Section: Breast Curriculum: Curriculum, page 13
Definition
- Metastatic
- No longer curable by local treatments
- < 10% present with intact primary and distant mets
- However most often it is pts under surveillance who develop metastatic disease
Principles of Treatment:
- Active disease management
- Active symptom management
- Support for family and patient
Assess Disease Extent
- Bloods – FBC, U+E, LFTS, LDH, Ca2+, CEA, CA15-3 (useful to assess response)
- Imaging – Bone scan, CT CAP +/- brain if new sx, +/- CT PET
- CT-PET if potentially resectable oligomestastic disease
- Get a tissue biopsy, recheck hormonal status of met site
- Triple negative
- IHC for PD-1 (Immunotherapy)
- All cancers
- Tropomyosin receptor kinase (TRK)
- Microsatellite-high/DNA mismatch-repair deficiency
- Germline testing for BRCA1/2 pathogenic variants
- Can give PARP inhibitors
Treatment
Hormone receptor positive
- Typically endocrine therapy alone +/- target therapy
- Can consider including chemotherapy
- Target therapy
- CDK4/6 inhibitors
- Palbociclib (Ibrance) - funded
- Ribociclib (Kisqali) - not funded
- Abemaciclib (Verzenio) - not funded
- mTOR inhibitors
- Everolimus (Afinitor)- not funded
- PI3K inhibitor
- Alpelisib (PIQRAY) - not funded HER2+
- CDK4/6 inhibitors
- Anti-HER2
- Chemotherapy + targeted HER2
- Targeted therapy
- Anti-HER2
- Trastuzumab - funded
- Pertuzumab - funded
- Anti-body drug conjugate
- Trastuzumab emtansine /T-DM1 (Kadcyla) - not funded (funded in early breast if no PCI as an adjuvent treatment)
- Trastuzumab deruxtecan/T-Dxd (Enhertu) - not funded
- Tyrosine kinase inhibitors
- Anti-HER2
Triple negative
- Guided by PD-1 expression
- Chemotherapy + Immune checkpoint inhibitors if positive
- Target therapy
- Immune checkpoint inhibitors
- PD-1
- Pembrolizumab (Keytruda) - funded in 1st October 2024
- PD-L1
- Atezolizumab - not funded
- PD-1
- BRCA1/2 mutations
- PARP inhibitor
- Olaparib (Lynparza) - not funded
- Talazoparib (Talzenna) - not funded
- PARP inhibitor
- Immune checkpoint inhibitors
Treatment for other complications
Bony Metastases
- Metastases can stimulate local osteoclasts
- Tumours can be osteoblastic or lytic
- Cancer cells can directly absorb bone, can also produce PTHrP
- Osteolysis releases TGF-β which stimulates cancer growth
- Location - Spine (20%), pelvis, skull, ribs, femur
- Symptoms = Pain, fracture (long bones), spinal cord compression, hypercalcemia
- Management
- Bisphosphonates
- Reduce fractures, analgesic, and reduce hypercalcemia
- SE: Fever, arthralgia, myalgia, GI upset, renal toxicity and rarely osteonecrosis of jaw
- Stabilisation
- Better if prophylactic rather than acute
- Done prophylactically if high risk of fracture (osteolytic, painful, > 50% bone diameter)
- Bisphosphonates
- Palliative Radiotherapy
- Following stabilisation of long bones, vertebral #, spinal cord compression
- Chemical
- Bleomycin, Tetracycline, povidone iodine, or talc slurry introduced into the pleural space through a chest drain
- Irritation between the parietal and the visceral layers of the pleura which closes off the space between them and prevents further fluid from accumulating
- Povidone iodine is equally effective and safe as talc and may be preferred because of easy availability and low cost
- Chemical pleurodesis is painful; premedicated with a sedative and analgesics. A local anaesthetic may be instilled into the pleural space, or an epidural catheter may be placed for anaesthesia
- Surgical
- Performed via thoracotomy or thoracoscopy
- Involves mechanically irritating the parietal pleura, often with a rough pad
- Surgical removal of parietal pleura is an effective way of achieving stable pleurodesis
Cerebral Metastases
- Symptoms
- Headache (worse in morning)
- Persistent Nausea
- Difficulty walking
- Visual changes
- Altered sensation/weakness
- Treatment - Short course radiotherapy or neurosurgical removal
Prognostis
- STAGE 1 -5YS 80%-10YS 50%
- STAGE 2 - 50% - 35%
- STAGE ¾ <25%