San Antonio, TX—Effective symptom management and preservation of quality of life are the most important goals in caring for patients with metastatic breast cancer, said Polly Nirvath, MD, Associate Professor, Smith Breast Center, Baylor College of Medicine, Houston, TX, at the 2013 San Antonio Breast Cancer Symposium.
Of patients with metastatic breast cancer, 10% to 15% have known brain metastases, but with median survival after brain metastases now reaching almost 2 years, quality of life is paramount, said Dr Nirvath.
Cognitive decline is one of the consequences of brain metastases and their treatment. Strategies to prevent or to slow cognitive decline include the use of smaller radiation doses over more fractions and the use of stereotactic radiosurgery rather than whole-brain radiation when possible. According to the American Society for Radiation Oncology, stereotactic radiation is suitable for small brain lesions (<10 cc) without neurologic symptoms, with a limit of 3 lesions, and as salvage treatment for recurrent brain metastasis after whole-brain radiation.
Overaggressive end-of-life care is pervasive. A 2008 review of Medicare claims from 215,484 patients aged >65 years who died of cancer determined that there is a steady increase in administering chemotherapy within 2 weeks of death, there is an increase in intensive care unit admissions in the last month of life, and 14.3% of hospice patients were in hospice for <3 days.
Wright and colleagues (Wright AA, et al. JAMA. 2008;300:1665-1673) found that end-of-life discussions with patients with metastatic cancer and their caregivers take place in only approximately 37% of patients at the time of their diagnosis of advanced cancer. End-of-life discussions were associated with fewer aggressive interventions near death and earlier hospice referral.
Such aggressive care is not driven by patients or by more effective cancer therapies, said Dr Nirvath. Patients cared for by an oncologist in the last month of life were more likely to be treated with chemotherapy and were more likely to initiate hospice within 3 days of death.
She ended with several tips to improve end-of-life care:
- Have discussions with patients and families early and often to prepare them for end-of-life goals
- Be frank and upfront with patients
- Do not offer treatments with minimal possibility of benefit or high likelihood of risk
- Aggressively and adequately control pain
- Encourage communication with loved ones
- Give patients a sense of control by keeping them honestly informed.