What Is De Novo Metastatic Breast Cancer?

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De novo metastatic breast cancer (also known as Stage 4 breast cancer) is a relatively rare breast cancer. It is generally considered incurable as it has already spread to other parts of the body at the time of diagnosis. However, advances in treatment options can improve and prolong the lives of patients.

According to the American Cancer Society, de novo metastatic breast cancer (MBC) accounts for approximately 6% of cases of U.S. women diagnosed with breast cancer.

What Is De Novo?

"De novo" indicates that the cancer is the first diagnosis, not a recurring cancer.

Asian female cancer patient smiling to doctor

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Symptoms of De Novo Metastatic Breast Cancer

Symptoms of de novo metastatic breast cancer can vary by individual. Generalized symptoms may include fatigue, unintentional weight loss, loss of appetite, nausea, vomiting, insomnia, depression, sexual dysfunction, and pain.

If you have had these symptoms for some time, speak with your doctor so they can help you figure out the cause of your symptoms and make a diagnosis.

The signs and symptoms may depend on which areas the cancer has spread to. The most common site of metastasis (where the cancer has spread) for de novo MBC is the bones (40%–75% of patients), while the least common site is the brain (less than 5%). Over time, 75% of patients will develop metastases to other organs in addition to when they are first diagnosed.

Here is a chart describing the associated symptoms with each possible site of metastasis:

 Site of Metastasis  Symptoms
General Fatigue, insomnia, depression
Bone Pain, hypercalcemia (high calcium levels in blood), fractures, loss of mobility
Central nervous system (brain and spinal cord) Headache, confusion, weakness, pain, seizure, altered mental activity, speech impairment
Skin Pain, infection, bleeding
Gastrointestinal tract Pain, nausea, vomiting, diarrhea, feeling full, loss of appetite, difficulty breathing, jaundice, bleeding
Pulmonary (lungs) Pain, difficulty breathing, coughing, coughing blood
Lymph nodes Pain and decreased mobility in the side of the neck and arms

Causes

Many patients that are diagnosed with this cancer have been negatively impacted by social determinants of health, which are conditions in a person’s environment that interfere with health treatment and outcomes. For various reasons, they may not have access to high-quality healthcare and preventive services, are uninsured, or live in rural areas.

Other reasons that patients may be diagnosed with de novo MBC is if they delay seeking medical care despite experiencing symptoms of breast cancer. A 2019 study showed that the top reasons that women delayed seeking treatment include:

  • Dependents/other pressing matters
  • Employment responsibilities
  • Transportation costs and difficulty
  • Fear of not being able to afford treatment

While the exact cause of de novo MBC is unknown, potential risk factors for breast cancer in general include:

  • Increasing age and being born female (these are the top risk factors)
  • BRCA1 or BRCA2 gene mutations
  • Personal or family history of breast cancer
  • History of certain tumors or breast conditions
  • High-dose radiation to the chest at a young age
  • Menstrual periods that start early in life and/or end late in life
  • Not having children or having children after age 30
  • High levels of estrogen or testosterone hormones
  • Recent use of hormonal contraceptives
  • Overweight or obesity
  • Undergoing hormonal therapy
  • Drinking alcohol
  • Physical inactivity

Diagnosis

De novo metastatic breast cancer is diagnosed through screening and tests of the breasts and for metastases. The primary tumor may be diagnosed by physical exam and confirmed by biopsy (removing a sample tissue for laboratory testing) and MRI or other imaging techniques.

Further tests may be conducted to determine where the cancer has spread. Screening and tests may differ based on what symptoms are present and the likely site the cancer has metastasized to. Paying close attention to any symptoms and changes in symptoms can help your doctor determine the appropriate screening tools to confirm a diagnosis.

Treatment

The fact that de novo MBC can be spread to any organ and body system means that a systemic treatment approach is needed. Treatment will be tailored according to the specific metastatic location. For example, Xgeva (denosumab) may be added to the treatment scheme for bone metastases.

As always, method of treatment depends on the goals of the patient and family. The goals of care must balance potential control of cancer while managing symptoms and maintaining the highest quality of life.

Cancer Control

There is some controversy over whether patients should have surgery for de novo MBC. In one study, surgery significantly improved the overall five-year survival rate for patients. However, it is unclear if the surgery provided the benefit.

Unless the tumor is causing the patient a great deal of physical discomfort, surgery is generally not recommended for patients with de novo MBC since the cancer cells have already spread to other parts of the body. Generally, surgery for patients with de novo MBC has declined over the years.

Depending on where the cancer has spread to, systemic treatments may be recommended, including hormone therapy, chemotherapy, targeted therapies, and immunotherapy. While some families may desire the continuation of anticancer treatment, it's important to continue communicating with the patient and assessing the situation.

Despite the number of patients who continue to receive anticancer therapy toward the end of life, there is often no benefit to survival of continuing systemic treatments two weeks before the end of life. Sadly, many patients who continue receiving chemotherapy (cancer-fighting drugs) toward the end of life generally delay palliative care (symptom relief) and hospice (end-of-life care) and are only admitted within three days of death.

Symptom Management

There are many strategies for managing symptoms. It's important to accurately describe the symptoms to your doctor so that you can be treated accordingly. This includes describing the type of symptoms, the location and duration of pain or other symptoms, and how they interfere with your daily life. Managing symptoms can help a patient prolong the best quality of life throughout the duration of treatment and when treatment is discontinued.

Here is a chart describing some of the most commonly reported symptoms and management strategies:

 Symptom Treatment
Pain Opioids, adjuvant (after initial treatment) analgesics such as antidepressants and anticonvulsants, topical anesthetics, glucocorticoids for pain related to inflammation, nonsteroidal anti-inflammatory drugs and acetaminophen, radiation therapy
Fatigue Regular physical activity, cognitive behavioral therapy, psychostimulants and antidepressants, energy conservation strategies, distractions such as music, games, or socializing, adequate sleep, massage
Depression and anxiety Antidepressants, anxiolytics, psychosocial support such as group counseling and cognitive behavioral therapy
Difficulty sleeping Cognitive behavioral therapy, complementary and alternative medicine (CAM) therapies such as aromatherapy, expressive therapy, expressive writing, healing, massage, muscle relaxation, mindfulness-based stress reduction, and yoga
Lymphedema Manual lymph drainage, compression garments, remedial exercises, and skin care, laser therapy
Local recurrence Surgery and/or radiation, systemic therapy 
Difficulty breathing Opioids, oxygen
Bone metastasis Opioids, corticosteroids, bone conserving drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), surgery, or radiation therapy
Gastrointestinal symptoms Nausea, vomiting, and anti-inflammatory medication, stool softener or bulking agents, nutrition counseling, appetite stimulants, or diuretics

Prognosis

While de novo metastatic breast cancer is generally considered incurable, the prognosis has improved significantly with advances in treatment options. Unfortunately, it is unclear which treatment patterns or factors, independently or combined, has the best prognosis. Generally, the goal of treatment for de no novo MBC is to improve and prolong quality of life.

While the prognosis continues to be poor, over the past few decades, the overall five-year survival rate has increased from 20% to 40%.

Many studies researching what may impact prognosis are conflicting and inconclusive. Possible factors that may contribute to impact overall survival rate (OS) include:

  • Presence of hormone receptor positive and HER2+ tumors improve OS
  • Surgical removal of the primary tumor improves prognosis for some women
  • Higher socioeconomic status improves OS
  • Ethnicity (Asian women have higher OS, African American women have lowest OS)
  • Older age decreases OS
  • Lack of insurance decreases OS

More research is needed to understand the best treatments and factors that may influence prognosis for de novo MBC.

Coping

Patients diagnosed with de novo metastatic breast cancer may experience many concerns that require social, psychological support, support groups, and counseling. These normal and common concerns include:

  • Fear of dying
  • Declining quality of life
  • Distressing side effects of treatment
  • Decreasing physical ability and the ability to care for family
  • Inability to maintain relationships
  • Disagreement with family about care at the end of life

It is critical to have ongoing conversations with the patient and patient's family to ensure these social and psychological supports are met and to help families navigate through a very difficult time.

Your healthcare team can help connect you and your family with social and psychological support systems to help you through your diagnosis, treatment, and any end-of-life decisions.

A Word From Verywell

Receiving any cancer diagnosis can be surprising, distressing, and devastating, especially an advanced stage cancer.

If you've been diagnosed with de novo breast cancer, speak with your healthcare provider to discuss your options moving forward. You may also want to discuss your plan with family, therapists, or other professionals before making decisions. You should continue to monitor your symptoms and update your healthcare team on any changes you experience.

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Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy.
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