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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 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 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
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
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 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
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 women who have not had trastuzumab or chemotherapy to treat it. It is combined with trastuzumab and docetaxel (Taxotere). Pertuzumab may not be covered by all provincial health plans.
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
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.
The time in a woman’s life when her ovaries stop producing estrogen and she has not had a menstrual period for 12 months. Most women start menopause between 45 and 55 years of age.
Menopausal means referring to or having to do with menopause, as in menopausal symptoms.
Sometimes referred to as change of life.
See also premenopause, perimenopause and post-menopause.
A hormone that stimulates the ovaries to make eggs and the testicles to make sperm.
Follicle-stimulating hormone is made by the pituitary gland.
The time after menopause.
Post-menopausal means referring to or having to do with the time after menopause.
The time before menopause.
Premenopausal means referring to or having to do with the time before menopause.
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