Stage 4 is the most advanced form of breast cancer. It is often called metastatic breast cancer because it has spread (metastasized) beyond the original site in the breast to other organs in the body. Metastatic disease can be found in bones, lungs, the liver, the brain, and the skin. Stage 4 is often diagnosed when a recurrence of breast cancer is found, but it may also be how the cancer is initially discovered. Treatment goals will include controlling the spread of cancer and promoting good quality of life. And in some cases, a cure may be possible.
Defining Stage 4 Breast Cancer
Stage 4 breast cancer is a disease that is found after it has already traveled away from the breast to other areas of the body. Dr. Susan Love writes that the first place that hormone-sensitive breast cancer usually spreads is to the bones. Those metastases may be controlled with bisphosphonates and other medicines that are typically prescribed for osteoporosis; higher doses can also be effective at controlling spread in the bones. Estrogen-negative breast cancers may travel to bones, but more commonly show up in lungs, liver, and the brain. Breast cancer in the lungs and liver may best respond to systemic therapies such as anti-hormones (if positive for hormone receptors), chemotherapy and newer biologic therapies. When breast cancer is found in other organs, it is still breast cancer. It may travel to the bones, but it isn't bone cancer - under a microscope the cells are still breast cancer.
Surviving With Stage 4
Being diagnosed with metastatic breast cancer is quite difficult to process. The goal when managing early stage breast cancer is obtaining a permanent remission, e.g., a cure. But for stage 4, beating the beast is a daily and lifetime battle. It is not generally considered curable, but with new therapies, it may be treated as a chronic disease. The 5-year survival rate for metastatic patients is 24.3%. That number is based on SEER statistical data from 2003-2009, and survival rates vary by race. Some patients respond well to treatment and go on living for many years. Katharine Russell Rich, who chronicled her battle with breast cancer in The Red Devil, lived with metastatic disease for 18 years, making her a member of a very exclusive club. And syndicated liberal newspaper columnist Molly Ivins went for 8 years with Inflammatory Breast Cancer, but continued to work until two weeks before her passing.
Understanding Your Diagnosis
Stage 4 is scored T(any), N(any), M1 in the TNM system. These numbers refer to scores for the Tumor, Node Status, and Metastasis. Your tumor may be any size, your lymph node involvement may be only a few or a large number of nodes. It is the Metastasis score that defines advanced breast cancer because a score of M1 means that the cancer has spread beyond the region of your breast and local lymph nodes, and is showing up in bones and major organs. A diagnosis of metastatic disease will also include hormone involvement, HER2 status, tumor grade, tumor size and many other factors.
Treatments for Stage 4 Breast Cancer
Each case of metastatic breast cancer will be treated differently because of the variety of sites to which the cancer may spread. Your treatment plan will be customized to focus on limiting the spread of cancer and maintaining a good quality of life. You may not need all of the standard therapies that are available, but you will have a lot of options, including participation in a clinical trial. The full array of treatments may include targeted options such as surgery and radiation. You may also need systemic treatments such as chemotherapy (either intravenous or oral), hormone therapy, and targeted biologic therapies. These treatments may be used in combination with other therapies or they may be used one after the other. When one therapy becomes ineffective, you may be given the option to switch to a different drug.
Quality of Life During Treatment
Some of your treatments can make you feel better - if a painful tumor shrinks in response to radiation or hormone therapy - you could feel great relief. But it is a fact of oncology treatment that many drugs will cause unpleasant side effects - nausea, fatigue, pain, neuropathy, mucositis, hair loss, constipation and diarrhea. Try to keep a log of your side effects and bring it with you to your doctor visit. This will help them understand what you are dealing with. You can ask for palliative care to help you cope with these challenges. Medications, physical therapy and other counseling can be given that will help.
Coping With Your Emotions
It is natural to feel depressed, sad, anxious, or even angry when you are diagnosed with metastatic breast cancer. Most of us like to feel that we have some control over our health and our future, but cancer can remove our certainty, limit our plans for the future, and inspire fear in us and in those who care about us. When that happens, draw your loved ones close and find support. Stage 4 support groups welcome new members and are very understanding of your difficulties. Talk with your doctor and nurses about your feelings and ask for help. They may able to prescribe antidepressants, help you find a support group, or refer you to cognitive behavioral therapy or counseling. If you have trouble sleeping, seek out a yoga group or try good sleep hygiene.
AJCC Cancer Staging Manual 6th Edition. Springer Verlag, New York, NY. 2002, pp. 223-240.
Breast cancer survival rates by stage. American Cancer Society. Last Revised: 06/11/2012.
Surveillance Epidemiology and End Results (SEER) Cancer Statistics Review. National Cancer Institute. SEER Stat Fact Sheets: Breast, Survival & Stage. November 2012.
Stages of Breast Cancer. Stage IV. National Cancer Institute. Last Modified: 06/21/2012
Symptom Management in Metastatic Breast Cancer. William Irvin, Jr, Hyman B. Muss, and Deborah K. Mayer. Oncologist. 2011 September; 16(9): 1203-1214. Published online 2011 August 31.
When Cancer Comes Back. Pages 584-597. Dr. Susan Love's Breast Book. Susan M. Love, M.D. Fifth Edition, 2010.