Will Your Breast Cancer Come Back?

If you’ve been through cancer treatment, there’s a nagging question that likely set in right around the time you finished your course of therapy: Will my cancer come back? When it comes to breast cancer, this concern is not unfounded: About 30% of people with breast cancer who are free of disease after initial local and regional treatments will have a recurrence at some point, according to research in the Journal of Clinical Oncology. However, the risk of recurrence is not the same for everyone, and understanding the factors that drive up your odds of cancer returning can help prevent unnecessary anxiety.

For starters, certain types of breast cancer are more likely to recur than others, says Constance Chen, M.D., a plastic surgeon and breast reconstruction specialist in private practice in New York City. These include inflammatory breast cancer (IBC) and triple-negative breast cancer (TNBC), she says.

In addition, “the higher-risk types [for recurrence] generally involve factors like larger tumors, spread to the lymph nodes, or certain patterns of gene expression," says Wesley Talcott, M.D., a radiation oncologist at Northwell Lenox Hill Hospital in New York City.

Let’s look more closely at the risk factors for breast cancer recurrence, along with signs that might indicate that a recurrence is happening.

Breast cancer recurrence is when the cancer returns after treatment. It can happen in the same breast as the original cancer, the opposite breast, or somewhere else such as the lymph nodes or another part of the body entirely.

With any type of breast cancer, the risk of recurrence is influenced by several factors, says Dr. Chen. Some are things you can modify, like smoking and following recommendations for treatment of your original cancer; others, like your age, genes, and what type of cancer you had, can’t be changed. Risk factors for recurrence include:

• Age. "Patients who are younger at diagnosis generally have disease recur at higher rates than older patients,” says Dr. Talcott. This is due to cancer being more aggressive in those who are diagnosed younger

• Genetic mutations such as BRCA1 and BRCA2

• Larger tumor size (bigger than 2 inches, or 5 centimeters, across)

• Lymph node involvement

• Overall health

• Smoking

• Stage of cancer at diagnosis (this is determined by your tumor size and lymph node status)

• Type of breast cancer

Other factors that can increase the likelihood of disease recurrence include incomplete surgery (leaving behind tumors in the breast) or not having recommended radiation therapy, chemotherapy, or endocrine therapy after surgery, Dr. Talcott adds.

Although all types of breast cancer can recur, there are two aggressive subtypes that are more likely to come back than other types: inflammatory breast cancer (IBC) and triple negative breast cancer (TNBC).

Inflammatory Breast Cancer

IBC involves rapid cancer cell growth that can spread to lymph nodes and organs. This is an uncommon type, representing approximately 1% to 5% of all breast cancers, but recurrence rates are as high as 50%—meaning that up to half of people with IBC experience recurrence, according to research in the journal Oncotarget. The researchers noted that because IBC is characterized mainly by skin changes in the breast—like redness, warmth, thick patches, and dimpling—it may be misdiagnosed as a dermatology issue, resulting in a delay in diagnosis and treatment. That can contribute to its spread in the body.

Triple-Negative Breast Cancer

Triple negative breast cancer means that the cancer cells don’t have receptors for the hormones estrogen or progesterone (hormone receptor negative), nor are they characterized by overexpression of the HER2 protein (meaning triple-negative breast cancer is what’s called HER2 negative). HER2 is a type of protein prompted by a certain gene that contributes to cancer cell growth.

According to research in the Journal of Medicine and Life, there are fewer treatment options available for TNBC compared to breast cancers that can be treated with therapies that target their hormone receptors or genes. If you had breast cancer categorized as hormone receptor-positive, for example, your doctor may prescribe a hormone therapy (also called endocrine therapy) such as tamoxifen to prevent a recurrence. Tamoxifen blocks the effects of estrogen on breast cancer cells so that they cannot grow. No such preventive option exists for triple-negative breast cancer.

TNBC is more common than IBC, accounting for about 10% to 15% of breast cancers, and is especially prevalent among Black and premenopausal women, research finds. The risk of recurrence within five years of diagnosis is nearly three-fold higher compared to other cancer types such as hormone receptor-positive cancer, that research suggests.

There are three ways in which previously treated breast cancer can return:

• Local recurrence: This is when cancer cells regrow in the same area as the original cancer, such as the same breast or in the chest wall (the muscles supporting the breast).

• Regional recurrence: This happens when cancer cells grow in nearby lymph nodes or in the immediate area of the initial tumor.

• Distant recurrence: Also known as metastatic breast cancer, this occurs when breast cancer cells travel to parts of the body that are farther away from the affected breast, such as the bones, lungs, brain, or liver.

The average time frame for breast cancer recurrence depends on various factors, but Dr. Chen says most breast cancer recurrence happens within five years after initial diagnosis.

Signs of a breast cancer recurrence can take several forms, but they generally appear as new, chronic issues that aren't resolved with at-home remedies like over-the-counter pain medication, says Parvin Peddi, M.D., a medical oncologist and director of breast medical oncology at the Margie Petersen Breast Center at Providence Saint John's Health Center in Santa Monica, CA.

These issues may involve the breasts but may also affect other parts of the body, she adds. Dr. Peddi says the most common signs include:

• Changes in nipple color or shape

• Cough that doesn't go away

• Frequent headaches that are worsening or are difficult to alleviate

• A swollen, firm lymph node that doesn't go away after several weeks

• Loss of appetite

• Neurological concerns like leg weakness that worsens

• New breast mass

• New skin changes in the breast, such as a rash or thickened patches of skin

• Unexpected weight loss

Also, "one place where cancer can recur is the bones," says Dr. Peddi. "If someone is complaining of new back pain or hip pain and there hasn't been an injury, that could be a sign of recurrence."

Watching for symptoms like these is important, but she adds that it's also essential to keep in mind that recurrence isn't inevitable, and that symptoms like those above may also stem from other causes. The important thing is to get them checked out promptly.

If you’ve had breast cancer, you should have a physical exam by your oncologist or primary care physician every six to 12 months, says Dr. Talcott. The doctor will look for or assess any new symptoms like lumps or skin changes. If you have residual breast tissue after surgery, you should also undergo annual breast imaging for at least the first five years after treatment, he adds. "This may include mammogram, ultrasound, or MRI testing depending on the composition of a patient’s breast and the specifics of their tumor,” he says.

If there are any suspicious findings on examination or imaging, the timeframe for surveillance may shorten to allow the care team to closely monitor these findings.

Knowing the specifics about your cancer and its likelihood of returning can help you manage the (very natural) anxiety about recurrence that comes with being a cancer survivor. So can doing what you can to manage the risk factors for recurrence that are modifiable, like embracing a healthy lifestyle and not smoking. "We don't like to use the word 'remission' because that implies the cancer is asleep right now but it’s not gone, and it will wake up at some point," says Dr. Peddi. "For the majority of people with localized breast cancer, we're able to cure that. It can cause anxiety to assume your cancer will come back at some point, so the best approach is to talk with your doctor about your risk level and stay on top of your monitoring checkups, but also remind yourself that the cancer might not come back at all.”