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After treatment of the primary breast cancer is completed, checkups by the doctor are done periodically (usually every 2 - 3 months immediately following completion of all therapy and gradually increasing to six month or even yearly intervals). A mammogram of the non-treated breast and the breast treated with lumpectomy (if that was the case), is done annually. Sometimes mammograms are obtained at more frequent intervals in the first year or two after breast conserving treatment to establish a new 'baseline'. A pelvic examination is part of the routine annual checkup, as it is for women with no history of breast cancer. Some physicians also do blood tests to check tumor markers recurrence (proteins secreted by some breast cancers which can be monitored for disease activity) such as CEA, 15-3 or 27-29, but these tests have not proven effective in detecting recurrence much before symptoms occur. If a patient is experiencing symptoms and these markers are elevated, they are helpful in raising suspicion that the symptoms are due to recurrent cancer. In general, tumor marker studies, various scans, such as a bone or liver scan, and x-rays are not routine and are advised only when there is a sign or symptom that the cancer has recurred (returned). Of course, anytime there are symptoms, the appearance of a lump, a swollen lymph node, changes in the skin over the chest wall, back pain or pain of almost any type that can not be readily explained, shortness of breath, a loss of appetite, changes in vision, a new pattern of headaches or anything unusual, tests are done to evaluate the situation. These tests may include a blood test of liver function and tumor markers, bone scan, CT scan, MRI, a biopsy, and/or a chest x-ray. Often times the symptoms of breast cancer are identical to dozens of other conditions that normally afflict us, and unless the physician knows about the patient's prior history of breast cancer or the patient sees her oncologist, the association between the symptoms and a possible recurrence may be missed. When a recurrence occurs and metastasis is detected, a thorough examination is done to identify any other sites of metastasis. Regional lymph nodes (axillary or armpit lymph nodes, lymph nodes over and under the collarbone, and lymph nodes along the edge of the breastbone) are examined if they were not removed earlier. The skin over the breast, chest, and abdomen are checked, and liver function studies, a CT scan, MRI, chest x-ray, and bone scan may be done. Breast cancer can spread to ANY organ in the body, but the most common sites of recurrence are: skin over the chest wall or breast where the original tumor was; the arm pit on the same side as the tumor, but sometimes in other node areas; the bones, especially the back, upper thighs, shoulders, upper arms, and skull; the scalp; the lung and the lining of the lung; and the liver. Recurrent breast cancer that has spread to other organs or areas of the body is not considered curable, but usually is highly treatable with systemic therapy (chemotherapy and/or hormone therapy), with responses ranging from months to years depending on the individual situation. In general, the longer the disease-free interval -- that is, the period of time between the first treatment of the primary cancer and the date of cancer recurrence -- the better the outcome following treatment. People whose cancer recurs within one to two years after the initial diagnosis, for example, have a less favorable prognosis than those whose cancer recurred more than two years after diagnosis. How cancer recurrence and metastasis are treated depends on the disease-free interval, the location and number of metastatic sites, the estrogen and progesterone receptor status, the HER-2/neu, and the prior treatment. In general, when breast cancer spreads it spreads to many different places. However, they may not all present at one time. Because we know that breast cancer is usually in many different places, the mainstay of treatment for metastases is systemic therapy: either hormone therapy, chemotherapy, or a combination of these. In addition, local treatments are sometimes added. For example, patients with a painful bone lesion in addition to other sites may have radiation therapy to the bone lesion. There are some sites where systemic therapy has limited value. The best example of this is the brain. And occasionally only local treatment will be appropriate. For example, if a patient has a recurrence on the chest wall many years (e.g. 10 years) after mastectomy, it might be reasonable just to remove that nodule and do nothing further. In the vast majority of patients like this, additional metastases will eventually appear, but it might be some additional years before this happens. Its nice if the patient can have this time without any symptoms from treatments. The specific site of metastasis also will affect treatment decisions. In some cases, radiation therapy is more effective; in others, chemotherapy is best. The person's age and receptor status -- that is, whether or not the tumor has estrogen and/or progesterone receptors-- and the person's capacity to tolerate the side effects of chemotherapy or hormone therapy drugs (if treatment with these drugs is an option), also will be considered, just as it was for the primary treatment. Treatment Surgery Cancer recurrences following breast surgery (breast conserving [lumpectomy] or mastectomy) usually occur within two to six years after the initial diagnosis by may be as long as decades later. Breast cancer recurrences may occur in the same breast (for lumpectomy patients), the chest wall or surgical scar (for mastectomy patients) or to another organ or area of the body. Recurrences that occur in the breast or chest wall are called "local recurrences" and are usually detected by the appearance of a new lump in the breast or changes in the mammogram. Any new breast lump or mammography change could represent a recurrence of the first breast cancer, or be a new breast cancer that is unrelated to the first cancer. A biopsy of the suspicious area will determine the diagnosis and provide guidance for treatment. Treatment options for a local recurrence in the breast or chest wall include surgery or radiation therapy. In most cases, radiation therapy cannot be given twice to the same breast and patients who have had a lumpectomy have also received radiation therapy. Hence, the recommended treatment for a local recurrence for lumpectomy patients is mastectomy. In some cases, if the tumor is small and does not involve the skin of the breast, ribs, or chest wall, limited surgery (removing the tumor and a rim of surrounding normal tissue--much like the original lumpectomy) may still be possible. For patients who have had prior mastectomy, radiation therapy is usually recommended. Following treatment of the local recurrence, a decision regarding the need for chemotherapy and/or hormonal therapy (systemic therapy) will be made by the doctor after careful evaluation of the patient's individual situation and personal preferences. Important factors that will be considered include: prior chemotherapy or hormone therapy; side effects experienced by any prior therapy; stage of the disease; prognostic factors such as estrogen/progesterone receptor status and HER-2/neu status; any current symptoms from the cancer; age; performance status, and general health. When cancer recurs in distant organs or other parts of the body, surgery can often be used if the recurrence is localized as in the breast. For example, a small, single tumor in the liver or lung may be able to be surgically removed. Surgery can be very helpful in relieving symptoms from large tumors that are causing pain or pressure on another vital organ or body tissue. Surgery in this situation is called "palliative surgery", as the treatment goal is to provide comfort and relief of symptoms rather than cure. Radiation Therapy In the case of a local recurrence in the chest wall after a mastectomy, radiation therapy is helpful in preventing another recurrence. Radiation therapy can be most useful in treating specific sites of metastasis. Systemic Therapy Hormone Therapy As with its use in treating the primary cancer, hormone therapy is used with recurrent tumors that are estrogen and progesterone receptor positive or unknown status. The treatment plan will be individualized for each patient. Usually patients who respond best to hormone therapy at this time have had a disease-free interval of two years or longer. Tamoxifen is usually the hormone treatment of choice for postmenopausal women (if it has not just recently been taken or the patient's cancer progressed while on prior tamoxifen as an adjuvant therapy) and it is especially effective in treating soft tissue or bone metastases. Should the recurrent tumor progress during tamoxifen therapy, other new hormone suppressing drugs are now available (called second-line hormone therapy), which are also effective in controlling the cancer or achieving a remission. The new hormone-altering drugs are well tolerated and are administered as a daily table, like tamoxifen. Hormone therapy options for premenopausal women include tamoxifen and/or ovarian ablation (ovarian castration). Ovarian ablation can be accomplished by the surgical removal of the ovaries (oophorectomy), by a short course of radiation therapy, or by the administration of new drugs that stop the ovaries from functioning. The treatment goal of ovarian ablation is to shut down or block the ovaries from producing and secreting estrogen, the hormone that may be supporting the growth of the tumor. If estrogen is not available to the tumor, tumor regression usually occurs, and a positive response to the treatment is achieved. A combination of both tamoxifen and ovarian ablation may also be used, depending on the individual patient's situation. Chemotherapy As a systemic therapy, chemotherapy is used in recurrent or metestatic cancer to treat disease that has spread beyond the breast or chest region, especially when symptoms of the disease are present. Chemotherapy is used preferentially for women who are not likely to benefit from endocrine therapy. Chemotherapy typically consists of a combination of drugs (as with adjuvant chemotherapy in early stage disease), although a single drug may be chosen. The same chemotherapy combination that was used to treat the first cancer may be used again if the patient responded well the first time and there has been an interval of 6 months or more since the last time the treatment was used. Chemotherapy is very effective in reducing and controlling the tumor and relieving any distressful symptoms for metastasis to major organs such as the liver or lungs. Chemotherapy is equally effective against disease in bone, soft tissues, nodes, etc. It also is commonly used when hormone therapy no longer works or the tumor does not respond to hormone therapy. The most common combination chemotherapy regimens used to treat recurrence and metastasis are the same as those used to treat primary breast cancer: CMF (cyclophosphamide, methotrexate, 5-fluorouracil with or without prednisone) CA (cyclophosphamide and Adriamycin), and CAF (cyclophosphamide, Adriamycin, and 5-fluorouracil). Other drugs commonly used in advanced, metastatic breast cancer are the taxanes -- paclitaxel and docetaxel - as well as capecitabine, mitomycin-c, epirubicin, vinorelbine, gemcitabine and Herceptin for HER-2/neu positive cancers. High dose chemotherapy followed by bone marrow or stem cell transplant remains highly controversial in treating metastatic breast cancer as there is no proven survival benefit over standard chemotherapy. Due to the high cost, potentially life-threatening toxicities, and unproven benefit, this treatment is not recommended outside of a clinical research trial. Research studies are ongoing to determine its true value and place in the treatment of breast cancer. Treatment of Specific Sites of Metastases Central Nervous System Breast cancer can spread to the central nervous system (CNS), which includes the brain, spinal cord and spinal canal. Metastasis to the CNS is usually treated with radiation therapy. In some cases, however, surgery is required in addition to radiation therapy. For a small number of patients, treatment of CNS metastasis is successful and the patient may remain symptom-free for years. Even is survival is not changed, significant relief of symptoms can most always be achieved. Chemotherapy or hormone therapy (systemic therapies) are not used to treat metastasis to the brain as most current drugs are unable to pass through the protective lining of the brain and be absorbed into the brain tissue. If the cancer has spread into the spinal canal, chemotherapy can be considered and injected in the area with a special needle and syringe to reduce the number of tumor cells and relieve symptoms. Bone Metastases The bones are a common and frequent area of breast cancer spread and the treatment of choice is hormone therapy with tamoxifen. Hormone therapy is very effective in controlling the cancer that has spread to the bones and in relieving any symptoms and no other therapy may be needed, if that is the only area of metastasis. If bone pain exists due to the spread of cancer or if the disease progresses while the person is on tamoxifen, chemotherapy would then be implemented to treat the cancer and the painful symptoms. Radiation therapy can be administered to bone lesions that are particularly large and painful. However, if the physician thinks there is a high chance that the bone will break, the placement of a surgical rod or metal plate needs to be considered because hormone therapy, chemotherapy, and radiation therapy will not result in rapid healing of the bone. Just like a fracture where we use a cast for some period of time, a bone that has had cancer will remain weak and must repair itself after the cancer is successfully treated, and this may take months. A new drug called pamidronate disodium (Aredia) is being prescribed for women with metastasis to the bone to help reduce further bone breakdown, relieve pain, and minimize fractures. It should be noted that Aredia is not an anticancer drug and has no effect on the cancer cells themselves. Anedia works by blocking the breakdown of bone from the cancer and reducing complications from the bone metastases. Aredia is given intravenously (IV) as an outpatient procedure every four weeks and usually is well tolerated. Since it does not interfere with the effects of chemotherapy, Aredia and chemotherapy drugs may be given together. Liver and Lung Metastases When nodules (tumors) are present in the liver and lung, chemotherapy will be used to try to shrink or eliminate the tumors and control the cancer. However, the use of hormone therapy should not always be ruled out just because there are liver metastases. If there is evidence that the liver metastases have grown slowly and the patient is ER positive, it may be very reasonable to use hormone therapy. Chemotherapy is used more often, however, because liver metastases often become symptomatic and even life threatening very early. If a patient has a low ER, the chances of responding to chemotherapy will be much higher than responding to hormone therapy. Therefore, a physician will usually provide the therapy he/she is most certain will work. In some cases, the cancer may spread into the lining of the lung and cause an accumulation of fluid between the inner and outer lung lining, which leads to shortness of breath and difficult breathing. When this happens, a needle is inserted into the lung area and the fluid is drained. A small chest tube may be placed temporarily (usually for no more than several days) to fully drain the fluid and allow the lung to re-expand. If the fluid tends to recur on a frequent basis, talc or various drugs are administered through the chest tube to cause an inflammation of the lung lining. This causes the inner and outer linings to stick together as they heal, making it very difficult for fluid to reaccumulate in the area. Radiation therapy also may be used, in conjunction with chemotherapy, if there are large, bulky tumors that cause pain, pressure or bleeding. In this situation, radiation can be very effective in shrinking the tumor enough to relieve symptoms and is only given in a short course, perhaps five to ten treatments. Other Sites Although the areas of the body discussed above are the most common sites for breast cancer to spread, metastases may appear in any part of the body depending on where individual cancer cells travel (through the blood and/or lymph system) and establish growth. In general, if there are multiple sites of spread accompanied by bothersome symptoms, systemic therapy with chemotherapy or hormone therapy will be utilized. Palliative Care In the late stages of advanced breast cancer, one or all of the above treatments may be used to shrink a tumor that is causing symptoms such as pain, difficult breathing, or bleeding. This is called "palliative care" as the treatment is designed to offer comfort, not to control the disease or attempt to bring the cancer into remission. Surgery may be used, for example, to stabilize a bone that has fractured because of cancer invasion. All treatment of metastases are first and foremost designed to palliate the patient's symptoms and improve her quality of life. In addition, it is clear that these therapies will prolong survival even if no patient is actually cured by them.  This content is reviewed regularly. Last Updated 6/6/2007
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