Metastatic Breast Cancer — Palliative Modalities (NCCN-inspired)

Systemic therapy

Mainstay for metastatic disease

Selection guided by receptor status (ER/PR/HER2), pace of disease, prior therapy and patient goals.

Choices & principles

Endocrine therapy — first line for HR‑positive disease; often combined with CDK4/6 inhibitors.
HER2‑directed agents — trastuzumab, pertuzumab, ADCs for HER2‑positive disease.
Cytotoxic chemotherapy — for visceral crisis or rapidly progressive disease.
Targeted therapies — e.g., PIK3CA, PARP inhibitors where indicated.
Immunotherapy — selected use in PD‑L1 positive TNBC with chemotherapy.

Systemic therapy: endocrine therapy for HR+ (±CDK4/6), HER2‑directed agents for HER2+, chemotherapy for rapid progression/visceral crisis; targeted therapy guided by biomarkers (PIK3CA, BRCA); immunotherapy for selected TNBC with PD‑L1.

Radiation therapy

Powerful for symptom relief

Useful for pain, bleeding, cord compression and brain metastases.

Common palliative RT approaches

Short course RT — e.g., 8 Gy ×1 or 20 Gy in 5 fractions for bone pain.
SRS / SBRT — for limited oligometastatic lesions (brain, lung, liver, bone).
Urgent RT — for spinal cord compression (+ steroids) or symptomatic central lesions.
WBRT — for diffuse brain metastases when indicated.

Radiation: short hypofractionated courses (eg 8 Gy×1, 20 Gy×5) for bone pain; SRS/SBRT for limited metastases; urgent RT for cord compression; WBRT or SRS for brain mets.

Surgery & procedures

Primarily local, symptom‑directed

Consider for bleeding, infection, impending fracture, or selected metastasectomy.

Role of surgery

Resection of symptomatic primary (ulceration, bleeding) to improve quality of life.
Orthopaedic fixation for pathological fractures or imminent fracture.
Neurosurgical decompression for selected spinal or brain lesions.

Surgery: resection of symptomatic primary (bleeding/ulceration), orthopaedic fixation for pathologic fractures, neurosurgical decompression for selected spinal/brain lesions.

Supportive & palliative care

Symptom control & holistic care

Early palliative involvement improves quality of life and may improve outcomes.

Elements of supportive care

Pain management — opioids, adjuvants, interventional options as needed.
Dyspnoea, nausea, fatigue — targeted meds and non‑pharmacologic measures.
Psychosocial support, goals of care and advance care planning.
Bone‑directed agents (bisphosphonates/denosumab) for skeletal events.

Supportive care: opioids and adjuvants for pain, antiemetics, steroids for symptom relief, bisphosphonates/denosumab for bone mets, early palliative care involvement and advance care planning.

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