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.