A mastectomy is a surgical procedure to remove breast tissue, often performed to treat breast cancer. This operation can involve removing one or both breasts, depending on the individual’s diagnosis and treatment plan. While a mastectomy significantly reduces the amount of breast tissue where cancer can develop, it does not eliminate the possibility of recurrence. A small number of cancer cells can sometimes remain undetected, leading to cancer returning.
Understanding Recurrence After Mastectomy
Breast cancer can return in different ways after a mastectomy, categorized by where it reappears. Recurrences stem from microscopic cancer cells not visible or removable during initial treatment. Even with extensive surgery, these cells can persist and grow into detectable tumors.
Local recurrence refers to cancer reappearing in the chest wall or scar area where the mastectomy was performed. Regional recurrence involves cancer reappearing in nearby lymph nodes, such as those in the armpit, above the collarbone, or along the breastbone. These lymph nodes are part of the lymphatic system, which transports cancer cells from the primary tumor site.
Distant recurrence, also known as metastatic breast cancer, occurs when cancer spreads to other parts of the body far from the original breast area. This can include organs like the bones, lungs, liver, or brain, where cancer cells establish new tumors.
Factors Influencing Recurrence Risk
Several factors influence the likelihood of breast cancer returning after a mastectomy. Original tumor characteristics play a significant role. Larger tumor sizes and higher tumor grades, which describe how abnormal cancer cells appear under a microscope, are associated with an increased recurrence risk. Lymph node involvement at initial diagnosis is also a strong indicator; more involved lymph nodes mean higher risk.
The biological profile of cancer cells, particularly their hormone receptor and HER2 status, also affects recurrence risk. Hormone receptor-positive cancers (with estrogen or progesterone receptors) tend to grow more slowly but can recur many years after treatment. Aggressive subtypes like triple-negative breast cancer (lacking ER, PR, and HER2) or HER2-positive breast cancer have higher recurrence rates, often earlier. However, targeted therapy advancements have reduced recurrence risk for HER2-positive cancers.
Genetic mutations, such as in BRCA1 or BRCA2 genes, can increase the risk of developing a new primary breast cancer, sometimes mistaken for a recurrence. These mutations affect DNA repair, leading to a higher predisposition to cancer.
The type and completeness of adjuvant therapies received after surgery also influence recurrence risk. Adjuvant therapies, including chemotherapy, radiation, hormone therapy, and targeted therapy, eliminate remaining microscopic cancer cells and reduce recurrence. For instance, hormone therapy significantly reduces recurrence risk in hormone receptor-positive cancers, and radiation after mastectomy lowers local recurrence rates, especially if lymph nodes were involved.
Recognizing Potential Signs of Recurrence
Awareness of potential breast cancer recurrence signs is important for timely intervention. Symptoms vary depending on where the cancer has returned.
Local recurrence, appearing on the chest wall or near the mastectomy scar, may manifest as new, painless nodules or lumps on or under the skin. Other signs include new thickening along the scar, skin discoloration, redness, or itching.
Regional recurrence involves changes in lymph nodes close to the original cancer site. Swollen lymph nodes in the armpit, above the collarbone, in the neck, or near the breastbone can signal this recurrence. These swollen nodes can lead to symptoms like chronic chest pain, difficulty swallowing, or pain, swelling, or numbness in the arm or shoulder.
Distant recurrence, or metastatic breast cancer, produces symptoms related to the specific organs involved.
Bone Metastases
If cancer spreads to the bones, persistent bone pain or fractures may occur.
Lung Metastases
Lung involvement can cause a chronic cough, shortness of breath, or chest pain.
Liver Metastases
Liver metastases can lead to jaundice, abdominal pain, or unexplained weight loss.
Brain Metastases
Headaches, seizures, vision changes, or behavioral changes could indicate spread to the brain.
Reporting any new, persistent, or unusual symptoms to a healthcare provider is important for prompt evaluation.
Monitoring and Treatment Approaches
Regular monitoring is a fundamental part of post-mastectomy care to detect recurrence early. Follow-up appointments involve physical examinations of the chest wall, underarms, and neck. These appointments are scheduled more frequently in the first five years after treatment, every three to six months, and then annually thereafter.
While routine imaging for asymptomatic recurrence is not always recommended, specific imaging modalities are used if recurrence is suspected. For those with a single mastectomy, yearly mammograms of the remaining breast are important. For individuals with a double mastectomy, mammograms are not needed for the removed breast side, but physical exams remain crucial. If a suspicious area is identified, further imaging such as ultrasound, MRI, CT scans, PET scans, or bone scans may be used, depending on the suspected recurrence location. MRI is highly sensitive for detecting breast cancer recurrence, and PET/CT scans assess distant metastases.
Recurrence is confirmed through a biopsy, where a tissue sample from the suspicious area is taken and examined. This biopsy confirms if cancer has returned and re-evaluates its characteristics, as hormone receptor or HER2 status can change.
Treatment strategies for recurrence depend on its type, location, cancer cell characteristics, and prior treatments. For local recurrence on the chest wall, surgery to remove the new tumor is the primary approach, sometimes followed by radiation if not part of initial treatment. Regional recurrence involving nearby lymph nodes is treated with surgery, potentially combined with radiation. Systemic therapies like chemotherapy, hormone therapy, or targeted therapy can also be used with or after local treatments.
Distant recurrence, or metastatic breast cancer, requires systemic treatments to target cancer cells throughout the body. These include chemotherapy, which uses drugs to kill cancer cells; hormone therapy, which blocks hormones that fuel cancer growth; and targeted therapy, which focuses on specific molecules involved in cancer cell growth. Immunotherapy, which helps the body’s immune system fight cancer, can also be an option for certain metastatic breast cancer types. The treatment plan is individualized, aiming to control the disease, manage symptoms, and maintain quality of life.