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About Breast Cancer>Types of breast cancer>Metastatic > Treatment for metastatic breast cancer

Treatment for metastatic breast cancer

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At LBBC, we know how overwhelming a metastatic breast cancer diagnosis can be. Coming to terms with being in some form of treatment for the rest of your life is an ongoing process. There’s no right way to feel, and feelings will change and evolve over time.

Metastatic breast cancer treatment has three main goals:

  • Helping you live as long as possible while controlling the cancer
  • Reducing symptoms caused by the cancer
  • Keeping treatment side effects to a minimum

The cancer’s characteristics and location in your body, and whether you’ve had treatment for breast cancer before, can all affect your treatment plan. We know it’s complicated. We’re here for you with information and support as you make decisions with your healthcare team.

As you’re planning treatment, let your healthcare team know what’s most important in your life. Maybe it’s family connections, maintaining a fulfilling career, or going on mountain hikes. Maybe it’s playing with grandkids, making art, or all of the above. Talking with your team about what you want can help in creating a treatment plan that works for your life.

Below, we’ll talk about the different types of medicines and therapies used to treat metastatic breast cancer and when they might be prescribed.

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Your treatment team

No matter which treatments you need, a number of experts will be involved in your care. Your healthcare team will work together and meet regularly to discuss your treatment.

Your treatment team may include:

  • A radiologist, who looks at images of your body tissues for signs of cancer
  • An interventional radiologist, who can perform image-guided biopsies and can also treat areas of metastasis
  • A pathologist, who looks at biopsied tissue samples to figure out what kind of breast cancer it is
  • A medical oncologist, who diagnoses the cancer and treats it with medicine
  • A radiation oncologist, who can treat certain areas and types of breast cancer spread with radiation therapy
  • A surgeon, who can perform surgery to treat metastasis-related fractures, spinal cord compression, or to remove areas of brain metastasis
  • Nurses, patient navigators, social workers, and therapists, who are all available to help you with treatment, emotional, and practical needs
  • Palliative care specialists, who can help you manage pain, symptoms, and significant stress

There are many other experts you may meet along the way. For example, most metastatic breast cancer does not require surgery, but if you need surgery, a surgical oncologist will perform it. If you have a strong family history of breast cancer, you might meet with a genetic counselor to consider genetic testing.

Understanding why your healthcare team may be recommending a particular treatment can help reduce feelings of uncertainty. Here are some questions to get you started:

  • What are the benefits of the treatment?
  • Why do you believe this treatment is the best option for me?
  • What are the short and long-term side effects?
  • How is the treatment given?
  • Which medicines will I get at which times?
  • Will this treatment’s side effects prevent me from enjoying daily activities?
  • What side effects mean I should call you immediately?
  • If this treatment doesn’t work or has too many side effects, what are my other options?
  • Am I eligible for any clinical trials?

Learn more about your treatment team.

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Types of treatment

A metastatic breast cancer diagnosis means living with breast cancer in the long term. If you were treated for breast cancer before, you know that diagnosis and the start of treatment can feel sudden and that there’s an end of treatment to focus on. With metastatic disease, the focus is on finding the treatment that works best for you.

Treatments for metastatic breast cancer sometimes may not seem as aggressive as those given for early-stage breast cancer, especially if you’ve been treated for breast cancer before. This is because early-stage treatment is short-term, and the goal is to reduce the risk of a metastatic recurrence. If the disease does recur, the goal of treatment for metastatic breast cancer is to manage the disease over the long term while helping you live with as few treatment side effects as possible. Two things that can help you get the most out of treatment:

  • Confirming the type of breast cancer: Whether you’ve had breast cancer before or this is your first diagnosis, your medical oncologist may recommend that you get a biopsy of one or more of the cancer sites. Sometimes, metastatic breast cancer has different characteristics than the type found in a past diagnosis. And even if the cancer is the same type as a past diagnosis, you will often need different treatments than you did before. Cancer cells sometimes stop responding to past treatments. Or, a past treatment may be too toxic to have more than once.
  • Creating a flexible treatment plan: Treatment for metastatic breast cancer changes over time as the cancer adapts and builds resistance to medicines. Usually, treatment is used until the cancer grows or travels to a new part of the body, or the side effects become too much to manage. Then, you and your healthcare team will decide on a new treatment. It’s hard to predict how long a specific treatment will work against a certain breast cancer. For some people, a single treatment type will manage the cancer for many years, while others need to change treatments more often.

On this page, we’ll talk about the types of treatments available for metastatic breast cancer.

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Hormonal therapy

After a biopsy of an area of metastatic breast cancer, a pathologist will examine the cells to see if hormone receptors for estrogen or progesterone are present. These hormones occur naturally in your body. If receptors are found, it means one or both hormones are helping the cancer cells to grow and multiply. This type of metastatic breast cancer is hormone receptor-positive.

Hormonal therapy treats hormone receptor-positive breast cancer. It’s a medicine that interferes with the way certain hormones work in order to stop the cancer from growing or traveling further. Here, we’ll share examples of hormonal therapies that treat metastatic breast cancer.

If you are a woman with hormone receptor-positive breast cancer, the recommended hormonal therapy will be based on whether or not you’ve started menopause. For women who are premenopausal (have not started menopause) or perimenopausal (have started missing periods, but still sometimes have one):

For postmenopausal women or for men:

  • Aromatase inhibitors, including anastrozole, exemestane, and letrozole, work to lower estrogen levels in the body. These medicines are given in pill form. The American Society of Clinical Oncology recommends that men taking AIs also take GnRH / LHRH antagonists.
  • Tamoxifen, given in pill form, blocks estrogen from helping hormone receptor-positive breast cancer to grow.
  • Toremifene (Fareston), given as a pill, blocks estrogen from attaching to hormone receptors on breast cancer cells.
  • Fulvestrant is an injected medicine that blocks estrogen from attaching to hormone receptors on breast cancer cells.

Side effects of hormonal therapy depend on the specific drug but can include menopausal symptoms such as hot flashes, vaginal dryness or discharge, joint pain, weight changes, bone loss, and changes in sexual desire.

Some hormonal therapies, such as aromatase inhibitors and fulvestrant, can be given in combination with targeted therapies to treat metastatic breast cancer. You can learn more about targeted therapy below.

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Targeted therapy

Targeted therapy is a type of cancer treatment that targets specific cell characteristics or processes in the body that help breast cancer to grow. Targeted therapy treats the cancer in a focused way, so it’s less likely than chemotherapy to harm healthy cells, and may have fewer side effects.

Hormonal therapy targets the way hormones help hormone receptor-positive breast cancer to grow. Other targets can also be used to interfere with breast cancer growth, including cell proteins, enzymes, and in some cases, blood vessels that supply tumors with nutrients. We’ll walk you through these targeted therapies here.

For hormone receptor-positive, HER2-negative metastatic breast cancer

In addition to hormonal therapies, there are targeted therapies available for metastatic breast cancers that are hormone receptor-positive and HER2-negative. HER2-negative means that the cancer cells have a normal amount of HER2 (human epidermal growth factor receptor-2) proteins, and they don’t grow or spread as quickly as HER2-positive breast cancers.

Here are the targeted therapies available to treat this type of metastatic breast cancer:

CDK 4/6 inhibitors. This type of medicine targets two specific kinases, or enzymes, that help tumor cells grow. These enzymes are called kinase 4 and kinase 6. CDK 4/6 inhibitors block the enzymes from telling cancer cells to multiply, which helps slow the growth or spread of the cancer. If you’ve been diagnosed with hormone receptor-positive, HER2-negative metastatic breast cancer, CDK 4/6 inhibitors may be the first treatment recommended for you.

  • Abemaciclib (Verzenio) targets proteins that help cancer cells grow and divide. It’s given in pill form with an aromatase inhibitor or fulvestrant, and can be taken by pre- or postmenopausal women. If the cancer has grown despite treatment with hormonal therapy and chemotherapy, abemaciclib can be given by itself.
  • Palbociclib (Ibrance) targets proteins that help cancer cells grow and divide. Palbociclib is given in pill form along with hormonal therapy, such as an aromatase inhibitor or fulvestrant to pre- and postmenopausal women.
  • Ribociclib (Kisqali) targets proteins that help cancer cells grow and divide, and is given as a pill with an aromatase inhibitor or fulvestrant to pre- and postmenopausal women.

mTOR (mammalian target of rapamycin) inhibitors. There is one mTOR inhibitor approved to treat hormone receptor-positive, HER2-negative metastatic breast cancer:

  • Everolimus (Afinitor) stops cancer cells from dividing and may block the growth of blood vessels that tumors need to grow. Everolimus is given as a pill with the aromatase inhibitor exemestane to postmenopausal women with hormone receptor-positive, metastatic breast cancer. Everolimus can also be given to premenopausal women with ovarian suppression medicine and hormonal therapy.

PI3K (phosphatidylinositol 3-kinase) inhibitors. There is one PI3K inhibitor approved to treat hormone receptor-positive, HER2-negative metastatic breast cancer:

  • Alpelisib (Piqray) blocks an overactive cell signaling pathway in tumors that carry a genetic mutation in the PIK3CA gene. This medicine works with the hormonal therapy fulvestrant to keep these cancers from growing. Alpelisib is for postmenopausal women and is taken as a pill. Alpelisib can also be given to premenopausal women.

For HER2-positive breast cancer

HER2 is a gene that helps regulate normal breast cell growth. But in some breast cancers, the HER2 gene does not act normally, instead making too many copies of itself (HER2 gene amplification and overexpression). HER2 overexpression signals breast cancer cells to grown and survive. With so many HER2 receptors, breast cancer cells have too many growth signals and start growing too often and too fast. This type of breast cancer is called HER2-positive.

While HER2-positive breast cancer is more aggressive than HER2-negative breast cancer, many effective targeted therapies are available to treat it:

Monoclonal antibodies. In breast cancer treatment, monoclonal antibodies work by attaching to HER2 proteins and blocking signals that help cancer cells grow. Here are the monoclonal antibodies approved to treat HER2-positive metastatic breast cancer:

  • Trastuzumab (Herceptin) is an IV treatment that blocks HER2-positive, metastatic breast cancer cells from receiving growth signals. There are also treatments available that are similar, but not identical to, trastuzumab. These medicines, like generic drugs, have been proven to be just as effective as the brand name drug Herceptin, and they may be more affordable. These drugs are called biosimilars, and they include:
    • Trazimera (trastuzumab-qyyp)
    • Ontruzant (trastuzumab-dttb)
    • Ogivri (trastuzumab-dkst)
    • Herzuma (trastuzumab-pkrb)
    • Kanjinti (trastuzumab-anns)
    • Pertuzumab (Perjeta) is an IV treatment used with trastuzumab and the chemotherapy docetaxel to treat metastatic, HER2-positive breast cancer. Pertuzumab blocks HER2 receptors on breast cancer cells from receiving growth signals.
  • Pertuzumab, trastuzumab, and hyaluronidase-zzxf (Phesgo) is a different way to receive two drugs mentioned above: as a combination of pertuzumab, trastuzumab, and a protein that allows it to be given as an injection. The injection is given at the same time as chemotherapy. This medicine prevents HER2 receptors on the surface of cancer cells from picking up growth signals.
  • Margetuximab (Margenza) is an IV medicine that blocks HER2 receptors on cancer cells from receiving growth signals. Margetuximab is given with chemotherapy to treat metastatic, HER2-positive breast cancer after it’s been treated with at least two other kinds of targeted therapy.

Tyrosine kinase inhibitors. These drugs interfere with the HER2 protein’s ability to help cancer to grow. There are three tyrosine kinase inhibitors approved to treat HER2-positive metastatic breast cancer:

  • Lapatinib (Tykerb), given as a pill, blocks the activity of the HER2 protein from inside HER2-positive metastatic breast cancer cells. Lapatinib is given with the chemotherapy pill capecitabine (Xeloda). In postmenopausal women with hormone receptor-positive, HER2-positive breast cancer, lapatinib is given with letrozole.
  • Neratinib (Nerlynx), given as a pill, irreversibly attaches to HER2 receptors, preventing cancer cells from growing and multiplying. Neratinib is given with the chemotherapy pill capecitabine to treat metastatic, HER2-positive breast cancer that has grown despite treatment with at least two previous targeted therapies.
  • Tucatinib (Tukysa) blocks the activity of the HER2 protein from inside the cell. Tucatinib is a pill given with trastuzumab and the chemotherapy pill capecitabine to treat metastatic, HER2-positive breast cancers that have grown after previous HER2-targeted treatments.

Antibody-drug conjugates. These medicines work to deliver chemotherapy directly to HER2-positive metastatic breast cancer cells. There are two antibody-drug conjugates approved to treat this kind of breast cancer:

  • Ado-trastuzumab emtansine (Kadcyla) is an intravenous (IV) treatment that delivers chemotherapy directly to metastatic, HER2-positive breast cancer that has grown despite treatment with HER2-targeted therapy trastuzumab (Herceptin) and taxane chemotherapy.
  • Fam-trastuzumab-deruxtecan-nxki (Enhertu) is an IV treatment that delivers chemotherapy directly to metastatic, HER2-positive, hormone receptor-negative breast cancer that has grown after at least two past treatments.

For triple-negative metastatic breast cancer

Breast cancer that tests negative for hormone receptors and HER2 overexpression is called triple-negative breast cancer. Here are the targeted therapies approved to treat triple-negative, metastatic breast cancer:

  • Pembrolizumab (Keytruda) is an IV immunotherapy given with chemotherapy to treat triple-negative breast cancer that overexpresses the PD-L1 protein. Pembrolizumab blocks PD-L1 from interfering with the immune system’s ability to kill cancer cells.
  • Sacituzumab govitecan (Trodelvy) is an IV medicine called an antibody-drug conjugate. Sacituzumab govitecan delivers chemotherapy directly to triple-negative breast cancer cells by targeting a protein called Trop-2, found on the cells of many triple-negative breast cancers.

For metastatic breast cancer in people who test positive for a BRCA mutation

If you have hormone receptor-positive, HER2-negative breast cancer or triple-negative breast cancer, and you also test positive for a BRCA mutation, there are two targeted therapies available to you. PARP inhibitors stop an enzyme in the body known as poly (ADP-ribose) polymerase, or PARP, from repairing cancer cell DNA. Cancer cells in people with BRCA mutations already have a hard time repairing their own DNA. PARP inhibitors make it even harder, and can cause the cancer cells to die. The two approved PARP inhibitors, given in pill form, are:

  • Olaparib (Lynparza)
  • Talazoparib (Talzenna)

Different targeted therapies can cause different side effects. These can include nausea, diarrhea, anemia, low blood cell counts, and fatigue. Learn more in Targeted therapy.

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Chemotherapy

Chemotherapy kills rapidly dividing cells in order to slow or stop the growth of cancer. Chemo is often given intravenously (by injection into a vein). Some chemotherapies are available in pill form. For metastatic breast cancer, chemotherapy will often be given after other treatments stop working against the cancer.

Whether you get chemotherapy depends on many factors, such as:

  • The specific type of cancer cells
  • Your age
  • The presence or absence of estrogen and progesterone receptors
  • The amount of HER2 protein on the surface of the cancer cells
  • Which treatments you had in the past
  • Where the cancer is in your body, and how much there is

If you’re receiving chemotherapy intravenously (IV chemotherapy), you will be treated at regularly scheduled appointments at your cancer center. There are different ways you can receive IV chemotherapy:

  • Through a vein in your arm
  • Through an access port, sometimes called a port-a-cath, placed under the skin in the upper part of the chest, connecting to a major vein
  • Through a PICC (peripherally inserted central catheter) line: a long, flexible tube inserted into an arm vein that gives access to larger veins

A port or PICC line allows a person to avoid repeated needlesticks in the arm, and can reduce the risk of IV medicines irritating the blood vessels.

There are many possible side effects of chemotherapy, and there’s no way to know who will experience each one. Some common side effects include:

  • Nausea
  • Hair loss
  • Weight gain or loss
  • Low blood cell counts
  • Fatigue

Your healthcare team can recommend effective ways to manage some side effects with lifestyle changes or medicine. Visit the chemotherapy section to learn more.

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Radiation therapy

Radiation therapy focuses the power of high-energy x-rays on specific areas of cancer. It’s a local treatment, which means it impacts only cells at or near the location receiving treatment. Radiation is thought to cause breaks in strands of DNA, which can keep the cancer cells from dividing and growing.

Most often, radiation for metastatic breast cancer is used to:

  • Shrink tumors
  • Manage pain from tumors in the bone
  • Treat or prevent symptoms caused by breast cancer in the brain or lungs
  • Lessen pain and prevent injury to nerves by treating tumors of the spine that are pushing on the spinal cord

The side effects of radiation therapy are very specific to the part of the body being treated. If you receive radiation to the liver, for example, nausea or vomiting may be side effects. If the breast cancer has traveled to the brain, radiation therapy can cause changes in thinking and memory. If your healthcare team recommends radiation therapy, you and your radiation oncologist will talk before and during treatment about possible side effects and how to manage them. Visit the radiation therapy page for more information.

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Surgery

Surgery is rarely done for metastatic breast cancer, but there are a few reasons your doctor may recommend it:

  • If you have pain or bleeding, removing the original tumor can help ease symptoms.
  • If there are tumors in places outside the breast that are causing you pain or other symptoms, removing them can help reduce symptoms.
  • If you have metastatic breast cancer that has spread to the bones, orthopedic surgery can be done to reduce the risk of bone breaks and to ease pain. Specific situations can include:
    • Surgery to insert metal rods within bone to provide stability
    • Kyphoplasty, a surgery in which cement is inserted into a bone to ease pain
      • If breast cancer has spread to the brain, a surgery called craniotomy is sometimes performed to remove a tumor. Craniotomy is performed by a neurosurgeon and involves removing a small piece of skull to get to the tumor and remove it. Other team members may include a neurologist or neuro-oncologist.

If there is cancer in your bones, lung, liver, or brain, and the cancer is not growing, or is in only one place, talk with your doctor about whether cancer-removing surgery may be an option.

If you’re premenopausal and the cancer is hormone receptor-positive, you may have the option of having your ovaries removed in a surgery called oophorectomy. Having the ovaries removed takes away most of the estrogen in the body, and can greatly reduce the risk of hormone receptor-positive cancer growth in premenopausal women. But it’s important to know that in these women, oophorectomy causes sudden menopause. Side effects include hot flashes, an increased risk for heart disease, bone loss or fractures, and decreased sexual desire.

Talk with your doctor about your individual situation and whether surgery is an option to consider.

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Complementary and integrative medicine

Complementary therapies are physical, mental, and spiritual practices used in addition to standard cancer treatment. While complementary therapies do not treat cancer directly, research shows they can ease some side effects, such as nausea, fatigue, anxiety, and depression.

Standard medical care combined with complementary therapies is called integrative medicine. Integrative medicine works to control the cancer with standard-of-care treatment while using complementary therapies to support mental and spiritual well-being.

Complementary therapies include:

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Yoga

Although yoga is not a treatment for breast cancer, studies suggest practicing yoga during breast cancer treatment can help relieve stress, anxiety, depression, insomnia, and fatigue. Some women who practice yoga have reported less pain, fewer hot flashes, and improved strength and body image.

In general, yoga is safe for people with metastatic breast cancer. But some poses may not be right for everyone, including:

  • Twists
  • Forward-bending stretches
  • Backbends
  • Balance poses
  • Inversions, poses that place your head lower than your heart

The location of cancer in your body may impact how you practice yoga:

  • With bone metastasis, bones may fracture more easily, so ask your doctor about any poses that may put too much stress on an area of bone metastasis.
  • With liver metastasis, avoid poses that put tension on the abdomen.
  • Some deep-breathing yoga practices may be difficult if you have lung metastasis.

Always discuss new physical activities with your doctor before starting, and listen to your body. If something doesn’t feel right, stop.

Try an all-levels yoga class, featuring instructor Kathy DiGiorgio:

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Reviewed and updated: December 13, 2021

Reviewed by: Douglas Yee MD

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