Recognising the signs of secondary breast cancer

This Breast Cancer Awareness Month, Breast Cancer Now’s senior clinical nurse specialist Catherine Priestley and clinical nurse specialist Katie Peduto highlight the signs and symptoms of secondary (metastatic) breast cancer that healthcare professionals should be aware of.

Breast Cancer Awareness Month presents a timely opportunity to raise awareness of secondary breast cancer, which occurs when breast cancer spreads to other parts of the body, such as the bones, liver, lungs, or brain. This can happen months, years, or even decades after a primary breast cancer diagnosis.

A prompt diagnosis is vital to ensure patients have timely access to treatment and support, which in turn can make a positive difference to their quality of life.

However, identifying secondary breast cancer can sometimes be challenging, as symptoms can be non-specific, and similar to those of other conditions or side effects of treatment. We often hear from patients who have experienced a delay in diagnosis because their signs and symptoms were not recognised or assumed to be due to a different cause rather than a possible sign of recurrence.

That’s why it’s essential that healthcare professionals are equipped to recognise the potential signs, consider them as red flags for breast cancer recurrence, and know when and how to take further action.

Accessing advice and support

For patients with a history of primary breast cancer, follow-up care may provide a clear route to report symptoms. However, follow-up protocols may vary depending on local services and risk of recurrence. Some patients may have been discharged from follow-up and feel unsure who to report new changes to, especially if symptoms arise months or years after treatment.

In many cases, general practice is the first point of contact. That’s why it’s vital for nurses in primary care to be aware of symptoms and have clear knowledge of guidance on referral pathways including those for vague or non-specific symptoms.

Related Article: ‘Urgent need’ for better breast cancer education and screening, survey shows

General symptoms to be aware of

Patients may initially present with general symptoms. While these aren’t always related to cancer, if they’re persistent or unexplained, they should be taken seriously and investigated further. These may include:

• Unexplained fatigue
• Unexplained nausea
• Unexplained weight loss and loss of appetite.

Common areas of spread and associated symptoms

Breast cancer can spread to multiple sites. You’ll find below the more common sites of spread and associated symptoms.

Bones

The most common site of spread in breast cancer is the bones.

Symptoms can include:

• Bone pain, that doesn’t have an identifiable cause. While pain cause by injury will improve with time, patients with bone metastases will often have increasing requirements for analgesia. They may describe the pain as worse on lying down or at night or worse with certain activities.
• Symptoms of hypercalcaemia. This can include unexplained nausea/vomiting, fatigue, frequent micturition, excessive thirst and confusion.
• A pathological fracture. This is a break in a bone that occurs in an area weakened by disease, rather than by trauma or injury. Cancer that has spread to the bone weakens it by compromising the structural integrity.
• Signs of metastatic spinal cord compression (MSCC). This can include bladder or bowel dysfunction, gait disturbance or difficulty walking, limb weakness, neurological signs including numbness, paraesthesia or sensory loss and radicular pain. If you suspect MSCC the patient should be directed to A+E.

Lungs

The lungs are the second most common site of spread in breast cancer. It’s worth noting that lung metastases do not always show up on a chest X-ray.

Symptoms that could indicate that breast cancer has spread to the lungs include:

• A new, persistent shortness of breath that has no identifiable cause.
• Chest pain or chest tightness which is often worse on exertion.
• A new and persistent cough. This can sometimes be accompanied by haemoptysis.
• Unexplained voice change which can be a result of pressure on the laryngeal nerve.
• Suspected pleural effusion on chest examination. This will usually be unilateral.

Liver

Breast cancer can spread to the liver, causing a number of abdominal symptoms. Note that Liver Function Tests (LFTs) can be normal even in the presence of metastases.

Symptoms to look out for include:

• Deranged LFTs. This would only show up on a blood test if there is significant tumour burden or obstruction.
• Jaundice due to a rise in bilirubin. Look out for yellowing to the skin and eyes. Patients may also report dark urine, and pale, clay-coloured stools and itchiness.
• Abdominal pain, often in the right upper quadrant.
• Right shoulder tip pain. This is because the enlarged liver stimulates nerves that connect to nerves in the shoulder, called referred pain.
• Unexplained nausea, vomiting or loss of appetite.
• Persistent hiccups.
• Ascites – swelling to the abdomen caused by a build up of fluid.
• Unexplained fatigue.

Brain

Patients with HER2-positive or triple negative breast cancer are more at risk of developing brain metastases.

Symptoms to look out for include:

Related Article: Women who miss first mammogram have 40% higher risk of breast cancer death

• A persistent headache which can be worse on waking due to a rise in intra-cranial pressure.
• Persistent nausea and/or vomiting, also often worse on waking.
• Weakness or numbness down one side of the body.
• Dizziness or unsteady gait.
• New and unexplained seizures.
• Patients may report changes to their vision or speech.
• New confusion and/ or memory
• Friends and family may report personality changes.

Skin

Less commonly, breast cancer can spread to the skin. Skin metastases are different to a local recurrence where breast cancer has come back in the chest or breast area or in the skin near the original site or scar. Skin metastases can occur near the original breast cancer, or to other areas including the scalp, neck, back and arms.

Symptoms can include:

• A new, persistent and unexplained rash.
• Skin discolouration.
• Palpable skin nodules.
• A new onset of lymphoedema. This usually affects the upper limbs.
• A fungating wound, which does not heal.

Lymph nodes

Breast cancer can spread to the lymph nodes. This can affect lymph nodes near to the primary cancer, or nodes that are more distant, including the chest (mediastinum) and neck (cervical).

Symptoms can include:

• Palpable lymph nodes, which patients may report as lumps under the armpit (axilla), in the area around the neck (cervical) and near the collar bone (supra-clavicular).
• A new onset of lymphoedema. This usually affects the upper limbs.
• Pain, this will depend on the site of the lymph nodes.
• A new and unexplained dry cough, which could be caused by irritation from enlarged mediastinal nodes.

Abdomen

A spread of breast cancer to the abdomen is more common in, but not exclusive to,  lobular breast cancer. Breast cancer can spread to different places within the abdomen. These include the lining of the abdomen (peritoneum), the digestive system, including the stomach and bowel, and the reproductive organs, including the ovaries. Symptoms can be variable depending on the organ impacted, but can include:

• Ascites – swelling to the abdomen caused by a build-up of fluid.
• Generalised abdominal pain.
• Persistent nausea and/or vomiting.
• Feeling full quickly or feeling bloated.
• Changes in bowel habit, including constipation or diarrhoea.
• Unexplained loss of appetite and weight loss.

Persistent, unexplained, or progressive symptoms shouldn’t be dismissed, especially in patients with a history of breast cancer where these may be red flags for disease recurrence.

Related Article: HRT should be considered for breast cancer survivors, review suggests

As many investigations routinely performed via primary care such as blood tests and plain X-rays are not always sensitive enough to detect metastatic disease, prompt referrals can make a real difference, leading to earlier diagnosis and better patient experience.

For more information and resources on secondary breast cancer, visit https://breastcancernow.org/healthcare-professionals-hub.