Treatment

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, read 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 4 cm has a better prognosis than a woman with a tumor larger than 4 cm.

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 to breast cancer genes

Even though the doctor will specifically tailor the treatment for breast cancer for each patient, there are some general steps for treating breast cancer. If the cancer can be removed by surgery, that is usually the first treatment. After surgery, a woman may have additional treatment, called adjuvant therapy, which removes any remaining cancer cells. Adjuvant therapies include radiation therapy, chemotherapy, and targeted therapy. Although adjuvant therapy lowers the risk of recurrence, it does not necessarily eliminate it. It is still being determined if adjuvant therapy is the best course of treatment for metaplastic carcinoma of the breast.

Along with staging, other sophisticated tools can help determine prognosis and help you and your doctor make decisions about adjuvant therapy. The website Adjuvant! Online (www.adjuvantonline.com) is one such tool that your doctor can access to interpret a variety of prognostic factors. This website should only be used with the interpretation of your doctor.

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

The treatment of recurrent cancer and metastatic cancer depends on how the cancer was first treated and the characteristics of the cancer mentioned above. More complete descriptions of each treatment option are listed below.

Surgery

Generally, the smaller the tumor, the more surgical options a woman 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. For DCIS and an invasive cancer, follow-up radiation therapy to the remaining breast tissue is recommended. A lumpectomy may also be called a partial mastectomy or a segmental mastectomy.
  
  
• A total mastectomy removes the entire breast, but not the underarm lymph nodes. This surgery is also called a simple mastectomy.
  
  
• A modified radical mastectomy removes the breast, some of the underarm lymph nodes, and the lining over the chest muscles.
  
  
• Axillary lymph node dissection involves the surgeon removing lymph nodes from under the arm and having them examined by a pathologist for cancer cells. The actual number of nodes removed may vary.
  
  
• Sentinel lymph node biopsy is a procedure in which the surgeon finds and removes the sentinel (first) lymph node (generally 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 around the nipple. The dye or tracer will travel 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). Sentinel lymph node biopsy often has a lower risk of lymphedema (swelling of the arm) than axillary lymph node dissection. 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. For more information, read the Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer.
  
  
• 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 or at some point in the future.

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 necessary. Research is underway to determine if this continues to be true.

To summarize, surgical treatment options include the following:

• Lumpectomy or partial mastectomy and radiation therapy
  
  
• Total mastectomy, with or without immediate reconstruction, with or without sentinel node biopsy and possible axillary lymph node dissection
  
  
• Modified radical mastectomy with or without immediate reconstruction

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.

For more information about considerations after breast cancer surgery, read after a mastectomy and preventing lymphedema after breast cancer treatment, breast reconstruction, and choosing a breast prosthesis.

Radiation therapy

Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. Adjuvant radiation therapy is given regularly for a number of weeks after a lumpectomy or partial mastectomy to eliminate any remaining cancer cells near the tumor site or elsewhere within the breast. 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. Adjuvant radiation therapy is effective in reducing the chance of breast cancer returning in both the breast and the chest wall. 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, and skin changes. A small amount of the lung can be affected by the radiation, although the risk of pneumonitis, or a radiation-related pneumonia, is rare. In the past, with older equipment and techniques of radiation therapy, women treated for a left-sided breast cancer 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. While exposure to radiation is thought to be a risk factor for cancer after many years, less than one in 500 survivors will develop a different kind of cancer, other than a breast cancer, within the area that was treated. Clinical trials comparing lumpectomy and adjuvant radiation therapy with mastectomy have not shown a difference in the number of patients developing or dying of other cancers within a 20-year time span.

The most common type of radiation treatment is called external beam radiation therapy, which is radiation therapy given from a machine outside the body. When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy. In this treatment, small radioactive pellets are placed in or near the site of the breast tumor within plastic catheters placed temporarily in the breast. A balloon catheter placed near the breast that delivers radiation therapy (called Mammosite) is another type of radiation therapy.

Standard radiation therapy after a lumpectomy or partial mastectomy is external-beam radiation therapy given for five days (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 because it reduces the risk of a recurrence in the breast. This boost is also usually given for women with in situ breast cancer and is the subject of an ongoing international clinical trial.Standard radiation therapy after a mastectomy is given to the chest wall for five days (Monday through Friday) for five to six weeks. 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.

There has been growing interest in newer radiation methods 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 approach 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. 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.

Two approaches to lessen the side effects of radiation therapy, partial breast irradiation (PBI, radiation that is given directly to the tumor area instead of the entire breast) and intensity-modulated radiation therapy (IMRT, a more precise method of delivering radiation to the breast by varying the intensity of radiation) are not generally being recommended for patients with metaplastic breast cancer at this time. More information about these techniques can be found in the Cancer.Net Guide to Breast Cancer and by talking with your doctor.

For more information on radiation therapy, read the Cancer.Net Feature: Understanding Radiation Therapy, the Cancer.Net Feature: Radiation Therapy—Your Personal Experience, and the Cancer.Net Feature: Side Effects of 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. 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.

Chemotherapy may be given orally (by mouth) or intravenously (injected into a vein) and is usually given in cycles. Chemotherapy generally does not require a hospital stay; it is given in an outpatient setting. Chemotherapy may be neoadjuvant therapy (given before surgery to shrink a large tumor) or adjuvant therapy (given after surgery to reduce the risk that the cancer returns). Chemotherapy may also be given at the time of a breast cancer recurrence. Patients in clinical trials may be offered new drugs or new combinations of existing drugs.

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

• Cyclophosphamide (Clafen, Cytoxan, Neosar)
  
  
• 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 may be used to treat recurrent breast cancer and metastatic breast cancer:

• Vinorelbine (Navelbine)
  
  
• Capecitabine (Xeloda)
  
  
• Protein bound paclitaxel (Abraxane)
  
  
• Pegylated liposomal doxorubicin (DOXIL, Dox-SL, Evacet, LipoDox)
  
  
• Gemcitabine (Gemzar)
  
  
• Carboplatin
  
  
• AT (doxorubicin and docetaxel; doxorubicin and paclitaxel)
  
  
• GT (gemcitabine and paclitaxel)
  
  
• Docetaxel and capecitabine
  
  
• Ixabepilone (Ixempra)

Bevacizumab (Avastin, see below) may be given with chemotherapy in particular situations.

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. Learn more about your prescriptions through Cancer.Net’s Drug Information Resources, which provides links to multiple drug databases.

Targeted therapy

Targeted therapy is a treatment that targets faulty genes or proteins that contribute to cancer growth and development. Because metaplastic breast cancer does not have HER2, drugs that target this protein are not used to treat this type of cancer.

Bevacizumab is used to treat metastatic or recurrent breast cancer (see below). This drug blocks angiogenesis (the formation of new blood vessels), which is needed for tumor growth and metastasis. When combined with paclitaxel, bevacizumab appears to shrink the tumor and remain smaller for a longer time in women whose breast cancer has spread compared with paclitaxel alone. This combination was approved by the U.S. Food and Drug Administration in 2008.

Recurrent and metastaticbreast 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; or in another part of the body, including distant organs (such as the lungs, liver, and bones). Some patients live years after a recurrence of breast cancer.

Breast cancer may also spread to other organs such as the brain, the opposite breast, adrenal glands, spleen, and ovaries and is called metastatic breast cancer. For example, metaplastic carcinoma of the breast is most likely to spread to the lungs. This type of cancer is treatable, but not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the growth of the tumor.

Generally, a recurrence is detected when a person has symptoms. Even though there are tests that may detect a metastatic recurrence before the onset of symptoms, research has shown that having such tests does not improve the response to treatments used for advanced disease, nor do they prolong life.

Signs and 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

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 ER, PR, and HER2 status, because this may have changed from the time of the original diagnosis.

The treatment of metastatic or recurrent breast cancer depends on the previous treatment(s) and the characteristics of the tumor. For women with a recurrence within the breast after initial treatment with lumpectomy and adjuvant radiation therapy, the treatment is mastectomy. For women with a 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 be given to the same area more than once). Chemotherapy and targeted therapies may also be used to treat metastatic cancer. Radiation therapy and surgery may be used in certain situations for women with a distant metastatic recurrence.

Treatment guides from ASCO for breast cancer include Aromatase Inhibitors for Early Breast Cancer,Bisphosphonates for Breast Cancer, Follow-Up Care for Breast Cancer, HER2 Testing for Breast Cancer, Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer, and Tumor Markers for Breast Cancer.

To learn about the terms used in this section, read the Cancer.Net Feature: Cancer Terms to Know: During Treatment.