View All Pages

Breast Cancer - Metastatic - Introduction

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Metastatic Breast Cancer. Use the menu to see other pages. Think of that menu as a roadmap for this complete guide.

About metastatic breast cancer

Cancer begins when healthy cells change and grow out of control, forming a mass or sheet of cells called a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. A benign tumor means the tumor can grow but will not spread.

When breast cancer is limited to the breast and/or nearby lymph node regions, it is called early stage or locally advanced. Read about these stages in a different guide on Cancer.Net. When breast cancer spreads to an area farther from where it started, doctors say that the cancer has “metastasized.” They call the area of spread a “metastasis,” or “metastases” if the cancer has spread to more than 1 area. The disease is called metastatic breast cancer. Another name for metastatic breast cancer is “stage IV (4) breast cancer.”

Doctors may also call metastatic breast cancer “advanced breast cancer.” However, this term should not be confused with “locally advanced breast cancer,” which is breast cancer that has spread to nearby tissues or lymph nodes but not to other parts of the body.

Metastatic breast cancer may spread to any part of the body. It most often spreads to the bones, liver, lungs and brain. Even after cancer spreads, it is still named for the area where it began. This is called the “primary site” or “primary tumor.” For example, if breast cancer spreads to the lungs, doctors call it metastatic breast cancer, not lung cancer. This is because the cancer started in breast cells.

Metastatic breast cancer can develop when breast cancer cells break away from the primary tumor and enter the bloodstream or lymphatic system. These systems carry fluids around the body. The cancer cells are able to travel in the fluids far from the original tumor. The cells can then settle and grow in a different part of the body and form new tumors.

Most commonly, doctors diagnose metastatic breast cancer after a person previously received treatment for an earlier stage (non-metastatic) breast cancer. Doctors sometimes call this a “distant recurrence” or “metastatic recurrence.”

Sometimes, a person’s first diagnosis of breast cancer is when it has already spread. Doctors call this “de novo” metastatic breast cancer.

Types of breast cancer

There are several types of breast cancer, and any of them can metastasize. Most breast cancers start in the ducts or lobules and are called ductal carcinomas or lobular carcinomas:

  • Ductal carcinoma. These cancers start in the cells lining the milk ducts and make up the majority of breast cancers.

  • Lobular carcinoma. This is cancer that starts in the lobules.

Less common types of breast cancer include:

  • Medullary

  • Mucinous

  • Tubular

  • Metaplastic

  • Papillary breast cancer

  • Inflammatory breast cancer is a faster-growing type of cancer that accounts for about 1% to 5% of all breast cancers.

  • Paget’s disease is a type of cancer that begins in the ducts of the nipple.

Breast cancer can develop in women and men. However, breast cancer in men is rare. Less than 1% of all breast cancers develop in men.

Breast cancer subtypes

Breast cancer is not a single disease, even among the same type of breast cancer. When you are diagnosed with breast cancer, your doctor will recommend lab tests on the cancerous tissue. If you have been diagnosed with metastatic breast cancer after being treated for non-metastatic breast cancer, your doctor may want to repeat the tests to see if the tumor’s cells have changed in any way. These tests will help your doctor learn more about the cancer and choose the most effective treatment plan. Metastatic breast cancer is not curable, but it is treatable. Many patients continue to live well for many months or years with the disease, and treatments continue to improve.

Tests can find out if your cancer is:

  • Hormone receptor-positive. Breast cancers expressing estrogen receptors (ER) and/or progesterone receptors (PR) are called “hormone receptor-positive.” These receptors are proteins found in and on cells. Tumors that have estrogen receptors are called “ER-positive.” Tumors that have progesterone receptors are called “PR-positive.” These cancers may depend on the hormones estrogen and/or progesterone to grow. Hormone receptor-positive cancers can occur at any age. However, they may be more frequent in women who have gone through menopause. About 60% to 75% of breast cancers have estrogen and/or progesterone receptors. If the cancer does not have ER or PR, it is called “hormone receptor-negative.”

  • HER2-positive. About 15% to 20% of breast cancers depend on the gene called human epidermal growth factor receptor 2 (HER2) to grow. These cancers are called “HER2-positive” and have many copies of the HER2 gene or high levels of the HER2 protein. These proteins are also called “receptors.” The HER2 gene makes the HER2 protein, which is found on the cancer cells and is important for tumor cell growth. HER2-positive breast cancers grow more quickly. They can also be either hormone receptor-positive or hormone receptor-negative (see above). Cancers that have no or low levels of the HER2 protein and/or few copies of the HER2 gene are called “HER2-negative.”

  • Triple-negative. If a person’s tumor does not express ER, PR, or HER2, the tumor is called “triple-negative.” Triple-negative breast cancers make up about 15% of invasive breast cancers. This type of breast cancer seems to be more common among younger women, particularly younger black women. Triple-negative breast cancer may grow more quickly. Triple-negative breast cancers are the most common type of breast cancer diagnosed in women with a BRCA1 gene mutations. This means that you may be more likely to have a BRCA1 gene mutation if you have been diagnosed with triple-negative breast cancer. All people younger than 60 with triple-negative breast cancer should be tested for BRCA gene mutations. Find more information on BRCA gene mutations and breast cancer risk.

Looking for More of an Introduction?

If you would like more of an introduction, explore these related items. Please note that these links will take you to other sections on Cancer.Net:

The next section in this guide is Statistics. It helps explain the number of people who are diagnosed with breast cancer and general survival rates. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Statistics

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will find information about the number of people who are diagnosed with breast cancer each year. You will also read general information on surviving the disease. Remember, survival rates depend on several factors. Use the menu to see other pages.

This year, an estimated 271,270 (268,600 women and 2,670 men) in the United States will be diagnosed with invasive breast cancer. Breast cancer is the most common cancer in women, excluding skin cancer.

About 6% of women have metastatic breast cancer when they are first diagnosed. More research is needed to determine how many people with non-metastatic breast cancer later develop metastatic breast cancer.

Breast cancer is the second most common cause of death from cancer in women. It is estimated that 42,260 people (41,760 women and 500 men) will die from breast cancer this year. Metastatic breast cancer will cause the vast majority of those deaths.

The 5-year survival rate tells you what percent of people live at least 5 years after the cancer is found. Percent means how many out of 100. The 5-year survival rate for women with metastatic breast cancer is 27%. The 5-year survival rate for men with metastatic breast cancer is 25%.

It is important to remember that breast cancer is treatable at any stage. Treatments for metastatic breast cancer are continually improving and have been proven to help people with metastatic breast cancer live longer with better quality of life.

In addition, statistics on the survival rates for people with metastatic breast cancer are an estimate. The estimate comes from annual data based on the number of people with this cancer in the United States. Also, experts measure the survival statistics every 5 years. So the estimate may not show the results of better diagnosis or treatment available for less than 5 years. Talk with your doctor if you have any questions about this information. Learn more about understanding statistics.

Statistics adapted from the American Cancer Society's (ACS) publication, Cancer Facts & Figures 2019, the ACS website (January 2019), and the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) program.

The next section in this guide is Risk Factors. It explains the factors that may increase the chance of developing metastatic breast cancer. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Risk Factors

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will find out more about the factors that increase the chance of developing metastatic breast cancer. Use the menu to see other pages.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. Knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

Risk factors for breast cancer

Most people who develop breast cancer of any stage have no obvious risk factors and no family history of breast cancer. But multiple factors may raise a person’s risk of developing the disease. Visit the Risk Factors section of the main Breast Cancer guide to learn about them.

Risk factors for metastatic breast cancer

Any type of breast cancer can metastasize. It is not possible to predict which breast cancers will metastasize. Whether metastasis happens depends on several factors, including:

  • The type of breast cancer, such as hormone-receptor and/or HER2-positive or triple-negative breast cancer (see Introduction).

  • How the cancer grows. For example, is it a faster growing cancer or a slower growing cancer?

  • The stage of the cancer when first diagnosed, such as the tumor size and whether cancer was found in nearby lymph nodes.

There is no proven way to completely avoid developing metastatic breast cancer. Research continues on why metastatic breast cancer occurs and how to prevent, slow, or end the growth of metastatic cells.

The next section in this guide is Symptoms and Signs. It explains what body changes or medical problems metastatic breast cancer can cause. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Symptoms and Signs

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. Use the menu to see other pages.

The symptoms and signs that people with metastatic breast cancer may experience depend on where and how much the cancer has spread. Sometimes people with metastatic breast cancer do not have any of these changes. Or, the cause of a symptom may be a different medical condition that is not cancer.

The following signs or symptoms should be discussed with a doctor.

Bone metastasis symptoms

  • Bone, back, neck, or joint pain

  • Bone fractures

  • Swelling

Brain metastasis symptoms

  • Headache

  • Nausea

  • Seizures

  • Dizziness

  • Confusion

  • Vision changes, such as double vision or loss of vision

  • Personality changes

  • Loss of balance

Lung metastasis symptoms

  • Shortness of breath

  • Difficulty breathing

  • Constant dry cough

Liver metastasis symptoms

  • Yellowing of the skin and whites of the eyes, called “jaundice”

  • Itchy skin or rash

  • Pain or swelling in the belly

  • Loss of appetite

Other symptoms and signs

  • Loss of appetite

  • Weight loss

  • Nausea

  • Vomiting

  • Fatigue

If you are concerned about any changes you experience, please talk with your doctor. You doctor will ask how long and how often you have been experiencing the symptom(s), in addition to other questions. This is to help figure out the cause of the problem, called a diagnosis.

If the doctor diagnoses metastatic breast cancer, relieving symptoms is an important part of care and treatment. This may be called palliative care or supportive care. It is often started soon after diagnosis and continued throughout treatment. Be sure to talk with your health care team about the symptoms you experience, including any new symptoms or a change in symptoms.

The next section in this guide is Diagnosis. It explains what tests may be needed to learn more about the cause of the symptoms. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Diagnosis

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will find a list of common tests, procedures, and scans that doctors use to find out the cause of a medical problem. Use the menu to see other pages.

If metastatic breast cancer develops, it may or may not cause symptoms. Sometimes these symptoms may lead a doctor to perform tests to find metastatic breast cancer or learn if an earlier breast cancer has metastasized. Testing for metastatic disease may also be performed if a patient is diagnosed with locally advanced breast cancer. You can find information on breast cancer staging in the Diagnosis section of the earlier-stage Breast Cancer guide. Testing can also be helpful to follow the status of the disease. Doctors may also do tests to learn which treatments could work best.

Your doctor may consider these factors when choosing a diagnostic test:

  • Your medical history

  • Your symptoms

  • The location of the breast cancer in your body

  • Your physical examination results

Your doctor may recommend the following tests to diagnose metastatic breast cancer. Not all tests listed below will be used for every person.

  • X-ray. An x-ray is a way to create a picture of the structures inside of the body, using a small amount of radiation. A chest x-ray may be used to look for cancer that has spread from the breast to the lungs.

  • Bone scan. A bone scan may be used to look for spread of cancer to the bones. The scan uses a radioactive tracer to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone and is detected by a special camera. Healthy bone appears lighter to the camera, and areas of injury, such as those caused by the cancer, stand out on the image. Some cancers do not cause the same healing response and will not show up on the bone scan. Areas of advanced arthritis or healing after a fracture will also appear dark.

  • Computed tomography (CT or CAT) scan. A CT scan may be used to look for tumors in organs outside of the breast, such as the lung, liver, bone, and lymph nodes. A CT scan takes pictures of the inside of the body using x-rays taken from different angles. A computer combines these pictures into a detailed, 3-dimensional image that shows any abnormalities or tumors. A CT scan can be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail in the image. The dye can be injected into a patient’s vein and/or given as a liquid to swallow.

  • Positron emission tomography (PET) or PET-CT scan. A PET-CT scan may also be used to find out whether the cancer has spread to organs outside of the breast. A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive sugar substance is injected into the patient’s body. This sugar substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body.

    Areas that are most active appear as bright spots, and the intensity of the brightness can be measured to better describe these areas. A PET-CT scan may also be used to measure the size of tumors and to determine the location of the bright spots more accurately. A PET-CT scan will also show any abnormalities in the bone, similar to a bone scan (see above).

  • Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body. MRI can be used to measure the tumor’s size. A special dye called a contrast medium is given before the scan to create a clearer picture. This dye is usually injected into a patient’s vein.

  • Serum chemistry blood tests. These tests are often done to look at minerals in your blood, such as potassium and calcium, and specialized proteins called enzymes that can be abnormal if cancer has spread. These tests can also evaluate how well the liver and kidneys are working. Although these test results can be abnormal if cancer has spread in the body, many noncancerous conditions also cause changes in the test results.

  • Complete blood count (CBC). A complete blood count (CBC) measures the number of different types of cells, such as red blood cells and white blood cells, by testing a sample of a person’s blood. It is done to make sure that your bone marrow is working well.

  • Blood tumor marker tests. Serum tumor markers or biomarkers are tumor proteins in a person's blood. Higher levels of a serum tumor marker may be due to cancer or a noncancerous condition. For metastatic breast cancer, testing may be done for cancer antigen 15-3 (CA 15-3), cancer antigen 27.29 (CA 27.29), and/or carcinoembryonic antigen (CEA). These biomarkers may be found in the blood of people with breast cancer. However, abnormal levels of these biomarkers may also be a sign of another condition that is not cancer.

    Tumor marker testing may be useful to monitor the growth of recurrent or metastatic disease along with symptoms and imaging tests. The actual level of a tumor marker at any single time is less important than the changes in the levels over time. Decreasing levels of tumor markers usually mean that the treatment is working to shrink the cancer.

    Tumor markers should not be used to monitor for a recurrence, as such testing does not appear to improve a patient’s chance of recovery.

Analyzing the cancer

One of the most important tests when someone is diagnosed with metastatic breast cancer is a tumor biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. A biopsy can be done for many parts of the body, including lymph nodes, lungs, liver, bone, skin, or body fluids. The procedure is usually performed with guidance from a CT scan or ultrasound. Pain medication is used during this procedure to prevent discomfort. A pathologist will then analyze the tissue sample. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.

If you are diagnosed with metastatic breast cancer, your doctor may perform a biopsy to evaluate the features of the cancer and find out if they have changed in any way if you had an earlier diagnosis of breast cancer. These results are very important. Testing helps to determine the subtype of breast cancer, which is used to choose treatment options.

Standard testing of metastatic breast cancer looks at 3 important receptors:

Additional testing may also be done. For example, testing the tumor DNA may find mutations in the cancer’s genes. This can help the doctor determine how the cancer will behave and can help identify potential treatment options. The following testing may be done to look at cancer genes:

  • Genomic testing. Genomics is the study of how the genes in a cancer cell behave. Genomic tests look at the genes in breast cancer to help determine what is causing the cancer to grow. The information from these tests can help the cancer care team understand how the cancer may behave and help guide treatment decisions.

  • Molecular testing of the tumor. Your doctor may recommend running other laboratory tests on a tumor sample to identify specific genes, proteins, and other factors unique to the tumor. If you have locally advanced or metastatic breast cancer, your doctor may recommend testing for the following molecular features:

    • PD-L1, which is found on the surface of cancer cells and some of the body's immune cells. This protein stops the body’s immune cells from destroying the cancer.

    • Microsatellite instability-high (MSI-H) or DNA mismatch repair deficiency (dMMR). Tumors that are MSI-H or have a dMMR have difficulty repairing damage to their DNA. This means that they develop many mutations or changes. These changes produce abnormal proteins on the tumor cells that make it easier for immune cells to find and attack the tumor.

    • NTRK gene fusions, which is a specific genetic change found in a range of cancers, including breast cancer. 

    • PIK3CA gene mutations, which have been found in around 40% of advanced ER-positive breast cancers.

  • Genetic testing. Genetic testing looks at the genes inherited from a person’s parents. Genetic testing may be recommended if you have a family history of breast cancer. Finding out whether you have a genetic change linked with an increased risk of breast cancer may be important to other members of your family that could also have the genetic change. Learn more about inherited breast cancer risk.

After diagnostic tests are done, your doctor will review all of the results with you. You will find out more about the cancer, its location, and the tumor subtype.

For most patients, a diagnosis of metastatic breast cancer comes as a shock. People describe a range of emotions such as fear, anger, or sadness that may change day-to-day or over time. You may have concerns about how this diagnosis will affect many different aspects of your life, such as your relationships, work or career, family and social roles, and finances. You may be worried about suffering or having your life shortened by this disease. It is important to remember you are not alone.

Patients and their families are encouraged to talk about the way they are feeling with doctors, nurses, social workers, or other members of the health care team. It may also be helpful to talk with other people with metastatic breast cancer, such as through a support group.

Information about the cancer will help the doctor recommend a specific treatment plan. The next section in this guide is Types of Treatment. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Types of Treatment

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will learn about the different types of treatments doctors use for people with metastatic breast cancer. Use the menu to see other pages.

This section explains the types of treatments that are the standard of care for metastatic breast cancer. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug and how often it should be given, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of cancer. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

Researchers are also using other methods to better understand metastatic breast cancer and identify new treatment approaches. For example, the Metastatic Breast Cancer Project allows people with metastatic breast cancer to enroll themselves. Please note that this link takes you to another, independent website.

If you are diagnosed with metastatic breast cancer, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Treatment overview

In cancer care, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. Cancer care teams include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others. Ask the doctor in charge of your treatment which health care professionals will be part of your treatment team and what they do. This can change over time as your health care needs change.

A treatment plan is a summary of your cancer and the planned cancer treatment. It is meant to give basic information about your medical history to any doctors who will care for you during your lifetime. Before treatment begins, ask your doctor for a copy of your treatment plan. You can also give your doctor a copy of an ASCO Treatment Plan form to fill out.

The main goals of metastatic breast cancer treatment are to make sure that you have the:

  • Longest survival possible with the disease

  • Fewest possible side effects from the cancer and its treatment

  • Best and longest quality of life possible

There is no cure for metastatic cancer, but a good quality of life is possible for months or even years.

Treatment options for metastatic breast cancer vary based on:

  • Where in the body the cancer has spread

  • The presence and level of hormone receptors and/or HER2 in the tumor

  • Gene mutations in the tumor

  • Specific symptoms

  • Previous cancer treatments

  • Your overall health

How well treatment works depends on many factors as well, including how widespread the cancer is and what treatments have already been used. Because it is not unusual for metastatic breast cancer to stop responding to drugs over time, you may need to change treatments fairly often.

After testing is done, you and your doctor will talk about your treatment options. Your treatment plan may include certain treatments described below, but they may be used in a different combination or at a different pace. Your care plan also includes treatment for symptoms and side effects, an important part of cancer care.

Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for metastatic breast cancer because there are different treatment options. Learn more about making treatment decisions.

Therapies using medication

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally).

The types of systemic therapies used for metastatic breast cancer include:

  • Hormonal therapy

  • Chemotherapy

  • Targeted therapy

  • Immunotherapy

Each of these types of therapies are discussed below in more detail. A person may receive 1 type of systemic therapy at a time or a combination of systemic therapies given at the same time. The first set of drugs used for metastatic disease is called first-line treatment. If the cancer worsens or comes back, another combination of drugs may be used, called second-line treatment. These therapies can also be given as part of a treatment plan that includes surgery and/or radiation therapy.

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. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with cancer medications. Learn more about your prescriptions by using searchable drug databases.

Hormonal therapy

Hormonal therapy, also called endocrine therapy, is an effective treatment for many tumors that test positive for either ER or PR.

Hormone receptor-positive tumors may use hormones to fuel their growth. The goal of this type of therapy is to lower the levels of estrogen and progesterone in the body or to block these hormones from getting to cancer cells. If the hormones cannot get to the cancer cells, the cancer cannot use them to grow.

In general, hormonal therapy is recommended for all patients with hormone receptor-positive breast cancer. The available treatment options are based on several factors:

  • Whether a woman is still menstruating or has gone through menopause

  • The type of treatment you have already received or are receiving

  • How long it had been before the cancer recurred

  • How widespread the cancer is and whether you have symptoms that need to be managed

Options for hormonal therapy include:

  • Tamoxifen (Soltamox). Tamoxifen is a drug that blocks estrogen from binding to breast cancer cells. It is a pill taken daily by mouth. Common side effects of tamoxifen include hot flashes as well as vaginal discharge or bleeding. Very rare risks include a cancer of the lining of the uterus, cataracts, and blood clots. However, tamoxifen may improve bone health and cholesterol levels. The treatment is an option for both premenopausal and postmenopausal women.

  • Aromatase inhibitors (AIs). AIs decrease the amount of estrogen made by tissues other than the ovaries by blocking the aromatase enzyme. This enzyme changes hormones called androgens into estrogen when the ovaries have stopped making estrogen after menopause. These drugs include anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara). All of the AIs are pills taken daily by mouth.

    Side effects of AIs may include joint stiffness, sometimes with joint aches. AIs may also cause hot flashes, vaginal dryness, an increased risk of osteoporosis and broken bones, and increased cholesterol levels. Research shows that all 3 AIs work equally well and have similar side effects. However, women who experience too many side effects while taking 1 AI may have fewer side effects with another AI for unclear reasons. Women who have not gone through menopause should not take AIs, as they do not block the effects of estrogen made by the ovaries. Often, doctors will monitor blood estrogen levels in women whose periods have recently stopped, or in those whose periods have stopped because of chemotherapy, to be sure that the ovaries are no longer making estrogen.

  • Ovarian suppression. This is the use of drugs or surgery to stop the ovaries from producing estrogen. It may be used in combination with tamoxifen, an AI, or fulvestrant (see below). Drugs called gonadotropin or luteinizing releasing hormone (GnRH or LHRH) analogs can stop the ovaries from making estrogen, causing temporary menopause. Some examples of these medicines include goserelin (Zoladex) or leuprolide (Eligard, Leupron), which are usually taken monthly. Surgery permanently stops estrogen production.

    Ovarian suppression is commonly used to treat hormone receptor-positive metastatic breast cancer in women who have not been through menopause. This is because completely blocking estrogen may be helpful against the cancer.

  • Fulvestrant (Faslodex). Fulvestrant is a selective estrogen receptor downregulator (SERD) that blocks the ability of estrogen to attach to estrogen receptors. Unlike other oral hormonal therapies, fulvestrant is given monthly by an injection into a muscle. Most commonly, 2 injections are given every 2 weeks for the first 3 doses and then continued monthly. Fulvestrant is only for women who have been through menopause.

  • Other hormonal therapies. Other hormonal therapies occasionally used to treat metastatic breast cancer after AIs, fulvestrant, tamoxifen, and targeted therapy (see below) include megestrol acetate (Megace) and high-dose estradiol.

Recommendations for hormonal therapy for women with metastatic hormone receptor-positive breast cancer include:

  • Fulvestrant or an AI for women who have been through menopause.

  • Ovarian suppression and hormonal therapy with either tamoxifen or an AI for women who have not been through menopause.

  • A combination of anastrozole or letrozole and fulvestrant is an option for patients who have not previously had hormonal therapy.

  • If the first hormonal therapy given no longer works, another type may be an option unless the disease has worsened quickly and is affecting how well the body’s organs are working.

Some types of targeted therapy (see below) may be combined with hormonal therapy for metastatic breast cancer. However, chemotherapy is not recommended along with hormonal therapy.

This information is based on ASCO’s recommendations for hormonal therapy for metastatic breast cancer. Please note that this link takes you to a separate ASCO website.

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells, usually by keeping the cancer cells from growing, dividing, and making more cells.

Chemotherapy for metastatic breast cancer can be given on many different schedules depending on what worked best in clinical trials for that specific type of regimen, or schedule. It may be given once a week, once every 2 weeks (also called dose-dense), once every 3 weeks, or even once every 4 weeks. Weekly schedules often include weeks off as a break. In general, chemotherapy is often given continuously as long as it is working against the cancer and the patient isn’t experiencing too many side effects.

A patient with metastatic breast cancer usually receives 1 drug at a time, which means 1 after another, rather than as a combination, although occasionally a combination regimen is recommended. The best chemotherapy option for each patient depends on several factors, including the previous treatment received, potential side effects, the patient’s overall health, and the patient’s preferences.

Drugs that may be used for metastatic breast cancer include:

  • Capecitabine (Xeloda)

  • Carboplatin (available as a generic drug)

  • Cisplatin (available as a generic drug)

  • Cyclophosphamide (available as a generic drug)

  • Docetaxel (Taxotere)

  • Doxorubicin (available as a generic drug)

  • Pegylated liposomal doxorubicin (Doxil)

  • Epirubicin (Ellence)

  • Eribulin (Halaven)

  • Fluorouracil (5-FU)

  • Gemcitabine (Gemzar)

  • Ixabepilone (Ixempra)

  • Methotrexate (Rheumatrex, Trexall)

  • Paclitaxel (Taxol)

  • Protein-bound paclitaxel (Abraxane)

  • Vinorelbine (Navelbine)

Chemotherapy may be combined with other types of treatments. For example, therapies that target the HER2 receptor, such as the antibody trastuzumab, may be given with chemotherapy for HER2-positive breast cancer (see Targeted therapy, below).

The side effects of chemotherapy depend on the individual, the drug(s) used, and the schedule and dose used. These side effects can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, numbness from nerve damage, and diarrhea. These side effects can often be very successfully prevented or managed during treatment with supportive medications, and they usually go away after treatment is finished.

Many patients feel reasonably well during chemotherapy treatment and are active taking care of their families, traveling, and exercising during treatment, although each person’s experience can be different. Talk with your health care team about the possible side effects of your specific chemotherapy plan.

Learn more about the basics of chemotherapy.

Targeted therapy

Targeted therapy is a treatment that targets the cancer’s specific genes, proteins, or the tissue environment that contributes to cancer growth and survival. These treatments are very focused and work differently than chemotherapy or hormonal therapy. This type of treatment blocks the growth and spread of cancer cells while limiting damage to healthy cells.

Not all tumors have the same targets. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

There are different types of targeted therapies that vary in how they target the cancer cells:

  • Monoclonal antibodies. A monoclonal antibody recognizes and attaches to a specific protein in the cancer cells, and it does not affect cells that do not have that protein. Examples of monoclonal antibodies used for breast cancer include trastuzumab, pertuzumab, TDM-1, and atezolizumab (see below).

  • Small molecule inhibitors. Small molecule inhibitors are drugs designed to specifically target parts of a cancer cell that contribute to its growth and survival. The parts of a cancer cell that these drugs target may be receptors on the outside of the cell, enzymes on the inside of a cell, or a protein important for cell growth. Some of these types of drugs may target different parts of a cell. These are called “multi-targeted.” Small molecule inhibitors are often pills. Examples used for breast cancer include lapatinib, palbociclib, ribociclib, abemaciclib, olaparib, talazoparib, and everolimus (see below).

  • Tumor agnostic treatments. A tumor-agnostic treatment is a drug treatment that is used to treat any kind of cancer, regardless of where in the body it started or the type of tissue from which it developed. This type of treatment can be used when the tumor has a very specific molecular alteration that is targeted by the drug. The drug larotrectinib (Vitrakvi) is an example of a tumor agnostic targeted therapy. It is approved for any cancer with an NTRK fusion, including breast cancer, that is metastatic or cannot be removed with surgery and has worsened with other treatments. Another tumor-agnostic treatment for breast cancer is a type of immunotherapy called pembrolizumab (Keytruda; see Immunotherapy, below).

Talk with your doctor about possible side effects of specific targeted therapies and how they can be managed.

Targeted therapy for metastatic HER2-positive breast cancer

HER2-targeted therapies can be used to treat HER2-positive metastatic breast cancer. Some of these drugs may be used together with chemotherapy. In general, for a person with HER2-positive metastatic breast cancer, there is almost always a HER2-targeted therapy being used along with another systemic therapy.

Some of the HER2-targeted therapies may not be able to penetrate into the brain as easily as they reach the rest of the body. So, HER2-positive metastatic breast cancer that has spread to the brain is often treated with surgery and/or radiation therapy (see below).

  • Trastuzumab (Herceptin, Herzuma, Ogivri, Ontruzant). For metastatic breast cancer, trastuzumab can be given in combination with different types of chemotherapy or with hormonal therapy. Trastuzumab can be given as a weekly infusion, or once every 3 weeks. Patients receiving trastuzumab have a small (2% to 5%) risk of heart problems and should have monitoring with an echocardiogram.

  • Pertuzumab (Perjeta). Research shows that adding pertuzumab to trastuzumab and chemotherapy as part of first-line therapy for HER2-positive metastatic breast cancer lengthens lives with few additional side effects. Based on this data, the combination of trastuzumab, pertuzumab, and chemotherapy has become a standard of care for the first-line treatment of untreated metastatic HER2-positive breast cancer. Pertuzumab is an intravenous medication and generally causes few side effects, although it can occasionally cause diarrhea.

  • Ado-trastuzumab emtansine or T-DM1 (Kadcyla). This is approved for the treatment of metastatic breast cancer for patients who have previously received trastuzumab and chemotherapy with either paclitaxel or docetaxel. T-DM1 is a combination of trastuzumab linked to very small amount of a strong chemotherapy. This allows the drug to deliver chemotherapy into the cancer cell while lessening the chemotherapy received by healthy cells. T-DM1 is given by vein every 3 weeks.

  • Lapatinib (Tykerb). Women with HER2-positive metastatic breast cancer may benefit from lapatinib when other medications are no longer effective at controlling the cancer’s growth. The combination of lapatinib and the chemotherapy capecitabine is approved to treat metastatic HER2-positive breast cancer when a patient has already received chemotherapy and trastuzumab. The combination of lapatinib and letrozole is also approved for metastatic HER2-positive and ER-positive cancer. Lapatinib is also used in combination with trastuzumab for patients whose cancer is growing while receiving trastuzumab. Lapatinib may be able to enter into the brain, and could be an option for HER2-positive breast cancer that has spread to the brain.

Targeted therapy for metastatic hormone receptor-positive, HER2-negative breast cancer
  • Palbociclib (Ibrance). This oral drug targets a protein in breast cancer cells called CDK4/6, which may stimulate cancer cell growth. Used along with the AI letrozole, the drug is an option for women who have been through menopause and have ER-positive, HER2-negative metastatic breast cancer. Palbociclib can also be used with fulvestrant if the cancer has worsened after receiving other hormonal therapy. Palbociclib generally has few side effects. It can lower the number of white blood cells. But it does not appear to increase the risk of serious infections that are linked to low numbers of white blood cells.

  • Ribociclib (Kisqali). This oral drug also targets CDK4/6. Used with an AI or fulvestrant, it is an option for women who have been through menopause and have ER-positive, HER2-negative metastatic breast cancer. Side effects of ribociclib can include low numbers of white blood cells, increases in enzymes linked with liver damage, and changes in heart rhythms.

  • Abemaciclib (Verzenio) This is another oral drug that targets CDK4/6. It is approved by the FDA as a first-line treatment along with an AI for women who have been through menopause and have ER-positive, HER2-negative metastatic breast cancer. It may also be used along with fulvestrant if the cancer has worsened with other hormonal therapies. Abemaciclib may also be used alone as a treatment. It does not lower blood counts as much as the other CDK4/6 drugs, but it is more likely to cause diarrhea, which can be severe at times.

  • Everolimus (Afinitor, Zortress). Everolimus is used with the AI exemestane for ER-positive, HER2-negative metastatic breast cancer that has grown despite treatment with another AI. Side effects of everolimus can include mouth sores, rash, diarrhea, and, rarely, an inflammation of the lungs called interstitial pneumonitis.

  • Alpelisib (Piqray). Alpelisib is an option along with the hormonal therapy fulvestrant for men and women with hormone receptor-positive, HER2-negative metastatic breast cancer that has a PIK3CA gene mutation and has worsened during or after hormonal therapy. Side effects include diarrhea, rash, fatigue, changes in numbers of blood cells, nausea and vomiting, mouth sores, and changes in certain substances found in the blood, including high sugar levels and enzymes linked with liver damage.

Targeted therapy for people who have a BRCA1 or BRCA2 gene mutation
  • Olaparib (Lynparza). This oral drug may be used for patients with metastatic HER2-negative breast cancer and a BRCA1 or BRCA2 gene mutation who have previously received chemotherapy. It is a type of drug called a PARP inhibitor, which destroys cancer cells by preventing them from fixing damage. Common side effects include fatigue, anemia, and occasionally nausea, vomiting, and diarrhea.

  • Talazoparib (Talzenna). This drug is another option for patients with metastatic HER2-negative breast cancer and a BRCA1 or BRCA2 gene mutation. It is also a PARP inhibitor (see above). The most common side effects include fatigue, anemia, nausea and vomiting, headache, diarrhea, decreased appetite, hair loss, and lower levels of certain blood cells.

Immunotherapy

Immunotherapy, also called biologic therapy, is designed to boost the body's natural defenses to fight the cancer. It uses materials made either by the body or in a laboratory to improve, target, or restore immune system function.

  • Atezolizumab (Tecentriq). In 2019, the U.S. Food and Drug Administration (FDA) approved a combination of atezolizumab plus protein-bound paclitaxel (see Chemotherapy, above) for metastatic triple-negative breast cancer that tests positive for PD-L1 (see Diagnosis).

  • Pembrolizumab (Keytruda). This is a type of immunotherapy that is approved by the FDA to treat metastatic cancer or cancer that cannot be treated with surgery. These tumors must also have a molecular alteration called microsatellite instability-high (MSI-H) or DNA mismatch repair deficiency (dMMR) (see Diagnosis).

Different types of immunotherapy can cause different side effects. Common side effects include skin reactions, flu-like symptoms, diarrhea, and weight changes. Talk with your doctor about possible side effects for the immunotherapy recommended for you. Learn more about the basics of immunotherapy and immunotherapy and breast cancer.

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 is given by placing radioactive sources into the tumor, it is called brachytherapy.

Radiation therapy may be used to shrink or slow tumor growth. It can also treat symptoms from the cancer, such as pain. Used by itself, or in combination with surgery, radiation therapy can also treat breast cancer that has spread to the brain. Several different types of radiation therapy are used to treat brain metastases, including whole brain radiation, stereotactic radiosurgery, and fractionated stereotactic radiotherapy.

  • Whole brain radiation therapy is directed at the entire brain.

  • Stereotactic radiosurgery is the use of a single, high dose of radiation given directly to the tumor to avoid harming the surrounding healthy tissues.

  • Fractionated stereotactic radiation therapy is similar to stereotactic radiosurgery but divided into small daily doses called fractions that are given over multiple days or weeks, in contrast to the 1-day radiosurgery.

A radiation therapy regimen, or schedule, usually consists of a specific number of treatments given over a set period of time. Doctors will set the schedule and radiation dose for breast cancer metastases based on a patient’s individual medical needs and prior use of radiation therapy.

Radiation therapy can cause general side effects, such as fatigue and skin problems. In addition to general side effects, other side effects may occur and depend on the type of radiation therapy given and where on the body it is directed.

Learn more about the basics of radiation therapy.

Surgery

Surgery is the removal of a tumor and some surrounding healthy tissue during an operation. Surgery is not often used to treat metastatic breast cancer. However, doctors may recommend surgery to remove a tumor that is causing discomfort. Research continues on whether people who are first diagnosed with metastatic breast cancer live longer if the primary breast tumor is removed.

Surgery, used by itself or with radiation therapy, can be options to treat breast cancer that has spread to the brain. The goal is to shrink or temporarily get rid of the cancer in the brain. Usually, surgery of this type is done by a neurosurgeon, a specialist who operates on the head, brain, and central nervous system.

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Summary of treatment options for metastatic breast cancer

HER2-negative breast cancer

Hormonal therapy is considered the standard initial treatment for HER2-negative metastatic breast cancer that is also hormone receptor-positive. However, chemotherapy, targeted therapy, or immunotherapy may also be given.

  • Chemotherapy. There is no specific type of chemotherapy recommended for this type of breast cancer. Many drugs are available, including those discussed under "Chemotherapy," above. The best chemotherapy option for each patient depends on several factors, including the previous treatments received, potential side effects, overall health, and the patient’s preference.

    Generally, chemotherapy should continue until the disease worsens if a patient is not experiencing unmanageable side effects. At some point, chemotherapy may no longer be able to control the cancer’s growth. When this happens, patients may choose to stop chemotherapy while continuing to receive palliative care.

  • Targeted therapy and immunotherapy. Targeted therapy or immunotherapy may also be an option depending on the type and features of the breast cancer. See Targeted therapy and Immunotherapy, above, for more details.

This information is based on ASCO’s recommendations on Chemo- and Targeted Therapy for Women with HER2 Negative (or unknown) Advanced Breast Cancer. Please note that this link takes you to a separate ASCO website.

HER2-positive breast cancer that has spread to parts of the body other than the brain

In general, HER2-targeted therapy is regularly added to treatment for HER2-positive breast cancer that has spread. The drugs used depend on the treatments already given and whether the cancer is hormone receptor-positive. The treatment recommendations for first-line, second-line, and third-line or higher treatment are listed below. A clinical trial may also be an option for treatment at any stage.

First-line treatment
  • Treatment is usually a combination of pertuzumab, trastuzumab, and a type of chemotherapy called a taxane.

  • If the cancer is hormone receptor-positive, treatment may be a combination of hormonal therapy plus HER2-targeted therapy with either trastuzumab or lapatinib. Hormonal therapy may also be given alone if the cancer has not spread widely, a patient has other health conditions that could be worsened with HER2-targeted therapies, or the cancer has recurred after a long time.

  • Chemotherapy is generally given for at least 4 to 6 months or until the patient experiences too many severe side effects, or the disease worsens. For patients with hormone receptor-positive cancer, HER2-targeted therapy and hormonal therapy usually continue after chemotherapy ends.

Second-line treatment
  • For patients with early-stage breast cancer who had the cancer spread during initial treatment with trastuzumab or return within 12 months after stopping treatment with trastuzumab, second-line treatment is used.

  • The preferred second-line treatment is the drug T-DM1.

Third-line or higher treatment
  • T-DM1 is a treatment option for patients who have not already received it.

  • Pertuzumab is also an option for patients who have not already received it. It is usually given in combination with trastuzumab.

  • For patients who have already received T-DM1 and pertuzumab, other options include lapatinib with capecitabine, other combinations of chemotherapy with HER2-targeted therapy, or hormonal therapy when appropriate.

This information is based on ASCO’s recommendations on Systemic Therapy for Patients With Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer. Please note that this link takes you to a separate ASCO website.

HER2-positive breast cancer that has spread to the brain

The treatment of HER2-positive breast cancer that has spread to the brain often involves different types of radiation therapy. Sometimes, surgery and/or chemotherapy or targeted therapy may be used. Treatment in a clinical trial may also be an option.

In general, the treatment options available depend on the size and location of the tumor(s) in the brain, and the symptoms they are causing, as well as the patient’s general health.

Below is a general summary of when and how the above treatment options are used to treat brain metastases:

  • People with a single brain metastasis and good overall health generally receive surgery, followed by some type of radiation therapy. If the metastasis in the brain cannot be removed by surgery and the person is not having symptoms, stereotactic radiosurgery may be used.

  • People with 2 to 4 brain metastases generally receive stereotactic radiosurgery.

  • Treatment for people with cancer that has spread widely throughout the brain usually includes whole brain radiation therapy.

  • For people whose cancer in the brain is worsening even after receiving radiation therapy, additional treatment options depend on the initial treatment and include surgery, the types of radiation therapy discussed above, and/or a drug that can affect the whole body, such as chemotherapy or HER2-targeted therapy.

  • People who also have metastatic HER2-positive breast cancer in parts of the body other than the brain usually continue their treatment regimen if the disease outside the brain is not worsening. If the disease is worsening, HER2-targeted therapy may be added/changed based on the recommendations for HER2-positive cancer that has spread to parts of the body other than the brain (see above).

This information is based on ASCO’s recommendations on Disease Management for Patients With Advanced Human Epidermal Growth Factor Receptor 2–Positive Breast Cancer and Brain Metastases. Please note that this link takes you to a separate ASCO website.

The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for people with cancer. You may use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - About Clinical Trials

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will learn more about clinical trials, which are the main way that new medical approaches are tested to see how well they work. Use the menu to see other pages.

What are clinical trials?

Doctors and scientists are always looking for better ways to care for people with metastatic breast cancer. To make scientific advances, doctors design research studies involving volunteers, called clinical trials. In fact, every drug that is now approved by the U.S. Food and Drug Administration (FDA) was tested in clinical trials.

Clinical trials are used for all types and stages of breast cancer. Many focus on new treatments to learn if a new treatment is safe, effective, and possibly better than the existing treatments. For example, these types of studies may evaluate new drugs, different combinations of treatments, new approaches to radiation therapy or surgery, new methods of providing treatment, and the experience of receiving cancer therapy.

People who participate in clinical trials can be some of the first to get a treatment before it is available to the public. However, there can be risks with a clinical trial, including possible side effects and the chance that the new treatment may not work. People are encouraged to talk with their health care team about the pros and cons of joining a specific study.

Deciding to join a clinical trial

People decide to participate in clinical trials for many reasons. For some people, a clinical trial is the best treatment option available. Because standard treatments are not perfect, people are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other people volunteer for clinical trials because they know that these studies are a way to contribute to progress in treating metastatic breast cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with metastatic breast cancer.

Insurance coverage and the costs of clinical trials differ by location and by study. In some programs, some of the expenses from participating in the clinical trial are reimbursed. In others, they are not. It is important to talk with the research team and your insurance company first to learn if and how your treatment in a clinical trial will be covered. Learn more about health insurance coverage of clinical trials.

Sometimes people have concerns that, in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” When used, placebos are usually combined with standard treatment in most cancer clinical trials. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials.

Patient safety and informed consent

To join a clinical trial, people must participate in a process known as informed consent. During informed consent, the doctor should:

  • Describe all of the treatment options so that the person understands how the new treatment differs from the standard treatment.

  • List all of the risks of the new treatment, which may or may not be different from the risks of standard treatment.

  • Explain what will be required of each person in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment.

Clinical trials also have certain rules called “eligibility criteria” that help structure the research and keep patients safe. You and the research team will carefully review these criteria together.

People who participate in a clinical trial may stop participating at any time for personal or medical reasons. This may include that the new treatment is not working or there are serious side effects. Clinical trials are also closely monitored by experts who watch for any problems with each study. It is important that people participating in a clinical trial talk with their doctor and researchers about who will be providing their treatment and care during the clinical trial, after the clinical trial ends, and/or if they choose to leave the clinical trial before it ends.

Finding a clinical trial

Research through clinical trials is ongoing for all types of cancer. For specific topics being studied for metastatic breast cancer, learn more in the Latest Research section.

Cancer.Net offers a lot of information about cancer clinical trials in other areas of the website, including a complete section on clinical trials and places to search for clinical trials for a specific type of cancer, including metastatic breast cancer.

PRE-ACT, Preparatory Education About Clinical Trials

In addition, you can find a free video-based educational program about cancer clinical trials in another section of this website. 

The next section in this guide is Latest Research. It explains areas of scientific research for metastatic breast cancer. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Latest Research

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will read about the scientific research being done to learn more about this type of cancer and how to treat it. Use the menu to see other pages.

Doctors are working to learn more about metastatic breast cancer, including ways to prevent it, how to best treat it, and how to provide the best care to people diagnosed with this disease. The following areas of research may include new options for patients through clinical trials. Always talk with your doctor about the best diagnostic and treatment options for you.

  • Understanding the metastatic breast cancer process and finding ways to prevent and stop it.

  • Developing ways to best evaluate the genes and proteins contributing to cancer growth in each patient and each metastatic breast cancer to determine the best treatment options.

  • Testing new drugs and treatment combinations, such as new chemotherapies, hormonal treatments, and targeted therapies.

  • Studying the use of immunotherapy, which boosts the body’s natural defenses to fight cancer.

  • Determining the best ways to give hormonal therapy, and how to overcome tumor resistance to hormonal therapy.

  • Determining if surgical removal of the primary breast tumor can improve survival rates.

  • Testing various drugs for effectiveness against HER2-positive breast cancer that metastasizes to the brain.

  • Identifying new and effective treatments for triple-negative breast cancer.

  • Finding ways to check how well treatments are working against metastatic breast cancer and predict survival rates.

  • Learning more about the social and emotional factors that may affect patients’ treatment plans and quality of life.

  • Finding better ways of reducing symptoms and side effects of current metastatic breast cancer treatments to improve comfort and quality of life for patients.

Looking for More About the Latest Research?

If you would like additional information about the latest areas of research regarding metastatic breast cancer, explore these related items that take you outside of this guide:

  • To find clinical trials specific to your diagnosis, talk with your doctor or search online clinical trial databases now.

  • Visit the Cancer.Net Blog to review research announced at recent scientific meetings or in ASCO's peer-reviewed journals.

  • Visit the website of Conquer Cancer, the ASCO Foundation, to find out how to help support cancer research. Please note that this link takes you to a separate ASCO website.

The next section in this guide is Palliative Care. It how the symptoms and side effects of metastatic breast cancer and its treatment can be managed. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Palliative Care

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will read about managing the symptoms and side effects of metastatic breast cancer and its treatment. Use the menu to see other pages.

Cancer and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to manage the cancer.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of cancer, may receive this type of care. And it often works best when it is started right after a cancer diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to manage the cancer, such as chemotherapy, surgery, or radiation therapy.

The following options may be used to manage the symptoms and side effects of metastatic breast cancer.

Bone modifying drugs

If cancer has spread to the bone, medications that help to strengthen the bones can be used to lower the risk of bone pain, fracture, and the need for radiation therapy to the bone. ASCO recommends bone-modifying drugs for people with breast cancer when scans show there are metastases in the bone.

There are 2 different classes of bone-modifying drugs and both help stop the bone from breaking down. Both classes of drugs help reduce the risk of bone problems from metastatic cancer. The choice of drug depends on your overall health, your individual risk of side effects, your insurance coverage, and how you prefer to receive the drug.

  • Bisphophonates, such as zoledronic acid (Reclast, Zometa) and pamidronate (Aredia), block the cells that dissolve bone, called osteoclasts. Zoledronic acid is given by IV for at least 15 minutes every 3 to 4 weeks or every 12 weeks. Pamidronate is given by IV every 3 to 4 weeks for at least 2 hours. Side effects may include flu-like symptoms and kidney problems. If you are taking pamidronate or zoledronic acid, you should have a blood test to check how well the kidneys are working before each time you receive the drug.

  • Denosumab (Prolia, Xgeva) is an osteoclast-targeted therapy called a RANK ligand inhibitor. Denosumab is given as an injection under the skin (called a subcutaneous injection) every 4 weeks. Denosumab may cause low calcium levels in the blood, so you may need blood tests to monitor your blood calcium levels. You may also have tests to check kidney function.

A possible condition associated with bone-modifying drugs is osteonecrosis of the jaw. It is uncommon, about 1% to 2% of patients develop it, but it can be a serious condition. The symptoms of osteonecrosis of the jaw may include pain, swelling, and infection of the jaw; loose teeth; and exposed bone. It is recommended that you have a thorough dental examination, and any invasive procedures to the jaw bone or treatments for mouth infections should be done before starting these drugs. While receiving bone-modifying drugs, you should take good care of your teeth, mouth, and gums and avoid having any unnecessary invasive dental work done, such as elective dental surgery. Following these recommendations may help lower the risk of osteonecrosis of the jaw.

Although bone-modifying drugs may help reduce or lessen pain over the long term, they should not replace other treatments to reduce pain. Patients who experience bone pain should receive other medications, radiation therapy, and/or surgery, which are commonly used to manage pain.

This information is based on ASCO's recommendations for bone modifying drugs for metastatic breast cancer. Please note that this link takes you to a separate ASCO website.

White blood cell growth factors

White blood cell growth factors are proteins that help the body produce white blood cells. They are also called hematopoietic, meaning blood-forming, colony-stimulating factors (CSFs). White blood cells help fight infection and can be destroyed during some types of cancer treatment. Your doctor may recommend CSFs to help you avoid infections.

When treatment stops working

At some point, options for metastatic breast cancer treatment become very limited and the cancer will become difficult to control. When this happens, patients may choose to stop cancer treatment and focus on palliative care.

It is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have metastatic breast cancer and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable and preferable option for many families. Learn more about advanced cancer care planning.

Changing role of caregivers

A family caregiver plays a very important role in supporting a person diagnosed with cancer, providing physical, emotional, and practical care on a daily or as-needed basis. Many caregivers become focused on providing this support, especially if the treatment period lasts for many months or longer.

And, the caregiver's role often changes throughout treatment, often becoming more intensive if the cancer worsens.

Eventually, the need for caregiving related to the cancer diagnosis will come to an end. After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is Coping with Treatment. It offers some guidance in how to cope with the physical, emotional, social, and financial changes that cancer and its treatment can bring. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Coping with Treatment

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will learn more about coping with the physical, emotional, social, and financial effects of cancer and its treatment. Use the menu to see other pages.

Every cancer treatment can cause side effects or changes to your body and how you feel. For many reasons, people do not experience the same side effects even when they are given the same treatment for the same type of cancer. This can make it hard to predict how you will feel during treatment.

As you prepare to start cancer treatment, it is normal to fear treatment-related side effects. It may help to know that your health care team will work to prevent and relieve side effects. Doctors call this part of cancer treatment “palliative care” or "supportive care." It is an important part of your treatment plan, regardless of your age or the stage of disease. If cancer treatment fails or you choose to stop cancer treatment, palliative care will continue and will focus on reducing pain and other symptoms caused by the cancer.

Coping with physical side effects

Common physical side effects from each treatment option for metastatic breast cancer are listed in the Types of Treatment section. Learn more about side effects of cancer and its treatment, along with ways to prevent or control them. Changes to your physical health depend on several factors, including where in your body cancer has spread to, the length and dose of treatment, and your general health.

Talk with your health care team regularly about how you are feeling. It is important to let them know about any new side effects or changes in existing side effects. If they know how you are feeling, they can find ways to relieve or manage your side effects to help you feel more comfortable and potentially keep any side effects from worsening.

You may find it helpful to keep track of your side effects so it is easier to explain any changes with your health care team. Learn more about why tracking side effects is helpful.

Coping with emotional and social effects

Living with metastatic cancer is challenging. You can have emotional and social effects as well as physical effects after receiving this diagnosis. This may include dealing with difficult emotions, such as sadness, anxiety, anger, or hopelessness. Sometimes, people find it difficult to express how they feel to their loved ones. Some have found that talking to an oncology social worker, counselor, or member of the clergy can help them develop more effective ways of coping and talking about metastatic cancer.

Your loved ones might also need help coping. Having a family member or friend with metastatic cancer is challenging, especially for people who help care for you.

Talking about fears and concerns is important, even when treatment is working well. You can also find coping strategies for emotional and social effects in a separate section of this website. This section includes many resources for finding support and information to meet your needs.

Coping with financial effects

Cancer treatment can be expensive. It is often a big source of stress and anxiety for people with cancer and their families. In addition to treatment costs, many people find they have extra, unplanned expenses related to their care. For some people, the high cost of medical care stops them from following their cancer treatment plan. This can put their health at risk and may lead to higher costs in the future. Patients and their families are encouraged to talk about financial concerns with a member of their health care team. Learn more about managing financial considerations in a separate part of this website.

Caring for a loved one with cancer

Family members and friends often play an important role in taking care of a person with metastatic breast cancer. This is called being a caregiver. Caregivers can provide physical, practical, and emotional support to the patient, even if they live far away.

Caregivers may have a range of responsibilities on a daily or as-needed basis, including:

  • Providing support and encouragement

  • Talking with the health care team

  • Giving medications

  • Helping manage symptoms and side effects

  • Coordinating medical appointments

  • Providing a ride to and from appointments

  • Assisting with meals

  • Helping with household chores

  • Handling insurance and billing issues

Learn more about caregiving.

Talking with your health care team about side effects

Before starting treatment, talk with your doctor about possible side effects. Ask:

  • Which side effects are most likely?

  • When are they likely to happen?

  • What can we do to prevent or relieve them?

Be sure to tell your health care team about any side effects that happen during treatment and afterward, too. Tell them even if you do not think the side effects are serious. This discussion should include physical, emotional, and social effects of cancer. Also, ask how much care you may need at home and with daily tasks during and after treatment. This can help you make a caregiving plan.

Create a caregiving plan with this 1-page fact sheet that includes an action plan to help make caregiving a team effort. This free fact sheet is available as a PDF, so it is easy to print out.

Looking for More on How to Track Side Effects?

Cancer.Net offers several resources to help you keep track of your symptoms and side effects. Please note that these links will take you to other sections of Cancer.Net:

  • Cancer.Net Mobile: The free Cancer.Net mobile app allows you to securely record the time and severity of symptoms and side effects.

  • ASCO Answers Managing Pain: Get this 36-page booklet about the importance of pain relief that includes a pain tracking sheet to help patients record how pain affects them. The free booklet is available as a PDF, so it is easy to print out.

  • ASCO Answers Fact Sheets: Read 1-page fact sheets on diarrhea and rash that provide a tracking sheet to record the timing and severity of the side effect. These free fact sheets are available as a PDF, so they are easy to print out.

The next section in this guide is Living with Metastatic Breast Cancer. It describes how to cope with challenges in everyday life after a diagnosis of metastatic breast cancer. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Living with Metastatic Breast Cancer

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will read about how to cope with challenges in everyday life after a diagnosis of metastatic breast cancer. Use the menu to see other pages.

For many people with metastatic breast cancer, a good quality of life is possible for months or even years. When there are effective treatments for metastatic cancer, your situation may be like someone with a chronic (long-term) disease. The cancer can be treated to keep it from worsening, but it cannot be cured.

Living with metastatic cancer is challenging. Each person with metastatic breast cancer has individual concerns and challenges. With any challenge, a good first step is being able to recognize your fears and talk about them. Effective coping requires:

  • Understanding the challenge you are facing

  • Thinking through solutions

  • Asking for and allowing the support of others

  • Feeling comfortable with the course of action you choose

Many people with metastatic cancer find it helpful to join an in-person support group or an online community. This allows you to talk with people who are experiencing similar first-hand experiences. Other options for finding support include talking with a friend or member of your health care team, individual counseling, or asking for assistance at the learning resource center of the place where you receive treatment.

Monitoring your health

During treatment, your health care team will continue to check to make sure the cancer has not worsened, manage any side effects, and monitor your overall health. This may include regular physical examinations, blood tests, or imaging tests. The types of tests you receive depend on several factors including your current health and the types of treatment given.

The anticipation before having a test or waiting for test results can add stress to you or a family member. This is sometimes called “scan-xiety.” Learn more about how to cope with this type of stress.

Staying as healthy as possible

People with metastatic breast cancer are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, and managing stress. In addition, it is important to have recommended medical checkups and tests to take care of your health.

Regular physical activity can help with your strength and energy levels. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Cancer rehabilitation may be recommended, and this could mean any of a wide range of services such as physical therapy, pain management, nutritional planning, and emotional counseling. The goal of rehabilitation is to help people maintain control over many aspects of their lives and remain as independent and productive as possible for as long as possible.

The next section offers Questions to Ask the Health Care Team to help start conversations with your cancer care team. Use the menu to choose a different section to read in this guide

Breast Cancer - Metastatic - Questions to Ask the Health Care Team

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will find some questions to ask your doctor or other members of the health care team, to help you better understand your diagnosis, treatment plan, and overall care. Use the menu to see other pages.

Talking often with the health care team is important to make informed decisions about your health care. These suggested questions are a starting point to help you learn more about your cancer care and treatment. You are also encouraged to ask additional questions that are important to you. You may want to print this list and bring it to your next appointment. You can also download Cancer.Net’s free mobile app for a digital list and other interactive tools to manage your care. It may also be helpful to ask a family member or friend to come with you to appointments to help take notes.

Questions to ask after getting a metastatic breast cancer diagnosis

  • Where in my body has the cancer spread?

  • Are you experienced in treating people with metastatic breast cancer?

  • Would you recommend seeking a second opinion?

  • What is my prognosis?

  • Are there things I can do to improve my prognosis?

Questions to ask about treatment

  • What are my treatment options?

  • What clinical trial options are available for me? Where are they located, and how do I find out more about them?

  • Is there enough information to recommend a treatment plan for me? If not, which tests or procedures will be needed?

  • If I have already had treatment for non-metastatic breast cancer, do you plan on retesting the hormone receptor status and HER2 status of the cancer?

  • What treatment plan do you recommend?

  • What is the goal of each treatment? Is it to eliminate the cancer, help me feel better, or both?

  • What are the risks of each treatment?

  • How does having reached (or not reached) menopause affect my treatment options?

  • What is chemotherapy? What is hormonal or endocrine therapy? What is targeted therapy? What is immunotherapy?

  • What can I do to get ready for each treatment?

  • What are the new research advances for this type of cancer?

  • What are the potential side effects of each treatment?

  • Who should I contact about any side effects I experience? And how soon?

  • What care will be given to help control my symptoms and side effects?

  • Will I lose my hair, and can anything be done to prevent hair loss?

  • How will this treatment affect my daily life? Will I be able to work, exercise, and perform my usual activities?

  • Will this treatment affect my sex life? If so, how and for how long? Is there anything I can do to prevent or treat these effects?

  • When do I need to make a treatment decision?

  • Who will lead my overall treatment?

  • Who will be part of my health care team, and what does each member do?

  • If I have questions or problems, who should I call?

  • Do you communicate with your patients by email or with an electronic health record system?

  • What will happen if this treatment stops working?

  • What will happen if I choose to stop treatment?

Questions to ask about living with metastatic breast cancer

  • What level of caregiving will I need at this time?

  • Where can I find emotional support for me and my family?

  • What other services are available to me and my family?

  • If I am worried about managing the costs of cancer care, who can help me? Who can help me understand what is covered by my insurance?

  • Do you have a social worker I can speak with?

  • What should I tell my employer, if anything, and what laws protect my rights as an employee?

  • If I have questions or problems, who should I call?

Questions to ask about advanced cancer decision-making

  • Will palliative care continue even if I stop cancer treatment?

  • Where can I receive palliative care?

  • How often will I need to see a doctor?

  • What is hospice care? How is hospice care different than palliative care?

  • Am I at the point where I should consider hospice care? If not, will you tell me when I am?

  • Where can I receive hospice care and how can I manage its costs?

  • Do I need to choose a health care proxy to make medical decisions for me when I cannot?

  • What legal documents should I have in place that explain what medical treatment I want or do not want? A living will? CPR or do-not-resuscitate orders? A Physicians Orders for Life-Sustaining Treatment (POLST) form?

  • Are there resources you recommend to help me put my legal, financial, and business affairs in order?

  • What services are available to help me and my family with the emotional and spiritual aspects of death and dying?

The next section in this guide is Additional Resources. It offers some more resources on this website that may be helpful to you. Use the menu to choose a different section to read in this guide.

Breast Cancer - Metastatic - Additional Resources

Approved by the Cancer.Net Editorial Board, 04/2019

ON THIS PAGE: You will find some helpful links to other areas of Cancer.Net that provide information about cancer care and treatment. This is the final page of Cancer.Net’s Guide to Metastatic Breast Cancer. Use the menu to go back and see other pages.

Cancer.Net includes many other sections about the medical and emotional aspects of cancer for the person diagnosed and their family members and friends. This website is meant to be a resource for you and your loved ones from the time of diagnosis, through treatment, and beyond.

Here are a few links to help you explore other parts of Cancer.Net:

This is the end of Cancer.Net’s Guide to Metastatic Breast Cancer. Use the menu to choose a different section to read in this guide.