Synopsis
Confirm metastatic breast cancer, match systemic therapy to current biology and disease tempo, and manage bone, neurological and fungating-tumour symptoms alongside early palliative care.
- Metastatic breast cancer has spread beyond breast and regional nodes, commonly to bone, liver, lung or brain; treatment aims to prolong life, control disease and preserve quality of life.
- Biopsy an accessible metastatic site when safe if it will confirm recurrence, exclude another diagnosis or reassess ER and HER2 in a way that changes management.
- For initial distant diagnosis and staging, use CECT of chest, abdomen and pelvis or FDG PET-CT under NICE 2026; choose according to the clinical question, tumour uptake, access and patient preference. Consider the same effective modality for response assessment.
Key red flags
Acute neurological deficit, uncontrolled hypercalcaemia, pathological fracture, respiratory compromise, liver failure, sepsis or major bleeding from tumour requires same-day emergency and oncology assessment.
Investigation priorities
Confirm metastatic breast carcinoma and reassess ER and HER2 when results could alter treatment.
Management branches
A postmenopausal patient who completed adjuvant endocrine treatment six years earlier has new HR-positive, HER2-negative liver metastases, preserved organ function, mild symptoms and no previous systemic treatment for advanced disease.
- In this illustrative case, a postmenopausal patient completed adjuvant endocrine treatment six years earlier and has received no systemic treatment for advanced disease. She now has mild symptoms, liver lesions, preserved liver function and good performance. CECT of the chest, abdomen and pelvis defines the metastatic burden; there is no immediate organ-threatening deterioration.
- A safely accessible liver lesion is biopsied because confirming the diagnosis and current receptors will change care. Histology confirms metastatic breast carcinoma that remains HR-positive and HER2-negative. The team reviews prior endocrine exposure, comorbidity, interactions and the patient’s preference for disease control with an acceptable treatment burden.
Key medicines
Dexamethasone: Glenmark 4 mg soluble tablets for neurological MSCCNICE NG234: give 16 mg orally, or equivalent parenterally, as soon as possible for neurological symptoms or signs of MSCC, then 16 mg daily while awaiting surgery or radiotherapy. For this selected oral product, 16 mg is four 4 mg tablets dissolved in water (approximately 50 mL minimum) and drunk immediately. Do not subdivide tablets or the prepared solution. Reduce gradually after surgery or at radiotherapy start using an appropriate lower strength or formulation under the specialist plan; no fixed taper is implied.Do not delay the MSCC coordinator, MRI or definitive care. Monitor glucose and provide proton-pump-inhibitor protection. If given before imaging, stop when BOTH spinal metastases and MSCC are ruled out. Check hypersensitivity, untreated systemic infection, systemic fungal infection, peptic ulcer, live-vaccine and relevant parasitic-infection risks; the SmPC recognises that life-saving emergency use may override usual contraindications. Review renal, hepatic and cardiac disease, diabetes, infection and psychiatric history. Counsel about urgent mood, psychotic or suicidal symptoms. Check CYP3A inhibitors/inducers, including ritonavir, cobicistat and azoles; NSAIDs increase gastrointestinal risk, anticoagulation may need closer monitoring and glucose-lowering treatment may need adjustment. Pregnancy and breastfeeding require individual benefit–risk assessment. Use a suitable lower formulation for tapering rather than splitting this tablet or solution.