SECONDARY BREAST CANCER IN THE BRAIN

This information describes what secondary breast cancer in the brain is, possible symptoms and the treatments used.

We hope this information answers any questions you have about your condition and helps you discuss your options with your treatment team.

We suggest you listen to this information with our Secondary breast cancer information pack, which contains information that may be useful from the time you’re diagnosed and throughout your treatment and care. It also covers the physical and emotional impact of living with secondary breast cancer and the support available.

WHAT IS SECONDARY BREAST CANCER IN THE BRAIN?

Secondary breast cancer in the brain occurs when cancer that started in the breast has spread to the brain.

It’s not the same as having cancer that starts in the brain. The cells that have spread to the brain are breast cancer cells.

Breast cancer cells can spread to the brain through the lymphatic system or the blood.

You may hear this type of spread described as metastatic breast cancer, metastases, advanced breast cancer, secondary tumours, secondaries or stage 4 breast cancer.

For most people with secondary breast cancer in the brain, breast cancer has already spread to another part of the body such as the bones, liver or lungs. However, for some people, the brain may be the only area of secondary breast cancer.

OUTLOOK (PROGNOSIS)

When breast cancer spreads to the brain, it can be treated but cannot be cured.

Treatment aims to control and slow down the spread of the cancer, relieve symptoms and give you the best quality of life for as long as possible.

After a diagnosis of secondary breast cancer in the brain, many people want to know how long they’ve got to live. As treatments have improved, more and more people are living longer after a diagnosis of secondary breast cancer. Life expectancy is difficult to predict as each person’s case is different and no two cancers are the same.

Your specialist can talk to you about the likely progression of your secondary breast cancer. You may worry if they cannot give you a clear answer, but it’s difficult to accurately predict how each person’s illness will respond to treatment.

THE BRAIN

To understand some of the symptoms described in this booklet, it may help to know more about the brain.

The brain controls:

·         The body’s functions such as speech and movement

·         Our thought processes, feelings and emotions, and how we behave

·         Vision, coordination and balance

·         How we understand our surroundings

·         How we learn and our memory

SYMPTOMS

Symptoms will depend on which area of the brain is affected. This is because different parts of the brain are responsible for different functions in the body.

Symptoms can range from very mild to severe, depending on how much of the brain is affected by the cancer.

Report any new or lasting symptoms to your treatment team.

Symptoms include:

·         Headache

·         Nausea (feeling sick) and vomiting (being sick)

·         Weakness or feeling numb down one side of the body

·         Unsteadiness or loss of balance and co-ordination

·         Seizures (fits)

·         Difficulty with speech

·         Problems with vision

·         Changes in behaviour, mood or personality

·         Confusion

·         Memory problems

TESTS YOU MAY NEED

Your specialist will examine you and discuss any symptoms you have.

You may need one or more of the following tests to help confirm a diagnosis of secondary breast cancer in the brain.

Neurological examination

A neurological examination is a series of simple tests that provide information about the nervous system.

Your specialist may look in your eyes with an instrument called an ophthalmoscope to see if there is swelling at the back of the eyes caused by pressure from the brain.

They may check your arms and legs for changes in feeling and strength, and changes in your reflexes.

They may also look at your balance and how you are walking.

CT (computerised tomography) scan

This uses x-rays to take detailed pictures across the body.

Before the scan you may be given a liquid known as a contrast solution. This is usually injected into a vein, and helps produce clearer images to identify the number, size and location of areas of cancer.

A CT scan is more likely to be the first scan if your symptoms are sudden, for example if you went to A&E.

MRI (magnetic resonance imaging) scan

Doctors will usually use an MRI scan to look for secondary cancer in the brain. This scan uses magnetism and radio waves to produce a series of images of the inside of the body. An MRI does not expose the body to x-rays.

A contrast solution is usually injected into a vein before the scan.

An MRI provides a different type of picture of the brain than a CT scan, so your doctor may want you to have both types of brain scan.

Brain biopsy

In most cases your specialist will be able to tell if you have secondary breast cancer in the brain from your symptoms and scans. Very occasionally a biopsy is needed to confirm the diagnosis.

This involves removing a small piece of tissue from the brain, under general anaesthetic, to be examined under a microscope.

Tumour marker tests

Some people have a blood test for tumour markers. These are proteins found in the blood which may provide more information about how you’re responding to treatment or if the cancer is progressing. There’s some debate about the accuracy of measuring tumour markers, so they are not used by all specialists.

TREATING SECONDARY BREAST CANCER IN THE BRAIN

To treat secondary breast cancer in the brain and its effects you may be offered:

·         Steroids

·         Radiotherapy

·         Surgery

Treatments that affect the whole of the body include:

·         Hormone (endocrine) therapy

·         Targeted (biological) therapy

·         Chemotherapy

These treatments may be given alone, in combination or in sequence.

Cancer in the tissue around the brain and spinal cord

Sometimes breast cancer spreads to tissues and fluid that surround the brain and spinal cord. This is known as leptomeningeal metastases.

Symptoms are similar to those of secondary breast cancer in the brain, but may be less obvious and more difficult to diagnose.

It’s usually diagnosed using an MRI scan, but you may also have a lumbar puncture (a needle inserted into the spine) to take a sample of fluid to be looked at under a microscope.

Treatment can include steroids, radiotherapy and chemotherapy. Chemotherapy or targeted therapy drugs may be given directly into the fluid surrounding the brain and spinal cord to treat the cancer.

Decisions about treatment

When deciding how best to treat you, your treatment team will consider:

·         How many tumours you have

·         The total amount of space taken up by the secondary breast cancer in the brain

·         Which parts of the brain are affected

·         Whether the cancer has spread elsewhere in the body

·         Whether any other areas of secondary breast cancer are under control

·         Any symptoms you have

·         What treatment you’ve had in the past

·         The features of the cancer

·         Whether you’ve been through the menopause

·         Your general health

Your treatment team should discuss any recommendations for treatment with you and take into account your wishes.

They will talk with you about your options, explain what the aim of treatment will be and help you weigh up the potential benefits against the possible side effects you may have.

Who will treat me?

Your care will continue under your breast oncologist.

They will often ask the advice of the neuro-oncology multidisciplinary team. This is a team of doctors who specialise in treating tumours in the brain, and includes neurosurgeons, neuro-oncologists, clinical nurse specialists and radiographers.

Questions you may want to ask

To help you feel confident that you’re getting the best care, you may want to ask your treatment team about:

·         Your treatment options, and why they’re recommending a particular drug, type of treatment or procedure

·         The aim of your treatment

·         The side effects you might get and how you can manage them

·         Whether there are additional options for you, including new procedures or treatments at other centres where you could be referred

·         Any clinical trials you may be eligible for

·         Whether a referral to an expert, such as a surgeon specialising in the brain, is appropriate

·         The risks and benefits of each treatment they have recommended

·         What to do if you get new symptoms or side effects from your treatment

You can also ask if there’s a specialist nurse to go over your plan, repeat information or explain any new terms to you. It’s important that you understand what’s happening and why.

Steroids

Steroids are made naturally in the body, but can also be produced artificially for use as medicines.

Steroid drugs, such as dexamethasone, can reduce swelling and pressure caused by the growth of secondary breast cancer in the brain or its treatment (such as radiotherapy). They can also relieve symptoms such as headaches and nausea.

You may start taking steroids before you have any investigations because they can begin to relieve your symptoms quickly.

Steroids are taken as tablets, usually twice a day, in high doses at first.

Once any symptoms are controlled, your doctor will start to reduce the dose gradually. Your dose may be increased or decreased at different times, depending on your symptoms and any treatment you have had.

It’s very important not to stop taking steroids suddenly, so make sure you don’t run out.

Side effects of steroids

Some of the more common side effects of steroids in high doses are:

·         Indigestion, when taken on an empty stomach

·         Thrush (candidiasis) in the mouth

·         Increased appetite

·         Sleeplessness, when taken later in the day

·         Mood swings

·         Weight gain

·         Muscle weakness

·         Feeling restless or agitated

·         Skin changes

·         Diabetes

·         Blood clots

Taking steroids with food at breakfast and lunchtime will help avoid side effects such as indigestion. You will usually be given another tablet to protect your stomach lining.

Taking steroids earlier in the day can help prevent sleeplessness at night.

If you’re concerned about any of these side effects, it may help to discuss them with your treatment team or palliative and supportive care team.

In the UK, if you take steroids for more than three weeks you will be given a blue ‘steroid card’. Always keep hold of the card and show it to any doctor or nurse treating you.

Radiotherapy

Radiotherapy is the most common treatment for secondary breast cancer in the brain.

It uses high energy x-rays to destroy cancer cells.

It may be given as:

·         Stereotactic radiosurgery or radiotherapy

·         Whole brain radiotherapy

Stereotactic radiosurgery or radiotherapy

Stereotactic radiosurgery or radiotherapy is a very precise radiation treatment.

It may be considered for people with a single or limited number of small secondary cancers in the brain. It may also be given in combination with surgery or whole brain radiotherapy.

High doses of radiation are delivered with extreme accuracy to targeted areas, avoiding healthy brain tissue. Because of this, stereotactic radiosurgery causes fewer side effects than whole brain radiotherapy.

Treatment is often given in a single visit. It can be repeated if secondary breast cancer in the brain comes back.

Stereotactic radiosurgery or radiotherapy may be delivered using a number of different treatment machines, including Gamma Knife or CyberKnife.

It’s a specialist treatment that’s not available in all hospitals, so you may need to travel to a different centre.

Your treatment team will tell you if it might be suitable for you.

Whole brain radiotherapy

Radiotherapy may be given to the whole brain if there are a number of areas of secondary breast cancer in different parts of the brain, or if you have leptomeningeal metastases.

Whole brain radiotherapy may also be given after surgery or stereotactic radiosurgery.

It’s usually given in daily doses over one to ten days, but this can vary.

Side effects of radiotherapy

Fatigue (extreme tiredness) is a common side effect of radiotherapy and can be particularly noticeable when radiotherapy is given to the brain. For more information about fatigue.

Hair loss is another common side effect. Hair usually starts to grow back two to three months after treatment has finished, although it may not grow back completely or evenly. For more information see our Breast cancer and hair loss booklet.

Whole brain radiotherapy can cause changes to the brain tissue. You may have problems thinking clearly, difficulty managing tasks you previously found easy, and poor memory or confusion. For most people these symptoms settle over time. An occupational therapist can help you to manage everyday tasks. Ask your treatment team or GP if you’d like to be referred.

Surgery

Although it will not cure secondary breast cancer in the brain, surgery to remove the area or areas of cancer may be recommended.

Surgery is more likely if there is a single or very few areas of cancer in the brain that the surgeon can safely access. It may also be considered if the cancer is causing pressure on the brain.

Surgery can be repeated if secondary breast cancer in the brain comes back.

Surgery for secondary breast cancer in the brain is a very specialised treatment and is often followed by a course of radiotherapy.

Whether surgery is a suitable option will depend on the possible improvement to your quality of life, your general health and fitness, and whether secondary breast cancer is affecting other areas of your body.

Hormone (endocrine) therapy

Hormone therapy is used to treat breast cancers that are stimulated to grow by the hormone oestrogen.

This type of breast cancer is called oestrogen receptor positive (ER+).

Hormone therapies block or stop the effect of oestrogen in the body on breast cancer cells. Different hormone therapy drugs do this in different ways.

Testing for hormone receptors

If you had a biopsy or surgery for primary breast cancer, the tissue removed will have been tested to see if it was ER+.

In some people oestrogen receptors change when secondary breast cancer develops.

Your doctor may discuss doing a biopsy of an area of secondary breast cancer to retest for hormone receptors.

Blood–brain barrier

The blood–brain barrier is a natural filter that protects the brain from harmful chemicals. It only allows certain substances through from the blood to the brain tissues. Because of the blood–brain barrier some drugs may not be as effective in treating secondary breast cancer in the brain as they are in other parts of the body. Your treatment team can discuss this with you.

Hormone therapy drugs

If you’ve had hormone therapy before, your doctor may prescribe the same drug again or a different one.

The most commonly used hormone therapy drugs are:

·         Tamoxifen

·         Goserelin (Zoladex)

·         Aromatase inhibitors (anastrozole, exemestane and letrozole)

·         Fulvestrant (Faslodex)

It can take two to three months before any benefits from hormone therapy are seen.

Hormone therapy may be given in combination with targeted therapies (see below).

We have booklets and online information about different hormone therapy drugs, including their side effects.

Targeted (biological) therapies

This is a group of drugs that block the growth and spread of cancer. They target and interfere with processes in the cells that help cancer grow.

The type of targeted therapy you are offered will depend on the features of your breast cancer.

For information about different types of targeted therapy see breastcancernow.org/targeted-therapy

HER2 positive breast cancer

Some breast cancer cells have a higher than normal level of a protein called HER2 (human epidermal growth factor receptor 2) on their surface, which stimulates them to grow.

This is known as HER2 positive breast cancer.

If you had a biopsy or surgery for primary breast cancer, the tissue removed will have been tested to see if it was HER2 positive.

In some people HER2 levels change when secondary breast cancer develops.

Your doctor may discuss doing a biopsy of an area of secondary breast cancer to retest HER2 levels.

Targeted therapies for HER2 positive breast cancer include:

·         Trastuzumab (Herceptin is the best-known brand name)

·         Pertuzumab (Perjeta)

·         Trastuzumab emtansine (Kadcyla)

·         Lapatinib (Tyverb)

HER2 negative breast cancer

If your cancer is HER2 negative and oestrogen receptor positive, you may be offered a targeted therapy in combination with hormone therapy.

Targeted therapies for HER2 negative breast cancer include:

·         Palbociclib (Ibrance)

·         Ribociclib (Kisqali)

·         Abemaciclib (Versenios)

·         Everolimus (Afinitor)

Chemotherapy

Chemotherapy is sometimes used to treat secondary breast cancer in the brain.

Chemotherapy destroys cancer cells using anti-cancer drugs. These drugs may be given alone or in combination.

The drugs you’re offered will depend on many things, including any chemotherapy you had in the past and how long ago it was.

For general information about chemotherapy, see our Chemotherapy for breast cancer booklet or our booklets on chemotherapy drugs.

Clinical trials

Many breast cancer trials look at new treatments or different ways of giving existing treatments.

Your specialist may talk with you about a clinical trial, or you can ask them if there are any clinical trials you can enter.

You can find general information on clinical trials on our website. For listings of current trials visit the Cancer Research UK website cancerresearchuk.org or the National Institute for Health Research (NIHR) website bepartofresearch.nihr.ac.uk

Palliative and supportive care

Palliative and supportive care focuses on symptom control and support.

It’s extremely important for many people with secondary breast cancer and can significantly improve quality of life for them and their families.

People often associate palliative care with end-of-life treatment. However, many people value having it at any stage of their illness, alongside their medical treatment, to help prevent and relieve symptoms such as pain or fatigue. It can also help with the emotional, social and spiritual effects of secondary breast cancer.

The palliative and supportive care teams are based in hospitals, hospices and the community. Your treatment team, GP or breast care nurse can refer you depending on your situation.

Availability of treatments

Some treatments for secondary breast cancer may not be routinely available on the NHS. You may still be able to access these treatments in other ways.

Macmillan Cancer Support has information about what you can do if a treatment is not available. Visit macmillan.org.uk or call 0808 808 00 00 to find out more.

It can be frustrating and distressing if a treatment you and your cancer specialist feel could benefit you is not routinely available. For help and advice about accessing a treatment, you can speak to your treatment team. You can also call our free Helpline on 0808 800 6000 to talk through your concerns.

MANAGING SYMPTOMS OF SECONDARY BREAST CANCER IN THE BRAIN

Seizures (fits)

A seizure is a short-term period of abnormal activity in the brain. Usually the person will lose consciousness and their muscles will twitch. It can happen without warning and can be very frightening to watch.

Seizures may also happen without much movement. Instead, the person may stare into space or be unable to talk. Sometimes only the hand or leg will be affected – this is called a partial seizure.

Most seizures pass quickly and are not necessarily a medical emergency. However, seizures can have different causes so tell your GP or treatment team if you start having them.

If you have seizures, your doctor may prescribe epileptic drugs to keep them under control. They are usually given as tablets.

Nausea and vomiting

Nausea (feeling sick) or vomiting (being sick) can be caused by secondary breast cancer in the brain or elsewhere in the body, its treatment or emotional side effects such as anxiety.

It’s important for your doctor to try to find out the cause so that it can be managed effectively.

You can help your specialist or palliative care team decide what treatment will work best by keeping a record of what makes it worse or when it happens.

In most cases, nausea and vomiting can be controlled and treated with anti-sickness drugs, steroids or benzodiazepines. Benzodiazepines are drugs that work on the brain and nerves to produce a calming effect.

Pain

Pain relief is a very important part of the care of anyone with secondary breast cancer. Once pain is under control, many people feel less anxious and can eat and sleep better.

A build-up of pressure in the brain, caused by areas of secondary breast cancer, can lead to headaches. These might be different to headaches you’ve had before. They may get worse, continue for days or not go away completely.

Steroids and pain relief can control most pain. You can also be referred to a healthcare professional who specialises in pain management.

Read more about pain control in our Secondary breast cancer information pack, which also includes a personal organiser in which you can record your pain.

Fatigue (extreme tiredness)

Cancer-related fatigue is one of the most common symptoms experienced by people with secondary breast cancer.

Everyone knows what it feels like to be tired sometimes, but cancer-related fatigue can feel much more severe. It can come and go or be continuous, and this can be distressing and frustrating.

Fatigue has many causes, from the stress of coping with the diagnosis to side effects of treatment or the cancer progressing.

Fatigue may have a significant effect on your ability to cope with your cancer and its treatment. It can also affect your everyday activities and quality of life.

For more information on managing fatigue see our Secondary breast cancer information pack.

Blood clots

People with breast cancer have a higher risk of blood clots. Their risk is higher because of the cancer itself and some treatments for breast cancer.

You may be at risk of a blood clot forming known as a deep vein thrombosis (DVT). People with a DVT are at risk of developing a pulmonary embolism. This is when part of the blood clot breaks away and travels to the lung.

Blood clots can be harmful but are treatable so it’s important to report symptoms as soon as possible.

If you experience any of the following symptoms contact your local A&E department, GP or specialist team straight away:

·         Pain, redness/discolouration, heat and swelling of the calf, leg or thigh

·         Swelling, redness or tenderness where a central line is inserted to give chemotherapy, for example in the arm, chest area or up into the neck

·         Shortness of breath

·         Tightness in the chest

·         Unexplained cough (may cough up blood)

LIVING WITH SECONDARY BREAST CANCER IN THE BRAIN

Physical activity

Although there has been little research into exercise for people with secondary breast cancer, studies show it has benefits for people with primary breast cancer. People who exercise, even gently, during and between treatments may tolerate treatments better and have less pain, sickness, problems sleeping and fatigue.

There’s no reason to believe that people with secondary breast cancer would not have similar benefits.

However, you may need to take a little extra care.

While symptoms such as blurred vision, seizures, weakness, dizziness or balance problems may not stop you exercising, it’s important you don’t put yourself at unnecessary risk of injury. For example, if you have balance problems, an exercise bike may be better than cycling outdoors. If you have seizures, try to avoid exercising alone.

A GP exercise referral programme can help you increase your activity levels and improve health and wellbeing. Trained instructors can provide support if you want to start a new activity. It’s important the instructor knows about you and any changes to your health so they can advise you on how to exercise safely. You can ask your GP to refer you to a suitable exercise programme.

For more information on exercise and general health and wellbeing, see our Secondary breast cancer information pack.

Driving

If you drive, you are required by law to tell the Driver and Vehicle Licensing Agency (DVLA, or DVA in Northern Ireland) that you have secondary cancer in the brain. This is because it could affect your ability to drive safely.

You can call the DVLA on 0300 790 6806 or use their email service through the website gov.uk/contact-the-dvla

In Northern Ireland, you can contact the DVA on 0300 200 7861 or email dva@infrastructure-ni.gov.uk

It’s likely you will have to give up your licence. While this may be temporary, some people will not be allowed to drive again.

Giving up your driving licence can be hard to deal with. It can feel like you’re losing your independence.

You can ask your specialist nurse or local cancer information centre about services or practical help that may be available.

Coping emotionally

Knowing that your cancer has spread to your brain can cause a range of emotions.

There may be times when you feel very isolated or overcome by fear, anxiety, sadness, uncertainty, depression or anger.

Giving up your driving licence can also have a huge impact on your lifestyle and independence.

Sometimes symptoms may not improve. This can be frustrating and make you feel low in mood.

You may need help from the people closest to you. Some people also want support from professionals.

You can talk to your breast care nurse, palliative care nurse (who may be a Macmillan nurse), hospice or home care specialist nurse. They will have a good understanding of the specific needs of people with secondary cancers and will be familiar with different ways of coping and adapting to the diagnosis. They also have specialist knowledge in helping with pain and symptom control and can arrange for you to talk to a counsellor or psychotherapist.

If you’re not in regular contact with a palliative care nurse, you can ask for a referral to be made through your treatment team or GP.

You could also contact the Breast Cancer Now Helpline on 0808 800 6000 to talk through your concerns and find out what support is available in your area.

Finding support

Breast Cancer Now’s Living with Secondary Breast Cancer meet-ups take place monthly in locations throughout the UK.

Whether you have questions about pain management, treatments and side effects, or just want to talk openly to others who have had a secondary diagnosis, these sessions can provide you with helpful information and support in a relaxed environment.

For more information about Living with Secondary Breast Cancer, visit breastcancernow.org.uk or call 0345 077 1893.

Live Chat is a weekly private chat room where you can talk about whatever’s on your mind. Visit breastcancernow.org/ information-support/support-you/live-chat

You can also chat to other people living with secondary breast cancer on our online discussion Forum forum.breastcancernow.org

ABOUT THIS BOOKLET

Secondary breast cancer in the brain was written by Breast Cancer Now’s clinical specialists, and reviewed by healthcare professionals and people affected by breast cancer.

For a full list of the sources we used to research it: Email health-info@breastcancernow.org

You can order or download more copies from breastcancernow.org/publications

We welcome your feedback on this publication: health-info@breastcancernow.org

For a large print, Braille or audio CD version: Email health-info@breastcancernow.org

Breast Cancer Now, August 2020, BCC56, Edition 5, next planned review 2022

Breast Cancer Now is a company limited by guarantee registered in England (9347608) and a charity registered in England and Wales (1160558), Scotland (SC045584) and Isle of Man (1200). Registered Office: Fifth Floor, Ibex House, 42-47 Minories, London EC3N 1DY.