Treatment of Stage IV (Advanced) Breast Cancer
Most women with stage IV breast cancer are treated with systemic therapy. This may include hormone therapy, chemotherapy, targeted therapy, or some combination of these. Local treatments such as surgery or radiation might also be used sometimes to help prevent or treat symptoms.
Stage IV cancers have spread beyond the breast and nearby lymph nodes to other parts of the body. When breast cancer spreads, it most commonly goes to the bones, liver, and lungs. As the cancer progresses, it may also spread to the brain or other organs.
Treatment options for stage IV breast cancer
For women with stage IV breast cancer, systemic (drug) therapies are the main treatments. These may include:
- Hormone therapy
- Chemotherapy (chemo)
- Targeted drugs, such as trastuzumab (Herceptin) and pertuzumab (Perjeta)
- Some combination of these
Treatment can often shrink tumors (or slow their growth), improve symptoms, and help women live longer. But in general, these cancers are very hard to cure.
Systemic (drug) treatments for stage IV breast cancer
The types of drugs used for stage IV breast cancer depend on the hormone receptor status and the HER2 status of the cancer:
- Hormone receptor-positive cancers: Women with hormone receptor-positive (ER-positive or PR-positive) cancers are often treated first with hormone therapy (tamoxifen or an aromatase inhibitor). Women who are post-menopausal are often treated first with an aromatase inhibitor. This may be combined with a targeted drug such as palbociclib (Ibrance), ribociclib (Kisqali), or everolimus (Afinitor). Women who haven’t yet gone through menopause are often treated first with tamoxifen. But because hormone therapy can take months to work, chemo is often the first treatment for patients with serious problems from their cancer spread, such as problems breathing.
- Hormone receptor-negative cancers: Chemo is the main treatment for women with hormone receptor-negative (ER-negative and PR-negative) cancers, because hormone therapy isn’t helpful for these cancers.
- HER2-positive cancers: Trastuzumab (Herceptin) may help women with HER2-positive cancers live longer if it’s given along with chemo. Pertuzumab (Perjeta), another targeted drug, might be added as well. Another option is the targeted drug ado-trastuzumab emtansine (Kadcyla), which is given alone.
Treatment often continues until the cancer starts growing again or until side effects become unacceptable. If this happens, other drugs might be tried.
Local or regional treatments for stage IV breast cancer
Although systemic drugs are the main treatment for stage IV breast cancer, local and regional treatments such as surgery, radiation therapy, or regional chemotherapy are sometimes used as well. These can help treat breast cancer in a specific part of the body, but they are very unlikely to get rid of all of the cancer. These treatments are more likely to be used to help prevent or treat symptoms or complications from the cancer.
Radiation therapy and/or surgery may also be used in certain situations, such as:
- When the breast tumor is causing an open wound in the breast (or chest)
- To treat a small number of metastases in a certain area, such as the brain
- To help prevent bone fractures
- When an area of cancer spread is pressing on the spinal cord
- To treat a blood vessel blockage in the liver
- To provide relief of pain or other symptoms
In some cases, regional chemo (where drugs are delivered directly into a certain area, such as into the fluid around the brain or into the liver) may be useful as well.
If your doctor recommends such local or regional treatments, it is important that you understand their goal—whether it is to try to cure the cancer or to prevent or treat symptoms.
Relieving symptoms of advanced breast cancer
Treatment to relieve symptoms depends on where the cancer has spread. For example, pain from bone metastases may be treated with radiation therapy, drugs called bisphosphonates such as pamidronate (Aredia) or zoledronic acid (Zometa), or the drug denosumab (Xgeva). For more, see our information about the treatment of bone metastases. .
Advanced cancer that progresses during treatment
Treatment for advanced breast cancer can often shrink the cancer or slow its growth (often for many years), but after a time, it tends to stop working. Further treatment options at this point depend on several factors, including previous treatments, where the cancer is located, and a woman's age, general health, and desire to continue getting treatment.
Progression while on hormone therapy
For hormone receptor-positive (ER-positive or PR-positive) cancers that were being treated with hormone therapy, switching to another type of hormone therapy sometimes helps. For example, if either letrozole (Femara) or anastrozole (Arimidex) were given, using exemestane, possibly with everolimus (Afinitor), may be an option. If the cancer is no longer responding to any hormone drugs, chemotherapy is usually the next step.
Progression while on chemotherapy
If the cancer is no longer responding to one chemo regimen, trying another may be helpful. Many different drugs and combinations can be used to treat breast cancer. However, each time a cancer progresses during treatment, it becomes less likely that further treatment will have an effect.
Progression while getting HER2 drugs
HER2-positive cancers that no longer respond to trastuzumab (Herceptin) might respond to lapatinib (Tykerb), another drug that attacks the HER2 protein. This drug is often given along with the chemo drug capecitabine (Xeloda), but it can be used with other chemo drugs, with trastuzumab, or even alone (without chemo). Other options for women with HER2-positive cancers include pertuzumab (Perjeta) with chemo and trastuzumab, or ado-trastuzumab emtansine (Kadcyla).
Because current treatments are very unlikely to cure advanced breast cancer, if you are in otherwise good health, you may want to think about taking part in a clinical trial testing a newer promising treatment.
Morrow M, Burstein HJ, Harris JR. Chapter 79: Malignant Tumors of the Breast. In: DeVita VT, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2015.
National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Breast Cancer. Version 2.2016. Accessed at www.nccn.org on June 1, 2016.
Wolff AC, Domchek SM, Davidson NE, Sacchini V, McCormick B. Chapter 91: Cancer of the Breast. In: Niederhuber JE, Armitage JO, Doroshow JH, Kastan MB, Tepper JE, eds. Abeloff’s Clinical Oncology. 5th ed. Philadelphia, Pa: Elsevier; 2014.
Last Medical Review: June 1, 2016 Last Revised: March 14, 2017
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