Breast Cancer, Metastatic or Recurrent

Topic Overview

Is this topic for you?

This topic provides information about breast cancer that has spread or come back after treatment. If you are looking for information about first-time diagnosis and treatment of breast cancer, see the topic Breast Cancer.

What are metastatic and recurrent breast cancer?

Breast cancer occurs when abnormal cells grow out of control in one or both breasts. Treatment often cures breast cancer if it is found before it has spread.

But even after treatment that seemed to work, cancer can come back (recur) or spread (metastasize) to other parts of the body. Cancer that comes back in or near the original site is called locally recurrent breast cancer. Cancer that spreads to other parts of the body is called metastatic breast cancer.

For most women who have had breast cancer, their greatest fear is that the cancer will come back or spread. Finding out this has happened can turn your world upside down. But there is hope. Treatment can often cure recurrent breast cancer. Although metastatic breast cancer usually cannot be cured, treatment can help you manage the disease and live longer. Some women live for many years, managing their cancer like a long-term health problem.

Why does breast cancer come back after treatment?

Even with the best treatment, cancer can come back. If just a small cluster of cancer cells remains in your body, those cells can spread through the blood or lymph system and grow. This may happen from a few months to many years after the first diagnosis.

If your breast cancer has come back, you may be tempted to second-guess your previous treatment choices. But the fact is, there is no guarantee with any treatment.

The treatment decisions you and your doctor made in the past were the right ones at that time. But now it is time to make new decisions and explore other treatment options.

What are the symptoms?

The symptoms depend on where the cancer is and how large it is. The most common places for breast cancer to spread are within the breast or to the nearby chest wall or to the liver, lungs, or bones. Common symptoms include a lump in your breast or on your chest wall, bone pain, or shortness of breath.

You may not have any symptoms. Sometimes recurrent or metastatic breast cancer is found with an X-ray or lab test.

How is it treated?

To plan your treatment, your doctor will consider where the cancer is and what type of treatment you had in the past. Your wishes and quality of life are also important factors. Treatment choices may include surgery, medicines like chemotherapy or hormone therapy, and radiation. Sometimes a mix of these treatments is used.

Treatments for breast cancer can cause side effects. Your doctor can tell you what problems to expect and help you find ways to manage them.

Clinical trials to test new cancer treatments are going on all the time. Ask your doctor if it would be a good idea to take part in one of these studies.

If treatments have not worked, a time may come when your goal shifts from curing the disease to staying as comfortable as you can. Palliative care can provide symptom relief and support for you and your loved ones so you can make the most of the time you have left.

How can you handle your feelings about having breast cancer again?

It is common to have a wide range of emotions. It may be hard to stay hopeful when you are fighting cancer for the second or third time. These ideas may help.

• Get the support you need. Spend time with people who care about you, and let them help you. Talk to your hospital social worker if you need help with bills or other worries. Your local American Cancer Society may also be helpful.
• Take good care of yourself. Get plenty of rest. Eat healthy meals. Get regular exercise. Try meditation or guided imagery to help you relax. These steps can help you feel as well and stay as healthy as you can.
• Talk about your feelings. Find a support group. Talking with other people who have breast cancer can be a big help. Sharing your experience can help others too.
• Do everything you can to stay positive. Set a goal each day to do something special for yourself or someone else.

If your emotions are too much to handle, be sure to tell your doctor. You may be able to get counseling or other types of help.

You may want to think about planning for the future. A living will lets doctors know what type of life-support measures you want if your health gets much worse. You can also choose a health care agent to make decisions in case you are not able to. It can be comforting to know that you will get the type of care you want.

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Cause

The exact cause of breast cancer is not known. After you have had breast cancer, you have a higher than average risk of cancer. When cancer comes back or spreads, it is called recurrent or metastatic breast cancer. In most cases, a recurrence will show up within 5 to 10 years after a first diagnosis.¹

Although cancer is always treated aggressively, if even a small cluster of cancer cells is missed, cancer can come back (recur). If your breast cancer has recurred, you may feel angry or frustrated and may second-guess your previous treatments. And you may lose hope. But recurrent or metastatic breast cancer can be treated successfully. Some women live for many years, managing their cancer like a long-term health problem. The treatment decisions you and your doctor made in the past were the right ones at the time.

Symptoms

The symptoms of metastatic and recurrent breast cancer depend on how much the cancer has spread. You may have specific physical symptoms, such as a lump in your breast or on your chest wall, bone pain, or shortness of breath. Many women do not have symptoms. Recurrent or metastatic breast cancer is often found before symptoms appear, either on a chest X-ray or as part of another test.

Recurrent breast cancer

If you have cancer that recurs in the same area (local recurrence), you may have symptoms such as:

• A lump or thickening in the breast, chest wall, or armpit after you have had breast-conserving surgery or a mastectomy . You may notice that the skin of your chest looks or feels different.
• A change in the size or shape of the breast or a dimple or pucker in the skin of the breast.
• Discharge or bleeding from the nipple that occurs without squeezing the nipple (spontaneous discharge).
• A change in the nipple, such as a scaly or crusty look or a nipple that draws inward (retraction or inversion).

Metastatic breast cancer

Symptoms of metastatic breast cancer will depend on the area affected and how far your breast cancer has spread.

Inflammatory breast cancer

Inflammatory breast cancer is a specific type of breast cancer that involves the skin of the breast. It occurs when breast cancer cells form 'nests' and block the lymphatic drainage from the skin of the breast. Symptoms include redness, tenderness, and warmth. Thickening of the skin of the breast (orange peel appearance), rapid breast enlargement, and ridging of the skin of the breast may also occur. Some women may also develop itching, bruising, or a lump in the breast. See a picture of inflammatory breast cancer .

What Happens

Recurrent breast cancer

Recurrent breast cancer occurs when breast cancer comes back in or near the original location after treatment.

Local recurrence affects the skin of the breast or the chest wall. You may notice a change in the size or shape of your breast or a change in how your breast feels. If you had a mastectomy, you may notice small bumps along the scar line on your chest wall.

Regional recurrence affects nearby lymph nodes , such as those under the arm (axillary lymph nodes) or in the neck (supraclavicular lymph nodes). You may have swollen lymph nodes in your neck or under your arm. Your arm may also swell.

Both types of recurrence can often be treated with surgery and radiation therapy and are not the same as metastatic breast cancer.^{2, 3}

Metastatic breast cancer (distant recurrence)

Metastatic breast cancer occurs when cancer cells travel from the breast, either through the bloodstream or the lymphatic system, to other parts of the body and cause cancer in their new location. It is sometimes called "distant recurrence." If metastatic breast cancer cells affect your bones, you may have bone pain, and your bones may break more easily. Cells that travel to your lungs may make you short of breath. If your liver is affected, you may have swelling in your belly or yellow-looking, itchy skin. Breast cancer that affects the brain can cause confusion, changes in your vision, and even seizures.

Metastatic breast cancer can be present when a woman is first diagnosed with breast cancer or may occur months to years after treatment.¹

What Increases Your Risk

You have a risk of having metastatic or recurrent breast cancer if you have ever had breast cancer. Although the exact cause of breast cancer is not known, older women have the highest risk.⁴

Recurrent breast cancer

Breast cancer recurs in less than a third of all women after the initial diagnosis. Recurrence is highest in the first 5 years after treatment but can occur at any time.^{1, 5} The recurrence of breast cancer depends on many factors. No one can predict who will have recurrent breast cancer, but information about your breast cancer-such as the stage, how it looks under the microscope (classification), whether you had positive lymph nodes, and whether you have hormone receptors-can help predict how you will respond to treatment.

Metastatic breast cancer

Metastatic breast cancer doesn't usually show up until many months to years after the initial diagnosis of breast cancer. In a very small number of women, breast cancer has already traveled to another part of the body by the time the cancer is diagnosed.¹

When To Call a Doctor

You will have regularly scheduled follow-up visits with your doctor after you are treated for breast cancer. Some women with metastatic or recurrent breast cancer do not have any symptoms. This cancer is discovered on an X-ray or through other tests before symptoms appear.

When symptoms occur, they depend on the part of the body affected by the breast cancer. Call your family doctor, medical oncologist, radiation oncologist, or surgeon if you have any symptoms that last for more than 1 to 2 weeks, including:

• A lump or sore in your breast or on your chest wall.
• Swelling in the armpit or neck.
• Swelling of the arm.
• Bone pain, especially in the back or hips.
• Shortness of breath or a cough.
• Loss of appetite.
• Extreme tiredness.
• Nausea or vomiting.
• Recurrent headaches.

Watchful Waiting

There is no watchful waiting for metastatic breast cancer. A focus on symptom control may be considered if your breast cancer is so advanced that available treatment is not likely to improve your quality of life or survival time. You may receive treatment to control other symptoms, such as pain. Discuss your situation with your doctor to determine whether a focus on symptom control may be right for you.

Who To See

If you have received treatment for breast cancer, health professionals who can evaluate new problems include a:

• Medical oncologist.
• Radiation oncologist.
• Surgeon.
• Family medicine doctor.

To prepare for your appointment, see the topic Making the Most of Your Appointment.

Exams and Tests

Metastatic disease is present in a small number of women at the time breast cancer is first diagnosed. Breast cancer recurs in as many as 1 in 3 women after the initial diagnosis.¹ Your doctor may use the following tests to determine whether breast cancer has metastasized or recurred.

• Blood and tissue tests may include the following:
  • Blood tests, such as a complete blood count (CBC) and a blood profile, are used to investigate the cause of symptoms such as fatigue, weakness, fever, bruising, or weight loss.
  • Biopsy is a tissue sample of the suspected metastasis, such as a liver biopsy or a lung biopsy.
• Medical imaging studies may include the following:
  • Abdominal ultrasound produces a picture to determine the cause of abdominal pain or increased abdominal girth.
  • Chest X-ray produces a picture to help determine whether symptoms such as persistent coughing, coughing up blood, chest pain, or difficulty breathing are caused by metastatic disease involving the lungs.
  • CT scan produces a picture to help determine whether breast cancer has spread into the chest or organs in the abdomen or pelvis.
  • CT scan or MRI of the head produces a picture of the brain to evaluate symptoms such as confusion, paralysis, numbness, vision problems, vertigo, or headaches that might be signs of metastatic disease.
  • Bone scan or MRI of the spine produces a picture of the spine to determine whether pain in the back, hips, or pelvis may be caused by metastatic disease.

Tests your doctor may use to evaluate recurrent breast cancer that is confined to your breast (local recurrence) include:

• Mammogram, to screen for breast cancer and investigate lumps that can be felt during a breast exam.
• Clinical breast exam (CBE), to check for lumps or other unusual changes.
• Ultrasound, to investigate a lump found during a clinical breast exam or on a mammogram. Breast ultrasound is also used to locate lumps that could be cancerous and to distinguish between solid lumps and fluid-filled (cystic) lumps.
• Magnetic resonance imaging (MRI), which is sometimes used to locate lumps that could be cancerous and to distinguish between solid lumps and fluid-filled (cystic) lumps.
• Breast biopsy, to remove a sample of breast tissue and examine it under a microscope for signs of cancer. Tests that may be performed on any breast cancer cells that are found include:
  • Estrogen and progesterone receptor status, to determine whether these hormones influence tumor growth.
  • HER-2 receptor status, to determine whether a protein that regulates the growth of some breast cancer cells is present.

What to think about

You have a risk of developing recurrent breast cancer if you have had breast cancer in one breast. To be sure that the cancer has not returned, you will have regular checkups that include physical exams and mammograms.

If you find any unusual changes in the treated area or in your other breast, or if you have swollen lymph glands or bone pain, call your doctor to discuss these changes.

Treatment Overview

Decisions about how to treat metastatic or recurrent breast cancer are based on a combination of factors that include specific information about the cancer, your preferences, and your health.

• Because breast cancer can now be discovered at a much earlier stage, most women will not have metastatic or recurrent disease.
• Although most metastatic breast cancer cannot be cured, you can live for several years with treatment that will improve the quality of your life.
• The type of treatment you receive depends on your general state of health and how active you are (performance status).

Initial treatment

The treatment you receive depends on your symptoms, the area of your body involved, and whether your breast cancer has spread. Treatment may include:

• Hormone therapy with medicines such as tamoxifen or an aromatase inhibitor. These medicines are used if your breast cancer has estrogen receptors. Aromatase inhibitors are only used if you have already completed menopause.
• Trastuzumab (Herceptin), for HER-2 breast cancer. It is used to stop the cancer from coming back and to control breast cancer that has spread.
• Chemotherapy with medicines such as doxorubicin, taxol, or cyclophosphamide.
• Bisphosphonates, to reduce bone pain, fractures, and spinal cord compression caused by metastatic disease in the bones.
• Radiation treatments, to destroy cancer cells that are causing problems in a specific area.
• Surgery for a local recurrence. For example, you might have a mastectomy if breast cancer has returned to your breast after you had breast-conserving surgery. Some studies have shown better survival rates for women who have the primary tumor removed even when the cancer has already spread.⁶
• Corticosteroids, to reduce inflammation and swelling caused by metastatic disease of the brain and spinal cord.

Clinical trials that test new medicines and new combinations of medicines are ongoing. Talk with your doctor about participating in a clinical trial.

The length of time between visits to your doctor depends on the type of treatment you are receiving and your response to the treatment.

Emotional needs

If you have recently been diagnosed with metastatic or recurrent breast cancer, you may experience a wide variety of emotions. There is no "normal" or "right" way to react. You may feel angry or frustrated and may second-guess your previous treatments. And you may lose hope. But recurrent or metastatic breast cancer can be treated successfully. Some women live for many years, managing their cancer like a long-term health problem. The treatment decisions you and your doctor made in the past were the right ones at that time. But now, new decisions must be made and treatment objectives must be explored.

Get the support you need. There are many different types of support programs, including individual or group counseling and support groups. Some groups are formal and focus on learning about cancer or dealing with feelings. Others are informal and social. All types of support help you explore your feelings and develop coping skills. Thanks to the Internet, it's also possible to find women who are very willing to listen to you and share their own experiences through online support groups and chat rooms. Studies have found that people who take part in support groups have an improved quality of life, sleep better, and feel more like eating. Contact your local chapter of the American Cancer Society to help you find a support group. Talking with other people who may have had similar feelings can be very helpful.

Do not be afraid to ask for help. During times of emotional distress, it is important to allow other people to take over some of your responsibilities. Other people often feel the need to show you how much they care about you.

You may feel lonely and separate from other people. You may think that no one else can understand the depth of your feelings. Surrounding yourself with people that you love and talking about your feelings and concerns may help you feel less lonely and more connected with others.

Try alternative activities, such as meditation or guided imagery, to help you relax. Do not use alcohol or illegal drugs. Tell your doctor if you are using herbal preparations or other complementary treatments.

If the stress of having cancer is interfering with your ability to make decisions about your health, it is important to tell your doctor. Your cancer treatment center may offer psychological or financial services.

Staying hopeful when you have metastatic cancer

Living with cancer is one of the greatest challenges you will ever face. You may find it difficult to stay hopeful when you are fighting cancer for the second or third time. The following suggestions may help.

• Set goals and make every day special. Keeping a positive outlook can seem impossible at times. And, at times, it is okay to be frustrated and angry and to wonder, 'Why me?' These are all normal and necessary emotions. But, they don't do anything to help you enjoy quality of life. Turn your attention to making every day special. Set a goal each day to do something special for yourself or someone else. Consider getting a new pet to care for, or try planting a garden. Support others who have cancer.
• Seek support. Surround yourself with people who encourage and motivate you. Sources of support may include:
  • Another cancer survivor.
  • Family and friends.
  • Health professionals. Keep in contact with your health professionals. Let them know if you are having difficulties with any area of your care or if something has changed in your health or lifestyle that may require an adjustment in your cancer treatment.
  • Clergy or a grief counselor.
  • An organized cancer support group. Look for opportunities to attend meetings or classes where you can receive new cancer information or simply receive reinforcement of concepts that are already familiar to you.
• Keep things in perspective. Remember that cancer is a part of your life, but it does not have to take over your life. Also, remember that you are not alone. Cancer is very common-many other people have cancer. Enjoy today. None of us can be sure how long we are going to live, but we can all make the conscious decision to enjoy each day.
• Think positive. Continually remind yourself that everything you are doing to treat your cancer is making a difference in the quality of your life now and well into the future. It may be helpful to make a list of the health benefits of properly treating your disease and keep the list close at hand. Include things on the list that are important to you.

Side effects

Breast cancer and the treatment for it can cause may side effects. There are many things you can do at home to help manage these side effects. Let your doctor know if you are having problems with side effects and what you are doing to manage them. Your doctor may be able to prescribe medicines or other treatments to improve your sense of well-being and your quality of life. Good communication with your doctor can help prevent problems.

Treatment if the condition gets worse

Although many women with locally recurrent breast cancer are cured, metastatic breast cancer is usually a progressive condition. But with newer treatment techniques, some women live for many years, managing their cancer like a long-term health problem.

Second-line treatments with different chemotherapy drugs are commonly used. New drugs continue to become available. And you can consider talking to your doctor about getting treatment through a clinical trial.

Your doctor can address questions or concerns about maintaining your comfort if treatment to control the progression of your breast cancer is no longer an option.

For more information, see the topic Cancer Pain.

Palliative care

As your cancer gets worse, you may want to think about palliative care. Palliative care is a kind of care for people who have illnesses that do not go away and often get worse over time. It is different than care to cure your illness, called curative treatment. Palliative care focuses on improving your quality of life-not just in your body, but also in your mind and spirit. Some people combine palliative care with curative care.

Palliative care can help you manage symptoms or side effects from treatment. It could also help you cope with your feelings about living with a long-term illness, make future plans around your medical care, or help your family better understand your illness and how to support you.

If you are interested in palliative care, talk to your doctor. He or she may be able to manage your care or refer you to a doctor who specializes in this type of care.

For more information, see the topic Palliative Care.

End-of-life issues

A time may come when your goals or the goals of your loved ones may change from treating an illness to maintaining your comfort and dignity. Your oncologist will be able to address questions or concerns about maintaining your comfort when cure is no longer an option. Hospice health professionals can provide palliative care in the comfortable surroundings of your own home. For more information, see the topic Hospice Care.

You may wish to discuss with your doctor and your family the health care and other legal issues that arise near the end of life. It may be helpful and comforting to state your health care choices in writing (with an advance directive, such as a living will) while you are still able to make and communicate these decisions.

Think about your treatment options and which kind of treatment will be best for you. You may wish to choose a health care agent to make and carry out decisions about your care if you become unable to speak for yourself. For more information, see the topic Care at the End of Life.

Prevention

Initial treatment of breast cancer with chemotherapy or hormone therapy can help prevent metastatic or recurrent breast cancer. For women with estrogen receptor-positive (ER+) breast cancer, treatment with tamoxifen or an aromatase inhibitor, or both, can also help prevent recurrence. Recent studies have shown that an aromatase inhibitor, such as exemestane (Aromasin), works even better than tamoxifen in postmenopausal women who are also ER+.^{7, 8} For more information, see the topic Breast Cancer.

Home Treatment

During treatment for metastatic or recurrent breast cancer, you can use home treatment to help manage the side effects that often occur with breast cancer or cancer treatment. Home treatment may be all that is needed to manage the following common problems. In general, healthy habits such as eating a balanced diet and getting enough sleep and exercise may help control your symptoms. Be sure to follow any instructions and take any medicines your doctor has given you to treat these symptoms.

• Nausea or vomiting. If you have problems with nausea and vomiting while you are taking chemotherapy or receiving radiation therapy, let your doctor know. Prescription medicine is available to prevent and treat nausea and vomiting that may be caused by treatment. It is important to let your doctor know if you have nausea or vomiting in spite of the use of this medicine. Home treatment for nausea or vomiting includes watching for and treating early signs of dehydration, such as a dry mouth, sticky saliva, and reduced urine output with dark yellow urine. For more information on how to deal with these side effects, see:

  Cancer: Controlling nausea and vomiting from chemotherapy.

• Pain. Not all forms of cancer or cancer treatment cause pain. If you have pain, many treatments are available to relieve it. Be sure to follow the instructions and take the medicines that your doctor has given you to treat these symptoms. You may use home treatment for pain to improve your physical and mental well-being. Be sure to discuss with your doctor any home treatment you use for pain.
• Diarrhea. Some chemotherapy medicines can cause diarrhea. Let your doctor know if you have diarrhea while you are on treatment. Radiation therapy to the chest should not cause diarrhea. Home treatment for diarrhea includes resting your stomach and being alert for signs of dehydration. Check with your doctor before you use any nonprescription medicines for your diarrhea.
• Constipation. Pain medicines, chemotherapy, and medicines used to treat nausea and vomiting related to chemotherapy can sometimes cause constipation. Let your doctor know if you have problems with constipation after surgery or while you are on chemotherapy. Radiation therapy to the chest should not cause constipation. Home treatment for constipation includes gentle exercise along with enough fluids and a diet that is high in fruits, vegetables, and fibers. Check with your doctor before you use a laxative for constipation.
• Fatigue. Breast cancer and treatment for it can cause fatigue. Your emotional reaction to a diagnosis of breast cancer and the stress related to treatment may make you feel tired. Some fatigue is expected after surgery and during both chemotherapy and radiation therapy. Fatigue is often worse at the end of treatment or just after treatment is completed. Home treatment for fatigue includes making sure you get extra rest while you are receiving chemotherapy or radiation therapy. Let your symptoms be your guide. You may be able to stay with your usual routine and just get some extra sleep. Let your doctor know if you are feeling unusually tired.

You may have other issues, including:

• Hair loss from chemotherapy. This can be emotionally distressing. Not all chemotherapy medicines cause hair loss, and some people have only mild thinning that is noticeable only to them. Other treatments, including hormone therapy (such as tamoxifen) and radiation therapy, do not cause hair loss. Talk to your doctor about whether hair loss is an expected side effect with the medicines you receive.
• Swelling of the arm (lymphedema). Normally, lymph nodes filter fluid as it flows through them, trapping bacteria, viruses, and other foreign substances, which are then destroyed by white blood cells called lymphocytes. Lymph nodes are removed from under the arm to help determine the stage of your breast cancer. When these lymph nodes are removed in an axillary dissection, fluid can build up in the affected arm, and you can develop lymphedema. Medicines such as tamoxifen, radiation therapy, and injury to the lymph nodes can also cause lymphedema. Not everyone will have a problem with lymphedema. You can reduce your risk of developing lymphedema by protecting your arm on the side where you had surgery and letting your doctor know right away if you have swelling or redness in that arm. For more information, see:

  Lymphedema: Managing lymphedema.

• Sleep problems. If you have trouble sleeping, you may find that having a regular bedtime, getting some exercise during the day, avoiding naps, and using other tips to relieve sleep problems may help you sleep more easily. Tell your doctor if you continue to have difficulty sleeping.

Emotional needs

If your breast cancer has come back, you may feel angry or frustrated and may second-guess your previous treatments. And you may lose hope. But some women live for many years, managing their cancer like a long-term health problem. The treatment decisions you and your doctor made in the past were the right ones at that time. But now, new decisions must be made and treatment objectives must be explored.

• You may be able to reduce your stress by talking about your feelings to others. Stress and tension affect our emotions. By discussing your feelings with others, you may be able to understand and cope with them. Learning relaxation techniques may also help you reduce your stress.
• Expressing yourself through writing, crafts, dance, or art is a good tension reliever. Some dance, writing, or art groups especially for individuals diagnosed with cancer may be available.
• Join a support group. Talking about a problem with your spouse, a good friend, or other people with similar problems is a valuable way to reduce tension and stress. Social support is very important both during and after treatment. Talk to your doctor or contact the American Cancer Society to find out about support groups in your area. If you have access to the Internet, you may also find an online support group.
• Your feelings about your body may change after a diagnosis of breast cancer and the need for treatment. Adapting to your body image changes may involve talking openly about your concerns with your partner and discussing your feelings with your doctor. Your doctor may also be able to refer you to organizations that can offer additional support and information.

If your reaction is interfering with your ability to make decisions about your health, it is important to talk with your doctor. Your cancer treatment center may offer psychological or financial services.

End-of-life issues

A time may come when your goals or the goals of your loved ones may change from treating an illness to maintaining your comfort and dignity. Talk to your doctor about prescription medicines to help you manage pain and other symptoms that may happen along with metastatic breast cancer. Your oncologist will be able to address questions or concerns about maintaining your comfort when cure is no longer an option. Hospice health professionals can provide palliative care in the comfortable surroundings of your own home. For more information, see the topic Hospice Care.

You may wish to discuss with your doctor and your family any health care issues and other legal issues that arise near the end of life. It may be helpful and comforting to state your health care choices in writing (with an advance directive or living will) while you are still able to make and communicate these decisions.

Think about your treatment options and which kind of treatment will be best for you. You may wish to choose a health care agent to make and carry out decisions about your care if you become unable to speak for yourself. For more information, see the topic Care at the End of Life.

Medications

Metastatic or recurrent breast cancer is treated with a variety of medicines, including chemotherapy and hormone therapy. The treatment regimen your doctor suggests for you depends on your symptoms, characteristics of your breast cancer, location, degree of spread, and prior treatment you have had.

Medication Choices

Medicines that may be used include:

• Hormone therapy with aromatase inhibitors, tamoxifen, antiestrogens (such as fulvestrant), or Megace.
• Chemotherapy. Usually a combination of medicines is used.
  • The most commonly used combinations are AC (which combines Adriamycin and Cytoxan) and CMF (which combines Cytoxan, methotrexate, and 5-FU).
  • Other medicines that may be used to treat advanced breast cancer include Taxol, Navelbine, Taxotere, gemcitabine, lapatinib (Tykerb), and capectabine.
• Biological therapy with Herceptin to block the protein HER-2.
• Corticosteroids, which may be used if metastatic disease involves the brain or spinal cord. They are also used with other medicines to treat nausea and vomiting caused by chemotherapy.
• Bisphosphonates, such as Zometa, Didronel, or Aredia, may be used to reduce bone pain, high calcium levels, fractures, and spinal cord compression cause by metastatic breast cancer that involves the bones.

Treatment can often cause nausea and vomiting. Your doctor will prescribe medicines to be taken with your treatments and when you get home to help relieve any nausea that you may have. Medicines to control and prevent nausea and vomiting may include:

• Serotonin antagonists, such as ondansetron (Zofran), granisetron (Kytril), or dolasetron (Anzemet). These medicines work by blocking the effects of a chemical (serotonin), which is produced in the brain and the stomach and controls vomiting. They are more effective when they are combined with corticosteroids, such as dexamethasone, which reduce swelling in the part of the brain that controls nausea.
• Aprepitant (Emend), which is used in combination with ondansetron and dexamethasone as part of a 3-day program.
• Phenothiazines, such as promethazine and prochlorperazine. These medicines stop nausea and vomiting by reducing the activity of the central nervous system.
• Metoclopramide (Reglan), which increases the movements or contractions of the stomach and intestines. This decreases the amount of time it takes for the stomach contents to move through the digestive tract.
• Dimenhydrinate (Dramamine), which is often used to treat motion sickness. It relieves nausea by blocking motion signals to the brain.

Clinical trials are ongoing to test new chemotherapy and hormone therapy and new combinations of medicines. If you have been diagnosed with metastatic or recurrent breast cancer, talk with your doctor about participation in a clinical trial.

What To Think About

Although chemotherapy and hormone therapy are not likely to cure metastatic breast cancer, they can reduce symptoms and increase your quality of life, and they may help you live longer.

Talk to your doctor about prescription medicines to help you manage pain and other symptoms that may occur with metastatic or recurrent breast cancer. For more information, see the topic Cancer Pain.

Surgery

Surgery is not generally used to treat metastatic breast cancer. Mastectomy may be used to treat breast cancer that has recurred in the breast (local recurrence) following breast-conserving surgery and radiation.

Other Treatment

Metastatic breast cancer often affects the bones or the brain. Radiation treatments are often used to treat breast cancer that has spread to the bones or brain. They may be a good choice to treat brain metastases, relieve bone pain, and control the spread of the cancer. The treatments reduce pain and can control the spread of the breast cancer. The type and length of radiation therapy depends on the extent of the breast cancer, the area of the body affected, your general health, and other symptoms you may be having. Even though radiation treatments may not cure your cancer, they may improve your quality of life.

Clinical trials are ongoing to test other treatments for metastatic or recurrent breast cancer. If you have been diagnosed with metastatic or recurrent breast cancer, talk with your doctor about participation in a clinical trial.

Other Places To Get Help

Organizations

Related Information

• Breast Cancer
• Breast Problems
• Cancer Pain
• Fibrocystic Breasts

References

Citations

1. Ellis MJ, et al. (2004). Treatment of metastatic breast cancer. In JR Harris et al., eds., Diseases of the Breast, 3rd ed., pp. 1101-1159. Philadelphia: Lippincott Williams and Wilkins.

2. Ellis MJ, et al. (2000). Treatment of metastatic breast cancer. In JR Harris et al., eds., Diseases of the Breast, 2nd ed., pp. 749-797. Philadelphia: Lippincott Williams and Wilkins.

3. Wood WC, et al. (2005). Malignant tumors of the breast. In VT DeVita Jr et al., eds., Cancer: Principles and Practice of Oncology, 7th ed., vol. 1, pp. 1415-1477. Philadelphia: Lippincott Williams and Wilkins.

4. National Cancer Institute (2006). Probability of breast cancer in American women. National Cancer Institute Fact Sheet. Available online: http://www.cancer.gov/cancertopics/factsheet/Detection/probability-breast-cancer.

5. Weiss RB, et al., (2003). Natural history of more than 20 years of node-positive primary breast carcinoma treated with cyclophosphamide, methotrexate, and fluorouracil-based adjuvant chemotherapy: A study by the Cancer and Leukemia Group B. Journal of Clinical Oncology, 21(9): 1825-1835.

6. Rapiti E, et al. (2006). Complete excision of primary breast tumor improves survival of patients with metastatic breast cancer at diagnosis. Journal of Clinical Oncology, 24(18): 2743-2749.

7. Goss PE, et al. (2003). A randomized trial of letrozole in postmenopausal women after five years of tamoxifen therapy for early-stage breast cancer. New England Journal of Medicine, 349(19): 1793-1802.

8. Coombes RC, et al. (2004). A randomized trial of exemestane after two to three years of tamoxifen therapy in postmenopausal women with primary breast cancer. New England Journal of Medicine, 350(11): 1081-1092.

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