Doctor’s blog

The treatment of systemic or metastatic breast cancer is mainly palliative. So, there should be balance between the potential toxicities of therapies with that of response to the treatment. Several variables can influence the response of metastatic breast cancer treatment to systemic therapy. The presence of estrogen and progesterone receptors is a strong indication for endocrine therapy, whereas the patients with short disease-free intervals (remissions), rapidly progressive visceral disease (involvement of liver or other viscera), pulmonary involvement, or intracranial (involvement of brain) disease do not respond to endocrine therapy.

In many cases of metastatic breast cancer, systemic therapy can be withheld and the patient managed with appropriate local therapy. Sometimes radiation therapy and surgery (occasionally) are effective at relieving the symptoms of metastatic breast cancer; this is true particularly when bones are involved. Patients with only bone involvement or bone involvement dominant disease have a progressive course. In these situations, radiation therapy may be effective for long periods, whereas the effects of systemic chemotherapy may be modest.

Some patients with systemic involvement may be only helped with palliative therapy with strontium 89 and/or bisphosphonates and it dose not have any effect on the course of the disease. Bisphosphonates should be given to most of the patients with metastatic breast cancer and especially to patients with bone involvement.

Pathological fracture of the axial skeleton and spinal cord compression (most hazardous complications) etc. should be avoided to maintain well-being for as long as possible. New back pain in patients with systemic cancer should be explored aggressively without waiting for neurologic symptoms to develop, which can cause a potentially serious complication.

If endocrine organs are involved by metastasi of breast cancer, it can cause profound dysfunction, like adrenal insufficiency and hypopituitarism. If there is obstruction of the biliary tree or other impaired organ function, these conditions may be better managed with a local therapy than with a systemic approach.

Approximately half of the breast cancer patients treated for local disease develop metastatic (metastasis means spread of cancer from its original location to different location including distance location) disease. Metastasis of breast cancer generally occurs through lymphatic system or blood stream. Although a small number of these patients enjoy long remissions when treated with combinations of systemic and local therapy, most eventually die due to metastatic breast cancer. Breast cancer generally metastasizes to soft tissue, bone, and viscera (like lung and liver). Each of these (soft tissue, bone, and viscera) generally account for approximately one third of the recurrence (metastasis). But, by the time of death, most patients usually have involvement of bone. Recurrences (generally due to metastasis) can appear at any time after primary therapy, but half of all initial cancer recurrences occur before 5 years after initial therapy of breast cancer.

Metastatic breast cancers are more difficult to treat than primary breast cancers and they may be less sensitive to radiation therapy and chemotherapy. Due to the difficulty and lesser sensitivity to treatment modalities the survival rate of patients with breast cancer metastasis is dismal.   

Metastsis of breast cancer should always (invariably) be diagnosed with biopsy. Otherwise other diseases (tuberculosis, gallstones, sarcoidosis, or other nonmalignant diseases misdiagnosed and treated as though they had metastatic breast cancer or even another cancer such as multiple myeloma may be treated as recurrent or metastatic breast cancer) may be treated as metastatic breast cancer, which can be catastrophic. So any suspicion of metastatic breast cancer should be confirmed with biopsy before starting treatment. Because the diagnosis of metastatic disease alters the outlook for the patient drastically, it should not be made without biopsy.

The choice of treatment of metastatic breast cancer requires consideration of local therapy needs, the overall medical condition of the patient, and the hormone receptor status of the tumor. The therapy of systemic disease is palliative; the potential toxicities of therapies should be balanced against the response rates.