The insulin-like growth factors (IGFs) signaling via the type I insulin-like growth factor receptor (IGF-1R) regulate multiple aspects of malignancy. The importance of IGF-1R in regulating the malignant phenotype is currently being validated in numerous clinical trials for cancer including breast cancer. This review discusses the regulation of breast cancer metastasis by IGF-1R. IGF-1R stimulates invasion and survival in anchorage independent conditions. The regulation of metastasis independently of tumor growth by IGF-1R is also discussed. Finally, the impact of this on clinical trial design and outcomes, and the need for biomarkers, other than reduction in tumor size, are discussed in light of the fact that inhibition of metastasis is not measured in conventional clinical trial design.