Treatment of the terminal stages of breast cancer

Clinical management of women with metastatic breast cancer: a descriptive study according to age group

Background

The primary aim of treatment of a patient who has developed metastatic disease is palliation. The objectives of the current study are to describe and quantify the clinical management of women with metastatic breast cancer from the diagnosis of metastatic disease until death and to analyze differences between age groups.

Methods

Data were collected from the medical files of all patients (n = 116) who had died after December 31, 1999, after a diagnosis of metastatic breast cancer in two teaching hospitals in the south of the Netherlands.

Results

Of the 116 patients included in our study, 10 (9%) already had metastatic disease at diagnosis and 106 developed distant disease after the diagnosis of localized breast cancer. Before they died, 70% of the 116 patients developed metastases in one or more bones, 50% in the lung and/or pleura, 50% in the abdominal viscera, 23% in the central nervous system, and 19% in the skin. Patients younger than 50 years were much more likely to develop metastases in the central nervous system than patients 50 years and older. Seventy-seven (66%) of the 116 patients with metastatic breast cancer received chemotherapy. This proportion decreased with age (p = 0.005), as did the number of schemes per patient. Together, they received 132 chemotherapy schemes, of which 35 (27%) resulted in partial remission or stabilization of the disease process. Ninety-eight patients (84%) received hormonal treatment. This proportion did not differ between the three age groups. Together, they received 216 hormonal treatments, 38 (16%) of which resulted in partial remission or stabilization of the disease process. Seventy-nine patients (68%) received palliative radiotherapy. This proportion decreased with age (p = 0.03). Together, they underwent 216 courses, 176 (77%) of which resulted in relief of the complaints.

Conclusion

Patients aged 70 years and older are less likely to receive chemotherapy or radiotherapy. Part of this difference could be explained by their shorter survival time after the diagnosis of metastatic disease and their lower risk of developing brain and bone metastases. However, more research is needed to understand the age-related differences in the treatment of metastatic breast cancer, and especially how comorbidity and frailty limit therapeutic choices.

Intensity of diagnostic and treatment activities during the end of life of patients with advanced breast cancer

The aim of this study was to assess the intensity of diagnostic testing and cancer treatment of 335 women with advanced breast cancer during their last 6 months before death between 1995 and 1998 in the Pirkanmaa and Satakunta health care districts and to compare it to the practice in earlier decades, the 1970s and 1980s. Data for 1990s material were collected from medical records in 30-day periods starting from the patient's death backwards. In this material 46.9% of all laboratory tests and 40% of radiological tests during the last 6 months of life were made during the last 2 months prior to death. In the last month 63.9% of patients continued on endocrine therapy and 19.7% on chemotherapy. Patient symptoms and deterioration in general condition showed the appropriate point to discontinue cancer-related treatment and concentrate on palliation of symptoms to be about 2 months prior to death. Resources devoted to diagnostic investigations and treatment of cancer in terminally ill patients could be better used for their care. This would be more likely to improve patients' quality of life and save resources.

Weekly schedule of vinorelbine in pretreated breast cancer patients

PURPOSE

In this phase II study, we explored tolerability and activity of vinorelbine administered according to a dose-dense weekly schedule with hematopoietic growth factor support in pretreated, advanced breast cancer patients.

PATIENTS AND METHODS

From January 1994 to March 1996, 40 patients with metastatic breast cancer, pretreated with at least one prior anthracycline-containing regimen, were entered into the study.

PATIENT CHARACTERISTICS

median age 53 years (range 32-70); ECOG performance status 0-1: 34 patients, 2: 6 patients; dominant visceral metastatic disease: 15 patients, dominant non-visceral: 25; anthracycline-refractory/resistant: 2 patients, sensitive: 38 patients. Six patients were treated as first-line therapy for metastatic disease and 34 in second- or subsequent lines. All patients received vinorelbine at the dose of 25 mg/m2/week as a short intravenous infusion, together with routine antiemetic medication. Granulocyte-colony stimulating factor (Lenograstim) at the dose of 150 microg/m2 subcutaneously on day 3 was included in the treatment schedule.

RESULTS

The median number of treatment weeks was 23 (range: 4-24), with a delivered dose-intensity (DDI) of 23.8 mg/m2/week (range: 18.7-25, 95.2% of projected dose-intensity). Toxicity was mild, with non-complicated neutropenia being the main toxicity observed (grade 3-4 in 25% of the patients but only 2% of treatment weeks). Overall response rate was 52.5%, with complete responses in 12.5% of patients. Median duration of the response and median time to progression were 10 and 9 months, respectively. Median overall survival was 19 months.

CONCLUSION

Dose-dense weekly vinorelbine is safe and effective with minimal toxicity in pretreated advanced breast cancer patients.

Beyond health outcomes: the benefits of health care

Most of the debate surrounding standards in medical care, issues of medical audit and what constitutes benefit from health care assumes that what is obtained from health care is health and only that. This is an assumption which most health economists at least implicitly appear to endorse. This paper questions that assumption. There are various outcomes beyond health and there are various processes involved in health care about which patients are not indifferent. This paper calls for a fuller investigation as to what it is that patients want from their health services and the adoption of a more pluralistic conception of health care benefits. It is further argued that the objectives of health care systems are those in which citizens qua citizens also have interests and which may be different from those of patients. It is yet less likely that citizens' interests in health care will be restricted to health.

Optimising treatment outcomes: a review of current management strategies in first-line chemotherapy of metastatic breast cancer

Metastatic breast cancer remains an essentially incurable disease and chemotherapy, despite producing frequent and clinically useful responses, has had a disappointing impact on survival. Several highly promising lines of clinical research with new agents, combinations and dosages may yet produce an improved outcome. Of the new drugs that have been studied, the taxoids, docetaxel and paclitaxel appear to be the most active agents yet discovered in this setting; navelbine is also active. Investigations of high-dose chemotherapy have produced the highest rates of complete response achieved in patients with this condition. The results of recent randomised trials confirm the high activity of this modality and also suggest a survival advantage compared with more traditionally dosed treatment. Active research into biological therapy is also under way and vaccines, antibodies and inhibitors of growth factors are all being evaluated.

An observational study of the role of pain control and food adaptation of elderly patients with terminal cancer

Anorexia and a distaste for food are common in patients with terminal cancer and often lead to the use of invasive therapeutic measures. In our prospective study involving 116 elderly patients with terminal cancer, we found that this nutritional behavior could be modified by making certain changes in the treatment. The most important of these are control of pain and distressing symptoms and nutritional adaptation to the condition and tastes of the patients. Ninety-two percent of the subjects could eat until the day they died. The eating pattern of these patients was found to be identical to that observed in elderly patients without cancer. Only 15 patients who had cancer (13%) refused food containing meat.

Continuity of the doctor/patient relationship during the routine follow-up of a breast cancer patient

All 551 breast cancer patients diagnosed in 1977-1980 in the Tampere University Hospital District (Finland) were followed-up for 5 years. The patients experienced a total of 1778 woman years during the first 5 years of follow-up. There were more than 20 visits in the first 5 patient years, most to hospitals with specialists in surgery or oncology. Patients saw the same doctor twice, on average, and met an average of 10 different doctors during the 5-year follow-up. The case notes consisted of virtually complete information on the diagnostic tests and disease but rather incomplete information on patients' well-being. It is concluded that the continuity of the doctor/patient relationship was poor, and that consulting the same physician would probably improve the quality of life among breast cancer patients.

Advanced breast cancer and its prevention by screening

In discussions on breast cancer screening, much attention has been focussed on the possible morbidity generated by screening. Favourable effects like the prevention of advanced disease seem underestimated, probably because quantification is that difficult. To analyse the amount of care and treatment given to women with advanced breast cancer, we report on patients followed from first recurrence until death using patient files and national sources. A random sample of 60 female cases from computerised registries of two cancer centres and a sample of 20 cases from a non-computerised hospital registry was taken. A total of 68 patient files were sufficiently documented. A woman with advanced breast cancer is estimated to have a 39% loss in utility compared to a healthy woman (range 27-45%). Hormonal treatment is the main modality during 14 and chemotherapy during 4 months. Total medical cost from diagnosis of advanced disease until death amounts to 17,100 US dollars, or 21,000 when including extramural cost. The effect of breast cancer screening by preventing the occurrence of advanced disease is quantified. The resulting gain in quality of life contributes 70% of the total gain in quality of life. In the long run, almost half of the annual cost of screening will be offset by savings in the cost for advanced disease. Only the changes in palliative surgery and/or radiotherapy will be small in contrast to primary treatment changes. Besides the mortality reduction, screening is justified by the improvements in quality of life and cost savings for women prevented from reaching advanced disease.

Diethylstilbestrol revisited in advanced breast cancer management

Prior to the introduction of tamoxifen, diethylstilbestrol (DES) was widely used as the first-line endocrine therapy in postmenopausal women with advanced breast cancer. Since randomized trials reported that tamoxifen has a similar response rate but fewer side effects than DES, its use has declined markedly. We administered DES in a dose of 10-20 mg daily to 11 postmenopausal women with advanced breast cancer, all of whom had received previous endocrine and some cytotoxic therapy also. Four women showed tumour responses to DES (1 complete and 3 partial), 5 had stable disease, and 2 progressive disease. Amongst the patients who responded, 2 had previously been unresponsive to other endocrine treatments. Of the women with stable disease, 3 had prolonged relief of symptoms. No withdrawal responses were noted. The major side effects were nausea (severe in 2 patients, mild in 1) and cardiac failure (2 patients). We conclude that DES remains a useful, active agent in the management of advanced breast cancer in postmenopausal women, even in patients with tumours unresponsive to other endocrine therapy.