1. Definition of metastatic disease of the breast
2. Factors influencing the behaviour of meastases
3. Signs of metastatic breast cancer
4. Treatment options for metastatic disease
5. Clinical trials available to patients with metastatic breast cancer
6. Emotional issues with metastatic breast cancer
7. Resources for patients with metastatic breast cancer

1. Definition of metastatic disease of the breast

Metastatic disease of the breast (also known as distant or systemic recurrence) is when breast cancer cells have escaped into the blood stream or the lymphatic system prior to the first treatment. Some cancer cells can be resistant to adjuvant treatments and can grow and divide into detectable cancer metastases.¹

The most common sites for breast cancer to metastasize to are the bones, lungs, liver and brain. Other parts of the body that can be affected include the lymph nodes, skin, eyes, spinal cord, and ovaries.¹

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2. Factors influencing the behaviour of a metastases

The average survival after breast cancer has metastasized is about two years, but many women live much longer. The behaviour of a metastatic breast cancer is dependent on:

• the amount of time passed since the original cancer was diagnosed: a longer time since the diagnosis means the recurrence will grow more slowly;
• the type of initial cancer: the less aggressive, the better;
• the tumour's estrogen receptor status: estrogen receptor-positive tumours respond better to treatment than estrogen receptor-negative tumours;
• the number of tumour sites: the fewer the better;
• the site of the metastases: e.g., bone metastases are often slower growing than liver mets; and
• the physical state of the woman.¹

3. Signs of metastatic breast cancer

The symptoms of breast cancer metastases depend on the part of the body affected and they generally need to persist for longer than 24 hours. Cancer in the bones usually causes increasing pain or a spontaneous fracture. In the lungs it may cause cough or shortness of breath. In the liver it causes loss of appetite, pain in the right upper abdomen and sometimes jaundice. If cancer spreads to the brain it may cause headache, numbness or weakness of an arm or leg, loss of balance, confusion or seizures.¹

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4. Treatment options for metastatic disease

With a diagnosis of metastatic breast cancer, the treatment goal shifts from cure to relief of symptoms, maintenance of quality of life, and prolonged survival. Treatments often include hormones, radiotherapy, chemotherapy,management and sometimes surgery. Nutritional support, pain management and psychological support are also important considerations.

Systemic therapy is given if there are symptoms from metastases or if the cancer is growing rapidly. The type of systemic therapy used depends on:

• whether the tumour is responsive to estrogen or progesterone;
• whether the tumour is HER2 positive;
• the length of time since the original diagnosis: even if the initial tumour was ER-negative a recurrence occurring many years later may suggest a hormone-responsive cancer;
• the organs involved: bone mets may respond better to hormones;
• the severity of the symptoms: if the recurrence is widespread and causing a lot of symptoms then the patient needs more rapid relief that might come from chemotherapy or trastuzumab, rather than waiting;
• the age of the patient: chemotherapy may be too harsh for an elderly woman with other health problems; and
• the response to previous therapies: if one hormone therapy had a benefit others may too.

View indications for radiotherapy; hormone therapy; and surgery in the treatment of metastatic disease.

Table 1 shows the hormone treatment recommendations for metastatic disease based on menopausal status:

See metastatic disease for indications for chemotherapy in metastatic breast cancer and indications for bisphosphonate therapy for metastatic breast cancer to the bone.

View protocols for chemotherapy for advanced breast cancer.

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5. Clinical trials available to patients with metastatic breast cancer

Find BC Cancer Agency open clinical trials for metastatic breast cancer.

6. Emotional issues with metastatic breast cancer

"Attention to the symptomatic and pain relief needs of the woman with advanced breast cancer is central to her emotional and physical well-being (Massie and Holland, 1992). The management of pain syndromes, including post-mastectomy pain syndrome, was well described in the 1980s by Foley (1985). The early study of Spiegel and Bloom (Spiegel and Bloom, 1983) documented interventions to reduce distress and pain in metastatic breast cancer. Breitbart and colleagues (Breitbart et al., 2000) have shown the association of pain and the increase in symptoms of depression and anxiety. A biopsychosocial model, illustrating the interplay of somatic (pain) with psychosocial aspects was outlined by Syrjala and Chapko (Syrjala and Chapko, 1995). In the presence of uncontrolled pain, the woman with breast cancer will function at a lower level and will likely become less able to maintain her usual social role as mother, spouse, worker, or caretaker, although many women continue their normal activities in the face of major functional impairments. Concern for spiritual and existential matters often marks this phase of the illness, as women focus on their legacy to their families and children and engage in planning for their future (Butler et al., 2003, Foley, 2000, McGuire et al., 1989)." ³

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7. Resources for patients with metastatic breast cancer

Navigating Your Path: A Guide for People with Advanced Breast Cancer (PDF)

References:

1. Olivotto I, Gelmon K, McCready D, Pritchard K, Kuusk U. Intelligent patient guide to breast cancer. 4th ed. Edwards C, editor. Vancouver (B.C.): Intelligent Patient Guide Limited; 2006, pg.236-237.

2. Olivotto I, Gelmon K, McCready D, Pritchard K, Kuusk U. Intelligent patient guide to breast cancer. 4th ed. Edwards C, editor. Vancouver (B.C.): Intelligent Patient Guide Limited; 2006, pg.238-239.

3. Hewitt M, Herdman, R, Holland, J, editors. Meeting psychosocial needs of women with breast cancer. Washington, D.C.: The National Academies Press; National Cancer Policy Board; 2004; pg.31