The key signs of metastatic breast cancer depend on where the cancer has spread.
Metastatic breast cancer is the most advanced stage of breast cancer (also known as stage IV), which means the cancer has spread beyond the breast to other parts of the body.
Some women have metastatic breast cancer when they are first diagnosed (called de novo metastatic breast cancer), but this is uncommon. “About 10% of breast cancers present initially with metastatic disease, but the majority of patients present with early stage breast cancer,” says Amy Tiersten, MD, a hematologist and oncologist at the Mount Sinai Hospital in New York City.
While many cases of early stage cancer can be cured, in some instances the cancer comes back years later as metastatic breast cancer, and is typically diagnosed during routine follow-up appointments. “Those visits are about screening patients for any symptoms that could be suggestive of metastatic disease,” says Dr. Tiersten. “[Looking for] metastatic breast cancer is very symptom driven.”
Symptoms of Metastatic Breast Cancer
The most common sites for metastatic breast cancer to spread are:
- Lymph nodes
Rarely, metastatic breast cancer will spread to the ovaries. The symptoms that present with metastatic breast cancer usually depend on where the cancer has spread.
“[During the follow-up appointment] we do a very careful history about any new symptoms they might be having as well as a physical exam,” says Dr. Tiersten. “So, it could be something we find on physical exam. For example, if someone has lung metastases with fluid around the lung you can hear that with a stethoscope.”
Bone metastasis symptoms
The bones are the most common place where metastatic breast cancer cells tend to spread. For more than half of women who develop stage IV breast cancer, the bones are the first site of metastasis. Although breast cancer can spread to any bone, the most common sites are the ribs, spine, pelvis, and long bones in the arms and legs. If metastatic breast cancer has spread to the bones, the patient might have:
- Unexplained bone pain
- Weakened bones that are more vulnerable to fractures
“We all get aches and pains, but the key finding here is that there’s no explanation [and] no injury. There’s a new pain somewhere and it’s just not getting better or it’s getting worse. That would be something to call your oncologist about,” says Dr. Tiersten.
Lung metastasis symptoms
When breast cancer moves into the lungs, it often causes no symptoms. Instead, a tumor might be first discovered on an imaging study done as part of treatment follow-up, such as a chest CT (computed tomography) scan. If metastatic breast cancer has spread to the lungs, a patient might have these symptoms:
- Chronic cough
- Shortness of breath
- Chest pain
Liver metastasis symptoms
When breast cancer moves into the liver, it may not present symptoms either. It may first be picked up by liver function tests, which are blood tests that measure certain levels of enzymes and proteins in the blood. Abnormal levels can indicate liver disease or damage. If metastatic breast cancer has spread to the liver, a patient might have these symptoms:
- Jaundice (yellowing of the skin or eyes)
- Itchy skin or rash
- Abnormally high enzymes in the liver
- Abdominal pain
- Appetite loss
- Vomiting or nausea
Lymph node metastasis symptoms
If breast cancer has spread to the lymph nodes, it doesn’t automatically mean you have metastatic breast cancer. After or during early stage breast cancer treatment, your doctor may perform a physical exam to check for changes to the lymph nodes. Lymph nodes are small and hard to find, but when there’s an infection or cancer, they can grow larger. Your doctor will look for:
- A lump or swelling in the armpit
- A lump or swelling in the collar or breast bone
Even though a physical exam may be performed, a pathology exam is the best way to know your lymph node status. To conduct this, your doctor will remove one or more of the lymph nodes under the arm near the original cancer site to see if the cancer has spread. If cancer cells are found, that’s called lymph node involvement.
The more lymph nodes that contain cancer cells, the more serious the cancer might be. “Breast cancer can spread through the lymph nodes under the arm, and travel by lymphatic channels or blood vessels to other parts of the body,” says Dr. Tiersten.
Brain metastasis symptoms
About 10% to 15% of women with stage IV breast cancer develop brain metastases. In most cases, the breast cancer has already traveled to another part of the body, such as the bones, liver, or lung. However, for about 17% of women in this group, the brain is the only site of metastasis. If metastatic breast cancer has spread to the brain, a patient might have these symptoms:
- Persistent, progressively worsening headaches or pressure to the head
- Vision disturbances
- Vomiting or nausea
- Behavioral or personality changes
The risk of cancer spreading to the brain is usually highest for women with more aggressive subtypes of breast cancer, such as HER2-positive or triple-negative breast cancer.
If you’ve had early-stage breast cancer, it’s important to be on the lookout for any of these new or unusual body changes, and talk to your oncologist if you’re concerned. But Dr. Tiersten doesn’t want her patients living in constant fear of metastatic breast cancer either.
“It’s really important to educate people on how well people can do. A lot of patients can do really well with metastatic disease and live many years with good quality and quantity of lives, we have great treatment for it,” says Dr. Tiersten. Patients are living sometimes without evidence of disease for many years more and more.”
Dr. Tiersten is a professor of medicine, hematology, and medical oncology at the Icahn School of Medicine at Mount Sinai. She sees patients at the Dubin Breast Center.
00:00:00,000 --> 00:00:03,288
00:00:03,288 --> 00:00:07,460
We typically see patients every three
months the first year, usually every
00:00:07,460 --> 00:00:11,435
six months after that, so those visits
are about screening patients for
00:00:11,435 --> 00:00:15,180
any symptoms that could be
suggestive of metastatic disease.
00:00:15,180 --> 00:00:19,320
So it's really generally
a symptom-directed workup in presentation
00:00:20,970 --> 00:00:24,417
00:00:24,417 --> 00:00:28,463
Metastatic breast cancer is breast cancer
that has spread from the breast to other
00:00:28,463 --> 00:00:29,410
parts of the body.
00:00:29,410 --> 00:00:32,910
So that would be most commonly bone,
followed by lung or
00:00:32,910 --> 00:00:35,200
liver, sometimes lymph nodes.
00:00:35,200 --> 00:00:37,830
It can also,
sometimes spread to the brain.
00:00:37,830 --> 00:00:39,440
If cancer is spread to the bone,
00:00:39,440 --> 00:00:42,675
the most common symptom someone
will present with is bone pain.
00:00:42,675 --> 00:00:44,346
And we all get aches and pains, but
00:00:44,346 --> 00:00:48,326
they key finding here is that there's no
explanation, there is not injury said,
00:00:48,326 --> 00:00:52,305
there's a new pain somewhere and it's
just not getting better or getting worse,
00:00:52,305 --> 00:00:55,480
that would be something to
call your oncologist about.
00:00:55,480 --> 00:00:59,570
In terms of lungs, patients can sometimes
present with a cough that doesn't go away,
00:00:59,570 --> 00:01:01,630
sometimes shortness of breath.
00:01:01,630 --> 00:01:08,158
And liver metastasis can sometimes present
with a change in appetite, nausea.
00:01:08,158 --> 00:01:11,420
In a very advanced situation,
sometimes people present with jaundice.
00:01:11,420 --> 00:01:16,410
And if there's obstruction of the bile
duct and can present with yellow eyes or
00:01:16,410 --> 00:01:18,060
00:01:18,060 --> 00:01:22,220
Breast cancer can spread through
the lymph nodes under the arm and
00:01:22,220 --> 00:01:27,670
travel by lymphatic channels or
blood vessels to other parts of the body.
00:01:27,670 --> 00:01:31,500
You worry about brain metastasis if
someone presents with new dizziness,
00:01:31,500 --> 00:01:35,900
new blurry vision, new headaches that are
persistent that are not getting better,
00:01:35,900 --> 00:01:40,950
change in personality, memory changes,
things along those lines.
00:01:40,950 --> 00:01:45,800
About 10% of breast cancers present
initially with metastatic disease, but
00:01:45,800 --> 00:01:49,590
the majority of patients present
with early stage breast cancer.
00:01:49,590 --> 00:01:53,760
And although we're doing so much better in
terms of curing so many of those patients,
00:01:53,760 --> 00:01:57,960
some of those patients ultimately
do recur with distant metastases.
00:01:57,960 --> 00:02:02,681
It is not recommended to do routine blood
work or routine scans in the follow up of
00:02:02,681 --> 00:02:06,849
early stage breast cancer patients
looking for metastatic disease.
00:02:06,849 --> 00:02:10,098
And that's really because it's
never been shown to be helpful, so
00:02:10,098 --> 00:02:11,470
it's very symptom driven.
00:02:11,470 --> 00:02:15,330
So we see patients who follow up usually
every three months the first year,
00:02:15,330 --> 00:02:17,580
every six months or so after that.
00:02:17,580 --> 00:02:21,660
And we do a very careful history about any
new symptoms they might be having as well
00:02:21,660 --> 00:02:22,804
as any physical exam.
00:02:22,804 --> 00:02:26,504
And I think it's really important
to educate people about how well
00:02:26,504 --> 00:02:27,370
people can do.
00:02:27,370 --> 00:02:32,010
Not everyone, but a lot of patients can
do very well with metastatic disease and
00:02:32,010 --> 00:02:35,690
live many years sometimes with
good quality and quantity of life.
00:02:35,690 --> 00:02:39,300
Do normal things, continue to work,
go to bab mitzvahs and weddings and
00:02:39,300 --> 00:02:40,680
live their lives.
00:02:40,680 --> 00:02:43,690
Patients are living sometimes
without evidence disease for
00:02:43,690 --> 00:02:45,390
many years more and more.
00:02:45,390 --> 00:02:47,410
We're seeing more and more of that.
00:02:47,410 --> 00:02:48,811
Systemic treatment for metastatic breast cancer: General principles. UpToDate. (Accessed on April 9, 2018 at https://www.uptodate.com/contents/systemic-treatment-for-metastatic-breast-cancer-general-principles)
Breast Cancer Treatment (PDQ®)–Patient Version. National Cancer Institute, 2018. (Accessed on April 9, 2018 at https://www.cancer.gov/types/breast/patient/breast-treatment-pdq#section/_148)
Lymph Node Status. Susan G. Komen Breast Cancer Foundation. (Accessed on April 9, 2018 at https://ww5.komen.org/BreastCancer/LymphNodeStatus.html)
Lymph Nodes and Cancer. American Cancer Association. (Accessed on April 9, 2018 at https://www.cancer.org/cancer/cancer-basics/lymph-nodes-and-cancer.html)