Treatment options and supportive care

In Germany, metastatic breast cancer can be treated in certified breast cancer centers (Brustkrebszentren) or tumor centers as well as practices that are specialized in oncology. There, specialists from different disciplines work together to treat the various effects that both the disease and the treatment have on your body and mind. Metastatic breast cancer can also be treated in hospitals or practices without this certification.

If breast cancer has spread to other parts of the body, the entire body is usually treated with medication (systemic therapy) to limit tumor growth. Either hormone treatment or chemotherapy can be used for this purpose. Certain types of breast cancer can also be treated with targeted therapies, for example antibody therapy or CDK4/6 inhibitors.

Usually, different treatments are used one after the other or combined with each other. If tumor cells stop responding to a certain drug after a while, another drug or treatment approach can be tried out. This step-by-step approach is known as sequential therapy.

Depending on where they are growing, some metastatic tumors can be treated individually – they can be targeted with radiation, for instance, or perhaps removed surgically.

Because the type of breast cancer and the way it progresses varies so much from woman to woman, there’s no such thing as “the” best treatment. It is important to find suitable, individually tailored treatments for each phase of the disease and to coordinate the different treatments in the best possible way. That requires close cooperation between the doctors and within the treatment team.

Questions often arise in these situations – for instance, about the treatment options, what effects the treatment might have, or whether you can take part in clinical trials. It can help to write these questions down before going to an appointment. You can also ask a loved one to come to the doctor’s appointment with you so you don't forget anything.

You will normally be able to take your time to consider the pros and cons of a suggested treatment and think things over for a few days or weeks. Starting treatment a bit later generally doesn’t affect the outcome of treatment. If necessary, you can also get more information or a second opinion before making a decision. And you always have the right to refuse a treatment or to stop it – no matter whether it has been offered or started at a doctor’s practice, in a hospital, or as part of a clinical trial.

Some people set their hopes on alternative approaches if conventional medicine can't guarantee a cure or significant improvement (anymore). But constantly trying out new therapies can lead to repeated disappointment. You should be particularly careful when it comes to remedies or methods that are meant to be used instead of medical treatment rather than alongside it, that promise to cure the cancer and/or that are very expensive and that you have to pay for yourself. People making these kinds of promises may turn out to be charlatans.

Cancer treatment can be difficult to go through. It often has severe side effects and sometimes leads to other health problems. The side effects vary depending on the kind of treatment, but they can usually be effectively treated themselves. Treating side effects is part of what is known as supportive care. If the treatment is too distressing, though, there may be good reasons for deciding not to have (further) treatment.

One common side effect is fatigue (debilitating physical and mental exhaustion). This can make it impossible or very difficult to perform even small everyday tasks. People may be affected by fatigue the whole time they are having treatment, and sometimes even longer. It is most likely caused by physical and psychological reactions to the disease and the treatment. Fatigue can be a big problem and make people feel (more) down. It is important to talk to your doctor and find your own personal way to deal with fatigue. Exercise, endurance sports and strength training can help to relieve the fatigue when adjusted to suit your overall physical condition.

Any life-threatening disease that involves repeated courses of physically draining treatment will inevitably end up affecting your mental health too. Most people in this situation will feel down from time to time. If these feelings last for a longer period of time, depression may develop. Depression is also a serious illness, so it's important to seek treatment for it.

The disease and treatment can be physically and mentally challenging, but there’s no need to face it alone. It is anything but easy to come to terms with the shock of the diagnosis, dealing with worries about the future and existential questions concerning life and death. Accepting help can allow you to save your strength and make it easier to find ways to live as good a life as possible with the disease.

Nowadays, psycho-oncological care is an important part of good cancer treatment. Psycho-oncologists are psychological experts, medical experts and/or social workers who are specially trained to help cancer patients. If you wish, they can support you and your family in coping with the emotional and social aspects of the disease. They may offer things like relaxation therapy, individual or group talking therapy sessions, couples counseling, and art or music therapy.

Note: The following information describes the situation in Germany. The specifics of treatments and other offers may be different in other countries.

In the hospital, this kind of support is mainly provided by doctors and nurses. They sometimes work together with psycho-oncology services (psychoonkologische Dienste). Psycho-oncological support is also offered as part of rehabilitation. People who are at home can make use of outpatient help. This kind of support is offered by the following specialists and facilities:

• Outpatient psycho-oncology departments of hospitals and certified centers
• Practices specialized in oncology
• Psychosocial cancer information centers (psychosoziale Krebsberatungsstellen)
• Practice-based psychotherapists

Disease management programs are structured treatment programs for people who have chronic diseases. They aim to provide patients with treatments that have a scientifically proven benefit and are tailored to their individual situation. People with a chronic disease should be offered comprehensive care, advice and information. Statutory health insurance funds in Germany have offered DMPs since 2002.

The programs include regular doctor’s appointments, consultations and examinations. Participation is voluntary and doesn't involve any extra costs. But people who take part in a DMP commit to actively participating in their treatment. That includes regularly going to doctor's appointments, for example. Doctors and medical facilities that take part in these programs are committed to complying with certain quality requirements. You can contact your statutory health insurer to find out whether they offer a DMP for breast cancer.

Under certain conditions, it might be possible to have treatment as part of a clinical trial. This is a type of scientific study that tests medications or non-drug treatments and compares them with other treatments. For example, participants might be given new drugs, the effects of which are not yet completely known, or for which more experience with larger patient groups is needed in order for them to be approved. But this doesn't mean that patients are exposed to incalculable risks. Clinical trials are carefully planned according to strict quality standards, reviewed by expert committees and supervised by specialists. Both the effectiveness and the side effects of the medications that are used are closely monitored. You can choose to leave a clinical trial at any time.

Patients who take part in a clinical trial have more intensive care. But they also have to be prepared to be more involved in the treatment and, in many cases, to have more check-ups than usual. In order to weigh the pros and cons of taking part in a clinical trial, it's important to get all the information and advice you need first. It is also important to discuss this option and coordinate things well with your doctors.

In Germany, the German Society of Senology and the German Clinical Trials Register can provide further information and help you to look for clinical trials of breast cancer treatments.

Cancer therapies that aim to slow down or to stop cancer cell growth often have severe side effects. Some women might decide not to have further treatment if their treatment is having little effect, but a lot of unpleasant side effects.

If women decide not to have treatment to fight the cancer itself, they can still have palliative treatment to relieve the pain and symptoms caused by the disease. In other words, if you decide not to have a (new) course of treatment, you will still receive medical care. You can also decide to have cancer treatment again after a treatment-free period whenever you wish.

Treatment that doesn't aim to cure a disease, but instead help you live with it and relieve symptoms like pain, is also called “palliative care." People often think this only applies to the last few weeks of someone’s life. But you can have palliative care for many months or years. Depending on the patient’s symptoms and wishes, this treatment can already start shortly after metastatic cancer is diagnosed.

Palliative treatment, care and support can either be provided at home or in an inpatient facility. It is also provided in hospitals or hospices that offer care during the day.

A specially trained team of doctors, nurses, physiotherapists, social workers, chaplains and volunteers manages the palliative care. Depending on the person's physical and mental health, the focus may be on managing in everyday life or on accompanying them towards the end of life.