Metastatic Breast Cancer Awareness Day

 

Metastatic Breast Cancer Awareness Day

Hope and Strength: Living with Metastatic Breast Cancer

Being diagnosed with metastatic breast cancer generally comes as a shock. But it’s still possible to treat breast cancer even if there are metastases. With well-planned and individualized treatment, it’s often possible to live with the disease for years with a good quality of life.

What is Advanced Breast Cancer?

The diagnosis “advanced breast cancer” can have several meanings.

If it refers to “metastatic breast cancer”, the cancer has spread outside the breast in the body — for example to the bones, lungs or liver. In rare cases, the brain or skin can be affected. In most cases, metastatic breast cancer is a relapse following treatment for early-stage breast cancer. In around three out of 100 women, breast cancer is only discovered when it has already metastasized.

However, advanced breast cancer can also be a recurrence. In this case, the breast cancer has recurred in the same breast and is referred to as a “local recurrence”. It can also develop if the entire breast has previously been surgically removed (mastectomy) — for example on the chest wall or as a “locoregional recurrence” in the neighboring lymph nodes.

How Do Metastases Develop?

When breast cancer metastasizes, cancer cells might separate from the original tumor. They spread to other parts of the body through the blood or lymphatic fluid. They are usually detected and destroyed by the body’s immune system — but not always. The cancer cells then spread to other organs, forming a new, developing malignant tissue known as a metastasis. Metastases displace healthy tissue and impair the function of infiltrated organs. This may result in pain and serious complications. Overall, one in four patients develops metastases in the further course of the disease.

Despite the fact that research has discovered an array of factors, it is still unclear why some cancer cells detach from the initial tumor and multiply elsewhere. It is also still not known why metastases arise in some women many years after their initial disease.

Why Does Breast Cancer Comes Back?

In the initial treatment of breast cancer, attempts are made to render all cancer cells harmless through surgery, radiation or medication. However, despite all medical advances, it is not always possible to destroy all tumor cells. Whether these remaining tumor cells start growing again, locally or as metastases, is not predictable. However, a number of risk factors are known.

The likelihood of a relapse depends on the initial tumor staging (read more about breast cancer staging in our earlier blog), the tumor biology such as hormone receptor status, and the age of the patient.

The spread of a tumor and thus its characteristics influence which surgical method is used to treat it. As a result, the risk of recurrence is often divided into two situations:

• After breast-conserving surgery, five to ten out of 100 patients develop another tumor in the same breast (recurrence) within ten years of the initial treatment — in the remaining breast tissue and/or in the directly adjacent lymph nodes.
• After a complete removal of the breast (mastectomy), a tumor in the chest wall and/or the immediately adjacent lymph nodes can recur in four to 20 out of 100 patients within ten years of the initial treatment.

The time factor is also crucial: the highest risk of recurrence is in the three years following the initial diagnosis. However, more than half of the relapses only occur from the fifth year onwards. These are mostly metastases. Important to know: Lifestyle plays only a minor role in both the development of breast cancer and the development of metastases.

What Signs May Indicate Relapse?

Possible signs of a recurrence in the already diseased breast (local recurrence) can be nodular changes or reddening of the skin.

Metastases can be accompanied by different symptoms depending on the organ affected.

• in the bones: pain and in some cases unexplained bone fractures
• in the lungs: cough or shortness of breath
• in the liver: feeling of fullness, loss of appetite, digestive problems, unexplained weight loss
• in the brain: possible signs include headaches, paralysis, sensory disturbances, dizziness, severe fatigue, confusion

It is important that you seek medical advice if you have unclear symptoms. Your treatment team will clarify the symptoms using the appropriate examination methods.

You can help to detect a relapse at an early stage by attending follow-up appointments and regularly examining your breasts yourself.

How to Treat Recurrent and Metastatic Breast Cancer

The treatment of a local recurrence aims to cure. The treatment is similar to that for early-stage breast cancer, with surgery (typically a mastectomy) followed by radiotherapy. Depending on the individual situation and risk factors, a subsequent pharmacological therapy may be beneficial.

In contrast, metastatic breast cancer is currently incurable and is treated with the following objectives:

• avoiding or alleviating symptoms
• prolonging life
• maintaining quality of life

In most cases, surgery is no longer an option, as it is not possible to completely remove the spread cancer cells. Instead, your treatment team will suggest treatment options including radiotherapy, medication, and supportive treatment to alleviate symptoms.

Treating Metastases with Radiation

Radiotherapy can be used to treat some metastases in a targeted manner — usually in combination with other treatment methods such as medication. Bone metastases in particular respond well to radiotherapy. For example, it can alleviate pain caused by the metastases.

In individual cases, the following metastases can also be irradiated:

• in the liver
• in the soft tissues (for example connective tissue or muscles)
• in the brain
• in the skin

With the help of radiosurgery or stereotactic radiation, metastases can be treated specifically with a high dose of radiation, while the neighboring tissue is largely spared.

Chemotherapy for Recurrence or Metastases

Chemotherapy is only used in rare cases of metastatic breast cancer. These include

• rapid progression of the breast cancer.
• hormone receptor-negative breast cancer for which anti-hormone therapy is not effective.
• when the cancer cells no longer respond to anti-hormone therapy (resistance).

In these situations, medicine speaks of palliative (alleviating) rather than curative chemotherapy. It aims to prevent the further spread of tumor cells and alleviate symptoms. In this way, palliative chemotherapy may prolong life and maintain quality of life.

The course of chemotherapy depends on the patient’s individual situation. In some cases, it is combined with targeted medication.

Hormone Therapy in Metastatic Breast Cancer

Anti-hormone therapy in metastatic breast cancer follows the same rules as for early-stage breast cancer. The decision for anti-hormone therapy depends on the presence of hormone receptors in the tumor and on the onset of the menopause. Further treatment options are available for the anti-hormone therapy of metastatic breast cancer:

• Anti-Estrogen: In addition to the already known blockade of the estrogen binding site (tamoxifen), there are anti-estrogens (Fulvestrant) that completely switch off the hormone receptor and even lead to its degradation.
• Combination of anti-hormone therapy with targeted therapies: Targeted drugs interfere with certain signaling pathways or structures of a breast cancer cell, preventing it from dividing. They can also improve the effect of the anti-hormone therapy used at the same time.

Targeted Therapies for Hormone Receptor-Positive Breast Cancer

Three groups of active substances are available for the targeted therapy of hormone receptor-positive, metastatic breast cancer. They are usually taken once a day in tablet form.

mTOR inhibitors and anti-hormone therapy: mTOR is the abbreviation for “mechanistic target of rapamycin”. The enzyme mTOR kinase influences certain signaling pathways in cancer cells that play an important role in their growth. If the mTOR signaling pathway is overactive, hormone receptor-positive breast cancer cells can no longer respond to anti-hormone therapy. They become resistant. mTOR inhibitors block the mTOR signaling pathway and reverse the resistance so that anti-hormone therapy can work again.

PI3K inhibitors: In around 40 percent of patients with hormone receptor-positive breast cancer, changes in the PIK3CA gene are found in the cancer cells. It contains the blueprint for the enzyme PI3Kα, which influences the structure and growth of cells. Due to this mutation, the PI3Kα enzyme functions incorrectly and promotes the proliferation of tumor cells with uncontrolled growth signals. PI3K inhibitors can block the faulty enzyme and thus stop or slow down tumor growth.

CDK4/6 inhibitors and anti-hormone therapy: The abbreviation CDK4/6 stands for the enzymes “cyclin-dependent kinases 4 and 6”. Both influence cell division and are often overactive in hormone receptor-positive breast cancer cells. This can lead to uncontrolled division of cancer cells and thus to the growth of cancerous tissue. In addition, these cancer cells develop resistance to anti-hormone therapy. CDK4/6 inhibitors can slow down the proliferation of cancer cells and restore the effectiveness of anti-hormone therapy. CDK4/6 inhibitors are usually combined with aromatase inhibitors such as Tamoxifen.

Therapeutic Approaches Against Bone Metastases

Bone metastases in breast cancer are common. In around three quarters of breast cancer patients, they are discovered when the disease progresses. Bone pain is often the first sign of this. The aim of treatment is therefore to relieve pain, maintain bone stability and reduce the metastases.

If a metastasis settles in the bone, it releases various signaling substances that cause either increased bone resorption or bone formation. This means that they stimulate the cells responsible for bone resorption, the osteoclasts, to become more active. When the bone substance is destroyed, substances are released that stimulate the growth of the tumor cells and thus the formation of new metastases. A vicious circle is created. The aim of various medicinal approaches is to break this cycle.

The treatment of bone metastases in breast cancer is primarily aimed at preventing or alleviating pain, avoiding bone fractures and preventing further growth of the metastases. Although bone metastases are very rarely curable, the associated complications can be treated well.

Bisphosphonates: are stored in the bones and intervene directly in their metabolic processes. They thus prevent further bone resorption by osteoclasts. This also indirectly alleviates bone pain. These medicines are administered in the form of infusions or tablets. Bisphosphonates are generally well tolerated. Possible side effects depend on the form and dosage in which the medication is taken.

RANKL inhibitors: This antibody acts against a signaling substance known as “RANKL”, a protein that stimulates osteoclasts to break down bone and in this way prevents bone loss caused by metastases. The antibody is injected under the skin.

Surgery: Under certain conditions, it is even possible to surgically remove individual metastases from the bone and then irradiate the site. As a rule, however, surgical interventions for bone metastases are more likely to be carried out if, for example, a vertebral fracture is imminent or has already occurred. In this case, filling the fracture sites with a cement-like substance or silicone can stabilize the vertebrae and relieve pain.

Radiotherapy: is regarded as the most important local therapy measure against metastases. A distinction is made between two methods: external and internal radiation. External radiation is mainly used when individual, localized metastases are found in the bone. Radiation from the inside, known as radionuclide therapy, is used when there are numerous metastases. The most important goals of both forms of radiation are to relieve pain, destroy tumor cells, prevent bone fractures, and improve the function and mobility of the affected bones.

How Much Time Do I have?

Can a patient with metastatic breast cancer hope to be cured? How long can you live with metastatic disease? A general answer to these questions is not possible.

Statistics show that only very few women succeed in bringing the disease to a complete and permanent remission. The aim of treatment is to control the disease for as long as possible, prevent tumor-related symptoms and maintain quality of life. However, the current data also make it clear that more and more women with advanced breast cancer can expect to live for a long time despite the metastases. This is particularly true for women who only have bone metastases.

Their everyday life is then similar to that of many other people with a chronic illness: they may need treatment in the long term, but the disease does not have to dominate their lives all the time.

TheKnowHow Independent Second Opinion Service

Are you or a loved one suffering from advanced breast cancer? You are overwhelmed or unsure about further treatment?

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