Advanced Breast Cancer

Advanced Breast Cancer

• Learning with Lillie
• Aprender con Lillie
• Overview & Staging
• Descripcion General
• Treatment Planning
• Supportive Care
• Monitoring Your Cancer
• Financial Considerations
• Survivors
• Resources
• Back to Breast Cancer

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Advanced Breast Cancer

Treatment Planning

Today, the goal of treating advanced and metastatic breast cancer is to prevent or slow the spread of the cancer and to relieve any pain or discomfort. New advances in treatment continue to be introduced, offering more hope for a cure and more ways to improve the quality of life for people who are living with these diagnoses.

Once you receive a diagnosis, you will work closely with your doctor and a multi-disciplinary team to develop a treatment plan. Just as no two breast cancer diagnoses are the same, your treatment plan will be customized to your cancer and its biomarkers.

During treatment planning, it is important to discuss your expectations for quality of life. Some questions to ask yourself and discuss with your doctor include the following:

• Will I feel well enough to work?
• Can I travel extensively?
• Can I take my treatment at home instead of going into a clinic?
• What kind of side effects should I expect, and how can they be managed?

Once treatment begins, you will be monitored closely so that your therapy can be adapted as needed. Therefore, communicating regularly with your health care team and keeping follow-up appointments are crucial. 

Drug Therapy

Multiple types of drug therapy may be used and include targeted therapy, hormone therapy, chemotherapy and immunotherapy. These treatments are systemic because they travel throughout the body. You may receive them through an IV into a vein, through a port in your body, as an injection (shot) or orally as a pill or liquid.

Targeted therapy uses drugs or other substances to identify, attack and destroy specific types of cancer cells or to slow disease progression. Some interfere with the cancer cells’ internal functions; others attack specific receptors on the cancer cells’ surfaces; and some target the blood vessels that supply the tumor. Targeted therapy is typically used for HER2+ breast cancer and is usually combined with chemotherapy. Other targeted therapy drugs are sometimes used in combination with hormone therapy to treat ER+ or PR+ breast cancers or HER2- breast cancer with the BReast CAncer 1 or 2 (BRCA1 or BRCA2) mutations.

Following are types of targeted therapies that may be used.

• Anti-HER2 drugs are laboratory-made proteins that can bind to cancer cells. They can be used alone or to carry drugs, toxins or radioactive substances directly to cancer cells. These drugs are often given with chemotherapy for ER+/PR+ and/or HER2+ breast cancer.
• Kinase inhibitors target cancer cells’ ability to grow and survive by targeting kinases, which are enzymes that speed up chemical reactions in the body. These inhibitors can be designed to attack enzymes within a cell, proteins or enzymes needed for a cell’s growth, or receptors on the cell’s surface. CDK inhibitors are often used for hormone positive, HER2- cancer. They may be used with endocrine therapy to control cancer longer. 
• Monoclonal antibodies (mAbs) are commonly used. Antibodies (proteins) are made by the immune system to help fight infection. Laboratory-made mAbs can attach to specific proteins and attack cancer cells. They can prevent growth signals from HER2 receptors and can deliver cell-specific chemotherapy to the tumor. 
• mTOR inhibitors block a protein called mTOR (mechanistic target of rapamycin), which helps control cell division. Blocking mTOR’s action may keep cancer cells from growing and prevent the growth of new blood vessels that tumors need to grow.
• A PIK3CA inhibitor blocks the PIK3CA gene, which is frequently mutated in breast cancer and can prevent growth of cells. 
• Poly (ADP-ribose) polymerase (PARP) inhibitors prevent cancer cells from repairing themselves and lead to tumor cell destruction.
• Tumor-agnostic treatment targets specific genetic mutations to prevent growth regardless of cancer type or where it is in the body. 

Hormone therapy, also called endocrine therapy, is primarily used to treat cancer that is estrogen- and/or progesterone-receptor positive (ER+/PR+). It is actually an anti-hormone because it reduces or blocks the stimulating effect of estrogen on tumor cells. When tumor cells test positive for one or both hormones (ER+ and/or PR+), that means hormones are fueling the cancer’s growth. Blocking hormone receptors can be highly effective in slowing cancer growth or stopping progression.

Drug therapies have been developed to target different combinations of ER, PR, and HER2 receptor expression (see Table 1). These are sometimes used in combination with other types of treatment.

Hormone therapy is not effective for cancer that is ER-/PR- because the growth is not driven by hormones. In some cases, biopsied tumor cells may test negative for all three biomarkers (ER-, PR- and HER2-), which is referred to as triple-negative breast cancer.

Following are types of hormone therapy that may be used.

• Antiestrogens are substances that keep cells from making or using estrogen. They may stop some cancer cells from growing or even destroy them.
• Aromatase inhibitors are drugs that prevent estradiol, a female hormone, from forming by interfering with an aromatase enzyme. They may benefit postmenopausal women with hormone-dependent breast cancer or younger women whose ovarian function is blocked by drugs or who have had their ovaries removed. Aromatase inhibitors cannot be used in premenopausal women with functioning ovaries.
• Hormones are made by glands, circulate in the bloodstream and control the actions of certain cells or organs. High doses may be used to stop cancer growth. 
• Ovarian ablation uses surgery, radiation or extreme heat or cold to permanently stop the ovaries from making hormones. 
• Ovarian suppression can stop the ovaries from making hormones that promote cancer growth in ER+/PR+ cancers. Drugs called luteinizing hormone releasing hormone (LHRH) agonists are typically used instead. For premenopausal women, these drugs provide an equivalent alternative to removing the ovaries. 
• Bilateral oophorectomy is surgery to remove both ovaries, and it may be an ablation option for premenopausal women. 

Chemotherapy kills rapidly multiplying cells throughout the body. It can be given as a single drug or combined with other chemotherapy drugs or other types of treatment. It is most often used to treat ER-/PR- cancers or ER+/PR+ cancers that no longer respond to hormone therapy.

It is also used to treat HER2+ cancers when combined with certain anti-HER2 targeted therapy drugs. It may be used before or after surgery or to help control symptoms caused by the tumor.

Immunotherapy harnesses the potential of the body’s own immune system to recognize and destroy cancer cells. The following types of immunotherapy are approved for advanced breast cancer.

• Immune checkpoint inhibitors prevent the immune system from slowing down, allowing it to keep up its fight against the cancer. These drugs do this by targeting and blocking PD-1 or PD-L1.
• Monoclonal antibodies (mAbs) are laboratory-made antibodies that are designed to target specific tumor antigens, which are substances that cause the body to make a specific immune response. When a mAb is combined with a toxin, such as a chemotherapy drug, it is called an antibody drug conjugate. 
• Tumor-agnostic treatment, when used as immunotherapy, is approved to treat any type of cancer that has molecular alterations known as microsatellite instability-high (MSI-H), deficient mismatch repair (dMMR) or tumor mutational burden-high (TMB-H). MSI-H describes cancer cells that have a greater-than-normal number of genetic markers called microsatellites, which are short, repeated sequences of DNA. Every time a cell reproduces itself, it makes a copy of its genes and DNA. During the process, errors in duplication can be made. The body normally corrects the error, but sometimes it is not caught and fixed, resulting in a dMMR. It then becomes a mutation that is reproduced in later versions of the cell. Cancer cells that have large numbers of microsatellites may have defects in the ability to correct mistakes that occur when DNA is copied. 

Bone-strengthening drugs or bone-modifying agents may be used to prevent or delay bone fractures, in addition to systemic treatment or radiation therapy, when breast cancer has spread to the bones. These include bisphosphonates, radiopharmaceuticals and targeted therapies that help increase bone mass and strengthen bones.

Radiation Therapy

This therapy uses high-energy X-rays to kill cancer cells or keep them from growing. The most common type is external-beam radiation therapy (EBRT), in which a machine targets radiation beams to specific spots on the body. It may be recommended for pain management or to reduce the size of tumors causing discomfort. If cancer has metastasized to the brain, whole brain radiation, stereotactic radiosurgery or fractionated stereotactic radiotherapy may be used. 

Surgery

This is not typically a primary treatment for advanced breast cancer but may be an option to alleviate pain related to large tumors or metastases in the brain, spine or lungs. When cancer has metastasized to the bones, surgery may help support or stabilize weakened or broken bones. 

Clinical Trials

These medical research studies may offer access to therapies not yet widely available. Extensive research is underway to study the effectiveness of new types of therapy, therapy combinations, drugs targeted at additional biomarkers and genetic markers, and improved treatments for managing various side effects. 

As of 1/27/23