September 2003: Metastatic Breast Cancer

Diet, exercise, and recurrence?

Question from MollyW: Due to lots of lymph node involvement, I am at high risk for recurrence. I am confused over whether I can do anything to increase the likelihood of remaining cancer-free. Can diet and exercise really make a difference? My doctor doesn't seem to think so, but my naturopath says they can. What is your opinion?

Answers —Eric Winer, M.D.: There's no question that treatments like chemotherapy, hormonal therapy, and radiation reduce your risk of having a recurrence. Your question, though, is whether exercise and diet also help. In fact, in terms of diet, your doctor's right that there's no evidence that changing your diet affects your chance of having a recurrence. In truth, there are still unanswered questions here. I personally am a believer in exercise, although you could also argue that the proof there is lacking. Although there's a bit more evidence with exercise than with diet, none of this means that you shouldn't change your diet and exercise if those changes make you feel better about your life and your chances of having a recurrence of cancer.

Musa Mayer, counselor: As Eric says, it's important to feel better about your life after the crisis of breast cancer treatment. There are many ways that you can seek to gain a sense of control. Some women will join a support group, some will follow a healthier diet, some will exercise, and some will try meditation or other techniques. All of these can be very important in helping you to feel better and cope with your illness. Whether or not they actually prevent recurrence is, in a way, less important than that they make you feel better day-by-day.

Marisa Weiss, M.D., president and founder: Staying close to your ideal body weight is the healthiest. There is soft evidence that after a breast cancer diagnosis, women who tend to be close to their ideal body weight may have a lower risk of recurrence.

Musa Mayer, counselor: This is a big challenge for many breast cancer patients, because—particularly if we have undergone chemotherapy or are on tamoxifen or other hormonal treatments—there is a tendency to gain weight. It's always a struggle.

Marisa Weiss, M.D., president and founder: For sure, many of you have struggled with your weight. It can become much more difficult after you go through treatment, experience weight gain from the treatment and supportive therapies, along with changes in your activity level. The main thing is to work towards a realistic goal consisting of a healthy diet and regular exercise. Give yourself credit along the way. Don't get too frustrated or impatient if it takes a lot of hard work over a long time. A support group can really be helpful here, as well as an excellent nutritionist and advice on resuming exercise in a safe and healthy way.

First site for metastasis?

Question from Pam: Is there a 'usual' first site for metastatic disease to show up?

Answer —Eric Winer, M.D.: Breast cancer can show up in a number of different places. The most common place for breast cancer to spread to is the bone, but it's by no means the only place. Of all of the places that breast cancer spreads to, the one place that is very uncommon as a first site is the brain. When a woman's had breast cancer—because breast cancer can potentially spread to a number of different places—if she has a new or unexplained symptom and it persists for a few weeks or longer, that's something to talk to her doctor about.

Regular testing for metastases?

Question from Hope: How do you know if you have a recurrence? I know I will be getting mammograms, but that won't show if it has metastasized somewhere else in my body. Should I be getting other tests like scans on a regular basis?

Answers —Eric Winer, M.D.: Generally, most of us don't recommend that women have routine scans after a breast cancer diagnosis and after they have completed treatment. Again, it becomes very important to let your doctor know if you have any unusual symptoms and, if so, lots of times, that is generally when additional tests would be obtained. You're not alone in the sense that it can be very unnerving not knowing for sure whether you're going to remain cancer-free, and this is, unfortunately, something that many woman who've had breast cancer simply have to learn to live with.

Musa Mayer, counselor: As it happens, I have so much to say about this that I've written a book called After Breast Cancer—Answers to the Questions You're Afraid To Ask. The reason I wrote this book is that I myself have had the experience for many years, as a 14-year survivor, of having symptoms that frightened me and wondering if I should have more tests or scans to find a recurrence at the earliest possible moment. So when I read the research that showed quite conclusively that there is no advantage to finding metastatic breast cancer before there are physical symptoms, I was shocked. I thought, "But what about early detection?" It turns out that early detection is only true for primary breast cancer, not for metastatic disease.

There is good research showing that having bone scans, tumor markers, and other tests done in the absence of symptoms only lets you know a little earlier that you have a recurrence. This is a really shocking concept for most women after they've finished their treatment for breast cancer. It's hard to get your mind around it. I found, after a while, that knowing this allowed me to let go of some of my vigilance—of some of my anxiety—so that I could trust my body to let me know if there was a problem.

Zometa for bone mets?

Question from Martha: What are your thoughts about Zometa for bone mets? I have a few spots on my ribs, no pain.

Answers —Eric Winer, M.D.: Zometa is a drug which is called a bisphosphonate, and the other drug in that same class that is often used for women who have recurrent breast cancer is Aredia. These drugs are very useful for many, many women who have breast cancer that has spread to the bone. They can decrease pain, prevent fractures, reduce the need for radiation to the bone, and reduce the chance that a woman will develop a high calcium level.

Without knowing a little bit more about those abnormalities you have in your bones, I can't say for sure that you should be on it, but it's certainly something you should talk to your doctor about, and it's a treatment that might be very useful. It is a treatment that is given intravenously, typically every 3-4 weeks. And, by the way, this is also a drug that is very helpful in treating osteoporosis.

Marisa Weiss, M.D., president and founder: It is in the same family of drugs as Fosamax and Actonel.

Chest wall metastasis outcome?

Question from Gaby: I was recently diagnosed with metastatic breast cancer, and the site is the same breast, in the chest wall, and two lymph nodes. Would this be considered better than if it had spread to the liver or somewhere else?

Answer —Eric Winer, M.D.: The answer is probably yes, but there are a number of factors that have to be considered other than just where the cancer is, in terms of knowing what the right treatment might be and what the likelihood is that the cancer will respond to the treatment.

Other factors that are important—both in terms of selecting treatment and having some sense as to how a woman with recurrent breast cancer is likely to fare in the years ahead—are: 1) how long an interval has passed since her initial diagnosis; 2) the hormone receptor status of the cancer (the estrogen and progesterone receptors); 3) the HER-2/neu status of the cancer; 4) the prior treatment that she's received; and, 5) her general health condition—whether or not she has other medical problems. With this information in hand, a woman can sit with her doctor and other health care providers and come up with an individualized treatment plan for her recurrent breast cancer.

Risk of third recurrence?

Question from SaraL: After undergoing cancer recurrence to the same right breast within a two-year time span, I would like to know what the chances are of the cancer recurring for a third time? Initial diagnosis was at the age of 37, and the second diagnosis was at the age of 39.

Answer —Marisa Weiss, M.D., president and founder: If you experience a breast cancer recurrence that is limited to the same breast where it started, this may be very effectively treated by mastectomy. After mastectomy, before recurrence, the risk of a second recurrence can be relatively low, depending on the nature of the recurrence. The risk of a second recurrence depends on tumor size, tumor grade, lymphatic/vascular invasion, the status of the margins, hormone receptors, whether the skin is involved or not, and if there is lymph node involvement.

If you are a young woman and you've had breast cancer twice, you may have inherited a genetic abnormality that could have contributed to each of these cancers. If a woman does have an inherited genetic abnormality, she is at increased risk for developing new breast cancers—on either side—over the course of her lifetime. It may be very helpful for you to seek further information from a skilled genetic counselor working together with your doctor to see if this is an issue for you or not.

Advanced breast cancer ER-, grade three?

Question from carrieNJ: Is it true that most advanced breast cancers are estrogen-receptor-negative, nuclear grade 3-type tumors at initial diagnosis?

Answers —Eric Winer, M.D.: Probably not. Certainly, many are estrogen-receptor-negative, and if a woman has estrogen-receptor-negative cancer, she is at higher risk of developing metastatic breast cancer than a woman with an estrogen-receptor-positive cancer who receives hormonal therapy. But because so many more breast cancers are estrogen-receptor-positive, if we look at all women living with metastatic breast cancer in the U.S., we find that a majority have estrogen-receptor-positive cancer.

Musa Mayer, counselor: Intuitively, it must seem that because your pathology report may have said when you were first diagnosed that these are very aggressive features, that if you do have a recurrence, it's because of those features. But those are just statistical predictions. Most of the women I know and work with who have metastatic cancer, like Eric says, have hormonally sensitive cancers and can be treated with drugs like tamoxifen and aromatase inhibitors, often for long periods of time. Metastatic cancers can behave very differently. Sometimes, they can be very slow growing, and sometimes extremely aggressive.

Eric Winer, M.D.: The good news is that one of the most aggressive forms of metastatic breast cancer, which used to be HER2/neu-positive metastatic breast cancer, can now be treated with a drug called Herceptin, which can be extraordinarily effective in some women. It has really changed the course of HER2-positive metastatic breast cancer. So, more and more, we're figuring out ways to help women live longer and better lives, even if they develop metastatic breast cancer.

Marisa Weiss, M.D., president and founder: Based on what Dr. Winer is saying, it is important to use the information that you can learn from your pathology report to help tailor the best treatment plan for you. Breastcancer.org offers a whole section on how to understand your breast cancer pathology report.

Bone scan normal after treatment?

Question from Yhu: Is the bone scan a normal procedure after finishing the chemo and radiation?

Answers —Musa Mayer, counselor: As I said a little bit earlier, bone scans are not routinely done in the absence of any symptoms. But if you have pain that is persistent over a period of time and is unlike any pain that you are used to (for example, pain in your lower back or some other part of your bones or skeleton), then, by all means, call your oncologist and ask to have the pain evaluated. It's less common now for women to have a bone scan as part of their initial diagnostic workup, but I'm glad that I did, because when I did have persistent lower back pain, the radiologist was able to compare that scan with the earlier scan.

But there is no need for a woman to have a bone scan every year. The bones are exquisitely sensitive often, and, as I said, your body will let you know if there is a problem. It can be treated at that time, and just as effectively as it would have been had you had a scan a few months earlier before you had any pain.

Marisa Weiss, M.D., president and founder: Many women use different words to describe pain. Your doctor may ask you, "Do you have any pain?" and you may say "No." And if you're asked the right question, you may volunteer that you have an ache or pull or discomfort or another word that may describe how you're feeling. It's important to let your doctor know how you're feeling right up front.

Also, you may experience other discomforts that may be a signal that a problem could exist—like a shooting discomfort that may start in the back area and go down your leg that may later become associated with back discomfort. Numbness can also be a symptom. Some women with significant involvement of the back area can experience these types of symptoms. But keep in mind that lower back pain is an extremely common symptom for people in general. This includes women who've had breast cancer.

Most of the time when you experience back pain, it's going to be because of a strain or other types of wear-and-tear on your back. As Dr. Winer said, if you experience a new symptom that persists or gets worse, bring it to your doctor's attention. If you are someone who has known bone metastases and you're being treated for that, your doctor may order bone scans intermittently to follow your response to treatment.

Delay rib radiation to avoid lung damage?

Question from Linda: Is it advisable to delay radiation to rib mets, if possible, due to possible damage to the lungs?

Answer —Marisa Weiss, M.D., president and founder: In general, rib metastases are associated with mild discomfort that is treatable with medication, unless there is a fracture associated with the metastasis. There are various ways to treat rib metastases when they occur without other sites of disease. Radiation can be very helpful and does not usually result in significant damage to surrounding tissues, including the underlying lungs. So, if you are experiencing significant rib pain and medication is not helping you to your satisfaction, ask your doctor to refer you to a radiation oncologist.

When to stop worrying about recurrence?

Question from Allison: Is it common for us who live with cancer to assume anything different from our 'normal' as a sign of recurrence? I don't want to be too cavalier and say, "I'm cured" for sure, but I don't want to be holding my breath waiting for the other shoe to drop either. What would be an appropriate way to face this uncertain future?

Answers —Musa Mayer, counselor: That is the question that women ask themselves after they've finished their treatment. If you talk to other women who've been treated for breast cancer, you soon find out that we all worry about recurrence, and that we're all up sometimes in the middle of the night wondering if this ache or that pain might be a recurrence of our cancer. If you can manage to be cavalier, I say, "More power to you!"

I would encourage you not to deny what has happened, but to trust that if something serious is going on, that it will persist and get worse; it will get your attention. For the most part, the transient aches and pains and lumps and pimples and various symptoms that we all worry about have nothing to do with cancer, but with all the other kinds of problems that we're subject to. As Dr. Weiss said, we're not immune to other physical problems, particularly as we age.

The first year to three years or four years after diagnosis and after you've completed your treatment are the hardest. It really helps to share your fears and feelings with other women and realize that you are normal for feeling this way. And, after a while, you can even laugh about some of the stories. I included the experiences of about 40 women telling their stories of cancer freak-outs in my book, and many women find it very comforting to know that they are not the only ones who worry this way.

Marisa Weiss, M.D., president and founder: There are many studies that have shown that what most helps women get through their treatment and beyond it is the connection to other women, as well as information.

Herceptin trials limit recurrence treatment?

Question from Sharon: By entering a Herceptin trial after a mastectomy and finishing chemo and radiotherapy treatment for early breast cancer, are you limiting treatment if the cancer does reoccur and you've already had Herceptin?

Answers —Eric Winer, M.D.: The trials are very carefully looking at whether Herceptin can help prevent recurrences. If, in fact, Herceptin does help prevent recurrences, then it becomes somewhat less of an issue whether this changes treatment options at the time of the cancer recurring—because fewer women will have recurrences, because more women are doing better. But this is something we don't know the answer to yet.

If a woman receives Herceptin as part of her trial and then subsequently has a recurrence of cancer, it would not be out of the question to treat with Herceptin again. It would very much depend on the time course of the recurrence. Many doctors might want to re-biopsy the cancer to confirm the HER2/neu status of the cancer.

Musa Mayer, counselor: In the treatment of metastatic breast cancer with Herceptin, some doctors—after one particular combination with Herceptin and a chemotherapy—will keep their patients on Herceptin and go to another chemotherapy until that one fails, and sometimes even another. So it has seemed to me as if resistance to the drug often develops more slowly than resistance to chemotherapy drugs, but I'm not sure that's supported by research.

Eric Winer, M.D.: I think it's supported by the hope that in years ahead we'll be able to prove or disprove this with the ongoing trials. Once a treatment has been shown to be useful in the adjuvant setting—Herceptin is not there yet—that it is preventing recurrence in women with early stage breast cancer, we generally use that treatment and don't worry about limiting options later on, since the real goal is to prevent a problem later on. If we prevent the recurrence, then we don't have to worry about how to treat a recurrence.

Musa Mayer, counselor: It's not as important these days, since we have many more treatments for metastatic breast cancer, to feel that you must save a treatment in case you have a recurrence. When I started working with women who have metastatic disease 7-8 years ago, there were relatively few treatments available. Since about 1995, there have been significant advances—drugs like Taxol, Taxotere, the aromatase inhibitors, Herceptin—and there are others in the drug development pipeline now that will further extend women's lives even when they cannot be cured.

New treatments for Stage IV?

Question from Cynthia: Are there any new treatments or any new drugs being researched for Stage IV?

Answers —Eric Winer, M.D.: There are many new drugs and treatments that are being looked at for women who have Stage IV breast cancer. There are new hormonal therapies, new chemotherapeutic agents, new vaccines, new small molecules. In general, the approach has been to try to find treatments that affect the cancer and prevent it from growing without having such severe side effects as some of our older treatments. I think we all wish that we were far further ahead than we are now, but there are dozens of new treatments being looked at in cancer centers, at other hospitals across the country, and around the world. Clearly, the collaborations and partnerships that exist around the world are incredibly important these days.

Marisa Weiss, M.D., president and founder: In fact, many of these new therapies are first introduced in clinical trials for women with Stage IV disease.

Musa Mayer, counselor: I would strongly encourage women who have metastatic breast cancer to ask about entering a clinical trial for one of these promising new drugs. There are resources online that can help you find out more. One good place to start is at www.clinicaltrials.gov, a U.S. government listing site, or call 1-800-4-CANCER.

Eric Winer, M.D.: Clinical trials are not for everyone, but for many people, they represent a very important option, a way of receiving treatments that are otherwise not available. Sometimes those treatments are effective, and sometimes they're not, but participation in a clinical trial almost always means that a woman is getting state-of-the-art care and at the same time, she is helping to identify new and better approaches for women with breast cancer in the future.

Cost for clinical trials?

Question from Gilley: I would be interested in taking part in a clinical trial sometime (when other treatments have been used up), but I live in Canada. There are few clinical trials in my area. Would I have to pay to get involved in a clinical trial somewhere in the U.S.?

Answer —Eric Winer, M.D.: Often times, the actual treatment on a clinical trial is provided at no cost. But what is generally the case is that women or their insurers are charged for the standard treatment costs for the care that would otherwise have been given if the women were not in the trial. There are some places, though, where it may be possible to receive care on a clinical trial without a great deal of expense, and one of those places might be the National Cancer Institute in the U.S.

Editor's Note: See Breastcancer.org's section on Clinical Trials for more information.

No cure for Stage IV?

Question from Jan: I have just been diagnosed with Stage IV breast cancer that has spread to my bones in quite a few places eight years after finishing chemo. Why isn't Stage IV metastatic breast cancer curable?

Answers —Eric Winer, M.D.: I think it's important never to say that anything is 100% incurable, but, generally speaking, metastatic breast cancer is not curable as you have said. This is because it has passed a certain point at which we no longer have treatments that are able to eradicate every last cancer cell. But—and this is a very important "but"—metastatic breast cancer can often be treated as a chronic and highly treatable illness for years and years and years.

While I fully realize that it is devastating to have a recurrence of cancer and feel that it can't be cured, one of the things to keep in mind is that having a recurrence of breast cancer eight years after diagnosis and primarily to bone is a situation where most of us would predict that you should be able to live with this for a long time. That does not even take into account potential advances that may occur over the next several years that you could take advantage of.

Musa Mayer, counselor: There is a recent study published by M.D. Anderson Cancer Center in Texas where they looked at survival of their metastatic breast cancer patients over the last 20 years. In the 1970s, only 10% survived five years after a metastatic diagnosis, while in the most recent period, 40% survived at least five years. Those are pretty significant figures for women who are facing metastatic disease. We are making progress.

Other antibody-type drugs in the works?

Question from Mary: I have metastatic breast cancer that presented itself in the lungs and liver. I do not qualify for Herceptin. I am currently receiving Taxol and Carboplatin, and I am wondering if they are working on any other antibody-type drugs. I feel that if I can make this a chronic illness and hang on, that I'm on the cusp of a cure. Do you agree?

Answers —Eric Winer, M.D.: As we were talking about, there are many new treatments, both antibodies and other types of treatments, that are in various stages of development, and many of which are in clinical trials. For the moment, it probably makes sense for you to continue your present treatment as long as it's working and as long as you're tolerating it reasonably well.

The time to look for a new treatment approach would be when you're ready to stop this treatment, and that would be a time to ask your doctor about clinical trials and what might be available either at the center where you're being treated or at other locations.

Musa Mayer, counselor: One way that people find out about new treatments and ongoing research is that they help one another discover what's available. One thing you might think of is joining a mailing list called BCMETS, a large international discussion list on which women and their partners discuss treatment and offer support. You can find out about this at www.bcmets.org.

Marisa Weiss, M.D., president and founder: Each month at Breastcancer.org, we have research news that features important new treatment advances. We also report on all of the major breast cancer conferences throughout the year. You can sign up for the Breastcancer.org free email updates on the homepage. There are also many forums within the Breastcancer.org discussion boards where women with advanced breast cancer share this important information, as well as encouragement.

Eric Winer, M.D.: I would agree that the name of the game for you at the moment is hanging in there and being hopeful that some of the new therapies that are being developed will be helpful for you. As a general rule, my own preference, in terms of using chemotherapy, is to use one drug at a time. Combinations like Carboplatin and Taxol are certainly fine regimens, but one of the problems we run into when they work is that we don't know whether it's the Taxol, Carboplatin, or both. Since these drugs all have side effects, it can mean that we're giving a drug that isn't effective but is still causing a number of side effects.

Studies have shown that when we give 2-3 drugs together, we can shrink tumors a little bit more often, but that the long-term results aren't different than giving one drug followed by another, and that either approach leads to the same number of women who are alive at various points down the road. Again, giving 2-3 drugs together is not wrong, but it's usually not the approach that I personally like to take. I would also say that the same is true in terms of combining hormonal therapy and chemotherapy. It's something I'll do rarely if I feel that there isn't going to be an opportunity to come in with another treatment in the future because a woman is so very sick.

Most of the time, my strong preference would be to first use a hormonal therapy and then a chemotherapy drug, or sometimes rarely in the other order, or use them in such a way so as to tell what's working and what's not working in an effort to individualize treatment for each patient, to maximize the benefits and minimize side effects.

Side effects lessen after initial chemo?

Question from Marita: After an initial, very aggressive chemo round, will the side effects and manageability of a single chemo drug, possibly Xeloda, be improved?

Answers —Musa Mayer, counselor: In the experience of many of the women I talk with who have tried Xeloda, it is one of the best chemotherapy drugs we have for advanced breast cancer. Not only can a woman take it at home by pill, but also it seems to be unusually long-lasting and effective for men and women. I'd also like to know from Dr. Winer if he believes that Xeloda can be effectively administered at a somewhat reduced dosage than that prescribed on the drug label.

Eric Winer, M.D.: I agree with all of your comments, and I use Xeloda a great deal. It is very much a drug, though, where the dosing has to be individualized and has to be adjusted over time. My sense is that lower doses than were initially used in the first clinical trials can be very effective. And, yes, I suspect a drug like Xeloda can be administered with far fewer side effects than the typical combination chemotherapy regimen that I think you were referring to.

The three biggest side effects with Xeloda are peeling of the skin and pain on the palms and soles, diarrhea, and mouth sores. Generally speaking, all of these are best managed by adjusting the dose. Sometimes, various moisturizers and creams can be useful in terms of the hand/foot problems, but at least in my experience, the real benefit comes from adjusting the dose.

Musa Mayer, counselor: Sometimes women will wait until their next appointment to tell their doctors that they're starting to experience real soreness and irritation of the skin of their palms and the soles of their feet. You should call your doctor as soon as you have any symptoms for a possible dose adjustment. Don't wait until the symptoms get unbearable, because then you may actually have to stop taking the drug for a period of time in order for the skin to heal.

Time between primary cancer and metastases?

Question from Gail Anne: What is the significance of the length of time between the primary breast cancer and the metastases?

Answer —Eric Winer, M.D.: There are no absolute rules, but, generally, the longer the time between initial diagnosis and the development of metastases, the more likely a woman will do well with her metastatic breast cancer, and the more likely that that cancer will be hormone-receptor-positive. But having said that, there are sometimes women who have very short intervals between diagnosis and recurrence who still go on and do well for an extended period of time.

Risk of metastasis with Stage II?

Question from mindy: How often does the cancer metastasize if found at Stage II?

Answers —Eric Winer, M.D.: Stage II is still fairly variable and heterogeneous. It depends a little bit on a number of different factors including the hormone receptors, the HER2/neu status of the tumor, how big the primary tumor is, and how many lymph nodes are involved—although the staging system has recently changed and has made this a little simpler.

In general, most women with Stage II breast cancer have a moderate chance of having a recurrence of cancer after they've finished treatment. And by moderate chance, I mean anywhere from as low as a 10% chance after treatment to as high as a 50% chance. I realize that that's a large range, but without knowing more specifics, both in terms of the tumor and treatment, it's hard to be any more accurate.

Musa Mayer, counselor: I was diagnosed with Stage II breast cancer 14 years ago, and I'm fine.

Eric Winer, M.D.: I think there are a lot of people who think because the cancer has spread to the lymph nodes, which is often the case with Stage II breast cancer, it means that the cancer is going to spread elsewhere and that simply isn't true.

Bone marrow transplant to treat metastases?

Question from Boop: I was diagnosed in December 2002 with breast cancer, with mets to the bone and bone marrow. Would a bone marrow transplant help at all?

Answer —Eric Winer, M.D.: Bone marrow transplants and stem cell transplants were commonly used throughout the late 80s and 90s with few exceptions. This treatment is no longer administered, because large clinical trials show that they were not better than far less toxic treatments. And, even if those treatments were still being used, anything having involvement of the bone marrow would actually be a reason not to consider such an approach because the transplant is actually from oneself. The good news is that we have new treatments today that are far less severe than bone marrow transplants, and they appear to be as or more effective.

When to take a break from chemo?

Question from Linda: When is a chemo break reasonable?

Answers —Eric Winer, M.D.: Again, this is an area where we can individualize treatment. In a woman who had very severe symptoms from her metastatic cancer and who is tolerating chemotherapy beautifully, I often continue chemotherapy for a long period of time, because studies have shown that the longer you continue, the longer the cancer will remain under control.

But with women who did not have such severe symptoms or who are tolerating chemotherapy poorly, I often stop the chemotherapy—because those same studies say that even though the cancer may start growing again, we can use the same treatment or other treatments at that time, and the long-term results will be very similar.

Musa Mayer, counselor: Living with metastatic breast cancer is a marathon, not a sprint. You need to have a life that is meaningful for you, and to undergo treatments that are tolerable and allow you to live that life. Sometimes that will mean taking a break. Maybe your doctor can 'rest you' on a milder treatment like hormonal treatment, or maybe you just need some time off. The important thing is to have the kind of relationship with your doctor where you can discuss your personal life and your goals, and work out a treatment plan together that makes you feel like you're in charge and that your life continues to be worth living.

Eric Winer, M.D.: One of the aspects of metastatic breast cancer that sometimes scares women the most is this idea that they're going to be on chemotherapy forever, and it just does not have to be that way. As Musa was just saying, sometimes treatment breaks can be very helpful for some people. I'm afraid that sometimes people, both patients and doctors, are afraid to take those breaks, but sometimes they're useful to travel or do certain things that would not be possible while getting treatment.

Also, sometimes those breaks allow people to recover so they can then face more treatment down the road. Some treatments are given once a month, every three weeks, or every week. As you heard before, we have some chemotherapy treatments that are oral and can be taken at home. In selecting an individual chemotherapy drug, doctors and women with breast cancer have to talk to each other and work closely and figure out what will work best, not only for the cancer but also, more importantly, for the woman and her life.

When to stop treatment?

Question from Becky: When does one say, "Enough!" and stop all treatments?

Answers —Musa Mayer, counselor: There comes a time for most women dealing with metastatic breast cancer when treatments are no longer effective and the toxicity is overwhelming. It's very difficult to make the transition from fighting the disease to beginning to think about what needs to be done and said with the people you love and how to prepare for the end of your life. That's a tremendous challenge. It's a difficult time and, obviously, members of your family will find it equally painful.

It's really important to get help and support as you enter this time from your doctor, possibly from hospice, and certainly from members of your family and friends. There is no hard and fast rule about when enough is enough. Some people prefer to receive treatment up to the last day of their lives, while others will stop and prefer to spend the last weeks and months with their families, with their pain and other symptoms relieved, but without having to deal with being in treatment anymore.

It's a very individual thing. The only constant is to keep the lines of communication open, even though this means shedding a lot of tears and facing very scary moments. These times can be very precious in the life of a family, and I've seen many women and their families approach the end of life with great courage. You may think that you could never be strong enough to do that, but people surprise themselves with their strength.

Eric Winer, M.D.: In terms of communication, I think it's important to emphasize in this discussion about when enough is enough that it is a conversation that should be going on between a woman with breast cancer and her doctor and nurse and others who are involved in the team over the course of an extended period of time.

If I can use a simple analogy, when you're evaluating an employee in a job, the yearly evaluation should never be a surprise. In this same way, having a conversation about stopping treatment shouldn't come as a surprise to either a doctor or patient, but should be a very natural transition as part of the conversations that have been going on in the months before. Communication is the key!

Marisa Weiss, M.D., president and founder: Sometimes, when you take a break from treatment and believe at that particular time that you'd like to stop, you might be surprised to find that you may feel relatively well off of treatment and can do well for an extended period of time. During the treatment break, it's also important to communicate with your doctor.

The decision to stop treatment is not irreversible. You can change your mind and initiate a form of treatment if it helps you feel better. There is a difference between treatment to extend your life that may involve more side effects, and treatment that can ease a particular symptom that is getting in the way of your quality of life. Again, as Dr. Winer and as Musa Mayer said, that communication is essential to the best care.