Understanding the Risk of Late Recurrence of Breast Cancer

May 25, 2017
Crystal Moore, MD, PhD, FCAP

Even as a young child, Crystal Moore, MD, PhD, FCAP, knew she wanted to be a physician. For her, medicine is not just a profession but also a calling. She received her MD/PhD at the Medical College of Virginia. Her PhD was awarded by the Department of Biochemistry and Molecular Biophysics. She completed her residency training in Anatomic and Clinical Pathology at Duke University and is a board-certified fellow of the College of American Pathologists. Follow Dr. Moore at www.DrCrystalMoore.com and on Twitter @DrCrystalAMoore.

An astonishing 15 years after her initial diagnosis and treatment, my mother’s breast cancer unexpectedly recurred. Eventually, it claimed her life. As a daughter, I felt blindsided. But as a physician, I grew determined to help all people with breast cancer understand the risk of late recurrence.

From surgery and reconstruction to radiation therapy, chemotherapy, adjuvant hormone therapy, and follow-up doctor visits, the road back to health after a breast cancer diagnosis can be long and difficult to navigate. Patients anxiously await the day when they’ll hear that seemingly magical word: “remission.”

While remission can signal the end of a long road, it does not necessarily mean that the journey is over.share on twitter Once there has been a diagnosis of breast cancer, the risk of a recurrence is never zero.

Beyond the first 5 years

The risk of breast cancer recurrence is highest during the first 2 years after the initial diagnosis. As time passes, the risk of recurrence steadily decreases. Many survivors celebrate their 5-year cancer-free date because it is well known that the vast majority of patients who have not had a recurrence by that time have a relatively low risk of recurrence at all.

A “late recurrence” of breast cancer is one that recurs after the 5-year milestone. Since the likelihood of recurrence is so low at this point, we must ask ourselves:

  • Who experiences a late recurrence?

  • What factors contribute to their risk?

  • Why do seemingly “cured” patients, like my mother, have to face their cancer again?

Doctors, scientists, and researchers have identified factors that are related to the potential risks for late recurrence of breast cancer. Generally, these factors relate to the patient’s age, the cancer’s stage at diagnosis, hormone receptor status, genetic information, and lymph node involvement. Overall, the risk of a recurrence after 5 years is low, but breast cancer survivors with a higher risk of late recurrence are:

  • Survivors with the following receptor statuses

    • Estrogen receptor-positive (ER+) tumor

    • Progesterone receptor-positive (PR+) tumor

    • HER2-negative (HER2­–) tumor

  • Premenopausal survivors who had

    • Tumor larger than 2 centimeters (cm)

    • High number of involved lymph nodes

  • Postmenopausal survivors who are younger than 60 and had

    • Tumor larger than 2 cm

    • High number of involved lymph nodes

  • Postmenopausal women who are older than 60 and had

    • High number of involved lymph nodes

    • Low levels of estrogen expression from the tumor

    • Received adjuvant hormone therapy, such as tamoxifen or aromatase inhibitors, for only a short time, because of the side effects or other reasons

Breast cancer recurrences fall into 2 categories: local or regional, which is cancer that is near the location of the original cancer, and distant, which is when the cancer spreads to other areas or organs such as bones, brain, lung or liver, called metastasis. Local recurrences are often discovered during follow-up mammograms, physical exams, or when the survivor notices a lump, bump, rash, or other change at the surgical site. Distant metastases tend to be diagnosed during follow-up exams, scans, or when people tell their doctors about new signs or symptoms.

When a late recurrence of breast cancer is found, your pathologist on the cancer care team will evaluate and categorize all of the details. For example, when a cancer is found in organs far from the original occurrence, the pathologist will determine whether this is a distant breast cancer metastasis or a totally different cancer that has developed, such as a lung cancer or liver cancer. Although most breast cancer recurrences tend to be the same type and have the same hormone receptor status as the initial cancer, for some women it can differ significantly. For example, a person initially diagnosed with an ER-positive or PR-positive breast cancer can have an ER/PR-negative recurrence. Your pathologist will make the diagnosis and let your oncologist know of the results. This critical information helps determine a treatment plan that will provide the best chances for a successful outcome.

Next steps for breast cancer survivors

Following a diagnosis of breast cancer, I always tell my patients to pace themselves. The journey after treatment can be long and challenging. The late, great Maya Angelou gave sage advice when she stated, “My mission in life is not merely to survive, but to thrive, and to do so with some passion, some compassion, some humor, and some style.”

These 5 steps can help you thrive in your overall health and cancer survivorship:

  1. Take care of yourself emotionally. Seeking social support, developing strong personal relationships, accessing mental health services, and having a solid spiritual foundation are effective steps to manage life’s stressors and especially those unique to cancer survivorship.

  2. Eat a healthy diet. Good nutrition supports overall health, such as eating a diet rich in fresh fruits, vegetables, and lean meats.

  3. Maintain a healthy weight. Research shows that maintaining a healthy weight through a healthy diet and moderate physical activity lowers the risk of developing diabetes, high blood pressure, and other cancers and chronic diseases.

  4. Stick with your follow-up care and other health screenings. Your routine oncology appointment is a good time to talk about any concerns. If you notice any changes or new symptoms before your scheduled appointment, be sure to alert your health care provider. Also, take care of your entire body, including other recommended health screenings, such as Pap tests, general blood tests, blood pressure checks, and colonoscopy.

  5. Take hormone therapies as prescribed. Completing the full course of hormone therapy, such as tamoxifen, letrozole, and others, can help reduce the risk of recurrence. If you experience side effects from hormone therapy, such as hot flashes, sexual problems, and uterine bleeding, talk with your doctor about ways to manage them.

Know that you, as the patient, are the most important member of your cancer care team. Put yourself at the top of your busy to-do list. The more empowered and proactive you are, the better you will be able to manage your overall health and well-being and thrive in your life and survivorship.

Revised February 28, 2020.

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