Secondary breast cancer in the lung - This booklet is for people who have been diagnosed with secondary breast cancer in the lung. It describes ...

Secondary breast
cancer in the lung
 This booklet is for people who
 have been diagnosed with
 secondary breast cancer in the
 lung. It describes what secondary
 breast cancer in the lung is,
 what the symptoms are and the
 treatments used.

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  We hope this booklet answers some of your questions about
  secondary breast cancer in the lung and helps you to discuss
  your options with your specialist team. We suggest you read it
  alongside our Secondary breast cancer resource pack.

  What is secondary breast cancer in the lung?
  Sometimes breast cancer cells spread to one or both lungs through the
  blood or lymph system. It’s not uncommon for the lymph nodes in the
  centre of the chest (mediastinum) to also be affected. The cells that have
  spread to the lungs are breast cancer cells. It’s not the same as having
  cancer that starts in the lungs (a lung cancer).
  When breast cancer spreads to the lungs it can be treated but cannot
  be cured. The purpose of treatment is to try to relieve symptoms and/or
  slow the growth of the cancer.
  You may hear this type of spread described as metastases, advanced
  breast cancer, recurrence of the cancer, secondary tumours, Stage 4
  or secondaries.

  How do the lungs work?
  To understand some of the symptoms described in this booklet it may
  help to look at how the lungs work.

    Collarbone

                                                          Pleura
    Pleural space

                                                           Diaphragm

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The lungs take up most of the chest area, extending from above the
collarbone down to the waist. They are protected by the ribcage. When
we breathe in, our chest expands, our lungs inflate and air is drawn in.
The lungs are attached to the inside of the chest wall by two thin layers
of tissue called the pleura. The inner layer is attached to the outside of
the lungs and the outer layer lines the inside of the chest wall. There’s
a small space between the two layers of tissue that is filled with a small
amount of fluid (sometimes called the pleural space). This fluid allows
the pleura to move over each other smoothly and stops the two layers of
tissue rubbing together when we breathe.
Each lung is made up of sections called lobes. The air we breathe in
is carried to our lungs by tubes known as the left bronchus and right
bronchus (or bronchi when talking about both). The bronchi then divide
into smaller tubes called bronchioles. At the end of the bronchioles
are millions of tiny air sacs (alveoli). It’s here that oxygen from the air
we breathe in is absorbed into the bloodstream and carbon dioxide is
passed from the bloodstream into the air we breathe out.

What investigations will I have?
You may need one or more of the following tests in order for your
doctors to confirm a diagnosis of secondary breast cancer in the lung.

Chest x-ray
A chest x-ray is often the first investigation that will be done.

CT (computerised tomography) scan
You may also have a CT scan. This is a type of scan that uses x-rays to
take a series of detailed pictures across the body, also known as a
CAT scan.

PET (positron emission tomography) scan
This type of scan shows how effectively parts of the body are working.
It’s not often used for diagnosis but may help your specialist team see
how far the cancer has spread and how well it’s responding to treatment.

PET-CT scan
This combines a CT scan with a PET scan in one test to create a more
detailed picture.

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  MRI scan (magnetic resonance imaging)
  This scan uses magnetism and radio waves to produce a series of
  cross-sectional images of the inside of the body.

  Biopsy
  Sometimes a biopsy of the lung is taken. This is done under local
  anaesthetic and a tube (called a bronchoscope) is put through the
  mouth and down into the lungs.
  A small piece of lung tissue can then be removed and examined under
  a microscope. Sometimes a biopsy can be taken through the skin using
  a CT scan for guidance. In some cases, fluid can collect in the space
  around the lungs (the pleural space). If this happens, a small amount
  may be removed with a biopsy for testing.

  Blood tests
  You may have blood tests although the type of test can depend on your
  symptoms and any treatment you are currently having. Your specialist
  team will discuss what tests they are doing and why you are having
  them. Some people have a blood test for tumour markers. These are
  proteins found in the blood which may provide additional information
  about how you are responding to treatment but there is some debate
  about how accurate they are so they are not always used.

  What treatments might I be offered?
  You will be offered treatments aimed at slowing the growth of the
  cancer as well as treatments to relieve symptoms such as pain
  or breathlessness. Your treatment may include hormone therapy,
  chemotherapy, radiotherapy and targeted therapies, either alone or in
  combination.
  Some people may consider asking for a second opinion. You can
  ask your specialist team to refer you to another specialist in the same
  hospital or elsewhere. The second opinion may not be different from the
  one you have already had. The time taken to get a second opinion may
  delay your treatment slightly, and the specialist treating you will be able
  to discuss any impact this might have.
  You may be offered one or more of the following treatments.

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Hormone (endocrine) therapy
Hormone treatments are used to treat cancers that are stimulated to
grow by the female hormone oestrogen (known as oestrogen receptor
positive or ER+). The tissue from the biopsy or original surgery for
primary breast cancer will usually have been tested to see if it is ER+.
The hormones oestrogen and progesterone help to stimulate some
types of breast cancer to grow. This happens if the tumour cells have
hormone receptors on their surface that respond to the hormone. These
cancers are sometimes called hormone receptor positive. Your specialist
will occasionally discuss taking a sample of lung tissue to re-test the
hormone receptor status depending on your individual situation.
If you have previously had hormone therapy, your doctor may prescribe
the same hormone therapy again or change it to a different drug.
For more information about these treatments, see our individual
hormone therapy drug booklets.

Chemotherapy
You may be offered chemotherapy which can be a combination of
chemotherapy drugs or a course of a single drug. This will depend on
any chemotherapy you have had in the past and how long ago you had it.
For more general information about this treatment see our
Chemotherapy for breast cancer booklet or our information on
chemotherapy drugs.

Radiotherapy
Radiotherapy is sometimes used to treat symptoms caused by
secondary breast cancer in the lung, for example, if large lymph nodes
in the centre of the chest are causing symptoms. It can be given as a
single dose or divided into a number of doses over a few days.

Targeted cancer therapies
This group of drugs works by blocking specific ways that breast
cancer cells divide and grow. The most well-known targeted therapy is
trastuzumab (Herceptin) but the benefits of others are being looked at in
clinical trials so it is likely more targeted therapies will become available
in the future.
Only people whose cancer has high levels of HER2 (HER2 positive),
a protein that makes cancer cells grow, can benefit from having

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  trastuzumab. To find out whether breast cancers are HER2 positive, a
  laboratory test will usually have been done on tissue from the biopsy or
  original surgery for primary breast cancer. However, your specialist will
  occasionally discuss taking a sample of lung tissue to re-test the HER2
  receptors depending on your individual situation.
  If your cancer is HER2 negative, then trastuzumab (Herceptin) will
  not be of benefit to you. For more information see our Trastuzumab
  (Herceptin) booklet.

  Surgery
  Surgery is rarely used for secondary breast cancer in the lung,
  especially if more than one area of the lung is affected. If you
  have secondary breast cancer in the lung you may have microscopic
  secondary breast cancer cells in other parts of your body too, so
  surgery will not be appropriate. However, if the secondary tumour in
  the lung is very small and you have no symptoms or disease elsewhere,
  your doctor may consider surgery.
  Video-assisted thoracoscopic surgery (VATS) is a type of operation that
  allows doctors to see inside the chest and lungs. During this operation
  a thin tube with a built-in camera (known as a thoracoscope) is placed
  through a small cut in the side of the chest to help the surgeon see
  inside. One or two other small cuts are made in the skin, and surgical
  instruments can be passed though these. It can be used to take tissue
  from the lung for a biopsy or to treat a pleural effusion (see page 8).

  What symptoms might I have and how can they
  be managed?
  If you have secondary breast cancer in the lung you may have a number
  of different symptoms.

  Breathlessness
  One of the more common symptoms of secondary breast cancer in the
  lung is breathlessness. The medical term for this is dyspnoea. You may
  find breathing is uncomfortable, or feel that you can’t get enough air into
  your lungs. This is often more noticeable when you are moving but some
  people may experience breathlessness when they are still or lying down.
  Breathlessness can happen for different reasons. For example,
  sometimes the lymph channels in the lung are affected by the cancer,

Visit www.breastcancercare.org.uk 7

and can become inflamed and blocked. This is called lymphangitis.
Steroid drugs such as dexamethasone or prednisolone can sometimes
help reduce this.
Secondary breast cancer in the lung can increase the risk of chest
infections, which can also cause breathlessness. In this case you may
be treated with antibiotics.
Not being able to breathe properly can make you feel anxious and
frightened. This can lead to feeling panicky, which can make your
symptoms worse. There are several practical things you can do to help
ease your breathlessness. Using a hand-held fan or sitting near an open
window to get cool air on your face can be helpful.
Learning relaxation and breathing techniques to use when you start
feeling breathless can also help. Your medical team may be able to refer
you to a physiotherapist or to a palliative care doctor or nurse to teach
you breathing exercises which may help. If necessary, your doctors can
give you medicines such as lorazepam from a group of drugs called
benzodiazepines (which have sedative and muscle relaxant properties),
or Ventolin, a drug that can relax the airways, or low doses of codeine or
morphine to help ease the feeling of breathlessness.
You may also find exercise can help relieve breathlessness
(see page 10).

Cough
A persistent cough is another common symptom that can be distressing
and tiring. It may be caused by the cancer itself, or an infection. Phlegm
can build up in the chest and throat and may be difficult to bring up.
Cough medicines may help to either control coughing or loosen the
phlegm. Using a nebuliser can also help to loosen the phlegm, making it
easier to bring up.
If the cough is very difficult to control your doctors may prescribe a
codeine-based drug or low-dose morphine.

Pain
Most pain can be relieved or controlled. Always tell your doctors if you
have pain. They will ask you to describe where the pain is, how it feels,
how strong it is and what makes it better or worse.
This will help them decide what to do to control your pain. There are
many different types of pain relief and often a combination of drugs may

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  be needed. If pain relief does not seem to be helping, tell your doctors,
  as they will be able to prescribe a different treatment. You may also be
  referred to a specialist palliative care or symptom control team, who are
  experts in managing symptoms.

  Pleural effusion
  A pleural effusion is a build-up of extra fluid between the pleural layers
  and will usually be confirmed with a chest x-ray. It may make you feel
  breathless but this can sometimes be eased by taking away the extra
  fluid. This can be done in two ways. A small amount can be removed by
  numbing the skin over the area with a local anaesthetic and drawing the
  fluid off with a needle and syringe.
  If there is a larger amount of fluid, a narrow drainage tube can be
  inserted into the pleural space (see ‘How do the lungs work’ on page
  2), also with a local anaesthetic. It will then be stitched into place and
  connected to a drainage bottle. This allows the fluid to drain out slowly
  over time (often a few days). This procedure can be repeated if the fluid
  builds up again. Sometimes after a pleural effusion has been drained
  another procedure called a pleurodesis is performed. This involves
  injecting a drug or powder preparation into the drain, then leaving the
  drain clamped for about one hour before removing it. This seals the two
  layers of the pleura together to prevent the fluid building up again.

  Loss of appetite and weight loss
  When you have secondary breast cancer in the lung you may feel less
  hungry than usual and lose weight. This can be caused by the effect of
  the cancer or by the treatment. It may help to eat little and often rather
  than eating normal-sized meals. Nutritional supplements may be useful
  if you feel you are not managing to eat enough. Your GP (local doctor) or
  specialist can prescribe these or refer you to a dietitian for advice.

  Fatigue
  Cancer-related fatigue is one of the most common symptoms
  experienced by people with secondary cancer. Everyone knows what
  it feels like to be tired sometimes, but cancer-related fatigue can feel
  much more severe. It can come and go or be unrelenting, and this can
  be distressing and frustrating. It has many causes, from psychological
  factors such as the stress of coping with the diagnosis, to physical
  ones such as the side effects of treatment or progression of the cancer.

Visit www.breastcancercare.org.uk 9

Fatigue may have a significant impact on your ability to cope with your
cancer and its treatment.
It can also affect your everyday activities and have an adverse effect on
your quality of life. However, there are things you may wish to try to help
you manage fatigue and reduce its effects.
•   Tell your doctor, as its cause may be treatable.
•   Plan your days so you have a balance of activity and rest.
•   Try to have short, achievable periods of physical activity each day,
    even if it’s a short walk.
•   Accept that you may have good days and bad days.
•   Try to prepare for a special occasion by resting beforehand.
•   Try to eat well. If your appetite is poor, it may help to eat smaller
    amounts more often and drink plenty of fluids to keep hydrated. You
    could also ask to be referred to a dietitian for advice.
•   Accept offers of practical help from other people to save your energy
    for things you enjoy.

Physical activity
Although there has been little research into the benefits of exercise
for people with secondary breast cancer, several studies have looked
at its effectiveness for people with primary breast cancer. The results
have been positive and there seems no reason to believe that people
with secondary breast cancer would not experience similar benefits. In
fact, people who exercise, even gently, during treatment (for example
chemotherapy or radiotherapy) may tolerate treatments better and
experience less pain, nausea, sleeplessness and fatigue.
Regular exercise may also help to:
•   increase fitness, strength, stamina and flexibility
•   control weight (when combined with a healthy diet)
•   boost the immune system
•   reduce blood pressure.
However, it is advisable for people with secondary breast cancer to take
a little extra care when starting to exercise. Before starting any exercise
it’s important to discuss it with your specialist team. If you exercised
regularly before being diagnosed, you may find you can continue in
exactly the same way. However, you may need to adapt this depending
on how you are feeling.

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  What is regular exercise?
  Any amount of activity is better than none, so try to minimise the time
  you spend sitting down or being inactive.
  Guidance suggests ‘regular exercise’ means 30 minutes of moderate
  intensity exercise at least five days a week. That can be a lot so you can
  begin gently and build up gradually. You do not need to do half an hour
  in one session.
  ‘Moderate intensity’ means you may breathe harder, become warmer
  and be aware of your heart beating slightly faster than normal. However,
  you should be able to talk and it should not feel as if you are pushing
  yourself too hard. If you are currently receiving treatment you may need
  to exercise at a lower level. It’s important to listen to your body and
  stop straightaway if it hurts or feels like you are working too hard. When
  choosing your exercise, try to focus on aerobic-type activities such as
  walking, swimming or cycling. However, less structured activities such
  as dancing and gardening can also be beneficial. You could also include
  some light toning or conditioning exercises such as stretching or
  low-impact yoga. The most important thing is to choose something
  you enjoy.
  The symptoms experienced by many people with secondary breast
  cancer in the lung are similar to those experienced by people with
  long-term respiratory diseases such as chronic obstructive pulmonary
  disease (COPD) and asthma. Research has found that when people
  with respiratory disease exercise regularly they are less breathless, have
  more stamina, are better able to perform everyday tasks and have a
  better quality of life.
  There are a number of things you can do to avoid or reduce
  breathlessness. Firstly, try to avoid exercising in very cold or dry
  conditions as this makes it more difficult for your lungs to expand,
  whether you are exercising or not. Swimming is ideal because swimming
  pool buildings are usually quite warm and the air is damp. Secondly,
  always start your exercise session with a gentle warm up to get your
  body, especially your lungs, ready to exercise and to slowly increase
  how hard you are breathing so your lungs have time to adjust. Finally,
  you could try ‘pursed lip breathing.’ This involves pursing your lips and
  breathing in and out through the narrowed opening. This reduces the air
  pressure, making it easier for your lungs to expand and contract.

Visit www.breastcancercare.org.uk 11

Living with secondary breast cancer in the lung
Knowing that your cancer has spread to one or both lungs may
leave you feeling a range of emotions similar to when you were first
diagnosed, only stronger. There may be times when you feel overcome
by fear, anxiety, sadness, depression or anger. The uncertainty of living
with secondary cancer can sometimes leave you feeling emotionally
very up and down.
You may be able to cope with these feelings on your own or with the
support of those closest to you. Some people want support from
professionals: you can talk to your breast care nurse, palliative care
nurse (who may be a Macmillan nurse), clinical trials nurse, hospice or
home care specialist nurse. They will have a greater understanding of
the specific needs of people with secondary cancers and will be familiar
with different ways of coping and adapting to the diagnosis. They also
have specialist knowledge in helping with pain and symptom control, or
can put you in contact with someone who does.
If you are not in regular contact with a palliative care nurse or Macmillan
nurse you can ask for a referral to be made through your GP or hospital.
You could also contact the breast care nurse who supported you during
your treatment for primary breast cancer. You can also contact the
Breast Cancer Care Helpline on 0808 800 6000 to talk through your
concerns and find out what support may be available in your area.
If you would like more help to look at ways of coming to terms with
your secondary diagnosis, you can ask if it is possible to speak to a
counsellor or psychotherapist.

12 Call our Helpline on 0808 800 6000

  Notes

Visit www.breastcancercare.org.uk 13

Helping you
face breast cancer
A diagnosis of secondary breast cancer can be overwhelming. And
the support you need might feel like it’s hard to come by. We’re
here to help. Meet other women with secondary breast cancer and
get specialist information on topics relevant to you with our living
with secondary breast cancer services. We can help you feel less
alone and more in control to make confident decisions about your
treatment, lifestyle and care.

Ask us
Our free Helpline is here to answer any questions about breast cancer and
talk through concerns. Or you can Ask the Nurse by email via our website.
Free Helpline 0808 800 6000 (Text Relay 18001)
Monday–Friday 9am–5pm, Saturday 10am–2pm
www.breastcancercare.org.uk/ATN

Meet people like you
Come along to our free Living with Secondary Breast Cancer meet-ups for a
chance to chat and share experiences with people who understand what it
means to live with secondary breast cancer.
They’re also a unique opportunity to increase your knowledge as we run
longer sessions with guest expert speakers every other month. Topics
include pain management, fatigue, claiming benefits and side effects of
treatment. Call 0345 077 1893 or visit www.breastcancercare.org.uk/
secondary to find out more.

Talk to someone who understands
Exchange tips on coping with the side effects of treatment, ask questions,
share experiences and talk through concerns at our website’s discussion
Forum. There’s a dedicated area for people with secondary breast cancer,
it’s easy to use and professionally hosted. Live Chat sessions exclusively for
people living with secondary breast cancer take place weekly in a private
area of our website. Each session is facilitated by an experienced moderator
and a specialist nurse who can point you to sources of help and information.
But for most people, being able to talk to others who know what you’re
going through is what counts.

We’re here for you: help us to be there
for other people too
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donation. Our information resources and other services are only free
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About this booklet
Secondary breast cancer in the lungs was written by Breast
Cancer Care’s clinical specialists, and reviewed by healthcare
professionals and people affected by breast cancer.

       For a full list of the sources
       we used to research it:
       Phone 0345 092 0808
       Email publications@breastcancercare.org.uk

       You can order or download more copies from
       www.breastcancercare.org.uk/publications

       For a large print, Braille, DAISY
       format or audio CD version:
       Phone 0345 092 0808
       Email publications@breastcancercare.org.uk

© Breast Cancer Care, July 2014, BCC40
Edition 4, next planned review 2016

Breast Cancer Care is the only UK-wide charity providing specialist
support and tailored information for anyone affected by breast cancer.
Our clinical expertise and emotional support network help thousands
of people find a way to live with, through and beyond breast cancer.
Visit www.breastcancercare.org.uk or call our free Helpline on
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