Brain Metastasis and End-of-Life Care in Metastatic Breast Cancer

TON - January/February 2014 Vol 7 No 1

Of all newly diagnosed breast cancer, 6% to 10% is metastatic, and a proportion of women with early breast cancer eventually develop metastasis. Treatment of metastatic breast cancer has improved considerably, and patients are living longer with metastatic disease. Thus, quality of life (QOL) is an important consideration, explained Polly Niravath, MD, Baylor College of Medicine, Houston, Texas.

At the 2013 San Antonio Breast Cancer Symposium, Niravath addressed 2 important considerations for patients with metastatic breast cancer: the management of brain metastasis and end-of-life (EOL) care.

Brain metastasis occurs in up to 15% of patients with metastatic breast cancer, and additional patients may have occult brain metastasis.

Studies have shown that surgery is superior to whole-brain radiotherapy (WBRT) for treatment of patients with an isolated brain metastasis. Surgery improves overall survival, decreases local recurrence, and increases functional independence, Niravath said.

WBRT following surgery reduces recurrences in the brain as well as neurologic deaths. The technique is suitable for treatment of patients with 3 or more lesions. However, WBRT comes with the cost of increased toxicity, in particular, cognitive decline. This has led to adjusted protocols using smaller doses of radiation given over more fractions. Amended protocols of WBRT are used to treat brain metastasis in patients who have a somewhat longer life expectancy.

According to Niravath, a recent study suggests that administering memantine during radiation may reduce cognitive decline. However, further study is needed to validate this drug’s usefulness.

Stereotactic surgery (SRS) is a technique that promises to spare cognition, she said. Studies comparing SRS with WBRT show that SRS is associated with less toxicity.

SRS without WBRT is appropriate for treatment of patients with 1 to 3 smaller lesions of 8 to 10 cc, she said. When used on larger lesions, it can cause edema of the brain.

SRS reduces cognitive decline, is more convenient, and is associated with quicker recovery than WBRT, allowing for less delay in initiating chemotherapy. SRS leads to improved functional independence and overall survival compared with WBRT. This has led to a paradigm shift, she said.

An example of how WBRT and SRS can be integrated into management of brain metastasis was offered: If a patient is treated with SRS and has a recurrence after a disease-free interval, she could undergo repeat SRS; if she has another recurrence, she could be treated with WBRT and SRS.

This type of treatment prolongs QOL, Niravath told the audience.

End-of-Life Care
Niravath said that many patients with breast cancer and metastatic disease are not receiving appropriate EOL care. Often they are overtreated with chemotherapy that has little chance of benefit.

“Misuse of treatments results in higher rates of hospitalization and ER visits, and worse QOL,” she noted.

Hospice care is appropriate EOL care. However, hospice is underused and misused, she continued. Many physicians refer patients to hospice less than 3 days before death, when in actuality the patients should have been under hospice care for several months.

Physicians and nurses should strive for good communication with patients about EOL care, she stated. “In a survey of patients with metastatic breast cancer at EOL, more than one-third said they had conversations with their physicians, and these women had less hospitalization, less treatment, and were referred to hospice earlier,” Niravath told listeners.

By contrast, patients who had more medical interventions had decreased QOL. The evidence suggests that oncologists implement more aggressive EOL care when patients are treated in the last month of life. Oncologists are more likely to order computed tomography scans and refer patients to hospice within 3 days of death.

“Oncologists want to provide hope and are worried about not meeting the patient’s and family’s expectations. It may be easier to offer chemotherapy and treatment than to initiate EOL discussions with patients,” Niravath stated.

She gave some suggestions for improved EOL communication with patients and families. “Be frank and up-front. Do not offer treatment with a minimal possibility of benefit or a high chance of risk. Pain control is a priority at this time. Encourage communication with loved ones and advise patients to mend relationships. Give them a sense of control by informing them about what to expect next,” she advised.

Patients have a right to a meaningful death, she concluded.

Niravath P. Symptom management and quality of life in metastatic breast cancer. Presented at: San Antonio Breast Cancer Symposium; December 10, 2013; San Antonio, TX.

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