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When breast cancer spreads to other areas outside of the breast, such as bones, lungs or liver, it’s referred to as metastatic breast cancer. Other terms commonly used are advanced cancer or stage IV cancer. Some people have metastatic breast cancer when they’re first diagnosed, but metastases more often develop some time after treatment for a previous diagnosis of earlier stage breast cancer, when that treatment was unable to eradicate all the cancer cells. When cancer returns after an original diagnosis, it is referred to as a recurrence.
The process of diagnosis and treatment of recur- rent breast cancer has some similarities to the first experience, but there are some key differences. If your oncologist suspects you may have recurrent breast cancer based on results of a mammogram or physical exam, or because of signs and symptoms, the oncologist may recommend additional tests to confirm the diagnosis.
Imaging tests may include magnetic resonance imaging (MRI), computerized tomography (CT), X-ray, bone scan or positron emission tomography (PET). Not every person needs every test. Your oncologist will determine which tests are most helpful in your situation. These tests can help determine whether a biopsy — a procedure to collect a tissue sample for lab testing — is needed to confirm whether cancer has spread to a specific area.
From the biopsy sample, a pathologist can deter- mine if the cancer is a recurrence of cancer or a new type of cancer. Tests also show whether the cancer is sensitive to hormone treatment or targeted therapy since these may have changed since your original cancer diagnosis.
When cancer has spread to other organs, it is typically incurable. Nonetheless, treatment can help control the cancer effectively, with the goals of extending your life and helping you to live as well as possible, for as long as possible. As breast cancer treatments become more and more effective, people are surviving longer with metastatic breast cancer. Importantly, treatment can also relieve many symptoms that are caused by the cancer, improving quality of life in addition to length.
Goals and options for treatment
Whether you’re newly diagnosed with metastatic breast cancer or have been previously treated for a breast cancer that has now recurred or progressed to an advanced stage, treatment of your metastatic breast cancer will likely be very different from that of early- stage breast cancer.
The goals of your treatment options will depend on your situation — such as the characteristics of the tumor, how long you’ve been without cancer, where and how far the cancer has spread, and whether the cancer is causing any symptoms or difficulties with specific organ functions.
Most importantly, treatment goals will depend on your preferences. When deciding on treatment options, it is important to discuss and consider not only the potential benefits of the treatment, but also the potential side effects. As a wider variety of treatment options becomes available, your providers may be able to select treatments that have a side effect profile you’re willing to consider.
Treatment options
Depending on the characteristics of your breast cancer, treatments may include:
- Endocrine therapy If your cancer contains hormone receptors — which means that the breast cancer cells are dependent on female hormones to grow and multiply — you may benefit from a hormone treatment known as endocrine therapy. This treatment targets the estrogen receptor and blocks the tumor’s access to estrogen, which in turn decreases cancer cell growth. In cancers that are dependent on estrogen, endocrine therapy is typically more effective than chemotherapy, particularly in the initial phases of the disease. In general, endocrine therapy also has fewer side effects than chemotherapy and can be more convenient, as there are several oral options.
- Chemotherapy Chemotherapy involves medications that kill rapidly growing cells. Because cancer cells typically replicate at a faster rate than healthy cells, chemotherapy can effectively kill cancer cells, regardless of whether they are dependent on estrogen or not. Your oncologist may recommend chemotherapy if your cancer is hormone receptor negative, if endocrine therapy is no longer working, or if your tumor has certain genetic alterations such as being HER2 positive.
- Immunotherapy Immunotherapy involves medications that stimulate your immune system to help it recognize and attack cancer cells. Cancer cells often produce proteins that help them hide from immune system cells. Immunotherapy works by interfering with that process. It might be an option in combination with chemotherapy if you have triple-negative breast cancer, which means that the cancer cells don’t have receptors for estrogen, progesterone or HER2.
- Targeted therapy This involves medications that interfere with specific cellular processes that allow cancer cells to grow more rapidly or become resistant to other treatments. Examples of targeted therapies include CDK 4/6 inhibitors, PI3 Kinase/ AKT/mTOR pathway inhibitors, or HER2 directed therapy. Targeted therapies are often given in combination with other treatments such as endocrine therapy or chemotherapy.
- Clinical trials Your oncologist may recommend a clinical trial that is appropriate for your circum- stances. When you talk to your health care team about treatment options for metastatic breast cancer, ask if you qualify for a clinical trial. This question is an important way to advocate for yourself and make sure you’re getting the best possible care. Feel free to bring up participation in a clinical trial with your cancer care team if you are interested learning more about it. See Chapter 7 for more on clinical trials.
- Supportive care treatments Radiation therapy and surgery may be used in certain situations to ease symptoms caused by advanced breast cancer, such as pain, but these treatments typically aren’t used to try to get rid of the cancer. Additionally, if cancer has spread to your bones, your doctor may recommend a bone-building drug to reduce your risk of developing broken bones or reduce bone pain you may experience.
After starting treatment, you’ll have regular checkups to make sure that you’re feeling well, your cancer symptoms are manageable and treatment side effects are tolerable. You’ll also have regular blood tests and scans to ensure that the treatment is working and not causing problems in other organs. If your treatments aren’t working or the side effects are not tolerated, your oncologist may recommend a different treatment.
Treatment goals
When considering your treatment plan, your oncologist is likely to have these goals for you in mind:
- The fewest side effects from the cancer for as long as possible.
- The fewest side effects from the treatment for as long as possible.
- The longest life.
- The best quality of life.
It’s also important for you to think about your own priorities. Understanding what you want out of treatment can help guide your treatment decisions. Some people want to treat their cancer for as long as they can and are willing to undergo some discomfort to do so. Others would like to focus on quality of life rather than length of life, preferring to avoid harsh treatment side effects. It is critical to discuss your treatment goals with your cancer care team and your loved ones. Honest and frank communication can help make sure that everyone is on the same page and striving for the same goals.
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