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Treatment Options For Recurrence

The type of treatment you have will depend on the type of recurrence, as well as the treatments you received for your initial breast cancer.

Local Recurrence After Breast Conservation (Lumpectomy)

If the tests are normal (only five to 10% of women with local recurrences will have signs of disease elsewhere in their bodies), then the next step is to determine how to eradicate the tumor from the breast. This usually means having a mastectomy. The research still isn't clear on whether chemotherapy is required after a local recurrence in the breast, but it is often considered in high-risk women. If your tumor is hormone-sensitive and you were on tamoxifen, it is reasonable to switch to an aromatase inhibitor, or vice versa.

New Primary Tumor

Most often the local treatment will be a mastectomy, since you can receive radiation therapy only once to a particular area. However, the newer approaches to partial radiation may change this. The addition of chemotherapy and/or hormone therapy will depend on the size and type of tumor you have.

Local Recurrence After Mastectomy

Most commonly the lesion will be removed surgically and followed by radiation to the chest wall if the woman has not previously had radiation. Occasionally, even larger lesions will be surgically removed, including sections of rib and breastbone. Although this approach has not been shown to increase survival, it can improve the quality of life by preventing further local spread, which can be difficult to manage.

Regional Recurrence

Treatment to this area with either surgery or radiation often takes care of the problem, although systemic therapy may also be used. Regional recurrence in lymph nodes elsewhere, such as the neck or above the collarbone, has a more serious implication, since it is more likely to reflect spread of the tumor through the bloodstream. Akin to local recurrence following mastectomy, it usually warrants a more aggressive approach.

Metastatic Disease

When a cancer spreads to a different organ, it's known as a distant recurrence, or a metastasis. If your breast cancer spreads to your lung, liver, or bones, that does not mean you now have lung cancer, liver cancer, or bone cancer. It's still breast cancer.

The treatment approaches to metastatic disease are different from the approaches to primary breast cancer. With metastatic disease, the goal is to put cancer into remission and to keep it there as long as possible in order to prolong survival. At this point, nothing we know of can guarantee a cure for metastatic breast cancer. However, as new therapies are continuously being developed, we have reason to hope that we can one day convert metastatic breast cancer into a chronic disease.

During and after your treatment for metastatic disease you'll be followed with staging tests—bone scan, chest X-ray, and blood tests—as well as with CT scans, PET scans, or MRI. These tests and scans can help to determine if you're responding to treatment, although your symptoms are in fact the best test of effectiveness than these tests.

Treatment options for metastatic disease include:

Radiation

Radiation for metastatic cancer is the same as for initial breast cancer, but the treatment is for a different purpose—to alleviate pain or other symptoms. It usually takes a couple of weeks before the pain noticeably lessens. The timing is somewhat different too. There are usually 10 to 15 treatments, spread over two and a half to four weeks. A smaller dose of radiation is used than what was used to treat the original tumor.

Hormonal (Endocrine) Treatments for Premenopausal Women

Metastatic disease in premenopausal women with hormone-sensitive tumors is first treated with hormone (endocrine) treatments. When a woman has responded to one hormone therapy,  she's likely to respond to a second and possibly a third, so these treatments are used serially.

Ovarian ablation (stopping ovarian functioning) either by surgical or chemical means is the first line of treatment for premenopausal women (women who are still menstruating). The drugs used to induce a reversible menopause are the gonadotropin-releasing hormone (GnRH) agonists such as leuprolide (Lupron) or goserelin (Zoladex). Removing the ovaries or stopping their functioning will put a woman into immediate menopause, complete with mood swings and hot flashes. But it also can almost immediately relieve metastatic breast cancer symptoms.

If ovarian ablation is effective, no other treatments are necessary until symptoms recur. The next step is to try tamoxifen or an aromatase inhibitor. The aromatase inhibitors—anastrozole (Arimidex), letrozole  Femara), and exemestane (Aromasin)—can only be used if the ovaries have been removed or if a woman continues to take a drug like Lupron or Zoladex to induce menopause. If this drug stops working, the next step would be fulvestrant ( Faslodex) and, following that, megestrol acetate (Megace), which is a kind of progestin. Both of these can only be used if the ovaries have been removed or you take a drug like Lupron or Zoladex along with them.

For more information on current recommendations, you can review the National Comprehensive Cancer Network Breast Cancer Treatment Guidelines. New medications and new combinations of medications are being tested all of the time, which means a clinical trial may be the best choice for someone with metastatic disease.

Hormonal (Endocrine) Treatments for Postmenopausal Women

Metastatic disease in postmenopausal women with hormone-sensitive tumors  is treated first with endocrine treatments. Women who are postmenopausal (whether by chemotherapy or naturally) can use an aromatase inhibitor (AI), such as anastrozole (Arimidex), letrozole (Femara), or exemestane (Aromasin). If the aromatase inhibitors stop working, the next step is to try fulvestrant (Faslodex), which is a different type of estrogen receptor blocker. If this stops working, you can move on to megestrol acetate (Megace), which is a kind of progestin.

For more information on current recommendations, you can review the National Comprehensive Cancer Network Breast Cancer Treatment Guidelines. New medications and new combinations of medications are being tested all of the time, which means a clinical trial may be the best choice for someone with metastatic disease.

Chemotherapy

If a woman's tumor is estrogen receptor (ER)-negative and progesterone receptor (PR)-negative or if her tumor is hormone-sensitive but is no longer responding to hormone treatments, chemotherapy is used.

About 15 different types of chemotherapy drugs are used commonly in breast cancer treatment. Interestingly, breast cancer creates the kind of tumor that is responsive to the greatest array of drugs—most other cancers don't respond to as many chemicals. Chemotherapy drugs you may receive include:

  • cyclophosphamide (Cytoxan)—the C in a chemo regimen
  • methotrexate—the M in a chemo regimen
  • 5-fluorouracil (also known as 5-FU)—the F in a chemo regimen
  • doxorubicin (Adriamycin)—the A in a chemo regimen
  • epirubicin—the E in a chemo regimen
  • paclitaxel ( Taxol) or docetaxel (Taxotere)—the T in a chemo regimen
  • Paclitaxel, albumin bound (Abraxane)
  • Capecitabine (Xeloda)
  • Carboplatin (Paraplatin)
  • Cisplatin (Platinol)
  • Eribulin (Halaven)
  • Gemcitabine (Gemzar)
  • Ixabepilone (Ixempra)
  • Liposomal doxorubicin (Doxil)
  • Vinorelbine (Navelbine)

For more information on current recommendations, you can review the National Comprehensive Cancer Network Breast Cancer Treatment Guidelines. New medications and new combinations of medications are being tested all of the time, which means a clinical trial may be the best choice for someone with metastatic disease.

Targeted Therapy

Targeted therapies are designed to slow or stop cancer growth by targeting  specific molecules that help cancer cells grow or spread. They differ from chemotherapy because they are designed to attack only cancer cells. Chemotherapy drugs attack all rapidly dividing cells. Targeted therapies approved for treating metastatic breast cancer include:

For HER2-Negative Tumors

  • Everolimus (Afinitor) is an mTOR (mammalian target of rapamycin) inhibitor. It is approved for the treatment of ER+, HER2-negative metastatic breast cancers in postmenopausal women who have been treated with the aromatase inhibitor letrozole (Femara) or anastrozole (Arimidex).
  • Palbociclib (Ibrance) is a kinase inhibitor. It is used along with letrozole (Femara) to treat postmenopausal women with ER+, HER2- metastatic breast cancer

​​For HER2-Positive Tumors

  • Trastuzumab (Herceptin) is a HER2-targeted therapy used to treat early-stage and metastatic HER2+ breast cancer.
  • Lapatinib (Tykerb) is a HER2-targeted therapy approved for use along with letrozole (Femara) for the initial treatment of metastatic, postmenopausal breast cancer that is both HER2-positive and hormone sensitive.
  • Pertuzumab (Perjeta) is a HER2-targeted therapy used along with Herceptin and doxetaxel.
  • T-DM1/trastuzumab emtansine (Kadcyla) is a HER2-targeted therapy approved to treat HER2-positive metastatic breast cancer in patients who have already been treated with(Herceptin) and a taxane.

For more information on current recommendations, you can review the National Comprehensive Cancer Network Breast Cancer Treatment Guidelines. New medications and new combinations of medications are being tested all of the time, which means a clinical trial may be the best choice for someone with metastatic disease.

Bisphosphonates

A bisphosphonate is a drug that blocks the resorption (breakdown) of bone. It has been shown to be very effective in treating bone metastasis. When there is cancer in the bone, there is an increase in the resorption, which is one of the reasons the bone gets weaker and often fractures. Options include pamidronate ­(Aredia) or zolendronic (Zometa), both of which are given by IV every three to four weeks

The use of these drugs has dramatically lowered the risk of bone fractures. However, they also come with a risk of complications such as osteonecrosis of the jaw, so prior to starting, everyone needs to have a dental exam and routine preventative dental work.

For Lung Metastasis

For lung metastases, the treatment is usually systemic; fluid in pleura 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,  the pleura may need to be fastened to the lung itself. Occasionally women with recurring 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 (using any one of the methods just described), and a systemic therapy.

For Liver Metastases

The major treatment for extensive liver disease is chemotherapy, especially if your liver function blood tests are elevated. Hormone therapy can work well on ER+ and slower-growing liver metastases, and the decision to use it usually depends on the extent of damage present in the liver. 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.

For Brain Metastases

Treatments for brain metastases depend on the the number of metastatic sites. They include surgery or radiation with stereotactic radiosurgery or whole brain radiation therapy. If you are experiencing pain or other symptoms, you may also need to be put on steroids to reduce the brain swelling. If you’re having seizures, you’ll also be put on anti­-seizure medication. Unfortunately chemotherapy does not work will on brain metastases. There are clinical trials now underway looking at targeted therapies for treating brain metastases.

For Spinal Cord Compression

The treatment is generally emergency surgery if there is any evidence of nerve damage, muscle weakness, or a large tumor pressing on the spinal cord. If it’s one spot, it may be possible to remove the tumor and decompress the spinal cord. Surgery, if performed, is then followed by radiation therapy. Alternatively, the treatment could be emergency radiation alone; it is one of the few instances in which radiation is used as an emergency treatment. The radiation shrinks the tumor and steroids prevent the spinal cord from swelling.

Experimental Treatments/Clinical Trials

Women with metastatic disease will often have opportunities to participate in phase III clinical trials—trials of drugs or treatments that have been tested in earlier phases and shown not to harm the patient. Phase I or phase II trials may also be an option as well. These are earlier stages in the testing of a drug, designed to determine first the toxicity of a possibly useful drug and then whether it works.

Since you know that traditional treatments, which were so helpful with your first diagnosis, offer only a slim chance of cure, an experimental treatment may be worth considering. Generally there is no harm in trying an innovative new therapy and postponing treatment with other standard therapies.

When is the best time to join an experimental trial? Classically, people do it when nothing else has helped and they’ve run out of options. However, by the time you run out of options you’re least likely to be able to respond to the new treatment: you have no resources left. So the best time may be when you have been diagnosed with metastatic ­disease but are feeling well. You have a chest X-ray or bone scan that shows a lesion but you actually have modest symptoms. At this stage, there’s no rush to use chemotherapy or hormone therapy since there’s no evidence that treating with chemo earlier will give you better survival odds than waiting until you have symptoms. Trying something experimental at this point, gives you an opportunity to see if it works; if it doesn’t you can still get the usual chemotherapy if symptoms worsen. Learn more in Clinical Trials.

While a clinical trial may help you, the treatments tested in these trials can also cause side effects. Only you can decide what price in toxicity you are willing to pay. Some women want to try everything new and others don’t. Don’t let yourself be pushed by your doctor or family. Decide in your own heart what the best approach is for you.