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NCCN Guidelines for Patients



Breast Cancer – Metastatic (STAGE IV), Version 2.2017


Treatment guide

Hormone receptor–positive cancers

Supportive care

This book focuses on cancer treatment. However,

supportive care is important, too. Supportive care

doesn’t aim to treat cancer but aims to improve

quality of life. It can address many needs.

One example of supportive care is treatment for

physical and emotional symptoms. Read the next


Breast cancer in bone

, for an example.

Supportive care can also help with treatment

decisions as you may have more than one option.

It can also help with coordination of care between

health providers. Talk with your treatment team to

plan the best supportive care for you.

Breast cancer in bone

A bone metastasis is the spread of cancer to the

bone. It is not the same as bone cancer, which starts

in bone. Your bones are at risk for injury and disease

when cancer spreads to them. Such health problems

include bone fractures, bone pain, and squeezing

(compression) of the spinal cord. High levels of

calcium in the blood, called hypercalcemia, may also


There is supportive care to prevent bone problems

caused by bone metastases. Your doctor may

prescribe denosumab (Xgeva™), zoledronic acid



), or pamidronate (Aredia


). Your treatment

team may advise you to take these drugs with

calcium and vitamin D.

Denosumab, zoledronic acid, or pamidronate

may damage your jawbone. This condition is

called osteonecrosis of the jaw. Your chances for

osteonecrosis of the jaw are higher if taking certain

medications such as chemotherapy. Poor dental

health and dental work during cancer treatment will

increase your chances, too. Get a dental exam and

treatment for any dental problems before starting

cancer treatment.

Hormone receptor–positive


Most breast cancers are hormone receptor–positive.

Female hormones help hormone receptor–positive

cancers grow. Endocrine therapy is a standard

treatment for these cancers. It can work just as well

as chemotherapy and its side effects are less severe.

For some women, targeted therapy with endocrine

therapy may be an option.

Endocrine therapy

Some people refer to endocrine therapy as hormone

therapy. However, hormone therapy can then be

confused with hormone replacement therapy. The

former treats breast cancer whereas the latter treats

menopausal symptoms.

Endocrine therapy affects female hormones by one

of two methods. Some therapies block hormones

from working. Others lower hormone levels in the

body. The main types of endocrine therapy are

described next. The section,

Treatment options

, lists

which ones may be an option for you.

Aromatase inhibitors

lower estrogen levels in the

body. These drugs block a protein that changes

a hormone (androgen) into estrogen. They do

not affect estrogen made in the ovaries. See

Guide 2

for a complete list of drugs for hormone-

related growth.


stop the effect of estrogen on

cell growth. SERMs (








odulators) attach to estrogen receptors and block

estrogen from attaching. SERDs (








egraders) block and destroy estrogen


See Figure 7.


may treat breast cancer when taken

in high doses. It is not known how hormones stop

breast cancer cells with hormone receptors from

growing. Hormones are not often used for treatment.