Breast Cancer - Metaplastic: Treatment Options

This section has been reviewed and approved by the Cancer.Net Editorial Board, 08/2010

ON THIS PAGE: You will learn about the different ways doctors use to treat people with this type of cancer. To see other pages, use the menu on the side of your screen.

The treatment of metaplastic carcinoma of the breast depends on the size and location of the tumor, whether the cancer has spread, and the woman's overall health. In many cases, a team of doctors will work with the woman to determine the best treatment plan.

This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, see the Clinical Trials section.

Because metaplastic carcinoma of the breast is rare, the best course of treatment has not yet been determined. Therefore, metaplastic carcinoma of the breast is treated in the same way as a more common breast cancer is treated. It has been suggested in multiple studies, however, that a woman's prognosis is related to the size of her tumor, rather than the number of lymph nodes that contain cancer. Specifically, a woman with a tumor smaller than 40 mm has a better prognosis than a woman with a tumor larger than 40 mm.

Overview of breast cancer treatment

The biology and behavior of a breast cancer affects the treatment. Some tumors are small but grow fast, while others are large and grow slower. When planning the treatment for breast cancer, the doctor will consider many factors, including:

  • The stage and grade of the tumor
  • The patient's age and general health
  • The patient's menopausal status
  • The presence of known mutations in inherited breast cancer genes (BRCA1 or BRCA2)

Even though the doctor will specifically tailor the treatment for each patient and the breast cancer, there are some general steps for treating breast cancer.

For early-stage invasive breast cancer, doctors generally recommend surgery to remove the tumor. To ensure that the entire tumor is removed, the surgeon will also remove a small area of tissue around the tumor. Although surgery aims to remove all of the visible cancer, it is known that many times microscopic cells can be left behind, either in the breast or elsewhere.

The next step in the management of early-stage breast cancer is to lower the risk of recurrence (return of the cancer) and to get rid of any hidden remaining cancer cells. This is called adjuvant therapy. Adjuvant therapies include radiation therapy, chemotherapy, and/or targeted therapy (see below for more information on these types of treatment). The need for adjuvant therapy is determined based on an estimate of the chance of residual cancer in the breast or the body. Although adjuvant therapy lowers the risk of recurrence, it does not necessarily eliminate it.

Along with staging, other sophisticated tools can help determine prognosis and help you and your doctor make decisions about adjuvant therapy. Talk with your doctor for additional information.

When surgery to remove the cancer is not possible, chemotherapy, targeted therapy, and/or radiation therapy may be used.

Additional descriptions of the most common treatment options for breast cancer are listed below.

Surgery

Surgery is performed to remove the tumor in the breast and to evaluate the surrounding axillary (underarm) lymph nodes. A surgical oncologist is a doctor who specializes in treating cancer using surgery. Generally, the smaller the tumor, the more surgical options a patient has. The types of surgery include the following:

  • A lumpectomy is the removal of the tumor and a small, clear (cancer-free) margin of tissue around the tumor. Most of the breast remains. For both DCIS and invasive cancer, follow-up radiation therapy to the remaining breast tissue is generally recommended. A lumpectomy may also be called breast-conserving surgery, a partial mastectomy, or a segmental mastectomy.
  • A mastectomy is the surgical removal of the entire breast.

Lymph node removal and analysis

Lymph nodes can trap cancer cells traveling away from the original tumor site. It is important to find out whether any of the lymph nodes near the breast contain evidence of cancer.

In an axillary lymph node dissection, the surgeon removes many of the lymph nodes from under the arm, which are then examined by a pathologist for cancer cells. The actual number of nodes removed varies.

Sentinel lymph node biopsy

The sentinel lymph node biopsy procedure allows for the removal of one to a few lymph nodes, reserving a bigger axillary lymph node dissection procedure for patients whose sentinel lymph nodes show evidence of cancer. The smaller lymph node procedure helps patients lower the risk of lymphedema(swelling of the arm) and decreases arm mobility and range-of-motion problems. Learn more about preventing lymphedema after breast cancer treatment.

In this procedure, the surgeon finds and removes the sentinel (first) lymph node (as a practical matter, one to three nodes) that receives drainage from the breast. The pathologist then examines it for cancer cells. To identify the sentinel lymph node, the surgeon injects a dye and/or a radioactive tracer into the area of the cancer and/or around the nipple. The dye or tracer travels to the lymph nodes, arriving at the sentinel node first. The surgeon can find the node when it turns color (if the dye is used) or emits radiation (if the tracer is used).

If the sentinel node is cancer-free, research has shown that there is a good possibility that the subsequent nodes will also be free of cancer and no further surgery of the lymph nodes is performed. If the sentinel lymph node shows cancer is present, then the surgeon will perform an axillary lymph node dissection, removing additional lymph nodes to look for the presence of more cancer. Find out more about ASCO's recommendations for sentinel lymph node biopsy.

Most patients with invasive cancer will undergo either sentinel lymph node biopsy or an axillary lymph node dissection. For those with sentinel nodes that indicate cancer, an axillary lymph node dissection is still considered the standard procedure. If there is obvious evidence of cancer in the lymph nodes before any surgery, then the preferred approach is a full axillary lymph node dissection without a sentinel lymph node biopsy.

Reconstructive (plastic) surgery

Women who undergo a mastectomy may wish to consider breast reconstruction, which is surgery to rebuild the breast. Reconstruction may be done with tissue from another part of the body, or with synthetic implants. A woman may be able to have this done at the same time as a mastectomy (immediate reconstruction) or at some point in the future (delayed reconstruction). In addition, reconstruction may be done after a lumpectomy to improve the look of the breast. Talk with your doctor for more information. Read more about breast reconstruction after a mastectomy, and choosing a breast prosthesis.

Surgical summary

To summarize, surgical treatment options include the following:

  • Removal of cancer in the breast: Lumpectomy (partial mastectomy) almost always followed by radiation therapy or mastectomy, with or without immediate reconstruction
  • Lymph node evaluation: Sentinel lymph node biopsy and/or axillary lymph node dissection

Women are encouraged to talk with their doctors about which surgical option is right for them. More aggressive surgery (such as a mastectomy) is not always better and may result in additional complications. The combination of lumpectomy and radiation therapy has a higher risk of the cancer coming back in the same breast or near the breast, but the long-term survival of women is the same as those who have a mastectomy. Hear from an ASCO expert on mastectomy vs. lumpectomy.

Learn more about cancer surgery.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment is called external-beam radiation therapy, which is radiation given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. A radiation therapy regimen (schedule) usually consists of a specific number of treatments given over a specific time (see below for additional information).

After surgery, adjuvant radiation therapy is given regularly for a number of weeks to eliminate any remaining cancer cells near the tumor site or elsewhere within the breast. The lowest risks of cancer recurrence in the breast after lumpectomy are associated with the use of radiation therapy. Early randomized clinical trials showed, in general, recurrence rates of 30% or more without radiation therapy, compared with 10% recurrence rates with radiation therapy.

Adjuvant radiation therapy is also recommended for some women after a mastectomy, depending upon the size of their tumor, number of cancerous lymph nodes under the arm, and width of the tissue margin around the tumor removed by the surgeon.

Neoadjuvant radiation therapy is radiation therapy given before surgery to shrink a large tumor, which makes it easier to remove, although this approach is rare.

Radiation therapy can cause side effects, including fatigue, swelling of the breast, and skin changes. Other side effects may include upset stomach and loose bowel movements. Most side effects go away soon after treatment is finished. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related inflammation of the lung tissue, is low. In the past, with older equipment and techniques of radiation therapy, women treated for left-sided breast cancers had a small increase in the long-term risk of heart disease. Modern techniques are now able to spare most of the heart from radiation damage. The risk of a different cancer due to radiation therapy is low—less than one in 500 survivors develop a new cancer in the area that was treated.

Many types of radiation therapy may be available to you; however, many of these methods have not been well studied in women with metaplastic breast cancer. Talk with your doctor about the options, advantages, and disadvantages of these options.

Radiation therapy schedule

Standard radiation therapy after a lumpectomy is external-beam radiation therapy given daily for five days per week (Monday through Friday) for six to seven weeks. This usually includes radiation therapy to the whole breast first for four-and-a-half to five weeks, followed by a more focused treatment to the site of the tumor bed in the breast for the remaining treatments.

This focused part of the treatment, called a boost, is standard for women with invasive breast cancer to reduce the risk of a recurrence in the breast. If there is evidence of cancer in the underarm lymph nodes, radiation therapy may also be given to the lymph node areas in the neck or underarm near the breast or chest wall. Usually, patients who undergo mastectomy do not require radiation therapy. However, for patients with large cancers, several cancerous lymph nodes, or extension of cancer into the skin or chest wall, radiation may still be recommended after a mastectomy. Standard radiation therapy after a mastectomy is given to the chest wall for five days (Monday through Friday) for five to six weeks.

There has been growing interest in newer radiation regimens (schedules) to shorten the length of treatment from six to seven weeks to periods of three to four weeks. In one method (called hypo-fractionated radiation therapy), a higher daily dose is given to the whole breast each day so that the overall length of treatment is shortened to three to four weeks. This can also be combined with a higher dose given to the tumor bed in the breast either during or after the whole breast radiation treatments. Clinical trials from Canada and the United Kingdom have shown that these shorter schedules can be equally accepted by patients with the same cancer control rates and side effects as longer radiation treatment schedules in patients with node-negative breast cancer. These shorter schedules may become more accepted in the United States and are one way to improve the convenience and time required to complete a course of radiation (see also partial breast irradiation below).

Partial breast irradiation

Partial breast irradiation (PBI) is radiation therapy that is given directly to the tumor area, usually after a lumpectomy, instead of the entire breast, as is routinely done with standard radiation therapy. Targeting the radiation to the tumor area more directly usually shortens the amount of time that patients need to undergo radiation therapy.

When radiation treatment is given using localized radiation delivery methods, it is called brachytherapy. Brachytherapy can involve the implantation of small radioactive pellets, placed in or near the site of the breast tumor, or within plastic catheters placed temporarily in the breast. Most types of breast brachytherapy involve short treatment times, ranging from one dose to one week.

Additionally, PBI can be done with standard external-beam radiation therapy that is focused on the area of the tumor bed and not the entire breast. However, only some patients may be eligible for PBI. Although preliminary results have been promising, PBI is still being studied. It is the subject of a large, nationwide clinical trial, and the results proving the safety and effectiveness compared with standard radiation therapy are pending. This trial will help determine which patients and tumors are the best candidates for PBI.

Intensity-modulated radiation therapy

Intensity-modulated radiation therapy (IMRT) is a more advanced way to deliver external-beam radiation therapy to the breast. The intensity of the radiation directed at the breast is varied to target the tumor more precisely, give a uniform distribution of radiation throughout the breast tissue, and avoid damaging healthy tissue more than is possible with traditional radiation treatment. IMRT may reduce the dose to nearby important organs, such as the heart and lung, and reduce the risks of some immediate side effects, such as peeling of the skin during treatment. This can be especially important for women with medium to large breasts who are at greater risk for side effects such as peeling and burns, compared with women with smaller breasts. IMRT also may help to reduce long-term effects on the breast tissue that were common with older radiation techniques such as hardness, swelling, or discoloration. However, IMRT may not be appropriate for every patient.

Learn more about radiation therapy.

Chemotherapy

Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. Most people with breast cancer receive chemotherapy in their doctor's office or outpatient clinic. An adjuvant chemotherapy regimen consists of a specific treatment schedule of drugs given at repeating intervals for a specific number of times.

Chemotherapy may be given intravenously (injected into a vein) or occasionally orally (by mouth), and is usually given in cycles. Chemotherapy may be given before surgery to both shrink a large tumor and reduce the risk of recurrence or adjuvant therapy given after surgery to reduce the risk of recurrence. Chemotherapy is also commonly given at the time of a metastatic breast cancer recurrence. Patients in clinical trials may be offered new drugs or new combinations of existing drugs.

Different drugs are useful for different types of cancer, and research has shown that combinations of certain drugs are sometimes more effective than individual ones. The following drugs or combinations of drugs may be used as adjuvant therapy to treat breast cancer:

  • Cyclophosphamide (Cytoxan)
  • Methotrexate (multiple brand names)
  • Fluorouracil (5-FU, Adrucil)
  • Doxorubicin (Adriamycin)
  • Epirubicin (Ellence)
  • Paclitaxel (Taxol)
  • Docetaxel (Taxotere)
  • CMF (cyclophosphamide, methotrexate, and 5-FU)
  • CAF (cyclophosphamide, doxorubicin, and 5-FU)
  • CEF (cyclophosphamide, epirubicin, and 5-FU)
  • EC (epirubicin and cyclophosphamide)
  • AC (doxorubicin and cyclophosphamide)
  • TAC (docetaxel, doxorubicin, and cyclophosphamide)
  • AC followed by T (doxorubicin and cyclophosphamide, followed by paclitaxel)
  • TC (docetaxel and cyclophosphamide)

Because it is unknown if metaplastic carcinoma of the breast behaves like the typical infiltrating ductal or lobular cancer (which make up approximately 95% of breast cancers), some doctors will administer slightly different chemotherapy, such as cisplatin (Platinol)-based chemotherapy, usually with 5-FU.

Paclitaxel, docetaxel, and carboplatin (Paraplat, Paraplatin) may be given after standard adjuvant chemotherapy.

In addition to the drugs and combinations of drugs listed above, the following additional drugs may be used to treat recurrent or metastatic breast cancer, either individually or in combination:

  • Vinorelbine (Navelbine)
  • Capecitabine (Xeloda)
  • Protein bound paclitaxel (Abraxane)
  • Pegylated liposomal doxorubicin (DOXIL, Dox-SL, Evacet, LipoDox)
  • Gemcitabine (Gemzar)
  • Ixabepilone (Ixempra)

Bevacizumab (Avastin), a blood vessel blocking drug (called anti-angiogenic), is another targeted therapy that has been used in combination with chemotherapy for the treatment of metastatic breast cancer. (See the Targeted Therapy section below.)

The side effects of chemotherapy depend on the individual and the drug and the dose used, but can include fatigue, hair loss, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Rarely, long-term side effects may occur, such as heart damage, nerve damage, or secondary cancers, but studies have shown that these side effects do not shorten a woman's survival time.

Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases.

Targeted therapy

Targeted therapy is a treatment that targets specific genes, proteins, or the tissue environment that contributes to cancer growth and survival.

Anti-angiogenic targeted therapy (blood vessel blocking therapy)

Bevacizumab has been used to treat metastatic or recurrent breast cancer (see below) for many years. This drug blocks angiogenesis (the formation of new blood vessels), which is needed for tumor growth and metastasis. Because bevacizumab may not work well for all tumors, it is no longer approved by the FDA as a treatment for breast cancer. However, it is still used as a treatment in Europe. Research on bevacizumab for breast cancer is ongoing. When combined with paclitaxel, bevacizumab appears to shrink the tumor and keep it smaller for a longer time in women whose breast cancer has spread compared with paclitaxel alone. Recent studies have shown a benefit of adding bevacizumab to other chemotherapy as well.

Learn more about targeted treatments.

Anti-osteoclast targeted therapy (drugs that block bone destruction)

  • Bisphosphonates are a class of drugs that block the cells that cause bone destruction (osteoclasts). Bisphosphonates are commonly used in relatively low doses to prevent and treat osteoporosis. In patients with breast cancer that has spread to bone, higher doses of bisphosphonates have been shown to reduce the complications of cancer in the bone, including bone fractures and pain. Pamidronate (Aredia) and zoledronic acid (Zometa) are two intravenous bisphosphonates used to treat breast cancer bone metastasis. Recent studies have suggested that these drugs may also be able to reduce breast cancer recurrences when given in the adjuvant setting, although more data are needed.
  • Denosumab (Prolia) is in another new class of osteoclast-targeted therapies called RANK ligand inhibitors. Although not yet approved for patients with breast cancer, recent studies have shown great promise of these drugs in treating breast cancer bone metastases and osteoporosis.

Learn more about bisphosphonates for breast cancer.

Recurrent and metastatic breast cancer

Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (a local recurrence); in the chest wall (a regional recurrence); or in another part of the body, including distant organs such as the lungs, liver, and bones. A local recurrence is frequently considered curable with further treatment. A metastatic (distant) recurrence is generally considered incurable, but is frequently treatable. Some patients live years after a metastatic recurrence of breast cancer. The goal of treatment for advanced disease is to prolong survival and/or improve quality of life.

Generally, a recurrence is detected when a person has symptoms. These symptoms depend on the site of the recurrence and may include:

  • A lump under the arm or along the chest wall
  • Bone pain or fractures, which may signal bone metastases
  • Headaches or seizures, which may signal brain metastases
  • Chronic coughing or trouble breathing, which may signal lung metastases
  • Abdominal pain or jaundice (yellow skin and eyes), which may be associated with liver metastases

Other symptoms may be related to the location of metastasis and may include changes in vision, changes in energy levels, feeling ill, or extreme fatigue. A biopsy of the recurrent site is often recommended to be certain of the diagnosis and to check for tumor characteristics that might have changed from the time of the original diagnosis.

The treatment of metastatic or recurrent breast cancer depends on the previous treatment(s), the time since the original diagnosis, and the characteristics of the tumor.

  • For women with a local recurrence within the breast after initial treatment with lumpectomy and adjuvant radiation therapy, the treatment is mastectomy. This usually results in cure.
  • For women with a local or regional recurrence of the chest wall after an initial mastectomy, resection (surgical removal of the recurrence) followed by radiation therapy to the chest wall and lymph nodes is the treatment, unless radiation therapy has already been given (radiation therapy cannot usually be given at full dose to the same area more than once).
  • Total-body therapies such as chemotherapy and targeted therapies are generally the primary treatment in recurrent metastatic cancer. Radiation therapy and surgery may be used in certain situations for women with a distant metastatic recurrence. Often radiation is used to treat painful bone metastases.

Find out more about common terms used during cancer treatment.

The next section helps explain clinical trials, which are research studies. Use the menu on the side of your screen to select About Clinical Trials, or you can select another section, to continue reading this guide.