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Guidelines Help Oncologists Provide Individualized Palliative Care for People Diagnosed With Metastatic Breast Cancer

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General oncologists have received new specific, practical recommendations on how to offer individualized palliative care to people diagnosed with metastatic breast cancer, thanks to new guidelines written by a team led by MD Anderson Cancer Center researchers.

The guidelines were published in the April 1, 2021, issue of the journal JCO Oncology Practice. Read “Optimal Supportive Care for Patients With Metastatic Breast Cancer According to Their Disease Progression Phase.”

What is palliative care?
About the guidelines
What this means for you

What is palliative care?

The goal of palliative care is to manage the physical pain caused by cancer or other serious disease and to help control the stress and anxiety that being diagnosed with breast cancer can cause. People can receive palliative care alongside active treatment for breast cancer. Palliative care often is provided by a multidisciplinary team that may include doctors, nurses, registered dieticians, pharmacists, psychologists, and social workers. People can receive palliative care at any time during cancer treatment, from right after they are diagnosed to when they are nearing the end of life.

It’s important to know that palliative care is not the same as hospice care. Hospice care is reserved for people nearing the end of life (typically within 6 months). While the focus of both hospice care and palliative care is on improving quality of life, people don’t receive active treatment for disease with hospice care.

There are about 7,600 doctors who are board certified in palliative care in the United States. In 2017, the American Society of Clinical Oncology suggested that every person diagnosed with advanced-stage cancer see a palliative care team within 8 weeks of diagnosis. Scientists estimate 1.9 million new cases of cancer will be diagnosed in 2021. Of course, not all of these new cancer cases will be advanced-stage cancer, but the statistics highlight the shortage of palliative care doctors.

Because of this shortage, palliative care specialists are not available at every oncology practice. So general oncologists often have to consider their patients’ palliative care needs and must be familiar with how to best prioritize palliative care options.

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About the guidelines

Led by researchers in the Department of Breast Medical Oncology at the University of Texas MD Anderson Cancer Center, a team developed palliative care guidelines for people diagnosed with metastatic breast cancer to help general oncologists offer more individualized care.

The guidelines classify the progression of metastatic breast cancer into four types, with each type affecting a person’s quality of life in different ways:

  • Smoldering: The cancer progresses very slowly and people are often stable for 10 or more years.
  • Gradual: The cancer progresses slowly at the beginning, but progression and symptoms increase over time.
  • Rapid: The cancer progresses rapidly and symptoms are severe.
  • De novo: People are in poor general health when they are diagnosed with cancer and the cancer progresses rapidly.

Each progression type has what the researchers call an acute and a stable phase. In the acute phase, the cancer progresses rapidly, causing symptoms that may be severe. In the stable phase, symptoms don’t change much and progression is much slower.

The guidelines say that palliative care for people diagnosed with metastatic breast cancer should be based on the phase of disease progression. So the care people in the acute phase receive would be different from the care people in the stable phase receive.

Most palliative care guidelines say that people’s ability to function and do daily tasks are key to making decisions about palliative care. These new metastatic breast cancer palliative care guidelines say that healthcare providers also should consider psychosocial and cognitive status when making care decisions.

We’ve summarized the recommended palliative care for each symptom below.

Pain management

Both phases:

  • doctor should evaluate pain at each office visit and offer basic pain control and education for patient and family, as well as offer optimized medicines and other types of pain relief
  • patient should follow personalized pain plan, monitor pain levels, and contact doctor if pain gets worse or troubling side effects develop

Additional steps for acute phase:

  • doctor should consider a nerve block or palliative radiation therapy to control pain, as well as offer a referral to a pain specialist or palliative care specialist
  • patient should ask social services for help
  • caregivers should be aware of burnout and take steps to avoid it

Fatigue management

Both phases:

  • doctor should do a formal fatigue assessment and treat other symptoms that can contribute to fatigue, including pain, anemia, insomnia, depression, poor nutrition, and other medical conditions
  • doctor should consult with rehabilitation and nutrition specialists
  • doctor should refer patient to cancer-related fatigue clinic
  • patient should self-monitor energy levels and identify times of day when energy is highest and lowest
  • patient should assess sleep hygiene and make sure to get adequate sleep
  • patient should try non-medicinal steps to ease fatigue, including exercise, yoga, acupuncture, massage, and mindfulness meditation

Additional steps for acute phase:

  • doctor should offer medicine
  • patient should take steps to conserve energy, including delegating or delaying activities, using labor-saving devices such as a walker or wheelchair, scheduling important activities when energy is highest, and napping for less than 1 hour so sleep isn’t disrupted

Additional steps for stable phase:

  • doctor should recommend non-medicinal techniques, such as cognitive behavioral therapy, support groups, or educational programs
  • patient should exercise and try to overcome feelings of fatigue by doing something pleasurable, such as listening to music, playing a game, or socializing

Shortness of breath management

Both phases:

  • doctor should treat any conditions that may contribute to shortness of breath, including pneumonia, blood clots in the lungs, and airway obstructions
  • patient and caregivers should make sure nutrition is the best it can be
  • patient should learn optimal breathing techniques
  • patient should take frequent rest breaks and reduce activities

Additional steps for acute phase:

  • doctor should consider medicines to help, as well as supplemental oxygen and noninvasive ventilation
  • patient should aim to conserve energy and make sure body is in best position for breathing

Additional steps for stable phase:

  • doctor should assess the need for continued supplemental oxygen
  • patient should attempt activities to help breathing, including exercises, acupuncture, and cognitive behavioral therapy

Distress and anxiety

Both phases:

  • doctor should assess anxiety levels at every office visit, as well as factors that can contribute to anxiety, including practical, family, emotional, physical, and spiritual concerns
  • if needed, doctor should offer referral to mental health professional, social worker, or chaplain
  • patient should consider counseling and support groups

Additional steps for acute phase:

  • doctor should offer coping strategies or referral to healthcare professional who can provide coping strategies

Additional steps for stable phase:

  • doctor should assess needs and concerns of patient’s family and caregivers
  • patient should consider exercise, rehabilitation, meditation, and creative therapy

The guidelines also include exercise, nutrition, and advanced care recommendations by disease phase.

Exercise

Both phases:

  • doctor should weigh benefits and risk of exercise and develop program that is feasible and safe
  • doctor should consider referral for cardiovascular screening before exercise program starts if patient is at high risk for heart disease

Additional steps for acute phase:

  • doctor should offer options for the safest ways for patient to add exercise to daily routine

Additional steps for stable phase:

  • doctor should consider referral for physical therapy, occupational therapy, or personal training

Nutrition

Both phases:

  • doctor should recommend a diet full of vegetables, fruit, whole grains, lentils, beans, and protein, as well as drinking 2 liters (about 8.5 cups) of water per day
  • doctor should recommend patients avoid extremely fatty meats, alcohol, sweets, and undercooked or raw foods
  • doctor should offer referral to dietitian if patient has trouble eating
  • family and caregivers should understand patient’s eating patterns

Additional steps for acute phase:

  • patient should be free to eat whatever tastes good and should not be forced to eat

Advance care planning

Both phases:

  • doctor should talk to patient about expected outcomes, prognosis, and treatment options so patient can make decisions about personal preferences
  • doctor should understand patient’s goals for care and consider how patient wants to live

Additional steps for acute phase:

  • medical team should confirm with patient, family, and caregivers how they plan to make decisions about life-sustaining treatments
  • medical team should talk to family and caregivers to see if there are any conflicts between patient’s wishes and family’s wishes
  • doctor should discuss organ donation and autopsy options with patient

Additional steps for stable phase:

  • doctor should assess patient’s fears about dying and offer strategies to ease anxiety
  • doctor should assess patient’s decision-making capacity
  • doctor should talk to patient about preferences for end-of-life care and personal values; these preferences should be documented in patient’s medical records
  • doctor should ask if patient has a living will or has given someone medical power of attorney, medical proxy, or patient surrogate rights; if not doctor should talk to patient, family, and caregivers about options for these tasks

“The recent evolution in breast cancer treatment and palliative care has altered the clinical courses of many patients with metastatic breast cancer, with some cases rapidly progressing and others smoldering for years,” the authors wrote. “Personalized care requires a focus on when and how… cancer therapies and supportive measures should be delivered to optimize patient outcomes based on how the disease progresses and whether the patient is in an acute or [a] stable phase and experiencing symptoms or discomfort.”

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What this means for you

If you’ve been diagnosed with metastatic breast cancer, these palliative care guidelines can help you and your doctor make better choices about your care that reflect your personal beliefs, preferences, and values.

While the guidelines were written for oncologists, they can give you some background about why your doctor may be recommending certain treatments for you.

Learn more about Palliative Care for Metastatic Breast Cancer.

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Written by: Jamie DePolo, senior editor

Reviewed by: Brian Wojciechowski, M.D., medical adviser


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