Breast Cancer, Metastatic or Recurrent

Condition Basics

What is metastatic or recurrent breast cancer?

Breast cancer is the uncontrolled growth of abnormal cells in one or both breasts. Metastatic breast cancer means that cancer has spread to other parts of the body. It can be present when someone is first diagnosed with cancer. Recurrent breast cancer means that cancer has come back in or near the original site or in another part of the body. This may happen from a few months to many years after the first diagnosis.

What causes it?

Doctors don't know for sure what causes breast cancer to spread or come back. Even with treatment, cancer can come back. Some things increase the risk of breast cancer coming back. They include the stage and size of the tumor and whether the cancer cells have receptors for estrogen or progesterone.

What are the symptoms?

The symptoms depend on where the cancer is and how large it is. Symptoms of metastatic or recurrent breast cancer include a lump or change in your breast or on your chest, changes in your nipple, bone pain, belly pain, and shortness of breath. Or you may not have any symptoms.

How is it diagnosed?

If your doctor thinks that breast cancer has come back or spread, you may have a biopsy to check a sample of tissue. You may also have blood tests and imaging tests, such as a mammogram, an ultrasound, a bone scan, a CT scan, a PET scan, or an MRI.

How is metastatic or recurrent breast cancer treated?

Metastatic or recurrent breast cancer may be treated with chemotherapy, endocrine therapy, or targeted therapy. Other options may include surgery or radiation therapy. Your doctor may suggest a clinical trial.

Symptoms

The symptoms of metastatic and recurrent breast cancer depend on how much and where the cancer has spread. Some people have symptoms, but many don't.

Metastatic breast cancer

Symptoms of metastatic breast cancer will depend on the area affected. For example:

• If your bones are affected, you may have bone pain. And your bones may break more easily.
• If your lungs are affected, you may be short of breath or cough.
• If your liver is affected, you may have pain in your belly or yellow, itchy skin.
• If cancer spreads to your brain, you may have confusion, headaches, or seizures.

Recurrent breast cancer

Cancer that comes back in the same breast or in your mastectomy scar is called a local recurrence. With this type, you may have symptoms such as:

• A lump or thickening in the breast, chest wall, or armpit after you have had breast-conserving surgery or a mastectomy. You may notice that the skin of your chest looks or feels different.
• A change in the size or shape of the breast or a dimple or pucker in the skin of the breast.
• Discharge or bleeding from the nipple that occurs without squeezing the nipple.
• A change in the nipple, such as a scaly or crusty look or a nipple that pulls inward.

Cancer that comes back in another part of your body, such as your lungs, is called distant recurrence. With this type, you may have some of the same symptoms as metastatic breast cancer.

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What Happens

Breast cancer occurs when abnormal cells grow out of control in one or both breasts.

• With metastatic breast cancer, the cancer cells travel from the breast to other parts of the body and cause cancer in a new location (metastasize). The cancer cells may travel through the bloodstream or the lymph system. Some people have metastatic breast cancer when first diagnosed. Or it may occur month to years after treatment.
• With recurrent breast cancer, the cancer comes back (recurs) after treatment. This can occur in or near the original location, in nearby lymph nodes, or in other parts of the body. When cancer comes back in other places, it may be called distant recurrence or metastatic cancer.

Your treatment plan will be based on many things, such as the stage of your cancer and whether the cancer is hormone-receptor positive. It'll also be based on what treatments you may have had in the past.

When to Call a Doctor

Be sure to follow your doctor's instructions about calling when you have problems, new symptoms, or symptoms that get worse.

Call your doctor if you have any symptoms, such as:

• A lump or sore in your breast or on your chest wall.
• Swelling in the armpit or neck.
• Swelling of the arm.
• Bone pain, especially in the back or hips.
• Shortness of breath or a cough.
• Loss of appetite.
• Extreme tiredness.
• Nausea or vomiting.
• Recurrent headaches.

Exams and Tests

After you've been treated for breast cancer the first time, you will have regular checkups. This is to check for any signs that the cancer has spread or come back. Your checkups may include a physical exam, a clinical breast exam (CBE), or a mammogram. An MRI of the breast may also be used.

If your doctor thinks that breast cancer has spread or come back, you may have tests to check for cancer. They include:

• Blood tests, such as a complete blood count (CBC).
• Tissue tests, such as a biopsy.
• Imaging tests, such as a mammogram, an ultrasound, a bone scan, a CT scan, a PET scan, or an MRI.

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Treatment Overview

Treatment for metastatic breast cancer is based on many things. These include the type and location of the cancer, your overall health, and what matters to you. The main treatments are medicines. These include chemotherapy, endocrine therapy, targeted therapy, and immunotherapy. Your doctor may suggest a clinical trial.

Other treatments may be used to help relieve symptoms. These include radiation therapy, surgery, or medicines.

Your doctor will talk with you about your options and then make a treatment plan.

Some people use complementary therapies along with medical treatment. Therapies like acupuncture or massage may help you cope with the symptoms and stress of cancer. Talk with your doctor about any of these options you would like to try.

Medicines

Medicines for metastatic breast cancer include:

Endocrine therapy.

These medicines block natural hormones that cause certain cancers to grow. This helps slow or stop cancer growth. Medicines that help block estrogen and progesterone include tamoxifen and aromatase inhibitors.

Targeted therapy.

These medicines target cancer cells and may cause less harm to normal cells. They help keep cancer from growing or spreading. Some of these medicines target a specific gene in the cancer cells. If testing shows that you have a gene that can be targeted, you may be given one or more of these medicines.

Targeted therapies include HER2-targeted therapies and PARP inhibitors. PARP inhibitors may be used for those who have BRCA1 or BRCA2 gene changes.

Chemotherapy.

These medicines kill fast-growing cells, including cancer cells and some normal cells.

For some types of cancer, chemotherapy may be combined with immunotherapy.

Immunotherapy.

This treatment helps your immune system fight cancer.

These medicines can be given in different ways. They are often put into a vein or taken as a pill.

Treatment for symptoms

You may have treatment to relieve cancer symptoms. This can help you feel better. It might include:

Radiation therapy.

This uses high-dose X-rays to destroy cancer cells and shrink tumors. It may be used to treat cancer that has spread to the brain. Or it may be used to relieve symptoms such as bone pain.

Surgery.

You may have surgery to remove tumors that are causing symptoms.

Medicines.

For example, corticosteroids may be given for cancer that has spread to the brain or spinal cord. Bisphosphonates are used for cancer that has spread to the bones.

Clinical trials

Clinical trials are an option for many people who have cancer. These research studies test promising new treatments or improvements to existing treatments. People in clinical trials may have access to the latest treatments before they're available to others.

Your doctor can tell you if there's a clinical trial that might be right for you.

Treatment for recurrent breast cancer

Treatment for recurrent breast cancer is based on the type and location of the cancer and other things, including the treatment you had before. Treatment options for local or regional recurrence may include:

Surgery to remove the cancer.

For example, if you already had breast-conserving surgery, you may have a mastectomy. The doctor may also remove lymph nodes under the arm.

Radiation therapy.

This uses high-dose X-rays to destroy cancer cells and shrink tumors. It may be given after surgery.

Chemotherapy.

These medicines kill fast-growing cells, including cancer cells and some normal cells.

Endocrine therapy.

These medicines block hormones that cause certain cancers to grow. This helps slow or stop cancer growth.

Other treatment options may include targeted therapy or immunotherapy. A clinical trial may be a good choice.

Your doctor will talk with you about your options and then make a treatment plan.

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Supportive Care

Palliative care is a type of care for people who have a serious illness. It's different from care to cure your illness, called curative treatment. Palliative care provides an extra layer of support that can improve your quality of life—not just in your body, but also in your mind and spirit. Sometimes palliative care is combined with curative treatment.

The kind of care you get depends on what you need. Your goals guide your care. You can get both palliative care and care to treat your illness. You don't have to choose one or the other.

Palliative care can help you manage symptoms, pain, or side effects from treatment. It may help you and those close to you better understand your illness, talk more openly about your feelings, or decide what treatment you want or don't want. It can also help you communicate better with your doctors, nurses, family, and friends.

End-of-life care

It can be hard to live with an illness that cannot be cured. But if your health is getting worse, you may want to make decisions about end-of-life care. Planning for the end of your life does not mean that you are giving up. It is a way to make sure that your wishes are met. Clearly stating your wishes can make it easier for your loved ones. Making plans while you are still able may also ease your mind and make your final days less stressful and more meaningful.

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Self-Care

• Take your medicines exactly as prescribed. Call your doctor if you think you are having a problem with your medicine. You may get medicine for nausea and vomiting if you have these side effects.
• Follow your doctor's instructions to relieve pain. Pain from cancer and surgery can almost always be controlled. Use pain medicine when you first notice pain, before it becomes severe.
• Eat healthy food. If you do not feel like eating, try to eat food that has protein and extra calories to keep up your strength and prevent weight loss. Drink liquid meal replacements for extra calories and protein. Try to eat your main meal early.
• Get some physical activity every day, but do not get too tired. Keep doing the hobbies you enjoy as your energy allows.
• Do not smoke. Smoking can make your cancer worse. If you need help quitting, talk to your doctor about stop-smoking programs and medicines. These can increase your chances of quitting for good.
• Take steps to control your stress and workload. Learn relaxation techniques.
  • Share your feelings. Stress and tension affect our emotions. By expressing your feelings to others, you may be able to understand and cope with them.
  • Consider joining a support group. Talking about a problem with your spouse, a good friend, or other people with similar problems is a good way to reduce tension and stress.
  • Express yourself through art. Try writing, crafts, dance, or art to relieve stress. Some dance, writing, or art groups may be available just for people who have cancer.
  • Be kind to your body and mind. Getting enough sleep, eating a healthy diet, and taking time to do things you enjoy can contribute to an overall feeling of balance in your life and can help reduce stress.
  • Get help if you need it. Discuss your concerns with your doctor or counselor.
• If you are vomiting or have diarrhea:
  • Drink plenty of fluids to prevent dehydration. Choose water and other clear liquids. If you have kidney, heart, or liver disease and have to limit fluids, talk with your doctor before you increase the amount of fluids you drink.
  • When you are able to eat, try clear soups, mild foods, and liquids until all symptoms are gone for 12 to 48 hours. Other good choices include dry toast, crackers, cooked cereal, and gelatin dessert, such as Jell-O.
• If you have not already done so, prepare a list of advance directives. Advance directives are instructions to your doctor and family members about what kind of care you want if you become unable to speak or express yourself.

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Complementary Treatments

Some people use complementary therapies along with medical treatment. They may help relieve the symptoms and stress of cancer or the side effects of cancer treatment. Therapies that may be helpful include:

• Acupuncture to relieve pain and other symptoms.
• Meditation or yoga to relieve stress.
• Massage and biofeedback to reduce pain and tension.
• Breathing exercises to help you relax.

Talk with your doctor about any of these options you would like to try. And let your doctor know if you are already using any complementary therapies. They are not meant to take the place of standard medical treatment. But they may help you feel better and cope better with treatment.

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Getting Support

Relationships take on new importance when you're faced with cancer. Your family and friends can help support you. You may also want to look beyond those who are close to you.

• Reach out to your family and friends.

  Remember that the people around you want to support you, and asking for help isn't a sign of weakness.

• Tell them how they can help.

  Your friends and family want to help, but some of them may not know what to do. It may help to make a list. For example, you might ask them to:

  • Run errands or pick up kids.
  • Deliver meals or groceries to your home.
  • Drive you to appointments.
  • Go to doctor visits with you and take notes.
• Look for help from other sources.

  Places to turn for support include:

  Counseling.

  Counseling can help you cope with cancer and the effect cancer is having on your life. Different types of counseling include family therapy, couples therapy, group counseling, and individual counseling.

  Your health care team.

  Your team should be supportive. Be open and honest about your fears and concerns. Your doctor can help you get the right medical treatments, including counseling.

  Spiritual or religious groups.

  These groups can provide comfort and may be able to help you find counseling or other social support services.

  Social groups.

  Social groups can help you meet new people and get involved in activities you enjoy. Focus on activities that bring you comfort, such as spending time outdoors or being with children.

  A cancer support group.

  Cancer support groups offer support and practical advice. You can hear others talk about:

  • What it's like to live with cancer.
  • Practical ways to manage your cancer treatment and its side effects.
  • Ways to cope with your illness.

Adjusting to body changes after treatment

Your feelings about your body may change after treatment for breast cancer. For example, you may find it hard to adjust to how your body looks after surgery. These and other physical changes may affect your body image. Or they may affect your desire to be intimate with a partner. Everyone has their own reaction to the challenges of cancer treatment.

If you have concerns, try to talk openly with your partner, if you have one. Or discuss your feelings with your doctor or nurse. Your care team may be able to help. Or they may refer you to counseling or a support group. Talking with others who've had similar feelings can be very helpful.

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