What should you pay attention to after breast cancer surgery?

As the most common cancer in women, breast cancer is well known to many people. Many popular science articles also tell us that breast cancer is a relatively easy-to-treat cancer, and the prognosis of early breast cancer is good. But does surgery mean that we don't have to worry about it anymore? In fact, I think a very important but easily overlooked issue is recurrence and metastasis.

How to avoid recurrence and metastasis? This has to mention the precautions after breast cancer surgery. Today, let's start with breast cancer and show you how to avoid recurrence and metastasis after breast cancer surgery.

01. About Breast Cancer

The following figure is the most comprehensive survey on the overall cancer situation in my country to date. The orange solid line is breast cancer, the left side is the number of cases (per 100,000 people), and the right side is the number of deaths (per 100,000 people). It can be seen that breast cancer is the most common cancer in my country, but its mortality rate ranks around fifth [1].

Therefore, it can be seen that breast cancer does have a lower mortality rate than other tumors such as lung cancer, but this does not mean that breast cancer is completely safe. For example, one of the main treatment strategies for early breast cancer is surgical resection, so many people also think that everything will be fine after resection and no longer pay attention to it. However, this is a big misunderstanding and underestimates breast cancer. It is essentially a cancer, and cancer will face a common problem: recurrence and metastasis.

02. Basic characteristics of cancer

Recurrence and metastasis are the basic characteristics of cancer. Many people have the impression that cancer is caused by the uncontrolled malignant proliferation of cancer cells. In fact, cancer cells have some basic characteristics, the most typical of which are invasiveness and metastasis[2]. Invasiveness refers to the invasion of cancer cells into the surrounding normal tissue spaces, lymphatic vessels, and blood vessels, resulting in the integration of cancer cells and normal tissues. One of the problems caused by this characteristic is that it is difficult to remove malignant tumors. A portion of normal tissue must be removed accordingly, and the situation of incomplete removal must also be considered.

Cancer metastasis refers to the fact that cancer cells not only develop at the location where they first appear (in situ), but also migrate to other tissues/organs and colonize, leading to the eventual onset of cancer in multiple locations. Although research on cancer metastasis is still incomplete, some studies have shown that cancer may begin to metastasize at a very early stage [3].

The above reasons together lead to the fact that even if early breast cancer is surgically removed, it still faces the risk of recurrence and metastasis.

We can also see this from the five-year survival rate of breast cancer. Overall, the five-year survival rate of breast cancer is about 80%. Of course, there are differences depending on the specific situation. For example, the later the stage of breast cancer, the worse the five-year survival rate[4].

One of the main reasons for the difference in breast cancer prognosis is the problem of breast cancer postoperative recurrence and metastasis mentioned above.

So, what factors determine the recurrence and metastasis of breast cancer? Here we introduce them one by one.

03. Recurrence of breast cancer

Breast cancer recurrence, as the name suggests, refers to the reappearance of breast cancer in the breast after treatment. It is divided into local recurrence, which occurs in the breast or chest wall on the same side as the original breast cancer site, and regional recurrence, which refers to the appearance of tumors in the lymphatic drainage area of ​​the affected side, such as the axilla, clavicle, etc. [5].

At present, the cause of breast cancer recurrence is still unclear. For example, the cancer cells are not completely removed during the surgical treatment of breast cancer, which leads to many people relaxing their attention after the treatment of breast cancer, or even not continuing the treatment. At this time, the latent cancer cells continue to proliferate. Of course, it is not ruled out that the factors that originally caused breast cancer continue to play a role and lead to breast cancer.

04. Breast cancer metastasis

Breast cancer metastasis refers to the cancer cells not only staying in the breast, but also traveling to other parts of the body through the human circulatory system. Breast cancer metastasis is most common in the late stages of the disease. Among late-stage breast cancer, bone metastasis is the most common, with an incidence rate of up to 65-75%. Bone pain, bone damage, and bone-related events are common complications of breast cancer bone metastasis during the course of late-stage breast cancer, and they also bring great pain to patients[6].

It can be said that for breast cancer, recurrence and metastasis are common situations in breast cancer treatment, but they are often easily overlooked by patients, which results in the final prognosis of breast cancer not being as good as imagined.

05. What factors can provide some indications for the recurrence and metastasis of breast cancer?

So what factors can provide some indication of the recurrence and metastasis of breast cancer?

The first is the most basic breast cancer staging, such as the common TNM staging system, which can be used to basically classify breast cancer. The letter T stands for tumor, which is used to indicate the size of the primary tumor, and is divided into 1-4 categories according to the severity. N stands for lymph node, which is used to describe the degree and range of lymph node involvement and is divided into 1-3 categories. M stands for metastasis, which is used to describe the metastasis of breast cancer. 0 means no distant metastasis, and 1 means distant metastasis. These factors together constitute a combined staging, in which each indicator plays an important role in the diagnosis, treatment and prognosis of tumors.

In fact, it has been found that there is a strong correlation between breast cancer staging and recurrence and metastasis. The more severe the staging, the greater the possibility of recurrence and metastasis. Therefore, for patients with more severe breast cancer staging, they must pay long-term attention to related situations after treatment[7].

The second is the molecular classification of breast cancer

In clinical practice, breast cancer is often stratified for management and treatment based on the expression of estrogen receptor (ERα), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) amplification status[8].

Histological grading is also an important factor affecting the prognosis of breast cancer. Breast cancer is divided into three levels according to the degree of differentiation of cancer cells, as shown in the figure below.

In addition, in recent years, the expression levels of some breast cancer-related proteins and genetic testing have also been found to have a certain impact on the recurrence and metastasis of breast cancer, such as BRCA1, BRCA2, PIK3CA, Ki-67 and PD-L1 [9,10].

06. Daily care after treatment

For breast cancer patients, after basic hospital treatment, it is best to do the following in daily life:

1. Regular review and follow-up

For breast cancer patients, it is important to pay attention to regular check-ups and follow-up visits to the hospital regularly to facilitate continuous tracking of physical conditions and prevent recurrence and metastasis of breast cancer.

2. Continued drug treatment

There are now many drugs that can continuously treat cancer. As we discussed earlier, breast cancer is by no means a cure, and follow-up drug treatment is necessary to further inhibit the recurrence and metastasis of cancer.

Of course, on this basis, some daily management is also essential. For example, regular work and rest, healthy diet and exercise are of great significance to improving personal immunity. After all, immunity is the first factor in our response to diseases including cancer.

In addition, it is also very necessary to maintain emotional stability and a good mentality. In fact, in recent years, there has been a lot of evidence showing the relationship between mentality, immunity and health. Although it is currently difficult for us to quantify the relationship between emotional mentality and immunity, maintaining a good mood is an important strategy for coping with diseases.

It can be said that the treatment of breast cancer is definitely not a once-and-for-all solution simply through surgery.

In fact, many times, when people promote the better prognosis of breast cancer, they tend to make people ignore the fact that breast cancer itself is a cancer, and it is still accompanied by the most common problems of recurrence and metastasis among cancers.

Therefore, for breast cancer, early treatment is important, but postoperative treatment tailored to the patient's specific situation is also essential.

1 Chen W, Zheng R, Baade PD, et al. Cancer statistics in China, 2015[J]. CA: A Cancer Journal for Clinicians, 2016, 66(2).

2 Waks, Adrienne G., and Eric P. Winer. "Breast cancer treatment: a review." Jama 321.3 (2019): 288-300.

3 Hüsemann Y, Geigl JB, Schubert F, et al. Systemic spread is an early step in breast cancer[J]. Cancer cell, 2008, 13(1): 58-68.

4 Chen, Lu, et al. "Trends in 5-year survival rates among breast cancer patients by hormone receptor status and stage." Breast cancer research and treatment 147.3 (2014): 609-616.

5 Ahmad, Aamir. "Pathways to breast cancer recurrence." International Scholarly Research Notices 2013 (2013).

6 Weigelt, Britta, Johannes L. Peterse, and Laura J. Van't Veer. "Breast cancer metastasis: markers and models." Nature reviews cancer 5.8 (2005): 591-602.

7 Gao Guoxuan, et al. "Clinical pathological characteristics and prognostic factors of breast cancer in young women." Chinese Journal of Practical Surgery 36.1 (2016): 122-125.

8 Giancotti, Vincenzo. "Breast cancer markers." Cancer letters 243.2 (2006): 145-159.

9 Yerushalmi, Rinat, et al. "Ki67 in breast cancer: prognostic and predictive potential." The lancet oncology 11.2 (2010): 174-183.

10 Genetic Tumor Marker Collaboration Group of Tumor Marker Professional Committee of Chinese Anti-Cancer Association, and Breast Cancer Marker Collaboration Group of Tumor Marker Professional Committee of Chinese Anti-Cancer Association. "Expert consensus on the clinical application of recurrent/metastatic breast cancer markers (2019 edition)." Chinese Journal of Cancer Prevention and Treatment 11.5 (2019): 363-374.