When you find out you have advanced breast cancer, called metastatic or stage IV cancer, you probably have a lot of questions. That's understandable.

"The goals of therapy are to prolong life while at the same time maintaining a good quality of life," says Julie Gralow, MD, of the Seattle Cancer Care Alliance and the University of Washington School of Medicine.

Although there's no cure, "there is no question that patients are living longer with metastatic disease, and our patients have many more treatment options than even just a few years ago," Gralow says.

It helps to know about each of those options, so you're prepared to talk about the plan your doctor recommends.

Remember that every case is different, so your treatment may not be the same as that of another person with breast cancer. You should talk to your doctor about which treatment is right for you.

Surgery

Most people with breast cancer will need surgery on their affected breast or breasts.

In rare cases, your doctor may also recommend surgery to remove a tumor that's spread to another organ. They typically recommend that if the breast cancer is very limited in its spread.

"When that happens, we can sometimes go in and remove that -- for example, if there's just one small spot on the liver," Gralow says.

Surgery may also help if you have pain that doesn't seem to go away, a weak bone that needs to be stabilized, or another problem.

Radiation

You can't get radiation therapy on a breast that's had radiation before. But you may need radiation to shrink tumors in other parts of your body. It can:

  • Stop the cancer from growing and keep symptoms under control. You might, for example, get radiation on a tumor that presses on your spine to make you more comfortable.
  • Control bleeding or pain from cancer that's spread to the bone or liver.

For some people, doctors may use "stereotactic" treatment -- highly focused radiation -- to target spots in the liver or the lungs.

Chemotherapy

Most women need chemo when they have advanced breast cancer. And it's likely to be easier to handle than in the past.

"Our aim is to keep the cancer under control for as long as possible with as few side effects as possible," says Virginia Borges, MD, of the University of Colorado-Denver School of Medicine.

There are several chemo drugs your doctor may choose from, depending on your particular case. Some are pills. Others you get through an IV tube in your arm. Talk with your doctor about what you prefer.

Hormonal Therapy

If your cancer is fueled by hormones such as estrogen, you may need to take hormonal therapy. You and your doctor might choose from various types of these drugs. They can lower the amount of estrogen your body makes so it's not available to fuel your breast cancer.

There are different types of hormonal treatments for breast cancer:

Tamoxifen and toremifene (Fareston) block estrogen from stimulating cancer cell growth. Doctors call these drugs "SERMS," which stands for selective estrogen receptor modulators.

Anastrozole (Arimidex), exemestane (Aromasin), and letrozole (Femara) stop the body from making estrogen in women who've gone through menopause.

Fulvestrant (Faslodex) counters estrogen throughout the body, not just in cancer cells. You get it in a shot. It's approved for use in postmenopausal women with advanced breast cancer who've already tried tamoxifen or toremifene.

Goserelin (Zoladex) and leuprolide (Lupron) stop the ovaries from making estrogen. Doctors may consider these meds, along with other hormone drugs, in women who have not yet been through menopause. After stopping these drugs, the ovaries may or may not make estrogen again.

Targeted Treatments

There are drugs that target specific proteins related to cancer.

Everolimus (Afinitor) targets a protein called mTOR, and palbociclib (Ibrance) and ribociclib (Kisqali) go after a protein called CDK 4/6. They're approved to treat advanced breast cancer in women after menopause if:

  • Their disease is sensitive to (meaning fueled by) estrogen. Doctors call this “ER-positive.” Most breast cancers are ER-positive.
  • Their cancer is not sensitive to the HER2 protein. Your doctor may call this “HER2-negative.” Most breast cancers are HER2-negative.

Some breast cancers -- about 20% -- make too much of the HER2 protein. They're more aggressive than other cancers. Drugs that target HER2 include:

Trastuzumab (Herceptin) blocks the HER2 protein from stimulating cancers cells to grow. You get it by IV once a week or every 3 weeks as a bigger dose. One of the risks is congestive heart failure, so your doctor will closely watch your heart's health if you take it.

Ado-trastuzumab emtansine (TDM-1, Kadcyla) is like trastuzumab with a chemo drug added to it. You get it by IV every 3 weeks.

Pertuzumab (Perjeta) works similarly to trastuzumab by blocking HER2. Doctors often give it along with the chemo drug docetaxel (Taxotere) and trastuzumab.

Lapatinib (Tykerb) may be an option if chemo and trastuzumab aren't working.

Other Treatments

If the disease is in your bones, you may need another medication, such as:

Denosumab (Prolia, Xgeva). This drug will slow down the growth of breast cancer in your bones, and it protects bones from breaking. It can also lower the blood's calcium level, so your doctor will monitor this. You get a shot of it, usually every 4 weeks.

Pamidronate disodium (Aredia). When breast cancer is in the bones, you may have too much calcium in your blood. This drug lowers your blood's calcium level. You get it by IV, usually every 3-4 weeks. Each session can take 2 or more hours, depending on your particular case.

Zoledronic acid (Zometa). This is the same type of drug as pamidronate disodium. It works the same way to lower your blood calcium level. You get it by IV, which takes about 15 minutes, every 3-4 weeks.

Talk with your doctor about the risks and benefits of each treatment. Keep your personal goals in mind as you decide how best to treat your cancer.

WebMD Feature

NEXT IN THE SERIES

You fight your metastatic breast cancer in more ways than one.

Approved Use

Patients should not take AFINITOR if they are allergic to AFINITOR or to any of its ingredients. Patients should tell their health care provider before taking AFINITOR if they are allergic to sirolimus (Rapamune®) or temsirolimus (Torisel®).

AFINITOR can cause serious side effects, such as lung or breathing problems, infections, or kidney failure. Some of these side effects can be severe and can even lead to death. Your health care team may have ways to help manage side effects that do occur. It's important to talk with your doctor or nurse about side effects you experience and the best ways to manage them. Serious side effects include:

Lung or Breathing Problems: Patients should tell their health care provider right away if they have any of these symptoms: new or worsening cough, shortness of breath, chest pain, difficulty breathing, or wheezing.

Infections: AFINITOR may make patients more likely to develop an infection, such as pneumonia, or a bacterial, fungal, or viral infection. Viral infections may include reactivation of hepatitis B in people who have had hepatitis B in the past. Patients may need to be treated as soon as possible. Patients should tell their health care provider right away if they have a temperature of 100.5°F or above, have chills, or do not feel well. Symptoms of hepatitis B or infection may include the following: fever, chills, skin rash, joint pain and inflammation, tiredness, loss of appetite, nausea, pale stools or dark urine, yellowing of the skin, or pain in the upper right side of the stomach.

Angioedema: Patients who take an angiotensin-converting enzyme (ACE) inhibitor medicine during treatment with AFINITOR are at a possible increased risk for a type of allergic reaction called angioedema. Talk with your health care provider before taking AFINITOR if you are not sure if you take an ACE inhibitor medicine. Get medical help right away if you have trouble breathing or develop swelling of your tongue, mouth, or throat during treatment with AFINITOR.

Kidney Failure: Patients taking AFINITOR may develop kidney failure. Patients should have tests to check their kidney function before and during their treatment with AFINITOR.

Delayed Wound Healing: AFINITOR can cause incisions to heal slowly or not heal well. Call your health care provider right away if your incision is red, warm, or painful; if you have blood, fluid, or pus in your incision; if your incision opens up; or if your incision swells.

Before taking AFINITOR, tell your health care provider about all your medical conditions, including if you:

  • Have or have had kidney problems
  • Have or have had liver problems
  • Have diabetes or high blood sugar
  • Have high blood cholesterol levels
  • Have any infections
  • Previously had hepatitis B
  • Are scheduled to receive any vaccinations. You should not receive a live vaccine or be around people who have recently received a live vaccine during your treatment with AFINITOR. If you are not sure about the type of vaccine, ask your health care provider
  • Have other medical conditions
  • Are pregnant or could become pregnant. AFINITOR can cause harm to your unborn baby. If you are able to become pregnant, you should use effective birth control while using AFINITOR and for 8 weeks after your last dose. Talk to your health care provider about birth control options while taking AFINITOR
  • Are breastfeeding or plan to breastfeed. Do not breastfeed during treatment and for 2 weeks after your last dose

Tell your health care provider about all of the medicines you take, including prescription and nonprescription medicines, vitamins, and herbal supplements. Using AFINITOR with certain other medicines can cause serious side effects. Keep a list of medicines you take and show it to your health care provider when you get a new medicine. Especially tell your health care provider if you take St John's wort (Hypericum perforatum), medicines that weaken your immune system (your body's ability to fight infections and other problems), or medicines for:

  • Fungal infections
  • Bacterial infections
  • Tuberculosis
  • Seizures
  • HIV-AIDS
  • Heart conditions or high blood pressure

If you are taking any medicines for the conditions listed above, your health care provider might need to prescribe a different medicine or your dose of AFINITOR may need to be changed. Tell your health care provider before you start taking any new medicine.

Common Side Effects

The most common side effect of AFINITOR in treating advanced hormone receptor-positive, HER2-negative breast cancer was mouth ulcers and sores (67%). Tell your health care provider if you have pain, discomfort, or open sores in your mouth. Your health care provider may tell you to use a special mouthwash or mouth gel that does not contain alcohol, hydrogen peroxide, iodine, or thyme.

Other common side effects of AFINITOR include:

  • Infections (50%)
  • Rash (39%)
  • Feeling tired (36%)
  • Diarrhea (33%)
  • Loss of appetite (30%)
  • Nausea (29%), vomiting (17%)
  • Weight loss (25%)
  • Cough (24%), shortness of breath (21%)
  • Abnormal taste (22%)
  • Headache (21%)
  • Pain in arms and legs (9%), back (14%), joints (20%)
  • Swelling of arms, hands, feet, ankles, face, or other parts of the body (19%)
  • Nose bleeds (17%)
  • Fever (15%)
  • Constipation (14%)
  • High blood glucose (14%)
  • Difficulty sleeping (13%)
  • Feeling weak (13%)
  • Itching (13%)
  • Dry mouth (11%)
  • Hair loss (10%)

Other side effects that may occur with AFINITOR:

  • Absence of menstrual periods (menstruation). You may miss 1 or more menstrual periods. Tell your health care provider if this happens
  • AFINITOR may affect fertility in females and males, and may affect your ability to become pregnant if you are female or your ability to father a child if you are male. Talk to your health care provider if this is a concern for you

Tell your health care provider if you have any side effect that bothers you or does not go away.

These are not all the possible side effects of AFINITOR. For more information, ask your health care provider or pharmacist. Call your doctor for medical advice about side effects.

You are encouraged to report negative side effects of prescription drugs to the FDA. Visit www.fda.gov/medwatch or call 1-800-FDA-1088.

Please see full Prescribing Information for AFINITOR, including Patient Information.

The brands listed are the trademarks or register marks of their respective owners and are not trademarks or register marks of Novartis.

Novartis

Novartis Pharmaceuticals Corporation East Hanover, New Jersey 07936-1080 © 2016 Novartis 8/16 AFB-1133407

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