Clinical practice guidelines for the management of advanced breast cancer

[Janine]

[From the , publications. These Clinical Practice Guidelines can give an indication of how your medical team is thinking. This guideline is current but you'll notice some of the content is a little dated.]


Prepared by the iSource National Breast Cancer Centre
Advanced Breast Cancer Working Group
NHMRC - National Health & Medical Research Council
Endorsed January 2001

"Synopsis of publication:
Advanced breast cancer includes both locally advanced and metastatic breast cancers.

The Clinical Practice Guidelines for the Management of Advanced Breast Cancer have been developed by a multidisciplinary working party, which has been rigorous in seeking the best available evidence, including research published up to mid-2000.

The guidelines are primarily intended for use by all health professionals involved in the management of women with advanced breast cancer.

Breast cancer has a longer history than many other common cancers and often takes the form of a chronic illness.

While recognising that there is a clear need for high level professional skills in diagnosis and management, careful attention has also been given to a patient's emotions, psychosocial inter-relationships and general well being.

The guidelines aim to provide material that will be helpful and supportive to those managing the difficult range of problems that may present in advanced breast cancer."

"
The following table provides a summary of the guidelines presented in this document. Each of the recommendations should be considered in the care and management of women with advanced breast cancer. To understand the context of this evidence, readers should turn to the appropriate chapter.
PSYCHOSOCIAL INTERVENTIONS
1. Psychosocial interventions can improve physical, functional and psychological adjustment and should be considered for introduction into patient care.
These include the following:
a) Appropriate counselling; an offer of referral for further support should be
made whenever concern exists.
b) Relaxation therapy to ease cancer pain
c) Education programs to improve pain control.
d) Supportive group counselling to improve 10–year survival.
e) Group therapy to increase self-esteem and reduce anxiety, depression and anger.
f) Education sessions to improve adjustment, knowledge, death awareness and self concept for women newly diagnosed with advanced breast cancer.
g) Antidepressants; most people with cancer who are depressed and are prescribed antidepressants, benefit from them without significant side effects.
h) Pharmacological agents as an integral part of the care of anxiety and depression.
i) Behavioural techniques, such as muscle relaxation and imagery, to reduce distress in cases of mild anxiety.
j) Encouraging the expression of thoughts and feelings about the diagnosis and its meaning.
2. Thorough review of women with advanced breast cancer involves an assessment of mood and coping, and enquiries about how the family is coping.
3. Depression in people with cancer is best evaluated by the severity of the dysphoric mood, loss of interest and pleasure, by the degree of feelings of hopelessness, guilt and worthlessness, and by the presence of suicidal thoughts.
FAMILIES, PARTNERS AND CHILDREN
4. The provision of information is important to the partners of women with breast cancer. Clinicians have a role in addressing these needs and in referring partners to appropriate sources of information.
5. Facilitating improved communication, cohesion and conflict resolution in families enhances their support of each other and reduces psychosocial problems.
6. It is appropriate for clinicians who diagnose women with advanced breast cancer to: enquire about the family and childrens’ adjustment; clarify what assistance the woman may require in discussing her diagnosis and treatment with her family and children; and facilitate referral for information and support as needed.
7. Professional and professionally supported services may reduce the risk of postbereavement morbidity.
8. The consumer version of these guidelines is recommended as a reference to all patients and their families.
MULTIDISCIPLINARY CARE
9. Multidisciplinary care improves outcomes for women with breast cancer, and should be considered throughout management and treatment.
CLINICAL TRIALS
10. There is indirect evidence that women who participate in clinical trials have better outcomes than similar women given similar treatment outside trials. It is appropriate for clinicians to discuss participation in clinical trials with women.
ASSESSMENT
11. For women who have been treated for early breast cancer and who continue to feel well, regular scans and tests do not improve the length or quality of life.
12. The routine use of tumour markers is not recommended.
PALLIATIVE CARE
13. Specialist palliative care services improve patient outcomes in relation to patient satisfaction, patients being cared for in their place of choice, family satisfaction, and control of pain, symptoms and family anxiety.
MANAGEMENT OF LOCALLY ADVANCED DISEASE
14. Optimal management of locally advanced breast cancer is a combined approach that uses chemotherapy, radiotherapy, surgery and/or endocrine therapy if applicable.
15. Chemotherapy before local therapy (neoadjuvant chemotherapy) for women with locally advanced disease may substantially reduce the tumour size.
16. Endocrine therapy should also be considered for the treatment of women with locally advanced breast cancer, particularly for those with hormone receptor positive tumours.
Locoregional recurrence following mastectomy
17. Complete excision of locoregional recurrent macroscopic disease allows more effective radiotherapy and improves local control.
Radiotherapy should be administered to the entire chest wall and draining nodal areas if they have not been previously irradiated.
18. If the local recurrence is too extensive for excision with primary closure, radiotherapy should be considered as an alternative to surgery, as high rates of complete response can be achieved with radiotherapy alone.
Locoregional recurrence following breast conservation
19. Local recurrence after breast conservation may be a marker for associated systemic disease, although to a lesser degree than local recurrence after mastectomy.
20. Mastectomy is the standard treatment for locoregional recurrence after primary treatment
for breast conservation to attain locoregional control.
Systemic therapy after locoregional recurrence
21. Systemic therapy may improve disease-free survival after local therapy for locoregional recurrence:
• tamoxifen
• chemotherapy
MANAGEMENT OF METASTATIC DISEASE
Typically, a combination of anticancer and supportive therapies provide the most effective overall management of metastatic disease.
Anticancer therapies
The following recommendations relate to anticancer therapies, endocrine therapy and chemotherapy.
22. In women with hormone receptor positive breast cancer without rapidly progressing visceral disease, endocrine therapy and chemotherapy are both reasonable options.
23. In women with rapidly progressing visceral disease, limited evidence suggests that chemotherapy is better than endocrine therapy.
24. In choosing endocrine therapy for patients with metastatic disease, it is important to consider the following:
a) There is no evidence that any one particular endocrine therapy is more effective than others.
b) Tamoxifen is the endocrine therapy with the fewest side effects.*
c) Within the standard range, higher doses of any given endocrine agent are no more
effective than lower doses.
d) Combinations of endocrine agents are no more effective than single endocrine
agents used sequentially.**
e) A response, including disease stabilisation, to one form of endocrine therapy often indicates sensitivity to subsequent endocrine manipulations.
* Preliminary results suggest that anastrozole was of equal efficacy with tamoxifen in first line treatment of post menopausal women and had somewhat fewer side effects.
** A recent randomised controlled trial reported that the combination of tamoxifen and buserelin yielded better results than either drug alone.
25. In choosing chemotherapy for patients, it is important to consider the following:
a) Although chemotherapy may have significant side effects, it can improve quality of life and should therefore be considered.
b) Treatment with a greater number of standard dose cycles of chemotherapy is associated with:
• longer survival; and
• better quality of life
than treatment with a fewer number of cycles.
c) Within the range of usual doses, there is no evidence that higher doses are of greater benefit than lower doses.
d) Treatment with standard doses of chemotherapy is associated with longer survival and better quality of life than treatment with less than standard doses.
e) Current evidence does not support the use of high dose chemotherapy with stem cell support in advanced breast cancer.
f) Combination therapy confers a modest survival benefit over single drug therapy.
g) There is no evidence of benefit for adding chemotherapy concurrently to endocrine therapy.
SUPPORTIVE TREATMENTS
26. Anthracyclines, alkylating agents and the platinums remain the most emetogenic.
A schedule including a serotonin antagonist and dexamethasone is recommended prior to their usage.
27. When given regularly to women with advanced breast cancer and at least one bony metastasis, bisphosphonates enhance quality of life and reduce bone pain, the need for analgesics, the rate of development of new bony lesions, the incidence of hypercalcaemia and the need for radiotherapy to bony lesions.
28. Steroids play an integral role in most chemotherapy anti-emetic regimes, particularly in the case of metastatic disease.
SPECIAL PROBLEMS OF ADVANCED BREAST CANCER
29. Treatment of spinal cord compression with radiotherapy is considered as equally effective as surgery in achieving symptomatic relief.
30. Radiotherapy is recommended following surgical treatment of spinal cord compression.
31. Patients with spinal cord compression who are ambulatory and retain bladder or bowel function prior to the commencement of radiotherapy, have the most favourable neurological outcome.
32. Intravenous pamidronate lowers serum calcium with in one to four days, and may be more effective than intravenous clodronate in severe cases.
33. Maintenance therapy with monthly intravenous pamidronate or daily oral clodronate reduces the number of episodes of malignant hypercalcaemia in women with bony metastases.
34. In treating pleural effusion, talc insufflation is superior to medical pleurodesis using either bleomycin or tetracycline.
35. Pericardiocentesis under echocardiographic control is a safe and initially effective treatment for pericardial effusion.
36. The instillation of bleomycin as a sclerosing agent is well tolerated and significantly decreases recurrence of pericardial effusion.
37. Palliative radiotherapy remains the most effective single modality for the treatment of local metastatic bone pain.
Various schedules of treatment are used and randomised studies have not shown a marked difference in pain relief from any particular schedule.
38. Local control of an isolated supraclavicular fossa recurrence improves survival.
39. Treatment of choroidal metastases with radiotherapy should be considered, as it can lead to visual improvement and prevent visual deterioration.
40. Treatment of cerebral metastases with radiotherapy should be considered, as it leads to improvement in symptoms.
PSYCHOSOCIAL INTERVENTIONS
41. Systematic chemotherapy may be an alternative to cerebral radiation therapy, particularly in patients with symptomatic metastases outside the brain.
42. Resection of solitary cerebral metastases followed by radiotherapy potentially results in increased local control and a longer disease-free survival than radiotherapy alone.
ANALGESICS FOR CANCER PAIN
43. Oral analgesics are the mainstay of pain relief in patients with cancer. Strong opioids are safe and effective for moderate to severe pain.
44. Analgesia should be taken regularly at prescribed times, rather than on an as-needed (prn) basis. Prn analgesics for chronic pain should be reserved for breakthrough pain only.
45. Radiotherapy plays a major role in the management of acute cancer pain.
46. The regular use of laxatives should be considered in conjunction with the administration of analgesics, preferably before constipation develops.
47. Bisphosphonates have a role in the treatment and prevention of bone pain in breast cancer.
48. Non-steroidal anti-inflammatory drugs have a role in the treatment of inflammatory or bone pain.
49. Epidural, intrathecal and intracerebroventricular opioids are often effective in treating acute pain that is not controlled with conventional treatment."