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Symptoms

Most recurrences are diagnosed because of symptoms noticed by the woman. While scans used to be done to look for early metastases, that approach has been found to make no difference in the outcome. Diagnosing metastatic disease early on a scan or blood test does not make the treatment easier or more effective. This means you do not have to kick yourself for not complaining sooner. Symptoms appear differently in different areas of the body.

These are some of the most common sites of metastasis

Bone

This is the most common site of metastases in women with breast cancer. This is true partly because it’s more obvious there than in other places, and partly because it creates definite symptoms. Even if it first appears elsewhere, as the disease progresses it usually reaches the bone at some stage.

Metastasis to the bone is generally diagnosed when the patient experiences pain. Usually the pain you get with breast cancer in the bones is fairly constant and doesn’t improve over time, but it may wax and wane and/or it may move around. Also, the location is important. Pain in the feet, ankle, and hands is usually caused by arthritis or even by your treatment, as tamoxifen and especially the aromatase inhibitors can cause muscle and joint pain. In general, though, if you have pain that lasts for more than a week or two with no sign that it’s going away, and it isn’t like whatever other back pain or arthritic pains have become familiar to you, you should see your doctor. They will most likely recommend an X ray and then a bone scan, PET scan or CT scan depending on the situation.

Lung

We also see breast cancer metastasis fairly often in the lungs. Usually the symptoms are shortness of breath and/or a chronic cough. If your breast cancer has spread to your lungs, you may experience shortness of breath on less-than-normal exertion. It can be fairly subtle. It comes on slowly, since the cancer has to use up a lot of your lungs before it compromises your breathing.

Another form of metastasis in the lung is called lymphangitic spread. Here the cancer spreads along the lymphatics, and instead of forming nodules it occurs in a fine pattern throughout the lung. This isn’t all cancer since; some of the changes in lung are due to a back up of lymphatic drainage and fibrosis of these lymph channels. It’s subtler and harder to detect on a chest X ray. It ultimately causes shortness of breath, since it takes up room and scars the lungs, making them less able to expand and contract and bring oxygen into your bloodstream.

The third way it can show is through fluid in the pleura, the lining of the lung. (The pleura is a sack with a smooth lining around it; the lung sits in it so that it can move without sticking to the chest wall.) This usually indicates that the spread is in there rather than in the lung itself. The cancer creates fluid around the lung (effusion), and the fluid causes the lung to collapse partially. Here again, you’ll experience shortness of breath. Usually breast cancer in the lungs doesn’t cause pain.

If the doctors think your cancer may have metastasized to your lung and the chest X-ray doesn’t show nodules, fluid, or any of the other signs, then they may recommend a CT scan.

Liver

This is the third most common site for metastases. The symptoms occur because the cancer takes up a lot of room in the liver, and that takes some time to happen. The symptoms are common—weight loss,  loss of appetite, nausea, gastrointestinal symptoms, and pain or discomfort under your right rib cage. You may have some pain in the right upper quadrant of your liver, which occurs when the liver’s covering tissue is stretched out. A diagnosis of liver metastasis is often suspected from blood tests and confirmed by CT, MRI, PET scanning or, on occasion, ultrasound.

Brain

Adjuvant chemotherapy does not get into the brain as effectively as it does into the rest of the body. Because of this, we are seeing brain metastases with somewhat greater frequency as systemic adjuvant therapies have become better at eradicating disease outside the brain. Behavior or mental changes are sometimes, though rarely, caused by the tumor. You can have weakness or unsteadiness in walking, or seizures. It can resemble a stroke: you suddenly can’t talk, part of your body is abruptly very weak, or you can’t see out of one eye. Those kinds of symptoms occur when a portion of your brain is blocked, which cancer growth can cause. The best way to diagnosis it is through MRI or CT scan. About half of patients have one lesion; the rest has several.  Another kind of brain metastasis you can get is a form of meningitis called carcinomatosis meningitis. This affects the lining of the brain rather than the brain itself. It causes weakness in the eye and mouth muscles, headaches, stiff neck, and sometimes confusion, the way any form of meningitis does.

Spinal Cord

Most of the pain is aching and continuous. Its onset is gradual and it gets worse over time; it often becomes severe as it pushes on the spinal cord. It is also very localized: you feel it exactly on the spot where the tumor is. There is another kind of pain that goes downward the way sciatica does, when a disk compresses the nerves and goes down your leg, getting worse if you cough or sneeze. You may also feel pain in your shoulder or back from spinal cord compression. This is typically diagnosed by CT scan or MRI. Anyone with metastatic breast cancer who has unrelenting pain in one spot, and any neurological symptoms, should be concerned. If you have no other signs of metastasis, it probably isn’t spinal cord compression, since that’s rarely the first sign of metastatic disease, although it can be.

Eye

This is rarely the first place metastasis occurs, but breast cancer can spread to the eye. The initial symptoms are double or blurred vision. It’s diagnosed by CT scan or MRI. It’s also treated with radiation, which can often prevent loss of vision.

Bone marrow

The main symptom is anemia, caused by a decrease in the number of red blood cells, and the white blood cells and platelets can also decrease.

Frequently Asked Questions

How will I know if my cancer has spread to my lungs?

Many women who have metastatic breast cancer develop lung metastases. Usually the symptoms are shortness of breath and/or a chronic cough. The symptoms can be fairly subtle, and they typically come on slowly, since the cancer has to use up a lot of your lungs before it compromises your breathing.

There are a couple of different places the cancer can appear in your lung. One is in nodules—usually several—that show up on a chest X ray. If it shows up in only one nodule, your doctor will want to do a needle biopsy or a full biopsy to find out if it's lung cancer or a breast cancer that has spread. (Lung cancer usually starts in just one spot, but a cancer that has spread to the lung through the bloodstream or lymphatic channels is likely to hit multiple spots in the lung.)

Another form of metastasis in the lung is called lymphangitic spread. In this situation, the cancer spreads along the lymphatics and instead of forming nodules it occurs in a fine pattern throughout the lung. This isn't all cancer. Some of the changes in the lung are due to a lack of lymphatic drainage and fibrosis in the lymph channels. This type of metastasis is subtler and harder to detect on a chest X ray, but it, too, will ultimately cause shortness of breath, since it takes up room and scars the lungs, making them less able to expand and contract and bring oxygen into your bloodstream.

The third way it can show up is through fluid in the pleura, the lining of the lung. (The pleura is a sack with a smooth lining around it. The lung sits inside of this sack so that it can move without sticking to the chest wall.) This usually indicates that the cancer has metastasized only to the pleura and not the lung itself. In this situation, the cancer creates fluid around the lung (effusion), and the fluid causes the lung to collapse partially. This, too, will result in shortness of breath.

For lung metastases, the treatment is usually systemic—chemotherapy or hormone therapy. If you develop fluid in the pleura, it can be treated by sticking a needle into the chest and draining the fluid. This works immediately, but frequently for only a short time. Often the fluid comes back right away. In order to prevent the reaccumulation, your doctor may want to perform a procedure that will fasten the pleura to the lung itself. However, often an effective hormonal therapy or chemotherapy will keep the fluid in the lung from reaccumulating, at least for a while. Occasionally women with reocurring fluid will have a catheter left in so that they can be drained as needed. However, many women with such fluid in the pleura will get permanent relief by a combination of local drainage, scarring of the pleura, and a systemic therapy.

Among patients who die of breast cancer, 60–70% percent have it in their lungs. The lungs are the only obvious site of metastasis in about 21% percent of cases.

How will I know if my cancer has spread to my liver?

The liver is the third most common site for metastases. The symptoms of liver metastases, which are often quite subtle, don't begin to occur until after the cancer has taken up a lot of room in the liver, and that takes some time to happen.

The symptoms are common—weight loss, anorexia (loss of appetite), nausea, gastrointestinal symptoms, and pain or discomfort under your right rib cage. You may have some pain in the right upper quadrant of your liver, which occurs when the liver's covering tissue is stretched out.

A diagnosis of liver metastasis is often suspected from blood tests and confirmed by CT, MRI, PET scanning or, on occasion, ultrasound. The major treatment for extensive liver disease is chemotherapy, especially if your liver function blood tests are elevated. Hormone therapy can work well on hormone-sensitive and slower-growing liver metastases, and the decision to use it usually depends on the extent of damage present in the liver.

In certain kinds of cancer, like colon cancer, liver metastasis can be a single lesions or just a few, and thus on rare occasions can be cut out. But with breast cancer there is usually more than one spot involved and surgery becomes impossible. In the uncommon exceptions when there is only one spot, your surgeon will be able to remove part of the liver to relieve symptoms or use radiation therapy. But this is really a last resort when the patient has a large and painful liver that is not responding to chemotherapy.

There are also new techniques for a small number of liver metastases that involve putting hot (hyperthermia) or cold (cryosurgery) probes into the tumors and burning or freezing them. This can help the obvious spots but must be followed with systemic therapy to control the rest of the micrometastatic liver disease.

If you are in a lot of pain, your doctor may recommend that your liver be radiated, to shrink it. This is only typically done for particularly severe symptoms that are not responding to systemic therapy or for the rare case of a woman whose only apparent disease is in the liver. Another option may be to put chemotherapy directly into the liver through a catheter in the artery leading into the organ. This is typically done to treat metastases if the cancer doesn't respond to more comfortable forms of chemotherapy. Liver transplants do not work in this situation because the disease is usually more extensive, and not just in the liver.

About two-thirds of women who die of breast cancer have cancer that has metastasized to their liver, and about a quarter have it there initially.