Metastatic breast cancer (MBC) is a disease that challenges the knowledge, competence, creativeness and emotions of the doctor. For the patient, who generally (and understandably) cannot come to terms with not being part of the successful survivorship statistics, and for the doctor, who is often overwhelmed by the frustration of this failure, coping and treating this disease is emotionally draining. After 30 years of clinical practice in the breast cancer field I share the opinion of those who feel that little has changed—until a few years ago. Surgeons feel somehow 'protected' by not being expected to take action (with a few exceptions), radiotherapists look for a role in the treatment of MBC, which should be better defined, and medical oncologists generally accept that there is a high risk of getting lost in the labyrinth of procedures and treatment plans.

“Treatment of [MBC] is considered to be an art” affirms the recommendations proposal from the European School of Oncology–MBC Task Force co-chaired by Fatima Cardoso (Brussels) and Eric Winer (Boston). Contrary to the early breast cancer setting, where level 1 evidence exists for the majority of treatment options, for MBC there are few approved standards of care, particularly after first-line treatment. Consequently, while several international guidelines exist and are widely used for adjuvant therapy, international guidelines for MBC treatment are rare and not usually followed by the majority of treating oncologists.

Advances in breast cancer care and new drug development have been quite impressive in the past decades and fortunately a wide array of options exists for the management of MBC, such as hormonal therapies and chemotherapy, used as single regimens or in combination. Notwithstanding these improvements, many questions remain unanswered, particularly since MBC is still an incurable disease where the main goal is to improve the quality and, whenever possible, increase the quantity of life. The treatment of this disease is, therefore, remarkably different among countries, centers and even among individual oncologists. With the ever increasing costs of new treatments, biological markers and supportive and palliative care measures, a wise and balanced use of resources is paramount.

From first diagnosis of MBC, patients should be offered personalized appropriate psychosocial, supportive and symptom-related interventions.

Given the complex issues surrounding this disease, the European School of Oncology in collaboration with the European Breast Cancer Conference (EBCC) organizers has created a task force with the aim of developing international guidelines for the management of MBC. The first step was to prepare a list of 12 statements highlighting the main issues and providing general recommendations regarding MBC management. The 12 statements were generated at a meeting that took place in March 2006 at the EBCC-5 in Nice. This list of statements was discussed by a panel of experts with active interaction with the audience in a plenary session during EBCC-5, and is now published in the February issue of the journal The Breast (http://ees.elsevier.com/thebreast/).

The main message of the publication is that management of MBC is complex; therefore, involvement of all appropriate specialties in a multidisciplinary team (e.g. medical, radiation, surgical and imaging oncologists, palliative care, psycho-social, among others) is crucial. From first diagnosis of MBC, patients should be offered personalized appropriate psychosocial, supportive and symptom-related interventions as a routine part of their care.

Following thorough assessment and confirmation of MBC, the realistic treatment goals must be specified and discussed. Patients and family members should be invited to participate in all decision-making. We expect a fair debate to arise from their exercise and a new effort to improve our capability to control the disease.