Myth #: The Mental And Emotional Experience Of People With Mbc Is The Same As That Of Earlier
People with MBC report hearing comments such as, At least you have a good type of cancer, Arent you glad so much research on breast cancer has been done?, Fortunately you have so many options. These might comfort people with early-stage breast cancer, who can look forward to one day finishing treatment and moving on but people with MBC dont have that luxury. They know they will be in treatment for the rest of their lives. They also know that their life is likely to be shorter than theyd planned.
Mentally and emotionally, people with MBC have a completely different experience. For them, the whole ringing the bell idea does not work, says Dr. Gupta. I have patients who are coming in once a week and have to plan their lives around their treatment. The whole pink brigade idea is very upsetting to them.
Fortunately, more and more people with MBC are speaking up and calling attention to how their experience differs from that of people with earlier-stage breast cancer. People with MBC live with cancer always in the background of their lives, but with new and emerging therapies, many are living longer and maintaining their quality of life.
Clearly, the experience of metastatic breast cancer is quite different from early-stage breast cancer. But there are so many patients who understand just what youre going through. Read more about Living with Metastatic Breast Cancer and join our discussion forum for people with stage IV/metastatic disease.
The Wide Window Of Relapse In Breast Cancer
In contrast with other solid tumours in which metastatic recurrence can occur within a few weeks or a few years following diagnosis, breast cancer is characterised by a wide window of relapse, spanning months to decades after surgery. The basis of this peculiar pattern of recurrence is still elusive, but is likely to be linked to the aforementioned molecular differences underlying each subgroup, with basal-like and HER2-enriched patients experiencing early relapses , as opposed to patients with luminal cancers characterised by a more favourable prognosis.,, Nonetheless, patients with luminal B tumours tend to have shorter survival times than luminal A patients. In addition to the contribution of the molecular subtype of the primary tumour, the risk and timing of recurrence is also influenced by other tumour-related factors that constitute the pillars of the TNM classification system: tumour size and spread , regional lymph node involvement and the presence of distant metastasis . Based on the premise that the chance of survival is intimately linked to the anatomic extent of the disease, the TNM staging system stratifies cancer patients at diagnosis into four stageswith patients with Stage I disease having a much better prognosis as opposed to patients with Stage IV diseasethus representing the gold standard tool for prognostication.
Treatment Options For Metastatic Breast Cancer
Treatment for metastatic breast cancer often is based on systemic therapies, which use drugs rather than surgery or radiation. Metastases treatments are designed to shrink tumors and slow their growth, help ease symptoms and improve quality of life. Treatment may change, such as when one therapy stops working, or the side effects become too uncomfortable. Rather than having only one treatment, most patients undergo several treatments combined to help fight the cancer.
The four broad categories of drug-based treatments are:
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Esmo Clinical Practice Guideline For The Diagnosis Staging And Treatment Of Patients With Metastatic Breast Cancer
Published in 2021 – Ann Oncol. 2021 Authors: A. Gennari, F. André, C. H. Barrios, et al, on behalf of the ESMO Guidelines Committee
- This ESMO Clinical Practice Guideline provides key recommendations and algorithms for managing metastatic breast cancer.
- It covers diagnosis, staging, risk assessment, treatment, disease monitoring, palliative care and the patient perspective.
- ESMO-MCBS and ESCAT scores are given to describe the levels of evidence for treatment choices.
- The authors comprise an international expert group, with recommendations based on available evidence and expert opinion.
- In clinical practice, all recommendations provided need to be discussed with patients in a shared decision-making approach.
Personal Genetic Testing For Inherited Gene Mutations
The National Comprehensive Cancer Network recommends everyone diagnosed with metastatic breast cancer get genetic testing for BRCA1 and BRCA2 inherited gene mutations . If you have a mutation in one of these genes, a PARP inhibitor may be included in your treatment plan.
Learn more about genetic testing.
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How Does Cancer Spread Or Metastasize
The spread of cancer usually happens through one or more of the following steps:
- Cancer cells invade nearby healthy cells. When the healthy cell is taken over, it too can replicate more abnormal cells.
- Cancer cells penetrate into the circulatory or lymph system. Cancer cells travel through the walls of nearby lymph vessels or blood vessels.
- Migration through circulation. Cancer cells are carried by the lymph system and the bloodstream to other parts of the body.
- Cancer cells lodge in capillaries. Cancer cells stop moving as they are lodged in capillaries at a distant location and divide and migrate into the surrounding tissue.
- New small tumors grow. Cancer cells form small tumors at the new location
Treatment Of Stage Iv Breast Cancer
Stage IV cancers have spread beyond the breast and nearby lymph nodes to other parts of the body. When breast cancer spreads, it most commonly goes to the bones, liver, and lungs. It may also spread to the brain or other organs.
For women with stage IV breast cancer, systemic drug therapies are the main treatments. These may include:
- Some combination of these
Treatment can often shrink tumors , improve symptoms, and help some women live longer. These cancers are considered incurable.
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Myth #: Metastatic Breast Cancer Is Curable
Whether metastatic breast cancer is someones first diagnosis or a recurrence after treatment for earlier-stage breast cancer, it cant be cured. However, treatments can keep it under control, often for months at a time. People with MBC report fielding questions from family and friends such as, When will you finish your treatments? or Wont you be glad when youre done with all of this? The reality is they will be in treatment for the rest of their lives.
A typical pattern is to take a treatment regimen as long as it keeps the cancer under control and the side effects are tolerable. If it stops working, a patient can switch to another option. There may be periods of time when the cancer is well-controlled and a person can take a break. But people with MBC need to be in treatment for the rest of their lives.
As Breastcancer.org Community member Vlnprh of Wisconsin comments: The vast majority of people have no idea what MBC treatment involves. They somehow think that you will undergo something similar to early-stage patients surgery, radiation, chemo, whatever and then be done. They want to see you as a pink-tutu-wearing cheerleader jumping up and down declaring that you have beaten this disease
Amarantha of France writes: The one I get over and over is, How long will you be on this chemo? I mean doesn’t it end sometime? Yes, it ends when it stops working and then we go on to another treatment lather, rinse, repeat I guess until we run out of options.
Where Does Metastatic Breast Cancer Commonly Spread
Breast cancer typically spreads by invading healthy cells that surround the tumor. If the cancerous cells invade the lymph nodes, they can then travel throughout the lymphatic system to distant parts of the body. When breast cancer metastasizes, some of the tissues and organs most commonly affected include the:
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Key Differences Between Invasive And Metastatic Breast Cancer
Metastatic breast cancer isnât a specific type of breast cancer, but is the most advanced stage of breast cancer. Both invasive and metastatic breast cancer have spread beyond the exact point where they started. Invasive breast cancers may have spread within the breast only, or to nearby lymph nodes or tissues, or may have spread to distant body parts. All metastatic breast cancers have spread outside of the breast and nearby lymph nodes to distant body parts. If a cancer is only invasive within the breast, itâs usually easier for doctors to treat than metastatic disease.
Breast Cancer Subtypes Hormonal And Her2 Status And Survival Rates
Many research studies over the years have shown that Estrogen-positive breast cancers have better survival rates than all of the Estrogen-negative subtypes.
Progesterone-positive breast cancer also appears to have improved survival rates in comparison to progesterone-negative cases.
For ER+ sub-types survival rates were significantly better than all other subtypes. For example, at stage 1b,
ER+ PR+ HER2- 5-year survival rates were 98.6%ER+ PR- HER2+ 5-year survival rates were 97.3%
The subtype triple negative breast cancer had the worst survival rates over all three stages. At stage I the 5-year survival rate was 92.9% and at stage III 48.9%.
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Symptoms Of Metastatic Cancer
Metastatic cancer does not always cause symptoms. When symptoms do occur, what they are like and how often you have them will depend on the size and location of the metastatic tumors. Some common signs of metastatic cancer include:
- pain and fractures, when cancer has spread to the bone
- headache, seizures, or dizziness, when cancer has spread to the brain
- shortness of breath, when cancer has spread to the lung
- jaundice or swelling in the belly, when cancer has spread to the liver
Stage Iv Or Metastatic Breast Cancer
Although seldom curable, advanced breast cancer is a highly treatable illness. Palliation or prevention of symptoms without excess toxicity is the primary goal of treatment. The median survival after diagnosis of metastatic breast cancer is 2 to 3 years, although the range is great, and a small cadre of long-term survivors has been described. Several recent clinical trials have documented small improvements in survival with some of the newer therapies.
Most women with metastatic breast cancer present with symptoms or abnormalities on physical examination. Less than 10% of women present initially with metastatic disease rather, advanced disease is normally diagnosed in women with a previous diagnosis of early breast cancer for which they received treatment. Common sites for metastases include bone, soft tissues, lung, liver, and brain. If metastatic disease is suspected, relevant hematologic, biochemical, and radiographic evaluation is indicated to assess location and severity of involvement. Because of the import of the diagnosis, pathologic confirmation is preferred. This permits verification of recurrent disease, exclusion of other diagnoses, and reassessment of biologic features such as estrogen receptor, progesterone receptor, and HER2 expression. Elevation of tumor markers or the presence of circulating tumor cells is not diagnostic of recurrent disease, although these markers may be useful adjuncts in the assessment of the effects of therapy.
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Understanding Breast Cancer Metastasis
Metastasis is a complex process in which malignantcancer cells from the breast spread into other regions of the body. Once metastasis has occurred, it is much more difficult to effectively treat breast cancer.
If breast cancer has metastasized to other areas of the body, it is termed a Stage IV breast cancer. Sometimes metastasis has occurred at the time the original breast cancer is diagnosed.
However, in other cases, the metastasis of breast cancer is found months or even years after the initial treatment. This would be termed a recurrent breast cancer.
Local Or Regional Treatments For Stage Iv Breast Cancer
Although systemic drugs are the main treatment for stage IV breast cancer, local and regional treatments such as surgery, radiation therapy, or regional chemotherapy are sometimes used as well. These can help treat breast cancer in a specific part of the body, but they are very unlikely to get rid of all of the cancer. These treatments are more likely to be used to help prevent or treat symptoms or complications from the cancer.
Radiation therapy and/or surgery may also be used in certain situations, such as:
- When the breast tumor is causing an open or painful wound in the breast
- To treat a small number of metastases in a certain area, such as the brain
- To help prevent or treat bone fractures
- When a cancer is pressing on the spinal cord
- To treat a blood vessel blockage in the liver
- To provide relief of pain or other symptoms anywhere in the body
In some cases, regional chemo may be useful as well.
If your doctor recommends such local or regional treatments, it is important that you understand the goalwhether it is to try to cure the cancer or to prevent or treat symptoms.
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What About Clinical Trials
Its important that patients know they may be eligible for clinical trials of new, experimental agents when needed. A number of drugs are currently being investigated, including those that block the protein kinases CDK4/6, PIK3CA, and AKT, and drugs that block a mutated estrogen receptor. We are studying drugs that work against the androgen receptor in breast cancer these are typically used in the treatment of prostate cancer. There are also new agents being tested for patients with HER2-positive cancer and immunotherapies that are being evaluated in patients with metastatic breast cancer.
Patients being treated for advanced disease at MSK also can undergo IMPACT testing, which looks for hundreds of cancer genes that may be mutated. Some of these mutations may play a role in cancer growth. We are actively studying drugs that target these mutations.
Stage 3b Breast Cancer
Stage 3B breast cancer means a tumour of any size that has spread to other tissues near the breast such as skin, muscles, or ribs. At this stage, the tumour may or may not have spread to the lymph nodes. However, the cancer has not spread to other distant parts of the body.
Cancer that has spread to the skin of the breast might be inflammatory breast cancer, a rare form of cancer which can be aggressive and challenging to treat.
How Is Metastatic Breast Cancer Diagnosed
If you have symptoms of metastatic breast cancer, your provider may recommend tests including:
- Blood tests, including complete blood count and comprehensive metabolic panel.
- Imaging studies, including MRI, CT, bone scan and PET.
- Bronchoscopy, which uses a scope to look inside your lungs this can be done if there is a concerning spot in the lungs.
- Biopsy to remove tissue from a suspicious area and analyze it.
- A tap to remove fluid from an area with symptoms. For example, pleural tap removes fluid from the lung area. Spinal tap removes fluid from the spinal cord area.
Survival Rates For Stage Iv Breast Cancer
Stage of breast cancer at diagnosis is one of the most important prognostic factors. Above is a bar chart from the National Cancer Institute statistics for 2012. As we can see, the 5-year survival rate for women diagnosed with Stage IV breast cancer was 22%.
Remember, these figures are still quite dated as it takes 5 years to determine survival rates and treatment is improving all the time.
A recent study found that 37% of women survived for three years after a Stage IV breast cancer diagnosis, although some women do survive longer.
However, although the 5-year survival rates are much higher for earlier stages of breast cancer at diagnosis, there is no predicting which cases will progress to metastatic breast cancer in the future.
Although it is important to be realistic regarding the survival of metastatic breast cancer, each individual situation is unique and ultimately, statistics are meaningless.
There is a small subcategory of people with Stage IV breast cancer who beat the odds and live for years. However, it is difficult to predict who will fall into this group.
All that is known is that people in this group have secondary spread to the bones. Furthermore, cancer is often estrogen positive and responds to hormone treatments.
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Living With Metastatic Breast Cancer
When cancer comes back or is found in other parts of the body, it can be very upsetting for you, your family, and other loved ones. In this section, you can read about ways to live with metastatic breast cancer, manage feelings, get support, and talk to family and friends.
Why Does Metastatic Breast Cancer Happen
Most often, metastatic cancer occurs because treatment didnt destroy all the cancer cells. Sometimes, a few cells remain dormant, or are hidden and undetectable. Then, for reasons providers dont fully understand, the cells begin to grow and spread again.
De novo metastatic breast cancer means that at the time of initial diagnosis, the breast cancer has already spread to other parts of the body. In the absence of treatment, the cancer spreads.
There is nothing you can do to keep breast cancer from metastasizing. And metastatic breast cancer doesnt happen because of something you did.
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Treatment Options For Stage 3 Cancer
Stage 3 breast cancer treatment: The first step is typically either chemotherapy or surgery.
Called neoadjuvant chemotherapy, because its given before other treatment, this may help shrink a tumor enough that breast-conserving surgery is possible. If it doesnt shrink enough, the patient may need a mastectomy instead. HER2-positive cancers may also be treated with targeted drugs before surgery.
After surgery, depending on the type of breast cancer, your treatment may continue with radiation. Chemotherapy and/or targeted drugs may be part of your treatment plan after surgery as well.
Stage 3 lung cancer treatment: This is highly dependent on how large the tumor is and which lymph nodes are affected. Generally, treatment begins with chemotherapy and/or radiation. You may have chemotherapy and radiation at the same time, or you may have them one after another. Surgery may follow this treatment if your care team thinks the remaining cancer may be successfully removed. After surgery, additional chemotherapy and/or radiation may be part of your treatment plan.
If chemotherapy, radiation or surgery arent appropriate options, immunotherapy drugs may be.
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