Published: Thursday, May 03, 2007
- Definition of locoregional recurrence
- Factors influencing locoregional recurrence
- Definition of distant (systemic) recurrence
- Signs of locoregional recurrence
- Local treatment recommendations for a locoregional recurrence in the breast previously treated with mastectomy
- Local treatment recommendations for a locoregional recurrence in the breast previously treated with breast-conserving surgery (BCS)
- Systemic treatment recommendations for patients diagnosed with a locoregional recurrence
- Emotional effects of a diagnosis of recurrent breast cancer
- Special nutritional concerns with a breast cancer recurrence
- Clinical trials available for those diagnosed with a breast cancer recurrence
- Resources available for patients at the time of recurrence
1. Definition of locoregional recurrence of the breast
A locoregional (local or regional) recurrence refers to relapse of breast cancer in the breast, the armpit, the skin or muscles of the chest wall or the surrounding lymph nodes. The most likely explanation for locoregional recurrence is that cancer cells present in the skin, muscles or lymphatic system were not removed at the time of surgery and were not killed by the subsequent treatments.1
2. Factors influencing risk of locoregional recurrence
The risk of recurrence is related to several factors, including whether the cancer is in situ or invasive, the size of the tumour, and the presence or number of lymph nodes affected. Those with in situ disease have a very low risk of a systemic recurrence, but there is a possibility of local recurrence in the treated breast or of a cancer developing in the other breast.1
For women with invasive disease, the risk of recurrence is related to the clinical stage of the cancer. This can occur anytime after initial treatment, but if it does occur, it is usually within the first two years.1
- Stage 1: 5-25% will relapse either locally or systemically within 10 years of treatment
- Stage II: 50% will relapse either locally or systemically within 10 years of treatment
- Stage III: 75% will relapse either locally or systemically within 10 years of treatment
Locoregional recurrence following modified radical mastectomy carries a poor prognosis but some 15% of patients will be long term survivors after further locoregional therapy. A significant proportion of patients who develop recurrence after mastectomy will already have demonstrable metastatic disease.2
Locoregional recurrence following BCS and radiation is approximately 2-10% within 10 years of treatment. Recurrence in the breast following BCS is usually curable. The survival of patients under these circumstances is parallel to that of patients with new tumours of similar stage.3
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3. Definition of distant (systemic) recurrence
Distant or systemic recurrence is when cancer recurs elsewhere in the body. This is also called metastasis. Common sites for breast cancer distant recurrence are bone, lung, liver and brain. Other body parts that may be affected are lymph nodes, skin, eyes, spinal cord, and ovaries.1
See further information on the treatment of metastatic disease.
4. Signs of locoregional recurrence
Women who were first treated with breast-conserving surgery (BCS) may have their recurrence detected through their annual mammogram. Other possible signs of local or regional recurrence include new lumps, "thickening" or rashes in the breast, chest wall or axilla or above the collarbone. Recurrence in the lymph nodes in the axilla or behind the collarbone may cause shoulder pain or arm swelling. A new pain that shoots down the arm, or numbness and weakness in the hand or arm, may be due to cancer pinching the nerves that extend down into the hand and arm from the neck. Any of these symptoms should be reported to a physician promptly.4
Tumours should be carefully assessed as some of these breast 'recurrences' are not recurrences but are new primary breast cancers which may require different treatment and may give a different prognosis. All patients experiencing a locoregional recurrence should have a completed metastatic work-up performed, including a biopsy to confirm recurrent disease and ER status, mammogram of the contralateral breast, complete blood count (CBC), enzymes, bone scan and chest X-ray. All patients diagnosed with locoregional recurrence should have a pre-operative consultation with an oncologist.2
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5. Local treatment recommendations for a locoregional recurrence in the breast previously treated with mastectomy
Mastectomy-treated patients should undergo surgical resection of the local recurrence, if possible, and radiotherapy (if the chest wall was not previously treated or if additional radiotherapy may be safely administered). The use of surgical resection in this setting implies the use of limited excision of disease with the goal of obtaining clear margins of resection. Unresectable chest wall recurrent disease should be treated with radiation therapy (RT) if no prior RT has been given.2
6. Local treatment recommendations for locoregional recurrence in the breast previously treated with breast-conserving surgery (BCS)
BCS-treated patients should undergo a total mastectomy and axillary dissection, if not done at the time of the original surgery. If the recurrence is in the axilla or supraclavicular fossa and these lymph node areas have not previously been irradiated, then radiation therapy should be offered to the axilla and supraclavicular node areas, with an appropriate blocking technique for the previously irradiated breast. For patients who initially had BCS and refused or were not given radiation and are now prepared to accept it on recurrence, they may choose repeat wide excision (if cosmetically possible) followed by radiation therapy.2, 3
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7. Systemic treatment recommendations for patients diagnosed with a locoregional recurrence
After local treatment, women with locoregional recurrence may be considered for systemic chemotherapy or endocrine therapy. It has not yet been determined whether chemotherapy added to surgery and/or radiation alone will cure more women with local relapse. However, if the recurrence is in the axilla or if lymphatic, vascular or perineural invasion is identified, or if the invasive tumour is >2 cms, any grade or >1 cm and grade III, or if the woman is younger, then adjuvant chemotherapy or hormone therapy may be considered, depending upon the patient's age, history of prior adjuvant treatment and estrogen receptor status. As yet, there are no data available to evaluate the benefit of systemic therapy in this setting.2, 5
Learn about the use of hormonal therapy in the treatment of locoregional recurrence.
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8. Emotional effects of a diagnosis of recurrent breast cancer (locoregional or distant)
"While shock and disbelief are common emotions at diagnosis, hopefulness and a treatment plan that is expected to lead to long-term disease-free survival usually counter these emotions. In contrast, recurrence of breast cancer is experienced as a failure by both the patient and her treatment team. One recent study of 378 long-term breast cancer survivors showed that many women attribute their disease to stress (42 percent) and a lack of recurrence to having a positive attitude (60 percent) (Stewart et al., 2001). This suggests that many women with breast cancer blame themselves for their disease or its recurrence."6
"Recurrence is almost always associated with clinical symptoms from the cancer - insidious onset of pain, cough, or the development of skin nodules, for example. The clinical symptoms of recurrence provide tangible evidence of the seriousness of the situation, and the emotions that had been elicited at the time of diagnosis tend to recur and are intensified, particularly with respect to depressive symptoms. This is often a challenging time for the patient, her family, and the treatment team. In a recent study, significant impairments in physical, functional, and emotional well-being were found among women with recurrent breast cancer, and family members reported significant impairments in their own emotional well-being (Northouse et al., 2002)."6
"Nevertheless, women who faced initial aggressive treatments are often unwilling to accept less intensive treatments at recurrence. In the 1990s many women sought high-dose chemotherapy programs in spite of insufficient evidence for efficacy. Often this occurred because these women were reluctant to contemplate long-term and unending therapies. They saw intensive, time-limited, “potentially curative” therapies as an alternative. To some extent, this approach fulfilled a psychological need to gain some control over a situation that felt out of control. Physicians often shared in this misconception regarding treatments that were unproven. For many of these women, taking an action, obtaining second opinions, and seeking experimental therapies became the focus of their efforts when they faced metastatic breast cancer. Today, many women are beginning to view recurrent breast cancer as a chronic condition that can be controlled long-term, even if it cannot be cured. The comparison to the control of diabetes is often helpful. Awareness of second- and third-line therapies for recurrent disease makes this concept more plausible. Women may reach their decisions either on the advice of their physician or by sharing in decision making in various ways (Chou, 2003)." 6
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9. Special nutritional concerns with a breast cancer recurrence
The recommendations for nutrition and a healthy lifestyle at the time of recurrence are the same as the recommendations for prevention, during treatment, and for life after breast cancer. Women are encouraged to follow a diet that is lower in fat, with lots of fruits, vegetables and whole grains. Maintenance of a healthy body weight and being physically active are also important lifestyle factors to reduce the risk of cancer recurrence.
10. Clinical trials available for those diagnosed with a breast cancer recurrence
Review BC Cancer Agency Open Clinical Trials for breast cancer.
11. Resources available for patients at the time of diagnosis
See Patient Needs.
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References
1. Olivotto I, Gelmon K, McCready D, Pritchard K, Kuusk U. Intelligent patient guide to breast cancer. 4th ed. Edwards C, editor.Vancouver (B.C.): Intelligent Patient Guide Limited; 2006, pg. 228.
2. BC Cancer Agency (http://www.bccancer.bc.ca). Vancouver (B.C.): 2006. (cited Oct 25, 2006). Available from: http://www.bccancer.bc.ca/HPI/CancerManagementGuidelines/Breast/Management/
LocoregionalRecurrence.htm
3. Olivotto I, Gelmon K, McCready D, Pritchard K, Kuusk U. Intelligent patient guide to breast cancer. 4th ed. Edwards C, editor.Vancouver (B.C.): Intelligent Patient Guide Limited; 2006, pg. 234.
4. Olivotto I, Gelmon K, McCready D, Pritchard K, Kuusk U. Intelligent patient guide to breast cancer. 4th ed. Edwards C, editor.Vancouver (B.C.): Intelligent Patient Guide Limited; 2006, pg. 233.
5. Breast cancer: practice guidelines in oncology, Version 2.2006, 12-05-05 © 2005, National Comprehensive Cancer Network, Inc.
6. Hewitt M, Herdman, R, Holland, J, editors. Meeting psychosocial needs of women with breast cancer. Washington, D.C.: The National Academies Press; National Cancer Policy Board; 2004; pg.29-31.