My treatment plan

This section will outline the general treatment plan for the following personalization options:
Stage IV
Type: IDC, ILC, Rare, I don’t know
HR+, HER2+

Oncologists follow specific guidelines when deciding on the treatment plan that is right for you. Below we outline the general guidelines and plans based on your stage, type and sub-type of breast cancer. We also identify where you can make decisions about your treatment and what those options may be. Finally, we outline the pan-Canadian standards of care for access and timing of treatments.

Making decisions related to your care can feel like a heavy burden. These are decisions that can have a great impact on your quality of life in the immediate and sometimes distant future. Your first impulse may to be start treatment immediately. It’s important to understand that you have the time to get accurate information about your options, find useful resources (like this tool), get support, ask questions, and gain some perspective before having to decide on a course of treatment.

*Remember: Not all experiences may follow this exact path and you may or may not have all the tests or treatments we outline within. We hope this pathway will give you a general understanding of the process and possible timelines. The standards of care reported in this tool are based on guidelines and not everyone will fall into these standard categories. We encourage you to always consult your doctor for the most accurate information and timelines specific to your circumstances.

1. Referral to cancer program

After your diagnosis, your doctor will refer you to the closest cancer program.

Stage IV metastatic breast cancer is different from other stages of breast cancer because it means that you will be living with cancer for the rest of your life. As you may recall from the Understanding My Breast Cancer section, metastatic breast cancer is cancer that has spread beyond the breast into other organs in the body. Cancer cells that have spread are still considered breast cancer and will be treated with breast cancer treatment.

One of your first appointments will be with a medical oncologist. Your medical oncologist will be responsible for your primary care relating to your cancer treatment. He or she will work with you to make decisions about the types of treatments you will receive and can help you manage any symptoms of your cancer or side effects from your treatments.

Tip: Ask about speaking to a social worker or patient navigator at your cancer centre. Oftentimes, these individuals can help you access practical and emotional support available at your centre or in your community to help you through your diagnosis.

Standards of Care:

• Your initial consultation with a breast cancer oncologist should take no longer than 2 weeks from the date of your referral.[1]

2. Your first appointment with your oncologist

Treatment for stage IV metastatic breast cancer takes a different approach than earlier stages of the disease. The goal of treating metastatic breast cancer focuses on shrinking tumours and slowing the growth of the cancer cells in order to lengthen survival and improve quality of life and symptoms, rather than curing the disease altogether.

At your first appointment with your oncologist, they will review the treatment options available to you and help to answer any questions you may have about your diagnosis.

Your primary treatment will be systemic therapy, with radiation and surgery becoming additional treatments to help with symptom management. Your oncologist will go over what treatments they recommend for your sub-type of cancer.

If you have oligometastatic breast cancer (metastatic breast cancer that has only spread minimally to a few other areas of the body), you may be able to take a similar approach to treatment as earlier stages of breast cancer. In some cases, if the cancer is easily able to be removed your oncologist may refer you to a surgeon or radiation oncologist to explore more curative forms of treatment.

Brain metastases (metastatic breast cancer that has travelled to the brain) are more common in HER+ breast cancers. There are some systemic therapies that can be used to treat brain metastases (which are listed below) as well as local radiation therapy.

3. Choosing a treatment plan

When choosing a drug treatment, your oncologist will outline the recommended options for your breast cancer based on:

• Your menopausal status (whether you are pre-menopausal or post-menopausal)
• Your previous treatment history (if you had breast cancer in the past)
• The location of the breast cancer metastases (lungs, liver, brain, bones, etc.)
• Your overall health, which may influence which treatments are safe for you
• Your own preferences, goals and priorities

The very first treatment you receive is called first-line; the second treatment is called second-line and so on. Unfortunately, each drug eventually stops working, and you may move on to the next line of therapy at that time (or if a previous drug is not well tolerated).

Tip: Ask your oncologist about available clinical trials before beginning treatment. There may be some new treatments being studied in the first-line setting that you would not have access to if you have taken other metastatic breast cancer treatments. Read more about clinical trials here.

HER2+ targeted therapy as well as hormonal therapy is often the first-line of treatment for HR+ HER2+ metastatic breast cancer.

Second- and third-line treatments typically consist of changing the targeted or hormonal therapy to another.

Below is an outline of the different treatments that may be offered to you. The drugs listed below are categorized based on the type of drug with information on:

• Line setting indications (whether they are approved for first-line, second-line, etc.)
• Pre- and post-menopausal indications (for hormonal therapies)

As mentioned above, you will likely receive a combination of these treatments.  

New drugs for metastatic breast cancer are frequently being developed and approved but it can take a couple of years for drugs to be publicly funded by provincial healthcare systems. This means that some treatments may be offered to you that would require you to seek funding elsewhere (private insurance or a manufacture patient support program) or pay a high out of pocket cost. Use our MedSearch drug database to see what drugs may treat your breast cancer.

Tip: Speak with your oncologist about how to access funding for these drugs and if there are any programs or drug access navigators at your cancer centre who can assist with paying for this drug.

Standards of Care:

• Your treatment should begin within 4 weeks of consultation.[2]

Targeted therapies

Most commonly, the first-line of therapy for HER2+ metastatic breast cancer is pertuzumab (Perjeta™) in combination with trastuzumab and a taxane-based chemotherapy. The chemotherapy portion of this regimen is usually given for 6 to 8 cycles, while pertuzumab and trastuzumab are continued for as long as they are working.

Trastuzumab and pertuzumab both work by attaching itself to the HER2 protein, blocking signals which lead to tumour growth and spread and attracting immune system cell destruction, shrinking cancers. This drug regimen is given through an IV. Regular heart function tests will be performed throughout the duration of your treatment to ensure there are no damaging effects on your heart (usually a temporary weakening of pumping strength).

A common second-line therapy given to people with HER2+ mBC is trastuzumab emtansine (Kadcyla™), also known as T-DM1. This regimen is essentially trastuzumab with a chemotherapy agent riding “piggyback” for delivery specifically to HER2+ cancer cells. It is also given through an IV.

Trastuzumab deruxtecan (Enhertu™): Trastuzumab deruxtecan is a newer HER2 targeted treatment that works similarly to T-DM1 but with a different type of attached chemotherapy. Combining these drugs into one solution allows trastuzumab to deliver the chemotherapy directly to the cancer cell. Like T-DM1, it is also given through IV. It is felt to be the preferred second-line therapy.

Funding: Trastuzumab deruxtecan is not currently funded by provincial public drug formularies.

Newer targeted therapies that may be offered in the second- or third-line setting include the following drugs listed below. New drugs for metastatic breast cancer are frequently being developed and approved but it can take a couple of years for drugs to be publicly funded by provincial healthcare systems. This means that some treatments may be offered to you that would require you to seek funding elsewhere (private insurance or a manufacture patient support program) or pay a high out of pocket cost. Use our MedSearch drug database to see what drugs may treat your breast cancer.

Tip: Speak with your oncologist about how to access funding for these drugs and if there are any programs or drug access navigators at your cancer centre who can assist with paying for this drug.

Epidermal growth factor receptor (EGFR) inhibitors: Also known as tyrosine kinase inhibitors, are drugs that not only target the HER2 receptor but the EGFR proteins within the tumour as well. EGFR proteins are important for cell growth and division. Blocking these receptors can inhibit cancer growth.

There are 2 EGFR inhibitor drugs for HER2+ metastatic breast cancer:

Lapatinib (Tykerb™) is an oral drug taken:

• In combination with capecitabine (chemotherapy) for patients whose disease has progressed on trastuzumab and chemotherapy.
• It can also be used in combination with letrozole (hormonal therapy) in post-menopausal patients with HR+ and HER2+ metastatic breast cancer.

Funding: Lapatinib is funded by most provincial public drug formularies.

Tucatinib (Tukysa™)  is an oral drug taken:

• In combination with trastuzumab and capecitabine for patients with HER2+ metastatic breast cancer who have received prior treatment with trastuzumab, pertuzumab, and trastuzumab emtansine.
• It can also be used for patients with brain metastases.

Funding: Tucatinib is not currently funded by provincial public drug formularies.

Neratinib (Nerlyx™) is an oral drug taken:

• In combination with capecitabine (chemotherapy) for patients whose disease has progressed on trastuzumab and chemotherapy.
• It can also be used for patients with treated brain metastases

Funding: Neratinib is not funded by provincial public drug formularies.

Hormonal therapies

Hormonal therapies are also an option to be included in treatments for HR+ and HER2+ breast cancer. After chemotherapy/Her2 targeted therapies achieve the desired response, Her2 targeted agents continue with hormonal therapy, usually with an aromatase inhibitor. Below are the various options for hormonal therapies.

Tamoxifen can be given to both pre- and post-menopausal patients for as long as it continues to work.

Aromatase inhibitors (Ais): These are the preferred first-line hormonal agents for stage IV disease. Before menopause, most of the estrogen in a woman’s body comes from her ovaries. After menopause, it is produced solely from converting a group of hormones called androgens (“male” hormones produced in the adrenal glands) into estrogen (in fat, muscle, and breast tissue) by means of the enzyme aromatase. AIs block this enzyme from working, and therefore reduce the amount of estrogen in the body.

Common AIs include:

• Letrozole
• Anastrozole
• Exemestane

AIs can be given to post-menopausal patients for as long as it continues to work. They may be given to pre-menopausal patients with ovarian suppression (induction of menopause).

Tamoxifen: This type of hormonal therapy is a “selective estrogen receptor modulator (SERM)”. Tamoxifen works to block the estrogen receptors so that the body’s estrogen cannot stimulate them. This can slow or stop cancer growth, or it can shrink the tumours. It is a once-daily tablet. It is typically given along with HR+ targeted therapy.

Fulvestrant: This type of agent is a “pure estrogen receptor antagonist” that blocks estrogen receptors by binding to them, blocking the action of the estrogen on them and breaking the receptors themselves down. Unlike tamoxifen, fulvestrant (Faslodex) does not have any estrogen-like properties in other tissues of the body. Fulvestrant is the only approved drug in this class and is taken by injection into the buttocks monthly.

Fulvestrant can be given to post-menopausal patients not previously treated with other hormonal therapy or as an alternative when tamoxifen is not working. They may be given to pre-menopausal patients with ovarian suppression.

Ovarian suppression/ablation: If you are pre-menopausal, most of the estrogen in your body comes from your ovaries, whose production of estrogen is controlled by the pituitary gland in the brain, through another hormone called luteinizing hormone (LH). Luteinizing hormone-releasing hormone (LHRH) agonists work by slowing down the pituitary gland’s signal to the ovaries. These drugs cause you to go into menopause as long as you are taking the injection.

Common LHRH drugs include goserelin (Zoladex) and leuprolide (Lupron) ™), given by injection every 1 or 3 months.

LHRH agonists are indicated for pre-menopausal patients and can be taken alone or in combination with tamoxifen, aromatase inhibitors, or fulvestrant for as long as needed.

Ovarian ablation is a more drastic way to block the ovaries from producing estrogen. Ovarian ablation is the surgical removal of the ovaries (oophorectomy) that puts a woman into permanent menopause. This can be done laparoscopically as day surgery, similar to the technique used to “tie the tubes” for contraception.

Chemotherapy

Chemotherapy is usually beneficial, in its turn, over your treatment journey. Unlike early breast cancer treatments, which use strong combinations of chemo drugs, stage 4 disease treatment uses single drugs in doses usually designed for long term use with less compromise to quality of life.

Anthracyclines, taxanes, and capecitabine are the standard treatments used for metastatic breast cancer:

• Anthracyclines and platinums target and damage the DNA of cancer cells, killing them before they can divide and multiply.
• Taxanes work by stopping the cancer cells from dividing and therefore blocking the growth of the cancer.  
• Capecitabine is a type of chemo called an antimetabolite. Antimetabolites mimic characteristics of the cancer cell and interferes with the replication of the DNA causing the cancer cell to stop growing.

Your doctor will likely prescribe one drug at a time instead of a combination of chemotherapies. This helps reduce potential side effects from treatment. Some common single agent chemotherapies offered include[3]:

• Doxorubicin: Given intravenously (anthracycline)
• Docetaxel: Given intravenously (taxane)
• Capecitabine: Given orally by pill
• Paclitaxel: Given intravenously (taxane)
• Paclitaxel-nab: Given intravenously (taxane)
• Pegylated liposomal doxorubicin: Given intravenously (anthracycline)
• Vinorelbine: Given intravenously
  • Can be given in the first-line if previously treated with chemotherapy for early breast cancer and experienced metastatic relapse within 6 months
• Gemcitabine:  Given intravenously

Combination chemotherapy regimens that may be considered (for more serious cancer involvement of vital organs) include:

• Gemcitabine: Given intravenously. Gemcitabine can be given alone but does show better results in combination with
  • Carboplatin
  • Docetaxel
  • Paclitaxel
• Doxorubicin & cyclophosphamide: Given intravenously
• Doxorubicin & docetaxel: Given intravenously

At any stage of your systemic treatment for metastatic breast cancer, you can ask about available clinical trials. Clinical trials offer additional, new treatment options that you may benefit from. Some clinical trials require no initial first-line treatments to qualify and some are available only to individuals who have progressed on standard treatments. Asking early in your diagnosis and when treatments are changed can help ensure you have exhausted all of your clinical trial options. For more information about clinical trials read our blogs:

• What Are Clinical Trials and Are They Right for Me?
• Debunking Common Myths About Clinical Trials

4. Supportive and additional treatments

Supportive treatments are used in addition to systemic therapies to help treat the cancer and its side effects. The use of these treatments is on a case-by-case basis and can be combined with other palliative care/symptom management options.

Local therapies are treatments that are given directly to the area where the cancer is located. Radiation and surgery are the two most common forms of local therapy for treating metastatic breast cancer. In some cases, local treatment can be used to help reduce the cancer. In most cases, it is used to help treat the side effects of the cancer. These treatments can be used to:

• Treat a small number of metastases (oligometastatic breast cancer)
• Brain metastases
• Prevent bone fractures for bone metastases
• Treat cancer that is impeding on the spinal cord or blood vessels
• Provide pain relief or other symptoms

The brain is a common site for breast cancer to spread in people with HER2+ breast cancer. These are called brain metastases. The three local forms of treatment for brain metastases include:

• Surgery can be performed if there are 1-2 lesions that can be safely removed.
• Stereotactic radiation therapy can be administered if there are a few lesions in the brain. This form of radiation can target specific areas instead of the whole brain. For more information on this form of radiation click here.
• Whole brain radiation delivers radiation to the entire brain.

Alternatively, there are some systemic therapies that can be used to treat brain metastases but not all treatments cross the blood-brain barrier. Speak to your oncologist about what systemic treatment options are available for your cancer.

The bones are a common site for breast cancer to spread in people with HR+ breast cancer. These are called bone metastases. In addition to radiation therapy and surgery, bone-strengthening medications may be used to help treat your bone metastases:

• Bisphosphonates can tip the balance in bone cells away from bone dissolving/recycling cells back towards bone building cells. Options include
  • Intravenous agents, like zoledronic acid or pamidronate every 1 to 3 months or,
  • Oral clodronate pills twice a day
• Denosumab (Xgeva™) is a human monoclonal antibody that counters a receptor in bone tissue that would usually stimulate bone to be reabsorbed. It is given by injection under the skin on a monthly basis.
• These agents dramatically reduce the future risk of fractures, worsening pain, or paralysis from spinal damage.

5. Monitoring treatment progress and disease progression

Your cancer and your treatments will be routinely monitored to ensure that the therapies prescribed are still working as anticipated.

Systemic therapy is typically monitored every 2 or 3 cycles while overall disease monitoring can take place every 2-6 months.[4]^{, [5]}Tests to monitor your treatment progress can include:

• Physical exams
• Tumour marker tests: a blood test that is performed to look for substances produced by tumours. Some breast cancers, however, do not make these markers.
• Bone scans: An imaging test that looks at bone abnormalities and can help monitor bone metastases.
• CT scans: a 3D imagining machine that takes multiple x-rays at different angles to look at organs or abnormalities within the body.
• MRI: a specialized imaging machine that uses magnetic and radio waves to create detailed images of specific areas in the body.
• X-ray: an imaging test that uses small amounts of radiation to create images of inside your body.

Everyone reacts differently to treatment. For some people, certain treatments may work for long periods of time while other treatments may not work as well. If your cancer responds well to treatment your tests and scans may show:

• Stable disease: this means that the cancer has stopped growing
• Regression/response: this means that the cancer has decreased in size
• It is possible to have periods of time where your tests show no evidence of disease (NED).

Even if you respond well to treatment, your cancer can eventually grow to resist it, meaning that you will need to move on to another treatment. When your cancer continues to grow, or when new tumours appear, it is called progression.

If your follow-up tests show evidence of progression, you and your oncologist will discuss what other treatments may be available to you. If you’re interested in exploring clinical trials, this may be a good opportunity to ask about what trials are available for your type of breast cancer.

6. Palliative care and symptom management

Palliative care and pain management are a large aspect of living with metastatic breast cancer. Palliative care can be incorporated into your treatment plan at any point where you feel you need it. It can be used for more than end-of-life care – it can be used to improve your overall quality of life.

Palliative care can look different to each person and can be treated differently depending on your needs and where you live. In some cases, your medical oncologist may take on the role of prescribing and managing your palliative care treatment. In others, your family doctor may coordinate palliative measures or you may be referred to a palliative care specialist.

Treatments for palliative care can include easing physical symptoms such as pain, nausea, vomiting and shortness of breath. They can also address psychological symptoms such as fear, anxiety, and depression. A palliative care team may also help you access support for family or financial needs.

7. Choosing to end treatment and transitioning to end-of-life care

There will come a time when you, your family and/or your oncologist will decide to end your treatments and focus on your end-of-life care. Making this decision can be difficult for you and your family. Hospice palliative care will provide you with the same palliative options you have been receiving but with a focus on making you as comfortable as possible as you transition to end-of-life.

Preparing for your end-of-life care in advance may help relieve some anxiety and fear. If you have specific wishes for your end-of-life care, creating an advanced care plan can help your loved ones understand your wishes and needs during your hospice care and after your death. It can also allow you to have a say in these decisions once you are no longer able to speak for yourself. For additional help, visit www.advancedcareplanning.ca.

For more information about end-of-life care see End-of-life care section.