment tools are now more individualized, more varied, and more effective. If your cancer returns, you will be treated with methods that are far better than what was available just a few years ago. If one treatment doesn’t work well, there is usually another to try.