LEWISBURG — Once treatment is completed for an initial round of breast cancer, no one ever wants it to come back.

On occasion, it does.

But there are some factors patients need to understand in terms of the likelihood of recurrences in breast cancer.

Dr. John Turner, medical director of cancer services at Evangelical Community Hospital and clinical co-manager of the Thyra M. Humphreys Center for Breast Health, explained there are three times in which recurrence happens among breast cancer patients.


Local recurrence

Turner said a local recurrence happens when a partial mastectomy or lumpectomy has been performed, and the cancer is discovered again within that same area.

“It is heavily determined by resection in surgery and the margin status,” he said.

The goal is to have free margins before surgery is finished, otherwise, some cells can be missed. Nationwide, Turner said, there is a 20 percent positive margin rate with such breast cancer surgeries.

“My margin is 13 percent and we use ultrasound,” Turner said, to help see the margin in the surgical process.

He said there is never a way of knowing that all cancer cells are completely gone after surgery. A margin is the rim around the cancerous area which is considered normal tissue. It should contain no cancer cells or be determined negative. This is also explained as “no tumor in ink,” indicating there are no cancerous cells in the margin.

Turner said this is more likely to happen with patients who choose not to undergo radiation after surgery, which puts them at a 30 percent risk of local recurrence.

This does not apply, however, to patients with non-invasive breast cancer who do not need radiation, Turner said.

Dr. Rosemary Leeming, breast cancer surgeon with Geisinger Health System,  said without radiation, and with the presence of positive margins, chances of breast cancer recurrence increase.

“If you remove the breast, cancer can come back on chest wall, but it is not as common,” Leeming said, adding it depends on how aggressive that cancer was.

The composition of the tumor is also a factor in terms of local recurrence, Turner said.

“A triple negative breast cancer has a higher rate of local recurrences, and we don’t like triple negatives ever,” Turner said, because they are more aggressive forms.

Those who experience a mastectomy and have the same likelihood of local recurrences based on whether or not they choose radiation as well as the composition of the cancer.

In a mastectomy many lymph nodes and some muscle is also removed. Still, Turner said, it is “foolish to assume there are no cancer cells in the tissue.”


Regional recurrence

Turner said regional recurrence most often occurs under the armpit and is due to lymph nodes being inadequately treated during the first cancer. Turner added this form is much less likely than it used to be due to better treatment.

Another reason for regional recurrence is the choice for no radiation treatment after surgery.

Turner referenced sentinel nodes, or the first few lymph nodes in which the tumor drains into from the breast. This is the first place the cancer is likely to spread, typically under the armpits.

Turner said he often tells his patients that when he performs this surgery, he will remove lymph nodes that are large or feel hard and small as a precaution.

“Those areas could be clinically involved,” he said.

Turner said if there is cancer in the lymph nodes discovered with the breast cancer initially, he recommends chemotherapy and/or another targeted therapy and then surgery. If the lymph node is still involved, then a lymph node dissection is done followed by radiation.

Turner said the side effect is often lymphedema or swelling to the area that is very uncomfortable.

Because of this issue, Turner now offers patients the opportunity to take part in a clinical trial that helps determine adequate control of the cancer in the lymph nodes.


Distant metastatic

Distant metastatic breast cancer is a recurrence which is found in other parts of the body, beyond the breast. This form of recurrence is not curable.

“It is a mistake to consider breast cancer one disease. It is actually several,” Turner said.

It often is found in the bones and other organs.

Treatment options include radiation and chemotherapy.


Second breast cancer?

Often patients fear having cancer in the opposite breast. This causes many to want a double mastectomy. This is not necessary, Leeming said, because cancer occurring in the opposite breast is very uncommon and is considered an entirely new cancer, not a recurrence.

The risk for someone without inherited mutation, is a half percent per year, Leeming said. “If you have one of the mutation risks, it is three to five percent per year, which is 10 times higher. Women overestimate typically getting a second breast cancer,” Leeming said.