Advanced Breast Cancer

Overview

Learning you have advanced breast cancer can be overwhelming. A Stage IV diagnosis is difficult to process, and it is important to give yourself time to absorb this news before making any decisions. Keep in mind that although a cure is not yet available, research advances are making it possible for more people with this diagnosis to live longer, higher-quality lives.

What is Metastatic Breast Cancer?

Advanced breast cancer is also referred to as metastatic breast cancer and is classified as Stage IV because it has metastasized, or spread, beyond the breast and nearby lymph nodes (see Staging). Malignant (cancerous) cells that began in breast tissue have broken away and traveled through your bloodstream or lymph vessels to one or more distant sites in your body. The most common are the bones, lungs, brain or liver. No matter where it spreads, it is still considered breast cancer and will be treated with breast cancer therapy.

Stage IV disease may be detected in a follow- up exam after treatment for early-stage breast cancer or because of new symptoms. If this is true for you, understand that nothing you did (or didn’t do) brought on this recurrence. A second primary breast cancer is not metastatic breast cancer. It is a new diagnosis. It’s also important to know that your experience will be different than before, when there was an end date to active treatment. The goal of treatment will now be to slow the cancer’s growth, or stop its progression, for as long as possible while keeping side effects manageable. It is likely you will receive treatment continually. Your doctor will use one treatment strategy until the cancer stops responding or starts to progress, or until side effects become too difficult to tolerate. Therapy will then be adjusted or stopped, and your doctor will discuss other options.

Frequent medical appointments and tests will become part of your routine. They help your doctor monitor for signs of cancer progression, symptoms of serious side effects and changes in your general health (see Monitoring Your Cancer).

With Knowledge Comes Confidence

Learning all you can about your diagnosis can be empowering and will better prepare you for making shared treatment decisions with your doctor. Actively participating in the direction of your care also offers you a much-needed level of control.

As you research using the reliable resources in this guide, you’ll discover advanced breast cancers aren’t all the same. More than 20 types, as well as subtypes, have been identified, and researchers continue to find differences in the ways these breast cancers grow and respond to treatment. Some examples of particular breast cancer histopathologic patterns (the appearance of diseased cells and tissue under a microscope) are described below, and any of these have the potential for metastasizing. The biomarker/molecular marker expression is critical in defining treatment, regardless of the histopathology.

  • Invasive ductal carcinoma is the most common. It starts in the lining of the milk ducts in the breast when abnormal cells grow out of control, forming a mass that spreads to normal breast tissue.
  • Invasive lobular carcinoma, the second most common, starts in the milk producing lobules (glands that make milk) and spreads to surrounding normal tissue.
  • Inflammatory breast cancer (IBC) is a rare, very aggressive form that grows rapidly and is automatically classified as Stage III or Stage IV, depending on whether it has spread. IBC tends to spread quickly, making it challenging to treat. Most cases are invasive ductal carcinomas in which cancer cells block the lymph vessels, causing the lymph fluid to build up. This results in breast tenderness, swelling, redness and pain. Breast skin can thicken and appear pitted like an orange peel. Some experts believe IBC occurs more often than statistics suggest but is misdiagnosed due to its atypical symptoms.

Your subtype is characterized by the biomarker and/or gene expression profile of your tumor, regardless of histopathologic pattern. It will help your doctor determine which therapies may be most effective in slowing the cancer’s growth or stopping progression. Your type and subtype should be noted in your pathology report, so ask your doctor about them and about anything else that isn’t clear to you. Don’t hesitate to ask for information to be repeated or written down.

Subtypes are based on specific hormones and proteins that may be found on and in breast cancer cells. They include the hormone receptors estrogen (ER) and progesterone (PR), as well as receptors for human epidermal growth factor-2 (HER2). Each can be positive (ER+, PR+ and HER2+) or negative (ER-, PR- and HER2-) in various combinations (see Table 1). Most advanced breast cancers are HER2-. Learn about a subtype called triple negative breast cancer.

For many years, genetic testing for certain inherited gene mutations, such as BRCA1 and BRCA2, helped people determine if they and their family members may be at increased risk for breast cancer. Today, doctors also use genetic testing to guide treatment for advanced breast cancers.

Table 1. Receptor and Treatment Response

Receptors Likely treatment response
ER+ and/or PR+, HER2- Typically responds to hormone (anti-estrogen) therapy
ER+ and/or PR+, HER2+ Typically responds to hormone therapy and anti-HER2 drugs (targeted therapy)
ER-/PR-, HER2+ Typically does not respond to hormone therapy but typically will respond to anti-HER2 drugs
ER-/PR-, HER2- (triple negative) Typically treated with chemotherapy, as response to hormone therapy and anti-HER2 drugs is less likely

 

Your Health Care Team

Some people diagnosed with metastatic breast cancer describe members of their health care team as “like family.” It’s essential to locate a doctor/treatment center with expertise in treating your type or subtype of metastatic breast cancer and access to leading-edge treatments and clinical trials. Because you will work together closely, your doctor’s manner, communication style and treatment philosophy should be a good fit for you. If not, don’t hesitate to choose another oncologist. Ask your general practitioner, friends or cancer advocacy groups for recommendations.

Consider getting a second or even third opinion about your diagnosis and treatment options. This doesn’t mean you doubt your current oncologist. It simply means you want as many informed opinions as possible before making decisions. Other doctors may have different recommendations depending on their expertise and experience. Most doctors support second opinions, and many cancer facilities offer consultations.

Supportive Care Can Begin at Diagnosis

If you’re not already taking advantage of supportive care, start now. Sometimes called palliative care, these services are designed to provide physical, emotional, practical, financial and spiritual support for you and your loved ones (see Supportive Care). Ask your patient navigator or doctor for more information. A key individual will be your case manager, who can be a great help in understanding and working with the often-complicated health care system. Your case manager, or a social worker if a case manager isn’t on staff, can also provide assistance with insurance related challenges or refer you to someone who can. The ongoing costs associated with treating metastatic breast cancer can often cause financial and emotional stress. Your case manager can arrange a meeting with a financial representative on your health care team to help you get a clear picture of what to expect and find out early about resources that may be available.

Build a Support System

Draw on strength from your family and friends, and explore the advanced breast cancer community. It is close-knit and resilient, dedicated to ensuring that no one has to go through this diagnosis alone. Ask your patient navigator about local and online support groups and advocacy organizations.

Some have peer-to-peer programs that match you with a phone friend who shares your diagnosis and understands what you’re feeling in a way that loved ones who haven’t experienced metastatic cancer simply can’t.

 

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