What happens if breast cancer returns?

Types of recurrence

There are different ways of classifying recurrent cancers; the one that is in most common use splits cancers into:

1 Local recurrence in the area around the breast and the axilla

2 Recurrence elsewhere in the body, which is known as a secondary growth or metastasis. 

Local recurrence

If you develop local recurrence and have no disease elsewhere in the body, it is usually possible just to remove this by surgery. If surgery is performed it will often be combined with radiotherapy and/or, if you have not had it previously, a change in drug treatment if you are taking hormonal drugs. Radiotherapy without surgery is used in some women who have not had this treatment to the area before.

Chemotherapy or newer biologic treatments may be used and can be given before or after surgery and/or radiotherapy.

The first sign of local recurrence is usually a lump in the breast, or in the skin of the breast, the armpit or in or close to the scar where you had your surgery. It is important if you do develop a lump or nodule in your breast at or around your scar or armpit to get this checked by your doctor.

Metastatic breast cancer

In some women cancer cells break away from the primary breast cancer and spread to other parts of the body forming so-called metastases.

These cells survive because they are resistant to the adjuvant hormone therapy and chemotherapy and so survive despite these therapies. They can lie dormant for many years and even decades before they start to grow.

In a few women there will be signs that the cancer has spread at the time they are first diagnosed. This will be evident because of abnormalities on X-rays or scans. The common sites for breast cancer to spread to are bone, liver, lungs and brain.

The treatments available include:

• hormonal therapy

• chemotherapy

• radiotherapy

• monoclonal antibody therapy – trastuzumab (Herceptin).

The best treatment for you will depend on:

• which parts of the body are affected by breast cancer

• whether you have had your menopause

• the treatment that you have had in the past

• your age and general health

• whether the cancer cells are hormone receptor positive

• whether the cancer cells are HER2 positive.

The treatment that you will receive is the one that is most likely to control the breast cancer and cause the fewest side effects. With cancer that has spread the aim of treatment is to control the cancer for as long as possible, improve any symptoms and prolong length of life. Most treatments are effective at shrinking the cancer or stopping its growth. Although cure is not expected, control of the disease is usually possible.

The same drug treatments used for early breast cancer are also used for cancer that has spread. This includes hormonal therapies, chemotherapy and biologic therapies such as trastuzumab. In some women the cancer has spread to only one specific site, whereas, in others, tests show that the cancer involves multiple sites. There are specific treatments for cancers that have spread to involve specifically the bones, lungs and brain.

Treatment of metastases

Bone metastases

X-rays of the bones, a bone scan, a CT scan or MR scan are the tests used to diagnose bone metastases.

The bones are the most common site to which breast cancers spread. The most common symptom is pain. This pain can usually be controlled by a combination of painkillers and radiotherapy.

If the bone is particularly weak and likely to break or if the bone has already broken, surgery can be effective at strengthening, repairing or replacing the affected bone.

Another effective treatment for cancer that has spread to bones is to give a bisphosphonate. These are bone-strengthening agents and stop the cancer cells damaging bone. Bisphosphonates are usually given as an intravenous injection every few weeks. Newer drugs take about 15 minutes to give. They reduce pain in the bones and strengthen the bone so reducing the chances of getting a fracture.

One recognised complication of advanced breast cancer is the production of too much calcium from the bones, called hypercalcaemia. Symptoms of hyper­calcaemia include nausea (feeling sick), abdominal pain, constipation, fatigue, confusion and drowsiness.

The best treatment for this is to flush the calcium out of the body by setting up a drip and giving fluid into the veins combined with regular bisphosphonates.

Lung metastases

These are diagnosed by a chest X-ray or CT scan of the chest. There are two types of involvement of the lung by breast cancer.

Outer lining of the lung

The most common is disease affecting the outer lining of the lung, known as the pleura, which results in fluid collecting around the lung, causing breathlessness. This is known as a pleural effusion.

Simple drainage is effective at removing the fluid but after simple drainage the fluid tends to re-collect.

Draining the fluid by placing a drain between the ribs into the fluid and leaving it in for two or three days is effective at draining off the fluid and in many patients stops the fluid coming back.

People who get recurrent build-up of fluid benefit from injection of talc or a chemotherapy agent called bleomycin into the space between the chest wall and

lungs, where the fluid builds up. This causes the lungs to stick to the chest wall and can stop the fluid continuing to collect.

Within the lung

If the lung itself is affected the symptoms include breathlessness and/or a cough. Cough medicines are often effective at controlling this symptom. Breathlessness caused by disease in the lungs is best treated by switching treatment to another chemotherapy drug(s) or another hormone drug.

Brain metastases

These can be diagnosed on a CT or MR scan of the brain. Symptoms of spread to the brain include nausea, vomiting, fatigue, weakness, feeling unsteady on your feet, double vision and fits. Some women get headaches that are worse in the morning, but most women with breast cancer who develop headaches do not have cancer spread to the brain.

Initial treatment is with steroids, which reduces swelling in the brain and improves symptoms. This is usually followed by radiotherapy.

When cure is not possible

If it is not possible to stop the cancer completely, it is nearly always possible to control symptoms such as pain and nausea. Most hospitals have a specialised palliative care team who can advise your GP or the hospital oncology department about the optimal use of drugs to help you.

These will probably include painkillers and drugs that combat nausea and diarrhoea. They can also advise on how to improve your appetite, which can often be poor as a result of the illness or the treatment.

Coping with recurrent or metastatic breast cancer

Many women find it even more difficult to face cancer that returns (secondary breast cancer) than they did when they were first diagnosed. Having been well for so long it is difficult to face going through further treatment that can be unpleasant.

You will need the support of your friends and family through this difficult time. Support is also available from your surgeon, oncologist, breast care nurse, GP and many self-help groups.

Some patients get support from Macmillan and Marie Curie nurses who come out and visit at home. A variety of organisations and self-help groups that also provide support are listed in ‘Further information’.

KEY POINTS

• Breast cancer can return in the breast/chest area and armpit (local recurrence) or elsewhere in the body (metastatic or secondary breast cancer)

• The most common sites of spread of breast cancer are bone, liver, lungs and brain

• When cure is no longer possible a variety of treatments is available to keep patients pain free and to control any symptoms from the cancer

• Similar treatments are used to those for treating early breast cancer but with metastatic cancer cure is not expected

• There are specific treatments that are effective at controlling disease in the bone, lungs and brain