Cancer Expert MD

Hearing that cancer has come back is often harder than the first diagnosis. But a recurrence is not the end of options. Some recurrences can still be cured, many can be controlled for years, and the tests and treatments available now are far better than when the cancer was first treated. This article walks through the steps that matter most after a recurrence: confirming and re-testing the cancer, finding exactly where it is, treating a small number of spots directly, choosing the next treatment, and strengthening the body.

Types of Recurrence

Local recurrence means the cancer has returned where it started. Regional recurrence means it has returned in nearby lymph nodes. Distant recurrence means it has spread to other organs such as the liver, lungs, bones or brain. Local and regional recurrences can often still be cured with surgery or radiation. Our article on why cancer comes back explains the biology behind recurrence.

Step One: Confirm and Re-Test the Cancer

A recurrence is not always the same cancer that was first treated. Cancers change over time and under treatment, and occasionally what looks like a recurrence is a new, different cancer. When it is safe, a biopsy of the recurrence confirms what it is now.

Markers can change (Sweden). A large Swedish study showed that in breast cancer, estrogen receptor, progesterone receptor and HER2 status often change between the original tumor and the recurrence, and these changes affect which treatments will work.¹ The same is true of the genes that targeted drugs act on in many cancers.

Re-sequencing and blood tests. Tumor DNA and RNA sequencing of the recurrence can reveal new treatment targets. When a biopsy is difficult, blood tests such as Guardant360 can find many of the same changes, and tests such as Signatera can track the cancer over time.

Step Two: Find Exactly Where It Is

Whether a recurrence is in one spot or many changes everything. Newer targeted PET scans, such as PSMA PET for prostate cancer and FAPI PET for many other cancers, can find small areas that standard scans miss. Our article on new PET scans explains them.

Step Three: Treat a Few Spots Directly

When cancer returns in only a few places, called oligometastatic disease, treating every spot directly can extend life. In the international SABR-COMET trial, run at centers in Canada, Scotland, the Netherlands and Australia, people with one to five metastases from cancers including breast, lung, colorectal and prostate were randomly assigned to standard treatment alone or standard treatment plus precise high-dose radiation, called stereotactic ablative radiotherapy, to every spot. After five years, 42.3 percent of the radiation group were alive compared with 17.7 percent of the standard group, and median survival was 50 months compared with 28 months.² Surgery or ablation can be used the same way. In prostate cancer, the Belgian STOMP trial showed a similar approach delayed the need for hormone therapy, as our article on a rising PSA after treatment explains.

Step Four: Choose the Next Treatment

Matched to the new test results. The re-testing in step one often opens targeted drugs or immunotherapy that were not options before. Several drugs are now approved for any cancer that carries a particular change, such as NTRK gene fusions, mismatch repair deficiency or high HER2 levels, regardless of where the cancer started.

Using an old treatment again (Italy). A treatment that worked before can sometimes work again after a break. In the Italian CHRONOS trial in colorectal cancer, blood tests were used to find patients whose cancer had lost the resistance mutations that developed during earlier treatment. When those patients were given the targeted drug panitumumab again, about 30 percent responded.³

Molecular tumor boards and clinical trials. For complex cases, a panel of experts reviewing the full molecular profile, as in the German MASTER program described in our article on driver pathways, can identify options a single doctor might miss. Clinical trials offer access to new treatments before approval. Our guide to what to do when chemotherapy stops working covers these steps in more depth.

Step Five: Strengthen the Body

A recurrence is a signal to look again at the terrain the cancer grows in: diet, exercise, sleep, stress, inflammation and the immune system. Our articles on holistic cancer treatment and preventing metastasis, and our guides to integrative cancer treatment options, natural compounds and repurposed drugs explain the options and the research behind them.

The right plan after a recurrence depends on the type of cancer, where it has returned, the new test results and the treatments already received. In a consultation, Dr. Silver, MD, educates you on the testing and treatment options, including the integrative options, and the research behind each one.

How Cancer Expert MD Helps

Cancer Expert MD provides education and consultation for people with every type and stage of cancer, and specializes in Stage IV and metastatic cancer. Our book, The New Reality of Cancer, covers testing and treatment for recurrent and advanced cancer in depth. See also our guide to stage 4 cancer options.

Frequently Asked Questions

Can recurrent cancer be cured?

Sometimes. Many local and regional recurrences can still be cured with surgery or radiation, and some people with only a few metastases treated directly live for many years. Other recurrences are treated with the goal of long-term control.

Should a recurrence be biopsied?

When it is safe, yes. The cancer may have changed since it was first treated, and a biopsy confirms what it is now and which treatments fit.

What is oligometastatic cancer?

Cancer that has spread to only a few places, usually one to five. Treating each spot directly with surgery, ablation or precise radiation can extend survival.

Can a treatment that stopped working be used again?

Sometimes, after a break. In colorectal cancer, blood tests can show when the resistance has faded enough for a targeted drug to work again.

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For more in-depth information on this topic and many others, get our book, The New Reality of Cancer: The Science of Recovery.

Explore our guides: Stage 4 Cancer Options · Advanced Cancer Testing · Integrative Cancer Treatment Options · Natural Compounds and Cancer · Repurposed Drugs for Cancer · Cancer Treatment by Type

More articles on stage 4 cancer options and all articles.

References

1. Lindström LS, Karlsson E, Wilking UM, et al. Clinically used breast cancer markers such as estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 are unstable throughout tumor progression. Journal of Clinical Oncology. 2012;30(21):2601–2608.
2. Palma DA, Olson R, Harrow S, et al. Stereotactic ablative radiotherapy for the comprehensive treatment of oligometastatic cancers: long-term results of the SABR-COMET phase II randomized trial. Journal of Clinical Oncology. 2020;38(25):2830–2838.
3. Sartore-Bianchi A, Pietrantonio F, Lonardi S, et al. Circulating tumor DNA to guide rechallenge with panitumumab in metastatic colorectal cancer: the phase 2 CHRONOS trial. Nature Medicine. 2022;28(8):1612–1618.

This article is for education only. It is not medical advice and does not diagnose or treat any condition. Cancer Expert MD has no financial relationship with any laboratory, drug maker, supplement company, clinic or hospital.