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SECONDARY BREAST CANCER
( By JASCAP )

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Symptoms & diagnosis

Symptoms of secondary breast cancer

General symptoms

The symptoms will depend on which part of the body is affected. However, there are a few general symptoms which some women have. These include:

  • being more tired than usual
  • generally feeling unwell
  • having less of an appetite.

It is important to discuss any new symptoms with your doctor, particularly if they seem to be continuing.

However, general symptoms may also be caused by other conditions, such as colds and flu. These symptoms are also side effects of cancer treatment and can occur for weeks or months after completing treatment for primary breast cancer. Therefore the side effects are not always due to a secondary breast cancer.

The following information is about specific symptoms of secondary breast cancer. We also have detailed information about secondary cancers in the bones, lymph nodes, liver, lung and brain. We have not included information about rarer symptoms of secondary breast cancer.

Local recurrence

Sometimes a small number of breast cancer cells, that were too small to see, are left at the area of the operation after surgery. If this happens, these cancer cells may grow and form a new lump. Lumps may form in the remaining breast tissue after a lumpectomy, in the skin near the breast after a mastectomy, or in the operation scar. However, most cancers that are found after a lumpectomy are new cancers and not a recurrence.

The first sign of a local recurrence is usually the development of a small lump (sometimes called a nodule) in the skin or in the scar, or there may be a lump in the deeper breast tissue. These local recurrences can usually be treated and controlled, but it is important to report it to your doctor as soon as you notice it. If it is left untreated the skin in the area may break down and become sore (ulcerated).

Secondary breast cancer in the lymph nodes

If the breast cancer cells have spread to the lymph nodes they will cause a firm, usually painless, swelling. This happens most often in the lymph nodes of the armpit (axilla) or in the neck, but can affect lymph nodes in other parts of the body, such as behind the breast bone (sternum) or next to the collar bones.

It is common for breast cancer to spread to the lymph nodes in the armpit. This isnít always a sign that the cancer is secondary or metastatic. Many women with early breast

cancer (stages 2Ė3) have cancer in these lymph nodes when the cancer is first diagnosed, and this is treated either by removing the nodes or by having radiotherapy.

Lymphoedema (swollen arm)

If cancer cells grow and block the lymph glands in the armpit, the arm on that side of the body can swell Ė this is called lymphoedema.

Lymphoedema can also occur if the lymph nodes in the armpit have been treated by radiotherapy or have been removed by surgery. This can cause scarring that damages the lymph nodes that drain the arm. If the lymph glands of the armpit are damaged or blocked, they may be unable to drain fluid from the tissues in the arm or fight infection. Fluid then builds up, causing swelling.

Lymphoedema can be very uncomfortable. It can make moving your arm difficult, and there is a greater likelihood of developing an infection in the arm.

Treatment for lymphoedema is discussed on the controlling symptoms page.

Secondary breast cancer in the bone

The first sign of a secondary cancer in the bones is usually a nagging ache in the affected bone. This can become painful, making it difficult to get to sleep at night or to move around without taking painkillers. The pain is generally present both day and night, whereas an arthritic type pain is often worse early in the morning and is not there all the time.

Women who have had treatment for breast cancer should always discuss any new pain which lasts more than two weeks with their doctor. It is very understandable to worry that a new ache or pain means the cancer has spread, but the cause is very often an everyday ache or muscle strain. Your doctor will do tests to find the cause of any continuing pain, which can help to put your mind at rest.

A secondary cancer in the bone may gradually damage the bone. The damage only happens in the part affected by the cancer cells. The more the bone is damaged, the weaker it becomes. Pain and weakness can make getting around difficult, and a bone that is very weak may break (fracture).

Sometimes breaking a bone is the first symptom of secondary breast cancer in the bone. These fractures can happen after a very minor injury, simply because the bone is weakened. When a bone breaks in this way, it is called a pathological fracture.

When bones are affected by secondary cancer cells, increased amounts of calcium (the substance that helps to build bones) may be released into the blood. Too much calcium in the blood is called hypercalcaemia. It can cause symptoms such as tiredness, feeling sick, constipation, thirst and confusion. However, in many people hypercalcaemia is discovered during a blood test before any symptoms develop.

Secondary breast cancer in a bone can be treated. For most women, treatment can be started long before the bone becomes weak enough to break or cause severe pain.

Treatment for hypercalcaemia is discussed on the controlling symptoms page.

Secondary breast cancer in the lungs

The first sign of secondary breast cancer in the lung may be a persistent cough, or breathlessness. Breathing problems can be frightening, but there are very effective ways of relieving breathlessness which can quickly make your breathing easier.

If cancer cells settle on the outside of the lungs, they irritate the membrane which covers the lungs (the pleura). This causes fluid to build up, which presses on the lungs. This is known as a pleural effusion.

We have further information on pleural effusions and coping with breathlessness.

Secondary breast cancer in the liver

Women whose breast cancer has spread to the liver may feel generally unwell and tired, with a loss of energy. It may feel uncomfortable in the area of the liver (on the right side of the abdomen, just under the lower ribs).

Some women feel sick (nauseous) and lose their appetite. Secondary breast cancer in the liver is only painful if the secondary cancer is on the outside of the liver and pressing on the capsule surrounding the liver, which is unusual.

The liver produces a substance called bile, which helps to digest food in the intestine. If the bile ducts leading out of the liver are blocked by secondary cancer, bile may build up in blood and cause jaundice. This causes the skin and the whites of eyes to become yellow and may make skin feel itchy.

The liver is a large organ and is capable of working efficiently when part of it, or even most of it, is affected by cancer. The symptoms of secondary breast cancer cells affecting the liver can usually be effectively controlled.

Secondary breast cancer in the brain

The idea of secondary cancer affecting a part of your brain can be very frightening. The brain controls the body, and it can be worrying to think of losing some control. However, the symptoms of a secondary tumour in the brain can often be well managed.

If a secondary breast cancer develops in part of your brain, pressure may build up and cause headaches and nausea (feeling sick). These symptoms may be worse on waking in the morning and get better through the day. The headaches are often at the back of the head. They are often worsened by coughing and sneezing.

Sometimes the first sign of a spread of the cancer to the brain may be a seizure (fit). Secondary cancer may affect an area of the brain which controls a certain part of the body. This can occasionally cause an arm or a leg to become weaker than usual, or there may be a feeling of numbness, tingling, or pins and needles. Sometimes, secondary cancer in the brain may cause a change in personality.

It is important to remember that no woman with secondary breast cancer is going to have all, or even most, of the symptoms discussed here. Secondary breast cancer is many different conditions; the only common factor is that the cancer cells all started from a primary breast cancer. Each condition has its own particular set of symptoms and treatment.

Diagnosing secondary breast cancer

Waiting for your test results

Waiting to have tests, and waiting for the results, will be a worrying time for you and the people close to you. You may worry that the cancer has come back or spread, but without the results of the tests you cannot know for sure. In this situation you may find yourself torn between believing there is some other cause for your symptoms and thinking the worst.

Often the uncertainty is the hardest part. It can sometimes be easier to cope once the results of the tests are known.

If the tests show that that you have secondary breast cancer, this can come as a huge shock. You may like to talk to your healthcare staff at the hospital, our cancer support specialists or another support organisation.

The bones

A blood test will be done to check the amount of calcium in the bloodstream. Too much calcium (hypercalcaemia) may indicate that there is cancer in the bones. You may also have a blood test called a full blood count. This measures the number of different blood cells in your blood and shows how well your bone marrow is working. The bone marrow is the spongy part in the centre of most bones that produces blood cells. On their own these blood tests canít diagnose a secondary cancer in the bone. X-rays and bone scans will usually be needed to confirm the diagnosis.

X-rays give a general picture of the condition of bones, but they may not be able to detect small areas of secondary tumours.

A bone scan is a more sensitive test which may pick up tiny areas of bone that have been affected by secondary breast cancer. A tiny amount of a mildly radioactive substance is injected into a vein, usually in the arm, and travels around the body in the bloodstream. Abnormal areas of bone absorb more radioactivity than normal bone and show up on a scanner. The scan pictures are usually taken 2Ė3 hours after the injection.

Bone scans canít always tell whether an abnormal area is due to cancer or other conditions such as arthritis. For this reason, more detailed scans such as CT or MRI scans may be needed.

The lungs

A chest x-ray may show whether there is any secondary breast cancer in the lungs and will also show any build-up of fluid between the membranes on the outside of the lungs (the pleura).

A CT (computerised tomography) scan may be used. This scan takes a series of x-rays which build up a three-dimensional picture of the inside of the body. The scan is painless but takes longer than an x-ray (about 10Ė20 minutes). Most people who have a CT scan are given a drink or injection to allow particular areas to be seen more clearly. You will probably be able to go home as soon as the scan is over.

An MRI (magnetic resonance imaging) scan is similar to a CT scan, but uses magnetic fields instead of x-rays to build up a series of cross-sectional pictures of the body. During the test you will be asked to lie very still on a couch inside a metal cylinder that is open at both ends. The whole test may take up to an hour and is painless - although the machine is very noisy. You will be given earplugs or headphones to wear.

The cylinder is a very powerful magnet, so before going into the room you should remove all metal belongings. You should also tell your doctor if you have ever worked with metal or in the metal industry or if you have any metal inside your body (for example, a cardiac monitor, pacemaker, surgical clips, or bone pins).

Some people are given an injection of dye into a vein in the arm, but this usually does not cause any discomfort. You may feel claustrophobic inside the cylinder, but you may be able to take someone with you into the room to keep you company. It may also help to mention to the staff beforehand if you do not like enclosed spaces. They can then offer extra support during your test.

The liver

Blood tests can show whether the liver is working properly, but they canít always tell whether any problem is due to secondary cancer or another condition. Liver scans can be used to build up a clearer picture of what is happening in the liver.

Liver ultrasound scans are done in the hospital scanning department. The test uses sound waves to build up a picture of the liver and can measure the size and position of any secondary cancers in the organ. Ultrasound is painless and only takes a few minutes. CT scans of the liver take cross-sectional pictures of the abdomen.

The brain

A CT or MRI brain scan can be used to build up an accurate picture of the brain and can show areas of secondary breast cancer in the brain.

You will lie on a couch with your head inside a scanner for these tests. They are completely painless and take about half an hour.

Detecting secondary breast cancer

All the tests mentioned above can help in detecting secondary breast cancer. However, they will not show up tiny groups of cancer cells. Tiny secondaries, known as micro-metastases, may lie dormant (inactive) and cause no symptoms at all. They may not be detected by the scans.

Although tests can help in detecting signs of secondary cancer, in many cases it is the woman herself who will suspect something is wrong. As mentioned before, the symptoms of secondary breast cancer are similar to those of many other far more common conditions. A woman who has back pain, for example, may suspect that breast cancer cells have spread to her spine but, in fact, the pain is more likely to be caused by a simple muscle strain. The tests listed here can help to tell whether or not symptoms are due to secondary breast cancer.

Sometimes scans may show a number of different secondaries, for example in several different areas of bone. In these situations, usually only a few of the secondaries will cause any symptoms or give any problems. Many metastases stay inactive (silent) and do not cause problems.


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