Treatment for secondary breast cancer

Aromatase inhibitors (AIs) stop oestrogen being made in the body. There are different types of AI. These include anastrozole, letrozole and exemestane. You take them daily as a tablet.

Tamoxifen stops oestrogen from attaching to breast cancer cells and encouraging them to grow. You take tamoxifen daily as a tablet. When you take tamoxifen for secondary breast cancer that has spread to the bone, the pain may be worse for the first few days. This will gradually improve.

Fulvestrant stops oestrogen reaching the breast cancer cells. This slows down or stops the growth of the cancer cells. Fulvestrant also reduces the number of receptors on the cancer cells.You have fulvestrant as an injection into a muscle in the buttock.

The drugs goserelin and leuprorelin stop the pituitary gland in the brain sending messages to the ovaries to produce oestrogen. This stops the ovaries making oestrogen. You have a temporary menopause while you are taking these drugs, and your periods will stop within a few weeks.

You have goserelin or leuprorelin as an injection under the skin of the tummy (abdomen). You have this injection once a month. 

Ovarian ablation is an operation to remove the ovaries. This reduces the amount of oestrogen in the body.

It can usually be done using keyhole surgery. The surgeon makes a small cut in the abdomen and inserts a thin tube with a small light and camera on the end. This is called a laparoscope. The surgeon uses it to help them remove the ovaries through the cut. You will be in hospital for a short stay. People usually recover quickly from this type of operation.

If you have ovarian ablation, your periods will stop straight away and you will have the menopause.

Abemaciclib (Verzenios^®), palbociclib (Ibrance^®) and ribociclib (Kisqali^®) are given with hormonal therapy drugs.

They are all a type of targeted therapy drug called a cancer growth inhibitor. They are sometimes called CDK4 and CDK6 inhibitors. CDK4 and CDK6 are proteins that tell cancer cells to grow and divide. These drugs block CDK4 and CDK6. This can slow or stop the growth of the cancer.

Abemaciclib comes in tablets that you take twice a day, every day without a break. You take palbociclib and ribociclib as tablets, usually for 3 weeks at a time. You then have a week off before starting them again.

Everolimus (Afinitor^®) is a targeted therapy drug that you may have with the hormonal therapy drug exemestane. You need to have already had treatment with certain hormonal therapy drugs before you can have everolimus.

Everolimus is a cancer growth inhibitor. It can help slow down how quickly the cancer is growing. It also stops the cancer cells from making new blood vessels. This may help shrink the cancer. You take everolimus as a tablet once a day.

Alpelisib (Piqray^®) is a targeted therapy drug that is given with the hormonal therapy drug fulvestrant. You will only be offered alpelisib if both these things apply to you:.

• The breast cancer has a PIK3CA gene change.
• You have already had hormonal therapy alongside a CDK4 or CDK6 inhibitor.

Trastuzumab is a targeted therapy drug used to treat HER2 positive secondary breast cancer. It attaches to the HER2 protein (receptor) on the breast cancer cells and stops them from growing and dividing.

You have trastuzumab every 3 weeks as a drip (infusion) or as an injection under the skin. You may have it with pertuzumab and chemotherapy drugs, such as docetaxel (Taxotere^®), or chemotherapy drugs.

If the cancer spreads to the brain or spinal cord (central nervous system), you usually continue taking trastuzumab. Your cancer doctor may also give you other drugs or radiotherapy to control the cancer in the central nervous system. 

Pertuzumab is another targeted therapy drug that attaches to the HER2 protein (receptor). But it attaches to a part that is different from the one trastuzumab attaches to.

Pertuzumab is usually given with trastuzumab and either docetaxel or capecitabine. These are chemotherapy drugs. If you have not had targeted therapy or chemotherapy before, you may have pertuzumab with trastuzumab and either docetaxel or capecitabine as a first treatment. You have pertuzumab as an injection under the skin. 

Phesgo^® is a combination of trastuzumab and pertuzumab. It is given as an injection under the skin (subcutaneously). The nurse gives you the injection every 3 weeks. You have this injection in the thigh.

Trastuzumab emtansine (Kadcyla^®) is trastuzumab with the chemotherapy drug emtansine attached to it. Trastuzumab targets the cancer cells and delivers the chemotherapy to them. You have it as an infusion every 3 weeks.

Trastuzumab deruxtecan (Enhertu^®) is trastuzumab with the chemotherapy drug deruxtecan attached to it. Trastuzumab targets the cancer cells and delivers the chemotherapy to them. You have it as an infusion every 3 weeks.

Tucatinib (Tukysa^®) belongs to a group of targeted therapy drugs called tyrosine kinase inhibitors (TKIs). It blocks the HER2 protein on cancer cells. This stops the cells from growing and dividing.

You usually have tucatinib in combination with trastuzumab and a chemotherapy drug called capecitabine. You take tucatinib twice a day as tablets. You take it for as long as it is controlling the cancer and side effects are being managed.

Sacituzumab govitecan (Trodelvy^®) is the targeted therapy drug sacituzumab with the chemotherapy drug SN-38 attached to it.

Sacituzumab is a cancer growth inhibitor. Some triple negative breast cancers have a protein called TROP2. This protein tells the cancer cells to grow and divide. Sacituzumab govitecan can block these proteins. This can slow or stop the growth of the cancer.

You usually have a course of several cycles of treatment. Each cycle is 21 days (3 weeks). You have a drip into a vein (intravenous infusion) on days 1 and 8 of the cycle. You then have a rest from treatment for 1 week before the next cycle starts.

Olaparib (Lynparza^®) is a targeted therapy drug called a PARP inhibitor. PARPs are proteins that help damaged cells repair themselves.

Olaparib blocks how PARP proteins work in cancer cells that have a change (mutation) in the BRCA1 or BRCA2 gene. This is more common in triple negative breast cancer. You take olaparib as a tablet.

Olaparib is only available through the compassionate access scheme in the UK. Your cancer doctor can tell you more about this if they think this treatment is suitable for your situation.

If a secondary breast cancer has weakened a bone, you may need an operation to strengthen the bone. This is usually in the hip, leg or the upper arm.

You have the operation under a general anaesthetic. The surgeon puts a metal pin into the centre of the bone. They may also fix a metal plate to it. The pin and plate stay in permanently. They hold the bone in place and prevent it from breaking.

If 1 of your hip joints has been affected by the cancer, you may have surgery to replace the joint. This is called a hip replacement.

Surgery is also sometimes used to treat secondary breast cancer that has spread to the bones in the spine. Surgery can help strengthen the area of bone and relieve pressure on the spinal cord (spinal cord compression).

You have to stay in hospital for a week or longer after the operation so you can recover fully. But you can usually start walking 2 days after surgery. You usually have radiotherapy to the bone afterwards. We have more information about secondary cancer in the bone.

Sometimes it may be possible to remove a small cancer that is contained in only 1 part of the liver. If there is more than 1 tumour in the same area, it may be possible to remove them all. This is rare. It is major surgery that is done by a specialist liver surgeon.

A treatment called radiofrequency ablation may be used instead of surgery. The cancer doctor places needles in the liver tumour. Heat from a laser or microwave is then passed through the needle directly into the tumour to destroy cancer cells. We have more information about secondary liver cancer.

Some people may have surgery to the brain. This is usually if there is only 1 tumour in the brain. The tumour must also be in an area where it is possible to operate. You will be referred to a specialist brain surgeon called a neurosurgeon. They will assess whether surgery is possible. The surgeon and specialist nurse will tell you what to expect before and after your operation. You will usually be in hospital for at least 1 week.

Your cancer doctor will prescribe steroids to reduce the swelling around the tumour and improve your symptoms. You take them before your operation and for a few weeks afterwards, depending on your symptoms. You usually have radiotherapy to the brain (see above) after you have recovered from the operation.

Very rarely, it may be possible to have surgery to remove the primary cancer in the breast or chest. This is usually only an option for people who have breast cancer that has only spread to 1 or 2 areas. The cancer also needs to have responded well to treatment, and the response to treatment needs to be long lasting. Your cancer doctor or specialist nurse can explain if this may be suitable for you.