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
Don’t know subtype

Introduction

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 subtype 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 be to 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.

Your subtype will typically fall into one of these 4 categories:

• HR positive, HER2 negative
• HR positive, HER2 positive
• HER2 positive, HR negative
• Triple negative (HR negative & HER2 negative)

The subtype of your breast cancer plays an important role in determining your treatment options. It can have a large impact on the types of treatments that may be offered to you. Your subtype is often determined during your initial breast biopsy. These include the hormone receptor (ER and PR) status and HER2 status, and the results can be found on the pathology report created from that procedure. Ask your oncologist what sub-type you are and how it impacts your treatment options.

1. Referral to cancer program

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

Stage IV metastatic breast cancer means the cancer has spread beyond the breast to other parts of the body. Cancer cells that have spread are still considered breast cancer and will be treated with breast cancer treatment. Although it cannot be cured, treatment can help control the cancer and manage symptoms.

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. They 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.

In many provinces, triple negative breast cancer is eligible for BRCA genetic testing. See our section on genetic and genomic testing to see if you are eligible based on your province and ask your oncologist about referring you for testing. 

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:

• Many cancer programs in Canada aim for the first appointment with a medical oncologist to be within 2 to 4 weeks of referral [1] [2]. Actual timing varies by province. 

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 is to control the cancer growth, manage symptoms and maintain quality of life.

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 (drug treatment), with radiation and surgery becoming additional treatments to help with symptom management. Your oncologist will go over what treatments they recommend for your subtype of cancer.

Some people are diagnosed with a type of metastatic breast cancer called oligometastatic disease. This is breast cancer that has spread to only a few spots (often under 5). Limited research on the definition and standards of care for oligometastatic disease means that treatment decisions vary by doctor and the person’s individual circumstances, like how aggressive the cancer is or where the cancer has spread. In some cases, surgery and radiation may be used and can be discussed at a Multidisciplinary Cancer Conference (MCC). MCCs are meetings where oncologists, surgeons, and other specialists review cases together to decide on the best treatment plan.

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.)
• The results of your biopsy, including hormone (HR) receptor status, HER2 status, and other biomarkers (PD-L1 and BRCA status)
• Your overall health, which may influence what 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. When the first-line of therapy stops working you may move on to the next line of therapy.

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.

The options your oncologist will recommend will be based on your subtype. Below you will find the options based on each subtype. Be sure to talk to your oncologist about your subtype and what options are available to you.

Some drugs listed below are being developed and approved for use by Health Canada but may not be funded through all provincial or territorial drug formularies. This means it could require you to seek funding elsewhere (private insurance or manufacturer patient support programs) 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 the cost.

Standards of Care:

• Treatment usually begins shortly after your consultation, once any required tests are done and the funding has been approved. Average wait times may be 2 to 4 weeks, but actual timing depends on the province. [3]

HR positive, HER2 negative Treatment Options

The common first-line treatment for HR positive mBC combines a hormone therapy with a CDK4/6 inhibitor. This combination has been shown to help people live longer and delay the need for chemotherapy.

Second- and third-line treatments typically consist of changing the hormone or targeted therapy to another, or to give chemotherapy alone, if needed.  

Hormone Therapies

HR positive breast cancers use estrogen or progesterone to grow. This makes hormone therapy a common first treatment for this subtype. There are several different types of hormone therapies, which may be offered alone or in combination with other hormone or targeted therapies.

• Aromatase Inhibitors (AIs): If you are post-menopausal, an AI may also be recommended to you. Before menopause, most of the estrogen is produced by the ovaries. After menopause, it is produced solely from converting a group of hormones called androgens (“male” hormone) into estrogen by means of the enzyme aromatase. AIs block this enzyme from working, and therefore, reduce the amount of estrogen in the body. Examples include letrozole, anastrozole and exemestane.  AIs are usually combined with a CDK4/6 inhibitor as the first treatment.
• SERM: Tamoxifen is a “selective estrogen receptor modulator (SERM)”. It works to block the estrogen receptors so that the body’s estrogen cannot stimulate them. It is a once-daily tablet and is the oldest and best-known hormonal therapy. It is used less often for metastatic disease but is available for pre- or post-menopausal people who cannot take AIs or fulvestrant.
• SERD: Fulvestrant is a “selective estrogen receptor degrader (SERD)”. It 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 can be given to post-menopausal people often in combination with targeted therapies. They may be given to pre-menopausal people with ovarian suppression.
• Ovarian Function Suppression (OFS): If you are pre-menopausal, your doctor may recommend OFS to lower estrogen levels by shutting down the ovaries. This is usually done with medications called LHRH agonists, like goserelin, that temporarily cause menopause [4]. Another option is an oophorectomy that permanently blocks the ovaries from producing estrogen by surgically removing the ovaries.

Targeted Therapies

Cyclin-dependent kinase inhibitors (CDK4/6): CDK4/6 inhibitors are targeted therapies used for HR positive breast cancers in combination with hormone therapies. CDK4/6 are proteins that control how fast cells grow and divide in the cell cycle. There are 3 CDK4/6 inhibitor drugs for HR positive metastatic breast cancer:

Ribociclib (Kisqali™) is an oral drug taken:

• In combination with an AI for pre- or post-menopausal people as a first-line therapy. Pre-menopausal patients must also be treated with an LHRH agonist (ovarian suppression).
• In combination with fulvestrant for post-menopausal people as a first-line therapy or following disease progression.

Palbociclib (Ibrance™) is an oral drug taken:

• In combination with an AI (letrozole) for post-menopausal people as a first-line therapy.
• In combination with fulvestrant for pre- or post-menopausal people with disease progression following hormone therapy. Pre-menopausal patients must also be treated with an LHRH agonist (ovarian suppression).

Abemaciclib (Verzenio™) is an oral drug taken:

• In combination with an AI for post-menopausal people as a first-line therapy.
• In combination with fulvestrant for pre- or post-menopausal people with disease progression following hormone therapy. Pre-menopausal patients must also be treated with an LHRH agonist (ovarian suppression).
• As a monotherapy (alone) for post-menopausal people with disease progression following hormone therapy and at least 2 prior chemotherapy regimens.

PIK3CA/AKT/PTEN inhibitors: These are drugs that block part of the PIK3CA/AKT/PTEN pathway, which helps cancer cells survive and grow. Before using one of these medicines, your tumour may be tested for PIK3CA or AKT mutations.

Alpelisib (Piqray™) is an oral drug taken in combination with fulvestrant for post-menopausal people that have the PIK3CA mutation after disease progression following hormonal therapy.

Inavolisib (Itovebi™) is an oral drug taken in combination with palbociclib and fulvestrant for pre- or post-menopausal people that have a PIK3CA mutation. Pre-menopausal patients must also be treated with an LHRH agonist (ovarian suppression).

Capivasertib (Truqap™) is an oral drug taken in combination with fulvestrant for pre- or post-menopausal people that have one or more PIK3CA/AKT/PTEN mutations after disease progression following hormonal therapy.

mTOR inhibitors: These block the mTOR protein that regulates cell growth and cell reproduction.

Everolimus (Afinitor™) is an oral drug taken in combination with an exemestane (AI) for post-menopausal people after disease progression following letrozole or anastrozole (AIs).

Antibody-Drug Conjugates (ADCs): ADCs are a type of therapy that links a targeted therapy with a chemotherapy drug. The targeted therapy helps deliver the chemotherapy directly into the cancer cell.

Sacituzumab govitecan (Trodelvy™) is an IV treatment for people who have received hormone therapy and at least 2 additional therapies for metastatic breast cancer.

BRCA1/2: Olaparib (Lynparza™) is a drug therapy for people with BRCA mutated breast cancer, also known as germline BRCA-mutated (gBRCAm) breast cancer. It is an oral drug for pre- and post-menopausal people with an inherited BRCA1 or BRCA2 gene mutations and HER2 negative breast cancer who have previously been treated with chemotherapy. People with HR positive breast cancer should have also progressed on previous hormone therapy.

Chemotherapy

Chemotherapy may become an option if your metastatic disease progresses while taking the above hormone and targeted therapies.

See triple negative treatment options below for more information on chemotherapy options.

HER2 positive Treatment Options

HER2 targeted therapy in combination with chemotherapy is often the first-line of treatment for HER2 positive metastatic breast cancer.

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

Targeted Therapies

Monoclonal Antibodies: These drugs, combined with chemotherapy, work by binding to and blocking the HER2 receptors from helping the tumour grow:

Trastuzumab is an IV treatment given in combination with chemotherapy. It is the oldest and best known HER2-targeted therapy and is often combined with other treatments.

Pertuzumab (Perjeta™) is an IV treatment given in combination with trastuzumab and chemotherapy (called THP). The chemotherapy portion of this regimen is usually given for 6 months, while pertuzumab and trastuzumab are continued for as long as they are work.

This is combination (THP) is typically the standard first-line of therapy for HER2 positive metastatic breast cancer, including those with brain metastases. Because these drugs can sometimes affect the heart, you will have regular heart function tests during your treatment to make sure your heart stays healthy.

Antibody-Drug Conjugates (ADCs): ADCs are a type of therapy that links a targeted therapy with a chemotherapy drug. The targeted therapy helps deliver the chemotherapy directly into the cancer cell and are given intravenously. These are indicated for second- or third-line therapies, including those with brain metastases:

• Trastuzumab deruxtecan (T-DXd, Enhertu™)
  • T-DXd is the preferred second-line for most people
• Trastuzumab emtansine (T-DM1, Kadcyla™)
  • T-DM1 is generally considered after T-DXd, depending on prior therapy and availability

Tyrosine Kinase Inhibitors:  These drugs block an enzyme called tyrosine kinase, which helps HER2 positive cancer cells grow.

• Lapatinib (Tykerb™) is an oral drug taken in combination with chemotherapy (capecitabine) for people with HER2 positive breast cancer who have progressed on previous lines of HER2 targeted therapy.
• Tucatinib (Tukysa™) is an oral drug taken in combination with trastuzumab and chemotherapy (capecitabine) including those with brain metastases when they have progressed on previous lines of HER2 targeted therapy.

Hormone Therapies

Hormone therapies are also an option to be included in treatments for HR positive and HER2 positive breast cancer. Once the chemotherapy portion of the targeted regimen is completed, hormone therapy is added to your treatment.

See HR+ treatment options above for more information on hormonal therapy options.

Chemotherapy

Chemotherapy may become an option if your metastatic disease progresses while taking the above hormone and targeted therapies.

See triple negative treatment options below for more information on chemotherapy options.

Triple Negative Treatment Options

Immunotherapy

Immunotherapy helps the immune system detect and attack cancer cells. It blocks a protein called PD-L1, which allows cancer cells to hide from immune cells.

The primary immune checkpoint inhibitor developed for treatment of triple negative metastatic breast cancer is:

Pembrolizumab (Keytruda™) is an IV drug taken as a first-line treatment in combination with chemotherapy for people with PD-L1 positive triple negative metastatic breast cancer.

Chemotherapy

If PD-L1 is negative or immunotherapy is not an option, chemotherapy is the primary first-line systemic therapy used for metastatic TNBC. Unlike early breast cancer treatments where strong combinations of chemotherapy drugs are given, treatment for metastatic breast cancer gives one drug at a time. This helps reduce potential side effects from treatment.

Some common single agent chemotherapies offered include[5]:

• Capecitabine: Given orally by pill
• Carboplatin: Given intravenously
• Doxorubicin: Given intravenously
• Eribulin: Given intravenously
• Gemcitabine: Given intravenously
• Pegylated liposomal doxorubicin: Given intravenously
• Paclitaxel: Given intravenously
• Paclitaxel-nab: Given intravenously
• Vinorelbine: Given intravenously

Combination chemotherapy may be considered on a case-by-case basis and is usually used when the cancer is progressing rapidly or causing serious symptoms.

Targeted Therapies

Antibody-Drug Conjugates (ADCs): ADCs are a type of therapy that links a targeted therapy with a chemotherapy drug. The targeted therapy helps deliver the chemotherapy directly into the cancer cell and are given intravenously.

Sacituzumab govitecan (SG, Trodelvy™) is an IV drug taken as a second- or third-line treatment.

BRCA targeted therapy: If you have an inherited BRCA1 or BRCA2 mutation, you may be eligible to receive a targeted therapy called olaparib.

Olaparib (Lynparza™) is an oral drug given to people with metastatic TNBC who have previously been treated with chemotherapy.

At any point in your treatment for metastatic breast cancer, you can ask about available clinical trials. Clinical trials may offer new treatment options along with additional monitoring. 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 your clinical trial options. Read more about clinical trials here.

4. Supportive and additional treatments

Supportive treatments are added to help manage symptoms and protect affected areas of the body. They can be given along with your main treatments or as part of palliative care.

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 brain metastases
• Prevent bone fractures from bone metastases
• Treat cancer that is affecting the spinal cord or blood vessels
• Treat a small number of metastases (oligometastatic breast cancer)
• Provide pain or other symptom relief

The brain is a site where breast cancer is known to spread. These are called brain metastases. The three local forms of treatment for brain metastases include:

• Surgery can be performed if there are 1 or 2 lesions that can be safely removed
• Stereotactic radiation therapy can be used if there are a few lesions in the brain. For more information on this form of radiation click here.
• Whole brain radiation delivers radiation to the entire brain when there are many lesions.

The bones are another common site for breast cancer to metastasize. These are called bone metastases. In addition to radiation therapy and surgery, bone-strengthening medications may be used to help treat your bone metastases. These drugs include:

• Bisphosphonates that help strengthen the bone and stop the body from breaking down the bone. A common example is zoledronic acid given intravenously.
• Denosumab (Xgeva) is a bone-strengthening injection that helps reduce the risk of fractures and pain from metastases.

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. Your oncologist will also check for any side effects and adjust the dose if needed.

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

• Physical exams
• Complete blood count tests: this test looks at various characteristics of your blood including red or white blood cells, hemoglobin, or platelets
• Tumour marker tests: a blood test that is performed to look for substances produced by tumours. Some breast cancer, 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 imaging machine that uses x-rays and computer technology to create detailed images of specific areas of 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/spreading
• Partial response/ regression: this means that the cancer has decreased in size, but cancer is still visible on scans
• No evidence of disease (NED): this means no signs of cancer are seen on imaging or tests

Even if scans show no evidence of disease, microscopic cells can remain in the body, so ongoing treatment or monitoring is often needed.

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. This is also a good time to ask whether a clinical trial might be suitable for you.

6. Palliative care and symptom management

Palliative care and pain management are a large aspect of living with metastatic breast cancer. Palliative care focuses on relieving symptoms and supporting your physical, emotional and spiritual well-being. It can be incorporated into your treatment plan at any point where you feel you need it and can be used to improve your overall quality of life, not just at the end-of-life.

Palliative care can look different to each person and can be treated differently depending on your needs. It is coordinated through each provincial and territorial health system meaning it may look different depending on 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. Palliative teams may include nurses, counsellors or social workers who help you and your family manage symptoms and plan for future care.

Treatments for palliative care can include easing physical symptoms such as pain, nausea, vomiting and shortness of breath. They can also address the emotional aspects of a metastatic diagnosis such as fear, anxiety, or 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. This decision usually happens when treatments are no longer controlling the cancer. 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. It can take place in your home, a hospital, or a specialized hospice residence depending on your wishes and what’s available in your community.

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.advancecareplanning.ca.

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