Systemic therapies are treatments that affect cancer cells throughout the body by traveling through the bloodstream. Systemic therapy may be used to slow the progress of the disease. Chemotherapy, hormone therapy and targeted therapy are all systemic treatments.
Chemotherapy involves drugs that kill or prevent the growth of cancer cells and can be used in combination with other treatments, or on its own. Depending on the drug, it can be given either intravenously into a vein with a needle or in pill form. Chemotherapy is typically given in cycles. You may have a rest period of one to three weeks between cycles, which allows you to recover from some of the side effects you may experience.
Some of the side effects of chemotherapy include nausea, vomiting, hair loss, mouth sores and fatigue. It is unlikely you will experience all of these side effects, and it is important to inform your medical team of any side effects you experience, since there may be medications available to prevent or manage them.
Hormone therapy may be used when breast cancer cells have been identified as hormone-receptor-positive, meaning the cancer cells have receptors for the hormones estrogen and/or progesterone. When these hormones, particularly estrogen, attach to hormone receptors, the cancer cells are stimulated to grow. There are a number of hormone therapy drugs that either reduce the production of hormones in the body or block hormones from attaching to cancer cells. These drugs are usually pills and have relatively few side effects. Tamoxifen and aromatase inhibitors are types of hormone therapy drugs.
Targeted therapy is intended to “target” cancer cells, which causes less harm to healthy cells than chemotherapy and potentially fewer side effects. Targeted therapy uses drugs that are designed to interfere with specific molecules located in or on a cancer cell that help cancer cells to grow and divide. Targeted therapy may be used alone or in combination with other drugs.
Radiation and surgery are the most common forms of local therapy – therapy aimed at a particular area of the body. For metastatic breast cancer, local therapies are commonly, although not exclusively, used to manage symptoms such as pain.
Radiation uses high-energy rays or particles to fight cancer by destroying cells or slowing their growth. Radiation can have negative side effects, partly because the same rays that destroy cancer cells may also destroy healthy cells. When used in a site-specific way to manage metastatic cancer, the side effects (including sunburn-like effects) are mostly limited to the radiated site. For example, diarrhea and abdominal cramps may occur if the pelvis is radiated to treat bone metastases. Similarly, hair loss may be a consequence of radiation of the skull. Radiation may also make you feel tired.
Surgery can be used to alleviate specific symptoms (e.g., to relieve pressure on a nerve or the pressure created by the expansion of an organ, such as the liver or brain). For bone metastases, surgery may be used to implant metal rods to strengthen weakened bones. If metastatic breast cancer is your initial diagnosis, it is not likely that surgery to remove a breast tumour will be recommended. Many doctors believe that surgery does not improve survival, although some do. This is a discussion that you should have with your health care team.
There were standard treatment protocols that your health care team followed if you were diagnosed with breast cancer before. Treating metastatic breast cancer is much more individualized, with a treatment plan tailored for you.
Many factors will influence your treatment plan, including:
- The location and extent of your metastases
- Previous treatments and how you responded to those treatments
- The characteristics of both your primary cancer and the metastases
- Progression of the metastases (the response or lack of response of the cancer to treatment(s))
- How your cancer affects day-to-day living and your overall quality of life
- How you tolerated prior therapy
- What side effects you want to avoid
- Other personal issues and choices (e.g., number of visits to the hospital, time required for each visit)
- Your age and overall health
There is no single treatment or series of treatments that is best for everyone. Each person’s cancer is different, which means that response to treatment can vary from patient to patient. What causes serious side effects for someone else may not for you.
The first approach to treatment may be with a single therapy. Your doctor will schedule tests a few months after you have begun treatment to determine whether the cancer is progressing (tumours are growing or the cancer is spreading) or regressing (tumours are shrinking or the cancer is disappearing) or stable (unchanged).
If the cancer is progressing, a different therapy may be suggested, or, in some cases, a combination of therapies will be recommended. Treatments may stop your cancer from growing or slow its spread for months or even years.
The treatment choices you make will involve different benefits, risk and possible side effects that can affect your day-to-day living. Making these decisions can be stressful and you may go through this process more than once during treatment. You may feel like you are on an emotional rollercoaster as you deal with the success of some treatments and setbacks with others.
Remember that the final decision on whether to proceed with a particular treatment is always up to you. You can also consider stopping treatment temporarily to celebrate a family event, go on a holiday or simply give your body a rest.
How Different Types of Metastases are Treated
Bone metastases may be treated using chemotherapy or hormone therapy. A targeted therapy may also be a part of your treatment plan depending on the characteristics of the cancer. You may also be given drugs that are bone builders – including bisphosphonates or Xgeva® (denosumab). They are also used to prevent or delay osteoporosis (loss of bone mass). These drugs help make diseased bones stronger and prevent further weakening that can lead to fractures or broken bones. Some bone builders are also effective at managing the pain and discomfort associated with bone metastases. Radiation can also be used to relieve symptoms and reduce pain.
Tell your health care team if treatment does not relieve your pain. There are drugs and other options (such as heating pads) that can help you manage pain. Complementary therapies such as acupuncture and massage may also help. (See the section on Integrative and Complementary Approaches to your Care.) Getting relief from pain is important – you want the ability to focus on what is important to you.
Chemotherapy or hormone therapy is most often recommended to treat lung metastases. A targeted therapy may also be a part of your treatment. Surgery may be considered if you have a single tumour. If fluid builds up in your lungs, the doctor may drain it with a needle. Less often, you may need a chest tube inserted that may require a hospital stay.
Because liver metastases do not usually develop as a single mass or tumour, surgery is rare. Generally they are treated with chemotherapy or hormone therapy. A targeted therapy may also be a part of your treatment.
Brain metastases can be treated in many ways, including whole brain radiation, radiosurgery (target high-dose radiation also known as Gamma Knife or Cyber Knife), surgery (a craniotomy), targeted therapies, hormone therapies, corticosteroids, anticonvulsives and chemotherapy.
“Whenever I see my oncologist, I take a list of questions and concerns with me. And I usually take a scribe with me to write down her answers.”
After a diagnosis of metastatic breast cancer, it is important to surround yourself with a health care team that you trust will get you the care you need to live well. They will support you over a long period of time – you should feel comfortable talking with them and listening to them as they give you information that allows you to make an informed decision about your care.
You have many people on your team – your family physician (general practitioner), oncologists and other specialists, nurses, physiotherapists and social workers. Your pharmacist is also a key team member and an important key source of information about drugs you are taking or considering taking. Others may join your team as your treatment changes over time.
Practical tips for managing your care
- Ask for a copy of all your reports, medications and other health records and keep them in a binder.
- Keep a record of all your tests, appointments and contact information for everyone on your health care team: doctors, nurses, pharmacists, caregivers, family members, etc.
- Make sure you know how to reach medical staff after hours in case of emergency.
- Always take your records with you to all regular appointments and emergency visits.
- Keep a record of symptoms/side effects you may be experiencing.
Getting the most from your health care visit
- Prepare a list of essential questions ahead of time.
- Call Willow if you need help creating this list.
- Bring a family member or friend for emotional support and to record information.
- Talk about any new symptoms, side effects or changes since your last visit.
- Ask your most important questions first.
- If you are confused or don’t understand something, ask for clarification or ask for a simpler answer.
- Restate what you heard back to your doctor so you know you really understood it.
- Find out whom you can contact between appointments if you have further questions or concerns.
At some point you may decide to completely stop treatment. This decision is most often considered in the very advanced stages of metastatic breast cancer, at a time when quality of life issues override the desire for longevity. You may conclude that all that can be done has been done. Many women actually experience a sense of release as they withdraw themselves from the demands and side effects of treatment.
Any such decision is best made in consultation with your health care team. You will want to understand the various ways that your decision may change the course of your illness. Even when you choose to end treatment, your health care team will continue to monitor you. They will continue to help you manage your symptoms and will do whatever they can to minimize any discomfort associated with your cancer.