TREATMENTS FOR METASTATIC BREAST CANCER | metastatic breast cancer treatment

What is metastatic breast cancer?

metastatic breast cancer treatment. Metastatic breast cancer (also called stage IV or advanced breast cancer) is not a specific type of breast cancer, but rather the most advanced stage of breast cancer.

Metastatic breast cancer is breast cancer that has spread beyond the breast to other organs in the body (most often the bones, lungs, liver or brain).

Although metastatic breast cancer has spread to another part of the body, it’s considered and treated as breast cancer.

For example, breast cancer that has spread to the bones is still breast cancer (not bone cancer) and is treated with breast cancer drugs, rather than treatments for a cancer that began in the bones.

It’s estimated that at least 154,000 people in the U.S. have metastatic breast cancer [65]. Some women have metastatic breast cancer when they are first diagnosed (called de novo metastatic breast cancer). However, this isn’t common in the U.S. (6 percent of diagnoses) [1-2].

More commonly, metastatic breast cancer arises months or years after a person has completed treatment for early or locally advanced (stage I, II or III) breast cancer. This is sometimes called a distant recurrence.

The risk of metastasis after breast cancer treatment varies from person to person. It depends greatly on:

The biology of the tumor
The stage at the time original diagnosis
The treatments for the original cancer (trying to prevent recurrence)

Learn more about breast cancer staging.

Learn more about breast cancer recurrence.

metastatic breast cancer treatment

As hard as it may be to hear, metastatic breast cancer cannot be cured.

Unlike breast cancer that remains in the breast or nearby lymph nodes, you cannot get rid of all the cancer that has spread to other organs.

However, this doesn’t mean metastatic breast cancer can’t be treated.

Treatment of metastatic breast cancer focuses on length and quality of life.

Your treatment plan is guided by many factors, including:

Characteristics of the cancer cells
Where the cancer has spread
Your symptoms
Past breast cancer treatments

If the cancer is hormone receptor-positive, the first treatment is hormone therapy.

If the cancer is HER2-positive, anti-HER2 drugs such as trastuzumab (Herceptin) may be given.

Chemotherapy and radiation therapy can be used to shrink or slow the growth of tumors or to ease symptoms of the cancer itself. However, these therapies have side effects that can affect quality of life.

Learn more about factors that affect treatment options.

Learn about emerging areas in treatment.

Quality of life

Talking about quality of life issues with your health care providers and your family can help you decide what treatments are best for you.

Joining a support group may also help you think through these issues.

Learn more about quality of life.

Learn about symptom management and supportive care.

Learn about pain management.

Learn about support.

Treatment metastatic breast cancer treatment guidelines

Although the exact treatment for metastatic breast cancer varies from person to person, guidelines help ensure high quality care. These guidelines are based on the latest research and agreement among experts.

The National Comprehensive Cancer Network (NCCN) and the American Society of Clinical Oncology (ASCO) are two respected organizations that regularly review and update their guidelines.

In addition, the National Cancer Institute (NCI) has treatment overviews.

Talk with your health care providers about which treatment guidelines they use. Since there’s often a lag time between the latest research and guideline updates, most providers prefer to base their treatment on the latest research.

metastatic breast cancer treatment - Prognosis

Survival rates for metastatic breast cancer vary greatly from person to person, but overall, have improved over time.

Of the women who have metastatic breast cancer in the U.S. today, it’s estimated that 34 percent have had metastatic cancer for at least 5 years [65]. So, they’ve lived at least 5 years since being diagnosed with metastatic breast cancer. Modern treatments continue to improve survival for women diagnosed today. In fact, some women may live 10 or more years beyond diagnosis [4].

Learn more about survival statistics.

Monitoring metastatic breast cancer

Tumors often become resistant (stop responding) to drugs used to treat metastatic breast cancer.

Drug resistance

Some metastatic breast cancer cells need specific proteins or cell pathways to grow. Drugs that target the proteins or pathways can slow or stop the growth of these cancer cells for a period of time.

You can think of the proteins as traffic signs and the pathways as roads. Breast cancer cells must pass through the signs to continue along the road.

If the cancer cell hits a roadblock (such as a drug that targets the protein), it cannot continue down that pathway.

At some point however, the cancer cell finds a detour around the roadblock and uses another pathway to continue to grow.

Monitoring

If you have metastatic breast cancer, you’ll be monitored every few months to see if the cancer is responding to treatment.

These tests may include a physical exam, blood tests and/or imaging tests (such as an X-ray, CT scan, PET scan or bone scan) to see if the cancer is responding to the treatment. This is called “restaging.”

Because metastatic breast cancers often develop resistance to drugs, it’s common to change therapies fairly often.

You usually start one drug therapy and see whether:

The treatment controls the growth of the cancer
The side effects of the treatment can be managed

If the treatment is working (and you can deal with the side effects) at the time of restaging, then the treatment is typically continued.

If the treatment is no longer working or if you are having a lot of side effects, then you may be advised to switch to a different drug.

Blood tests for tumor markers

In some cases, blood tests for tumor markers may be used to help monitor metastatic breast cancer.

For example, you may be tested every few months for cancer antigen 15-3 (CA15-3) or cancer antigen 27.29 (CA27.29) [5]. These tests are similar. So, usually one, but not both, of these tests is done.

There is no test score that means the tumor has spread (the cancer has gotten worse).

Rather, whether your personal test score rises or falls over time may give some information on tumor spread.

Tumor marker tests are not helpful in every case. Some people with rising tumor marker levels don’t have tumor growth and some people with tumor growth have normal or unchanged tumor marker levels.

Health care providers don’t make treatment decisions based upon tumor marker testing alone.

Providers may combine findings from a tumor marker test with information on your symptoms and findings from imaging tests (such as bone scans). This combined information can help your providers understand if treatments are helping control tumor growth.

Talk with your provider about whether tumor marker testing is right for you.

metastatic breast cancer treatment - Hormone therapy

Hormone therapy is usually the first treatment for hormone receptor-positivemetastatic breast cancers.

Hormone therapy drugs work by preventing the cancer cells from getting the estrogen they need to grow.

For women, the choice of hormone therapy depends on menopausal statusand any past hormone treatment for early breast cancer [5].

Some hormone therapy drugs (like tamoxifen and aromatase inhibitors) are given in pill form. Others (like goserelin or fulvestrant) are given by injection.

Find a list of hormone therapy drugs used to treat metastatic breast cancer and whether they are given in pill form or by injection.

Learn more about hormone therapies.

Hormone therapy for premenopausal women

For premenopausal women with metastatic breast cancer, hormone therapy almost always begins with ovarian suppression.

Ovarian suppression lowers hormone levels in the body so the tumor can’t get the estrogen it needs to grow. This may involve surgery to remove the ovaries (oophorectomy) or, more often, drugs (such as goserelin or leuprolide) to stop the ovaries from producing hormones.

Tamoxifen is also used to treat metastatic breast cancer in premenopausal women. However, it may not be an option for women whose cancer progressed during past tamoxifen treatment.

Combining ovarian suppression and tamoxifen improves survival over either treatment alone [6-7].

Hormone therapy for postmenopausal women

After menopause, hormone therapy for women with metastatic breast cancer can be an aromatase inhibitor, tamoxifen or another anti-estrogen drug (such as fulvestrant).

If the first hormone therapy stops working and the cancer starts to grow again, a second hormone therapy can be used. If the second drug stops working, another can be tried.

At some point, even though it may be years away, hormone therapy almost always stops working. At this point, chemotherapy may be recommended.

Ovarian suppression isn’t helpful for postmenopausal women because their ovaries have already stopped producing large amounts of estrogen. (Postmenopausal women still make a small amount of estrogen in fat tissue and the adrenal glands.)

Find a list of hormone therapy drugs commonly used to treat metastatic breast cancer.

CDK4/6 inhibitors (abemaciclib, palbociclib and ribociclib) and hormone therapy

CDK4 and CDK6 are enzymes important in cell division. CDK4/6 inhibitors are a class of drugs designed to interrupt the growth of cancer cells.

The CDK4/6 inhibitors abemaciclib (Verzenio), palbociclib (Ibrance) and ribociclib (Kisqali) are FDA-approved for breast cancer treatment. Each drug can be used in combination with hormone therapy to treat hormone receptor-positive, HER2-negative metastatic breast cancers. Abemaciclib may also be used alone to treat these cancers.

Other CDK4/6 inhibitors are under study for use in metastatic breast cancer treatment.

Abemaciclib (Verzenio)

Abemaciclib in combination with hormone therapy (such as fulvestrant, an anti-estrogen drug) is used to treat hormone receptor-positive, HER2-negative metastatic breast cancers that have progressed during past hormone therapy.

Abemaciclib is also used alone to treat hormone receptor-positive, HER2-negative metastatic breast cancers that have progressed during past hormone therapy and chemotherapy.

Study findings have shown abemaciclib alone or in combination with fulvestrant gave women with hormone receptor-positive, HER2-negative metastatic breast cancer more time before the cancer spread compared to fulvestrant alone [67-68].

Abemaciclib is given in pill form.

Side effects of abemaciclib

Possible side effects of abemaciclib include diarrhea, low white blood cell counts, low red blood cell counts (anemia), nausea, abdominal pain, fatigue and vomiting [69].

Palbociclib (Ibrance)

Palbociclib in combination with hormone therapy (such as fulvestrant, an anti-estrogen drug or letrozole, an aromatase inhibitor) is used to treat hormone receptor-positive, HER2-negative metastatic breast cancer.

Study findings have shown that palbociclib in combination with fulvestrant or letrozole can give people more time before the cancer spreads better than letrozole or fulvestrant alone [8-9].

Palbociclib is given in pill form.

Side effects of palbociclib

Possible side effects of palbociclib include low white blood cell counts, low red blood cell counts (anemia), fatigue, nausea, mouth sores, hair thinning, diarrhea and in rare cases, blood clots [8-10].

Ribociclib (Kisqali)

Ribociclib in combination with hormone therapy is used to treat hormone receptor-positive, HER2-negative metastatic breast cancer.

Study findings have shown that ribociclib in combination with letrozole (an aromatase inhibitor) can give people more time before the cancer spreads better than letrozole alone [11].

Ribociclib is given in pill form.

Side effects of ribociclib

Possible side effects of ribociclib include low white blood cell counts, nausea, fatigue, diarrhea, hair loss, vomiting, constipation, headache and back pain [11-12].

In some cases, ribociclib can cause liver problems [12]. So, your liver function will be checked before treatment begins and throughout your treatment.

Everolimus (Afinitor) and hormone therapy

mTOR (mammalian target of rapamycin) inhibitors are a class of targeted therapy drugs that may increase the benefit of hormone therapy.

The mTOR inhibitor everolimus (Afinitor) is FDA-approved for the treatment of hormone receptor-positive, HER2-negative metastatic breast cancers in postmenopausal women.

Studies have shown the combination of everolimus and the aromatase inhibitor exemestane can slow the growth of such cancers better than exemestane alone [7,13-14].

Everolimus is given in pill form.

Side effects of everolimus

Possible side effects of everolimus include mouth ulcers, infections, rash, fatigue, diarrhea, decreased appetite and in rare cases, lung problems [13-14].

metastatic breast cancer treatment - Chemotherapy

Chemotherapy is a first treatment for metastatic breast cancers that are:

Hormone receptor-negative
Hormone receptor-positive, but no longer respond to hormone therapy
HER2-positive (in combination with anti-HER2 treatments)

One benefit of chemotherapy is response time. Chemotherapy may shrink tumors faster than hormone therapy.

As with hormone therapies, if the first chemotherapy drug (or combination of drugs) stops working and the cancer begins to grow again, a second or third drug can be used.

The use of each type of chemotherapy drug (or combination of drugs) for metastatic breast cancer is called a “line” of treatment.

For example, the first chemotherapy used is called the “first-line” treatment and the second is called the “second-line” treatment.

With each line of treatment, it becomes less likely the cancer will shrink. And, if the cancer does shrink, it’s often for a shorter period of time with each new drug.

It’s not uncommon for people to get multiple lines of chemotherapy regimens (often 4 or more) over the course of their treatment for metastatic breast cancer.

Learn more about chemotherapy.

Find a list of chemotherapy drugs commonly used to treat metastatic breast cancer.

Targeted therapy: Anti-HER2 drugs

HER2-positive breast cancer

About 10-15 percent of breast cancers have high amounts of a protein called HER2 on the surface of the cancer cells (called HER2-positive breast cancer) [15]. The HER2 protein is important for cancer cell growth.

HER2 status is determined by testing the tumor tissue.

Trastuzumab (Herceptin)

Trastuzumab (Herceptin) is a specially made antibody that targets HER2-positive cancer cells.

When attached to the HER2 protein, trastuzumab slows or stops the growth of these cells.

Trastuzumab is only used to treat HER2-positive breast cancers.

It can shrink tumors and slow the growth of HER2-positive metastatic breast cancers when used alone or combined with chemotherapy [16-18].

Trastuzumab is given by vein (through an IV).

Side effects and risks of trastuzumab

Trastuzumab has fewer side effects than chemotherapy. It doesn’t cause hair loss, nausea or vomiting, and has no effect on bone marrow.

In rare cases, deaths due to heart or lung problems have been linked to the use of trastuzumab [5,16]. Although the chance of such an event is small, discuss this risk with your health care provider before starting treatment.

Your heart will be checked before and during treatment to help ensure there are no problems.

For a summary of research studies on the use of trastuzumab in treating metastatic breast cancer, visit the Breast Cancer Research Studies section.

Pertuzumab (Perjeta)

Pertuzumab (Perjeta) is an antibody that targets HER2-positive cancer cells, but in a different way than trastuzumab.

Pertuzumab is FDA-approved as a first treatment of HER2-positive metastatic breast cancers.

Study findings have shown pertuzumab in combination with trastuzumab and chemotherapy can slow the growth of HER2-positive metastatic breast cancer and increased survival better than trastuzumab and chemotherapy alone [19].

Pertuzumab is given by vein (through an IV).

Side effects of pertuzumab

Possible side effects of pertuzumab include diarrhea, rash, vomiting, headache and dry skin [19].

Trastuzumab emtansine (T-DM1, Kadcyla)

Trastuzumab emtansine (T-DM1, Kadcyla) is a type of targeted therapy for HER2-positive metastatic breast cancer.

T-DM1 consists of trastuzumab linked to a chemotherapy called DM1. Combining these together allows the targeted delivery of chemotherapy to HER2-positive cancer cells.

T-DM1 is FDA-approved for the treatment of HER2-positive metastatic breast cancers that have progressed on trastuzumab and a taxane-based chemotherapy.

Study findings have shown T-DM1 can increase overall survival better than lapatinib plus the chemotherapy drug capecitabine for women with metastatic HER2-positive breast cancers [20].

T-DM1 is given by vein (through an IV).

Side effects of T-DM1

Possible side effects of T-DM1 include nausea, fatigue, muscle and joint pain, low platelet counts, headache and constipation.

It can also cause liver and heart problems.

It does not usually cause hair loss [21].

Lapatinib (Tykerb)

Tyrosine-kinase inhibitors, such as lapatinib (Tykerb), are a class of drugs that target enzymes important for cell functions (called tyrosine-kinase enzymes).

These drugs can block tyrosine-kinase enzymes at many points along the cancer growth pathway.

Lapatinib is FDA-approved for the treatment of HER2-positive metastatic breast cancer in women who have already had chemotherapy and trastuzumab.

Lapatinib is taken in pill form.

Lapatinib combined with chemotherapy

Compared to chemotherapy alone, chemotherapy combined with lapatinib may give women with HER2-positive metastatic breast cancer more time before the cancer spreads [22-23].

Lapatinib combined with hormone therapy

Compared to use of the aromatase inhibitor letrozole alone, letrozole combined with lapatinib may give women with HER2-positive breast cancer more time before the cancer spreads [24-25].

Lapatinib combined with trastuzumab

Compared to use of trastuzumab alone, trastuzmab combined with lapatinib may give women with HER2-positive breast cancer more time before the cancer spreads [26].

Lapatinib and brain metastases

Many therapies are not as effective at crossing the blood-brain barrier, but early findings show lapatinib holds promise for HER2-positive metastatic cancer with brain metastases since it can pass through the blood to the brain (referred to as the blood-brain barrier) [27-29].

In rare cases, lapatinib can help shrink or slow the growth of brain metastases [27-29].

Side effects of lapatinib

Possible side effects of lapatinib include diarrhea, nausea, vomiting, rash and fatigue.

In rare cases, it’s been linked to liver and lung problems [22-24,28].

For a summary of research studies on the use of lapatinib in treating metastatic breast cancer, visit the Breast Cancer Research Studies section.

If you have metastatic breast cancer, talk with your health care provider before getting a seasonal flu shot to make sure it's safe for you.

If you are a caregiver, the Centers for Disease Control and Prevention (CDC) recommends you get the seasonal flu shot.