Despite important therapeutic innovations within the past several years, the odds of patients with metastatic breast cancer achieving complete response remain extremely low. Judiciously applied multiple endocrine, chemotherapeutic, or biologic therapies attempt to induce a series of remissions and ultimately adequate palliation. Patients with localized breast or chest wall recurrences, however, may be long-term survivors with appropriate therapy. At present, there is a lack of both a consensus management algorithm and an ideal treatment model of specific subsets of women. Before treatment selection for recurrent or metastatic cancer, restaging to evaluate extent of disease is indicated. In the absence of symptomatic disease, the usefulness of a routine diagnostic work-up is not evidence-based. Diagnostic tests and staging procedures are directed by the organ sites most frequently involved in metastatic breast cancer and by patient signs and symptoms. Documentation of initial metastatic sites is helpful in treatment planning and in later assessment of response to treatment. Over the past 45 years, the American Joint Committee on Cancer has regularly updated its staging standards to incorporate advances in prognostic technology.1,2 However, until the development of prognostic indices based on molecular markers are incorporated, Tumor-Node-Metastasis (TNM) staging continues to quantify only the physical extent of the disease. Anatomic staging continues to play a major role in guiding treatment decisions. Clinical decision-making still involves a number of patient and tumor characteristics.3-5 Pretreatment prognostic (measures of tumor burden or hormonal receptor status) and predictive factors (hormonal receptor and HER-2/neu status) are considered in order to select a therapy most likely to benefit patients.6
Given the biologic heterogeneity of the disease in primary and metastatic settings, the potential for continued mutation, and the variety of treatment options available, the information obtained at the initial diagnosis of breast cancer may not be as relevant to planning the treatment for recurrence in women who have recurrent metastatic breast cancer years after their initial diagnosis. Appropriate risk and biologic stratification in breast cancer will offer the unique opportunity for development of more effectively tailored targeted therapies.
Obtaining a comprehensive history is essential to provide pertinent information of primary diagnosis, treatment management, toxicity complications, and interval period to disease recurrence. Comorbidity, current medications, allergies, and menopause status is important for management planning and treatment selection. There is a great heterogeneity in the clinical presentation of metastatic breast cancer. Certain characteristics can be used to predict favorable clinical course, including long disease-free interval, hormone receptor positivity, response to prior endocrine therapy or chemotherapy, single site of metastases, and lack of liver, parenchymal lung, or central nervous system involvement. Early failure (< 6 months) on hormone therapy suggests that cytotoxic chemotherapy should be the next modality employed.
In metastatic breast cancer, maintenance of quality of life and elimination of cancer-related symptoms is the major objective. Patients with estrogen receptor–positive tumors are especially unlikely to suffer recurrence initially in the brain or liver. Routine brain and liver imaging procedures are expensive and are not indicated in the absence of symptoms, physical findings, ...