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Treatment For Metastatic Breast Cancer

The goals of treatment for early stage breast cancer and metastatic breast cancer are very different. At this time, there is no cure for metastatic breast cancer and treatment focuses on controlling the disease and easing symptoms while trying to minimize treatment side effects and maintain quality of life. This is why treatment for metastatic breast cancer may sometimes seem less aggressive than for early stage disease, which aims to completely remove the breast cancer.

Research is giving us more information about managing metastatic breast cancer and more treatment options exist than ever before. These treatments are allowing people to live longer with metastatic breast cancer and with a better quality of life.

If you had treatment for early stage breast cancer, the treatment you receive for metastatic breast cancer may be different. Systemic treatmentsSystemic treatment:
A treatment method that is applied to and takes effect in the entire body. Chemotherapy, hormone therapy and HER-2 targeted therapy are systemic treatments for breast cancer.
such as hormone therapyHormone therapy:
A treatment method for breast cancer that uses medication to block the production of the hormone estrogen, or the way that it works in the body.
, chemotherapyChemotherapy:
A treatment method that uses medication to destroy cancer cells.
, and HER-2 therapyHER-2 targeted therapy:
A treatment method that uses medication to target HER-2 receptors that stimulate breast cancer growth.
act on the whole body and are most commonly used to help control metastatic breast cancer. Local treatments, such as radiation therapyRadiation therapy:
(Sometimes called radiotherapy) A treatment method that uses a high energy beam to destroy cancer cells by damaging the DNA of cancer cells so that they can’t continue to grow.
and surgery, may be used to help manage pain and serious symptoms associated with breast cancer metastasis, such as when it occurs in the brain or spinal cord.

The type of treatments you receive will depend on the size, location, and characteristics (e.g. receptor status) of the metastatic breast cancer. Speak to your health care team to learn about the benefits, limitations, and possible side effects of each option to help you make an informed decision about which treatment is best for you.

Hormone therapy

Metastatic breast cancer that is hormone receptor positive may be treated using hormone therapies such as anti-estrogen medications, aromataseAromatase:
An enzyme that helps to produce estrogen in the body. Aromatase inhibitors are a type of hormone therapy that works by blocking the ability of aromatase to produce estrogen, which helps to slow the growth of estrogen-sensitive breast cancer.
inhibitors, or ovarianOvary:
A female reproductive organ in which ova or eggs are produced. The ovaries also produce the female hormones estrogen and progesterone.
suppression. The goal of treatment is to shrink or slow the growth of the tumour(s) by blocking the production of estrogenEstrogen:
A female sex hormone that is produced mainly in the ovaries. A woman’s levels of estrogen fluctuate throughout her life. Estrogen has been linked to the development of breast cancer and may promote the growth of cancer cells.
or its effects on tumour growth. The type of treatment prescribed will depend on how the original cancer responded to hormone therapy before, and whether or not you have gone through menopauseMenopause:
A natural part of a woman's aging process, when the ovaries start to make less estrogen and progesterone and the menstrual periods stop. This change typically occurs between the late 40s and mid-to-late 50s.
.

If you are pre-menopausal, your doctor may recommend estrogen-blocking medications such as tamoxifen, along with treatment to shut down the production of estrogen by your ovaries.  For women who are post-menopausal, aromatase inhibitors, which act by stopping the production of estrogen outside of the ovaries, have been shown to be more effective as a first choice of treatment.  The most common side effects of hormone therapies are menopause-like symptoms such as hot flashes and vaginal dryness.

Most women with hormone receptor positive metastatic breast cancer will use different hormone therapies over the course of their treatment, usually one medication at a time. As long as a medication is working, you can continue to take it. Your health care team will monitor how you are responding to treatment, and will recommend switching to a different medication if the cancer grows or spreads. Hormone receptor positive breast cancer usually responds to hormone therapy for many months or even years before switching to another medication is needed.

Chemotherapy

Chemotherapy is a treatment method that uses medication to destroy cancer cells. Like hormone therapy, chemotherapy is a systemic treatment that takes effect on the whole body. The goal of chemotherapy in the treatment of metastatic breast cancer is to try to shrink or slow the growth of the tumour(s). 

Chemotherapy may be recommended if hormone therapy stops working, if the breast cancer is hormone receptor negative, or if it has metastasized to tissues such as the liver or the lungs. 

Chemotherapy for metastatic breast cancer is different than for early stage breast cancer in that generally only one medication is used at a time. This is because a single medication can usually achieve good results while reducing the side effects that you may experience.  Sometimes, your medical oncologistOncologist:
A doctor or surgeon who specializes in treating cancer. A medical oncologist specializes in drug therapy (chemotherapy) for cancer. A radiation oncologist specializes in treating cancer with radiation.
may recommend trying a combination of chemotherapy medications.

There are many chemotherapy medications available for the treatment of metastatic breast cancer. This means that if the cancer doesn’t respond to one medication, there is a chance that another chemotherapy medication may work.

The side effects that you experience from chemotherapy will depend on the medication prescribed. You may decide to start with less toxic medications before trying stronger chemotherapy drugs that have more side effects. You may also decide against stronger chemotherapy treatment altogether if your quality of life will be significantly impacted. There is no “right” decision – only the one that is best for you.

HER-2 therapy

HER-2 is a receptor that is normally found on the surface of cells and is thought to be involved in their growth and division. Some breast cancers make too many HER-2 receptors and are known as being “HER-2 positive”. Trastuzumab (Herceptin) is a medication that binds to and blocks HER-2 receptors, and may be used to treat metastatic breast cancers that are HER-2 positive. The goal of trastuzumab in the treatment of metastatic breast cancer is to try to shrink or slow the growth of the tumour(s).

Trastuzumab (Herceptin) is given by vein (intravenouslyIntravenous (I.V.):
A method of administering medication where the substance is given into a vein using a needle.
or I.V.) once a week or once every 3 weeks. In the treatment of metastatic breast cancer, it can be given indefinitely to try to keep the cancer cells under control as long as possible.

Possible side effects of trastuzumab (Herceptin) therapy include flu-like symptoms such as fever, chills and headache. The side effects are usually mild in comparison to the side effects of chemotherapy and decrease in severity over time.

If trastuzumab (Herceptin) is no longer working, you may be prescribed lapatinib (Tykerb). Lapatinab is a tablet that is taken daily by mouth and works by interrupting the HER-2 pathway of the cell.

Lapatinib (Tykerb) is generally well tolerated but can commonly cause diarrhea, fatigue and skin changes. Rare but serious side effects of lapatinib include heart rhythm disturbances, weakening of the heart muscle, and toxicity to the liver and lungs. Lapatinib is prone to interactions with many other drugs and things we eat. Your oncologist and Oncology pharmacistOncology pharmacist:
A pharmacist who has special training in how to design, give, monitor, and change chemotherapy for cancer patients.
will counsel you about this before prescribing lapatinib.

Surgery and Radiation Therapy

Surgery and radiation therapy may be used to help reduce pain and alleviate symptoms of metastatic breast cancer. Surgery to remove metastatic breast cancer is not usually done. However, sometimes surgery is recommended to lessen serious side effects that can occur when cancer has metastasized to the brain or bones in the spinal column. Radiation therapy may also be used to shrink tumours to help lessen pain and discomfort.

Your health care team may prescribe other treatments as needed depending on the signs and symptoms you are experiencing. Everyone experiences the symptoms of metastatic breast cancer differently. Your treatment plan will be tailored to your individual needs, with the goal of controlling the disease and easing symptoms while trying to minimize treatment side effects and improve your quality of life.

Pain management

If you are experiencing pain as a result of breast cancer that has metastasized to other locations in the body, there are options available to help you to manage the pain. Shrinking the tumour(s) that are causing the pain is often one of the best ways to manage the discomfort, and this is one of the goals of metastatic breast cancer treatment.

If treatments such as hormone therapy, chemotherapy, HER-2 therapy or radiation are unsuccessful in shrinking the tumour, or you need some additional pain relief, over the counter or prescription pain medications can be helpful. You may also wish to try complementary treatments for pain management such as acupuncture, massage therapy, meditation or yoga.

Clinical Trials

Your health care team may suggest that you receive treatment through a clinical trial. A clinical trial is a research study that looks at how effective a new medication or procedure is in treating a disease as well as the side effects it produces. Clinical trials are tightly controlled and you will need to meet criteria set by the research team to be able to participate. If you agree to participate in a clinical trial, you have the right to stop at any time. Clinical trials give you access to new treatments that have the potential to prolong life and/or improve quality of life. It’s important to remember that these treatments are still experimental, and there is a chance they may have small, no or negative effects. Your safety during a clinical trial is very important to the researchers and you will be closely monitored during the trial. If it becomes clear that the treatment is not effective or presents a risk to participants, the trial will be stopped.

Participating in a clinical trial may be a good option if other treatments for metastatic breast cancer are no longer working for you. They are not always a treatment of “last resort”, however, and if your health care team suggests that you enroll in a clinical trial, it does not mean that there are no other options left. Some studies can only include people that have not tried other standard treatments, and participating in a clinical trial first may give you more options in the long term. The decision to participate in a clinical trial is a very personal one, and everyone has different reasons for whether or not they choose to do so.

If you are interested in participating in a clinical trial, speak to your health care team about the benefits and limitations of participation, and how a clinical trial may fit into your overall treatment plan.

When treatment ends

A time will come when treatment is no longer able to control the metastatic cancer, or you may make a decision to stop treatment and focus on having the best quality of life possible. At this point, palliative care takes on a greater role – providing comfort, lessening any symptoms and pain you may be experiencing, and providing support as you move toward the end of life.

Resources and Supports

If you have been diagnosed with metastatic breast cancer, you will likely experience a range of emotions and have many questions – there is no “right” or “wrong” way to feel. Give yourself permission to feel any emotions that come up for you.

Everyone has a different approach to managing metastatic breast cancer. Your initial focus may be on controlling the cancer medically and learning as much as possible about the treatment options that are available to you. Over time, your focus may shift to having the best quality of life possible. It’s important access sources of support during this time – whether physical, emotional, spiritual, social, or practical and financial. You may choose to reach out to family and close friends for support, or even connect with other people who are living with metastatic breast cancer. Many people find strength and reassurance in learning about other people’s experiences with managing the disease.

 Many women live well for years with metastatic breast cancer. Over time, you may need to make some changes to adjust to living with the disease, but it’s important to take the time to enjoy activities that bring you pleasure. With the support of your family, friends, and health care team, you can continue to have a fulfilling, active life.

Your health care team can direct you to sources of support in the community including support groups for people with metastatic breast cancer, counseling services, or community based organizations that offer various kinds of support for people living with cancer. There are also online communities for people living with metastatic breast cancer, where you can ask questions, read about the experiences of others, or share your story, if that is helpful for you. 


Sources:

Canadian Cancer Society. Metastatic Cancer Overview. Accessed February 7, 2014.

Living Beyond Breast Cancer & Metastatic Breast Cancer Network. Guide for the Newly Diagnosed: Empowering you to make informed decisions and to cope with your emotions after a diagnosis of metastatic breast cancer. Accessed February 7, 2014.

National Cancer Institute. Metastatic Cancer. Accessed February 6, 2014.

Pusztai, L., Viale, G., Kelly, C.M., and Hudis, C.A. (2010). Estrogen and HER-2 receptor discordance between Primary Breast Cancer and Metastasis. The Oncologist, 15 (11), 1163-1168.