Metastasis is a complex and interconnected multi-step process. Each step in the process is a potential target for therapies to prevent or reduce metastasis. Those steps which have a good clinical window are the best targets for therapy. Each event in metastasis is highly regulated and requires a synergistic activation of different ECM proteins, growth factors and so on. Although the occasional patient with<unk>  benefits from surgical resection of an isolated metastasis and most patients receive radiotherapy (often for palliation alone) during the course of their disease, the treatment of metastatic<unk>  carcinoma typically involves the use of systemic therapy. There is no sufficient evidence on the benefits and risks of<unk>  surgery associated with systemic treatment for women diagnosed with<unk> . Chemotherapy Chemotherapy is one of the most important components of therapy for<unk> . Therapy of choice is based on three variables; 1. the extent, pattern and aggressiveness at first presentation. 2. what stage of menopause the patient is at. 3. What receptor hormone the tumour has. Observation of metastases provides direct feedback on the effectiveness of the treatment and often a number of chemotherapy agents are tried sequentially to determine one that works. Adding one or more chemotherapy drugs to an established regimen in women with<unk>  gives greater tumour shrinkage on imaging but also increased toxicity. Combination chemotherapy is often used in patients with<unk> . Research suggests no difference in overall survival time between sequential single agent chemotherapy and combination chemotherapy. Sequential single agent chemotherapy may have a more positive effect on progression-free survival. Taxanes are very active in<unk> , and abraxane is approved for patients with<unk>  who either relapsed within six months of adjuvant chemotherapy or failed to respond to combination chemotherapy. This has a higher response rate than solvent-based paclitaxel (15% vs 8%). Abraxane can also deliver a 49% higher dose of medication than solvent-based paclitaxel; however, the side effects are severe and include chemotherapy-induced peripheral neuropathy. In women with<unk> , taxane-containing chemotherapy regimens appear to improve survival and tumour shrinkage and decrease time to progression. Taxanes are associated with increased risk of neuro-toxicity and less nausea and vomiting when contrasted to non-taxane containing regimens. Vinorelbine is also active in<unk> . Eribulin was approved in the US in Nov 2010. A targeted therapy drug, Kadcyla, was approved in February 2013. This antibody-drug conjugate targets only cancerous cells. It works by only releasing its toxic payload when triggered by a protein found in the cancerous cells in HER2+<unk>  cancer. It has extremely low side effects using this target therapy method. Platinum-containing chemotherapy regimens are known to be effective for treating a variety of different cancer types. In women with<unk>  who do not have triple negative disease, there is little or no survival benefit and excess toxicity from platinum-based regimens. However, in women with metastatic triple negative<unk>  cancer, there may be a moderate survival benefit from platinum-based regimens. Antitumour antibiotics are also used in<unk> . Antitumour antibiotics work to prevent cancer cells multiplying by damaging them. A meta-analysis has demonstrated that women taking antitumour antibiotics as part of their regimen had an advantage in time to progression and tumour shrinkage, but also increased side effect such as cardiotoxicity, leukopenia and nausea. Tamoxifen and other anti-estrogens For estrogen-receptor-positive metastatic<unk>  carcinoma the first line of therapy is often tamoxifen or another anti-estrogen drug unless there are liver metastases, significant lung involvement, rapidly progressive disease or severe symptoms requiring immediate palliation. Radiotherapy Radiotherapy is used in the treatment of<unk> . The most common reasons for a patient with metastatic<unk>  carcinoma to be treated with radiotherapy are: *Spinal cord compression. Spinal-cord compression is an oncological emergency, as untreated spinal cord compression may cause permanent paralysis or death. In<unk>  cancer, spinal-cord compression occurs when a bone metastasis or spinal metastasis begins to push on the spinal cord this results in inflammation and, if untreated, spinal cord injury. Radiotherapy is an important component of therapy for cord compression secondary to<unk> , along with corticosteroids and laminectomy. *Liver metastases. Typically, pain from liver metastases responds to chemotherapy and analgesia. However, in cases when chemotherapy is contraindicated or the liver metastases are refractory to chemotherapy (and pain medication fails to provide appropriate palliation of liver metastasis-related pain, radiotherapy should be considered; it may relieve pain and shrink the metastases, and perhaps extend survival in a subset of patients with a good response to radiotherapy. *Brain metastases. Brain metastases occur in up to 10–15% of<unk> -cancer patients, and often (but not always) occur late in the disease. They require urgent treatment; brain metastases may progress rapidly, and can suddenly produce life-threatening complications such as increased intracranial pressure, herniation of the brain, and seizures. Radiotherapy is essential in the treatment of brain metastases from<unk>  cancer, as it halts tumor progression quickly and can induce a response in the majority of patients. *Bone metastases. The bones are a very common site of metastatic disease from<unk>  cancer, and bone metastases can cause severe pain, hypercalcemia and pathologic fracture. Radiotherapy is indicated to prevent pathologic fracture; it is also part of postoperative treatment following repair of a pathologic fracture. Strontium 89, a radiopharmaceutical which is injected into the bloodstream, is under investigation for the treatment of bone metastases from<unk>  cancer; there is evidence that it can relieve pain for up to three months after its administration. It is unknown whether or not it can prevent pathologic fracture, but it should be considered in patients who have three or more sites of painful bone metastases who cannot be treated with external-beam radiotherapy. In some patients with estrogen-receptor-positive<unk>  carcinoma metastatic to the bone only, external-beam radiotherapy followed by tamoxifen or another anti-estrogen may be sufficient to control disease, at least temporarily. In most cases, however, the combination of radiotherapy and hormonal therapy is not enough to maintain disease control, and chemotherapy is needed. "Alternative" and "complementary" therapies Some patients with<unk>  opt to try alternative therapies that are claimed to achieve healing effects similar to scientifically-tested medical approaches, but lack scientific evidence to support those claims. Approaches that are considered alternative therapies when applied to cancer treatment include vitamin therapies, homeopathic treatments, extreme diets, chiropractic treatment and acupuncture. Some alternative treatments are harmful or even life-threatening. Amygdalin, an extract derived from apricot kernels, exposes the patient to cyanide. Bee venom can cause a life-threatening allergic reaction. Severe dietary restrictions such as Macrobiotic diets can disrupt the body’s metabolism and cause dangerous weight loss. People should be aware that foods, vitamins, and other treatments may interfere with the effectiveness of surgery, chemotherapy or radiation. It is essential that patients work with their doctors and openly discuss possible effects of any treatment they are considering. Alternative and complementary therapies are not regulated by the U.S. federal government and may lack quality controls. While there is no evidence that any alternative treatments will cure cancer, there are treatments that may alleviate symptoms and improve quality of life for patients. When integrated into a broader medical treatment plan these are sometimes referred to as "complementary" or "integrative" therapies. For example, patients may find hypnosis, massage, meditation, relaxation techniques, tai chi or yoga to be helpful for issues such as stress, pain, nausea, and difficulty sleeping. Gentle exercise and a healthy diet can contribute to overall well-being and quality of life. Some early research suggests that women who refrain from eating for at least 13 hours overnight are less likely to have a cancer recurrence, possibly due to differences in insulin, ketone or glucose metabolism. As yet, the effects of nutrition and exercise on cancers are not well understood and some theories are controversial. Patients have been shown to face a greater risk of mortality if they refuse or delay scientifically-proven treatments in favor of alternative therapies. This is also true in the case of complementary therapies. A study published in JAMA Oncology compared the survival of those who used complementary cancer treatments and those who used only the medical cancer treatments recommended by their doctors. They found that those who used complementary treatments during cancer treatment were more likely to refuse some of the conventional cancer treatments their doctors recommended, resulting in a higher risk of dying as compared to those who used no complementary treatments at all. Those most likely to choose complementary treatments were young, affluent, well-educated women with private insurance. Experimental therapies Treatment of<unk>  is currently an active area of research. Several medications are in development or in phase I/II trials. Typically new medications and treatments are first tested in metastatic cancer before trials in primary cancer are attempted. Another area of research is finding combination treatments which provide higher efficacy with reduced toxicity and side effects. Experimental medications: * sorafenib a combined Tyrosine protein kinases inhibitor. Scheduling of drug
Metastatic breast cancer
Metastatic carcinoma
Cancer of unknown primary origin
Medullary carcinoma
Acinar cell carcinoma of the pancreas
Adrenocortical carcinoma
Hormone receptor positive breast tumor
Parathyroid carcinoma