When Breast Cancer Comes Back

Last Editorial Review: 5/20/2005

Recurrence is always possible. But when the cancer comes back, where it is and how it behaves all affect the outcome.

By Gina Shaw
WebMD Feature

Reviewed By Charlotte Grayson

It can happen a year after you finish treatment for breast cancer, or five, 10, even 20 years later. You find another lump, or a shadow appears on one of the mammograms you're having much more often now. Is the cancer back?

Every woman who's had breast cancer knows that recurrence is possible. Some may do a better job than others at keeping that worry in a tightly closed box on the other side of the room. But sometimes -- such as at follow-up visits with the oncologist -- it's hard to avoid.

And sometimes, the worry proves true. After all you and your doctors did, after those scary and exhausting and painful months of treatment, the cancer is rearing its ugly head again.

How often does breast cancer recur? That depends on a number of factors, including:

  • Size of the original tumor
  • Number of lymph nodes involved, if any
  • How aggressive the cancer was
  • How well you responded to your first course of treatment

For example, if your original tumor was less than 1 centimeter and had not spread to the lymph nodes, the chance of the cancer's returning may be only 5%. If you had a large tumor with multiple lymph nodes involved, the odds that it will in time recur can be significantly higher -- 50% or greater for some women.

Recurrence Can Mean Different Things

For some women, a recurrence can be metastatic -- the cancer has come back not in the breast (or not only in the breast), but elsewhere in the body as well. That's a much more serious situation (see Metastatic Breast Cancer as a Chronic Condition). Or, it may have come back much as the first time you were diagnosed, as a "new" cancer, and is treated as such.

Be aware that many people talk about recurrence and metastasis in the same breath. But they are not the same thing. If you have had a local recurrence, when the cancer remains confined to your breast, the good news is that your prognosis is not necessarily any worse than it was the first time.

"Whether it's a recurrence of the original cancer or a new primary cancer in the other breast, in both cases we assume we're dealing with a curable situation, and we attempt to think about those patients as we would anyone with a new presentation," says Clifford Hudis, MD, chief of the Breast Cancer Medicine Service at Memorial Sloan-Kettering Cancer Center in New York.

If, for example, you finished treatment for breast cancer seven or eight years ago, any recurrence or new cancer ("new primaries" are not common, but they do happen) would be treated largely as an entirely new problem.

"That woman will not only undergo surgery, but may well receive additional therapy that doesn't ignore the fact that she had a previous cancer, but recognizes that seven years out, her prognosis from the first cancer is excellent," says Eric Winer, MD, director of the Breast Program at the Dana-Farber Cancer Institute in Boston.

If, on the other hand, you finished treatment for your original breast cancer only six months or a year ago, and the cancer has already recurred, that may be a sign that the tumor may be very aggressive.

"This indicates to us that a woman may be at a higher risk to have a systemic recurrence," says Winer. If you didn't have chemotherapy before, doctors may recommend an aggressive chemotherapy regimen now. But if you've completed rigorous chemotherapy fairly recently, oncologists may not be in a rush to put you through that again.

Of course, there are some complicating factors to treatment no matter when a recurrence occurs. For example, a woman who has previously had Adriamycin (doxorubicin) or another chemotherapy drug that is known to damage the heart cannot be prescribed that drug again -- whether it's a year later or ten years later.

And a breast that has been treated with radiation cannot be radiated again. For that reason, if you had a lumpectomy the first time around, which was probably followed by radiation, your doctors will likely advise a mastectomy if the cancer recurs.

Decisions to Consider if Breast Cancer Recurs

Deciding on a course of treatment for breast cancer recurrence is complex. There's the question of what kind of treatment you had before and how well you responded to it. Also, doctors don't have a lot of information about comparing treatment approaches in women with recurrent breast cancer.

"There's something of an information vacuum here," says Winer. "Although there are studies looking at the natural history of these patients, telling us how well we can predict they will do, there are almost no definitive studies looking at which treatment strategy is better."

That's because while breast cancer recurrence is certainly not uncommon, it's uncommon enough to pose challenges in setting up a randomized clinical trial -- the gold standard of research to evaluate treatment options.

For women with hormone-receptor positive cancers, doctors know that hormonal therapy offers a benefit when the cancer recurs. "We do have the results of clinical trials showing that," says Eleftherios Mamounas, MD, medical director of the Aultman Cancer Center in Canton, Ohio, and Chairman of the National Surgical Adjuvant Breast and Bowel Project (NSABP) Breast Committee.

But, he adds, previous phase III trials attempting to evaluate whether women with breast cancer benefit from chemotherapy have not been successfully completed.

A New Clinical Trial

Doctors hope that will change soon. Beginning in January, the NSABP began signing up patients for a new trial that will assess the benefit of chemotherapy in women with local breast cancer recurrence.

Women in both parts of the trial will receive surgery and then hormonal therapies if they're eligible. One group of women will also receive chemotherapy, while the other will not. Women interested in signing up for the trial, which involves centers in more than 20 U.S. states and Canada, can find out more about the trial and who to contact here: http://www.nsabp.pitt.edu/B37_Information.htm.

Beyond the questions about treatment, a woman's biggest concern when breast cancer recurs is "What does this mean for the future?" You may be more experienced with breast cancer the second time around, but that doesn't necessarily make it any easier.

"When breast cancer first develops, women often feel a mistrust of their own body, thinking 'What's wrong with my body that this has happened?'" observes Winer. "When it happens again, these questions are even stronger."

What does it mean? Again, a lot depends on timing.

"A recurrence relatively soon after an initial diagnosis is worrisome," says Winer. "If it's a recurrence many years later, or a new primary breast cancer, our concerns are much less. That woman's prognosis will be largely defined by the new cancer's prognosis, and since most of them will have been picked up early on through the more vigilant screening you have after a breast cancer diagnosis, that prognosis is often very good."

Published May 2005.

SOURCES: Eric Winer, MD, director, Breast Program, Dana-Farber Cancer Institute, Boston. Clifford Hudis, MD, chief, Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, New York City. Eleftherios Mamounas, MD, medical director, Aultman Cancer Center, Canton, Ohio; chairman, National Surgical Adjuvant Breast and Bowel Project (NSABP) Breast Committee.

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