Treatment of Stage IIIB, IIIC, IV (inoperable disease)

The goals of treatment for advanced stage invasive breast cancers can be divided into curative or palliative.  Inoperable tumours are those that are attached to the chest wall or skin, or those that have spread to lymph nodes that are attached to other structures.  Surgery as the primary treatment is also not appropriate for breast cancers that have extensively spread to supraclavicular lymph nodes or to other organs [1].

Curative treatment:

Generally, multimodal treatment with the intent to cure applies to otherwise healthy patients with inoperable stage IIIB and IIIC disease [2,3].  Apart from biopsy to determine the receptor status and HER2/neu status of the tumour, no other surgery is initially performed.  The receptor status and HER2/neu status determines if endocrine and biologic therapy use will be beneficial to the patient [2,3].

Primary treatment for advanced stage IIIB and IIIC cancer involves aggressive combination chemotherapy.  Anthracycline and taxane chemotherapy drugs are typically used and studies show that the majority of patients show favourable responses to this treatment [2,3].  For tumours with ER/PR positive status, endocrine treatment may be given as an additional treatment.  For tumours with over expression of the HER2/neu gene, trastuzumab may be given as an additional treatment [1,2,3].

The degree of tumour response to chemotherapy will determine subsequent treatment options.  For tumours that decrease in size, surgery in the form of a modified radical mastectomy may now become an option followed by radiation therapy.  Studies have shown that 80-90% of previously inoperable cancers that undergo chemotherapy treatment will become operable breast cancers [3].  For tumours that do not respond well, regional radiation to the chest wall, axillary, and supraclavicular areas may be performed [1].

Palliative treatment:

Palliative treatment goals for women with metastatic stage IV disease include prolonging life, controlling symptoms, improving QOL (quality of life) and controlling tumour burden.  The median survival time for patients diagnosed with stage IV disease is 18-24 months [3].  The main treatment modality involves systemic treatment in the form of chemotherapy, hormone therapy or biologic therapy depending on the receptor status and HER2/neu status.  The goal of systemic therapy is to decrease the progression rate of disease and/or to control symptoms of metastasis [2,3].

External beam radiation treatment may be considered to control localized symptomatic metastases, such as painful bone metastases, spinal cord metastases, bronchial obstruction and large painful chest wall masses [1,2].

Surgery may be considered for palliative intent.  Mastectomies may be considered for patients with large painful fungating breast lesions.  Surgery for isolated brain or spinal cord metastases, isolated lung metastases, and/or isolated liver metastases may help control pain and other symptoms of metastatic disease [1,2].

9225328_07April2011_left breast fungating lesionExample of a fungating breast lesion

[1] Canadian Cancer Encyclopedia from the Canadian Cancer Society. Available at: http://info.cancer.ca/cce%2Decc/default.aspx?toc=10#Treatment.  Accessed July 15th, 2011.

[2] National Cancer Institute at the National Institutes of Health. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/breast/healthprofessional/page7.  Accessed July 15th, 2011.

[3] DeVita VT, Lawrence TS, Rosenberg SA. Cancer: Principles & Practice of Oncology 8th Edition Vol 2. Lippincott Williams & Wilkins, Philadelphia; 2008.

Last Updated: August 2013

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