Metastatic Breast Cancer (5)

Cytotoxic chemotherapy for metastatic breast cancer initially consisted of single-agent regimens. Combination therapy is currently considered up front, depending on the patient's performance status, because of higher response rates. When the patient has life-threatening disease and/or severe symptoms that require quick relief, combinations of cytotoxic agents may be preferable because of their high response rate and early onset of clinical benefit. Targeted agents often have low response rates when given as monotherapy, but they provide added benefit when given in combination with cytotoxic chemotherapy.

Treatment of breast cancer with a taxane in the metastatic setting after treatment in the adjuvant setting may be difficult because of residual toxicity. Although taxanes are not cardiotoxic, they can produce lingering neuropathy (especially paclitaxel) or problems with edema (docetaxel especially), which makes further administration problematic. Substitution of one taxane for another is possible, depending on the nature of the chronic toxicity.

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When PET is combined with CT scanning to assist in anatomic localization, scans can identify axillary and nonaxillary (eg, internal mammary or supraclavicular) lymph node metastasis for the purposes of staging locally advanced and inflammatory breast cancer before initiation of neoadjuvant therapy and restaging high-risk patients for local or distant recurrences.

Scintimammography is not indicated as a screening procedure for the detection of breast cancer. However, it may play a role in various specific clinical indications, as in cases of nondiagnostic or difficult mammography and in the evaluation of high-risk patients, tumor response to chemotherapy, and metastatic involvement of axillary lymph nodes.

Ultrasonography can provide valuable information about the nature and extent of solid masses and other breast lesions and can often provide useful information regarding the staging of the axilla.

The following are current indications for MRI:

• Patients with known hereditary gene for breast cancer such as BRCA1 or BRCA2 mutations


• Characterization of an indeterminate lesion after a full assessment with physical examination, mammography, and ultrasonography


• Detection of occult breast carcinoma in a patient with carcinoma in an axillary lymph node


• Further evaluation of suspected multifocal or bilateral tumor


• Evaluation of invasive lobular carcinoma, which has a high incidence of multifocality


• Evaluation of suspected extensive high-grade intraductal carcinoma


• Detection of occult primary breast carcinoma in the presence of metastatic adenocarcinoma of unknown origin

Jaundice is a late sign in patients who have metastasis to the liver when hepatobiliary obstruction happens. The liver enzymes and alkaline phosphatase are often elevated. A complete examination includes assessment of the axillae and supraclavicular fossae, examination of the chest and sites of skeletal pain, and abdominal and neurologic examinations. The clinician should be alert to symptoms of metastatic spread, such as the following:

• Breathing difficulties


• Bone pain


• Symptoms of hypercalcemia


• Abdominal distention


• Jaundice


• Localizing neurologic signs


• Altered cognitive function


• Headache

Sentinel lymph node biopsy may be offered to the following patients:

• Women with operable breast cancer and multicentric tumors


• Women with DCIS who will be undergoing mastectomy


• Women who previously underwent breast and/or axillary surgery


• Women who received preoperative/neoadjuvant systemic therapy

Sentinel lymph node biopsy should not be performed in patients with any of the following:

• Large or locally advanced invasive breast cancer (tumor size T3/T4)


• Inflammatory breast cancer


• DCIS (when breast-conserving surgery is planned)


• Pregnancy

For patients who have hormone receptor (ER and/or progesterone receptor)-positive disease without life-threatening disease or systemic symptoms requiring immediate palliation for comfort, in general, hormone manipulation is the initial treatment of choice. Response rates are higher with chemotherapy, but so is the incidence of potentially dangerous toxicity, and there is no evidence that patients live longer as a result of receiving initial chemotherapy.

For ER-positive metastatic breast cancer, using endocrine therapy is recommended rather than chemotherapy as first-line treatment, except in patients with immediately life-threatening disease or those with endocrine resistance.

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