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Stage 4 (Advanced or Metastatic) Breast Cancer

Advanced breast cancer (also known as metastatic, secondary or stage IV breast cancer) refers to cancer that has spread beyond the breast to other parts of the body. This process of spreading from the original location to a new location is known as metastasis.

The most common places of breast cancer spread include the bones, liver, lung, and brain. However, breast cancer may also spread to other organs.

The majority of women who are diagnosed with metastatic breast cancer have been diagnosed with an earlier stage of breast cancer before. In this instance, the original cancer in the breast is called the primary cancer. However, for some women, a diagnosis of metastatic breast cancer may be their first diagnosis of cancer (this is also called de novo metastatic breast cancer).

Symptoms of metastatic (advanced) breast cancer

Metastatic breast cancer can cause a number of symptoms. These symptoms can vary greatly depending on the part(s) of the body affected and may develop over time. Below are some common metastatic breast cancer symptoms associated with cancer that has spread to the bone, liver, lung and brain.

• Bone metastasis:

Symptoms of cancer which has spread to the bone may include a dull, persistent ache or pain in the bones that may get worse during movement and make it difficult to sleep at night. Although breast cancer can spread to any bone, common sites are the ribs, spine, pelvis, upper bones of the arms and legs.

• Liver metastasis:

Symptoms of cancer which has spread to the liver may include loss of appetite, weight loss, tiredness, pain in the area of the liver (the right side of the belly) or jaundice (yellowing of the skin or whites of the eyes). Some women may develop bloating or swelling in the abdomen due to a buildup of fluid.

• Lung metastasis:

Symptoms of cancer which has spread to the lung may include shortness of breath, a dry cough, chest pain or a feeling of heaviness in the chest.

• Brain metastasis:

Symptoms of cancer which has spread to the brain often may involve a persistent headache. Brain metastasis may also cause changes to a part of the body which is controlled by a specific part of the brain, such as weakness in one particular limb or blurred vision. Cancer in the brain may also cause nausea (feeling sick), vomiting, seizures, or in some cases, a noticeable change in personality.

When identifying symptoms, it is important to note many of the listed symptoms are common and may not be related to breast cancer at all. For example, bone pain may be a sign of arthritis, a cough may be a symptom of a cold or flu, and many people may have fatigue for reasons not related to cancer.

However, if you are concerned about any of these symptoms, or if symptoms persist, it is recommended that you discuss them with your doctor to determine the cause as soon as possible.

Diane’s story

Diane was diagnosed with inflammatory breast cancer in 2018. Diane’s grandmother and uncle had breast cancer, but her test results for BRCA 1 & 2 faulty genes were negative. A few days after her initial cancer diagnosis, concern about a problem in Diane’s lungs led to another biopsy, which showed that the breast cancer had metastasised. Diane completed 3 months of chemotherapy, had a mastectomy followed by 5 weeks of radiotherapy. Diane is now on a continuing regime of medication and injections. The nodules in her lungs have reduced significantly.

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Diagnosis of stage 4 breast cancer

If you are diagnosed with breast cancer, you may have further tests to determine the extent that the cancer has spread throughout the body. This is called staging. It helps you and your doctors decide on the best treatment options for you.

In addition the numbered staging system, the TNM staging system is also commonly used for breast cancer staging.

TNM staging system

TNM stands for Tumour, Node Metastasis:

• Tumour (T) refers to the size of the primary tumour.
• Node (N) describes whether the cancer has spread lymph nodes near the breast.
• Metastasis (M) describes whether or not the tumour has spread distant parts of the body, such as the liver or bones.

Numbers or letters following T, N, and M provide more details about each of these characteristics. In general, the lower the number or the earlier the letter following each component of TNM in the diagnosis, the less advanced the cancer.

In 2018, the TNM staging system was updated to include additional details to assist in classifying the cancer. This includes information about the and (if applicable) Oncotype DX test results. The staging system is complex, so it is best that you ask your doctor to explain how it specifically applies to you.

Coping with advanced breast cancer

Being told that you have advanced or metastatic breast cancer may be very confronting or overwhelming. Some women also find the news that their cancer has spread or come back is more devastating than their original diagnosis.

There are many resources available online to help you further understand the meaning of your diagnosis and how to manage the emotional, physical and practical issues arising from metastatic breast cancer. Below are some links where these resources can be accessed:

• Cancer Australia – General information
• Cancer Council Online Community
• Breast Cancer Network Australia – General Resources
• Breast Cancer Network Australia – Metastatic Breast Cancer Resources

Connecting and speaking with others who have gone through a similar experience can also be helpful. Cancer Council runs support groups all across Australia which can provide support and information for people with cancer and their families. Groups in each state can be accessed here:

• ACT
• NSW
• NT
• QLD
• SA
• TAS
• VIC
• WA

Although support groups can provide a safe place for people to express their feelings amongst others who share a similar experience, some people are more comfortable talking one-on-one, such as with a counsellor, therapist or trained volunteer (an example is the Cancer Connect service provided by the Cancer Council). Your GP can also refer you to a psychologist, social worker or other trained therapist. Every person is different and it is important to find a healthy support system that works for you.

Andrew and Tracey’s story

“All the statistics only talk about the number of women affected; what they don’t mention is the effect on the people that love them; parents, children, siblings, extended family, friends. My wife, Tracey, was diagnosed with breast cancer in late 2010 – and was told it had spread to her liver and lung in 2012. Firstly, there’s the pain that you have to watch your partner go through… the ongoing pain from metastasis – the spread of the cancer from her breasts to her spine, ribs, liver and lung. Secondly there’s the fear. Fear of losing her sooner rather than later and being alone.” – Andrew, Husband of Tracey, diagnosed 2010.

Treatment for advanced breast cancer

Treatment of metastatic breast cancer aims to control the growth and spread of the cancer, to relieve symptoms, reduce pain, and improve or maintain quality of life.

The treatment recommended by doctors will depend on which treatments are likely to control the breast cancer and what side effects the person can cope with. Treatment options may involve:

• Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells within the body. This treatment is used for patients of metastatic breast cancer to stop the cancer from growing or spreading, to relieve symptoms and improve quality of life. For some people, chemotherapy can make the cancer smaller. Chemotherapy can be administered orally (by tablets) or intravenously (through an IV drip). Common side effects of chemotherapy include hair loss, nail changes, mouth sores, loss of appetite or weight changes, nausea and vomiting or diarrhea.

• Hormonal therapy

Hormone therapy (also called endocrine therapy or hormone-blocking therapy) is the use of drugs that interfere with hormone signaling to treat breast cancers that are hormone receptor positive. This treatment can be used to control or slow the growth of hormone receptor-positive metastatic breast cancers. Hormone therapy is taken either orally or via an injection. Some common side effects of hormonal therapy include hot flushes and/or night sweats, headache, mild nausea, bone pain, and injection site pain.

• Targeted therapy

Targeted therapies are drugs used to treat certain types of breast cancer cells. Unlike chemotherapy, which affects all rapidly dividing cells within the body, targeted therapy attacks specific features of cancer cells to stop them from growing. For example, some targeted therapies for breast cancer target HER2-positive breast cancer by specifically targeting the HER2 protein. These are not effective for patients with HER2-negative breast cancer. Depending on the specific targeted therapy, these can be administered orally or intravenously (by IV drip). Side effects of targeted therapy may include fever, headache, and a rash.

Survival rates of stage 4 breast cancer

Unfortunately, cancer cells often become more difficult to treat and may develop drug resistance once they spread. According to the Australian Institute of Health and Welfare (AIHW), the 5-year survival rate for women whose breast cancer is metastatic at first diagnosis is 32%, compared to the 91% on average for all breast cancer patients.

Factors affecting survival rate of metastatic breast cancer

Survival rates can provide an estimate of what percentage of patients with the same stage of breast cancer (when first diagnosed) are still alive after a certain period of time (e.g. 5 years). However, they cannot predict how long any specific individual with breast cancer will live. The length of survival time for people with metastatic breast cancer can vary significantly from person to person, but there are a number of factors which can influence this including:

• Response to treatment
• The extent and location of metastases
• The presence of other health issues not related to cancer
• The specific subtype of breast cancer (hormone receptor positive, HER2-positive and triple negative). This is very important, as some types of cancer can be more aggressive than others and respond differently to treatment.

Jacqui’s story

Jacqui was diagnosed with stage 4 metastatic breast cancer in 2018 just years after recovering from early stage breast cancer or Ductal Cacinoma in Situ (DCIS). The cancer had spread to Jacqui’s bones and although there is no cure for metastatic breast cancer, thanks to research it is possible to control it with treatment for a number of years. Jacqui is grateful for research and knows if she’d been diagnosed just a decade before, there wouldn’t have been the treatment options to enable her to have extra years with her family.

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Is it possible to survive stage 4 breast cancer?

While there is no cure for metastatic breast cancer, it is possible to control it with treatment for a number of years. The cancer can also go into remission. There are different types of remission:

• Complete remission (or complete response): when there are no cancer signs and symptoms that can be detected by tests or scans.
• Partial remission (or partial response): when the cancer has partly responded to treatment. It is still present but it has gotten smaller.

It is currently not possible to predict how long remission will last. However, the repeated cycle of growing, shrinking and stabilising can mean survival for many years. New treatments also continue to be developed. Treatment can help to control the cancer, help relieve symptoms and help you live longer.

It is not always easy, but many people find that with time, they are able to adjust to their diagnosis. Despite the many challenges that metastatic breast cancer brings, people can continue to live full, meaningful lives.

Living with Stage 4 breast cancer

Metastatic breast cancer affects people in different ways. Some women who are diagnosed with metastatic breast cancer may experience a reduction in their overall health as a result of disease progression and/or the resulting side effects of their treatment. If you are experiencing any symptoms that concern you or if symptoms get worse, it is important that you discuss these with your doctor. In addition, while there is no strong evidence that a special diet will improve the prognosis of metastatic breast cancer, healthy lifestyle choices can help you to feel your best, manage symptoms and improve your overall wellbeing.

Many women also find the uncertainty of their situation difficult to manage. Some people cope best by living in the present and not thinking too much about the future. Other people prefer to plan ahead, which gives them a greater sense of control. The best approach is the one that works best for you.

Fear of progression

If you have metastatic breast cancer, you may worry about what lies ahead, for yourself and your family and friends. You may also feel a range of emotions after your diagnosis and during treatment, such as stress, sadness, fear and anger. Feeling anxious, depressed or sad is common for many people coping with cancer. However, when a person is emotionally upset for a long time or finding it difficult to cope with their day-to-day activities, they may have depression or anxiety that requires medical treatment. The anxiety and depression may be so severe that it is hard for them enjoy life and follow a treatment schedule.

However, anxiety and depression can be treated in different ways, including with medicine, therapy or both. If you are experiencing feelings that are overwhelming or preventing you sleeping or from doing everyday activities, it is important that you talk to your doctor or another member of your healthcare team. Treatment and support is available, which can help you continue to live well.

Research into advanced and metastatic breast cancer

As metastatic breast cancer remains the leading cause of death from breast cancer, NBCF is committed to funding a broad spectrum of research that helps to further understand breast cancer metastasis, develop improved treatment options and enhance patient quality of life for those with metastatic breast cancer.

NBCF Celebrates 30 Years of Breast Cancer Research

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