There are many different treatment options available for advanced breast cancer and the aim of treatment is to keep your cancer controlled for as long as possible while giving you the best possible quality of life. There is no ‘one size fits all’ for the management of advanced breast cancer and you may respond to several types of treatment. Your oncology team will decide the best course of action with you and will take into consideration:
- The type of breast cancer you have
- How far it has spread and which part of the body it has spread to
- What treatments you have had so far
- How quickly your cancer is growing
- Your general health
You might be offered a range of treatments which could include hormone therapy, radiotherapy, chemotherapy, biological therapies or you may be offered a drug trial. Your oncologist will be able to go through the benefits of each of the treatment options as well as the possible side effects. The list of potential side effects may appear daunting but the thing to remember is that you are very unlikely to suffer from all of the side effects listed. Your feelings and preferences will play an important part in making the decision that is right for you.
Hormones are substances produced naturally in the body. Prior to the menopause, female hormones oestrogen and progesterone are produced by the ovaries. After the menopause oestrogen is made in body fat and it is the oestrogen which can stimulate the growth of some types of breast cancer. Hormone therapy works in two ways, either by lowering the amount of oestrogen in the body or by blocking the action of oestrogen which can fuel the growth of breast cancer cells. The aim of hormone treatment for advanced breast cancer is to shrink or slow the growth of the cancer.
Hormones are substances produced naturally in the body. Prior to the menopause, female hormones oestrogen and progesterone are produced by the ovaries. After the menopause oestrogen is made in body fat and it is the oestrogen which can stimulate the growth of some types of breast cancer. Hormone therapy works in two ways, either by lowering the amount of oestrogen in the body or by blocking the action of oestrogen which can fuel the growth of breast cancer cells. The aim of hormone treatment for advanced breast cancer is to shrink or slow the growth of the cancer.Hormone therapy can only be used to treat advanced breast cancer if your breast cancer cells have been shown to be oestrogen receptor positive (ER+ve). This will have been tested at the time of your primary breast cancer. Sometimes the receptors can change to ER negative (ER-ve) so your oncologist may wish to sample tissue from your advanced breast cancer.
There are several types of hormonal therapy medicines. These include selective oestrogen receptor modulators (SERMs) which work by blocking the effect of oestrogen in the breast cancer cells, oestrogen receptor downregulators (ERDs) which are used in post-menopausal ER+ve women who have stopped responding to tamoxifen and aromatase inhibitors which are mainly used in post-menopausal women and work by reducing the amount of oestrogen in the body so there is less to stimulate the growth of hormone receptor positive breast cancer cells. The drug chosen for you will depend on whether or not you have gone through the menopause and what drugs you have had in the past. If one hormone treatment does not work, you may be offered another. Some are taken as a daily tablet whilst others are given by injection every four weeks. Hormonal treatments commonly in use are:
- Tamoxifen (SERM)
- Fulvestrant (Faslodex) (ERD)
- Anastrozole (Arimidex) (AI)
- Exemestane (Aromasin) (AI)
- Letrozole (Femara) (AI)
- Goserelin (Zoladex) (drug to shut down ovaries in pre-menopausal women)
- Megestrol acetate (Megace)
In premenopausal women, most of the oestrogen in the body is made by the ovaries. If tamoxifen has stopped working, your doctor may recommend an aromatase inhibitor but you will need to either have your ovaries removed or medically shut down. Goserelin works by telling the brain to stop the ovaries from making oestrogen. It is given as an injection once a month and once you stop taking it the ovaries begin to function again.
Megestrol acetate (Megace)
Megestrol acetate is a man made version of the female hormone progesterone. Megestrol can interfere with the hormone balance in the body so that the body makes smaller amounts of the hormone fuelling the cancer which may stop the cancer growing. It may also act directly on cancer cells so that they can’t grow. You take megestrol as a tablet daily.
You can find more information on hormone treatment for secondary breast cancer and side effects on the Cancer Research UK website.
The aim of chemotherapy is to destroy cancer cells and slow down the spread of your cancer. If hormone treatment fails to control progression of your cancer, if you are hormone receptor negative (ER-ve and PR-ve) or if you have spread to your liver or lungs, then chemotherapy may be considered to be the best treatment for you. Some chemotherapy drugs are given orally in tablet form, often a two week on, one week off regime, whilst others are given by infusion at either weekly or three weekly intervals. They may be given alone or in combination. Chemotherapy drugs which may be used for the treatment of advanced breast cancer are:
- 5 fluorouracil (5FU)5 fluorouracil (5FU)
- Abraxane (normally only used if you have an allergic reaction to paclitaxel)
- Capecitabine (Xeloda)
- Docetaxel (Taxotere)
- Doxorubicin (Adriamycin)
- FEC (combination of Fluorouracil 5FU, epirubicin and cyclophosphamide)
- FEC-T (combination of Fluorouracil 5FU, epirubicin, cyclophosphamide and docetaxol)
- Gemcitabine (Gemzar) Gemcarbo (combination of gemcitabine and carboplatin)
- Paclitaxel (Taxol)
- Vinorelbine (Navelbine)
Macmillan Cancer Support has one of the most comprehensive lists of all chemotherapy drugs and regimens.
Targeted or biological therapies are some of the latest treatments used to treat cancer. They act on processes within the cells and the different therapies can work in different ways. They may stop cancer cells from growing or dividing, seek out and kill cancer cells or encourage the immune system to attack cancer cells. To date, immunotherapy has been most successful in melanoma, kidney and lung cancer but new treatments are being developed which will hopefully prove of benefit in breast cancer.
Not everyone will benefit from targeted therapies. The most well known biological therapy is Herceptin but this will only work if your cancer is HER2 positive which only applies to around 20% of breast cancers. This will have been tested on your primary breast cancer but your oncologist may be able to organise for a biopsy of your advanced breast cancer to see if the cancer has changed its status which may make some of these drugs an option. Unfortunately, not all of these drugs are approved by NICE but some are currently available via the Cancer Drugs Fund in England (See our section on the Cancer Drugs Fund and the different rules for Scotland and Wales and Northern Ireland).
Targeted drugs in use at the moment to treat advanced breast cancer are:
- Trastuzumab (Herceptin)
- Trastuzumab Emtansine (Kadcyla)
- Lapatinib (Tyverb)
- Pertuzamab (Perjeta)
- Everolimus (Afinitor)
- Bevacizumab (Avastin)
- Denosumab (Xgeva) – a new treatment for breast cancer that has spread to the bone
More information on the side effects of the individual drugs can be found on the Macmillan website.
Occasionally your oncologist may offer you the opportunity to take part in a clinical trial. Some of the latest clinical trials have been testing targeted therapies sometimes in conjunction with existing hormone therapies but trials could also look at combining existing treatments to make them more effective or reduce side effects.
There can be many benefits to taking part in a clinical trial and you would be very carefully monitored throughout and after the trial. You may, however, prefer to try one of the standard treatment options for your cancer. Whatever your decision, it will be respected and there will be no change to the way you are treated by your team.
We think the Cancer Research UK website offers some of the most comprehensive information about clinical trials including some of the actual trials which may be open to you.
These drugs are used to treat advanced breast cancer that has spread to the bones and can help by relieving pain, preventing fractures and controlling the amount of calcium in the bloodstream. They may be taken orally or given by infusion. Drugs commonly used are:These drugs are used to treat advanced breast cancer that has spread to the bones and can help by relieving pain, preventing fractures and controlling the amount of calcium in the bloodstream. They may be taken orally or given by infusion. Drugs commonly used are:
- Clodronate (Bonefos or Loron) given as a tablet taken once or twice a day
- Ibandronic acid (Bondronat) given as a tablet once a day or an infusion 3 or 4 weekly
- Zoledronic acid (Zometa) given as an infusion 4 weekly
- Pamidronate given as an infusion 3 or 4 weekly
The side effects of bisphosphonates are usually mild. Some people just have a reaction at the beginning of treatment with a fever/flu type reaction. The most commonly reported side effects of bisphosphonates include: bone and joint pain, tiredness, flu-like symptoms, constipation, diarrhoea, low calcium levels and nausea.
A rare, but potentially serious side effect of bisphosphonates is osteonecrosis of the jaw. Prior to starting any bisphosphonate treatment, you will be advised to get a thorough dental check and it is important that when on treatment you let your team know immediately if you have any jaw pain or toothache. Invasive dental procedures like root canal fillings and extractions should, wherever possible, be avoided while on treatment.
Radiotherapy is a localised treatment for advanced breast cancer using high energy rays to destroy cancer cells. The rays destroy the cells within the area being treated so multiple areas can be treated at the same time. Radiotherapy is used mainly if your cancer has spread to the bones, lymph nodes under the armpit, skin or brain. The aim of the treatment is to control your disease and to relieve painful symptoms.
The side effects will vary depending on the part of the body being targeted but, as treatment is normally given as a short course over a few days, side effects are usually quite mild. Radiotherapy keeps working after treatment has finished and some people find their symptoms get worse initially until the full benefits can be seen up to two weeks after treatment.
STEREOTACTIC RADIOTHERAPY OR RADIOSURGERY
Stereotactic radiotherapy. also referred to as Gamma Knife or CyberKnife treatment, is a very precise radiation treatment which is most commonly used for brain metastases. Radiotherapy beams are aimed at the tumour from many different angles and because the tumour is targeted so specifically, higher doses of radiotherapy can be given. Sometimes the treatment can be used in other areas of the body such as lungs, liver or spine but this would only be considered for people with one or more small isolated metastases presenting in just one area of the body. If you only have 1 to 5 treatments of very high dose stereotactic radiotherapy, this is called radiosurgery. Stereotactic radiotherapy has very few side effects because less healthy tissue is exposed to the radiation.
As this is such a specialised treatment, it is not available at all hospitals. If your team thinks that this treatment may be an option for you, you will be referred to one of the specialist treatment centres.
Occasionally surgery may be an option for secondary breast cancer to remove a tumour if your cancer is very small and accessible.
It may be possible to operate to remove a small cancer in a single area of the liver or lung but this is major surgery and is only carried out by specialist surgeons. If you have one or a small number of secondary tumours in the brain, you may be referred to a neurosurgeon to assess if surgery is an option. If brain surgery is an option, you will usually have radiotherapy after you have recovered from the surgery to ensure that any small areas of cancer too small to be picked up on a scan can also be targeted.
The most common type of surgery used in advanced breast cancer is surgery to strengthen or replace a diseased bone where a surgeon will use a pin or metal plate to hold the bone in place and prevent it from fracturing. Surgery may also be used to replace a hip joint if it has been weakened by cancer in the bone.
Spinal cord compression is an acute medical emergency and sometimes surgery is used to help relieve pressure on your spinal cord and strengthen the spine. If a tumour is causing pressure on the spine, your surgeon will try to remove the tumour and any bone that is pressing on the spinal cord. They may undertake a technique called vertebroplasty which uses a special cement to fill any gaps or your surgeon may put steel or titanium rods into your spine to stabilise or strengthen your spine.
RADIOFREQUENCY ABLATION (RFA)
Radiofrequency ablation can be used to treat secondary liver cancer. It uses radio waves to destroy cancer cells by heating them to high temperatures. A fine needle is inserted into the centre of each tumour within the liver guided from a CT scan or ultrasound. Radio waves pass through the needles into the tumours, heating and destroying the cancer cells. The technique can treat tumours up to 5cm in size and can be repeated.
Normally the procedure is done as an outpatient. Side effects of the treatment may include bleeding, so you will be closely monitored before being allowed home.
SELECTIVE INTERNAL RADIATION THERAPY (SIRT)
SIRT is a relatively new technique which may sometimes be used for advanced breast cancer which has spread to the liver. The treatment involves having millions of microspheres (very tiny radioactive beads) injected into the liver which gives a very high dose of radiotherapy to the liver. This treatment will only be suitable if your disease is either confined to the liver or is stable elsewhere.
The treatment is done is two stages. Prior to the main treatment, an angiogram will be done to look at the blood flow within the liver to ensure that the microspheres don’t travel to other parts of the body when the treatment is given. This involves inserting a catheter in the groin which passes up into the hepatic artery. The second stage of the treatment is when the microspheres are injected through a catheter where they become stuck in the small blood vessels around the tumour.
The amount of radiation given off by the microspheres lasts for 10-14 days and damages both the cancer cells and the blood vessels feeding the tumour. The treatment requires a hospital stay of between 1-4 days and side effects can include fevers, abdominal pain, nausea, vomiting or diarrhoea. This treatment is normally not available on the NHS for advanced breast cancer.
Transcatheter Arterial Chemoembolisation (TACE) is a localised treatment which can be used for advanced breast cancer in the liver. The treatment allows a higher dose of chemotherapy to be injected directly into the liver via a catheter which goes from the groin to the hepatic artery. It is usually carried out under a local anaesthetic by an interventional radiologist. Typical side effects are pain, fever and tiredness. In certain circumstances the treatment can cause irreversible liver damage or cirrhosis which is why it is recommended that the treatment should be restricted to a single lobe of the liver or major branch of the hepatic artery at any one time. The treatment may be repeated if successful.
Cryotherapy, also called cryosurgery or cryoablation, uses extreme cold to destroy cancer cells. It can be used to treat advanced breast cancer which has spread to the liver in tumours up to 4cm in size. A probe is inserted into the centre of the tumour and liquid nitrogen is passed through the probe which freezes the surrounding area and destroys the cancer cells. The procedure usually involves a short stay in an intensive care unit followed by 2-3 days on a specialist liver treatment ward. Side effects may include pain and possibly fevers.
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