Metastatic Breast Cancer

Eribulin is a newer drug (FDA approved for metastatic breast cancer in 2010) that is effective in individuals who have been previously treated with chemotherapy. In a study, known as the EMBRACE trial, women were assigned to receive eribulin or to the treatment chosen by their doctors as predicted to have the best effect. There was a significant survival benefit of about 2.5 months in favor of the eribulin. The drug, derived from sea sponges, works by targeting a scaffolding protein (microtubule) within a cell and interferes with the construction of the scaffolding and stops the cancer cell from dividing. Eribulin is a newer drug (FDA approved for metastatic breast cancer in 2010) that is effective in individuals who have been previously treated with chemotherapy. In a study, known as the EMBRACE trial, women were assigned to receive eribulin or to the treatment chosen by their doctors as predicted to have the best effect. There was a significant survival benefit of about 2.5 months in favor of the eribulin. The drug, derived from sea sponges, works by targeting a scaffolding protein (microtubule) within a cell and interferes with the construction of the scaffolding and stops the cancer cell from dividing.

Breast cancer has a tendency to spread to certain locations in the body more so than others, for example, the lung, pleura (lining of the lung), bones, liver and central nervous system. Thus if an individual reports a cough, cough that is blood-tinged, shortness of breath at rest or when exerting oneself, bone pain that is localized, unusual and not relieved with typical remedies, abdominal pain, unusual/persistent headaches, weakness, imbalance, unexplained weight loss--these may be problems for which further testing may be advised. Breast cancer has a tendency to spread to certain locations in the body more so than others, for example, the lung, pleura (lining of the lung), bones, liver and central nervous system. Thus if an individual reports a cough, cough that is blood-tinged, shortness of breath at rest or when exerting oneself, bone pain that is localized, unusual and not relieved with typical remedies, abdominal pain, unusual/persistent headaches, weakness, imbalance, unexplained weight loss--these may be problems for which further testing may be advised.

Metastatic breast cancer means that the breast cancer has spread outside of the breast and outside of the underarm (axillary) lymph nodes. The most common sites of spread are to lymph nodes above the clavicle, in the chest, and to the lung, liver, bones, and brain. Metastatic breast cancer, or Stage IV breast cancer, is not considered curable, but modern treatments do allow for much longer survival with a better quality of life than older treatment regimens. Metastatic breast cancer means that the breast cancer has spread outside of the breast and outside of the underarm (axillary) lymph nodes. The most common sites of spread are to lymph nodes above the clavicle, in the chest, and to the lung, liver, bones, and brain. Metastatic breast cancer, or Stage IV breast cancer, is not considered curable, but modern treatments do allow for much longer survival with a better quality of life than older treatment regimens.

Uncertainty, especially under the circumstances of a cancer diagnosis, is one of most stressful experiences. I recommend exercise, meditation, and relaxation exercises as ways to cope with stress during this time. Check out this book by Dr. Michael Antoni, one of the leading researchers in this area: http://www.amazon.com/Stress-Management-Intervention-Breast-Cancer/dp/1557989419/ref=sr_1_2?s=books&ie=UTF8&qid=1332591278&sr=1-2 I also highly recommend finding online social networks, like on http://www.PatientsLikeMe.com to find and connect with others going through what you are going through. Even though family and friends may be supportive, it can be so helpful to talk to people who have been through or are going through what you are going through. Only they can truly understand your fears and concerns. And, because the people you meet in online social networks are not close family and friends, you may actually be able to speak more freely about your thoughts, feelings and challenges, especially to the extent that some of the challenges involve family and friends reactions to your cancer. Uncertainty, especially under the circumstances of a cancer diagnosis, is one of most stressful experiences. I recommend exercise, meditation, and relaxation exercises as ways to cope with stress during this time. Check out this book by Dr. Michael Antoni, one of the leading researchers in this area: http://www.amazon.com/Stress-Management-Intervention-Breast-Cancer/dp/1557989419/ref=sr_1_2?s=books&ie=UTF8&qid=1332591278&sr=1-2 I also highly recommend finding online social networks, like on http://www.PatientsLikeMe.com to find and connect with others going through what you are going through. Even though family and friends may be supportive, it can be so helpful to talk to people who have been through or are going through what you are going through. Only they can truly understand your fears and concerns. And, because the people you meet in online social networks are not close family and friends, you may actually be able to speak more freely about your thoughts, feelings and challenges, especially to the extent that some of the challenges involve family and friends reactions to your cancer.

If you have metastatic breast cancer and chemotherapy is part of your treatment plan, your doctor may use different tests to determine how well the chemotherapy is working and how you're handling the chemotherapy. These tests may include CT scans, bone scan, MRI, X-rays, laboratory studies, among others. If these tests show that the cancer is growing or that the cancer is showing up in new areas then that may signal a time when the chemotherapy needs to change. Chemotherapy may also change if it is causing too many side effects and problems for you. If you have metastatic breast cancer and chemotherapy is part of your treatment plan, your doctor may use different tests to determine how well the chemotherapy is working and how you're handling the chemotherapy. These tests may include CT scans, bone scan, MRI, X-rays, laboratory studies, among others. If these tests show that the cancer is growing or that the cancer is showing up in new areas then that may signal a time when the chemotherapy needs to change. Chemotherapy may also change if it is causing too many side effects and problems for you.

We consider reducing the dose of chemotherapy when there are either laboratory studies that are outside a safe range or when side effects become too troublesome for our patients. Chemotherapy may be reduced, for example, for low blood counts. Also, it may be reduced in the setting of abnormal liver or kidney function tests. Sometimes reducing the dose is not safe enough and your doctor may have to hold the treatment for a week or more. Often reducing or holding a dose of chemotherapy will allow you to be treated safely at a future date. We consider reducing the dose of chemotherapy when there are either laboratory studies that are outside a safe range or when side effects become too troublesome for our patients. Chemotherapy may be reduced, for example, for low blood counts. Also, it may be reduced in the setting of abnormal liver or kidney function tests. Sometimes reducing the dose is not safe enough and your doctor may have to hold the treatment for a week or more. Often reducing or holding a dose of chemotherapy will allow you to be treated safely at a future date.

During chemotherapy we hope to see an improvement in symptoms, if you are having any, within days or weeks of treatment. We expect to see changes on scans (for example, CT scans, X-rays, bone scans) within weeks of beginning treatment. Most often, we would recommend looking at scans within 6-8 weeks after starting chemotherapy. Sometimes the interval is related to how often you have the chemotherapy. For example, if your treatment is every 3 weeks then you may have scans at 6 or 9 weeks and if the chemotherapy is every 4 weeks then you may have scans in 8 or 12 week intervals. If the drug is working then we would expect to see tumors shrinking or staying the same size. If the drug is not working as well as we would like then we may see tumors getting larger or new tumors showing up on the scans. During chemotherapy we hope to see an improvement in symptoms, if you are having any, within days or weeks of treatment. We expect to see changes on scans (for example, CT scans, X-rays, bone scans) within weeks of beginning treatment. Most often, we would recommend looking at scans within 6-8 weeks after starting chemotherapy. Sometimes the interval is related to how often you have the chemotherapy. For example, if your treatment is every 3 weeks then you may have scans at 6 or 9 weeks and if the chemotherapy is every 4 weeks then you may have scans in 8 or 12 week intervals. If the drug is working then we would expect to see tumors shrinking or staying the same size. If the drug is not working as well as we would like then we may see tumors getting larger or new tumors showing up on the scans.

In general, most chemotherapy medicines can be used to treat metastatic breast cancer until side effects become a problem or the medicine stops being effective. Breast cancer that has metastasized will often require continual treatment whereas treatment in the non-metastatic setting typically has a defined number or duration of treatments. For example, in the non-metastatic setting, a usual care plan includes surgery with or without radiation therapy, and some type of systemic (drug) therapy, with the drug therapy specified as a certain number of cycles (if chemotherapy) or a certain duration of treatment (for example, tamoxifen for 5 years). In metastatic breast cancer, the goal of medicines is to destroy or damage tumor cells and to shrink tumors or keep tumors stable and in order to do that we have to keep patients on treatment most of the time. Sometimes when the cancer is stable we can provide our patients with some time off or drug holiday but most of the time we have to consider some type of systemic therapy. In general, most chemotherapy medicines can be used to treat metastatic breast cancer until side effects become a problem or the medicine stops being effective. Breast cancer that has metastasized will often require continual treatment whereas treatment in the non-metastatic setting typically has a defined number or duration of treatments. For example, in the non-metastatic setting, a usual care plan includes surgery with or without radiation therapy, and some type of systemic (drug) therapy, with the drug therapy specified as a certain number of cycles (if chemotherapy) or a certain duration of treatment (for example, tamoxifen for 5 years). In metastatic breast cancer, the goal of medicines is to destroy or damage tumor cells and to shrink tumors or keep tumors stable and in order to do that we have to keep patients on treatment most of the time. Sometimes when the cancer is stable we can provide our patients with some time off or drug holiday but most of the time we have to consider some type of systemic therapy.

Symptoms our often our main clue. We use a variety of imaging : plain xrays, bone scans, CT scans, PET scans. Which one is used is dependent on the problem that we are investigating. Tumor markers (from the blood) can be helpful in some cases. Symptoms our often our main clue. We use a variety of imaging : plain xrays, bone scans, CT scans, PET scans. Which one is used is dependent on the problem that we are investigating. Tumor markers (from the blood) can be helpful in some cases.

Malignant cells have a unique ability to break off from the mother tumor, float through the blood stream or lymphatics, get stuck somewhere, and not die. In fact they can survive quite well and continue to divide forming a new tumor mass [metastasis]. Then they have this nasty ability to produce a sort of hormone that causes blood vessels to grow to it thereby ensuring their continued survival. Sneaky little suckers. The good news is that some of our newer 'targeted' therapies take advantage of this ability and are effective at killing some of these tumors. Not the most scientific answer but hope this helps. Malignant cells have a unique ability to break off from the mother tumor, float through the blood stream or lymphatics, get stuck somewhere, and not die. In fact they can survive quite well and continue to divide forming a new tumor mass [metastasis]. Then they have this nasty ability to produce a sort of hormone that causes blood vessels to grow to it thereby ensuring their continued survival. Sneaky little suckers. The good news is that some of our newer 'targeted' therapies take advantage of this ability and are effective at killing some of these tumors. Not the most scientific answer but hope this helps.

The obvious answer is to prevent metastasis by improving early detection. If you ignore that, there are several new technologies that are very promising. One of the main problems with the systemic treatments (like chemotherapy) that are used to treat cancer is that they affect many normal cells, leading to unwanted side-effects. The best new treatments will have to limit their side-effects. These include:
1. Nanotechnology - this field uses microscopic particles to deliver drugs to cancer cells. They 'home' in to the cancer cells and don't hurt normal cells.
2. Anti-angiogenesis treatments- Angiogenesis is the development of blood vessels. Tumors 'trick' the body into providing them with blood vessels, giving them access to nutrients, oxygen and a way to spread. Because angiogenesis is limited to only a few normal conditions (i.e. pregnancy) in adults, these treatments have the ability to starve tumors. Anti-angiogenesis drugs (including Avastin) DO have side effects and do not always work.

They key is to find something that is UNIQUE to the particular cancer cells being treated, whether it is the things they need (like lots of sugar) or don't need. Newer targeted therapies are a step in this direction but they still affect normal cells to an extent. The obvious answer is to prevent metastasis by improving early detection. If you ignore that, there are several new technologies that are very promising. One of the main problems with the systemic treatments (like chemotherapy) that are used to treat cancer is that they affect many normal cells, leading to unwanted side-effects. The best new treatments will have to limit their side-effects. These include:
1. Nanotechnology - this field uses microscopic particles to deliver drugs to cancer cells. They 'home' in to the cancer cells and don't hurt normal cells.
2. Anti-angiogenesis treatments- Angiogenesis is the development of blood vessels. Tumors 'trick' the body into providing them with blood vessels, giving them access to nutrients, oxygen and a way to spread. Because angiogenesis is limited to only a few normal conditions (i.e. pregnancy) in adults, these treatments have the ability to starve tumors. Anti-angiogenesis drugs (including Avastin) DO have side effects and do not always work.

They key is to find something that is UNIQUE to the particular cancer cells being treated, whether it is the things they need (like lots of sugar) or don't need. Newer targeted therapies are a step in this direction but they still affect normal cells to an extent.

This is a very controversial question with no Level 1 data (prospective and randomized studies) to answer it. There is a prospective (forward looking) and randomized (patients are assigned to either mastectomy or leaving the breast alone randomly - they nor their physician have the choice) study taking place right now that is enrolling patients but we will not have the answer until the trial is over. So we must rely on what studies we have. There is a large review of a cancer database by Dr. Seema Khan that shows that removing the breast even in the face of metastatic disease (spread to bone as an example) will improve survival. Other similar studies have shown no difference in survival (and the patient had to undergo a surgery). There are circumstances that a patient would benefit from a mastectomy - bleeding, ulcerated, infected, foul smelling cancers can have these symptoms relieved by mastectomy - which may not improve survival but will improve the quality of life. This is a very controversial question with no Level 1 data (prospective and randomized studies) to answer it. There is a prospective (forward looking) and randomized (patients are assigned to either mastectomy or leaving the breast alone randomly - they nor their physician have the choice) study taking place right now that is enrolling patients but we will not have the answer until the trial is over. So we must rely on what studies we have. There is a large review of a cancer database by Dr. Seema Khan that shows that removing the breast even in the face of metastatic disease (spread to bone as an example) will improve survival. Other similar studies have shown no difference in survival (and the patient had to undergo a surgery). There are circumstances that a patient would benefit from a mastectomy - bleeding, ulcerated, infected, foul smelling cancers can have these symptoms relieved by mastectomy - which may not improve survival but will improve the quality of life.

Right now I'm on Xeloda, an oral chemo pill. So far, the symptoms have been limited to hand/foot syndrome (dry, discolored skin). I've been off an on chemo since my metastasis, but I've been in good health; it has not altered my lifestyle. In fact, I think I'm healthier now than I've ever been.

Coping? I try to take things one day at a time and appreciate all the blessings in my life. Right now, I'm visualizing my future. Writing and interviewing other cancer survivors in my situation (or worse) who have beat the odds has really helped. I have hope, and to me, that's the best medicine. Right now I'm on Xeloda, an oral chemo pill. So far, the symptoms have been limited to hand/foot syndrome (dry, discolored skin). I've been off an on chemo since my metastasis, but I've been in good health; it has not altered my lifestyle. In fact, I think I'm healthier now than I've ever been.

Coping? I try to take things one day at a time and appreciate all the blessings in my life. Right now, I'm visualizing my future. Writing and interviewing other cancer survivors in my situation (or worse) who have beat the odds has really helped. I have hope, and to me, that's the best medicine.

The FDA recommendation re:Avastin is not about whether it will continue to be available for treatment of metastatic breast cancer. Since the drug is prescribed for treatment of other cancers, physicians will be able to prescribe it "off label" for breast cancer as well. The issue is largely one of health care coverage. Avastin runs as much as $8000/treatment, and without insurance coverage that is likely to be prohibitive. While, I have heard that Genetech is looking at capping fees at $55,000/a year, that is still WELL beyond the reach of most of us.

A related issue, as Dr. Attai discusses elsewhere, is the need to focus energy and funds on better understanding which drugs will work in which patients with which cancers, so that we can get Avastin to the right patients, and protect the ones who could be harmed. The FDA recommendation re:Avastin is not about whether it will continue to be available for treatment of metastatic breast cancer. Since the drug is prescribed for treatment of other cancers, physicians will be able to prescribe it "off label" for breast cancer as well. The issue is largely one of health care coverage. Avastin runs as much as $8000/treatment, and without insurance coverage that is likely to be prohibitive. While, I have heard that Genetech is looking at capping fees at $55,000/a year, that is still WELL beyond the reach of most of us.

A related issue, as Dr. Attai discusses elsewhere, is the need to focus energy and funds on better understanding which drugs will work in which patients with which cancers, so that we can get Avastin to the right patients, and protect the ones who could be harmed.