What is the treatment and prognosis for breast cancer with metastatic disease to the spine?

From the Guidelines

Treatment for breast cancer with spinal metastases requires a multidisciplinary approach combining systemic therapy, radiation, and sometimes surgery, with the goal of improving quality of life and reducing morbidity and mortality. The backbone of treatment is systemic therapy based on the breast cancer subtype: hormone therapy (such as aromatase inhibitors, tamoxifen, or fulvestrant) for hormone receptor-positive disease, anti-HER2 therapies (trastuzumab, pertuzumab, T-DM1) for HER2-positive disease, or chemotherapy (taxanes, anthracyclines, capecitabine) for triple-negative disease 1.

Key Considerations

• For painful or structurally compromising spinal metastases, radiation therapy is typically given as external beam radiation in doses of 20-30 Gy over 5-10 fractions.
• Surgical intervention is reserved for cases with spinal instability, cord compression, or radioresistant tumors, often followed by postoperative radiation.
• Bone-targeted agents like zoledronic acid (4 mg IV every 3-4 weeks) or denosumab (120 mg subcutaneously every 4 weeks) are added to reduce skeletal-related events, as recommended by guidelines such as those from the ESMO 1 and NCCN 1.

Prognosis and Quality of Life

• Prognosis varies widely based on tumor biology, with median survival ranging from 6 months to several years.
• Better outcomes are associated with hormone-positive disease, good performance status, limited metastatic burden, and longer disease-free interval before metastasis.
• While metastatic breast cancer remains incurable, modern treatments can often provide years of good quality life with appropriate management, emphasizing the importance of a multidisciplinary approach that includes pain management and supportive care 1.

Management Approach

• The management of spinal metastases should be proactive, aiming to prevent complications and improve quality of life, as outlined in guidelines such as the Dutch national guideline on metastases and hematological malignancies localized within the spine 1.
• Patient participation and preferences should be considered in the decision-making process, alongside clinical factors and tumor biology.

From the FDA Drug Label

For patients with carcinoma of the breast, the following is recommended (see CLINICAL STUDIES: Breast Carcinoma section): 2) After failure of initial chemotherapy for metastatic disease or relapse within 6 months of adjuvant chemotherapy, paclitaxel at a dose of 175 mg/m2 administered intravenously over 3 hours every 3 weeks has been shown to be effective Paclitaxel Injection, USP is indicated for the treatment of breast cancer after failure of combination chemotherapy for metastatic disease or relapse within 6 months of adjuvant chemotherapy.

The treatment for breast cancer with metastatic disease is paclitaxel at a dose of 175 mg/m2 administered intravenously over 3 hours every 3 weeks.

• The prognosis is not directly addressed in the provided drug labels. 2 2

From the Research

Treatment Options

• Surgical intervention is often required for breast cancer metastases to the spine, with goals including preserving or restoring neurologic function, ensuring spinal stability, and relieving pain 3, 4, 5
• Advances in surgical techniques and instrumentation have allowed for more effective decompression and stabilization of the spine 3
• Treatment may also involve hormonal therapy, pharmacologic interventions, and radiotherapy, with the aim of providing palliative care 3, 6
• Targeted systemic therapies, such as those targeting PI3K mutations, may also be used to improve overall survival and delay progression of motor symptoms 7

Prognosis

• The prognosis for patients with breast cancer metastatic to the spine is generally poor, but aggressive surgical management can provide significant pain relief and preservation or improvement of neurological function 4, 5
• The incidence of spinal metastases in breast cancer patients is high, and timely diagnosis is crucial to improve outcomes 3
• Overall survival can be improved with the use of targeted systemic therapies, particularly in patients with specific somatic mutations such as PI3K 7
• Median survival following surgery can range from 1,025 days, with some patients experiencing significant improvement in ambulatory status and bladder function 4

Outcomes

• Surgical outcomes for patients with breast cancer metastatic to the spine can be favorable, with significant pain relief and preservation or improvement of neurological function 4, 5
• Complications can occur, but are generally acceptable, with early major surgical complications being more common when five or more levels are instrumented 5
• The use of targeted systemic therapies can delay progression of motor symptoms and improve overall survival, particularly in patients with specific somatic mutations 7