“Advanced breast cancer” includes both locally advanced and metastatic breast cancers.
Patients with locally advanced disease encompass a wide range of clinical scenarios including advanced primary tumors (stage T4), advanced nodal disease (fixed axillary nodes or involvement of ipsilateral supraclavicular [nodes under the collar bone on the same side as the breast cancer], or internal mammary nodes), and inflammatory carcinomas. This is often referred to as Stage III breast cancer.
Metastatic breast cancer, also referred to as metastases, secondaries or Stage IV breast cancer is a stage of breast cancer where the disease has spread to distant sites beyond the axillary lymph nodes.
Advanced breast cancer is usually treated with systemic therapy (drugs that travel through the bloodstream, reaching and affecting cells in the body). Systemic therapy includes hormonal treatment, chemotherapy, and targeted therapy. Radiation therapy also has a part to play especially if bones are affected. Palliative Care often forms part of the management plan for patients with life-threatening advanced breast cancer.
Locally advanced breast cancer
Locally advanced breast cancer has spread beyond the breast to the chest wall or the skin of the breast, or to many lymph nodes in the underarm area (axillary nodes), but not to other organs. It is treated with a combination of surgery, radiation therapy and chemotherapy. Depending on certain tumour characteristics, treatment may also include hormone therapy and/or targeted therapy.
Treatment for locally advanced breast cancer usually begins with neoadjuvant (before surgery) therapy. Neoadjuvant therapy helps shrink the tumour(s) in the breast and lymph nodes so that surgery can better remove all of the cancer.
Most women have neoadjuvant chemotherapy, usually with an anthracycline-based chemotherapy and a taxane-based chemotherapy. When possible, all the chemotherapy planned to treat locally advanced breast cancer is given before surgery. If the tumour does not get smaller with one combination of chemotherapy drugs, other combinations can be tried.
If the tumour is HER2-positive, neoadjuvant trastuzumab (Herceptin) may be given, but not at the same time as an anthracycline-based chemotherapy.
Some postmenopausal women with hormone receptor-positive tumours may get neoadjuvant hormone therapy (usually with an aromatase inhibitor).
In some cases, if the tumour does not respond to neoadjuvant therapy, radiation therapy may be given before surgery.
Inflammatory breast cancer
Inflammatory breast cancer (IBC) is a rare but aggressive type of locally advanced breast cancer. It is called inflammatory breast cancer because its main symptoms are swelling and redness of the breast (the breast looks inflamed). These and other symptoms include :
- Swelling or enlargement of the breast
- Redness of the breast (may also be a pinkish or purplish tone)
- Dimpling or puckering of the skin of the breast
- Pulling in of the nipple
- Breast pain
With other breast cancers, symptoms in the breast may not occur for years. However, with IBC, symptoms tend to arise within weeks or months. Because of the frequent lack of a breast lump and symptoms such as redness and swelling, IBC may first be mistaken for an infection. IBC is often diagnosed after symptoms do not improve with a course of antibiotics.
IBC tumours are often oestrogen receptor-negative and HER2 positive. Because these breast cancers are aggressive, most women with IBC have positive lymph nodes and 25 – 30% have metastasis when they are diagnosed . For this reason, when IBC is diagnosed, tests for metastatic breast cancer are done.
Metastatic Breast Cancer
The term, metastatic, describes a cancer that has spread to distant organs from the original tumor site. Metastatic breast cancer is the most advanced stage (Stage IV) of breast cancer. Cancer cells have spread past the breast and axillary (underarm) lymph nodes to other areas of the body where they continue to grow and multiply. Breast cancer has the potential to spread to almost any region of the body. The most common region breast cancer spreads to is the bone, followed by the lung and liver. Treatment of metastatic breast cancer generally focuses on relieving symptoms and extending a patient’s lifetime.
Breast Cancer Recurrence
The risk of breast cancer recurrence is lifelong. The highest risk of recurrence is in the first 3-4 years after initial diagnosis and treatment. While the risk of recurrence decreases over time, it never disappears. The likelihood of recurrence is increased in the presence of a high grade original tumour or where the stage of the original tumour was high. These statements are confirmed by the following graphs which are drawn from our database:
Time to Relapse by Site:
Time to Relapse by Grade:
Time to Relapse by Stage:
- Differences in survival among women with stage III inflammatory and noninflammatory locally advanced breast cancer appear early: a large population-based study. Dawood S, Ueno NT, Valero V, et al. 117(9):1819-26, 2011.
- Inflammatory Breast Cancer, Merajver SD, Iniesta MD, Sabel MS. Chapter 62: in Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the Breast, 4th edition, Lippincott Williams & Wilkins, 2010.
- Patterns of breast cancer relapse. Elder, E E; Kennedy, C W; Gluch, L; Carmalt, H L; Janu, N C; Joseph, M G; Donellan, M J; Molland, J G; Gillett, D J. European Journal of Surgical Oncology. 32(9):922-7, 2006 Nov.
The Role of Palliative Care
Palliative Care referral is often made late in an illness, after months or years of treatment, when symptoms such as pain are difficult to control. A referral to palliative care can be made at any time for patients with serious diseases such as advanced breast cancer.
Palliative care will make you as comfortable as possible by controlling pain and other distressing symptoms, while providing psychological, social and spiritual support for you and your family or carers. This is called an holistic approach, as it deals with the “whole” person rather than just one aspect of care.
It should be emphasized that referral to palliative care does not imply that death is not far away; nor does it mean that once palliative care is commenced, patients will be “drugged to the eyeballs”. If medication is needed to control symptoms, it will be administered with meticulous care. And palliative care may provide better and longer years of life.
End of Life Care includes:
- Comprehensive physical symptom management, especially pain management. Addressing anxiety, depression, adjustment difficulties, feelings of loss of control and loss of comprehension.
- Family support
- Introduction of community support services.
- Help with cognitive restructuring of goals and realistic expectations, always maintaining a focus on hope.
- A palliative care approach:- Is to understand the uniqueness of a person and their suffering.- To journey with the person and their family as they cope with the issues of their suffering.- To respond to these issues with understanding, symptom management and psychological support.- And to help the person find a realistic hope.
Of particular interest is the Palliative Care Unit at Concord Repatriation General Hospital which has only recently opened. It is staffed by a dedicated multidisciplinary team offering sensitive and compassionate medical and supportive care for patients with a life limiting illness, their families and friends. Support is provided in the Hospital, the palliative care centre and at home.
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