Treatments for recurrent breast cancer

The following are treatment options for recurrent breast cancer. Recurrent breast cancer means that the cancer has come back after it was treated. Breast cancer can come back in the same area of the breast where it was first found and treated (called a local recurrence). It can also come back in the other breast or other areas of the body, including the bones, liver, lungs and brain (called distant metastasis, or a distant recurrence).

Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan. The type of treatment given for recurrent breast cancer will depend on:

• if it is a local recurrence or distant metastasis
• the type and number of treatments you’ve already had for breast cancer
• the hormone receptor status of the cancer
• the HER2 status of the cancer
• if you have reached menopause
• your overall health

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.

Hormonal therapy is often offered for a local recurrence of hormone receptor–positive breast cancer.

Recurrent breast cancer cells sometimes have hormone receptors even if the cancer cells in the original tumour didn’t have hormone receptors. For this reason, hormonal therapy may be offered when hormone receptor–negative breast cancer recurs in older women, when it recurs only in 1 or 2 places, or if there is a long period of time between when the cancer was first treated and when it recurs.

Hormonal therapy is given for distant metastases to the bones and soft tissues, such as muscles or fat. It will also be given for distant metastases to internal organs, including the liver, lungs or brain, that aren’t causing symptoms.

If you were taking a hormonal therapy drug when the breast cancer recurred, you will be given a different one. You may be offered up to 3 different hormonal therapy drugs for recurrent breast cancer. If the breast cancer stops responding to the 3rd drug, you may be given chemotherapy.

The type of hormonal therapy given will depend on if you have reached menopause. If you hadn’t reached menopause when you first started treatment, your healthcare team may do blood tests to see if you are now in menopause. These tests look for the amount of estrogen or follicle-stimulating hormone (FSH) in your blood. Low estrogen and high FSH levels in your blood mean you are in menopause.

Hormonal therapy for post-menopausal women is an aromatase inhibitor such as letrozole (Femera), anastrozole (Arimidex) or exemestane (Aromasin). If they do not want to or can’t take an aromatase inhibitor, they may be offered tamoxifen (Nolvadex, Tamofen).

Hormonal therapy for premenopausal women may include ovarian ablation or ovarian suppression. These treatments stop the ovaries from making estrogen and cause treatment-induced menopause. Ovarian ablation or ovarian suppression is combined with one of the aromatase inhibitors listed above. Premenopausal women who do not want to have ovarian ablation or ovarian suppression may be offered tamoxifen alone.

Chemotherapy is used for HER2-negative and hormone receptor–positive recurrent breast cancer if it has stopped responding to 3 different hormonal therapy drugs (called hormone refractory). It is also used for HER2-negative and hormone receptor–positive recurrent breast cancer that is in the lungs, liver or brain and is causing symptoms.

Chemotherapy is also used for recurrent breast cancer that is HER2 negative and hormone receptor negative or HER2 positive and hormone receptor negative.

Chemotherapy drugs are often used alone to treat recurrent 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 recurrent 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

If breast cancer stops responding to one chemotherapy, doctors will try another drug or combination. If the cancer does not respond to 3 different chemotherapy drugs or drug combinations given one after another, chemotherapy is stopped.

The drug given will depend on whether or not you had targeted therapy for the original cancer and if the breast cancer has stopped responding to other treatments.

Trastuzumab (Herceptin) is the most common targeted therapy drug used for recurrent HER2-positive breast cancer.

• If you were given trastuzumab for the original cancer, this drug may be combined with the chemotherapy drugs pertuzumab (Perjeta) and docetaxel.
• If trastuzumab, chemotherapy with paclitaxel or docetaxel, or both have already been used, you may be offered trastuzumab emtansine (Kadcyla, T-DM1).

• If you have already had trastuzumab emtansine, you may be offered trastuzumab deruxtecan (Enhertu).

Other targeted therapy drugs are used to treat distant metastasis of breast cancer that no longer responds to other treatments.

Lapatinib (Tykerb) and the chemotherapy drug capecitabine may be given for recurrent HER2-positive breast cancer with distant metastasis when chemotherapy or trastuzumab no longer works.

Lapatinib and the hormonal therapy drug letrozole may be given for recurrent HER2-positive and hormone receptor–positive distant metastasis when hormonal therapy no longer works.

Neratinib (Nerlynx) may be used in combination with 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 recurrent metastatic breast cancer, if no other treatments for metastatic breast cancer have been given.

Everolimus (Afinitor) and exemestane may be given to treat post-menopausal women who have distant metastasis of recurrent HER2-negative and hormone receptor–positive breast cancer that no longer responds to hormonal therapy with letrozole or anastrozole.

Abemaciclib (Verzenio) is used for hormone receptor–positive, HER2-negative advanced or metastatic breast cancer. It is taken as pill daily and may be given with fulvestrant (Faslodex) if the disease progresses after hormonal therapy. Or it may be given alone if the disease progresses after hormonal therapy and at least 2 chemotherapy regimens.

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 and may be used until the disease progresses.

Surgery is offered for a local recurrence of breast cancer. The type of surgery done will depend on the kind of surgery that was used to treat the original cancer.

If the first surgery was breast-conserving surgery, a modified radical mastectomy may be offered. If the recurrent breast cancer has grown into the chest muscles (pectoral muscle), a radical mastectomy may be offered.

If a mastectomy was used to remove the original tumour, doctors may use surgery to remove a recurrent tumour in the skin, muscles or lymph nodes in the area of the mastectomy.

Surgery may be used as part of the treatment plan for distant metastasis. It may be used to remove a single metastasis from a lung or the liver. In rare cases, surgery is used to remove a metastasis from the brain. Surgery may also be done to treat a broken bone or spinal cord compression if cancer spreads to the bones.

External beam radiation therapy may be given after surgery to remove a local recurrence if it wasn’t given when the cancer was first treated. Radiation is directed at where the tumour was removed, the skin, chest muscles, the lymph nodes under the arm and the lymph nodes around the collarbone.

Radiation therapy is also used to control pain and other symptoms caused by distant metastasis to the bones, liver, lungs or brain.

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.

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.