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Breast cancer

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Treatment of recurrent breast cancer

The following are treatment options for recurrent breast cancer. The types of treatments given are based on the unique needs of the woman with cancer.

Invasive ductal and invasive lobular carcinomas are treated the same way.

The treatment for recurrent breast cancer will depend mainly on where the cancer has recurred:

  • local recurrence – The cancer has recurred in the same breast where the cancer was first found, including the remaining breast tissue, skin, chest wall or nearby lymph nodes.
  • metastatic disease – The cancer has spread to other parts of the body:
    • soft tissues
    • bones
    • liver
    • lung
    • brain

Other factors that affect the choice of treatment for recurrent breast cancer include:

  • the amount or extent of the recurrence
  • the type of treatment the woman has already received for breast cancer
  • the length of time since the last treatment
  • the hormone receptor status of the recurrent breast cancer
    • The hormone receptor status of the recurrent tumour may be tested if a biopsy is done to confirm the recurrence.
  • the HER2 status of the recurrent breast cancer
  • how the cancer responded to previous treatment
  • the number of previous treatments
    • Women who have breast cancer that is advancing after 3 different chemotherapy treatments may no longer benefit from any further chemotherapy treatments.
  • whether or not the woman has reached menopause
  • the woman’s overall health

Treatment options may include one or a combination of treatments.

Local recurrence

A local recurrence can occur in the remaining breast tissue, skin, muscles of the chest wall or nearby lymph nodes. The treatment options for a local recurrence of breast cancer are:

Surgery

The types of surgery that may be offered for a local recurrence of breast cancer are:

  • modified radical mastectomy – if recurrence follows breast-conserving surgery (BCS)
  • surgery to remove a tumour – if the recurrence follows a mastectomy

Radiation therapy

External beam radiation therapy may be offered for a local recurrence of breast cancer, if the woman has not had radiation to that area before.

Hormonal therapy

Hormonal therapy may be offered for a local recurrence of hormone receptor–positive breast cancer (ER+, PR+ or both).

The types of hormonal therapy that may be offered for local recurrent breast cancer are:

  • aromatase inhibitors – used only to treat post-menopausal women
    • letrozole (Femara)
    • anastrozole (Arimidex)
    • exemestane (Aromasin)
  • anti-estrogens
    • tamoxifen (Nolvadex) – the most common anti-estrogen
      • Tamoxifen is used to treat both premenopausal and post-menopausal women.
  • ovarian ablation – used to treat premenopausal women
    • luteinizing hormone–releasing hormone (LHRH) agonists
      • goserelin (Zoladex)
      • leuprolide (Lupron, Lupron Depot, Eligard)
      • buserelin (Suprefact)
    • surgery
    • radiation therapy

Chemotherapy

Chemotherapy may be offered for a local recurrence of breast cancer for:

  • hormone receptor–negative tumours
  • HER2-positive tumours
  • women with hormone receptor–positive tumours who do not wish to have hormone therapy

The type of chemotherapy given for a local recurrence of breast cancer is similar to adjuvant therapyadjuvant therapyTreatment given in addition to the first-line therapy (the first or standard treatment) to help reduce the risk of a disease (such as cancer) coming back (recurring). given for early stage breast cancer. The types of chemotherapy that may be offered are:

  • AC
    • doxorubicin (Adriamycin) and cyclophosphamide (Cytoxan, Procytox)
  • AC – Taxol
    • doxorubicin and cyclophosphamide, followed by paclitaxel (Taxol)
  • AC –Taxol (dose dense)
    • doxorubicin and cyclophosphamide, followed by paclitaxel, with less time between treatments (dose dense)
      • This combination is usually given with filgrastim (Neupogen) or pegfilgrastim (Neulasta).
  • TC
    • docetaxel (Taxotere) and cyclophosphamide
  • TAC (or DAC)
    • docetaxel, doxorubicin and cyclophosphamide
  • FAC (or CAF)
    • cyclophosphamide (by mouth), doxorubicin and 5-fluorouracil (Adrucil, 5-FU)
  • CEF
    • cyclophosphamide (by mouth), epirubicin (Pharmorubicin) and 5-fluorouracil
  • FEC
    • cyclophosphamide (into a vein – intravenous), epirubicin and 5-fluorouracil
  • FEC  – T
    • cyclophosphamide, epirubicin and 5-fluorouracil, followed by docetaxel
  • CMF – IV
    • cyclophosphamide (intravenous), methotrexate and 5-fluorouracil
  • CMF – PO
    • cyclophosphamide (by mouth), methotrexate and 5-fluorouracil
  • Taxol  – FAC
    • paclitaxel, followed by cyclophosphamide, doxorubicin and 5-fluorouracil

For more detailed information on specific drugs, go to sources of drug information.

Biological therapy

Biological therapy may be offered for a local recurrence of breast cancer. The type of biological therapy offered is trastuzumab (Herceptin).

  • This drug is offered to women with HER2-positive tumours.
  • Trastuzumab may be used alone or in combination with chemotherapy drugs like paclitaxel or docetaxel.
  • It is given until the cancer no longer responds to treatment or progresses.

Metastatic recurrence

Metastatic recurrence is breast cancer that has come back in distant organs, such as the bones, liver, lung or brain. Treatment for metastatic recurrence depends on:

  • the organ(s) where the cancer recurs
  • the type of treatment the woman has already received for breast cancer
  • how severe the symptoms are
  • how quickly a response is needed

Chemotherapy

Chemotherapy may be given to control metastatic recurrence and relieve symptoms. It is often used when:

  • the cancer recurs in several organs, especially the liver, lung or brain
  • the cancer is growing rapidly and causing severe symptoms
  • a quick response is needed
  • the cancer is not likely to respond to hormonal therapy

Chemotherapy given for metastatic recurrence of breast cancer is similar to chemotherapy given for stage IV breast cancer.

The types of single chemotherapy drugs are:

  • vinorelbine (Navelbine)
  • cisplatin (Platinol AQ)
  • capecitabine (Xeloda)
  • paclitaxel (Taxol)
  • docetaxel (Taxotere)
  • doxorubicin (Adriamycin)
  • 5-fluorouracil (Adrucil, 5-FU)
  • methotrexate
  • epirubicin (Pharmorubicin)
  • etoposide (Vesepid) – given by mouth (oral)
  • cyclophosphamide (Cytoxan, Procytox)
  • gemcitabine (Gemzar)
  • mitomycin (Mutamycin)
  • protein-bound paclitaxel (Abraxane)
    • The protein helps get the active drug (paclitaxel) into the cancer cells more easily.
  • eribulin (Halaven)
    • Eribulin may be used to treat metastatic breast cancer in women who have received at least 2 other chemotherapy regimens for metastatic disease. Previous therapy should have included an anthracycline (such as doxorubicin or epirubicin) and a taxane (such as paclitaxel or docetaxel).

Chemotherapy combinations that may be offered for stage IV breast cancer are:

  • AC
    • doxorubicin and cyclophosphamide
  • docetaxel and doxorubicin
  • FAC (or CAF)
    • cyclophosphamide (by mouth), doxorubicin and 5-fluorouracil
  • CMF – IV
    • cyclophosphamide (intravenous), methotrexate and 5-fluorouracil
  • CMF – PO
    • cyclophosphamide (by mouth), methotrexate and 5-fluorouracil
  • doxorubicin and paclitaxel
  • docetaxel and capecitabine
  • vinorelbine and epirubicin

For more detailed information on specific drugs, go to sources of drug information.

Hormonal therapy

Hormonal therapy may be given to control metastatic recurrent breast cancer and relieve symptoms. It is used for slowly progressing breast cancers. Bone metastases sometimes respond better to hormonal therapy than chemotherapy.

  • aromatase inhibitors – used only to treat post-menopausal women
    • letrozole (Femara)
    • anastrozole (Arimidex)
    • exemestane (Aromasin)
  • anti-estrogens
    • tamoxifen (Nolvadex) – the most common anti-estrogen
      • It is used to treat both premenopausal and post-menopausal women.
    • fulvestrant (Faslodex)
      • It is used to treat post-menopausal women who have cancer that is no longer responding to tamoxifen.
  • ovarian ablation – used to treat premenopausal women
    • luteinizing hormone–releasing hormone (LHRH) agonists
      • goserelin (Zoladex)
      • leuprolide (Lupron, Lupron Depot, Eligard)
      • buserelin (Suprefact)
    • surgery
    • radiation therapy
  • progestins – may be offered to women who have cancer that is no longer responding to other hormonal therapies
    • megestrol (Megace)
  • androgens – may be offered to women who have cancer that is no longer responding to other hormonal therapies
    • fluoxymesterone (Halotestin)

Biological therapy

Biological therapy may be offered for metastatic recurrent breast cancer. The types of biological therapy are:

  • trastuzumab (Herceptin) – offered to women with HER2-positive tumours
    • Trastuzumab may be used alone or in combination with chemotherapy drugs like paclitaxel or docetaxel.
    • It is given until the cancer no longer responds to treatment or progresses.
  • pertuzumab (Perjeta) may be given with trastuzumab and taxane chemotherapy (paclitaxel, docetaxel) for women with HER2-positive metastatic breast cancer who have not received prior chemotherapy or anti-HER2 therapy for metastatic disease
  • trastuzumab emtasine (Kadcyla or T-DM1) – offered to women with HER2-positive metastatic breast cancer who have received prior treatment with trastuzumab and taxane chemotherapy, separately or in combination
  • lapatinib (Tykerb) – offered in combination with:
    • capecitabine
      • This combination is used to treat women who have HER2-positive breast cancer when other types of chemotherapy or trastuzumab are no longer working.
    • letrozole
      • This combination is used to treat post-menopausal women with HER2-positive and estrogen receptor–positive metastatic breast cancer.

Bisphosphonates

Bisphosphonates can be used for recurrent breast cancer that spread to the bone (bone metastases). The types of bisphosphonates used are:

  • clodronate (Bonefos)
  • pamidronate (Aredia)
  • zoledronic acid (Zometa, Aclasta)

Radiation therapy

External beam radiation therapy may be used to relieve pain and other symptoms caused by recurrent metastatic breast cancer. It may be used for:

  • bone metastases
  • blockage of the bronchibronchiThe large tubes, or airways, that branch off from the windpipe (trachea) into the lungs, where they branch into smaller tubes (bronchioles) that end in the alveoli (air sacs). Bronchi carry air to and from the lungs. (bronchial obstruction)
  • brain or spinal cord metastases (rare)
  • painful, open, draining areas on the breast or chest wall

Surgery

Surgery is sometimes used to relieve pain and other symptoms caused by metastatic recurrent breast cancer. It may be used to:

  • remove a lump in the skin
  • remove a single or isolated metastasis in the:
  • fix broken (fractured) bones caused by metastasis
  • treat spinal cord compression caused by metastasis

Clinical trials

Women with breast cancer may be offered the opportunity to participate in clinical trials. For more information, go to clinical trials.

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