Synopsis
Distinguish potentially curable locally advanced disease from stage IV cancer, rescue organ-threatening complications, re-establish tumour biology and sequence endocrine, targeted, cytotoxic, local and supportive treatment around patient goals.
- Locally advanced M0 breast cancer remains potentially curable and usually receives systemic treatment first, followed by operability review, surgery and radiotherapy; stage IV disease is generally treated for durable control and quality of life.
- Inflammatory breast cancer is a clinical pattern of rapid erythema and oedema from dermal lymphatic involvement and needs prompt core and often skin biopsy, systemic staging and multimodality treatment.
- At metastatic diagnosis, biopsy an accessible lesion when feasible and repeat ER and HER2 because treatment targets can differ from the original primary.
- First-line staging commonly uses contrast CT chest, abdomen and pelvis with bone assessment or an appropriate whole-body modality; use brain MRI for neurological symptoms or subtype- and stage-directed indications.
- For ER-positive, HER2-negative metastatic disease without visceral crisis, endocrine therapy combined with a CDK4/6 inhibitor is generally preferred to upfront chemotherapy.
- Visceral metastasis is not synonymous with visceral crisis. Stable liver deposits with preserved function can still receive endocrine-based treatment when biology and tempo support it.
- HER2-positive disease receives sequential HER2-directed combinations; monitor cardiac function and recognise interstitial lung disease early with antibody–drug conjugates.
- Triple-negative treatment depends on PD-L1, germline BRCA and other current biomarkers, treatment-free interval, organ function and prior perioperative exposure.
- Bone-modifying therapy, dental prevention, calcium and vitamin D review, analgesia and stabilising or palliative radiotherapy reduce skeletal morbidity but do not replace systemic cancer control.
- Use local radiotherapy, surgery, ablation, drainage, stenting or wound care to relieve specific symptoms or prevent catastrophe while systemic treatment addresses disease elsewhere.
- Assess response by symptoms, examination, organ function and imaging at intervals appropriate to treatment; tumour markers may support a trend but should not alone trigger a regimen change.
- Discuss treatment goals, likely absolute benefit, toxicity, fertility and menopause, work, caregiving, future lines and preferred place of care before crisis removes choice.
Key red flags
New severe back pain, limb weakness, sensory change, gait disturbance or bladder or bowel dysfunction suggests metastatic spinal cord compression.
Seizure, progressive headache, focal deficit, vomiting or reduced consciousness raises brain metastasis, haemorrhage or raised intracranial pressure.
Rapid bilirubin rise, respiratory failure from lymphangitic disease or marrow failure from tumour can constitute visceral crisis requiring a fast-response plan.
Thirst, confusion, constipation, polyuria or dehydration suggests malignant hypercalcaemia and needs urgent corrected or ionised calcium assessment.
Fever during systemic treatment, new dyspnoea or unilateral leg swelling requires immediate assessment for neutropenic sepsis, drug pneumonitis or venous thromboembolism.
Brisk bleeding, malodour, spreading cellulitis or severe pain from a fungating breast or chest-wall mass needs urgent haemostasis, infection and wound support.
Headache, seizure, focal deficit, personality change, cranial neuropathy or radicular symptoms requires urgent contrast MRI and specialist review.
Investigation priorities
Confirm metastatic breast cancer, exclude a second primary and reassess predictive receptors.
Map visceral, nodal, chest-wall and osseous disease and create a measurable response baseline.
Management branches
Breast, skin, chest-wall or regional nodal extent is advanced but distant staging remains negative.
- Confirm histology and ER and HER2, clip tumour and positive nodes, complete systemic staging and assess inflammatory features, operability and baseline cardiac and functional status.
- Give subtype-appropriate neoadjuvant systemic treatment and assess clinical response during therapy, escalating immediately for progression or threatened ulceration and bleeding.
- Re-discuss at the MDT for mastectomy or selected conservation and axillary surgery, then deliver indicated radiotherapy and response-adapted postoperative systemic treatment.