Recurrent breast cancer is cancer that comes back following initial treatment. Although treatment is aimed at eliminating all cancer cells, a few may survive. These undetected cancer cells multiply, becoming recurrent breast cancer. 

Recurrent breast cancer may occur months or years after your initial treatment. The cancer may come back in the same place as the original tumor, known as local recurrence, or it may spread to other areas, typically your bones, liver or lungs.

Learning you have recurrent breast cancer may be harder than dealing with the initial diagnosis. But recurrent breast cancer is far from hopeless. Treatment may eliminate locally recurrent breast cancer. Even if a cure isn't possible, treatment may control the disease.

Signs and symptoms of recurrent breast cancer vary depending on where the cancer comes back. It may show up as a lump in the breast, thickening of the surgical scar or lump on the chest wall near where your original cancer was. It may be detected in an abnormal finding on a mammogram of the breast where you had a lump removed (lumpectomy), or show up in a distant place in your body such as a bone, your liver or your lungs.

Local recurrence
In a local recurrence, cancer reappears in the same area as your original, or "primary," tumor. This could be in the remaining breast in women who have had a lumpectomy, or it may be in the chest wall or skin in women who have had a mastectomy.

Signs and symptoms of local recurrence within the same breast may include:

• A new lump in your breast or irregular area of firmness
• A new thickening in your breast area
• A new pulling back of the skin at the lumpectomy site
• Skin inflammation or area of redness
• Flattening or indentation of your nipple or other nipple changes

Signs and symptoms of local recurrence on the chest wall after a mastectomy may include:

• One or more painless nodules on or under the skin of your chest wall
• A new area of thickening along or near the mastectomy scar

Regional recurrence
A regional breast cancer recurrence means the cancer has come back in the lymph nodes in your armpit or collarbone area. Signs and symptoms of regional recurrence may include:

• A lump or swelling in the lymph nodes under your arm, in the groove above your collarbone or around your breastbone
• Swelling of your arm
• Persistent pain in your arm and shoulder
• Increasing loss of sensation in your arm and hand
• Persistent chest pain
• Difficulty swallowing

Distant (metastatic) recurrence
A distant or metastatic recurrence means the cancer has traveled to distant parts of the body, most commonly the bones, liver and lungs. The signs and symptoms may include:

• Bone pain
• Persistent, dry cough
• Difficulty breathing
• Shortness of breath
• Chest pain
• Loss of appetite
• Abdominal tenderness or discomfort
• Persistent nausea, vomiting or weight loss
• Jaundice
• Severe headaches
• Visual disturbances
• Seizures, numbness or imbalance

When to see a doctor
After you've been treated for breast cancer, you should continue to see your doctor regularly for follow-up exams. Your doctor will check for any signs of cancer recurrence. You'll also have an annual mammogram if you had a lumpectomy. Still, many women discover recurrent breast cancer on their own. You know your body best — what feels normal and what doesn't. Check your breasts monthly to look for changes.

It's important to be aware of the signs and symptoms of recurrent breast cancer, such as new pain, changes or new lumps in your breast or surgical scar, weight loss, and shortness of breath. If you experience any signs and symptoms that might suggest a recurrence, talk to your doctor.

Recurrent breast cancer develops from cells that originally came from the primary breast tumor. The cancer returns after the initial treatment and a period of time when no cancer was detected. This can happen because treatment did not fully destroy or remove all the cancer cells. Even with surgery, small clusters of cancer cells may have been left behind that were too small to be detected with any test.

If the cancer is aggressive, isolated cells may survive the rounds of chemotherapy and radiation meant to stop recurrence. Occasionally, cancer cells may be resistant to these treatments or develop the ability to spread (metastasize).

Sometimes a single cancer cell may be dormant for years without causing harm. Then something happens that activates the cell, so it grows and makes other cells. Not all of the growth factors for cancer have been found.

It's also possible to develop a new tumor, called a second or new primary tumor, in the same breast as the first tumor or in the other (contralateral) breast. Doctors make a distinction between recurrent breast cancer and a second primary cancer in the breast. Women who have had breast cancer are at higher risk of cancer in the other breast, when compared with women who've never had breast cancer. The risk is higher if you have a strong genetic predisposition or hereditary breast cancer. Fortunately, the vast majority of women who have cancer in one breast never develop cancer in the opposite breast.

For breast cancer survivors, factors that increase the risk of a recurrence include:

• Lymph node involvement. Finding cancer in nearby lymph nodes at the time of your original diagnosis increases your risk of the cancer coming back. Women with many affected lymph nodes have a higher risk.
• Larger tumor size. Women with a large tumor face a higher risk. Women who have very large tumors (more than 5 centimeters, or about 2 inches) — especially if lymph nodes are involved — have a very high risk of the cancer recurring in the same area. These women should talk with their doctor about the role of radiation therapy, even if they undergo a mastectomy.
• Positive or close tumor margins. When you have an operation to remove a breast lump, the surgeon tries to remove the cancerous lump along with a healthy margin of normal tissue. If the borders of the removed tumor are free of cancer when examined under a microscope, that's considered a negative margin. If the edge of the tumor has cancer cells (positive margin), or the margin between the tumor and normal tissue is close, the risk of breast cancer recurrence is increased.
• Lack of radiation treatment following lumpectomy. Women who choose to preserve the breast by undergoing a lumpectomy (also known as "wide local excision") should undergo radiation treatments to the remaining breast to decrease the chance of a local recurrence. Research shows that lumpectomy followed by radiation works equally well as removal of the entire breast (mastectomy).
• Younger age. Women under age 60 — particularly those under age 35 — at the time of their original breast cancer diagnosis, face a higher risk of recurrent breast cancer.
• Inflammatory breast cancer. Women with inflammatory breast cancer face a higher risk of local recurrence, so their treatment typically involves mastectomy along with radiation to the chest wall.

In recent years, genetic tests designed to predict the risk of breast cancer recurrence have become available. These tests (MammaPrint, Oncotype DX) measure activity in up to 70 genes associated with breast cancer, a process known as gene expression profiling. The results are used to estimate the chance that a woman's cancer will come back. But so far these tests have a very limited role and are applicable only for women with estrogen receptor positive tumors that don't show any sign of spread to the lymph nodes. The tests have been used to plan treatment for primary breast cancer in a very small minority of women. More research is needed to determine whether these genetic tests might prove useful on a broader scale.

If you're seeing a different doctor than the one who treated your first breast cancer, you'll want to make sure the new doctor has access to your medical records from the initial treatment. You'll need to sign an information release form so that your new provider's office can call or write for the records.

Before your appointment:

• Write down what you want to talk about and questions you have. Be prepared to discuss your new symptoms and any other health problems you've had since your first cancer diagnosis.
• Make a list of all medications you take, including vitamins and supplements. Include the doses and how often you take the medication, such as once a day or occasionally as needed. If it's easier, bring the medications with you when you have your appointment.

Some questions you might want to ask your doctor are:

• What is my prognosis?
• What is the hormone receptor status of the cancer recurrence?
• What are my treatment options?
• Are there any clinical trials I should consider participating in?
• What other tests should I have done and why?

It's a good idea to bring someone you trust with you to your appointment to help take notes and provide emotional support.

If your doctor suspects recurrent breast cancer based on results of a mammogram or physical exam, or because of signs and symptoms, you'll likely need further imaging tests and a biopsy.

The following tests may be used to help diagnose recurrent breast cancer:

• Breast ultrasound. Ultrasound uses sound waves to produce images of the inside of the body. For women who've had lumpectomy, breast ultrasound may be used to evaluate an abnormality seen on a mammogram or found during a physical exam of your breast.
• Magnetic resonance imaging (MRI). MRI uses a magnet and radio waves to make images of the inside of your body. MRI may be able to detect abnormal areas within the breast, chest wall, lymph node areas, and blood vessels and nerves around the breast and armpit. The MRI by itself can't tell the difference between cancer and a benign process, but it can help your doctor determine the best areas for a biopsy or further testing. Not all women with a local recurrence benefit from having an MRI. Discuss your specific situation with your doctor.
• Computerized tomography (CT). A CT scan is a type of computerized X-ray that provides more-detailed pictures than do ordinary X-rays. CT scans of your chest, abdomen, pelvis, bones and head can help look for evidence of cancer that's spread to your internal mammary lymph nodes or to distant sites, such as the bones, lung or liver.
• X-rays. Chest X-rays may detect a recurrence in your lungs, while bone X-rays may be able to detect cancer in your bones.
• Bone scan. A bone scan can provide an image of your whole skeleton and may detect cancer recurrence in your bones. During a bone scan, a small, safe amount of radioactive material (tracer) is injected into your bloodstream. The tracer binds to your bone cells. Areas with cancer absorb more of the tracer and "light up" on the scan.
• Positron emission tomography (PET). A PET scan also uses radioactive material injected into your body to produce an image. Tumors often absorb greater amounts of the material and show up more prominently on the scan. A PET scan or hybrid PET/CT scan of your whole body may be used to look for areas of cancer recurrence.

Biopsy
A biopsy — a small sample of tissue removed for analysis in the laboratory — is needed to confirm the diagnosis of recurrent breast cancer. The tissue specimen will be tested for the presence of estrogen and progesterone receptors. A breast cancer that makes receptors for the female hormones estrogen and progesterone (hormone receptor positive cancer) can be treated with hormone therapy. The hormone receptor status of your cancer may change with a recurrence.

The tissue is also tested for extra amounts of the HER2 protein, which some breast cancers overproduce. Cancers that are HER2 positive can be treated with biotherapies that target this protein.

Blood tests
A complete blood count and liver function tests can help evaluate how your body is doing and may help guide future treatments. Doctors often use blood tests that measure breast cancer tumor markers to follow the course of cancer. But tumor markers aren't specific for a cancer recurrence. These tests aren't recommended for looking for a recurrence, as they aren't always reliable.

Local cancer recurrences can cause pain, swelling and discomfort in the area of the recurrence. Local recurrences can often be cured, but in about one-fourth to one-third of people who have a local recurrence, the disease later appears in a distant site in the body, such as a bone, the liver or a lung. Once a cancer has spread beyond the breast and nearby areas, the disease isn't usually curable.

To plan treatment for recurrent breast cancer, your doctor considers many factors, including the extent of the disease, its hormone receptor status and the type of treatment you received for your first breast cancer. Most women receive a combination of treatments that may include surgery, radiation, drugs to destroy cancer cells (chemotherapy) and hormone therapy. Breast cancers that make extra amounts of the HER2 protein may be treated with a biotherapy such as trastuzumab (Herceptin).

Treatment decisions for recurrent breast cancer are complex and individualized. Talk with your health care team to learn as much as you can about your treatment options.

Treating a local recurrence
Treatment for a local recurrence typically starts with an operation and may include radiation if you haven't had it before, chemotherapy and hormone therapy.

• Surgery. For recurrent breast cancer that's confined to the breast, the usual treatment is mastectomy. During a mastectomy, your surgeon removes all your breast tissue — lobules, ducts, fatty tissue, skin and nipple. If your first breast cancer was treated with mastectomy and the cancer comes back in the chest wall, you may have surgery to remove the new cancer along with a margin of normal tissue.

  A local recurrence may be accompanied by hidden cancer in nearby lymph nodes. For this reason, the surgeon may remove some or all of the lymph nodes under your arm (axillary dissection) during surgery if they weren't removed during your initial treatment.

• Radiation therapy. Radiation therapy uses high-energy X-rays to kill cancer cells and shrink tumors. If you did not have radiation therapy for your first breast cancer, your doctor may recommend it now. But if you had radiation after a lumpectomy, radiation to treat the recurrence isn't recommended because of the risk of side effects.
• Drug therapy (chemotherapy). If your recurrent breast cancer is the inflammatory type or involves the skin, your doctor may recommend chemotherapy before surgery. Chemotherapy may also be recommended if your recurrent cancer is so extensive that surgery isn't an option.
• Hormone therapy. Medications that block the growth-promoting effects of estrogen and progesterone may be recommended if your cancer is hormone receptor positive. Hormone therapy may shrink and control recurrent breast cancer. Hormone therapy may include tamoxifen (Nolvadex) or an aromatase inhibitor, such as anastrozole (Arimidex), letrozole (Femara) or exemestane (Aromasin).

Treating a regional recurrence
If it's possible, surgery to remove the recurrence is the recommended treatment for a regional recurrence. Your surgeon may also remove the lymph nodes under your arm (axillary dissection) if they're still present. Sometimes radiation therapy may be used after surgery.

If surgical removal isn't possible, radiation therapy may be used as the main treatment. Chemotherapy or hormone therapy may be recommended as the main treatment or may follow surgery or radiation.

Treating a metastatic recurrence
Treatment for recurrent breast cancer that's spread beyond the breast region involves many different options. It's important to work with your doctor to understand what's most appropriate for your particular situation. If one treatment doesn't work or stops working, you may be able to try other treatments.

In general, the goal of treatment for a metastatic recurrence isn't to cure the disease. Treatment may allow you to live longer and can help relieve symptoms the cancer is causing. Your doctor will try to achieve a balance between controlling your symptoms while minimizing toxic effects from treatment. The aim is to help you live as well as possible for as long as possible.

If the cancer has spread to other parts of the body, treatment for a metastatic recurrence usually involves whole body (systemic) therapy rather than local therapy such as surgery or radiation. Options for systemic therapy include hormone therapy, chemotherapy and biotherapy. Because hormone therapy is less toxic than chemotherapy, your doctor might start with tamoxifen or an aromatase inhibitor. But if your cancer is fast-growing or has already spread to organs such as the lungs and liver, your doctor might recommend starting with chemotherapy.

If your cancer is HER2 positive, you may also be given a biotherapy to attack the protein that's overproduced in these cancers. Biotherapies include trastuzumab (Herceptin), bevacizumab (Avastin) or lapatinib (Tykerb).

Depending on where the cancer has spread and what symptoms it's causing, you may also have localized treatments, such as medications or radiation to treat the disease in your bones.

Eating well, managing stress and exercising are ways to promote your overall health and cope with cancer and treatment.

Eat well
Good nutrition during cancer treatment can help you keep up your stamina and your ability to cope with the side effects of treatments. But eating well can be difficult if your treatment includes chemotherapy or radiation therapy. For times when you don't feel well, try these strategies:

• Eat protein-rich foods. Foods high in protein can help build and repair body tissues. Choices include eggs, yogurt, cottage cheese, peanut butter, poultry and fish. Kidney beans, chickpeas and black-eyed peas also are good sources of protein, especially when combined with rice, corn or bread.
• Keep an open mind about the foods you eat. Something that doesn't appeal today might taste better next week.
• When you do feel well, make the most of it. Eat as many healthy foods as you can. Prepare meals that you can easily freeze and reheat. Also look for low-fat frozen dinners and other prepared foods.
• Eat smaller amounts of food more frequently. If you can't face the thought of a large meal, try eating small amounts of food more often. Keep fruits and vegetables handy for snacking.

Stay active
Regular physical activity can help relieve anxiety and depression, improve your mood, and reduce signs and symptoms of fatigue, nausea, pain and diarrhea. The activity doesn't have to be strenuous — moderate activities such as walking, biking, swimming and yardwork bring benefits. A little bit of physical movement is better than none.

Manage stress
Methods for reducing muscle tension can help you manage stress. One simple and powerful technique is to close your eyes and notice your breathing. Pay attention to each inhalation and exhalation. Your breathing will become slower and deeper, promoting relaxation. Another technique is to lie down, close your eyes and mentally scan your entire body for any points of tension.

In addition, activities that require repetitive movement, such as swimming, can produce a mental state similar to that achieved with meditation. The same is true of yoga and other stretching exercises.

Finding out your breast cancer has returned can be equally or more stressful than getting the initial diagnosis. The prospect of more disruptions, treatments and uncertainty is stressful. After the initial blow of the diagnosis, many women find their outlook improves. In studies of women with recurrent breast cancer, their quality of life and emotional distress improved significantly six months after their diagnosis.

As you sort through your emotions and make decisions about treatment, the following suggestions might help you cope.

• Be informed. Learn what you can do for your health right now and about services available to you. Talk with your doctor, family and those you rely on for support about your treatment options and how you want to approach decision making.
• Get support. Talking with other women who are dealing with recurrent breast cancer can help you on both a practical and an emotional level. Find a support group near you through your doctor, a medical social worker or an organization such as the American Cancer Society. It can also help to express feelings of fear or uncertainty with a friend or counselor.
• Take time for yourself. Plan ahead for times when you may need more rest. Cut back on time commitments, and don't be afraid to ask for help. Find ways to relax.
• Learn to live with uncertainty. Try to take in the present moment rather than dwelling on an uncertain future. Use your energy to focus on wellness and finding ways to be peaceful inside yourself.
• Look for a connection to something beyond yourself. Having a strong faith or a sense of something greater than yourself helps many people cope with cancer.

Nothing can guarantee your breast cancer won't return. Most women who are treated for early-stage breast cancer remain free of disease. Many people who experience a cancer recurrence blame themselves for not eating right, missing a doctor visit or something else. It's important to realize that even if you do everything just right, the cancer might return.

The following factors may affect your risk of recurrent breast cancer:

• Tamoxifen and other hormone therapy. After initial treatment for estrogen receptor positive breast cancer, taking tamoxifen for five years reduces the risk of breast cancer recurrence by 41 percent each year. Other research suggests that some women would benefit even more by switching to an aromatase inhibitor after two to three years on tamoxifen, or by taking an aromatase inhibitor instead of tamoxifen. The decision needs to be made on an individual basis based on your particular cancer.
• Chemotherapy. For women at high risk of cancer recurrence, chemotherapy has been shown to decrease the chance it will recur, and those who receive chemotherapy live longer.
• Radiation therapy. Women who've had a breast-sparing operation to treat their breast cancer and those who had a large tumor or inflammatory breast cancer have a lower chance of the cancer recurring if they're treated with radiation therapy.
• Herceptin. For women whose cancer makes extra HER2 protein, the drug Herceptin can decrease the chance of the cancer recurring.
• Healthy weight. Weighing more than you should for your age and height increases the risk of recurrent breast cancer.

Research looking at specific aspects of diet — such as fruits and vegetables and fat — and risk of recurrent breast cancer hasn't been conclusive.