Having fear and feeling anxious about breast cancer recurrence is very common for people who have had breast cancer. These feelings can affect one’s ability to live and make plans for the future. Collectively, these can be termed “fear of recurrence”.
In a forum discussion for breast cancer, one post, titled “fear of recurrence” was written by a woman expressing her fear of dying from breast cancer, especially after the loss of her maternal aunt from the same disease that reappeared 15 years later. The post gained traction among many empathetic commenters who shared the same worry with similar stories.
Having cancer a second time is not a death sentence. This article will explain the types of breast cancer recurrence, its causes, risks, and the types of treatment available.
What is Breast Cancer Recurrence?
Breast cancer recurrence is when breast cancer reappears after initial treatment. Depending on the type and severity of the first diagnosis, it can take months or years to come back.
There are 3 types of breast cancer recurrence:
- Local: Cancer remains in the same breast as the first time.
- Regional: Cancer cells spread from the breast to the surrounding lymph nodes around the armpits.
- Distant: Also known as metastatic or Stage 4 breast cancer, cancer cells have spread to other organs like the lungs and brain.
Recurrent breast cancer is not always worse than the previous one. The prognosis remains positive if it is detected and treated early.
Causes and Risk Factors
Guilt is often the first reaction many patients experience when receiving a recurrence diagnosis. It is important to understand that how or when cancer reappears is not within our control.
Scientists are still not exactly sure how cancer recurrence works. Likely, the treatment did not fully eradicate all the cancer cells. The small population size makes it difficult for imaging tools to detect the remaining cancer cells. Over time, cancer cells develop mechanisms like a new protein or receptor that allows them to survive and multiply into a new tumour. Other abilities like hiding from immune cells and DNA repair increases resistance to drugs, creating opportunities for cancer recurrence.
Nonetheless, certain risk factors increase the chances of breast cancer reappearing. Do note that having them does not mean you will get breast cancer again:
Age
Recent studies have found a rising threat of breast cancer recurrence for young women aged 35 years old and below. Professionals attributed this to a combination of factors:
- More likely to have aggressive cancer types with larger tumours
- More likely to carry genetic mutations
- Delayed diagnosis: Mammograms are less effective for younger women as they tend to have denser breast tissues. Young women also tend to dismiss or miss out on early warning signs of breast cancer.
Type and Staging of Breast Cancer
The more advanced the initial diagnosis, the higher the risk of breast cancer recurrence. Large tumours, when removed via surgery, may retain a larger positive margin, an area of cancer cells that was not removed during surgery.
Certain types of cancers have a higher chance of recurrence:
- Inflammatory breast cancer: A rare and aggressive form of breast cancer that spreads from the breast tissues to the skin and surrounding lymph nodes. Its most notable symptoms are swelling, redness, and skin dimpling around the breast.
- Triple negative breast cancer (TNBC): Unlike ductal carcinoma in situ (DCIS), TNBC lacks three hallmark features: estrogen receptors, progesterone receptors, and HER2 protein overexpression. This means treatment options like hormone therapy are ineffective for TNBC. As they tend to grow faster than other types of breast cancer, this can complicate treatment plans.
Recurrence usually happens within the first 5 years after the initial treatment. Hence, follow-ups with the doctor 3 to 4 months after remission are required to watch out for any surviving cancer cells.
Lifestyle and Physical Attributes
Some patients have a family history of breast cancer due to genetic mutations like BRCA1 and BRCA2. As cancer treatment does not resolve these mutations, people with the mutated gene carry an extra risk of re-developing breast cancer.
Existing health conditions like stroke, diabetes, or other immunosuppressive issues make one more vulnerable to cancer cells regrowth. Certain habits like excessive smoking and drinking, a poor diet, and a sedentary lifestyle could worsen some of these conditions.
Signs and Symptoms
Symptoms will vary depending on the type of recurrence.
Local recurrence will show similar signs to ductal carcinoma in situ (DCIS), including:
- Breast pain
- Nipple inversion
- Skin changes e.g. dimpling around the breast
Patients with regional recurrence will also experience similar signs aforementioned. As the cancer cells spread to the lymph nodes, patients may notice additional swelling around the armpits and/or collarbone regions.
When cancer has metastasised, symptoms will vary depending on the organ affected. The general signs include:
- Headache
- Nausea/vomiting
- Fatigue
- Cough or shortness of breath
- Pain in the bones
Diagnostic Methods
A comprehensive diagnosis process includes physical and imaging examinations. Further blood tests may be required if abnormalities are found. If you have breast cancer before, keep a record of your cancer diagnosis and treatment. Communicate any lasting side effects from your last treatment with your doctor.
The process involves a physical examination by the physician to check for visible abnormalities such as lumps, skin or nipple changes. To observe and test the breast tissues, one or more of these methods will be scheduled:
Mammograms
A mammogram uses X-rays to capture images of the breast tissues. They help doctors detect any lumps, masses, or other abnormalities that could be indicative of breast cancer or benign tumours.
The process involves placing 2 compression plates on the top and sides of the breast. You may feel a slight pressure as the plates spread out the breast tissues, though it should not be painful. An X-ray machine will release X-rays that pass through the breast to a detector, forming an image for further analysis.
Dense tissues like tumours or cysts appear whiter while normal low-density tissues like fats appear darker in the images. A radiologist will analyse the images for any suspicious regions. If so, a small sample of the breast tissue is extracted for further lab examinations.
Ultrasound
An ultrasound is a scan that uses sound waves to produce images. They are good alternatives for pregnant or younger women with denser breast tissues.
While mammograms are better at detecting smaller changes across the entire breast, ultrasounds can determine if a suspicious lump is fluid-filled (cyst) or solid mass e.g. tumours. Additionally, they identify calcium deposits, a feature observed in breast cancer patients as well.
MRI
Magnetic resonance imaging uses large radiowaves to produce detailed images of the breast tissues. While they are more sensitive to early-stage cancers, the process is more complicated and riskier than other imaging tools. Hence, doctors will schedule an MRI on a case-by-case basis, usually for those with a high risk of developing breast cancer.
MRIs are also used after breast cancer has been diagnosed to measure the extent of the cancer growth and measure whether it is responding well to the treatment. A contrast dye will be injected into the breast tissues through an IV for better visualisation. Any metal-containing devices in the body such as defibrillators, cochlear implants, stents etc should be notified to the doctor.
Lab tests
Tissue samples from biopsies are sent for testing. Biomarkers, which are key features of cancer cells, are examined. These help doctors identify the type of breast cancer and the likelihood of cancer recurrence, which are useful information for crafting a good treatment plan. For breast cancer, three biomarker tests are routinely performed:
- HER2 protein: Breast cancer cells have extra HER2 receptors that allow them to grow uncontrollably, a hallmark event for cancer development.
- Estrogen and progesterone receptors: This determines if the cancer cells are sensitive to reproductive hormones, which opens up hormone therapy as a viable treatment option.
- PD-L1 protein: More commonly observed in metastatic breast cancer, this protein allows cancer cells to hide from the immune system and continue to grow.
Blood work may be done to measure the number of the various blood cell types. The results are useful indications on how well your body is responding to cancer treatment and whether adjustments are needed.
Outside of a doctor’s visit, monthly self-examinations are equally crucial for catching early warning signs of cancer. It is a quick 5-minute check preferably a week after the end of your menstruation. You can either lie down or stand in front of a mirror. Observe your breasts and underarms for:
- Rashes, redness, or lumps on your skin
- Changes in the shape and size of your breasts
- Nipple inversion
- Any bulging or puckered areas around the outline of your breast
Next, using your finger pads, apply different pressure in a circular motion from your collarbone to your cleavage and armpits to check for any lumps or distortions around your breasts. Gently squeeze your nipple to check for abnormal nipple discharge such as blood, yellow, or watery fluid.
Treatment Options
No two cancers develop the same way. Based on the type and stage of breast cancer, the treatment combination may be different from the previous time. Common treatment options include:
Radiation Therapy
This involves high-energy waves to target and destroy cancer cells. Depending on the size and location of the tumour, radiation therapy can vary in its dose, duration, and area applied. Radiation therapy is often after surgery to kill any cancer cells that were not removed during the operation. This minimises the risk of cancer recurrence.
Radiation is not specific to cancer cells; surrounding healthy cells may be destroyed as well. Hence, you may experience fatigue, sickness, and skin irritation around the treated region.
Chemotherapy
Chemotherapy is the use of drugs to kill or slow down cancer growth. They come in the form of tablets, injections, or topical creams.
The effectiveness of treatment can vary based on the duration, dosage, drug combination, and the patient’s overall health. As chemotherapy attacks healthy cells as well, patients may experience fatigue, nausea, hair loss, and more. They can be managed with supportive care and well-planned sessions. Given in cycles, physicians will ensure that patients have adequate time to recover and produce healthy cells in between sessions.
Hormonal Therapy
Effective for hormone receptor-positive breast cancer, hormone therapy blocks the reproductive hormones (estrogen and progesterone) from binding to the cancer cells. Common therapies include:
- Tamoxifen: Blocks estrogen receptors on cancer cells.
- Aromatase Inhibitors: Lower estrogen levels in postmenopausal women.
Targeted therapy/Immunotherapy Therapy
Drugs that target specific characteristics of cancer cells, such as a protein that allows cancer cells to grow rapidly and abnormally. Immunotherapy is a type of targeted therapy that enables the immune system to identify and target cancer cells only. Unlike chemotherapy, targeted therapy minimises harm to healthy cells, relieving patients of the side effects.
Surgery
Breast cancer surgery involves the removal of cancerous tissue from the breast. There are several types of surgeries including:
- Lumpectomy: Only the tumour and a small margin of surrounding tissue are removed.
- Mastectomy: One or both breasts are removed partially or entirely.
The choice of surgery depends on the cancer’s stage, size, location, as well as the patient’s overall health and personal preferences. The priority is to preserve the breast while eliminating as many cancer cells as possible.
Prevention and Risk Reduction
We cannot fully prevent getting cancer. However, we can lower the risks through better habits and greater awareness.
Lifestyle habits
Leading a healthy lifestyle is beneficial for both physical and mental health. Aim for at least 150 minutes of moderate to vigorous exercise per week. With the numerous workout videos, community classes and hobby clubs available, find something that excites you.
Post-workout nutrition is just as important as the workout itself. Maintain a healthy diet of high protein and fibre. Of course, a little indulgence at the bar or your favourite hotpot spot is fine–just remember to keep everything in moderation.
Awareness
Cancer recovery is tough physically, mentally, and emotionally. For some, the hospital or treatment clinic may be the last place they want to be in after cancer remission. However, awareness does not end with recovery. Follow-up appointments, regular breast screenings, and self-examinations are part of this recovery process to catch any early recurring cancer before it worsens.
Living with Recurrent Breast Cancer
Be it anger, fear, or hopelessness, one can feel overwhelmed at having to go through cancer therapy again. You may not want to express these concerns to your family or friends for fear of being a burden. However, your emotional well-being matters as well. Ask your provider for any counselling or local support groups. Even joining online forums like Reddit can be a good source of comfort.
A cancer treatment plan targets the cancer but neglects how your body responds to it. Consider palliative care to alleviate your pain during the treatment. Through a combination of physical, psychological, and spiritual therapy, your recovery journey will be less painful.
Conclusion
Breast cancer recurrence can be a daunting experience. However, they are not always worse or more difficult to treat. By seeking the right treatment and support, recovery is possible.
Cancer can reappear for many reasons, such as drug resistance, incomplete removal during the first treatment, or a random mutation. While these are out of our control, we can still minimise the risk of re-developing cancer by adopting healthy lifestyle practices being more in tune with our bodies. With increasing research in targeted therapy, the outlook for breast cancer recovery is improving. For now, the best solution is to take it one step at a time.
Safeguard Your Health Today
At Centre for Screening and Surgery, we prioritise delivering quality and comfortable early cancer screening and treatment using minimally invasive procedures. If you notice any abnormalities in the breasts and want a breast screening, call us to book an appointment today!
