Metastatic Breast Cancer

When breast cancer spreads from the breast and nearby lymph nodes to other parts of the body it’s called metastatic or stage IV breast cancer. Metastasis occurs when cancer cells break away from the original tumor or tumors in the breast and travel through the blood stream or lymphatic system to other parts of the body, causing tumors to grow in these new locations. These new tumors are made of breast cancer cells, so even though they are not located in the breast, the new tumors are categorized and treated as breast cancer.

For some people, this spread of the cancer comes months to years after the original breast cancer has been diagnosed and treated. For others, the cancer is diagnosed at a later stage when it has already spread beyond the breast.

Q: Where are the most common locations that breast cancer spreads?

A: The bones, lungs, brain, and liver are the most common locations for breast cancer metastases, but it can spread to other parts of the body. In 70% of the people who are diagnosed with metastatic breast cancer, the bones are the first location for metastases.

Q: What are the symptoms of metastatic breast cancer?

A: Symptoms depend on where the cancer has spread.

If it spreads to the bones, common symptoms include:

• Sudden, new bone and/or joint pain without a cause like an injury
• Bones that fracture more easily than they should
• Weakness or numbness in the arms and legs
• Joint swelling
• Hypercalcemia (higher than normal levels of calcium on the blood)

Breast cancer that has spread to the lungs often does not cause any symptoms. If lung metastases do cause symptoms, those symptoms can include:

• Persistent, chronic cough without another underlying cause
• Shortness of breath
• Pain in the chest
• Trouble catching your breath after exertion

Cancer that spreads to the liver also often does not cause symptoms. When it does, symptoms can include:

• Jaundice
• Itchy skin or development of new rashes
• Pain in the abdomen, especially on the right side where the liver is located
• Stomach pain
• Loss of appetite
• Nausea and vomiting
• Higher than normal liver enzymes
• Fatigue
• Losing weight without trying
• Fever

Breast cancer that spreads to the brain may cause:

• Persistent headaches or pressure in the head that worsens over time
• Memory problems
• Visual problems, including blurred vision, double vision, loss of vision, seeing flashes of light
• Seizures
• Behavior/ personality changes
• Nausea and vomiting
• Dizziness and balance problems
• Slurred speech
• Weakness on one side of the body

Q: How is metastatic breast cancer diagnosed?

A: If you’re experiencing symptoms that may be caused by breast cancer that has spread, talk to your oncologist, who will determine what tests are needed to uncover the cause of your symptoms.

Depending on the symptoms you’re experiencing, your provider may recommend:

• Biopsy
• Blood tests, including a complete blood count (CBC), liver enzymes, calcium levels, comprehensive metabolic panel
• Bronchoscopy, which uses a scope to examine your lungs
• Imaging, including bone scans, ultrasound, MRI, CT, PET
• Testing fluid drawn from lungs (thoracentesis), spine (lumbar puncture), or abdomen (paracentesis)

Q:  How do oncologists determine what treatment to recommend?

A: The recommended treatment depends on where the cancer has spread, the cancer’s hormone receptor and HER2 status, the symptoms you’re experiencing, what treatments you’ve undergone previously for breast cancer, whether you have the BRCA1 or 2 gene mutation, whether you have gone through menopause, your overall health, your age, and your treatment goals.

Q: What treatments are currently available for metastatic breast cancer?

A: Treatment generally falls into four categories—hormonal therapy, chemotherapy, targeted therapy, and immunotherapy. You may receive a combination of treatment types. Your oncologist will determine which treatment approach is most appropriate for you based on the factors outlined above.

• Hormone receptor-positive cancers: First-line treatment for these cancers can include hormone therapy (tamoxifen and aromatase inhibitors), which may be combined with a targeted therapy such as a CDK4/6 inhibitor. Other targeted therapies for this type of cancer include everolimus, a PI3K inhibitor such as alpelisib (Piqray), or an AKT inhibitor such as capivasertib (Truqap). Selective estrogen receptor degraders (SERDs), a type of hormone therapy, may be another option.
• Hormone receptor-negative cancers: For these types of cancers, chemotherapy is the primary treatment.
• HER2⁺ cancers: The first treatment for metastatic HER2⁺ cancers is usually chemotherapy plus HER2 targeted drugs (trastuzumab and pertuzumab). If those treatments are not effective, other options include antibody drug-conjugates (monoclonal antibodies linked to a chemotherapy drug that attach to the outside of the cancer cells, then enter the cell and release the chemotherapy drug), kinase inhibitors plus an anti-HER2 drug and/or chemotherapy, or other drugs that target HER2 plus chemotherapy.
• HER2^– cancers: For people with both this type of cancer and a BRCA gene mutation, a type of targeted treatment called a PARP inhibitor may be recommended with or without chemotherapy and hormonal treatments.
• Triple-negative cancers: Depending on the specific makeup of the cancer, immunotherapy in combination with chemotherapy and antibody-drug conjugates may be an option.

Depending on your symptoms, their severity, and their impact on your quality of life, your oncologist may also recommend localized radiation, bone-strengthening therapy, surgery, and regional chemotherapy (delivered directly to a specific area of the body).

Other options to help you manage the side effects of treatment and the symptoms of your cancer can include palliative care and complementary therapies such as mindfulness, yoga, meditation, and acupuncture.

Support from PinnacleCare

Trying to understand a serious or complicated diagnosis, like metastatic breast cancer, can be very confusing and difficult to know what to do next. With PinnacleCare, you get the support of a dedicated Health Advisor, who is with you every step of the way, in addition to a team of medial clinicians and researchers to help our members make confident decisions about their treatment plans. Reach out to one of our Relationship Managers to learn more about how we can help you with your serious diagnosis or everyday health needs.