RECURRENT BREAST CANCER

Breast cancer that recurs may be local, regional, or metastatic. Treatment may be local/regional or systemic and can range from surgery alone to high-dose chemotherapy. The choice depends on several factors, including but not limited to:

• Location and size of the new tumor(s)
• Length of time since the initial cancer diagnosis
• Degree of lymph node involvement
• Whether distant organs are involved

Cancer that recurs within two years after the initial treatment tends to be more aggressive than cancer that recurs later.

Local Recurrence

Breast cancer most commonly recurs locally—in or near the site of the original tumor, for example in or around the scar. When recurrent cancer is confirmed, the physician orders blood tests and a bone scan to determine whether the cancer has spread beyond the breast. Any cancer that recurs locally is regarded as aggressive and resistant to treatment. When cancer recurs locally after lumpectomy, mastectomy is the preferred treatment.

Regional Recurrence

When breast cancer cells have spread to the adjacent lymph nodes (usually in the axilla) or to the chest wall, it is termed a regional recurrence. This may require surgical treatment and/or localized radiation therapy as well as systemic treatment.

Cancer in a different part of the breast or in the contralateral (opposite) breast may be a new cancer, which is called a second primary cancer. This cancer may be an entirely different cell type and may be treated successfully with surgery alone, depending on the stage and tumor type. The biopsy may or may not be able to determine whether the new tumor is recurrent disease or a second primary, but it will help determine the treatment.

Metastatic Disease (Distant Metastasis)

Once breast cancer has spread to distant organs (stage 4), cure is no longer possible. However, palliative care measures—including radiation, chemotherapy, endocrine therapies, targeted therapies, and bisphosphonates—can significantly improve survival length and quality of life. The most common sites of metastasis for breast cancer are the bone, brain, lungs, and liver.

Breast cancer that metastasizes to the bone can be treated with targeted radiation therapy, either via stereotactic external beam or with radiopharmaceuticals. Therapies such as pamidronate (Aredia), zoledronic acid (Zometa), and denosumab (Xgeva, Prolia) can help reduce the pain of bone metastases, strengthen bones, and decrease morbidity due to skeletal-related events (SREs). There may be the need for surgical intervention, in some cases for rod placement, to either treat or prevent fracture in large, weight-bearing bones that are affected by disease. Patients with cancer in the bone should be cautioned about the increased risk of fracture (Eisen, 2022).

Metastatic cancer that develops in the brain or around the spinal cord can also be treated to improve quality of life. Steroid medications can be given to decrease pain, swelling, and neurological symptoms. Whole brain radiation or localized brain radiation (Gamma Knife treatment) can be used to treat patients whose cancer has spread to the brain.

Palliative Care

Palliative care can be offered during this time. Palliative care specialists work together with the healthcare team, such as nurses, nutritionists, social workers, chaplains, pharmacists, and others, to focus on creating an individual plan to address any lasting treatment side effects, pain, emotional aspects, and other concerns of the cancer patient. The idea is to treat the whole person—including the physical, emotional, social, and spiritual.

Palliative care is often confused with hospice care, which is provided for people who have a terminal diagnosis. Palliative care can be provided at any time during a cancer diagnosis, not just at the end of life.

The inclusion of palliative care may include positive benefits such as:

• Ability to fully complete treatment
• Improved quality of life during treatment
• Increased ability to perform daily activities
• Living longer
• Improved ability to respond to emotions
• Increased connection to social support
• Fewer hospitalizations

WHEN CURE IS NO LONGER POSSIBLE

When efforts to slow cancer growth are no longer effective, emphasis shifts from cure or control of the cancer to providing comfort and symptom management with a goal of providing the best quality of life possible. For many patients, making the decision to stop cancer treatment that is no longer working can be a powerful step to be free of the side effects of treatment and take control of their lives.

Patients with recurrent or metastatic breast cancer require support and understanding more than ever, not only from family and friends but from healthcare professionals as well. They need to be able to talk openly about their cancer, feelings and concerns, care preferences, and decisions about ending treatment. Helping patients and their family members change their focus from seeking cure to seeking the best comfort and quality-of-life measures with end-of-life care is paramount. Because this can be very stressful for some people, they may require support from various resources, such as social work, certified counseling/psychotherapy, peer support groups, and chaplains.

Cancer reminds us to take care of unfinished business, not only in personal relationships but also in practical matters, sometimes referred to as “getting one’s affairs in order.” Although family and friends may be uncomfortable with these discussions, they can be reassuring to the patient.

Hospice Care

Hospice care is provided for people once they receive a terminal diagnosis. The hospice team usually includes doctors, nurses, pharmacists, social workers, therapists, chaplains, and others. The goal of hospice is to provide the best quality of life during the time remaining and to allow the patient and family to have a peaceful and natural death experience.

People may mistakenly think that hospice refers to a place. Although there are some residential hospice facilities, most hospice care takes place in the client’s home or the home of a loved one, with family members participating in care if they choose. However, hospice care also occurs in hospitals and nursing home settings.

Often, when patients have reached a place of acceptance about nearing the end of life, they can be very peaceful about it but still fearful of death itself being painful. At this stage in the patient’s care, it is important to ensure that the level of pain control is satisfactory for the patient. Hospice nurses especially are trained in this area and work closely with the patient and physician in utilizing medications and strategies available to attain the best pain control possible while minimizing unwanted side effects.

Nurses and other healthcare professionals can provide information and resources to help friends and family members understand why implementing hospice care does not mean that the patient is “giving up” and may actually be comforting to the patient. For example, some people think calling in hospice will shorten the patient’s survival. However, patients who receive hospice care many times live longer than those who do not have hospice care.

No matter where patients are in their breast cancer journey, all healthcare professionals can empower them to cope in the best manner possible through individualized education, skilled care, encouragement, and support.