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When and where do recurrences occur?
Breast cancer can recur at any time, but most recurrences occur in the first
three to five years after initial treatment. Breast cancer can come back as a
local recurrence (in the treated breast or near the mastectomy scar) or as a
distant recurrence somewhere else in the body. The most common sites of
recurrence include the lymph nodes, the bones, liver, or lungs.
How do I know there is a recurrence?
Women who have been treated for breast cancer should continue to practice
breast self-examination, checking both the
treated area and the other breast each month. A woman should report any changes
to her doctor right away. Breast changes that might indicate a recurrence
include:
- An area that is distinctly different from any other area on either
breast
- A lump or thickening, in or near the breast or in the underarm, that
persists through the menstrual cycle
- A change in the size, shape, or contour of the breast
- A mass or lump, which may feel as small as a pea
- A marble-like area under the skin
- A change in the feel or appearance of the skin on the breast or nipple
[dimpled, puckered, scaly, or inflamed (red, warm, or swollen)]
- Bloody or clear fluid discharge from the nipples
- Redness of the skin on the breast or nipple
In addition to performing monthly breast self-exams, keep your scheduled
follow-up appointments with your health care provider. During these
appointments, your health care provider will perform a breast exam, order lab or
imaging tests as needed, and ask you about any symptoms you might have.
Initially, these follow-up appointments may be scheduled every three to four months.
The longer you are cancer-free, the less often you will need to see your health
care provider. Continue to follow your health care provider’s recommendations
on screening mammograms (usually recommended once a year).
Prognostic indicators
Prognostic indicators are characteristics of a patient and her tumor that may
help a physician predict a cancer recurrence. These are some common indicators:
Lymph node involvement — Women who have lymph node involvement are
more likely to have a recurrence.
Tumor size — In general, the larger the tumor, the greater the chance
of recurrence.
Hormone receptors — About two-thirds of all breast cancers contain
significant levels of estrogen receptors, which means the tumors are estrogen
receptor positive (ER+). ER+ tumors tend to grow less aggressively and may
respond favorably to treatment with hormones.
Histologic grade — This refers to how much the tumor cells resemble
normal cells when viewed under the microscope. The grading scale is 1 to 4.
Grade 4 tumors contain very abnormal and rapidly growing cancer cells. There
is a greater chance of recurrence the higher the histologic grade.
Nuclear grade — This is the rate at which cancer cells in the tumor
divide to form more cells. Cancer cells with a high nuclear grade (also called
proliferative capacity) are usually more aggressive (faster growing).
Oncogene expression — An oncogene is a gene that causes or promotes
cancerous changes within the cell. Tumors that contain certain oncogenes may
increase a patient’s chance of recurrence.
Treatment team
Following local breast cancer treatment, the treatment team will determine
the likelihood that the cancer will recur outside the breast. This team usually
includes a medical oncologist, a specialist trained in using medicines to treat
breast cancer. The medical oncologist, who works with the surgeon, may advise
the use of tamoxifen (tamoxifen citrate, Nolvadex) or possibly chemotherapy.
These treatments are used in addition to, but not in place of, local breast
cancer treatment with surgery and/or radiation therapy.
Treatment of breast cancer recurrence
The type of treatment for local breast cancer recurrences depends on the
woman’s initial treatment. If she had a lumpectomy, local recurrence is
usually treated with mastectomy, since radiation therapy cannot be delivered
twice to the same area. If the initial treatment was mastectomy, recurrence near
the mastectomy site is treated by removing the tumor whenever possible, usually
followed by radiation therapy. In either case, hormone therapy and/or
chemotherapy may be used after surgery and/or radiation therapy. If breast
cancer is found in the other breast, it may be a new tumor unrelated to the
first breast cancer. Treatment would include a lumpectomy or mastectomy and,
sometimes, systemic therapy.
Women with distant recurrence involving organs such as the bones, lungs,
brain, or other organs, are treated with systemic therapy using chemotherapy,
hormonal therapy, or both. Radiation therapy or surgery also may be recommended
to relieve certain symptoms.
Immunotherapy with trastuzumab (Herceptin) alone or with chemotherapy may be
recommended for women whose cancer cells have high levels of the HER2/neu
protein. Immunotherapy is generally started after hormonal or chemotherapy is no
longer effective.
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