Management of metastatic breast cancer

A. Cannot yet be considered curable; survival duration extremely variable, may be many years.

B. Hormone therapy in patients with positive estrogen receptor, long disease-free interval, and metastases to skin, nodes, bone.

C. Chemotherapy for ER negative, short disease-free interval, visceral involvement, refractory after hormone therapy.

D. Palliative X-ray therapy, especially to bone, is often very useful.

E. High dose chemotherapy with hematologic reconstitution using growth factors plus peripheral blood progenitor cells and/or marrow autografts.

1. Increasingly used but still lacking adequate controlled data on efficacy.
2. Is not indicated for refractory and/or heavily pretreated patients; essentially no long term disease-free survival in that setting.
3. Best results are as first treatment of metastatic disease after induction (proving responsiveness) with standard chemotherapy; young patients with minimal sites of disease, minimal volume of disease, no liver disease, no skeletal involvement are the best candidates.
   
   • Even in this most favorable small subset of metastatic breast cancer, continuing complete remissions achieved in only 20-40% of those transplanted.
   • It is unknown if whether "double transplants", marrow pursing can improve results.

F. On the horizon: clinical testing of compounds that specifically antagonize growth factors or block growth factor receptors.