Treatments for stage 4 breast cancer
The following are treatment options for stage 4 ductal carcinoma and lobular carcinoma. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan.
Stage 4 means that the breast cancer has spread to other parts of the body. It is also called advanced breast cancer, or metastatic breast cancer. Treatments cannot completely cure metastatic breast cancer, but they can control it very well, sometimes for many years. Doctors may offer one treatment until it stops working and then give another one.
The treatments offered for stage 4 breast cancer depend on the hormone-receptor status and the HER2 status of the cancer cells. They will also depend on where the cancer has spread, if it is causing any symptoms and your overall health.
Hormonal therapy @(Model.HeadingTag)>
Hormonal therapy is offered for hormone receptor–positive breast cancer that has spread to the bones and soft tissues, such as muscles or fat. It will also be given when cancer has spread to internal organs, such as the liver, lungs or brain, but it isn’t causing any symptoms.
The type of hormonal therapy given will depend on if you have reached
Hormonal therapy for post-menopausal women @(Model.HeadingTag)>
Hormonal therapy for
Hormonal therapy for premenopausal women @(Model.HeadingTag)>
Hormonal therapy for
Chemotherapy is given for hormone receptor–negative stage 4 breast cancer. It is also offered for hormone receptor–positive breast cancer that has spread to internal organs and is causing symptoms.
There is no standard drug or drug combination for advanced breast cancer. Chemotherapy is given as long as the cancer responds to it and the side effects do not cause problems. Once the cancer no longer responds to the treatment, a different drug may be offered.
Chemotherapy drugs are often used alone to treat metastatic breast cancer. This is because a single drug causes fewer side effects than a combination of drugs. Chemotherapy is given as long as the side effects do not cause problems and the breast cancer does not grow.
The following single drugs may be used:
- doxorubicin (Adriamycin)
- pegylated liposomal doxorubicin (Caelyx)
- paclitaxel (Taxol)
- nab-paclitaxel (Abraxane)
- capecitabine (Xeloda)
- gemcitabine (Gemzar)
- vinorelbine (Navelbine)
- cyclophosphamide (Procytox)
- carboplatin (Paraplatin, Paraplatin AQ)
- docetaxel (Taxotere)
- cisplatin (Platinol AQ)
- epirubicin (Pharmorubicin)
The following combinations of chemotherapy drugs may be used for stage 4 breast cancer:
- CAF (or FAC) – cyclophosphamide, doxorubicin and 5-fluorouracil (Adrucil, 5-FU)
- CEF (or FEC) – cyclophosphamide, epirubicin and 5-fluorouracil
- AC – doxorubicin and cyclophosphamide
- EC – epirubicin and cyclophosphamide
- docetaxel and capecitabine
- gemcitabine and paclitaxel
- gemcitabine and carboplatin
Targeted therapy @(Model.HeadingTag)>
Trastuzumab (Herceptin) is given for stage 4 HER2-positive breast cancer. It is usually added to chemotherapy. It may be given by itself if you are not well enough to have chemotherapy. When given alone, it is usually continued until the breast cancer starts to grow again.
Pertuzumab (Perjeta) may be used to treat metastatic HER2-positive breast cancer in people who have not had trastuzumab or chemotherapy to treat it. It is combined with trastuzumab and docetaxel (Taxotere).
Phesgo combines trastuzumab and pertuzumab into a single dose. It is given by a needle just under the skin (subcutaneously) instead of through a needle in a vein (intravenously). This means that treatment can be given more quickly and easily than giving the 2 drugs separately. Phesgo may be combined with the chemotherapy drug doxetaxel to treat HER2-positive metastatic breast cancer in people who have not had any treatments for metastatic disease.
Trastuzumab emtansine (Kadcyla, T-DM1) may be used to treat HER2-positive metastatic breast cancer that has already been treated with one of the following:
- trastuzumab alone
- chemotherapy with paclitaxel (Taxol) or docetaxel
- trastuzumab with either paclitaxel or docetaxel
Neratinib (Nerlynx) may be used in combination with the chemotherapy drug capecitabine for the treatment of metastatic HER2-positive breast cancer, after 2 or more treatments for HER2-positive treatment have been used to treat metastatic disease.
Palbociclib (Ibrance) may be given along with an aromatase inhibitor in post-menopausal women with estrogen receptor-positive (ER+), HER2-negative stage 4 breast cancer, who have not had trastuzumab or chemotherapy. It can be given as the first treatment for stage 4 breast cancer.
Abemaciclib (Verzenio) is used for women with hormone receptor–positive, HER2-negative breast cancer. It is taken as pill daily and may be given:
- with an aromatase inhibitor for post-menopausal women as hormonal-based therapy
- with fulvestrant (Faslodex) if the disease progresses after hormonal therapy
- alone if the disease progresses after hormonal therapy and at least 2 chemotherapy regimens
Olaparib (Lynparza) can be used to treat people with metastatic, HER2-negative breast cancer who have a BRCA gene mutation and have already had chemotherapy. Olaparib is usually taken by mouth.
Talazoparib (Talzenna) can be used to treat people with metastatic, HER2-negative breast cancer who have a BRCA gene mutation and have already had chemotherapy. Talazoparib is taken by mouth once a day.
If you can’t have or don’t want cancer treatment @(Model.HeadingTag)>
You may want to consider a type of care to make you feel better without treating the cancer itself. This may be because the cancer treatments don’t work anymore, they’re not likely to improve your condition or they may cause side effects that are hard to cope with. There may also be other reasons why you can’t have or don’t want cancer treatment.
Talk to your healthcare team. They can help you choose care and treatment for advanced cancer.
Clinical trials @(Model.HeadingTag)>
Many clinical trials in Canada are open to women with breast cancer. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.
Expert review and references
Hoffman La-Roche Limited Canada. Product Monograph Pertuzumab (Perjeta). https://www.rochecanada.com/PMs/Perjeta/Perjeta_PM_E.pdf.
American Cancer Society. Breast Cancer. 2015: http://www.cancer.org/cancer/breastcancer/index.
Burstein HJ, Temin S, Anderson H, Buchholz TA, Davidson NE, Gelmon KE, Giordano SH, et al . Adjuvant endocrine therapy for women with hormone receptor-positive breast cancer: American Society of Clinical Oncology clinical practice guideline focused update. Journal of Clinical Oncology. 2014.
Cardoso F, Costa A, Norton L, Senkus E, Aapro M, Andre F, Barrios CH, et al . ESO-ESMO 2nd International Consesus Guidelines for advanced breast cancer (ABC2). The Breast. 2014.
Drugs and Health Products, Health Canada. Regulatory Decision Summary: Lynparza. 2018: https://hpr-rps.hres.ca/reg-content/regulatory-decision-summary-detail.php?linkID=RDS00399.
Joy AA, Ghosh M, Fernandes R, Clemons MJ . Systemic treatment approaches in HER2-negative advanced breast cancer - guidance on the guidelines. Current Oncology. 2015.
Morrow M, Burstein HJ, and Harris JR . Malignant tumors of the breast. DeVita VT Jr, Lawrence TS, & Rosenberg SA. Cancer: Principles and Practice of Oncology. 10th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015: 79: 1117-1156.
National Cancer Institute. Breast Cancer Treatment for Health Professionals (PDQ®). 2015.
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Breast Cancer (Version 2.2015). http://www.nccn.org/professionals/physician_gls/f_guidelines.asp.
Partridge AH, Rumble RB, Carey LA, Come SE, Davidson NE, Di Leo A, Gralow J, et al . Chemotherapy and targeted therapy for women with human epidermal growth factor receptor 2-negative (or unknown) advanced breast cancer: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology. 2014.
Van Poznak C, Somerfield MR, Bast RC, Cristofanilli M, Goetz MP, Gonzalez-Angulo AM, Hicks DG, et al . Use of biomarkers to guide decisions on systemic therapy for women with metastatic breast cancer: American Society of Clinical Oncology clinical practice guideline. Journal of Clinical Oncology. 2015.
Zhu X, Verma S . Targeted therapy in HER2-positive metastatic breast cancer: a review of the literature. Current Oncology. 2015.