Treatment of BC

8/13/2019 Treatment of BC

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june 8 :: vol 25 no 40 :: 2011 49NURSING STANDARD

learning zoneCONTINUING PROFESSIONAL DEVELOPMENT

Aims and intended learning outcomes

The aim of this article is to provide an overviewof the treatment options available for peoplediagnosed with metastatic breast cancer and theimplications for nursing care. After reading thisarticle and completing the time out activities youshould be able to:

Identify common sites of metastaticbreast cancer.

Describe treatment options for patientswith metastatic breast cancer.

Identify side effects of treatment for metastaticbreast cancer.

Discuss the nursing implications for themanagement of metastatic breast cancer

Introduction

Nearly 46,000 people are diagnosed with breastcancer each year in the UK (Breast Cancer Care2010a). Over the past two decades, the diagnosis

and treatment of breast cancer has improvedsignificantly and associated mortality rates havefallen consistently (Cancer Research UK 2009).Breast cancer that has spread to other organs,most commonly the bone, lungs, liver and brain,is termed metastatic breast cancer. Although thereis no reliable national data of the incidence ofmetastatic breast cancer in the UK, it is estimatedthat approximately 35% of patients with primarybreast cancer develop secondary disease (Johnstonand Swanton 2006, Breast Cancer Care 2008a).

Although there are an increasing number of

treatments available for metastatic breast cancer,patients have to come to terms with living with anincurable chronic disease (Santhanam et al2004).Few other cancers have such a variable naturalcourse, with one-year survival rates of 55%,two-year survival rates of 35% and five-yearsurvival rates of 20% (Glare and Christakis 2008).

NS596 Beaumont T, Leadbeater M (2011) Treatment and care of patients with metastatic breast

cancer. Nursing Standard. 25, 40, 49-56. Date of acceptance: March 8 2011.

Treatment and care of patientswith metastatic breast cancer

Summary

This article provides an overview of the treatment options

available for patients diagnosed with metastatic breast cancer.

The article focuses on the four common organ sites affected

by metastatic breast cancer, including the bone, lungs, liver

and brain. The implications for nursing care are addressed,

highlighting common side effects of treatment and frequent

areas of concern for patients.

Authors

Tara Beaumont and Maria Leadbeater, clinical nurse specialistsin metastatic breast cancer, Breast Cancer Care St James, Sheffield.

Email: [email protected]

Keywords

Metastatic breast cancer, nursing care, oncology,

quality of life, treatment

These keywords are based on subject headings from the British

Nursing Index. All articles are subject to external double-blind peer

review and checked for plagiarism using automated software. For

author and research article guidelines visit the Nursing Standard

home page at www.nursing-standard.co.uk . For related articlesvisit our online archive and search using the keywords.

Page 58

Breast cancer multiplechoice questionnaire

Page 59

Read Claire Websters practiceprofile on chronic obstructive

pulmonary disease

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Guidelines on how towrite a practice profile

Time out 1

Define the terms osteoblast,

and osteoclast. What role do they

have in the development of bonemetastases. How would you explain

the development of metastatic breast

cancer in the bone to a patient?


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50 june 8 :: vol 25 no 40 :: 2011 NURSING STANDARD

number and action of osteoclasts, thus reducingthe breakdown of bone while allowing theproduction of new bone to continue as normal(Lightsey and Mendenhall 2009).

Bisphosphonate treatments are generally welltolerated, however they can cause gastrointestinaldisturbances, especially with oral preparations.Influenza-like symptoms can occur a few days after

administration of bisphosphonates. Renalfunction may be affected with long-term use,requiring regular monitoring (Cameron 2006).

Bisphosphonate-related osteonecrosis(destruction and death of bone tissue) of the jawis a rare complication associated with long-termuse, but it can be a cause of anxiety for patientsbefore and during therapy. Patients require a fulldental examination and any dental treatmentshould be completed before commencing therapy(Vahtsevanos et al2009).SurgerySurgical procedures to treat metastaticbreast cancer in the bone can be categorisedas follows (Reyna and Bruera 2006):

Prophylactic stabilisation of the bone at riskof fracture this is preventive surgeryperformed before a fracture occurs to minimisethe effect of a pathological fracture.

Reconstruction or stabilisation of the bonefollowing a pathological fracture thesetechniques can include replacement of jointsas well as insertion of plates to support andsecure the bone.

Decompression of the spinal cord withstabilisation of the vertebra techniquesinclude balloon kyphoplasty used to reducethe risk of imminent fracture.

RadiotherapyThe main aim of radiotherapyis to reduce pain by:

Acting directly on cancer cells to destroy andprevent them from replicating, and ultimatelyweakening the bone.

Inhibiting chemical mediators of painin the bone.

Radiotherapy is frequently given in singlefractions or short courses lasting one to twoweeks (Meeuse et al2010). Exacerbation ofpain in or around the bone can occur followingradiotherapy. Prophylactic use of dexamethasonemay reduce the incidence and extent of pain(Hird et al2009a, 2009b).Spinal cord compression Compression ofthe spinal cord is an oncological emergency

requiring immediate medical treatment. It iscommon in metastatic breast cancer and signsand symptoms include back pain, weaknessin the limbs and sensory disturbance (Cervantesand Chirivella 2004). Disruption to bladder and

Metastatic breast cancer in the bone

Approximately 80% of patients diagnosedwith metastatic breast cancer will have bone

metastases (Coleman 2004). The average lifeexpectancy following diagnosis of bonemetastases is around two years, with up to20% of patients surviving five years (Brownand Coleman 2002, Paterson 2006).

Metastatic breast cancer in the bone developsas a result of complex interactions betweencancer and bone cells. Osteoclast and osteoblastbone cells assist in the formation of bone.Osteoclasts destroy and remove small amountsof old or damaged bone and osteoblasts helpbuild up new bone. When breast cancer cellsspread to the bone, enzymes are produced thatdisrupt normal bone formation processes.Osteoclasts become overactive, resulting inmore bone being broken down than that beingreplaced (Coleman 2000).

The presenting symptom of breast cancer thathas spread to the bone is frequently pain in or nearthe affected area, which is often not resolved byrest and/or may worsen at night (Lipton 2010).All pain originating in or near the bone in patientswith a history of breast cancer requiresinvestigation because most patients witha pathological fracture have weeks of increasingpain before the fracture occurs (Bhangal andEvans 2006). Skeletal-related events orcomplications of bone metastases includehypercalcaemia (increased calcium levels in theblood), pathological fracture (fracture caused bycancer cells destroying bone), pain originating inor around the bone and spinal cord compression.Spinal cord compression develops when a tumourin the epidural space presses on the spinal cord(Langhorne et al2007). Diagnostic tests for

bone metastates may include X-ray, isotope bonescan and magnetic resonance imaging (MRI).Treatment Treatment options for bone metastaseswill depend on a number of factors, includingsymptoms, how far the cancer has spread in thebones and past treatments.BisphosphonatesThe National Institute forHealth and Clinical Excellence (NICE) (2009a)recommends the use of bisphosphonates fromthe time of diagnosis of bone metastases, basedon substantial evidence demonstrating theeffectiveness of this treatment in reducing

skeletal-related events and pain. Randomisedtrials in advanced breast cancer have shown thata major skeletal event occurs, on average, everythree to four months (Brown and Coleman 2002).Bisphosphonates function by decreasing the

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bowel function are often associated with lateconsequences of spinal cord compression(NICE 2008). NICE (2008) recommends theappointment of a metastatic spinal cordcompression co-ordinator in each centre treatingpatients with the condition. The co-ordinatorshould be available to give advice on immediatecare, seek senior clinical advice if necessary

and arrange for diagnostic tests. Treatmentmodalities for spinal cord compression includesteroids, radiotherapy and surgery.Nursing implications Information about bonemetastases, and treatment and support for boththe patient and family, are essential (NICE 2009a).Patients taking oral bisphosphonates requireadditional advice about the timing of takingmedication to reduce the risk of gastric irritation.

Nurses should be aware of the signs andsymptoms of complications of bone metastases,which can impair quality of life (Langhorne et al2007). Assessment of pain is crucial, particularlyas increasing pain may signal disease progression(Reyna and Bruera 2006). The inclusion of otherhealthcare professionals such as palliative,physiotherapy and pain specialists may berequired. A key role for the nurse is co-ordinatingthese different aspects of care for the patient(Lomas 2003, Leary et al2008).

Metastatic breast cancer in the liver

Multiple organ sites of metastatic breast cancerare common and an estimated 50% of patientswill develop disease in the liver; however, less than5% of patients will have metastatic spread to theliver only (Wilson et al2003, Adam et al2006).Signs and symptoms of liver metastases mayinclude abdominal discomfort, bloating andtenderness, nausea, weight loss, back pain,ascites, jaundice and abnormal liver function tests(Diamondet al2009). Blood tests for liverfunction, computed tomography (CT) scan,and/or ultrasound are common diagnostic tools,

although positron emission tomography andMRI are also used (Bassett et al2009). A biopsywould only be considered if there was insufficientinformation about the levels of oestrogen orhuman epidermal growth factor receptor-2(HER-2) a protein which signals cancer cellsto divide more quickly as this could affecttreatment options (NICE 2009a).TreatmentSystemic treatments such aschemotherapy, targeted therapies and/orhormone therapies may be offered to the patient.Surgical resection is not common because

metastatic breast cancer in the liver is frequentlymultifocal, meaning there can be widespread andnumerous cancer deposits in the liver (Wilson et al2003). Other novel therapies patients mayread about include thermal or cryoablation

(destroying the tissue by extremes of temperature)or selective internal radiotherapy, although norandomised clinical trials have been published toindicate the likely effectiveness of these therapies.Availability of new techniques along with carefulpatient selection based on the extent of disease arekey criteria when considering novel treatments(Diamond et al2009).

Complications of liver metastases will affectthe patients physical ability. Jaundice maydevelop as a result of high levels of serumbilirubin, resulting in the patients skin andeyes developing a yellow-green tone. Portalhypertension results in blood being divertedto the systemic circulation, which can leadto abdominal ascites (accumulation of fluidin the peritoneal cavity) (Day 2006).Nursing implications Care needs to focus onsupporting patients with a range of complexsymptoms. Assessment of pain is important. Painas a result of liver metastases can present as a dullor aching pain, which often radiates to the rightshoulder (Langhorne et al2007). Patients withabdominal ascites may present with breathingproblems, leading to decreased mobility. Increasedabdominal pressure will often cause nausea andvomiting, which will require management withanti-emetic medication and the need to addressthe persons diet and fluid intake. Drug treatmentusing a diuretic may be helpful, but when thepatients abdomen is tense and distended,abdominal paracentesis to drain the fluidgradually will be performed (TwycrossandWilcock 2009). The patient will need to beadmitted to hospital to undergo abdominalparacentesis and this provides an opportunityfor physical and emotional assessment.

Metastatic breast cancer in the lung

An estimated 60-70% of cases of metastaticbreast cancer will develop in the lungs, andfor 15-25% of patients it can be the first site the

cancer spreads to (Harris et al 2010). Symptomsrelate to the size and area of the lungs affected andmay include shortness of breath, a dry cough orpain. Some patients may be asymptomatic andlung metastases will be detected by chest X-rayor CT scan showing nodules or a mass (Yungand Brock 2009).

Diagnosis of lung metastases will often bebased on the patients history, X-ray and/or CTscan. However, as the incidence of primary lungcancer is increasing in women over the age of 60years (attributable to smoking) (Cancer Research

UK 2011), a biopsy of the lung may be needed toestablish the pathology of the tumour. Traditionallung biopsy is an invasive procedure using eitherbronchoscopic or transthoracic (via the chestwall) needle biopsy. However, there have been


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central nervous system metastases. The incidenceof breast cancer spread to the brain and centralnervous system is increasing (Weilet al2005).This may be because improved treatments andincreased life expectancy mean that the full extentof the metastatic process is now evident (Vogelet al2002). Over expression of HER-2 has beenlinked with a higher incidence of brain metastases

(Claytonet al2004, Weil et al2005).Presenting symptoms may include persistent

or increasing headache, fits, nausea, vomiting,speech problems, gait or limb deficits andpersonality changes, all of which can bedistressing for the patient and family members.CT or MRI scans will be used to diagnose brainmetastases. If the diagnosis is unclear, surgicalintervention may be required in the form ofbiopsy as there may be many possible causesof a brain lesion, such as an abscess or primarybrain tumours (Chang and Lo 2003).TreatmentThe aim of treatment for brainmetastases is palliation of symptoms andpreservation of neurological function (Chang andLo 2003). Any treatment decisions have to takeinto account the size and number of brain lesionsand the physical state of the patient. Steroidtreatment can be used to reduce any intracranialpressure and anticonvulsants can be used if thepatient is experiencing fits (Wadasadawala et al2007). Whole brain radiotherapy can improvethe patients quality of life and overall survivalby a few months. However, the one-year survivalrate for patients with brain metastases is about20% (Lin et al2004).

Surgery may be considered only in patients withgood physical status and if the brain lesions aresmall and surgically accessible. Sterotactic radiosurgery or gamma knife treatment may be analternative to surgery when the patient isphysically fit and brain metastases are small innumber and volume. The procedure is available inseveral centres across the UK for carefully selectedpatients. However, the choice of treatment for

patients who have brain metastases is highlyindividualised and needs to take into accountthe evolving evidence along with the patientsphysical status and the size and position of brainmetastases (Thomas and Dunbar 2010).Nursing implications Brain metastases andassociated treatment can cause a range ofsymptoms and side effects, includingcancer-related fatigue, steroid-induced increasedappetite and weight gain, and personalitychanges. The time from investigation throughto diagnosis and treatment can be frightening

for the patient, and the need for supportive careand regular assessment is essential.At the time of diagnosis, the doctor should

inform patients to contact the Driver andVehicle Licensing Agency (DVLA) about their

advances in minimally invasive surgicalprocedures such as keyhole video-assistedthoracic surgery (Hess and Klomp 2006) .TreatmentFollowing diagnosis of metastatic

breast cancer in the lung, the treatment planshould consider the patients physical status,other areas affected by the cancer and previoustreatment. Treatment options include hormonetherapy, chemotherapy and targeted therapy.Surgery is rarely an option for lung metastasesbecause of the frequent multifocal presentationof disease, but may occasionally be consideredfor patients with small solitary tumours.However, most patients will develop subsequentfurther metastases (Hess and Klomp 2006).

The onset of superior vena cava obstruction canbe gradual or rapid, occurring when the tumouror affected lymph nodes put pressure on thesuperior vena cava. This results in dilatedupper major veins, facial swelling and stridor(obstruction of the larynx or trachea resulting ina harsh, shrill breathing sound), requiring urgentmedical treatment. Radiotherapy and steroidscan be used to reduce swelling and obstruction,and stenting of the obstructed blood vessel may berequired (Cervantes and Chirivella 2004). Pleuraleffusions are a complication in approximately50% of patients with metastatic breast cancerin the lung. Cancer cells irritate the pleura andfluid builds up and presses on the lung causingincreasing breathlessness. Generally, drainageis required when pleural effusions are large andsymptomatic (Twycross and Wilcock 2009).Nursing implications Complications ofmetastatic breast cancer in the lung requireskilled and prompt treatment (Lomas 2003).Nursing care will frequently focus on strategiesto reduce breathlessness. This can involveteaching the patientbreathing techniques andhow to manage anxiety (Gysels

et al2007).

Andrewes (2002) recommended assessmentof the effect of breathlessness on the patient,including the level of breathlessness and theeffect on physical mobility. Practical supportsuch as establishing a comfortable environment,opening a window, oxygen provision or playingmusic may help to reduce anxiety associated withan acute episode of breathlessness (Andrewes2002). Psychological, medical and practicalsupport are required to ensure optimum qualityof life for patients (Lomas 2003).

Metastatic breast cancer in the brain

Approximately 10-20% of patients withmetastatic breast cancer will develop brain or



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medical condition. The DVLA will request thepatients driving licence. Thorough explanationabout why it is important not to drive andassessment of the effect this may have on thepatient, both practically and emotionally,is important. Not being able to drive can resultin a significant loss of independence forthe individual.

Systemic treatments for metastatic

breast cancerHormone treatments Oestrogen hormones canplay a role in the development and treatmentof breast cancer. Approximately two thirds ofbreast cancer cases will be hormone sensitive(Sousi and Loizidou 2010). Hormone treatmentwill be offered to patients who have metastaticbreast cancer that is oestrogen receptor positiveand is not immediately life threatening(NICE 2009a). Oestrogen receptor statustests will be carried out at primary diagnosisto assess whether the breast cancer is affectedby the hormone oestrogen (NICE 2009b).Approximately two thirds of breast cancercases are hormone receptor positive (Nabholtzet al2003).

The patients menopausal status will dictatethe type of hormone treatment. Aromataseinhibitors are currently licensed for use only inpostmenopausal women. Aromatase inhibitorsstop the conversion of androgen to oestrogen(Harris et al2010). Anastrozole, letrozole andexemestane are prescribed for use in the

treatment of hormone receptor positivepostmenopausal women in the UK (BritishNational Formulary 2011).

Tamoxifen is an anti-oestrogen, which blocksthe action of oestrogen on breast cancer cells and isused in both pre-menopausal and postmenopausalwomen (Johnston and Swanton 2006). Fulvestrantis an oestrogen-receptor antagonist given as anintramuscular injection. The progestogenmegestrol acetate was developed decades ago, butis still considered as a treatment option in late-stagedisease when weight loss is more of a problem,

as megestrol acetate is linked to weight gain(Johnston and Swanton 2006). To reducecirculating oestrogen in pre-menopausal women,ovarian ablation using surgery, radiotherapy orthe hormone injection goserelin may be offered.

While hormone therapy is generally welltolerated, for some women the menopausalsymptoms of weight gain, vaginal dryness,arthralgia and hot flushes cause physical andpsychological distress, manifesting in alteredbody image (Kissane et al 2004, Luoma andHakamies-Blomqvistet al2004). Possibleinterventions may include complementary

therapy or further medications dependingon the severity of distress caused by hormonetherapy (Breast Cancer Care 2011).Chemotherapy Oestrogen receptor positiveand negative metastatic breast cancer maybe treated with chemotherapy (NICE 2009a).The goals of treatment are to prolong life,control or prevent cancer-related symptomsand complications, and improve quality of life.While the aim of treatment is to prevent oralleviate symptoms, chemotherapy toxicitycan cause nausea, vomiting, diarrhoea, hairloss, mucositis, neutropenia (low white callcount), fatigue and neuropathy (Summerhayesand Daniels 2003).

Balancing the benefits and side effectsof chemotherapy in treating patientswith metastatic breast cancer is complex.Maintaining quality of life during thepatients disease trajectory may involvemultiple courses of chemotherapy, especiallyin individuals whose tumors are responsiveto chemotherapy treatment (Mayer andBurstein 2007).

Both combination and single agentchemotherapies are used to treat metastaticbreast cancer. The choice of regimen dependson previous treatments, patients generalwellbeing and patient choice (Cardoso et al2009). Combination regimens often have agreater side-effect profile compared with singleagent treatments, which are frequently welltolerated (NICE 2009a). Other chemotherapydrugs used include platinum-based drugs suchas carboplatin (Mavroudis et al2003).

Patients receiving chemotherapy requireongoing support and information to enablethem to self-monitor side effects and toaccess supportive care when required. Eachchemotherapy agent has a side-effect profile.The degree to which an individual patientwill be affected varies. It is essential thatpatients have 24-hour contact details for thechemotherapy unit treating them in case theybecome acutely unwell (Lennan et al2010).The development of a fever in a patient withsuspected neutropenia requires urgent clinical

assessment as more than half of patients willnot display any other symptoms of infection(Fischer et al2003). Common chemotherapydrugs used to treat metastatic breast cancer arelisted in Box 1.

Time out 2

Consider the implications of

caring for a patient with metastatic

breast cancer. Which other members

of the wider multidisciplinary team

might you need to refer the patient

or family to, and why?


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receive written information before startingtreatment (Breast Cancer Care 2008b).

Trastuzumab is well tolerated, but can causea decline in left ventricular function andconsequently cardiac failure (Murray et al2010).Therefore, patients require regular cardiacmonitoring using an echocardiogram ormulti-gated acquisition scanning (National

Cancer Research Institute Breast Clinical StudiesGroup 2005). Patients should understandthat potential cardiac failure is rare and theimportance of regular heart scans, as certainindividuals may be at increased risk becauseof previous treatments or underlyingcardiac conditions.

Newer targeted therapies such as lapatiniband bevacizumab have the potential eitherto delay the speed of disease progression orincrease survival time (Jones and Buzdar 2009).However, these drugs have not been approvedby NICE, but if judged clinically appropriatethey may be available privately, via theco-payment or top up system (Departmentof Health 2009) or by appeal to the localprovider organisation.

Discussion in relation to novel treatmentscan raise many questions and ethical dilemmas.There is a need to offer support and ensurepatients have realistic expectations whendiscussing availability and clinical benefitsof any possible targeted treatment.

Targeted or novel therapies

Directing drugs against specific targets withinthe cancer cells has led to the development ofa new group of cancer drugs also referred toas biological therapies, monoclonal antibodiesor targeted therapy. In breast cancer, there areseveral targeted therapies in development(NICE 2011). Trastuzumab is the onlyNICE-approved drug available at present in theNHS. Trastuzumab is a monoclonal antibodythat selectively binds to the HER-2 protein onthe cancer cell, which influences the divisionand growth of cancer cells (Langhorne et al2007). The HER-2 protein or antigen is overexpressed in 15-20% of breast cancers(Johnston and Swanton 2006) and animmunohistochemistry test is now performed atdiagnosis of primary breast cancer. Trastuzumabis given as an infusion either weekly or everythree weeks and treatment continues untildisease progresses outside the central nervoussystem (NICE 2009a). Side effects are generallyless severe in comparison with chemotherapytreatments, but influenza-like symptoms, nauseaand diarrhoea can occur. Patients need to bemade aware of potential side effects and should


Time out 3

Research some of the common

side effects of the chemotherapy

drugs in Box 1. List some of the

non-life-threatening side effects

that can affect a patients daily life.

Time out 4

Consider some of the ethical

dilemmas that may arise

when considering treatment

of metastatic breast cancer with

targeted and novel therapies. How

could you help support patients making

difficult treatment decisions?

Time out 5NICE (2009b) recommends

assessing patients preferred

level and type of information.

Either online or using your local

cancer information centre, read through

some of the patient information sources

from both the statutory and voluntary sector.

Consider the range of resources available,

including Breast Cancer Cares (2009, 2010a,

2010b, 2010c) four factsheets on metastatic

breast cancer in the bone, lungs, liver andbrain. Reflect on the issues pertinent

to when to offer this type of written

information to patients.

BOX 1

Intravenous chemotherapy

Cyclophosphamide.

Docetaxel.

Doxorubicin.

Epirubicin.

Fluorouracil.

Gemcitabine.

Paclitaxel.

Oral chemotherapy

Capecitabine.

Vinorelbine.

(National Institute for Health and Clinical Excellence 2009a)

Common chemotherapy drugs used to treatmetastatic breast cancer


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Conclusion

Treatment of metastatic breast cancer maybe varied depending on the extent and type ofdisease. Patients living with this form of cancershould be given information about the aims oftreatment and potential side effects so that theycan make informed decisions. Patients and their

families should be supported during this difficulttime and may require advice from a range ofhealthcare professionals in hospital, community

and palliative care settings. The nurse hasa major role in co-ordinating care to ensurethe patients needs are met and to improvequality of life NS

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