Navigating Treatment Options for Metastatic Breast Cancer

Before talking about all of the specific treatments which you may choose for metastatic breast cancer, it helps to talk about the types of treatments, the goals of treatment, and what particular treatments are often used first to address metastatic cancer.

You may be wondering how you can understand which treatments are best if you don’t have a background in medicine, but it is possible to learn enough to make the choices that are best for you as an individual. Let's look at the factors to consider when choosing a treatment, ways to learn what you need to know to make an educated decision, the importance of getting a second opinion (or at least a remote second opinion) and more.

Goals of Treatment

Unlike early-stage breast cancers, it’s not possible to cure metastatic breast cancer, but it’s still important to consider your goals in treatment.

For example, some people wish to try to live as long as possible with their cancer no matter the side effects. Others may instead feel the quality of their life is more important than quantity, and prefer treatments with fewer side effects.

We wish that everyone could have the goal of living long term with metastatic breast cancer, but at least for now, that isn’t an option for many people. With metastatic cancer, your quality of life becomes very important, but what this means can vary significantly from person to person.

Types of Treatments

Even though we now have many different types of treatment for cancer, these can be broken down into two main categories.

Local Treatments

Local treatments address cancer in the place in which it begins (or in a single metastasis to an organ.) These treatments include:

• Surgery
• Radiation therapy

Systemic Treatments

In contrast, these treatments address cancer cells wherever they happen to be in the body. These include:

• Hormonal therapy
• Chemotherapy
• Targeted therapies
• Immunotherapy

For metastatic breast cancer, systemic treatments play the largest role in treatment. Local treatments such as surgery or radiation are used primarily to treat metastases when these are causing symptoms, such as bone metastases which pose the risk of fractures or metastases to the skin or chest wall which are bleeding and painful.

Many people wonder why breast surgeries such as a lumpectomy or mastectomy are not often done in people who have metastatic breast cancer, at least for the 5% to 10% of people who have metastatic cancer at the time of diagnosis. The reasoning for this is that with metastases, the cancer has already spread well beyond the breast.

These treatments are unable to potentially cure cancer that has spread. Instead, surgery—due to recovery times and immune system suppression—might mean delaying systemic therapies, which ultimately play the largest role in treating your cancer.

Lines of Treatment

You will probably hear your healthcare provider talk about “first-line treatment,” “second-line treatment,” and so forth. This term simply means the first treatment or treatments, second treatments, and so on which may be used sequentially to treat your cancer.

It's very common with metastatic breast cancer to have several different “lines” of treatment. First-line treatment is usually selected based on what treatments are most likely to be successful with the fewest side effects, but there are many options available.

Typical First-Line Treatments

Everyone with metastatic cancer is different, and every cancer is different so it is difficult to talk about “typical” cancer treatment. That said, the first treatments chosen for metastatic cancer are often related to the hormone receptor status of your cancer.

These treatment approaches will depend on your receptor status after a “rebiopsy” of your tumor or a metastasis, not what your receptor status was when you were first diagnosed if your tumor is a recurrence. If your original cancer was estrogen receptor positive, it may now be negative, and vice versa.

Examples of possible first-line treatments based on receptor status include the following.

Estrogen Receptor (ER) Positive Metastatic Breast Cancer

The first treatment for estrogen receptor-positive breast cancer is usually hormonal therapy. The choice of drugs will depend on whether you were on hormonal treatment when your cancer returned.

For premenopausal women, tamoxifen is needed since the majority of estrogen produced by the body is from the ovaries. Alternatively, ovarian suppression with either Zoladex (goserelin) or less commonly, removal of the ovaries, may be followed by treatment with either tamoxifen or one of the aromatase inhibitors.

For postmenopausal women, aromatase inhibitors can be used alone or with specific enzyme inhibitors. If your tumor recurred while on an aromatase inhibitor, a different option may be using the anti-estrogen drug Faslodex (fulvestrant).

If your tumor is estrogen receptor positive but is progressing rapidly, there are several options. If your tumor is also HER 2 positive, a HER 2 targeted therapy may be added to hormonal therapy. Chemotherapy may also be used in addition to hormonal therapy for those who have tumors which are growing rapidly.

If you have significant symptoms related to metastases, other treatments may be added in as well. For bone metastases, radiation therapy or a bone-modifying drug may be used to lower the risk of a fracture, spinal cord compression, or to treat severe pain.

Likewise, metastases to the lungs causing bleeding or obstruction, or brain metastases which are causing significant symptoms may also be treated with local therapies such as radiation or surgery.

HER2 Positive Metastatic Breast Cancer

If you have a tumor which is estrogen receptor positive and HER 2 positive, first-line treatment may begin with hormonal treatment alone or the combination of a hormonal drug and a HER 2 positive drug.

First-line treatment for HER 2 positive metastatic breast cancer also depends on whether or not you were being treated with one of these medications when you experienced a recurrence. If your cancer recurred while on Herceptin, one of the other HER 2 medications may be used. If your tumor is growing rapidly, chemotherapy may be considered.

In 2022, the FDA expanded the use of Enhertu (fam-trastuzumab deruxtecan) to treat HER2-positive breast cancer and HER2-low breast cancer. If you have been treated with HER2-targeted drug therapy or chemotherapy, and your cancer comes back during or within six months of completing treatment, or the tumor cannot be removed by surgery or has spread to other parts of the body, Enhertu may be used.  

As with estrogen receptor positive tumors, symptomatic metastases may require local treatment as well. For example, painful bone metastases or metastases which increase the risk that you could fracture a bone may be treated with radiation therapy or a bone-modifying agent.

Triple Negative Breast Cancer

Triple negative metastatic breast cancer is more difficult to treat in general than breast cancers which are estrogen receptor or HER 2 positive, but there are still options.

Chemotherapy is often used first line for these cancers, and the choice of medications often depends on whether chemotherapy was used previously.

For Men

Metastatic breast cancer in men has several important differences, but in general, the same approach is taken. Treatment may begin with tamoxifen for those who have estrogen receptor-positive tumors, or with chemotherapy.

The Best Treatment

What do you need to know in order to make the best decisions about your treatment?

The first step is educating yourself about your disease. Read through the information provided here, and any information you received from your cancer center.

Keep a running list of questions to ask your oncologist, and bring them with you to each appointment. If you are still finding it hard to understand something, ask again.

There is a lot of information to digest in a short amount of time and, combined with the difficult emotions that go with a metastatic cancer diagnosis, your oncologist will not get upset if you need to ask the same questions over and over again. That is normal.

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You may find it helpful to talk to people who “have been there.” In addition to support groups in the community, we now have the advantage of 24/7 support provided by online breast cancer support communities. There are communities made up of only people with metastatic breast cancer, which can be very helpful as you face these decisions.

Talk to your friends and family and ask for their input—but the ultimate decisions are up to you. This can be a challenging time, especially if members of your family are not in agreement with your decisions.

Listen to your loved ones and thank them for their input, but remind them, if needed, that you need to choose the path which best honors your own needs and wishes for your care.

Factors That Influence Choice

There are many factors which may be considered in choosing the right treatment for your cancer, both initially, and as time goes on. Some of these include:

• Receptor status of the tumor
• Previous treatments (breast cancers often become resistant to a treatment over time)
• Tumor burden (how extensive your tumor(s) are and how large)
• The specific symptoms you have related to your cancer and how bothersome these are for you
• How fast the cancer is progressing
• Your personal preferences for ease of treatment (oral vs IV for example), and tolerance of side effects (some people find some side effects more distressing than others)
• Whether or not you are taking part in a clinical trial

Second Opinions

While many people are concerned that getting a second opinion could harm their relationship with their oncologist, it is not only expected, but most oncologists would request a second opinion themselves if diagnosed with metastatic cancer.

When choosing a healthcare provider for a second opinion, it's a good idea to find one who is not part of the same group. Ideally, requesting an opinion at one of the larger National Cancer Institute-designated cancer centers often offers the chance to see an oncologist who specializes in breast cancer. Support communities are sometimes a good place to learn about the centers that excel in breast health.

Getting a second opinion does not mean that you will have to travel to that center for treatment. You may not ever need to travel to see one of these specialists. Often times, a second-opinion healthcare provider can work with your local oncologist to offer guidance and recommendations. Many of the larger cancer centers now offer "remote second opinions," in which a specialist can look at your medical history, pathology results, and imaging studies, and talk to you over the phone about recommendations.

Some centers that offer remote second opinions include:

• Dana Farber Cancer Institute (in MA and affiliated with Harvard University)
• Massachusetts General Hospital (Boston, MA)
• MD Anderson Cancer Center (Houston, TX)
• Cleveland Clinic (Cleveland, OH)

For young women (less than age 45) and women who develop lung cancer while pregnant, the University of Colorado Cancer Center (in Aurora, Colorado) offers remote second opinions.

Remote second opinions are becoming more common, so you can check to see if they are offered at the cancer center you are considering for a second opinion.

Questions to Ask Yourself

You'll have many questions to ask with regard to specific treatments, but you may want to begin considering some questions even before entertaining different options, such as:

• Where do you want to receive your care?
• Are you willing to travel for a clinical trial if needed, or do you prefer to be near your home?
• If you do decide to travel, is there a cancer center located near friends or family you could stay with?
• Where can you go with your insurance?
• If you are considering out-of-network providers, what will this mean for you financially?
• Would you consider taking part in a clinical trial?
• Are friends and relatives available to help you with personal or family issues, such as childcare?

Prognosis With/Without Treatment

Some people want to know their prognosis—the “average” outcome for someone with their disease. Other people don’t want to know, and that is fine as well. The truth is that healthcare providers can’t really tell how any one person will do after they are diagnosed with metastatic breast cancer.

Statistics can give us some idea about how a person will do with a particular treatment, but statistics pose several problems. One is that statistics are numbers, not people. We can talk about the numbers of people, on average, who live a year or 10 years with metastatic breast cancer, but we do not have any way of predicting who those people will be.

Another reason statistics fail us is that they are a measure of how people did in the past.

At the current time (based, of course, on statistics) the median survival for metastatic breast cancer (including all types) with treatment is considered to be 18 to 24 months. This means that 24 months after diagnosis, half will have died and half will still be alive. Research suggests that the relative 5-year survival rate for metastatic breast cancer has increased to an estimated 36% in recent years, thanks to improved treatment options. There are also many people who have been living with metastatic breast cancer for 10 years or more.

A final thought to keep in mind is that we are truly making progress in the treatment of metastatic breast cancer. Clinical trials studying everything from immunotherapy to cancer vaccines for breast cancer are going on right now. It’s hoped that these new categories of treatments will soon be changing old breast cancer statistics for the better.

Advocating for Yourself

The best place to begin talking about treatment is your role as an essential member of your healthcare team. You’ve probably already heard that it’s important to be your own advocate in your care, but what does that really mean?

Being your own advocate means taking an active role in the decisions that go along with your treatment. It means asking questions when you don’t understand something, and continuing to ask until you do understand.

When we talk about being your own advocate with cancer we’re not implying that you will have an adversarial relationship with your oncologist and other members of your healthcare team. In contrast, being your own advocate enables you to help your oncologist understand what is most important to you as a person.

In the past, few choices often existed for people diagnosed with metastatic cancer. This has changed tremendously in recent years, and there now may be several different options which could equally meet your goals of treatment.

You won’t be asked to choose between a treatment that is expected to work well with few side effects and one that doesn’t work or has major side effects. The truth is that many of these choices will come down to differences in your own personal needs.

For example, you may need to choose between receiving treatment near your home or at a cancer center out of town, or perhaps make the choice between two different sets of side effects.

Some people find it more difficult than others to advocate for themselves. If you’re ordinarily soft-spoken and quiet—a peacemaker perhaps—you may find it hard to let your healthcare team know when things aren’t going as you would wish. If this fits your personality, it’s often helpful to choose a friend or family member to advocate for you and ask any difficult questions you may find hard to ask.

A Word From Verywell

The examples of possible first-line treatments above are only examples, and your oncologist may recommend a different approach based on the characteristics of your unique tumor. Many drugs are being evaluated in clinical trials, and one of these approaches may offer a different approach.

The important thing is to talk with your healthcare provider about why certain drugs would be recommended and to understand these choices as well as possible alternatives. Many people also find it helpful to ask about the treatments which would be recommended if this particular regimen does not control their tumor.

Being one step ahead in your mind may help you to cope just a little easier with the anxiety related to the unknowns ahead.