Background: Globally, breast cancer is the most common diagnosis in new cases of cancer, with 2.26 million new cases diagnosed in 2020. 1 Breast cancer treatment can be highly effective, especially when the disease is diagnosed early. Mortality rates have been on a steady decline in recent years in high-income countries, largely due to advancements in population screening programmes and early-stage treatments. 2 Metastatic breast cancer, also known as stage IV or advanced breast cancer, is rare as a primary diagnosis, making up 6-10% of new cancer diagnoses. Metastatic breast cancer has a current 5-year survival rate of 25-27% 3,4 , and is considered an incurable disease caused by the spread of breast cancer to other areas beyond the lymph nodes of the axilla to other sites in the body. 5,6 However some patients (estimated at 10%) will attain long-term disease control, or undetectable disease, and thus achieve a prolonged survival. 7
Improved survival rates for metastatic breast cancer have come predominantly as a result of advances in therapeutic options including targeted therapies, immune checkpoint inhibitors and antibody-drug conjugates. 2,5 Novel agents targeting the oestrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2) pathways, and the tumour microenvironment have been associated with improved survival outcomes; although adverse event profiles and response to therapy can vary between individuals 8,9 . As such, there has been a notable extension in survival time for patients with metastatic breast cancer, though it varies by the clinical, pathologic, and disease characteristics and extent of metastasis.
Management of Metastatic Breast Cancer
For metastatic breast cancer, the intention of treatment is to achieve longer-term disease control, manage tumour-related symptoms, extend survival and importantly, preserve quality of life. 4 Supportive care for patients is usually led by the primary oncology team, often with support from primary care, palliative care and other experts. The treatment approach is multidisciplinary and can include local therapy options (surgery, radiation therapy) and systemic therapies including endocrine therapy, chemotherapy and targeted therapies to extend survival. However, such treatments can be associated with bothersome short- and longer-term side effects. These can include the more recognized physical effects (e.g., nausea, fatigue, hair loss), but also emotional and social, such as the psychological burden or feelings of social isolation due to fatigue. 10
Studies focusing on metastatic breast cancer have tended to focus on the efficacy of various medical treatments and their impact on quality of life, 10 yet few studies focus on supportive care interventions to improve the quality of life of patients with metastatic breast cancer undergoing such treatments. In recent years, this area of supportive care has been gaining attention internationally as ideas of survivorship and what it means to ‘survive’ cancer have evolved. 11 Health care professionals have also sought to integrate acute oncology, palliative care and community services more effectively. Research supporting the benefits of early integration of palliative care services with standard oncology care is emerging. 12
Cancer survivorship is broadly defined as living with, through and beyond cancer, beginning at the time of diagnosis until the end of life. 13 Survivorship services have been identified as a priority area as they are underdeveloped and under-resourced. 14,15 The dominant model of care is specialist-led follow up care that focuses primarily on the detection of recurrences. This model of care may result in unmet supportive care needs, an issue that is becoming more salient as the prognosis of metastatic breast cancer improves and life postdiagnosis is extended. 8,14,16,17 Quality of life is typically assessed based on functional status of the individual and how the patient perceives their health status to affect their life, usually through patient reported outcomes. 18
Supportive Care Needs
Research has shown that unmet informational needs on treatment side effects, managing pain and alternative treatments are among the top concerns of patients with metastatic breast cancer. 1 Other concerns outlined include financial concerns over the high cost of treatment and the ability to continue employment. Individuals also report feeling under supported by healthcare providers and a lack of support outside of the hospital setting. 19 The concerns, issues and side effects associated with living with metastatic breast cancer are significant, yet interventions to address the issues raised are understudied. Indeed, it is suggested that minimising the physical and psychosocial impact of the disease and treatments should be considered an endpoint in itself, and that quality of life should be a primary focus of healthcare for those with metastatic disease. As such, it is essential that the focus is shifted to addressing the unmet supportive care needs of patients with metastatic breast cancer through more focused interaction of primary teams with palliative, supportive care, and allied health experts. Patients living with metastatic disease have unique needs that are found to diverge from those of patients with early breast cancer, specifically an increased need for support services. 10 Additionally, the rarity of male breast cancer means the gender dimension of the supportive care experience has been understudied and requires increased attention.
Supportive Care Interventions
Supportive care refers to the care provided to improve the quality of life for people with metastatic breast cancer, including palliative care, which aims to reduce the burden of symptoms of treatment or cancer itself. 20 Although research has shown that supportive care interventions improve quality of life, research in patients with metastatic breast cancer is limited. 2 Financial, informational, psychological, and social support are identified consistently as areas that patients require additional support; the provision of which was reported to have a positive impact on patients. 22,23
Psychological interventions such as cognitive behavioural therapy or psychotherapy can improve psychosocial outcomes like mood and quality of life but there is little evidence that such improvements are sustained or if interventions address the underlying causes of ongoing distress. 21 In a randomised controlled trial involving 64 women with metastatic breast cancer, greater mindfulness was associated with lower levels of symptoms (i.e. pain, fatigue, anxiety, depression, and sleep disturbance). 24 Psychological and physical problems have been managed with mindfulness meditation, which is increasingly being used in non-spiritual settings. Similarly, psychosocial interventions have led to improved sexual and relationship satisfaction. 25 Coping and communication skills training, mindfulness training, and sensate focusing are key components of effective psychosocial interventions to improve sexual relationships and function. Despite the availability of such interventions, many women find it difficult to discuss sexual concerns with their healthcare teams. 25 Increased research into internet-based interventions may aid in overcoming these barriers. 25
Technology Enabled Interventions
Technology enabled interventions could potentially aid in symptom self-management for patients with metastatic breast cancer. Given the time constraints that patients face when visiting their clinical care team, technology-based interventions for symptom management are being rolled out in this population. Research using a technology-based approach (Nurse AMIE intervention) has been shown to have great potential to address disparities in the provision of supportive care by reaching poor and medically underserved women with metastatic breast cancer. 26 Technology-based health interventions have the potential to reach a wide and diverse audience, having a significant and positive impact on quality of life, health self-efficacy, levels of psychological distress, and fatigue. 27 Similarly, a feasibility study based in Cork (the LYSA trial), is introducing a women’s malignancy survivorship clinic incorporating symptom management through ePRO into routine follow up care in patients with early-stage hormone receptor (HR)-positive breast cancer post primary curative therapy; however additional research is needed in the area of metastatic breast cancer. 28 While technology has huge potential and reach, as healthcare professionals, we must be mindful of segments of the population that may not have access to or the literacy to use such technology.
Diet and Exercise Interventions
Physical activity and nutrition are potentially modifiable aspects of a patient’s journey, which through self-management support, can be particularly empowering in the face of uncertainties surrounding their cancer journey. 29 Evidence has shown that walking interventions are beneficial for women with metastatic breast cancer, with improvements in walking distance, strength, and body mass index. 30 A meta-analysis of randomised controlled trials in participants with advanced cancers, found that supervised aerobic or resistance interventions could improve physical fitness and sleep quality. 31 According to epidemiological studies, a poor diet quality may have a negative impact on cancer recurrence and survival in patients with breast cancer; however, research in patients with metastatic breast cancer is limited. 32
Informational Support Interventions
Many patients with metastatic breast cancer have expressed a desire for more information relating to their disease. In a systematic review involving 11 studies, ten studies reported a need for informational support. 32 Women expressed a need for information about various aspects of their disease, such as treatment, disease, symptoms, and side effects. 33 Similarly, interviews with patients with metastatic breast cancer revealed that they wanted more information about their future, including how the illness might affect their daily lives, with less emphasis on survival estimates. One-third of those surveyed desired information on symptoms and side effects. 3 Despite this, there is limited research around the efficacy of informational interventions.
There are many limitations to the research surrounding supportive care interventions for patients with metastatic breast cancer. Sample sizes are often small, and patients may be lost-to-follow-up leading to incomplete study data and associated regulatory issues. These issues may be reflective of the challenges associated with living with metastatic breast cancer. This may result in extended accrual periods for clinical trials and associated higher monetary expenditures as additional resources may need to be dedicated to recruitment efforts. Furthermore, men with metastatic breast cancer are not represented in trials investigating supportive care interventions; a challenge observed across breast cancer stages.
Clinical trial recruitment may also be a challenge as some patients may be too unwell or too fatigued to participate, or travel may be challenging. Incomplete accrual may result in an inability to meet the primary objective of the study and thus inhibit the attainment of meaningful results. To ensure adequate participant numbers during the recruitment period, it is important for researchers to estimate feasible sample sizes, considering these unique challenges. 33 The development of clinical trials of supportive care interventions will both cater to an unmet clinical need in patients with metastatic breast cancer, and assist Irish cancer centres in reaching target clinical trial accrual goals provided by the National Cancer Strategy of 6%. 35
Many interventional studies in the field of physical or psychological support services report an improvement in patients’ quality of life. However, long-term adherence to behavioural interventions may be difficult without ongoing support. Permanent lifestyle changes are required for long-term health benefits; however, this is not always possible for patients with metastatic breast cancer. 36
It is critical to recognise the unique challenges affecting patients with metastatic breast cancer and subsequently the need for supportive care to optimise quality of life in this cohort. Further studies to validate efficacy and provide evidence for best supportive care interventions are needed. To address this gap, our team are currently conducting a needs assessment study for patients with metastatic breast cancer. Through focus group interviews with patients living with metastatic breast cancer and healthcare professionals interested in this area of care, our study aims to investigate and identify how supportive care services could be developed to meet the unmet needs of this cohort. We anticipate that results from this needs assessment will guide the development of dedicated services in the future.
With the continued support of the National Cancer Control Programme, designated cancer centres, HRB-funded cancer trials networks nationally and Cancer Trials Ireland; alongside charities and grant bodies we can conduct research to minimize disparities in care, improve the patient experience, enhance symptom management and quality of life.
The needs assessment study for patients with metastatic breast cancer referenced in this paper is supported by Irish Cancer Society and Pfizer through the Research Grant WHI21COHE. The opinions, findings and conclusions or recommendations expressed in this material are those of the author(s) and do not necessarily reflect the views of the Irish Cancer Society or Pfizer.
References available on request
Danielle Keane, BA Hons MPH 1 ; Grace Phillips, BSc MPH 1 ; Nicola Mitchell 2 ; Roisin M Connolly, MB BCh MD 3,4 ; Josephine Hegarty, PhD MSc BSc RGN RNT 1
1 School of Nursing & Midwifery, University College Cork
2 School of Medicine, University College Cork
3 Cancer Research @UCC, College of Medicine & Health, University College Cork
4 Department of Medical Oncology, Cork University Hospital, Cork
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