Where Will It Go? Metastatic Breast Cancer
After breast cancer treatment, becoming obsessed with symptoms and worrying that every twinge or cough might be a sign of metastasized cancer is all too easy. A few women go to the other extreme and live in denial despite clear warnings from their body that something is wrong. The bone, lungs, liver, and central nervous system are the most common places for cancer to spread, and each has its own symptoms. Research has shown that scans usually cannot catch metastases (mets) before the patient feels symptoms, so each woman needs to be alert and notify her doctor when something is wrong. Here are the most common types of mets, their symptoms, and current treatments.
The bones are the most frequent place to which breast cancer travels. Up to 70 percent of breast cancer patients with mets will have them in their bones. Bone pain is the most frequent indication of bone mets. Changes in blood work can also alert your doctor to the possibility. Because exercise, medications, and/or arthritis can also cause bone pain, see a doctor for any pain that lasts longer than a week or two, especially if the pain is constant. Bone mets pain does not "come and go" like a strain from exercise might, and it is not likely to be in the joints like arthritis pain. A bone scan is often the first test a doctor will order, but depending on the location and pattern of pain, the doctor may also use X-rays, MRI's, and PET scans to diagnose bone mets.
Fortunately, bone mets respond better to treatment than some of the other forms of breast cancer metastasis. Bisphosphonates like pamidronate (Aredia) and zolendronic (Fosamax) help patients by strengthening the bone to make it harder for cancer cells to spread and by preventing the bone fractures that sometimes occur when cancer weakens the bones.
Radiation, chemo, targeted therapies like Herceptin, and/or hormonal treatments may also be used to treat bone mets. Although doctors do not typically use surgery to remove a bone mets lesion, they may need it to stabilize bones and prevent fractures. Long-term Stage IV survivors like Katherine Russell Rich often have bone mets.
The lungs are the second most common place for breast cancer mets. In "Dr. Susan Love's Breast Book 4th edition," Dr. Love says that the lungs are the only place of metastasis for 21 percent of patients, and that of patients who eventually die of breast cancer, 60-70 percent will have it in their lungs. (Keep in mind that many people will have metastases to more than one location, so the percentages can add up to more than 100 percent.) Symptoms you should bring to your doctor's attention include shortness of breath, chest pain, or a cough. If you just climbed a mountain or a cough is making the rounds in your community, don't be alarmed. But if these symptoms have no logical explanation and don't get better, see your doctor. Because the breast cancer cells are gradually displacing healthy lung cells, the symptoms may progress slowly.
On lung imaging tests like an X-ray, CT, or PET scan, metastasized breast cancer in the lungs will usually be more diffuse than a lung cancer tumor, which tends to start in one spot and grow from there. Because most breast cancer lung mets are spread out, surgery is not usually an effective treatment. Chemotherapy is the most frequent treatment for lung mets. If fluid builds up in the lungs, it may be drained as part of the treatment.
Symptoms for liver metastasis vary widely and include changes in appetite and digestion, pain under the rib cage on the right side, and jaundice. During a physical exam, the doctor may notice that the liver is swollen, and blood work may also give clues that the liver is not functioning properly. Then the doctor will order imaging tests like a CT, ultrasound, or PET scan to find out whether the patient has liver mets or some other less dangerous problem.
If the tests show just one or two spots, the doctor may try surgery, radiation, or radiofrequency ablation to remove the cancer. Radiofrequency ablation targets specific spots and uses heat to kill the cancer cells. More often the spots are spread out. Either way, the doctor will probably recommend chemo because even if only one tumor is showing, the underlying assumption is that more cancer cells are present but not yet visible.
Central nervous system
Because breast cancer mets to the central nervous system are hardest to treat, it is fortunate that they are also less common, occurring in 6-15 percent of cases. Headaches, changes in vision, seizures, or weakness in one part of the body might be clues to brain or spinal cord mets. The brain controls our whole body, so symptoms can vary widely depending on what part of the brain the tumor is putting pressure on. A tension headache that lasts a day and goes away is nothing to worry about, but check with your doctor about any persistent changes.
The brain protects itself from toxic chemicals by something called the blood-brain barrier. Unfortunately, this barrier does not work to keep cancer cells out, but can be effective at preventing chemotherapy drugs from getting through. This barrier makes brain metastasis harder to treat.
If there is just one tumor, surgery may be an option, but as we have seen with other types of mets, frequently there may be several lesions. Whole brain radiation may be effective at shrinking the tumors. Another option is stereotactic radiosurgery, sometimes called gamma knife surgery. This does not involve an actual scalpel, but uses concentrated radiation coming from several angles to treat tumors. If the mets are causing brain swelling, steroids may help. Sometimes anti-seizure medications are prescribed.
Less common types
Much less frequently, breast cancer can metastasize to the eye, bone marrow, or other parts of the body.
Deciding on treatment
Although each type of metastasis has its preferred treatment, doctors generally want to use a systemic treatment when possible because so many women with mets in one organ will soon have them in a second or third organ. If the tumor is ER or PR positive, hormonal treatments can be very effective. Trastuzumab (Herceptin) plus chemo may work well for Her2/neu positive tumors. Chemo alone works well for some triple negative patients. Because the cancer has already spread despite the original treatment, doctors often want to change up the medication from whatever was first used.
Typically, Stage IV patients will go through several different drugs. One will work for a while until the cancer develops resistance. Then doctors try something else. Each year doctors are learning more about how to treat metastatic breast cancer and coming up with new drugs. Discussing the possibility of a clinical trial with your doctor is a good idea, especially if your cancer is not responding well to the more established drugs.
Although some women, especially those who have extensive metastases in several organs, may decide that they do not want further treatment, it makes sense to consult with doctors at a comprehensive cancer center or research hospital to find out what can be done before reaching that decision. If it turns out that the treatments interfere with quality of life or if they do not work, it is much easier to stop treatment than to find out several months into a Stage IV diagnosis that there was a new medicine or procedure that might have added years of life. Conversely, a woman should not continue in treatment to please her doctor or family if she is ready to focus on making the best of her remaining days.
Life is full of surprises. Sometimes the surprise is that a Stage IV cancer goes into remission. Many doctors refuse to answer the "How long do I have?" question from patients because they have been surprised too many times. One of my Stage IV friends was a smoker. Her doctors didn't tell her to quit because they didn't think she would live long enough for it to matter. She was an active volunteer in the breast cancer community in her city for five more years until her death.
Today there is hope for Stage IV patients. We have better services through hospice programs for those who are at the end of their earthly life. Researchers are finding treatments that are more effective and less toxic. More hospitals and treatment centers offer support groups and complementary treatments like Reiki, massage, and acupuncture to improve quality of life and control pain. Science will use what it learns from today's Stage IV patients to unlock the secrets of cancer that will someday give our sons and daughters a cancer-free world.