Incidence

There are approximately 35,000 people living with a diagnosis of secondary breast cancer in the UK. Nearly 1,000 people die from breast cancer each month, almost all of which are linked to secondary breast cancer.

Risk of recurrence

• Biological features, grade, tumour size and lymph node involvement all affect the likelihood of recurrence
• Triple negative breast cancers are more common in younger women and tend to relapse in the first 2-3 years. They are unlikely to recur after 5 years
• Older women are more likely to have an oestrogen receptor-positive (ER-positive) breast cancer
• Primary care professionals need to be aware of the risk of recurrence in all patients as low risk does not mean no risk
• NHS Predict website can support clinicians and patients to understand the risk of recurrence
• Local recurrence is the most common type of recurrence and occurs in the affected breast or associated lymph nodes
• Distant recurrence most commonly occurs in the bone, lung, liver and brain, but can occur in any site.

The most common sites of metastatic breast cancer are found in the areas below.

Bone metastases

The most common site of secondary breast cancer is the bone, most frequently affected are the spine, ribs, skull, pelvis and upper bones of the arms and legs. It can also occur in the bone marrow.

• Symptoms:
  • Focal persistent pain in the bones
  • Persistent pain that increases in severity in a patient with a history of breast cancer is concerning
• Investigations:
  • Bone metastases may be picked up on a plain film x-ray
  • Normal x-ray does not exclude bone metastasis and patients may need more specialist investigations such as CT or MRI scans.

Lung metastases

The second most common site of secondary breast cancer is the lungs. Presenting symptoms can be vague, and lung metastasis may be picked up on scans at follow-up appointments.

• Symptoms:
  • Key symptoms include progressive breathlessness, coughs and chest pain
  • Patients may be treated for recurrent chest infections prior to being diagnosed with lung metastases
  • Haemoptysis should be regarded as a red flag symptom
  • Patients with mediastinal node disease can present with a tickly dry cough
  • Patients can present with voice changes as a result of vocal cord paralysis from a recurrent laryngeal nerve palsy
• Investigations:
  • A chest x-ray is a useful initial examination, however it will not recognise hilar or mediastinal nodal disease
  • Further investigations are required for patients with persistent symptoms and a normal chest x-ray
• Treatment of lung metastasis is rarely curative, but can provide significant palliative benefits.

Liver metastases

Secondary breast cancer in the liver is uncommon. Presenting symptoms can be vague, and liver metastasis may be picked up on scans at follow-up appointments.

• Symptoms:
  • Liver disease often presents with vague symptoms such as nausea, weight loss, loss of appetite and malaise
  • These symptoms are common but liver metastases should be considered in any patient with new, persistent or progressive symptoms and a history of breast cancer
• Investigations:
  • Liver function tests and inflammatory markers may be helpful in diagnosing liver metastases, but normal results do not exclude the possibility of liver metastasis
  • Liver ultrasounds have a high sensitivity to metastasis but are not always specific, so further imaging may be required
• Treatment of liver metastasis is rarely curative, but can provide significant palliative benefits.

Brain metastases

Secondary breast cancer in the brain is less common than in the bone or the lungs. It can cause similar symptoms to those experienced from primary brain tumours. Patients with a HER2-positive disease are at a higher risk of brain metastasis.

• Symptoms:
  • The majority of patients with brain metastases present acutely with new onset fits or symptoms suggestive of transient ischaemic attack or stroke
  • Some patients present with new, persistent or worsening headache sometimes with associated symptoms of raised intracranial pressure such as vomiting
  • Other presenting symptoms are more vague and can include confusion, memory loss and changes in behaviour
• Investigations:
  • CT or MRI scans can be useful in diagnosing brain metastases
• Treatment of brain metastasis is rarely curative, but can provide significant palliative benefits
• Patients with brain metastases may need urgent referral.

Referral and management

• Patients with possible recurrence of their breast cancer should be referred back to their original treating team regardless of whether they are under active follow-up
• Many patients are now followed up using supportive self-management rather than having formal appointments in secondary care. These patients should have easy access back into secondary care via their original treating teams should the need occur
• Patients should normally be aware of their risk of recurrence from accessing the PREDICT website. Primary care professionals can also access this site
• Fear of recurrence is also a significant problem and is a rational response to the situation, but some patients develop intrusive anxiety and concern
• The patient’s clinical condition and level of anxiety should be considered when making the referral
• Macmillan and Pocket Medic produce useful patient information, however patients might require professional psychological input.

Breast Cancer Recurrence – Course Summary PDF

Click here to download a copy of the course summary.