Metastatic Breast Cancer

Treatment Strategies

The goal of treatment for metastatic breast cancer is to control the growth of disease for as long as possible and to maintain quality of life. Many treatment options are available, and the treatment for an individual woman depends on many factors, including:

  • The site or sites of metastasis
  • The hormone receptor and HER2 status of the cancer
  • Whether the disease is progressing rapidly or slowly
  • Your age, overall health and menopausal status
  • The time since your initial diagnosis and treatment (if the metastasis is recurrent cancer)

Even though metastatic cancer involves cancer in an organ other than the breast, the cancer cells are still breast cancer cells, which means the same treatments used for earlier-stage breast cancer are used for meta-static disease. These treatments include hormone therapy, surgery, targeted therapy, chemotherapy and radiation therapy. However, these treatments are often used for different purposes or with different goals.

Surgery or radiation therapy is typically not used as part of treatment for metastatic breast cancer. When they are used, it’s usually to relieve symptoms or to prevent complications.

Types of treatment

Hormone therapy

Hormone therapy, also known as endocrine therapy, is the recommended first choice for women with metastatic breast cancer that tests positively for estrogen and/or progesterone receptors (ER+ and/or PR+). Hormone therapy is also sometimes recommended if the hormone receptor status is not certain or is negative. This treatment is effective at slowing the growth of metastasis because it works by blocking the action or decreasing the amount of estrogen or progesterone, the very substances that fuel the growth of breast cancer cells in your body.

Several types of drugs can be used for hormone therapy, and they differ in how they work, who they can be used for, and what side effects they can cause. Your doctor will consider several factors when recommending the best type of hormone therapy for your particular case, including whether you are premenopausal or postmenopausal and whether you have received hormone therapy as a previous treatment for earlier-stage breast cancer (Table 1). Your doctor will discuss the advantages and disadvantages of these drugs so that you can decide together which treatment course is best for you.

Table 1. Hormone therapy options for metastatic breast cancer

Menopausal status Hormone therapy options
Postmenopausal
Aromatase inhibitors:
     anastrozole (Arimidex),
     Ietrozole (Femara),
     exemestane (Aromasin)
Selective estrogen-receptor modulator:
     tamoxifen (Nolvadex),
     toremifene (Fareston)
Fulvestrant (Faslodex)
Progestin (megestrol acetate, Megace)
High-dose estrogen (ethinyl estradiol)
Androgen (male hormone):
     fluoxymesterone
     (Halotestin)
Premenopausal
Tamoxifen
Luteinizing hormone receptor hormones
     (LHRHs): goserelin (Zoladex), 

     luprolide (Lupron)
Progestin (megestrol acetate, Megace)
High-dose estrogen (ethinyl estradiol)
Androgen (male hormone):
     fluoxymesterone (Halotestin)

Chemotherapy

Traditional chemotherapy is another option to treat metastatic breast cancer, especially if the cancer is ER-negative or PR-negative or if the cancer progresses during hormone therapy. Many chemotherapy drugs are options for treating metastatic breast cancer. Chemotherapy is sometimes given as a single drug and sometimes as a combination of two or three drugs, either given together or one after another (see Table 2). Your doctor will discuss the advantages and disadvantages of these drugs so that you can decide together which treatment course is best for you.

Table 2. Chemotherapy options for metastatic breast cancer

Type of cancer Chemotherapy agent or combination
  Generic name Brand name (Abbreviation)
HER2- Often-used single agents  
  doxorubicin Adriamycin
epirubicin Ellence
liposomal doxorubicin Doxil
paclitaxel Taxol
docetaxel Taxotere
protein-bound paclitaxel Abraxane
capecitabine Xeloda
gemcitabine Gemzar
vinorelbine Navelbine
eribulin Halaven
Other single agents  
cyclophosphamide Cytoxan
mitoxantrone Novantrone
cisplatin  
carboplatin  
etoposide VePesid
vinblastine Velban
fluorouracil (5-FU) Adrucil
methotrexate various products
ixabepilone Ixempra
Often-used combinations  
cyclophosphamide, doxorubicin, fluorouracil (CAF/FAC)
fluorouracil, epirubicin, cyclophosphamide (FEC)
doxorubicin, cyclophosphamide (AC)
epirubicin, cyclophosphamide (EC)
doxorubicin and docetaxel or paclitaxel (AT)
cyclophosphamide, methotrexate (Folex), fluorouracil (CMF)
docetaxel and capecitabine  
gemcitabine, paclitaxel (GT)
Other combinations  
ixabepilone and capecitabine  
HER2+ trastuzumab plus preferred agents  
  pertuzumab (Perjeta) and docetaxel  
pertuzumab and paclitaxel (not approval indication)  
trastuzumab plus other agents  
paclitaxel (alone or with carboplatin)  
docetaxel  
vinorelbine  
capecitabine  
HER2+, previously treated with trastuzumab    
  lapatinib (Tykerb) and capecitabine  
trastuzumab and capecitabine  
trastuzumab and lapatinib  
trastuzumab and other agents  

Targeted therapy

Targeted therapy is treatment directed at genes, proteins or other substances that contribute in some way to the growth and development of cancer cells. Targeted therapy is personalized treatment, tailored to the individual characteristics of the breast cancer cells in your body. These agents slow the progression of metastatic disease by blocking signals from various proteins that stimulate the growth of new cells. Blocking the signals slow any new growth of cancer cells.

Various targeted therapy drugs have been approved for breast cancer (see Table 3):

  • Some approved medications are known as anti-HER2 agents because they inhibit HER2; only tumors that are HER2+ can respond to an anti-HER2 agent.
  • Another is the first in a class known as mTOR (mammalian target of rapamycin) inhibitors, which blocks a type of protein that helps all cells – both healthy and cancerous – get the energy they need. When these proteins don’t act normally, they can help certain breast cancers grow. This drug has been approved for postmenopausal women with advanced hormone-receptor positive, HER2- breast cancer.

Table 3. Targeted therapy options for metastatic breast cancer

Targeted therapy agent Type of metastatic breast cancer Approved/recommended treatment Notes
trastuzumab (Herceptin) HER2+ In combination with paclitaxel for first-line treatment
 
As a single agent after failure of one or more chemotherapy regimens
Approved for use in 1998
lapatinib (Tykerb) HER2+ In combination with capecitabine after failure of anthracyclines, taxanes (paclitaxel or docetaxel) and trastuzumab Approved for use in 2007
HER2+ and hormone receptor positive In combination with letrozole (Femara) Approved for use in 2010
pertuzumab (Perjeta) HER2+ In combination with trastuzumab and docetaxel Approved for use in 2012
ado-trastuzumab emtansine (Kadcyla) HER2+ As a single agent after failure of trastuzumab and taxanes Approved for use in 2013
everolimus (Afinitor) Hormone receptor positive, HER2- In combination with exemestane (Aromasin) Approved for use in 2012

Resistance to treatment

Resistance – when breast cancers that have been responding to therapy begin to grow again – may be caused by several factors. Sometimes it is common after particular types of drugs (for example, anthracyclines, hormone therapies and taxanes) and sometimes it occurs after long-term exposure to a certain drug.

Researchers have begun to focus on how to overcome resistance, and some combinations of different kinds of drugs – such as a targeted drug and a chemotherapy drug – delay the time to disease progression. Researchers are also evaluating the order drugs are given in – known as sequential treatment – to see if one order produces better results than another. At the same time, research is ongoing to learn how breast cancer cells become resistant so that new drugs can be developed to overcome resistance and offer new options to women with breast cancer.

Choosing treatment

Choosing a treatment can be challenging because of the number of options, but if the first treatment doesn’t work, other treatments can be tried. Your doctor will talk to you about the various options for your particular type of breast cancer, and you should learn as much as you can about each option.

In deciding on a treatment, it’s important to think about your personal priorities. Some women want the most aggressive treatment available, and other women want to focus on supportive care. Communicate your priorities to your doctor. While he or she will make recommendations, the final decision is yours. Note, too, that your priorities may change over time as you continue through treatment, so talk to your doctor about these changes.

Some women prefer to take a break from treatment if disease has stabilized and their quality of life is good. If you think you may wish to do this, talk to your doctor about the benefits and risks. If you do take a break, you can always resume treatment when you feel ready or if the disease starts to progress.

The choice to stop treatment permanently is not an easy one, but at some point, it may seem like the right decision for you. If you decide to stop treatment directed at the metastatic disease, it is important to receive palliative care, or treatment that is designed to help you live more comfortably. You should consider receiving palliative care as part of hospice care. Most people misunderstand hospice care and do not appreciate its value. Hospice is not about dying; it’s about living with a higher quality of life. Hospice care can often be delivered in your own home and provides pain relief and other supportive care as well as psychological, spiritual and logistical support for you and your family and help with daily living tasks. Most people have reported that once they started hospice care, they regretted not choosing it sooner.

Clinical trials

New treatments and combinations of treatment for metastatic breast cancer are being evaluated in clinical trials. All women with metastatic breast cancer should talk to their doctor about the possibility of participating in a clinical trial. Participating is a personal decision, so carefully weigh all the options before making this decision.

You can search for clinical trials on a number of websites:

Additional Sources of Information

 

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