Primary metastatic breast cancer: the impact of locoregional therapy

Consensus views on an advanced breast cancer education curriculum for cancer nurses: A Delphi study

BACKGROUND

Specialist nursing care is a core indicator of quality care for people living with advanced breast cancer. However, access to and quality of nurse education programmes in advanced breast cancer is variable.

OBJECTIVES

This study aims to define the topics for inclusion in an international curriculum for an advanced breast cancer education programme.

METHODS

A modified four-round Delphi study was undertaken with experts by profession and experience in advanced breast cancer. Thirty-four topics related to advanced breast cancer and six online teaching and learning methods were pre-selected following a systematic review. Between September 2021 and March 2022, the expert panel determined the importance of topics for inclusion in the education programme. Consensus was defined by at least 80 % agreement on the highest three points on a 9-point Likert scale.

RESULTS

A total of 31 experts participated in rounds 1-3 of this study, and 156 experts by profession and experience participated in an additional fourth round, including people living with advanced breast cancer (n = 72, 46 %), healthcare professionals (n = 46, 29 %), family members or caregivers of a person diagnosed with advanced breast cancer (n = 30, 19 %) and advocacy professionals working in the area of advanced breast cancer (n = 8, 5 %). In round 4, 36 topics and five of six learning methods reached consensus.

CONCLUSIONS

The results of this study provide a framework to develop education programmes in advanced breast cancer, defining the essential elements of curriculum content for such programmes. The results highlight the need for advanced breast cancer education programmes to use multiple teaching and learning methods to promote nurses' understanding of person-centred supportive care and the physical, psychosocial and spiritual issues experienced by people living with advanced breast cancer.

Advanced breast cancer education for cancer nurses: A systematic review

BACKGROUND

Access to comprehensive, integrated, multidisciplinary care is one of the most urgent and actionable recommendations of the Advanced Breast Cancer Global Alliance. However, access to specialist breast care units, and specialist breast cancer nurses is variable, influenced by access to specialist education and role recognition. To date, there has not been a synthesis of evidence regarding educational programmes related to advanced breast cancer education for nurses.

OBJECTIVES

The aim of this review was to determine the content, mode of delivery, assessment and outcomes of education programmes related to advanced breast cancer for nurses.

REVIEW METHODS

A systematic review was undertaken, according to the Joanna Briggs Institute's mixed methods review methodology.

DATA SOURCES

MEDLINE, PUBMED, CINAHL, Scopus, PsycInfo, Joanna Briggs Institute, Web of Science and grey literature sources were systematically searched. Eleven publications met the inclusion criteria. Data relating to programme content, mode of delivery, assessment and outcomes were extracted and analysed.

RESULTS

This review identifies a limited number of educational programmes within this specialist area of nursing practice. Shortcomings in the development, implementation and evaluation of advanced breast cancer education programmes included limited use of educational standards, theoretical frameworks and patient and public involvement to inform programme development. Evaluation of education programmes related to advanced breast cancer relied predominantly on self-reported learning, with limited consideration of the impacts of education on service delivery, patient experience or quality of care.

CONCLUSIONS

Future development of advanced breast cancer education programmes must consider the alignment of programme content and learning outcomes with existing educational and competency standards. Evaluation of educational programmes in this field must endeavour to enhance rigour of methods, incorporating standardised questionnaires, and multiple methods and sources of data to evaluate the broader impacts of advanced breast cancer education for nurses.

Primary-Site Local Therapy for Patients with De Novo Metastatic Breast Cancer: An Educational Review

BACKGROUND

Until 2001, the paradigm guiding the management of women with de novo metastatic breast cancer (dnMBC) stipulated that primary-site locoregional therapy (PSLT) did not alter the course of metastatic disease and was necessary only for palliation of symptoms. Since 2002, retrospective data have begun questioning this paradigm. However, selection biases driving an observed survival advantage associated with PSLT in dnMBC were quickly recognized and led to several randomized clinical trials (RCTs) addressing this question.

METHODS AND RESULTS

Four published RCTs have since tested the value of PSLT added to systemic therapy (ST) or not, with overall survival (OS) as the primary end point. The results of three published trials show no OS benefit for the addition of PSLT: Indian Tata Memorial, U.S./Canada E2108, and Austrian POSYTIVE (although POSYTIVE did not reach full accrual). The fourth RCT (Turkey, MF07-01) shows an OS benefit for PSLT at 5 years (42 % vs 24 % in the ST arm; hazard ratio [HR], 0.66; 95 % confidence interval [CI], 0.49-0.88). However, the 5-year survival in the PSLT arm of MF07-01 is similar to that in both arms of E2108, suggesting that the worse survival in the ST arm of MF07-01 is a result of biologically worse disease (from imbalanced randomization). Locoregional control was improved by PSLT in all trials, but without improvement in quality of life.

CONCLUSIONS

The current evidence fails to refute the 20th century paradigm guiding management of de novo metastatic breast cancer. Discussion continues regarding the survival value of PSLT for patients with bone-only disease or oligometastases, but unbiased evidence is lacking.

Practical consensus recommendations regarding role of mastectomy in metastatic breast cancer

Whether to recommend mastectomy in metastatic disease or not has been a matter of debate. Is local therapy, such as mastectomy, of any benefit in advanced breast cancer is the main question. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations for the benefit of community oncologists.

Local Surgery Improves Survival in Patients with Primary Metastatic Breast Cancer: A Population-Based Study

The clinical value of local surgery in the breast cancer patients with distant metastasis is still unclear. A total of 8,922 primary metastatic breast cancer patients from the Surveillance, Epidemiology, and End Results (SEER) database were analyzed in the current study. Primary outcome variables included breast cancer-specific survival (BCSS) and overall survival (OS). Among the patients, 1,724 (19.3%) who underwent surgical treatment (ST) of primary breast tumor had increased OS (p < 0.001) and BCSS (p < 0.001) compared with those in the nonsurgical treatment (NST) group. Multivariate analysis revealed that surgery improved survival and was an independent prognostic factor for OS (hazard ratio [HR] = 0.617; 95% confidence interval [CI], 0.562-0.676, p < 0.001) and BCSS (HR = 0.623; 95% CI, 0.565-0.686, p < 0.001). Further result showed that ST tended to prolong the survival of patients with 1 or 2 distant metastatic sites (p < 0.05 for OS, p < 0.05 for BCSS). However, no differences were found in prognostic outcomes between different surgical procedure groups (p = 0.886 for OS, p = 0.943 for BCSS). In conclusion, our study suggested that local surgery appeared to confer a survival benefit, which may provide new understanding of treatment for these patients.

The Impact of Locoregional Treatment on Survival in Patients With Metastatic Breast Cancer: A National Cancer Database Analysis

BACKGROUND

Although systemic therapy is the standard treatment for metastatic breast cancer, the value of locoregional treatment (LRT) of the primary tumor and its impact on survival is controversial. This study evaluates survival outcomes in patients with metastatic breast cancer after receiving LRT (surgery and/or radiation therapy) of the primary tumor.

MATERIALS AND METHODS

The National Cancer Database was used to identify 16,128 qualifying cases of metastatic breast cancer who received systemic therapy with or without LRT from 2004 to 2013. Treatment modality was divided into surgery (Sx), radiation therapy (RT), surgery followed by RT (Sx + RT), and no LRT. The median survival and 3-year actuarial survival rates (OS) were analyzed for each treatment group. On multivariate analyses, adjusted hazard ratios (HRs) with 95% confidence intervals (CIs) were computed using Cox regression modeling to adjust for patient and clinicopathologic characteristics.

RESULTS

Overall, the median follow-up was 28.3 months, and the median survival for all patients was 37.2 months. With 9761 deaths reported, the estimated 3-year OS was 51.3%. The Sx + RT group (n = 2166) had the highest 3-year OS of 69.4%, followed by the Sx group (n = 4293) with 57.6%, the no LRT group (n = 8955) with 44.3%, and the RT group (n = 714) with 41.5% (P < .0001). On multivariate analysis, compared with the no LRT group, a decreased HR was noted in patients receiving Sx (adjusted HR, 0.68; 95% CI, 0.65-0.71; P < .0001) and Sx + RT (adjusted HR, 0.46; 95% CI, 0.43-0.49; P < .0001).

CONCLUSION

LRT, especially surgery followed by RT, in addition to systemic therapy, was associated with improved survival in patients with metastatic breast cancer.

Evaluation at 3 years of concurrent bevacizumab and radiotherapy for breast cancer: Results of a prospective study

PURPOSE

To determine the 3 years late toxicity among patients with non-metastatic breast cancer who received concurrent bevacizumab and locoregional radiotherapy.

MATERIAL AND METHODS

This is a single-arm, multicentre, prospective study, of the toxicity of adjuvant concomitant association of bevacizumab and radiotherapy in patients with breast cancer. Toxicity was assessed by the Common Terminology Criteria for Adverse Events version 3.0 during the radiotherapy and follow-up clinics at 12 and 36 months after its completion. The study was designed to evaluate the toxicity at one year, 3 years and 5 years.

RESULTS

Sixty-four patients were included from October 2007 to August 2010. All of them received concurrent adjuvant radiotherapy and bevacizumab (in 24 cases after primary systemic treatment). All patients received non-fractionated radiotherapy to breast or chest wall with or without irradiation of regional lymph nodes. Early toxicity has been previously reported. Median follow-up was 46.4 months (range: 18-77 months). Median age was 53 years old (range: 23-68 years). The 3-years overall survival was 93% (range: 87-100%). Evaluation of the toxicity at 3 years was available for 67% of the patients. There was a low rate of toxicity: 14% grade 1 pain, 9% grade 1 fibrosis, 2% grade 1 telangiectasia, 2% grade 1 paresis, 7% grade 1 lymphedema and 2% grade 3 lymphedema. No grade 4 toxicity was observed. No patient had a left ventricular ejection fraction below 50% at 3 years.

CONCLUSIONS

Concurrent bevacizumab with locoregional radiotherapy is associated with acceptable 3-years toxicity in patients with breast cancer.

Readdressing the Role of Surgery of the Primary Tumor in de Novo Stage IV Breast Cancer

The impressive advances in breast cancer treatment observed in recent years also apply to the metastatic setting, where a subset of patients with favorable metastatic disease enjoy long-term survival with systemic therapy. In patients with distant disease, the primary tumor in the breast has not classically been though to merit specific locoregional therapy. However, about 6% of Stage IV patients in the USA and up to 20% in limited resource environments present with synchronous distant metastases at the time of initial diagnosis. For this group, who have an intact primary tumor, retrospective studies suggest that local therapy for the primary site may be beneficial. However, these retrospective analyses are biased in that women receiving local therapy to the primary site were younger and had biologically favorable tumors and lower volume metastatic disease. Two completed randomized clinical trials have shown conflicting results, and others are ongoing. In this chapter, we discuss the results of these studies through the present day and summarize their conclusions and their implications for clinical management.

Local Resection of Primary Tumor in Upfront Stage IV Breast Cancer

BACKGROUND

This study aimed to identify the association of local surgery of the primary tumor in metastatic breast cancer (MBC) patients with overall survival (OS) and prognostic factors.

PATIENTS AND METHODS

Patients with primary MBC (1990-2006) were included in our retrospective analysis (n = 236). 83.1% had surgery for the primary tumor. OS was evaluated using Kaplan-Meier estimates. Predictive factors for OS were determined.

RESULTS

Median follow-up was 123 months for all patients still alive at the time of analysis. In univariate analysis, patients with surgery of the primary tumor had significantly prolonged OS (28.9 vs. 23.9 months). Within the surgery group, patients with MBC limited to 1 organ system had a better outcome (39.3 vs. 24.9 months), as did asymptomatic patients. Independent risk factors for shorter OS were hormone receptor negativity, symptoms, and involvement of ≥ 1 organ system.

CONCLUSION

Patient selection for local therapy was confounded by a more favorable profile and a lesser tumor burden before surgery, which might implicate a bias. Nevertheless, our univariate results indicate that local surgery of the primary tumor in MBC patients could be considered as part of the therapeutic regimen in selected patients. However, larger patient numbers are needed to prove these findings in the multivariate model.