Treatment of advanced breast cancer

Breast cancer may occasionally present as metastatic disease without evidence of a primary tumour (that is with an occult primary). The diagnosis is made partly by exclusion of another site for the primary and may be confirmed by histology of the metastatic lesions. Treatment should be aimed at palliation of the symptoms and treating the breast cancer, usually by endocrine manipulation.

Locally advanced inoperable breast cancer

Locally advanced inoperable breast cancer, including inflammatory breast cancer, is usually treated with systemic therapy

      either chemotherapy or hormone therapy.

Occasionally ‘toilet mastectomy’ or radiotherapy is required to control a fungating tumour, but often incision through microscopically permeated tissues makes the outcome worse than the original.

Metastatic carcinoma of the breast

Metastatic carcinoma of the breast will also require some form of palliative systemic therapy to alleviate symptoms. Hormone manipulation is often the first line because of its minimal side effects. It is particularly useful for bony metastases. However, only about 30 per cent of these tumours will be hormone responsive, and unfortunately even these will in time become resistant to this treatment. First-line hormone therapy for postmenopausal women is tamoxifen, and for premenopausal women ovarian suppression, but where resistance to these has developed, other hormonal agents can prove useful, with about half of the response rate seen in the first-line therapy. Synthetic progestagens such as medroxy­progesterone acetate (‘Provera’) aromatase inhibitors or the newer agents such as antiprogestins and pure antioestrogens are all candidates for this role.

Cytotoxic therapy is used, particularly in younger women or those with visceral metastases and rapidly growing tumours. A variety of regimens is available and although none prolongs survival, contrary to expectations quality of life and symptom control is often better with more aggressive treatments, responses being seen in up to 70 per cent of patients.

Local treatment may also prove useful for some metastatic disease such as radiotherapy for painful bony deposits and internal fixation of pathological fractures.