Metastatic Breast Cancer Supportive CareDr Michelle White

Setting the scene

• A diagnosis of metastatic breast cancer is a devastating diagnosis for the patient and their family.

• Clearly treatment decisions are critical as they will be throughout the patient’s illness.

• However the care of a patient with metastatic breast cancer does not solely consist of choosing the next line of cancer treatment.

• Just as important is supportive care which involves maintaining the mental, physical and spiritual health of the patient as much as possible.

Setting the scene

• Part of maintaining the best quality of life is ensuring symptoms are being managed as well as possible.

• Patients don’t travel their illness journey alone and support must be extended to their family.

The patient’s role in treatment decision making

• At each point where a new treatment is required it is important oncologist and the patient sit down and review their options.

• Typically oncologists like to use the most active medications early in the metastatic cancer illness.

• However, sometimes the patients might decide to have a less active treatment because it has a better side effect profile.

• The patient has a major role to play when deciding on treatments.

Management of Physical Symptoms

• Long list of potential physical symptoms for patients diagnosed with MBC including• Pain • Fatigue• Nausea and vomiting• Loss of appetite• Menopausal symptoms• Headache• Loss of weight• Side effects of treatment

Pain Management

• Pain is one the most feared symptoms associated with metastatic breast cancer.

• Increasing list of medications available to help manage this symptom.

• Important for the treating team to understand the mechanism of the pain as different treatments recommended depending on the cause of pain

Types of Cancer Pain

Bone pain

• Often related to movement

• Usually responds to usual pain medication such as anti-inflammatories and opioids

Neuropathic Pain

• Most difficult type of pain to manage

• Often doesn’t respond to usual pain medication

• Drugs specific to nerve pain such as gabapentin and lyrica

Visceral (organ) pain

• Often associated with liver metastases

Approach to Pain Management in Oncology

1 Start with simple analgesia such as Panadol or anti-inflammatories

2. If no relief acting medication escalate to stronger medications such as oxycodone,

morphine or fentanyl.

3.Add in other medications that may help

• Drugs for neuropathic pain

• Steroids

4 Consider referral to pain specialist

5 Look at definitive therapies such as chemo

or radiotherapy to attack the cancer.

Management of Nausea

• Like with pain it is important to understand the cause of the symptom.

• Like pain greatly feared by many patients.

• May be related to

• metastatic disease such as with liver metastases or brain metastases.

• Cancer treatment such as chemotherapy or radiation

• Other medications such as pain relief (opioids, like morphine)

Medication to Manage Nausea

• Many different anti-emetics (nausea medications) available. Can be given orally, intravenous or subcutaneous.

• Nausea medications include drugs such as

• Metoclopramide

• Domperidone

• Ondansotron

• Haloperidol

• Cyclizine

• Drugs such as dexamethasone may also be of assistance.

• Gaining control of the cancer with radiation or chemotherapy will also improve the symptoms.

Supportive Care Services

• To support mental health: Many psychology services available- some psychologists specialise in cancer- psycho-oncologists.

• Can be expensive to see psychologists as not covered by Medicare

• Mental health plan can allow these costs to be minimized, set up through GP.

• To support physical health: exercise physiologist, dietians, physiotherapists, podiatrists.

• Chronic health plan set up through GP allow cheaper consults.

Exercise and Advanced Cancer

• Increasing evidence that regular exercise is vital for patients diagnosed with stage 4 cancer.

• Good evidence it improves ability to cope with treatment, especially chemo.

• Also positively impacts quality of life and maybe survival.

• Many trials starting to address the positive impact of this. Need someone like an exercise physiologist to design a program around the patient’s specific needs.

Credible resources and services

• BCNA My Journey online tool

• Cancer Australia

• Look Good Feel Better

• Living with Cancer programs

• Breast Cancer Trials

• OTIS Foundation

• Gather My Crew

• National Breast Cancer Foundation

• Hospital and community resources

• Psychology / counselling

• Dieticians

• Dentists

• Social workers

• Exercise physiologists / physiotherapists / occupational therapists

• Specialist clinics (menopause, lymphoedema, familial cancer, sexual health)

• Specialist nurses (BCNs, palliative care, district nurses, oncology, radiotherapy)

• Specialised MBC nursing roles

The Role of the Breast Cancer Nurse

• Breast cancer nurses (BCN) are a vital cog in the wheel of breast cancer care in Australia.

• Over recent years greater understanding that patients in the early and metastatic patient have very different needs.

• In last 10 years the role of the metastatic BCN has evolved and now many centres have both early and metastatic BCN

• BCN’s are a great advocate for patients and can help them navigate the medical system and advise on what supportive measures are available

wecan.org.au

Palliative Care

• Patients often perceive a discussion with their doctor about palliative care means their doctor thinks their death is imminent.

• This is generally not the case and early referral is always preferred to maintain the best quality of life.

• Palliative Care Services available both in inpatient and outpatient setting.

• Role is broader than end of life care. These teams of doctors and nurses play a major role in managing complex symptoms also.

• Extend across metropolitan areas and some rural settings.

• May discharge a patient when situations improve and be available for involvement later in the patient’s illness.

Palliative Care Services

• Different community services based on post code.

• Will have a team of nurses and some doctors to provide care in the community.

• Often will visit regularly to provide symptom support

• Not able to assist with showering or other aspects of personal care.

• Often have helpful services like financial planning and allied health to provide assistance.

Decisions about ceasing active treatment

• Ultimately patient reaches a stage when further anti-cancer therapy is not in their best interest.

• These are some of the most difficult discussions as patient and doctor have often become quite close during their cancer journey.

• There is no value on continuing with futile therapy or when the harm of therapy outweighs the benefit.

• Often easier to just keep treating rather having these often painful and difficult discussions but important to do.

Alternative Therapies

• As most patients with advanced cancer have an incurable illness it is under-standable they explore alternative to conventional medicine.

• Managing this situation can be one of the most challenging areas of oncology.

• Most important key to this situation is that patient feels comfortable to tell their oncology team about what they are considering.

• Important to note that if websites are offering amazing results with their treatment without much evidence to support, this is hard to believe

Alternative Therapies

• It is quite likely that some alternative therapies may help with side effects of treatment or possibly have anti-cancer activity.

• In oncology we try to use “evidence based medicine” which means we have clinical trial data that demonstrates a treatment is better than previous treatments.

• These trials are extremely expensive and are often financially supported by pharmaceutical companies.

• Due to cost these trials are lacking for alternative therapies.

Helpful Website

Advanced Care Plans

• For any patient with incurable cancer it is of value to have an idea about their wishes towards the end of their life.

• Advanced care directives are a document that can be included in your hospital file as well as patient keeping a copy.

• A painful process but empowering.

Voluntary Assisted Dying

• In some states such as Victoria, Western Australia and Tasmania VAD is now a legally approved process.

• Strict process in place to safeguard the system.

• Doctors involved are required to add specific training.

• 2 doctors need to agree that the patient is of sound mind to make the decision and agree their prognosis is less than 6 months for cancer and less than 12 months for neurological conditions.

• For some patients this is an issue they would like to explore.

VAD

• Can be confronting discussions between patients and doctors and important not left until too late illness to discuss as takes some weeks/months to set in place.

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In summary

• Holistic care of a patient with advanced breast cancer extends beyond prescribing anti-cancer drugs.

• Supportive care measures allow patients to maintain the best quality of life possible.

• Patient awareness of the many resources available to them is paramount.