Recurrent breast cancer

Recurrent breast cancer is breast cancer that comes back after initial treatment. Treatments usually try to remove or destroy all the cancer cells, but some cells may survive. These surviving cancer cells multiply, becoming recurrent breast cancer.

When breast cancer comes back, it happens most often in the first few years after treatment. But it also can happen many years later. The chances of breast cancer returning after treatment depend greatly on the type of breast cancer you had and the cancer's stage.

Recurrent breast cancer can come back in different parts of the body:

• Local recurrence means the cancer comes back in the same area as the original cancer. The cancer might grow in the nearby breast tissue after lumpectomy. Or it might grow in the skin or tissue of the chest wall after mastectomy.
• Regional recurrence means the cancer comes back in the nearby lymph nodes.
• Distant recurrence means the cancer has spread to other parts of the body, such as the bone, liver or lungs. This also is called a metastatic recurrence.

Treatment for recurrent breast cancer depends on where the cancer is in the body and what treatments you had before. Treatments may be different when the cancer comes back because the cancer can change over time.

Treatments may offer a cure for a local or regional breast cancer recurrence. For a distant recurrence, a cure may not be possible. Treatments can slow the growth of the cancer and extend your life. Newer treatments and more personalized treatment approaches are helping many people live longer with recurrent breast cancer.

Learning that breast cancer has come back can bring many emotions, including shock, anger and grief. You also might feel more prepared and empowered as you face cancer again. Compared with your first diagnosis, you may know more about treatments, feel more comfortable asking questions and better understand what helps you through difficult days. Even when things feel uncertain, your experience may help you navigate the challenges ahead.

Signs and symptoms of recurrent breast cancer vary depending on where the cancer comes back.

Local recurrence

In a local recurrence, cancer comes back in the same area as the original cancer.

After a lumpectomy, the cancer can come back in the remaining breast tissue. After a mastectomy, the cancer can come back in the tissue that lines the chest wall or in the skin.

Symptoms of local recurrence after lumpectomy include:

• A breast lump or thickened area of skin that feels different from the surrounding tissue.
• A nipple that looks flattened or turns inward.
• Changes in the size, shape or appearance of a breast.
• Changes to the skin over the breast, such as a rash, skin that looks dimpled or skin that looks like an orange peel.

Symptoms of local recurrence after a mastectomy may include:

• A new area of thickening along or near the mastectomy scar.
• One or more nodules on or under the skin of your chest wall.
• Skin changes, such as a rash, skin that looks dimpled or skin that looks like an orange peel.

Some people are surprised to learn that breast cancer can come back in the chest after mastectomy. While a mastectomy removes nearly all of the breast tissue, small amounts can remain. If cancer cells are present in that tissue, the cancer can return.

Regional recurrence

A regional breast cancer recurrence means the cancer has come back in the nearby lymph nodes.

Symptoms of regional recurrence may include a lump or swelling in the lymph nodes located:

• Under your arm.
• Near your collarbone.
• In the groove above your collarbone.
• In your neck.

Distant recurrence

A distant recurrence means the cancer has traveled to distant parts of the body, most commonly the bones, liver and lungs. It's also called a metastatic recurrence.

Symptoms include:

• Pain that won't go away or gets worse, such as chest, back or hip pain.
• Cough that won't go away.
• Difficulty breathing.
• Loss of appetite.
• Weight loss without trying.
• Severe headaches.
• Seizures.

When to see a doctor

After your breast cancer treatment ends, your healthcare professional will likely create a schedule of follow-up exams for you. During follow-up exams, your healthcare professional checks for any symptoms or signs of cancer recurrence.

You also can report any new symptoms to your healthcare professional. Make an appointment with your healthcare professional if you have any symptoms that worry you.

Recurrent breast cancer occurs when cells that were part of your original breast cancer break away and hide nearby in the breast or in another part of your body. Later, these cells begin growing again.

The treatment you had after your first breast cancer diagnosis was meant to kill any cancer cells that were left over after surgery. But sometimes these treatments don't kill all the cancer cells.

Sometimes cancer cells may live in your body for years without causing harm. Then something happens that activates the cells, so they grow and spread to other parts of the body. It's not clear why this occurs.

Healthcare professionals consider several factors when estimating the risk of recurrent breast cancer. These include the type of breast cancer, the size and stage of the cancer, and the treatments you've had. Tools such as genomic tests and recurrence risk calculators also may help refine that estimate. This information can help guide treatment decisions and follow-up care after treatment.

Risk factors related to the type of breast cancer that you have include:

• Cell types. Invasive ductal carcinoma forms in the milk ducts, while invasive lobular carcinoma forms in the breast lobules. Invasive lobular carcinoma is more likely to recur many years after treatment.
• Hormone receptor status. Breast cancers that use hormones to help them grow are called hormone receptor (HR) positive cancers. HR positive breast cancers can recur many years after treatment. HR negative breast cancers are more likely to recur in the first few years after treatment ends.
• HER2 status. Breast cancers that make too much HER2 protein are called HER2-positive breast cancers. HER2-positive breast cancers are more likely to recur in the first few years after treatment.
• Inflammatory breast cancer. People with inflammatory breast cancer have a higher risk of local recurrence after treatment.
• Triple-negative breast cancer. Triple-negative breast cancer (TNBC) cells are HR negative and HER2 negative. TNBC is more likely to recur in the first few years after treatment.

Risk factors related to the results of breast cancer surgery include:

• Size of the cancer in the breast. People with larger cancers have more cancer cells and a greater risk of recurrent breast cancer.

• Positive or close cancer margins. During a typical breast cancer surgery, the surgeon removes the cancer along with a small amount of the healthy tissue that surrounds it. Healthcare professionals in a lab examine the edges of the tissue to look for cancer cells.

  If the borders are free of cancer, that's considered a negative margin. If any part of the border has cancer cells, that's a positive margin. If no cancer cells are found at the border but the distance between the cancer cells and healthy tissue is small, that's a close margin. Positive and close margins can raise the risk of breast cancer recurrence.

• Lymph node involvement. Finding cancer in nearby lymph nodes at the time of your original diagnosis increases your risk of the cancer coming back.
• Genomic testing. Genomic tests, such as Oncotype DX and MammaPrint, look at patterns of genes inside cancer cells to help estimate the risk of recurrence. These tests are used for certain types of breast cancer in certain situations. The results may help guide decisions about additional treatments to lower the risk of recurrent breast cancer.
• Residual cancer burden score. For those who have treatment with medicines before surgery, the residual cancer burden (RCB) score helps the healthcare team assess the risk of recurrence. To get the RCB score, healthcare professionals measure how much cancer remains in the breast and nearby lymph nodes after treatment. If there is little or no remaining cancer, the score is low and the risk of recurrence also is low. If more cancer remains, the score is higher and so is the risk of recurrence.

Risk factors related to adjuvant therapy include:

• Lack of radiation following a lumpectomy. Many people who choose a lumpectomy for breast cancer treatment also have radiation therapy to reduce the risk of recurrence. Not everyone needs this additional treatment. But if your healthcare team recommends radiation therapy and you choose not to have it, you may have a higher risk of local breast cancer recurrence.
• Lack of estrogen blocker therapy. For people with HR positive breast cancers, using estrogen blocker therapy after surgery can lower the risk of recurrence. If your healthcare team recommends this treatment but you choose not to have it, you may have a higher risk of recurrence.
• Lack of treatment that targets HER2. For people with HER2-positive breast cancers, treatment with targeted therapy after surgery can lower the risk of recurrence. These medicines target the cells that are making extra HER2. They often are combined with chemotherapy. If your healthcare team recommends this treatment but you choose not to have it, you may have a higher risk of recurrence.

Other risk factors include:

• Younger age. Younger people, particularly those under age 35 at the time of their original breast cancer diagnosis, face a higher risk of recurrent breast cancer.
• Obesity. Obesity raises the risk of recurrence.

There's no sure way to prevent recurrent breast cancer, but some treatments and lifestyle changes may help lower the risk that the cancer will come back.

After your initial treatment, your healthcare team may assess your risk of recurrence and recommend treatments to help lower that risk. Treatments used in this way are called adjuvant therapies. Your care team also may recommend healthy lifestyle choices that can support your overall health and may help lower recurrence risk.

Treatments that lower the risk of recurrence

Your healthcare professional might recommend treatments to lower the risk of breast cancer recurrence. Treatments used in this way include:

• Estrogen blocker therapy. Taking estrogen blocker therapy after surgery may lower the risk of recurrence if you have hormone receptor positive breast cancer. This typically involves taking medicines for several years after your cancer treatment.
• Surgery to remove the ovaries. In those who haven't been through menopause, estrogen blocker therapy may be combined with treatment to stop the ovaries from making hormones. Often this is done with medicines, but sometimes it can involve surgery to remove the ovaries. This surgery is called oophorectomy.
• Chemotherapy. For people who have a higher risk of breast cancer recurrence, chemotherapy can lower the chance that cancer will come back and may improve survival.
• Radiation therapy. Radiation therapy helps lower the risk of cancer coming back after lumpectomy. It also lowers the risk of recurrence in those who have a large cancer in the breast or have inflammatory breast cancer.
• Targeted therapy. If your cancer makes extra HER2 protein, medicines that target that protein can help lower the chance of the cancer coming back.
• Bone-building medicines. In some people with a higher risk of recurrence, bone-building medicines may help lower the risk of breast cancer spreading to the bones. Cancer that spreads to the bones is called bone metastasis.

Researchers continue to study ways to reduce the risk of breast cancer recurrence. One newer area of interest is glucagon-like peptide 1 (GLP-1) medicines, which are used to treat diabetes and obesity. Some studies have suggested these medicines may lower the risk of some cancers, while other studies have not found this. So far, there isn't enough evidence to prove whether GLP-1 medicines lower or raise cancer risk. This makes it hard to say for sure whether GLP-1 medicines might affect breast cancer recurrence risk. More research is needed.

Self-care to lower the risk of recurrence

To lower the risk of recurrent breast cancer, healthcare professionals generally recommend making healthy choices that support overall health. These include eating a balanced diet, exercising regularly, maintaining a healthy weight and limiting alcohol.

Try to:

• Avoid alcohol. Research links drinking alcohol to a higher risk of breast cancer, but it's not clear whether alcohol raises the risk of the cancer coming back. If you choose to drink alcohol, limit how often you drink and keep the amount small. For overall health, drink one or fewer drinks a day. Do not drink every day. The less you drink, the better.
• Follow a healthy diet. Choose a diet that's rich in fruits, vegetables and whole grains. Limit how much red meat, processed meat and sugar you eat.
• Stay active. Aim to exercise most days of the week. If you don't exercise regularly, get your healthcare professional's OK first. Start out with short sessions of an activity you enjoy and build up the amount of exercise over time.
• Strive for a healthy weight. Ask your healthcare professional what weight is healthy for you. If you are at a healthy weight, work to maintain it. If you need to lose weight, aim to do so slowly. Start by making healthy choices, such as eating fewer calories, moving more and sitting less.

Your healthcare professional may suspect you have recurrent breast cancer based on a mammogram, a physical exam, or your signs and symptoms. When this is the case, your healthcare professional may recommend testing to confirm a recurrent breast cancer diagnosis.

Blood tests

Your healthcare professional may use blood tests to learn more about your overall health and look for signs that breast cancer may have returned or spread. Blood tests alone usually can't confirm a recurrent breast cancer diagnosis.

Researchers also are studying blood tests that look for tiny pieces of DNA from cancer cells in the blood. These tests, called circulating tumor DNA (ctDNA) tests, may detect signs of recurrent breast cancer before changes appear on imaging tests. More research is needed to understand who may benefit from these tests and how they should be used.

Imaging tests

Imaging tests make pictures of the body that healthcare teams can use to look for signs of cancer. What imaging tests you'll have depends on your specific situation. Imaging tests may include:

• Bone scan.
• Computerized tomography (CT).
• Magnetic resonance imaging (MRI).
• Positron emission tomography (PET).
• X-ray.

Not every person needs every test. Your healthcare professional determines which tests are most helpful in your situation.

Biopsy

A biopsy is a procedure to remove a sample of tissue for testing in a lab. Your healthcare professional may recommend a biopsy procedure to collect suspicious cells for testing. This is the only way to confirm whether your cancer has returned.

A pathologist can tell whether the cancer is a recurrence or a new cancer. Tests also can show whether the cancer is sensitive to estrogen blocker therapy or targeted therapy. These features may have changed since your first cancer diagnosis.

The treatments used for recurrent breast cancer may depend on several factors. These include:

• Extent of the disease.
• HER2 status.
• Hormone receptor status.
• Type of treatment you received for your first breast cancer.
• Your overall health.

Your healthcare professional also considers your goals and your preferences for treatment.

Treatment for a local recurrence

Treatment for a local breast cancer recurrence typically starts with an operation and may include radiation if you haven't had it before. Chemotherapy and estrogen blocker therapy also may be recommended.

• Surgery. For recurrent breast cancer that's confined to the breast, treatment usually involves removing any remaining breast tissue.

  If your first cancer was treated with a lumpectomy, your healthcare professional may recommend a mastectomy to remove all your breast tissue. This typically includes removing all of the lobules, ducts, fatty tissue, skin and nipple.

  If your first breast cancer was treated with a mastectomy and the cancer comes back in the chest wall, you may have surgery to remove the new cancer along with some healthy tissue.

  A local recurrence may be accompanied by hidden cancer in nearby lymph nodes. For this reason, the surgeon may remove some or all the nearby lymph nodes if they weren't removed during your initial treatment.

• Radiation therapy. Radiation therapy treats cancer with powerful energy beams. The energy can come from X-rays, protons or other sources. If you didn't have radiation therapy for your first breast cancer, your healthcare professional may recommend it now. But if you had radiation after a lumpectomy, radiation to treat the recurrence isn't usually recommended because of the risk of side effects.
• Chemotherapy. Chemotherapy treats cancer with strong medicines. Your healthcare professional may recommend chemotherapy after surgery to lower your risk of another cancer recurrence.
• Estrogen blocker therapy. Estrogen blocker therapy medicines that block the growth-promoting effects of the hormones estrogen and progesterone may be recommended if your cancer is hormone receptor positive.
• Targeted therapy. Targeted therapy for cancer is a treatment that uses medicines to attack specific chemicals in the cancer cells. By blocking these chemicals, targeted treatments can cause cancer cells to die. Your healthcare team may test your cancer cells to see if targeted therapy might help you. For example, if the cells make extra HER2 protein, your care team may recommend medicines that target that protein.
• Immunotherapy. Immunotherapy for cancer is a treatment with medicine that helps the body's immune system kill cancer cells. The immune system fights off diseases by attacking germs and other cells that shouldn't be in the body. Cancer cells survive by hiding from the immune system. Immunotherapy helps the immune system cells find and kill the cancer cells. Immunotherapy might be an option for treating triple-negative breast cancer.

Treatment for a regional recurrence

Treatments for a regional breast cancer recurrence include:

• Surgery. If it's possible, surgery to remove the cancer is the recommended treatment for a regional recurrence. Your surgeon also may remove the lymph nodes under your arm if they're still present.
• Radiation therapy. Sometimes radiation therapy may be used after surgery. If surgery isn't possible, radiation therapy may be used as the main treatment for a regional breast cancer recurrence.
• Medicines. Chemotherapy, targeted therapy or estrogen blocker therapy also may be recommended as the main treatment or may follow surgery or radiation.

Treatment for a distant recurrence

Many treatments exist for a distant breast cancer recurrence, also called a metastatic recurrence. Your options depend on where your cancer has spread. If one treatment doesn't work or stops working, you may be able to try other treatments.

In general, the goal of treatment for metastatic breast cancer isn't to cure the disease. Treatment may allow you to live longer and can help relieve symptoms the cancer is causing. Your healthcare professional works to achieve a balance between managing your symptoms while minimizing toxic effects from treatment. The aim is to help you live as well as possible for as long as possible.

Treatments may include:

• Estrogen blocker therapy. If your cancer is hormone receptor positive, you may benefit from estrogen blocker therapy. In general, estrogen blocker therapy has fewer side effects than chemotherapy. So it's often the first treatment used for metastatic breast cancer.
• Chemotherapy. Your healthcare professional may recommend chemotherapy if your cancer is hormone receptor negative or if estrogen blocker therapy is no longer working.
• Targeted therapy. If your cancer cells have certain characteristics that make them vulnerable to targeted therapy, your healthcare professional may recommend these medicines.
• Antibody-drug conjugates. Antibody-drug conjugates are medicines that combine targeted therapy with chemotherapy. These medicines use targeted therapy to target the cancer cells and deliver chemotherapy directly to the cells. Antibody-drug conjugates are typically used alone or with other medicines to treat breast cancer that spreads.
• Immunotherapy. Immunotherapy might be an option if you have triple-negative breast cancer, which means that the cancer cells don't have receptors for estrogen or progesterone and don't make extra HER2. For triple-negative breast cancer, immunotherapy is combined with chemotherapy to treat advanced cancer that's spread to other parts of the body.
• Bone-building medicines. If cancer has spread to your bones, your healthcare professional may recommend a bone-building medicine to lower your risk of broken bones or reduce bone pain.
• Other treatments. Radiation therapy and surgery may be used in certain situations to manage symptoms of advanced breast cancer.

The prognosis for breast cancer recurrence depends on where the cancer comes back. When it comes back in the breast, chest wall or lymph nodes, a cure may be possible. If the cancer spreads to other parts of the body, a cure often isn't possible. Treatments focus on slowing the growth of the cancer, helping manage symptoms and extending your life.

Your healthcare team can help you understand your prognosis. Your care team may consider many factors when thinking about your outlook, including:

• HER2 status. If the cancer cells make a lot of HER2, treatment that targets that protein may help. HER2-positive cancer has a better prognosis.
• Hormone receptor status. If the cancer cells are hormone receptor positive, treatment with estrogen blocker therapy and other treatments that target hormone-sensitive cells might help. Hormone receptor positive cancer has a better prognosis.
• Symptoms. Breast cancer that spreads to other parts of the body but causes few or no symptoms may have a better prognosis than cancer that causes significant symptoms.
• The length of time since your first diagnosis. Breast cancer that comes back soon after the first diagnosis tends to have a worse prognosis. Cancer that comes back many years later has a better prognosis.
• Where the cancer comes back. Cancer that comes back in the breast or chest wall has a better prognosis than cancer that spreads to other parts of the body.
• Where the cancer spreads. When the cancer spreads, where it goes also may affect prognosis. Cancer that spreads to the bones has a better prognosis than cancer that spreads to organs.
• Your overall health. Having other serious health conditions may affect the ability to tolerate treatments and give a worse prognosis.

Your healthcare team knows the details of your cancer and treatment. Care team members can give you a personalized outlook and help you make sense of what it means for you. Some people want to know as much as possible about prognosis, while others choose to focus on treatment and day-to-day life. The amount of information that feels helpful is different for everyone.

No alternative medicine treatments have been found to cure recurrent breast cancer. But complementary and alternative medicine therapies may help you cope with side effects of treatment when combined with your healthcare professional's care.

For instance, many people diagnosed with cancer experience distress. If you're distressed, you may feel sad or worried. You may find it difficult to sleep, eat or focus on your usual activities.

Complementary and alternative treatments that can help you cope with distress include:

• Art therapy.
• Dance or movement therapy.
• Exercise.
• Meditation.
• Music therapy.
• Relaxation exercises.
• Yoga.

Your healthcare professional can refer you to professionals who can help you learn about and try these alternative treatments. Tell your healthcare professional if you're experiencing distress.

Finding out your breast cancer has returned can be as or more upsetting than your initial diagnosis. As you sort through your emotions and make decisions about treatment, the following suggestions might be helpful:

• Learn more about recurrent breast cancer. Ask your healthcare professional about your recurrent breast cancer, including your treatment options and, if you like, your outlook. As you learn more about recurrent breast cancer, you may become more confident in making treatment decisions.
• Keep friends and family close. Keeping your close relationships strong may help you deal with your recurrent breast cancer. Friends and family can provide the practical support you may need, such as helping take care of your house if you're in the hospital. And they can serve as emotional support when you feel overwhelmed by cancer.

• Find someone to talk with. Find a good listener who you can talk to about your hopes and fears. This may be a friend or family member. You also may find it helpful to talk with a counselor, medical social worker or clergy member. Or join a cancer support group for understanding and guidance.

  Ask your healthcare team about local support groups, or contact the American Cancer Society or another cancer organization in your area to find resources. Find support online through Mayo Clinic Connect, a community where you can connect with others for support, practical information and answers to everyday questions.

• Look for a connection to something beyond yourself. Many people find that having a strong faith or a sense of something greater than themselves helps them cope with cancer.

If you have any signs or symptoms that worry you, make an appointment with your healthcare professional.

Your healthcare professional can recommend the necessary tests and procedures to confirm a diagnosis of recurrent breast cancer. Then you'll likely be referred to an oncologist. This is a doctor who specializes in diagnosing and treating cancer.

What you can do

• Be prepared to discuss your new symptoms and any other health problems you've had since your first cancer diagnosis.
• If you're seeing a new healthcare professional, request your medical records from your former healthcare professional. If you already have these, bring your medical records and any imaging tests you have with you. Otherwise, you'll need to sign an information release form so that your new healthcare professional's office can get the records.
• Make a list of all medicines, vitamins or supplements that you're taking. Let your healthcare professional know if you have tried any alternative treatments for your cancer.
• Consider asking a family member or friend to come with you. It may be hard to remember all the information you hear during an appointment. Someone who goes with you may remember something that you missed or forgot.
• Write down questions to ask your healthcare professional.

Some basic questions to ask your healthcare professional include:

• Has my cancer come back?
• Are there other possible causes for my symptoms?
• What kinds of tests do I need? Do these tests require any special preparation?
• What are the hormone receptor status and the HER2 status of the cancer recurrence?
• What treatments are available to me and which do you recommend?
• What types of side effects can I expect from treatment?
• Are there any alternatives to the approach that you're suggesting?
• Are there any clinical trials open to me?
• What's my outlook?

What to expect from your doctor

Your healthcare professional is likely to ask you several questions. Being ready to answer them may allow time to go over points you want to discuss in more detail. Your healthcare professional may ask:

• When did you first notice symptoms again?
• Has there been a change in the symptoms over time?
• Do these symptoms feel different from when you were first diagnosed with cancer?
• How do you feel overall?
• Have you had any unexpected weight loss? Have you lost your appetite?
• Are you having any pain?