By: Leah Lawrence
Breast cancer remains the second leading cause of cancer death among women in the U.S. Although treatments for metastatic breast cancer — whether a new diagnosis or recurrent disease — have improved in recent years, metastatic disease remains incurable, explained Dawn L. Hershman, MD, MS, director of breast oncology at the Herbert Irving Comprehensive Cancer Center at Columbia University in New York City.
“There are a lot of treatments for many types of metastatic breast cancer, but the natural history is such that when we give treatment, the cancer can sometimes shrink or even disappear, but eventually it will come back and progress,” Hershman said. “As the cancer progresses from one treatment to the next, it often becomes more and more resistant.”
One of the most challenging aspects of treating metastatic breast cancer is prognostication of the disease course, said Molly E. Collins, MD, director of medical education, supportive oncology and palliative care program at Fox Chase Cancer Center in Philadelphia.
The current 5-year survival estimates in metastatic breast cancer are 28% for women and 22% for men. However, survival rates vary by disease subtype, Hershman said.
“Some patients have cancer that progresses very rapidly but others can live years with metastatic disease,” Hershman said. “This is especially true for patients that have hormone-sensitive disease or HER2-positive disease where we sometimes see patients living 5 years, 10 years, or longer with metastatic disease on treatment.”
A 2017 study found that the number of women in the U.S. living with metastatic breast cancer is increasing. The median relative survival increased from 22.3 months in 1992-1994 to 38.7 months in 2005-2012 for women diagnosed at ages 15-49, and from 19.1 months to 29.7 months for those ages 50-64. More than 11% of those diagnosed from 2000-2004, who were younger than age 64, lived more than 10 years.
These variations in survival make knowing when during a patient’s disease course to stop active treatment and initiate conversations about end-of-life care particularly challenging.
Optimism With Realism
“As an oncologist you are always walking a tightrope between being the cheerleader for the patient, being optimistic, and also being a realist in terms of making sure a patient has all the information needed to make appropriate decisions,” Hershman said.
Conversations about certain aspects of end-of-life care, such as living wills or power of attorney, can be initiated early in any stage of a patient’s journey with serious illness, Collins said, although this may vary from patient to patient.
Some patients may be coping well with minimal symptoms and may already have an advance directive in place. This type of patient may have their palliative care needs handled by their treating oncologist, which is called primary palliative care.
“It is the hope that all oncologists have primary palliative care skills that include basic symptom management, and communication skills around breaking bad news and helping patients prepare for the future,” Collins said. “One of the goals of the palliative care specialty is to help teach those skills when needed.”
Collins compared approaching these topics to gently leaning on a door. Clinicians could say, “Many of my patients tell me they are thinking about the future. What are you worried about? What are you hoping for?”
“Some patients may take that opportunity to kick open the door and want a discussion about preparing for the future and end of life,” Collins said. “Other patients may close the door until they are ready to talk about it. Both are normal and even the same patient may open and close the door at different times.”
Other patients may be in more need of a consultation with a palliative care specialist. These are patients with significant symptom burden despite basic interventions, those who are not coping well, perhaps have psychosocial challenges, or a limited understanding of their disease, Collins said.
Clinicians should not wait until end of life to refer patients with advanced cancer to a palliative care team, if one is available. Guidelines from the American Society of Clinical Oncology (ASCO) recommend a palliative care consultation be initiated within 8 weeks of any cancer diagnosis.
Shifting a patient’s needs from earlier, “upstream” palliative care, to end-of-life care, can be even more challenging. Conversations about end-of-life care can include difficult topics such as stopping active treatment, unfavorable prognoses, advance care planning, concerns about coping, life goals, and where the patient wishes to end life.
In its guideline, ASCO recommends setting up a hospice information visit when it is possible a patient could die within the next 6 months. Prognostication continues to be a big challenge for medical oncologists and palliative care clinicians, Collins said.
“The closer you get to the end of life, the more precise you can be. You can look at a patient who is clearly dying and estimate that they likely have hours to days,” Collins said. “The further upstream you are of that scenario the less accurate prognostication is, though we still owe our patients our best estimates and a likely range based on what we know.”
In addition, Hershman said that sometimes the oncologist who has treated a patient for years may not be in the best situation to judge whether treatment is doing benefit or harm. That is why it is important that other people are involved in the discussion.
“A fresh perspective can really help,” Hershman said. “If you make conversations about end of life an ongoing discussion, many patients will tell you when they are ready to stop or when they feel quality of life is more important. Other patients may want to continue to try treatment.”
Some patients with advanced disease may want to continue to try new treatment options through enrollment in phase I clinical trials.
If that is the case, Hershman emphasized that clinicians should be honest and not offer false hopes. Phase I clinical trials may provide treatments that will benefit the patient, but there is also a good chance they will not benefit.
“As an oncologist I have had many patients who do benefit for long periods of time on these treatments and you never know who those people are going to be,” Hershman said. “We also have to accept the limits of what we know in terms of not being overly aggressive. We have to talk with patients to set goals and priorities in line with what the patient’s wishes are.”
At the end of the day, Hershman said, communication is the most important thing to making appropriate end-of-life decisions for any patient.
Barbara Jacoby is an award winning blogger that has contributed her writings to multiple online publications that have touched readers worldwide.