Metastatic Breast Cancer as a Chronic Disease: Evidence-Based Data on a Theoretical Concept

A mixed-methods study to inform development of a caregiver-specific problem list for cancer distress screening

OBJECTIVE

Oncology guidelines for distress management recommend use of the single-item distress thermometer (DT) and accompanying Problem List (PL) to identify patients with high distress levels and their potential sources of distress. However, oncology practices have yet to establish standardized protocols to screen and triage caregivers with high distress levels. With an eye toward integrating caregiver-centered support services into cancer care, this mixed-methods study sought to assess caregiver distress and challenges that may contribute to their distress.

METHODS

Nineteen caregivers of metastatic breast cancer patients (60% female, 47% ethnic/racial minority) completed an interview and a survey comprised of the DT, the original 39-item PL, and five additional caregiver-specific PL items.

RESULTS

Caregivers reported moderate distress levels and more than half exceeded the National Comprehensive Cancer Network (NCCN) cut-off, denoting significant distress. There was no association between caregiver distress and the number of items endorsed on the original PL. Qualitative analysis identified nine problem domains as areas of caregiver unmet need needs (i.e., practical challenges, caregiving responsibilities, social/relationship issues, caregiver and patient emotional well-being, caregiver and patient physical well-being, spiritual well-being, and communication). Two of the problem domains (caregiving responsibilities and communication) were not captured in any way by the original PL.

CONCLUSION

With further research and development, the identified domains could serve as the basis for a caregiver-specific PL to facilitate triage and referral when incorporated as part of routine distress screening.

Very Late Recurrence in Breast Cancer: Is Breast Cancer a Chronic Disease?

Although breast cancer treatments have made great strides in recent decades, there are still many recurrences. Late recurrence is one of the characteristics of breast cancer. Here, we present four cases of recurrence more than 10 years after the initial diagnosis. The time from diagnosis to recurrence was 13 to 20 years in our four cases, which were all estrogen receptor (ER)-positive, and one was also human epidermal growth factor receptor 2-positive. Long-term hormone therapy for 10 years is necessary to prevent late recurrence of breast cancer, but we need to know that late recurrence remains common. Risk factors for late recurrence include ER positivity, progesterone receptor positivity, and low Ki67. The most common sites of recurrence are the lungs/pleura and bones, which was also the case in our experience. It is no exaggeration to say that breast cancer is a chronic disease similar to hypertension and diabetes. This is because breast cancer is not completely cured by surgery alone and lasts for a long time, with patients requiring long-term hormone therapy. Moreover, it can recur even after 10 years or more.

Epidemiology of De Novo Metastatic Breast Cancer

Most cases of metastatic breast cancer (MBC) arise as a recurrence of a previously treated early breast cancer. Distinct from recurrent MBC is de novo MBC (dnMBC), which describes patients who present with distant sites of disease at initial diagnosis and is reviewed here. dnMBC represents approximately 3% to 6% of new breast cancer diagnoses in high-income countries. This incidence has not declined despite decades of widespread use of population-based mammography screening. Overrepresentation of both biologically aggressive tumors and patients negatively impacted by social determinants of health are characteristics of dnMBC. Survival has generally been superior for patients with dnMBC compared with those with recurrent MBC, although it is similar to that for patients with recurrent MBC with long disease-free intervals. Subgroups of patients with dnMBC who experience prolonged survival include those with human epidermal growth factor receptor-2-positive disease or hormone receptor-positive bone-only disease. Opportunities to decrease dnMBC presentation may include novel screening modalities suited for biologically aggressive breast tumors and improved access to health care. Recognizing that there will remain some women diagnosed with dnMBC, refining our ability to identify those likely to be long-term survivors could allow for appropriate escalation or de-escalation of care. Finally, evaluation of tumor genomics in robust sample sizes has the potential to advance our knowledge of the biology of dnMBC as an entity distinct from recurrent MBC.