Treatment for Metastatic Breast Cancer

Treatment for Metastatic Breast Cancer

There are a number of different approaches to treating metastatic breast cancer. Every cancer is unique and treatment can be tailored to your specific circumstances.

If you’ve been diagnosed with metastatic breast cancer, it’s important to know there are a number of different treatment options for you and your doctors to consider. Most treatment decisions depend on where in the body the cancer has spread, the cancer’s characteristics (such as hormone receptor status and HER2 status), and any cancer treatments you’ve had in the past.

Doctors usually treat metastatic breast cancer in any part of the body with systemic medicines, which treat cancer throughout the entire body. Chemotherapy, hormonal therapy, targeted therapies, and immunotherapy are all systemic medications. Local treatments that target a specific part of the body, such as surgery or radiation, are sometimes recommended.

You and your doctor need to be in agreement about the approach to your care. It’s up to you whether or not you want to try a recommended treatment, especially if various treatment options are available to you. For example, your doctor may recommend a treatment that is given more frequently or one that may have more severe side effects than another treatment.

Open, clear communication with your doctor is important as you develop a treatment plan that honors your feelings and decisions. Listen carefully to your doctor, and at the same time, make sure your doctor is listening to you. It’s important to tell your doctor what your priorities and preferences are regarding treatment, whether it’s quality of life, pain control, or being as aggressive as possible. Talk about the risks and benefits of each treatment choice. Take time to think about your doctor’s recommendations and then, together, develop a plan.

Remember that you can change your mind about your treatment choices. You may want to alter your treatment plan depending on how it’s affecting your daily life, family, or finances. Your treatment plan isn’t written in stone. You can talk to your doctor about changing your treatment approach at any time.

It may also be a good idea to get a second opinion from another breast oncologist, who can provide an outside perspective on the pathology of the cancer and your treatment recommendations. A second opinion consultation can be arranged by making an appointment with an oncologist at a different hospital. If you need help preparing for this appointment, that oncologist’s office staff can help you. It may feel odd to go outside your own doctor’s office for additional insights, but getting a second opinion can be an important part of treatment planning.

When making treatment choices for metastatic breast cancer, consider the following:

  • What are your treatment preferences? Do you want to try any and all treatments that may stop the cancer from growing?

  • What is your general overall health? Can you tolerate treatment with more severe or frequent side effects?

  • How important are quality of life issues? Are you willing to put up with side effects that may reduce your quality of life?

  • How important is pain control?

  • Are you interested in joining a clinical trial?

  • Do you have health insurance? Is the cost of treatment a concern for you?

  • Do you have a support network of people who can help you with day-to-day activities if you need it?

  • What’s the best way for your medical team to talk to you? Do you want direct, straightforward scientific information about your health? Or do you prefer a softer approach?

Questions you may want to ask your doctor about treating metastatic breast cancer include the following:

  1. Do I need a biopsy to find out whether the cancer’s hormone receptor or HER2 status has changed?

  2. Why are you recommending a particular treatment?

  3. What are the benefits of each possible treatment? What are the side effects?

  4. How can each treatment affect my quality of life?

  5. How do I know the treatment is working?

  6. What kinds of tests can I expect to have?

  7. What happens if a treatment stops working?

  8. How do I know when to switch treatments?

  9. What happens if I decide to not have a treatment?

  10. Are there clinical trials you think would be beneficial for me?

Learn more below about treatment options and making a treatment plan for metastatic breast cancer.

 

How to make a treatment plan

After a diagnosis of metastatic breast cancer, it’s helpful to take the time you need to gather as much information as possible. Once you are ready, you can make plans and informed decisions about your care, treatment, and quality of life.

Building your medical team

You may already have a medical oncologist if this is a recurrence of a previous breast cancer diagnosis. If appropriate, your oncologist can recommend other specialists who can join your medical team. Together, you will develop a metastatic breast cancer treatment plan.

If metastatic breast cancer is your first breast cancer diagnosis (called de novo metastatic breast cancer), you probably don’t have a medical oncologist. Your primary care physician can recommend an oncologist and other specialists to you so you can put together your medical team.

The doctors on your medical team may be involved in your care at the same time or at different points throughout your care. Either way, everyone on your medical team needs to communicate with one another about your tests and treatments.

Your breast cancer medical team may include a number of specialists:

  • a surgeon, who performs biopsies and other procedures and removes single metastatic cancers

  • a medical oncologist, who specializes in chemotherapy, hormonal therapy, targeted therapies, immunotherapy, new treatments that may be available through clinical trials, pain medications, and nutritional support

  • a radiation oncologist, who specializes in radiation therapy

  • a radiologist, who takes and interprets mammograms, ultrasounds, bone scans, CT scans, MRIs, PET scans, and other imaging tests to determine the location and size of the cancer and to help determine how the cancer is responding to treatment

  • a pathologist, who examines biopsy samples and conducts special tests on cancer tissue to determine the cancer’s characteristics, such as its hormone receptor status and HER2 status

You may meet with some of these specialists in person, while others will consult only with your medical oncologist.

Communicating with your medical team: Video series

If you’ve been diagnosed with metastatic breast cancer, it’s important to communicate with your medical team to ensure you’re getting the support you need.

In this video series, Timothy J. Pluard, MD, and Savannah Geske, PhD, of Saint Luke’s Cancer Institute, explain several strategies for building a supportive relationship, navigating difficult conversations, and seeking a second opinion. Christine Lieb and Christine Patrick — who are both living with metastatic breast cancer — share their best tips for communicating your wants and needs.

 
 
Take your time

When you first learn that you have been diagnosed with breast cancer, it can be difficult to process what your doctor is saying. If you can, it’s a good idea to take someone with you who can take notes. You can also ask your doctor if it’s OK to record the conversation with your cell phone or a recording device.

Still, you may find that you need to have a few follow-up conversations with your doctor or other breast cancer specialists. Gathering as much information as you can and asking all the questions you may have can help you make better choices about your care and treatment.

Some questions you may want to ask include:

  • How many specialists you I expect on my medical team?

  • How do members of my medical team plan to communicate with each other about my treatment and care?

  • Do you plan to do a biopsy of the metastatic cancer? Why or why not?

The answers you get can help complete the whole treatment picture. Take the time you need to make decisions. Each person makes decisions differently. If you prefer to think about treatment options before making a final decision, let your doctor know.

Consider genetic testing

If you’ve been diagnosed with metastatic breast cancer, it can be helpful to find out whether or not you have a genetic mutation linked to breast cancer. In some cases, testing positive for a genetic mutation could mean that you’re eligible for different treatment options or a clinical trial testing potential treatments.

Dana Yorko was diagnosed with stage III inflammatory breast cancer in 2013. She later experienced a recurrence and was diagnosed with metastatic breast cancer. Dana had genetic counseling with Cristina Nixon, MS, L/CGC, a licensed certified genetic counselor with the Main Line Health Genetics Risk Assessment Programs. She then had genetic testing for mutations linked to breast cancer.

 
 
Consider complementary and holistic medicine

The goal of complementary and holistic medicine is to balance, strengthen, and energize you as a whole person — physically, mentally, and emotionally — while conventional medicine fights the cancer. Some people with metastatic breast cancer have found that complementary therapies help to:

  • ease the symptoms of metastatic breast cancer

  • lessen treatment side effects

  • improve quality of life

Complementary medicine can include practices such as acupuncture, massage, hypnosis, meditation, and yoga. Some dietary supplements also are considered to be forms of complementary medicine.

Scientists are doing research to better understand the benefits complementary therapies offer people who are diagnosed with metastatic breast cancer. Although some studies show that complementary therapies provide benefits, complementary techniques usually haven’t undergone the same rigorous testing as conventional medicine.

It’s smart to talk to your doctor before adding complementary and holistic medicine techniques to your treatment plan. It’s important to be sure the therapy is safe and won’t interact with any of your conventional treatments.

 
 
Taking a break from treatment

Living with metastatic breast cancer can be like running a long race. It can help to pace yourself. This can mean that you sometimes take a break from your treatments so your body can rest and recover. You may want to talk to your medical team about your personal goals and quality of life, and work out a treatment plan that includes breaks when you need them.

When you take a break from treatment, you may be surprised to find that you feel pretty good and that the cancer may be controlled for an extended period of time. While you probably won’t see your medical team as often while you’re taking a break from treatment, it’s important to stay in touch with them. Set up a schedule to make sure you check in with them on a regular basis.

 

Surgery

In some cases, doctors may recommend surgery for metastatic breast cancer. Your doctor may suggest surgery for a few different reasons.

Surgery for metastatic recurrence

Doctors usually don’t recommend surgery when breast cancer has spread to another part of the body because it’s unlikely to get rid of all the cancer cells. This is especially true if the cancer has spread to more than one location. Still, in some cases, doctors may recommend surgery or radiation therapy (or both) to prevent broken bones or cancer cell blockages in the liver, or to ease pain and other symptoms.

Surgery for de novo metastatic breast cancer

Nearly 10% of women diagnosed with metastatic breast cancer have de novo metastatic disease. It's unclear how many men are diagnosed with de novo disease. De novo means the cancer is first detected and diagnosed at stage IV, after it has already spread to other parts of the body.

Some research suggests that some women with de novo metastatic breast cancer may have better survival rates if they have surgery to remove the primary tumor in the breast. If you are diagnosed with de novo metastatic disease, you may want to ask your doctor if surgery to remove the breast tumor would be a good option for your specific situation.

Surgery to remove liver metastasis

Surgery to remove metastatic breast cancer isn’t common, but a small study suggests that some women can benefit from surgery to remove breast cancer that has metastasized to the liver if the cancer has the following characteristics:

  • it’s hormone receptor-positive

  • it responded to chemotherapy before surgery (called neoadjuvant chemotherapy)

  • it didn’t grow in the time between metastatic diagnosis and surgery

Right now, we don’t know if women who have surgery to remove metastatic breast cancer in the liver have better outcomes than women who don’t have surgery. Still, if you have liver metastases, you may want to ask your doctor about the benefits and risks of surgery in your specific situation.

Learn more about Liver Metastasis.

Cryotherapy for metastatic breast cancer

Some people with small, isolated metastatic breast cancer tumors aren’t good candidates for surgery. In these situations, some doctors may recommend a minimally invasive procedure called cryoablation or cryotherapy.

Guided by ultrasound, CT scan, or MRI, a surgeon inserts a special freezing probe — a type of catheter — through the skin and into the tumor. Once the tip of the probe is in the right spot inside the tumor’s core, the surgeon injects pressurized argon gas through the probe into the tumor, freezing and destroying the cancerous tissue.

Cryoablation techniques may vary from one cancer treatment facility to another. Cryoablation is more common in cases where systemic treatments such as chemotherapy and hormonal therapy are controlling the breast cancer.

 

Chemotherapy

Chemotherapy destroys or damages cancer cells as much as possible and, therefore, doctors recommend it as a treatment for metastatic breast cancer. Because chemotherapy medicines are systemic treatments — meaning they affect the entire body — doctors generally recommend chemotherapy if:

  • the cancer is growing despite other forms of treatment

  • there is a significant amount of cancer in organs such as the liver or lungs

  • the cancer is growing quickly

Doctors often combine chemotherapy with targeted therapies, which are medicines that target specific characteristics of cancer cells.

Each person’s chemotherapy treatment plan is different. But there are some general guidelines that doctors follow when using chemotherapy to treat metastatic breast cancer:

  • If you’ve had chemotherapy before or do not have severe organ dysfunction, your doctor may recommend using only one chemotherapy medicine at a time to treat metastatic disease. This way you can get benefits with fewer possible side effects.

  • In general, doctors use most chemotherapy medicines to treat metastatic disease until side effects become a problem or the medicines stop being effective.

  • Some chemotherapy medicines seem to work better against cancer tumors when they are combined. Research has shown that combining treatments has contributed to a better overall prognosis for some metastatic cancers.

If breast cancer comes back after chemotherapy or doesn’t respond to chemotherapy medicines, you can try a different combination of medicines. There are many chemotherapy medicines, and if one medicine or combination of medicines doesn’t work, there is almost always something else you can try.

 
 
 

Radiation therapy

If you’ve been diagnosed with metastatic breast cancer and are having symptoms, your doctor may recommend radiation to:

  • control the cancer in a specific area

  • ease pain

  • lower the risk of a cancer-weakened bone breaking

  • reduce internal bleeding or bleeding from the skin caused by tumor invasion

  • open a blocked airway to improve breathing

  • reduce pressure on a pinched nerve

The radiation dose and schedule to treat metastatic breast cancer depends on a number of factors, including:

  • the level of pain or amount of function lost

  • the size of the cancer

  • the location of the cancer

  • the amount of previous radiation you’ve had

  • the schedule for any other treatments

 
 
 

Hormonal therapy

Hormonal therapy medicines — also called endocrine therapy or anti-estrogen therapy — are used to help shrink or slow the growth of hormone receptor-positive metastatic breast cancer.  Hormonal therapy medicines include:

  • tamoxifen

  • Arimidex (chemical name: anastrozole)

  • Aromasin (chemical name: exemestane)

  • Femara (chemical name: letrozole)

  • Faslodex (chemical name: fulvestrant)

Hormonal therapy does not work on hormone receptor-negative breast cancer.

Hormonal therapy medicines treat hormone receptor-positive breast cancers in two ways:

  • by lowering the amount of the hormone estrogen in the body

  • by blocking the action of estrogen in the body

For women, the American Society of Clinical Oncologists (ASCO) recommends hormonal therapy based on cancer stage and menopausal status. ASCO recommends that post-menopausal women diagnosed with metastatic hormone receptor-positive breast cancer consider taking an aromatase inhibitor (Arimidex, Aromasin, or Femara). For pre-menopausal women, ASCO recommends taking tamoxifen or an aromatase inhibitor. If the cancer stops responding to an aromatase inhibitor or tamoxifen, people can consider Faslodex.

For men diagnosed with hormone receptor-positive, metastatic breast cancer, ASCO recommends any of the hormonal therapy medicines as the first treatment.

You usually take hormonal therapy to treat metastatic hormone receptor-positive breast cancer for as long as it works. If the cancer stops responding to one hormonal therapy medicine, doctors usually recommend a different hormonal therapy medicine.

After any period of time from a few months to several years, the cancer may progress while you’re taking hormonal therapy. Your doctor may then recommend chemotherapy. If you start chemotherapy, your doctor may have you stop taking hormonal therapy. Your doctor also may recommend targeted therapies if they’re appropriate for your specific situation.

 
 
 

Targeted therapy

Targeted therapies are treatments that target specific characteristics of cancer cells, such as a protein that allows the cancer cells to grow in a rapid or abnormal way. Targeted therapies are generally less likely than chemotherapy to harm normal, healthy cells. Some targeted therapies are antibodies that work like the antibodies made naturally by our immune systems. Because of this, they are sometimes called immune-targeted therapies.

 
 
 

Immunotherapy

Cancer immunotherapy medicines work by helping your immune system work harder or more efficiently to fight cancer cells.

Your immune system is made up of a number of organs, tissues, and cells that work together to protect you from foreign invaders that can cause disease. When a disease- or infection-causing agent, such as a bacterium, virus, or fungus, gets into your body, your immune system reacts and works to kill the invaders. This self-defense system works to keep you from getting sick.

Immunotherapy uses substances — either made naturally by your body or man-made in a lab — to boost the immune system to:

  • stop or slow cancer cell growth

  • stop cancer cells from spreading to other parts of the body

  • be better at killing cancer cells

 
 
 

Local treatments for areas of distant metastasis

Local treatments for distant areas of metastasis — such as the bones, lungs, brain, or liver — are directed to those locations. Although local treatments aren’t usually the first choice to treat metastatic breast cancer, doctors do recommend them under certain circumstances:

  • Local treatments can help alleviate pain or other symptoms caused by metastatic breast cancer that can affect quality of life. The most common example of local treatment is medication to control bone metastasis. Others include surgery to remove the cancer or focused radiation to destroy it.

  • Local treatments can be effective when there are just one or two areas of metastasis and doctors believe they can completely remove the cancer, possibly preventing future problems.

Your medical team can work with you to make the best plan that is right for you and your specific situation.

You may be a candidate for local treatment of distant metastasis if:

  • metastatic breast cancer is causing pain or other symptoms that are affecting your day-to-day life and function

  • you have just one or two areas of metastasis and doctors believe they can completely remove the cancer, possibly preventing future problems (this is called oligometastatic disease)

Metastatic breast cancer can affect functioning when:

  • tumors press on critical areas of the brain or spinal cord

  • bone metastases weaken the bone so much that it is poses a risk of fracture

  • lesions in the lung make it hard to breathe

  • tumors interfere with normal liver function

The goal of local therapies is to improve these symptoms and prevent the cancer from causing further problems.

Some doctors also consider local treatments for carefully selected people with metastatic breast cancer who aren’t experiencing major symptoms. If you’re generally feeling well and have just one or two cancerous growths in one area of the body, local treatment may be an option. When making this decision, it makes sense to ask your medical team about whether the potential benefit — getting rid of those growths — is likely greater than the risk of side effects from the treatment. Since there is currently no cure for metastatic breast cancer, the goal of many treatment strategies is to increase the odds of a long period in which there is no evidence of disease (NED), which people often called remission.

If you’re in this situation, you can use the following questions to help guide your discussion with your doctor:

  • Your overall health and level of function: How healthy do you feel? How well are you functioning? Are you able to be fairly active during the day and engage in normal activities?

  • Whether you’re age 65 or older: Do you have any age-related health conditions or complications?

  • The extent of the cancer: Is the breast cancer in one area or many? If just one area, do you have one growth or a few? How large are the areas? Local treatment may be an option if there are one or two small tumors in a single area.

  • The cancer’s characteristics: Less aggressive cancers — such as those that are estrogen receptor-positive or low-grade — tend to be more treatable.

  • Likelihood of complete removal (if surgery is being considered): Is it likely that all of the cancer can be removed if you have surgery?

  • Time between your original diagnosis of breast cancer and diagnosis with metastasis: If you were successfully treated for an earlier-stage breast cancer in the past, how much time passed before you were diagnosed with a metastatic recurrence? Did you have at least a few years with no evidence of disease before metastases appeared? In general, how well has the breast cancer responded to treatment until now?

If your doctor recommends local treatments either for symptom relief or cancer control, another specialist — such as a radiation oncologist, an interventional radiologist, or a surgeon — may join your medical team so you can all come up with a treatment plan.

 

Clinical trials for metastatic breast cancer

Clinical trials are research studies in which people volunteer to try a new drug under careful supervision to help doctors find out if it’s safe and effective. By joining a clinical trial, you can potentially try a treatment that isn’t otherwise available and that might be beneficial for you. These studies help improve the overall standard of care.

Learn more
 

What happens if treatment stops working?

In some cases, a treatment may stop working and the cancer may start growing. If this happens, you and your doctor will talk about other treatment options.

Learn more
 

Make exercise part of your treatment plan

Many organizations, including the American Cancer Society, recommend that people diagnosed with cancer complete 150 minutes per week of moderate exercise or 75 minutes per week of vigorous exercise, plus two sessions per week of strengthening and flexibility/stretching movements. Research has shown that these same recommendations are safe and effective for people diagnosed with metastatic disease, including metastatic breast cancer.

Learn more
 

Expanded Access and Right to Try: Alternative paths to experimental treatments for metastatic breast cancer

If you would like to find out whether there’s an experimental drug that could be beneficial for you, talk to your medical team. Make sure that you’ve thoroughly researched whether there are any clinical trials you can join. In most cases, you won’t be eligible to request an experimental drug through Expanded Access or Right to Try unless participating in a clinical trial is not possible for you.

Learn more

Doctors recommend enrolling in a clinical trial if you’re eligible since your participation helps advance treatments for breast cancer and, by participating, you receive extra medical attention and monitoring of side effects during the trial.

— Last updated on August 17, 2022, 12:47 PM