Metastatic Breast Cancer as a Chronic Condition
For women whose breast cancer has spread, treatments can improve their condition and add years to their life.
By Gina Shaw
Reviewed By Charlotte Grayson
When a woman is first diagnosed with breast cancer -- any stage of breast cancer -- one of her greatest fears is "What if it's spread?"
Not long ago, a diagnosis of metastatic breast cancer, meaning the disease has spread well beyond the breast into places like the bones, lungs, or liver, meant it was time to get your affairs in order. In the 1970s, only 10% of women were still alive five years after a diagnosis of metastatic breast cancer, according to a comprehensive review by the MD Anderson Cancer Center in Houston, published in January 2004.
Today, say the MD Anderson researchers, as many as 40% of women with recurrent or metastatic breast cancer survive at least five years. "More and more, both doctors and patients approach it as a chronic condition," says Eric Winer, MD, director of the Breast Program at Boston's Dana-Farber Cancer Institute. "We can't cure it, but we can manage it for many years."
Managing metastatic breast cancer as a chronic condition isn't the same as managing a disease like diabetes. "Diabetes, ultimately, can shorten one's life, but that's over the horizon of a few decades," Winer says.
"With breast cancer metastases, the majority of women know that this is an illness that's ultimately going to take their life. That may not be in a year or two or three, but it certainly tends to be in less than a decade."
However, enormous treatment improvements do mean that thousands of women are living longer and better lives even though they have metastatic breast cancer.
Treatments for Breast Cancer that Has Spread
Treatments for metastatic and earlier-stage breast cancer are very different. For earlier-stage breast cancer -- particularly for women who are relatively young and healthy -- doctors will often advise a very aggressive, rigorous course of treatment aimed at getting rid of the cancer completely. The side effects can be difficult, but there's a finish line in sight: initial breast cancer treatment usually lasts no more than six to nine months.
With metastatic cancer, some form of treatment will be a fact of life more or less from now on. This means the treatment philosophy changes. "We're looking to gain maximal control of the tumor at the lowest possible cost in terms of toxicity," says Clifford Hudis, MD, chief of the Breast Cancer Medicine Service at New York's Memorial Sloan-Kettering Cancer Center.
Quick GuideBreast Cancer Diagnosis and Treatment
That usually involves one or more of three primary options:
- Hormonal therapies, like Tamoxifen or Arimidex. These treatments tend to have fewer side effects than chemotherapy. They control metastatic disease just as well as or better than more aggressive treatment, doctors say. They are only effective in women whose disease is estrogen-receptor positive.
- Herceptin. A monoclonal antibody, Herceptin works by specifically targeting cells that overexpress the Her2 protein -- something that happens in about one of every four breast cancers. Trials show that Herceptin can lengthen survival for these women by an average of about 13 months.
Chemotherapy. Chemotherapy for metastatic disease is a very different animal from the aggressive regimens for early-stage breast cancer. This often involves relatively high doses of multiple drugs.
"For metastatic cancer, we usually prefer to use sequential single-agent chemotherapy rather than a combination," says Hudis. "Our goal is enough of a response rate to control the tumor while having a minimal impact on the quality of a woman's life."
Although the precise chemotherapy drugs used may vary, one of the best currently available for metastatic disease is Xeloda, which is long lasting and effective and can be taken at home in pill form.
Newer treatment approaches have also done wonders to reduce the often painful symptoms of the disease. "Supportive care has gotten a lot better, so that the symptoms that people have from treatments and progression of the disease are much more controlled," says Musa Mayer, survivor of stage II breast cancer, patient advocate with the National Cancer Institute, and author of Advanced Breast Cancer: A Guide to Living with Metastatic Disease.
For example, a class of drugs known as bisphosphonates -- both pill medications like Fosamax and Actonel, and stronger versions given by intravenous injection called Aredia and Zometa -- has changed things dramatically for women with cancer that has spread to their bones.
"These drugs have been very beneficial, because they slow the breakdown of bone. One of the big problems with bone metastases used to be fractures," says Mayer. "With these drugs, you don't have the kind of damaging, progressive bone disease that we used to see."
Living Well in Spite of the Unknown
But despite all the progress, a diagnosis of metastatic breast cancer is still a fearful, life-changing one. "A lot of people are very afraid initially, and feel that many doors have been closed to them," says Mary Jane Massie, MD, attending psychiatrist at Sloan-Kettering's Breast Center.
"Our task is to help people see that they can move ahead with their lives -- always needing excellent health care follow-up, but often living for relatively uninterrupted periods of life."
The hardest part, for most women, is the uncertainty. "Over time, some people get used to the idea that they'll be living with, or despite, the disease, but they won't be rid of it. But what's hardest is confronting the uncertainty and the general lack of control -- not just the disease and the drugs, but more globally, the fact that we don't know what the next months will bring with anyone with this disease," says Hudis.
Coping with the "extended marathon" of life with metastatic breast cancer means different things to different women. Some seek support from counselors or group therapy sessions at their cancer centers, while others find it online. The web-based support group BCmets (www.bcmets.org) is one of the oldest and largest.
"Some women want to keep working full time for as long as possible and keep their focus away from the illness," says Mayer. "Others say, 'OK, I have a limited time, and I don't want to spend it in my office. I want to travel, work in my garden, spend time with my grandchildren.' Everyone has different priorities."
One of the most important things for women with breast cancer metastases to remember, says Winer, is the exciting progress of research. "This doesn't mean that we'll have new treatments in six months, but a lot more may be possible in just three or four years," he says.
"That informs much of our strategy: to keep you alive, in good shape, and functioning well, so that the approaches being worked on now may be something for you in a few years. Is that a guarantee? No. Is it possible? Absolutely."
Published May 2005.
SOURCES: Eric Winer, MD, director, Breast Program, Dana-Farber Cancer Institute, Boston. Clifford Hudis, MD, chief, Breast Cancer Medicine Service, Memorial Sloan-Kettering Cancer Center, New York City. Musa Mayer, author, Advanced Breast Cancer, A Guide to Living with Metastatic Disease. Mary Jane Massie, MD, attending psychiatrist, Memorial Sloan-Kettering Cancer Center, New York City. Giordano et al, "Improvement in breast cancer survival: results from M.D. Anderson Cancer Center protocols from 1975-2000," presented to the American Society for Clinical Oncology Annual Meeting 2002. Breastcancer.org.
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