Consider the possibility of metastatic breast cancer if the patient has a symptom that persists over several weeks, tending to get worse rather than better and is otherwise unexplained.

Some cases of metastatic disease will be detected at the same time as presentation with the initial primary breast cancer (‘de novo metastatic disease’).

Signs and symptoms will depend on the type of cancer initially diagnosed and the location of metastatic disease. They may be discovered by the patient or by surveillance in the post-treatment period. Symptoms can often present as bone pain (most common), shortness of breath or cough, weight loss, abdominal symptoms or jaundice.

Other patients may present with symptoms of recurrent disease after a previous cancer diagnosis. Patients can present with symptoms of recurrent disease in the locoregional area, or at distant sites, or both. This may include a breast mass, skin nodules, enlarged lymph nodes or inflammatory cancer symptoms. Some local recurrence is detected at follow-up imaging only.

Some cases of recurrent disease will be detected by routine follow-up in a patient who is asymptomatic.

All cases should undergo investigation (staging scans) to establish the extent of disease and be rebiopsied if possible; biopsies should have receptor status re-evaluated.

Access to the best available therapies, including clinical trials, as well as treatment overseen by a multidisciplinary team, are crucial to achieving the best outcomes for anyone with metastatic or recurrent disease.

Managing recurrent or metastatic disease is complex and should therefore involve all the appropriate specialties in a multidisciplinary team including palliative care where appropriate.

A rebiopsy of accessible sites and re-evaluation of breast cancer receptor profile should be undertaken. Non-bony sites are preferred because processing of bone specimens hinders evaluation of HER2 status.

A complete assessment of the sites of disease including CT of the abdomen and pelvis and of the chest plus bone scans, or PET-CT and blood tumour markers should also be undertaken. Brain CT or MRI may be required. Assessment of organ function and comorbidities are necessary.

From the time of diagnosis, the team should offer patients appropriate psychosocial care, supportive care, advance care planning and symptom-related interventions as part of their routine care. The approach should be personalised to meet the patient’s individual needs, values and preferences. The full complement of supportive care measures as described throughout the optimal care pathway and in Appendices A and B, and in the special population groups section should be offered to assist patients and their families and carers to cope. These measures should be updated as the patient’s circumstances change.

Survivorship care should be considered and offered at an early stage. Many people live with advanced cancer for many months or years. As survival is improving in many patients, survivorship issues should be considered as part of routine care. Health professionals should therefore be ready to change and adapt treatment strategies according to disease status, prior treatment tolerance and toxicities and the patient’s quality of life, in addition to the patient’s priorities and life plans.

If there is an indication that a patient’s cancer has returned, care should be provided under the guidance of a treating specialist. Each patient should be evaluated to determine if referral to the original multidisciplinary team is necessary. Often referral back to the original multidisciplinary team will not be necessary unless there are obvious aspects of care involving different therapeutic and supportive care disciplines not otherwise accessible. The multidisciplinary team may include new members such as palliative care specialists and metastatic breast cancer nurses. If a metastatic breast cancer nurse is not available, then a resident breast cancer nurse who cares for early and metastatic breast cancer patients may be included.

Treatment will depend on the location, extent of recurrent disease, previous management and the patient’s preferences and may include all modalities of therapies (surgery, radiation therapy and systemic therapy). Antiresorptive therapy may be warranted if bone metastases are present.

In most cases, a combination of anti-cancer and supportive therapies will provide the most effective overall management of recurrent disease.

Regular assessment of the patient’s response to therapy should be undertaken and the therapy changed if disease progresses or as appropriate.

In patients with hormone receptor-positive breast cancer without rapidly progressing visceral disease, endocrine therapy combined with a CD4/6 inhibitor may be the most appropriate treatment initially with use of chemotherapy when endocrine responsiveness is lost.

Many endocrine therapies are effective in producing anti-tumour responses in metastatic breast cancer. These can often be used in sequence to gain successive responses to treatment. They include:

• ovarian ablation/suppression in premenopausal women
• selective oestrogen receptor modulators such as tamoxifen
• aromatase inhibitors, which block oestrogen production
• pure antioestrogen fulvestrant.

Treatment may focus on disease control or palliation based on the extent of disease, general health or the patient’s preferences and values.

The potential goals of treatment should be discussed, respecting the patient’s cultural values. Wherever possible, written information should be provided.

Encourage early referral to clinical trials or accepting an invitation to participate in research.

Advance care planning is important for all patients with a cancer diagnosis but especially those with advanced disease. Patients should be encouraged to think and talk about their healthcare values and preferences with family or carers, appoint a substitute decision-maker and consider developing an advance care directive to convey their preferences for future health care in the event they become unable to communicate their wishes (AHMAC 2011).

Refer to section 6.6 ‘More information’ for links to resources.

Refer patients and carers to http://www.advancecareplanning.org.au or to the Advance Care Planning National Phone Advisory Service on 1300 208 582.

Early referral to palliative care can improve the quality of life for people with cancer and in some cases may be associated with survival benefits (Haines 2011; Temel et al. 2010; Zimmermann et al. 2014). The treatment team should emphasise the value of palliative care in improving symptom management and quality of life to patients and their carers.

The lead clinician should ensure timely and appropriate referral to palliative care services. Referral to palliative care services should be based on the patient’s need and potential for benefit, not prognosis.

Pain management intervention may be required. Palliative care services would preferably have access to interventional radiologists and pain services to assist with patients whose pain does not respond to conventional medications.

The ‘Dying to Talk’ resource may help health professionals when initiating discussions with patients about future care needs (see ‘More information’). Ensure that carers and families receive information, support and guidance about their role in palliative care (Palliative Care Australia 2018).

The patient, with support from their family or carer and treating team, should be encouraged to consider appointing a substitute decision-maker and to complete an advance care directive.

These online resources are useful:

• Advance Care Planning Australia
• Care Search
• Dying to Talk
• the Palliative Care resource kit
• Palliative Care Australia (for patients and carers)

The treatment team should support the patient to participate in research and clinical trials where available and appropriate.

For patients with metastatic breast cancer, participation in clinical trials should be revisited by the multidisciplinary team due to alterations in the patient’s disease such as resistance to current treatment or new trials available.

For more information visit the Cancer Australia website.