Metastatic breast cancer

Last reviewed: 28 Feb 2023
Last updated: 23 Feb 2023

Summary

Definition

History and exam

Key diagnostic factors

  • presence of risk factors
  • bone pain
  • pleural effusion
  • palpable mass after treatment of the primary tumour
More key diagnostic factors

Other diagnostic factors

  • shortness of breath
  • anorexia
  • weight loss
  • neurological pain or weakness, headaches, seizures
Other diagnostic factors

Risk factors

  • female sex
  • age >50 years
  • family history of breast and/or ovarian cancer
  • breast cancer susceptibility genes
  • tumour >5 cm in diameter
  • high number of positive nodes (e.g., >10)
  • lymphovascular invasion
  • unfavourable 70-gene signature
  • high-risk 21-gene signature
  • high-risk PAM50 gene expression signature
  • minimal residual disease (MRD)
  • bone metastasis and lung metastasis gene signatures
  • Lynch syndrome (hereditary non-polyposis colorectal cancer)
  • CHEK2 mutations
  • ATM mutations
More risk factors

Diagnostic investigations

1st investigations to order

  • FBC
  • LFTs
  • calcium
  • CT (of chest and abdomen)
  • bone scan
More 1st investigations to order

Investigations to consider

  • MRI (focused on area of concern; e.g., bone, brain)
  • PET scan
  • biopsy of metastatic lesion
  • genetic testing
  • multi-gated acquisition (MUGA) scan
  • pleural cytology
  • biomarkers
More investigations to consider

Treatment algorithm

ONGOING

hormone receptor-positive, HER2-negative, without visceral crisis: post-menopausal

hormone receptor-positive, HER2-negative, without visceral crisis: pre-menopausal

hormone receptor-positive, HER2-positive, without visceral crisis: post-menopausal

hormone receptor-positive, HER2-positive, without visceral crisis: pre-menopausal

hormone receptor-negative, HER2-positive, without visceral crisis

PD-L1-negative, triple-negative (hormone receptor-negative, HER2-negative), without visceral crisis

PD-L1-positive, triple-negative (hormone receptor-negative, HER2-negative), without visceral crisis

hormone receptor-positive or negative, HER2-negative, with visceral crisis

hormone receptor-positive or negative, HER2-positive, with visceral crisis

Contributors

Authors

Edward Sauter, MD, PhD
Edward Sauter

Medical and Program Officer

Division of Cancer Prevention

National Cancer Institute

Rockville

MD

Disclosures

ES declares that he has no competing interests.

Wajeeha Razaq, MD

​Breast Cancer Site Chair

University Oklahoma School of Medicine

Oklahoma City

OK

Disclosures

WS declares that she has no competing interests.

Acknowledgements

Dr Edward Sauter and Dr Wajeeha Razaq would like to gratefully acknowledge Dr Puja Nistala, Dr Donald Doll, Dr Carl E. Freter and Dr Michael Perry, previous contributors to this topic.

Disclosures

PN, DD, CEF and MP declare that they have no competing interests.

Peer reviewers

Alan Neville, MD

Professor

Assistant Dean

Undergraduate Program

McMaster University

Hamilton

Ontario

Canada

Disclosures

AN declares that he has no competing interests.

Gianfilippo Bertelli, MD, PhD, FRCP (Edin)

Consultant

Honorary Senior Lecturer in Medical Oncology

South West Wales Cancer Centre

Swansea

UK

Disclosures

GB has received honoraria for participation in advisory boards (AstraZeneca, Novartis, Pfizer, Roche, GSK, Cephalon, Amgen, Sanofi, Aventis), speaker's fees (AstraZeneca, Novartis, Sanofi, Aventis), and hospitality at conferences (AstraZeneca, Novartis, Pfizer, Roche, Aventis).

Christos Vaklavas, MD

Assistant Professor

Division of Hematology/Oncology

Department of Medicine

University of Alabama at Birmingham

Birmingham

AL

Disclosures

CV declares that University of Alabama at Birmingham has received research support from Pfizer, F. Hoffmann-La Roche, and Incyte.

  • Differentials

    • Lung cancer
    • Osteosarcoma
    • Breast sarcoma
    More Differentials
  • Guidelines

    • Management of advanced human epidermal growth factor receptor 2-positive breast cancer and brain metastases: ASCO guideline update
    • Biomarkers for systemic therapy in metastatic breast cancer: ASCO guideline update
    More Guidelines
  • Patient leaflets

    Breast cancer, locally advanced: what is it?

    Breast cancer, locally advanced: what treatments work?

    More Patient leaflets
  • padlock-lockedLog in or subscribe to access all of BMJ Best Practice

Use of this content is subject to our disclaimer