Advanced Breast Cancer

Treatment Options

Ongoing medical research and scientific discoveries continue to lead to more and better therapies for people diagnosed with advanced breast cancer. At this time, the disease is not yet considered curable, so you can plan to receive some form of treatment or related care from now on. Your medical team’s focus will be to slow the cancer’s growth, stop its progression and/or shrink tumors while minimizing side effects and helping you live your best life.

“Best quality of life” means different things to different people. Is it feeling well enough to continue to work? Finding a regimen that allows you to travel extensively? Taking treatment at home instead of receiving it at a medical facility? As your doctor outlines treatment options, ask about the potential side effects of each therapy and how likely such symptoms are to occur so you can weigh the benefits against the risks. Share your expectations of how you envision your day-to-day routine and how the side effects fit in with continual treatment.

Many Factors Shape Treatment Plan

Sharing your wishes can also help your doctor tailor your treatment plan, which is based on many considerations.

  • Cancer type and tumor subtype
  • Location(s), number and extent of cancer metastases in the body
  • Presence or absence of specific biomarkers and genetic markers
  • Menopausal status
  • Previous cancer treatments
  • General health status
  • Your personal preferences

A major factor will be whether biopsied cells from your tumor test positive or negative for receptors for estrogen, progesterone or a protein called the human epidermal growth factor-2 (HER2). Estrogen and progesterone are hormones that naturally circulate in your body, and HER2 is a protein involved in cell growth.

When tumor cells test positive for one or both hormones (ER+ and/or PR+), that means hormones are fueling the cancer’s growth. A positive result for HER2 testing (HER2+) indicates this protein is being overexpressed and is encouraging cancer growth. Blocking hormone receptors and HER2 receptors can be highly effective in slowing cancer growth or stopping progression, and drug therapies have been developed to target different combinations.

In some cases, biopsied tumor cells may test negative for all three biomarkers (ER-, PR- and HER2-), which is referred to as triple negative breast cancer.

Your treatment plan may include therapy combinations and solutions to help you manage side effects. Your regimen may change fairly often depending on the effectiveness and side effects of the treatment, or it may remain the same for many months or years. Your comfort and well-being are primary concerns, so report pain or other side effects that interfere with your quality of life immediately to your health care team so these issues can be addressed.

Types of Medications

Drug therapies are systemic, which means they travel throughout the body. You may receive them through an IV into a vein, through a port in your body, as an injection (shot) or orally as a pill or liquid.

Hormone therapy, also called endocrine therapy, reduces or blocks the stimulating effect of estrogen on the tumor cell and is the primary choice to treat cancer that is estrogen- and/or progesterone-receptor positive (ER+/PR+). It is sometimes used in combination with other types of treatment. Hormone therapy is not effective for cancer that is ER-/ PR- because this indicates cancer growth isn’t driven by hormones. Following are various types of hormone therapy that may be used.

  • Antiestrogens are substances that keep cells from making or using estrogen. They may stop some cancer cells from growing or even destroy them.
  • Aromatase inhibitors are drugs that prevent estradiol, a female hormone, from forming by interfering with an aromatase enzyme. They may benefit postmenopausal women with hormone-dependent breast cancer or younger women whose ovarian function is blocked by drugs or who’ve had their ovaries removed.
  • Hormones are made by glands, circulate in the bloodstream and control the actions of certain cells or organs. High doses may be used to stop cancer growth. Estrogen and synthetic androgens (similar to male hormones) are sometimes used to manage metastatic symptoms but are not used as often as aromatase inhibitors.
  • Ovarian suppression can stop the ovaries from making hormones that promote cancer growth in ER+/PR+ cancers. Although this can be achieved surgically, drugs called luteinizing hormone releasing hormone (LHRH) agonists are typically used instead. For premenopausal women, these drugs provide an equivalent alternative to removing the ovaries.

Chemotherapy includes powerful drugs to kill rapidly multiplying cells throughout the body. It can be given as a single drug, combined with other chemotherapy drugs or combined with other types of treatment. It is most often used to treat ER-/PR- cancers or ER+/PR+ cancers that no longer respond to hormone therapy. It is also used to treat HER2+ cancers when combined with certain targeted therapy drugs. It may also be used before or after surgery or to help control symptoms caused by the tumor.

Targeted therapy uses drugs or other substances to identify and attack specific types of cancer cells to destroy the tumor cells or to slow disease progression. Some are designed to interfere with the cancer cells’ internal functions; others attack specific receptors on the cancer cells’ surfaces; and some target the blood vessels that supply the tumor. Targeted therapy is typically used for HER2+ breast cancer and is usually combined with chemotherapy. Other targeted therapy drugs are sometimes used in combination with hormone therapy to treat ER+ or PR+ breast cancers or HER2- breast cancer with the breast cancer 1 or 2 mutations (BRCA1 or BRCA2).

Following are types of targeted therapies that may be used.

  • Anti-HER2 drugs are laboratory-made proteins that can bind to cancer cells. They can be used alone or to carry drugs, toxins or radioactive substances directly to cancer cells. These drugs are often given with chemotherapy for ER+/PR+ and/or HER2+ breast cancer.
  • Kinase inhibitors target cancer cells’ ability to grow and survive by targeting kinases, which are enzymes that speed up chemical reactions in the body. They can be designed to attack enzymes within a cell, proteins or enzymes needed for a cell’s growth, or receptors on the cell’s surface.
  • Poly (ADP-ribose) polymerase (PARP) inhibitors work by keeping cancer cells from repairing themselves once they’ve been targeted and damaged by cancer treatment.
Commonly Used Medications (as of 10/8/19)
Chemotherapy
capecitabine (Xeloda)
carboplatin (Paraplatin)
cisplatin
cyclophosphamide
docetaxel (Taxotere)
doxorubicin (Adriamycin)
epirubicin (Ellence)
eribulin (Halaven)
fluorouracil – also known as 5-FU
gemcitabine (Gemzar)
ixabepilone (Ixempra)
liposomal doxorubicin (Doxil)
paclitaxel (Taxol)
protein-bound paclitaxel (Abraxane)
vinorelbine (Navelbine)
Hormone Therapy
PREMENOPAUSAL
Antiestrogen
  • tamoxifen
Hormones
  • fluoxymesterone
  • megestrol acetate (Megace)
LHRH Agonists
  • goserelin acetate (Zoladex)
  • leuprolide acetate (Eligard, Lupron, Lupron Depot)
POSTMENOPAUSAL
Antiestrogens
  • fulvestrant (Faslodex)
  • tamoxifen
  • toremifene (Fareston)
Aromatase Inhibitors
  • anastrozole (Arimidex)
  • exemestane (Aromasin)
  • letrozole (Femara)
Hormones
  • ethinyl estradiol
  • fluoxymesterone
  • megestrol acetate (Megace)
Targeted Therapy
Anti-HER2 Agents
  • ado-trastuzumab emtansine (Kadcyla)
  • lapatinib (Tykerb)
  • pertuzumab (Perjeta)
  • trastuzumab (Herceptin)
  • trastuzumab-anns (Kanjinti)
  • trastuzumab-dkst (Ogivri)
  • trastuzumab-dttb (Ontruzant)
  • trastuzumab-pkrb (Herzuma)
  • trastuzumab-qyyp (Trazimera)
  • trastuzumab and hyaluronidase-oysk (Herceptin Hylecta)
Kinase Inhibitors
  • abemaciclib (Verzenio)
  • alpelisib (Piqray)
  • palbociclib (Ibrance)
  • ribociclib (Kisqali)
  • ribociclib and letrozole (Kisqali Femara Co-Pack)
PARP Inhibitors
  • everolimus (Afinitor, Afinitor Disperz)
  • olaparib (Lynparza)
  • talazoparib (Talzenna)

Local Therapies Relieve Symptoms

These therapies focus on cancer in one location.

Radiation therapy uses high-energy X-rays to kill cancer cells or keep them from growing. The most common type is external beam radiation therapy (EBRT), in which a machine targets radiation beams to specific spots on the body. It is rarely used as a primary treatment but may be recommended to help with pain management or to reduce the size of tumors causing discomfort. If cancer has metastasized to the brain, whole brain radiation, stereotactic radiosurgery or fractionated stereotactic radiotherapy may be used.

Surgery is not typically a primary treatment for advanced breast cancer but may be an option to alleviate pain related to metastases in the brain, spine or lungs. When cancer has metastasized to the bones, surgery may help support or stabilize weakened or broken bones with the help of pins, screws, rods, plates or other devices. Clinical trials are researching whether surgically removing the primary breast tumor in patients with distant metastases will extend life longer than using other therapies to treat it.

Bone-strengthening drugs or bone-modifying agents may be used to prevent or delay bone fractures, in addition to systemic treatment or radiation therapy, when breast cancer has spread to the bones.

  • Bisphosphonates slow the loss of bone mass caused by cancer or its treatments.
  • Radiopharmaceuticals give off low-level radiation intended to travel directly to the spot where cancer has metastasized.
  • Targeted therapy inhibits a protein responsible for bone loss; it can help increase bone mass and strengthen bones.

Clinical trials: A Key Consideration

Clinical trials may provide opportunities to receive treatments that are not yet available to the general public. Extensive research is underway to study the effectiveness of new types of therapies, combinations of therapies, drugs targeted at additional biomarkers and genetic markers, and improved treatments for managing various side effects. Scientists are also addressing treatment resistance by exploring drug combinations and evaluating the order in which drugs are given (sequential treatment).

Clinical trials are conducted across the United States and in other parts of the world. To participate, you must meet certain trial specific qualifications, such as having certain biomarkers or genetic markers, location of metastasis and past history with cancer treatments. Clinical trial options may vary between doctors and cancer centers, so don’t hesitate to talk with experts at other locations about these important studies. You can also search for clinical trials on your own online.

Resistance

Resistance occurs when breast cancers that were responding to treatment begin to grow again. Ongoing cancer research is seeking to better understand the factors that contribute to resistance and to overcome these obstacles. The promising news is that if disease progresses during treatment, a different drug may be an option and may be highly effective.

Listen to Your Heart to Choose the Right Path

Continually undergoing treatment can be physically and emotionally challenging. You may feel you need a break, or you might be in a really good place and choose to stop treatment for a while. Talk with your doctor to ensure you understand the pros and cons of interrupting your treatment plan, even for a short time.

Your family, friends, fellow survivors and others will likely weigh in with their opinions, but the decision is yours to make. Consider how treatments and related side effects fit into your idea of a good quality of life, as this may affect your decision to continue or forgo treatment. Share your feelings with your doctor if you reach a point that you no longer want to continue treatment. Should you make that difficult decision, you are strongly encouraged to explore hospice care. These specialized services focus on alleviating pain, maximizing comfort and supporting you and your loved ones physically, emotionally and spiritually.

This care can take place in your home, at a hospice center or in most hospitals. Hospice professionals are extensively trained to help you and your family with advance planning for your end-of-life care to help ensure it will be exactly on your terms. Having such a plan in place can help reduce fear and stress for you and your loved ones.

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