Treating metastatic breast cancer in the brain

Treatment options are available when breast cancer has spread to the brain.

The goals of treatment are to:

• control the cancer for as long as possible
• control or relieve symptoms so you have the best possible quality of life.

Your treating team will recommend the most appropriate treatment for you.

How treatments can help

Treatments for brain metastases are often effective. They can stop the growth, or decrease the size, of the cancer deposits in the brain.

Treatment can help relieve:

• headaches
• nausea
• trouble with vision caused by swelling in the brain
• loss of balance
• seizures
• weakness in parts of the body
• difficulty with speech or memory.

What influences treatment decisions

The treatments recommended for you will depend on:

• your symptoms
• how many brain metastases there are
• how much space the metastases are taking up
• which parts of the brain are affected
• the subtype of the cancer – such as ER+, PR+, HER2+positive
• the treatments you’ve had in the past
• your general health
• your personal preferences
• discussion with your treating team about the benefits and side effects of treatments.

Surgery

Surgery can be done if there is only a single metastasis or very few metastases. This option depends on their size and location in the brain. You will be referred to a neurosurgeon if surgery is recommended.

Gamma Knife treatment

Gamma Knife is an advanced treatment for certain brain conditions, including metastatic breast cancer. Despite its name, there is no knife or surgery involved.

Instead, it uses highly focused beams of radiation. This treats the problem area in your brain, while protecting the healthy tissue around it.

The procedure is painless and usually takes a few hours. You won’t need general anaesthesia – you’ll be awake the whole time.

Advantages:

• It’s non-invasive – you don’t need time to recover from cuts or incisions.
• Most patients go home the same day.
• It’s very precise, so it is ideal for areas of the brain that are hard to reach with regular surgery.

Disadvantages:

• Gamma Knife is not covered by Medicare. This procedure can cost thousands of dollars.

Speak to your oncologist about whether it is suitable for you.

Radiotherapy

Radiotherapy is the most common treatment for metastatic breast cancer in the brain. It may be used after the surgery to destroy any remaining cancer cells.

It may be given as:

• localised radiotherapy (‘stereotactic radiosurgery’)
• whole brain radiotherapy.

About localised radiotherapy

This treatment provides 1 or several targeted radiation treatments to the brain or spine.

It may be appropriate when:

• there are only a few brain metastases
• metastases come back after whole brain radiotherapy or previous surgery.

The procedure is complex and needs a team of specialists including a radiation oncologist and a neurosurgeon. They use scans to be very precise and guide radiation to the cancer. This causes minimal damage to healthy tissue.

You usually have localised radiotherapy as an outpatient. Most people can leave hospital a few hours after treatment. 

Speak to your oncologist if you would like to know more about this treatment and whether it is appropriate for you.

About whole brain radiotherapy

Whole brain radiotherapy is a common treatment for breast cancer that has spread widely throughout:

• the brain
• the tissues and fluid that surround the brain and spinal cord (‘leptomeningeal metastases’).

You have a daily dose, usually for 5 to 10 days.

Radiotherapy can cause a temporary increase in symptoms such as headaches, nausea and fatigue. This can be controlled using steroid medication (dexamethasone).

Side effects of whole brain radiotherapy

Whole brain therapy can have side effects. These can happen for many months after treatment has finished but get better over time.

If you are concerned about the impact of these side effects, talk with your radiation oncologist about what is important to you.

Side effects include:

• temporary hair loss. Your hair will usually grow back several months after you finish radiotherapy. It may grow back thinner, with a different texture or be patchy.
• fatigue during treatment and for a few weeks afterwards. Light exercise, such as walking, can help.
• skin irritation, where the area treated may become red, dry and itchy. To reduce skin reactions:
  • use a gentle, non-scented shampoo
  • avoid chemicals such as hairsprays
  • wear a hat when you’re outdoors.
• blocked ears, which are temporary and will get better on their own.

High doses or repeated courses of treatment may cause other symptoms including problems with:

• memory
• speech
• concentration
• balance.

These changes to your cognitive function and thinking may mean:

• you find it hard to manage tasks that are normally easy
• you are sometimes confused or have memory loss.

For most people, these symptoms get better over time. If they affect your life badly, ask your specialist or GP to refer you to an occupational therapist. They can help you manage everyday tasks.

Newer treatment methods can avoid damaging the parts of the brain that manage thinking and cognitive function and are at low risk of containing cancer cells (such as the hippocampus).

Your radiation oncologist can talk about whether hippocampal-sparing whole brain radiotherapy is appropriate for you.

Steroids

Steroids such as dexamethasone can reduce swelling and pressure caused by the cancer or its treatment (such as radiotherapy).

They can also relieve symptoms such as headaches, nausea and fatigue.

Treatments not normally used

Many systemic therapies do not get across the blood-brain barrier into the brain. This means they do not work to control brain metastases. A few drugs do work in the brain, but surgery or radiotherapy are usually the main treatments.

Clinical trials are always looking for new systemic treatments that work in the brain.