Symptom management and quality of life in metastatic breast cancer

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Published: 20 Dec 2013
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Dr Polly Niravath - Baylor College of Medicine, Houston, Texas

Dr Niravath talks to ecancertv at SABCS about symptom management and quality of life in metastatic breast cancer

Approximately 40,000 women in the US die each year of metastatic breast cancer. Because the disease is incurable at this stage, effective symptom management and preservation of quality of life are paramount for these patients. For those with brain metastases, consideration of cognition, quality of life, and overall survival are extremely important because some subsets of patients with breast cancer metastases to the brain may now enjoy prolonged survival of almost 2 years.

For solitary brain metastasis, surgical resection followed by whole brain radiotherapy is known to prolong survival, though the addition of whole brain radiotherapy is associated with significant cognitive impairment and decreased quality of life without clear improvement in overall survival. Stereotactic radiosurgery (SRS) shows promise as a therapeutic option for patients with asymptomatic, smaller brain lesions. SRS, as compared to open surgery, results in improved quality of life. Bone metastasis is another common management dilemma for breast cancer patients.

Commonly used bone agents, such as bisphosphonates and RANK ligand inhibitors, are known to decrease bone pain and increase quality of life, as well as reduce skeletal-related events. However, safe and optimal duration of bisphosphonates or RANK ligand inhibitors remains unclear in the metastatic breast cancer population. Finally, we will discuss quality measures for delivering end of life care, trends in the country, and methods for improving end of life care with goals of earlier hospice referrals and less treatments at end of life which lead to hospitalizations or ICU stays.

I began by talking about how the landscape of metastatic breast cancer has changed considerably. Our treatment options have now improved to the point where metastatic breast cancer survival has improved tremendously, just even over the past twenty years. Now, metastatic breast cancer survival, on average, is up to almost two years for all comers, regardless of biomarker status. So, given that longer life that our metastatic breast cancer patients enjoy, quality of life becomes even more important; it takes a paramount role in our treatment considerations and in our discussions with our patients. So I talked a little bit about specifically the management of brain metastases for metastatic patients and I talked about the fact that whereas there is excellent evidence for giving whole brain radiation therapy for patients with brain metastases, there is newer evidence coming out stating that there may be things that we can do during whole brain radiation therapy to perhaps prevent the cognitive impairment that we see. There is some data that says that even up to 25% of patients can’t continue their jobs after having had whole brain radiation therapy because of the cognitive impairment so it’s a significant quality of life problem. There was a trial, an RTOG trial, that looked at memantine versus placebo. Memantine is a drug that’s commonly used for Alzheimer’s disease and they randomised people to either receive memantine during radiation or placebo. They actually found that the people who received memantine tended to have less cognitive problems after the radiation than placebo. So future studies are needed to validate this but it could be something that we can use in the future to prevent cognitive decline for patients receiving whole brain.

The other thing that I talked about is also increasing use of stereotactic radiosurgery. By targeting only the lesions in the brain that are actually cancerous and leaving the rest of the brain untouched by radiation we see significantly less cognitive decline as compared to whole brain radiation therapy. And now that this modality is becoming more commonly used it is increasing cognitive function in metastatic patients and it’s also increasing survival without brain metastases.

What are the benefits of stereotactic surgery?

For stereotactic radiosurgery the idea is that it allows you more opportunities for more local treatment. So, for example, if you have stereotactic radiosurgery for a small number of lesions, one or two lesions, and then you’ll experience some period of disease free survival after that, if you should recur again in the brain you now have the option of again doing stereotactic radiosurgery which will then give you a further disease free survival interval. Whereas, had you done whole brain radiation therapy in the very beginning there’s no other option beyond that; you can’t go back and re-irradiate the brain.

The other topic that I discussed yesterday in my talk was also the issue of quality of life care, particularly quality in end of life care, particularly delivering quality end of life care for metastatic patients. What I discussed mostly was having those discussions early; we found that there’s a lot of data that shows that oncologists unfortunately are not doing a good job of discussing with patients very early in their metastatic course that the disease is incurable and to talk to them about their wishes, what their wishes would be if something should happen to them, meaning would they want resuscitation and intensive ICU care and so forth. There are several studies to show that patients actually do appreciate it when doctors have these honest and frank discussions with them up front. It helps them to be better prepared for what’s coming and we find that patients who are more aware of this because their doctor has discussed it actually have less hospitalisations within the last two weeks of death, less ICU stays, less intubations, less resuscitations which are all good measures of care. Because, in the end of life, we know that these measures are not likely to benefit a patient. They also reported higher quality of life and similarly those patients who were actually referred to hospice earlier in their course, as opposed to very late hospice referrals meaning hospice referral within three days of death, those patients reported significantly improved quality of life and improved satisfaction with their provider.

One of the things that consistently shows up in all of the trials that have looked at end of life quality of care is that patients truly appreciate being honestly and frankly informed about their disease status and how they’re doing because it gives them a sense of empowerment, it gives them a sense of control over what’s happening to them. While they realise that they may not be able to ever be cured of the cancer, if they can at least have some sense of control over their own decisions that they make in terms of their own quality of life versus the treatment of the cancer, patients do describe that they’ve very satisfied with that.