Treatment of Stage IV (Metastatic) Breast Cancer

Most women with stage IV breast cancer are mainly 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 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. 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:

Surgery and/or radiation therapy may be useful in certain situations (see below).

Treatment can often shrink tumors (or slow their growth), improve symptoms, and help women live longer. These cancers are considered incurable.

Systemic (drug) treatments for stage IV breast cancer

Treatment often continues until the cancer starts growing again or until side effects become unacceptable. If this happens, other drugs might be tried. 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 (estrogen receptor-positive or progesterone receptor-positive) cancers are often treated first with hormone therapy (tamoxifen or an aromatase inhibitor). This may be combined with a targeted drug such as a CDK4/6 inhibitor, everolimus or a PI3K inhibitor.

Women who haven’t yet gone through menopause are often treated with tamoxifen or with medicines that keep the ovaries from making hormones along with other drugs. 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 breathing problems.

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 or with other medications such as hormonal therapy or other anti-HER2 drugs. Pertuzumab (Perjeta), another targeted drug, might be added as well. Another option is the targeted drug lapatinib (which may be given with certain chemotherapy drugs or hormone therapy) or ado-trastuzumab emtansine (Kadcyla).

HER2-negative cancers in women with a BRCA gene mutation

These women are typically treated with chemotherapy (and hormone therapy, if the cancer is hormone receptor-positive). An option after getting chemo is treatment with a targeted drug called a PARP inhibitor, such as olaparib or talazoparib.

HER2-negative breast cancers in women with a PIK3CA mutation

Alpelisib is a targeted drug known as a PI3K inhibitor that can be used along with fulvestrant to treat postmenopausal women with advanced hormone receptor positive breast cancer.

Triple-negative breast cancer

Atezolizumab can be used along with Abraxane (albumin-bound paclitaxel) in people with advanced triple-negative breast cancer whose tumor makes the PD-L1 protein. (The PD-L1 protein is found is about 20% of triple-negative breast cancers.) For women with TNBC and a BRCA mutation whose cancer no longer responds to common breast cancer chemo drugs, other chemo called platinum drugs (like cisplatin or carboplatin) may be considered.

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 and spinal cord) 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 (sometimes 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 being treated with 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. Another option might be using fulvestrant (Faslodex)  or an aromatase inhibitor (such as letrozole), along with a CDK inhibitor. If the cancer has a PIK3CA mutation and has grown while on an aromatase inhibitor, fulvestrant with alpelisib might be considered. If the cancer is no longer responding to any hormone drugs, chemotherapy is usually the next step.

Progression while being treated with 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 being treated with 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 also be used with an aromatase inhibitor. Other options for women with HER2-positive cancers include pertuzumab (Perjeta) with chemo and trastuzumab, or ado-trastuzumab emtansine (Kadcyla). For HER2-positive cancers that have spread to the brain the combination of neratinib and capecitabine has also been shown to be effective.

Because current treatments are very unlikely to cure metastatic breast cancer, if you are in otherwise good health, you may want to think about taking part in a clinical trial testing a newer treatment.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

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Jagsi R, King TA, Lehman C, Morrow M, Harris JR, Burstein HJ. Chapter 79: Malignant Tumors of the Breast. In: DeVita VT, Lawrence TS, Lawrence TS, Rosenberg SA, eds. DeVita, Hellman, and Rosenberg’s Cancer: Principles and Practice of Oncology. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2019.

National Cancer Institute. Physician Data Query (PDQ). Breast Cancer Treatment – Health Professional Version. 2019. Accessed at https://www.cancer.gov/types/breast/hp/breast-treatment-pdq on August 9, 2019.

National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Breast Cancer. Version 2.2019. Accessed at https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf on August 8, 2019.

Last Medical Review: September 18, 2019 Last Revised: September 18, 2019

 

 

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