I Have Metastatic Breast Cancer: What Are My Options?

This article is for people who have hormone receptor (HR)-positive metastatic breast cancer (MBC), their care partners, and others who want to learn more about this disease. The goal is to learn about your treatment choices for HR-positive MBC.

You will learn:

• What HR-positive MBC is and your next steps after diagnosis

• Treatments for HR-positive MBC

• Benefits and side effects of treatments

• Tips for working with your healthcare team

• Questions to ask your healthcare team

Metastatic breast cancer (MBC) is disease that has spread from your breast to other parts of your body, such as your bones, lungs, liver, or brain. It's also called stage IV or advanced breast cancer.

Hormone receptor (HR)-positive breast cancer means your cancer cells need the hormones estrogen and/or progesterone to grow. A hormone is a chemical your body makes to control certain cell functions.

There's no cure for HR-positive MBC, but approved treatments and clinical trials can help control your disease. In general, HR-positive cancers grow more slowly than HR-negative ones.

Whether HR-positive MBC is your first diagnosis, or you've already had treatment for early or locally advanced breast cancer, it's very difficult to learn that you have this disease.

Many people start to gain a sense of control once they have a treatment plan. But you still may feel sad, worried, alone, angry, and afraid at times. Keep in mind:

• Your feelings are normal. Turn to friends, family, your cancer care team, support groups, or counselors for help and support

• SHARE, a cancer support non-profit, offers 10 MBC telephone support groups every month nationwide

• Living Beyond Breast Cancer has a Helpline that provides peer support and will match you with a trained volunteer living with MBC

Have open talks with your cancer care team -- they want to help you make informed decisions. Tell them when you don't understand what they're saying. Bring a family member or friend with you who can remind you of questions to ask and take notes.

You and your team will select a treatment based on your breast cancer diagnosis -- the type and stage -- and:

• What you share about yourself and what you do

• What's important to you in your day-to-day life and in the future

• Your overall health

• The benefits and risks of each medicine

• How you take each medicine, and how often

Your doctor tested your cancer to see if it was HR-positive because that helps you and your healthcare team choose the right treatments. He or she may also test (or retest) you for HER2 -- a protein on some breast cancer cells that helps the cells to grow and affects your treatment options. Most women with breast cancer have HER2-negative disease.

Your treatment plan is also guided by:

• Where your cancer has spread

• Your overall health

• Your symptoms, if any

• Any past breast cancer treatment you've had

• Whether or not you've been through menopause

• Other test results

HR-positive MBC is treated with hormone therapy and other medicines, including cyclin-dependent kinase 4 and 6 (CDK4/6) inhibitors. You may also receive chemotherapy (chemo) or everolimus, which helps stop breast cancer cells from growing.

Hormone therapies (tamoxifen, letrozole, fulvestrant, exemestane, and others) lower the amount of estrogen in your body, or block it from breast cancer cells. CDK4/6 inhibitors (palbociclib, ribociclib and abemaciclib) slow the growth of HR-positive breast cancer cells by stopping them from dividing.

These medicines reach cancer cells almost anywhere in your body. You can take them in different orders and combinations for as long as they control your disease.

CDK 4/6 inhibitors and some other breast cancer medicines are usually taken in combination. For example, you may take letrozole or fulvestrant with palbociclib, or exemestane with everolimus.

Table 1. 

HR-Positive MBC Medicines At-a-Glance
Generic Name	Brand Name
Abemaciclib [a bem ah SKY klib]	Verzenio®
Anastrozole [an AS troe zole]	Arimidex®
Exemestane [ex e MES tane]	Aromasin®
Everolimus [e ver OH li mus]	Afinitor®
Fulvestrant [fool VES trant]	Faslodex®
Letrozole [LET roe zole]	Femara®
Palbociclib [pal boe SYE klib]	Ibrance®
Ribociclib (rye boe SYE klib]	Kisqali®
Tamoxifen [ta MOX i fen]	Nolvadex®

How Are the Medicines Used?
Tamoxifen (pill)	May be taken if you're premenopausal or postmenopausal
LetrozoleAnastrozole Exemestane (pills)	May work better for you than tamoxifen if you're postmenopausal; may be taken if you're premenopausal along with certain other medicines
Everolimus (pill)	May be taken with exemestane after other medicines if you're postmenopausal and have already taken other HR-positive MBC medicines
Palbociclib Ribociclib (pills)	These CDK4/6 inhibitors may be taken if you're postmenopausal
Abemaciclib (pill)	This CDK4/6 inhibitor may be taken if you're pre- or postmenopausal
Fulvestrant (injection)	May be taken after other hormone medicines if you‘re postmenopausal

Abemaciclib may be used to treat you for HR-positive MBC whether you've been through menopause or not. The same is true for tamoxifen. But tamoxifen may not be an option if you've taken it in the past. If so, your healthcare provider can prescribe a different medicine, such as an aromatase inhibitor (AI).

With certain MBC medicines, your doctor may also prescribe medicines to temporarily stop your ovaries from making estrogen if you are premenopausal. Or, you and your healthcare provider may decide that taking an AI along with surgery to remove your ovaries is your best option.

Your healthcare provider may prescribe medicines to help prevent bone loss or to treat breast cancer that has spread to your bones. If so:

• Have a full dental exam before you start the medicine

• Talk with your cancer care team before you have any dental work done

• Tell your team about any pain or swelling in your teeth or jaw once you start treatment

If other medicines stop working, or are not likely to work for life-threatening symptoms, your treatment may include chemo, surgery, or radiation therapy. For cancers that are both HR-positive and HER2-positive, you may get 1 or more medicines that target HER2 along with chemo.

Common side effects of medicines may include:

Tamoxifen: Hot flashes, vaginal dryness or discharge, mood swings

AIs: Muscle pain, joint stiffness or pain

Everolimus: Mouth sores, upset stomach, feeling tired, low blood cell counts, shortness of breath, cough

Fulvestrant: Hot flashes, night sweats, headache, mild nausea, bone pain, injection site pain

CDK4/6 inhibitors: Low blood cell counts, tiredness, diarrhea

Your doctor can manage your side effects with medicines that reduce your symptoms or by lowering the dose or stopping the one you're on for a while. Serious side effects are less common but can happen, so be sure to talk to your cancer care team about their signs.

You may want to get a second opinion from another breast cancer specialist to:

• Go over your original doctor's treatment plan

• Talk about other treatments

Usually waiting a short time to start treatment does not pose a risk. You and your cancer care team can talk about how much of a delay is okay for you. And even if you've already started treatment, it's not too late to get a second opinion.

Ask your cancer care team what to expect from treatment for your type of breast cancer:

• What treatments do you recommend and why?

• What are the side effects of those treatments?

• Are there any tests or treatments in clinical trials that might be right for me?

• How soon do I need to start treatment?

• How long will it last?

• How will it affect my daily activities?

• How will we know if the treatment is working? What if it doesn't stop my cancer from growing?

• What tests will I need?

Congratulations!

You have successfully completed the program: I Have Metastatic Breast Cancer: What Are My Options?

View Additional Materials from SHARE and Living Beyond Breast Cancer, 2 organizations that offer free support, information, and education about MBC.

With Love and Support: A Guide for Latinas With Metastatic Breast Cancer and Their Families Metastatic Breast Cancer: Guide for the Newly Diagnosed