9 Facts about metastatic breast cancer everyone should know

At 42000 deaths each year, metastatic breast cancer is one of the most common causes of death from cancer among women. Recent studies have shown that people are not aware of metastatic breast cancer. Most participants of the study reported that they knew little to nothing about breast cancer and believed that if caught early and treated well, the disease will go into remission-- which is not always true. Therefore a serious effort for metastatic breast cancer awareness is required to know the facts and have realistic expectations about the disease.

In medical practice, as we have found, awareness is half the battle. Across hundreds of studies, here are the facts about metastatic breast cancer that everybody should know, men included! This information will help us in being proactive and in setting the right expectations.

1. Early detection does not equal cure; 20-30 % of women with the diagnosis of early-stage breast cancer develop metastasis:

It's a common misconception that early detection of breast cancer will help cure the disease. This statement is far from the truth. 30-40 % of women with a diagnosis of early-stage breast cancer develop metastasis, as long as 20 years after the initial cancer treatment.

Cancer can recur after a few months to decades after the initial diagnosis, either as local recurrence or metastasis. While no one can predict which patients will have a recurrence, few contributory factors are: 

The stage at which the diagnosis was first made-- Earlier the diagnosis, lesser the chances of recurrence.

The type of cancer patient had -- Triple-negative breast cancer is more aggressive and more likely to metastasize.

The treatment a patient receives -- People treated with Trastuzumab for HER-2 positive breast cancers are more likely to develop brain metastasis. (P.S: the metastasis, in this case, occurs as a side-effect and not because of wrong treatment).

Although some cases have a higher risk of recurrence and metastasis, everyone who has had breast cancer before is at risk of recurrence with metastasis. 

2. 10% of the breast cancer patients will be diagnosed as metastatic at the beginning:

About 6-10% of the diagnosed patients are metastatic right from the start. Meaning at first diagnosis, they already had breast cancer spread to distant organs. This is known as the de novo Stage 4 Breast Cancer; where de novo means "from the beginning".

However, just because the disease is metastatic from the beginning doesn't mean that it's the worst of all. It is still a serious condition, but the prognosis of de novo breast cancer is better as compared to metastatic breast cancer arising from a lower stage of cancer. The reason being that in the case of de novo breast cancer, the cancer cells have not previously undergone any treatment, and therefore, they respond well to the treatment. On the other hand, metastatic breast cancer stops responding to medical treatment after a while, as the cancer cell develop resistance against the treatment pretty quickly.

The treatment for de novo breast cancer is not different from other types of breast cancer. In particular, cancer responds well to surgery followed by radiotherapy, resulting in a better prognosis. 

3. No one dies of breast cancer itself, but due to the complications arising from metastasis:

Metastatic breast cancer is the last stage of breast cancer, i.e., Stage IV. During this stage, the cancer cells migrate from their site of origin and spread to the distant organ(s) through the bloodstream. Although it's a terminal stage, no one dies from the breast cancer itself. Instead, as per a study, most patients die due to the complications arising from metastasis. 

In this study, the most common cause of death, was found to be metastatic disease to various organs, comprising about 42% of the deaths, followed by infections with 27%. Other causes include cardiac disease (15%), hepatic insufficiency (14%), hemorrhage (9%) and CNS involvement in 9%. 

Tumor growth in organs of the endocrine system, lungs, heart, and genitourinary system often goes unnoticed; seen only in the autopsy, and this contributes to death from metastasis. 

4. Bone, liver, lung, and brain are the most common organs affected:

The most common site for metastasis is bone, liver, lung, and brain. You may have symptoms according to the system involved; bone pain, difficulty in breathing, headaches, hemorrhage, etc.

Cancer formed in the distant organs is made up of breast cancer cells (and not bone cells or liver cells). They are, therefore referred to as metastatic breast cancer and not bone cancer or liver cancer. Being made of breast cancer cells, they respond well to the usual breast cancer treatment. 

Chemotherapy is an essential mode of treatment for distant metastasis, as it's a systemic therapy and the drugs used in chemotherapy can travel via the blood and reach to the sites of metastasis, including the sites that might not be clinically identified. 

Besides chemotherapy, the treatment is given as per the symptoms and complications that result from the involvement of these organs. 

5. Young women, including teens, can have metastasis too:

Another lesser-known fact is that young women can develop breast cancer, as well. There are recorded cases of patients as young as 13 years of age. 

The incidences are pretty low, with less than 6.6% of breast cancer occurring below 40 years of age. For teenagers, the incidence is less than 2%. 

The cause of breast cancer in younger ages is not known. But they have a strong association with a genetic mutation in the BRCA gene, with a strong family history of breast cancer. 

Breast cancer occurring in younger women is typically very aggressive and spreads quickly. They are usually found at later stages of cancer and are less likely to respond to the treatment. This overall results in a poor prognosis. One of the reasons for the delay in diagnosis could be the fact that younger women have a denser breast, and so by the time, a lump appears, the disease reaches an advanced stage. Also, young women tend to ignore minor changes as nobody thinks that breast cancer can occur in younger ages as well. 

For teens, it's important not to confuse the breast bud with a breast cancer lump, as a breast bud also appears as a tender lump. Consulting your doctor will help you clear up any doubts. 

With the onset of your twenties, American Cancer Society recommends: 

Breast exams by a doctor every three years.

To monitor any breast change, which should be brought to the notice of a doctor. 

Mammograms are not recommended at a younger age, as the lumps in younger females are not easily picked up by them due to the density of their breasts. 

6. Even men can have metastatic breast cancer:

Yes, men do have breast. Their breast may not be as developed as a woman, but they do have breast tissue, and this makes them prone to breast cancer as well.

Some of the risk factors for the development of male breast cancer are an imbalance between estrogen and testosterone, history of high radiation treatment for lymphoma, history of the treatment of prostate cancer with estrogen-based drugs, obesity, use of estrogen or testosterone, Klinefelter syndrome, etc.

It is to note that an increased breast size in men does not indicate breast cancer. That is a condition called Gynaecomastia, which is an entirely different, non-cancerous condition.

The incidence of breast cancer in males is 1 in 1000, which contributes to less than 1% of all breast cancers, making them very rare. A rough estimate suggests that about 2670 men will be diagnosed as a case of breast cancer in 2019.

Characteristically, male and female breast cancers do share similar features, and the factors that cause malignant changes are the same in both as well. In fact, breast cancer in males behaves quite similar to breast cancer in postmenopausal females.

It was found in a study that the average time between the occurrence of the first symptom and the diagnosis of male breast cancer was around 29 months initially. Recent studies indicate a reduction by six months. As seen in this study, male breast cancer is usually diagnosed at a later stage -- stage 3 or 4-- unlike most cases in females. The reason for this is lack of awareness; most people don't know that men can have breast cancer as well. 

7. There is no cure, but it can be managed:

Metastatic breast cancer is quite resistant to modern medicine. Therefore, there is no cure for stage IV breast cancer. 

No therapy fits all, and so efforts are made to slow down the spread of the cancer cells and controlling the symptoms, like pain. This overall gives longer life and a better quality of life to the patient. 

Studies have shown that metastatic cells keep on evolving into mutated cells that are resistant to the current treatment. This is one of the significant reasons why it is challenging to cure metastatic breast cancer. As the cells develop resistance against the treatment, Oncologists change the modes of treatment. While this might show an initial improvement, it could be followed by a rapid progression. This cycle continues until the disease stops responding to any treatment.

Treatment can vary depending upon which type of breast cancer the patient is suffering from, and what are the predominant symptoms. The treatment options include chemotherapy, surgery, radiation therapy, hormonal therapy. While these are the same as in other stages of breast cancer, for stage IV, they are intended to stabilize the disease rather than cure it. 

Other modes of treatment are pain management, nutrition therapy, mental and spiritual support. These options contribute to improving the quality of the patient's life. 

8. It is difficult to predict the progression of the disease:

A tumor forms when a cell, for reasons like mutation, fails to stop its growth and continues to multiply-- not following the signals of the body to stop multiplying. This cell will continue to divide and form a bunch of cells together that multiply abnormally fast and enlarges in size rapidly. 

So, in general cancer does not follow the typical "growth rules" of the body, and on top of that, every individual is genetically different. Therefore, it is hard to make predictions like the pace at which the disease will spread, which organs will be involved first, and how the disease will respond to the treatment. 

However, there's a 5-year survival rate given by the American Cancer Society, which provides an estimate of the number of people who will survive for five years following the diagnosis. For metastatic breast cancer, the rate is about 27% for females and 23 % for males. 

 5-Year Survival rate of Breast Cancer*

 *Data from American Cancer Society

9. Men have a lower survival rate as compared to females:

The above table shows that men have a lower survival rate as compared to women. Males also have a lower recurrence survival rate. 

As suggested by a study, the likely cause is that even though male breast cancer is a lot similar to female breast cancer, there are certain biological characteristic differences in the cancer cells of males and females. But because the disease is very rare and has not been studied well yet, the treatment followed for male breast cancer is based on studies conducted in females. 

It was also found in the same study that males were less likely to receive radiation therapy following mastectomy. Radiation therapy is done following surgery to make sure that the cancer cells that may remain after the operation are killed. Therefore, it helps prevent recurrence to a great extent. 

Interestingly, most male breast cancers are hormone-receptor-positive in nature. The treatment for this includes medications that suppress the hormones causing cancer. But it was found in a study that about 20% of males stop taking the medications because of side-effects, like the neurocognitive deficit, sexual dysfunction, leg cramps, thromboembolism, bone pain, etc. These all could be the contributory factor for the lower survival rates in males. 

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