Radiotherapy
Bone pain / bony metastases
Symptomatic disease of the skeleton is present in about one half of patients with metastatic breast cancer.
Metastases may be present but sub-clinical at diagnosis. Sites of possible metastases may be identified as "hot spots" on radio-isotope bone scans and diagnosis confirmed by plain X-ray.
Magnetic Resonance Imaging (MRI)is probably the most sensitive technique to investigate bony metastasesand may be used in difficult diagnostic situations. However, it isoften (but not invariably) of limited access.
Diseasemanagement includes radiotherapy and general systemic treatment formetastatic breast cancer and for selected patients treatment with bisphosphonates.Follow up of bone metastases is made, as indicated, by X rays tomonitor response and to give early warning of progression.
Isolated bone metastases may be controlled by local radiotherapy and inmore widespread disease radiotherapy often provides palliation ofsymptoms.
Bony metastases are often (but not invariably) susceptible to endocrine treatment.
Localised bone pain may be managed by external beam radiotherapy, NSAIDs and analgesics (including opiates).More widespread bone pain may be controlled by wide field radiotherapy.Bone pain may increase sharply on rapid progression of disease and mayprecede pathological fracture.
Treatment options for fracture include internal fixation of the affected regions and irradiation. Prophylactic internal fixation should be considered for those patients with a large lytic metastasis in a long bone.
Bisphosphonates are now available for the management of bone pain andthe prevention of skeletal lesions. (See prescription rationale).
Options for treatment of recurrence
Loco-regional recurrence may be treated locally by further surgery orradiotherapy or a combination of both. This may be supplemented orreplaced by systemic treatment with endocrine or chemotherapeuticagents.
The choice of agent and schedule will be made on thebasis of the tumour characteristics, disease free interval (DFI) andeffectiveness of former treatment.
It is important to realisethat recurrence may represent the onset of advanced disease andtreatment options are at that point essentially palliative in intent,however 50% may be curable by local measures (this is particularly sofollowing breast conserving treatment).
Distant recurrencewill be treated according to the site and nature of disease and mayrequire a combination of local and systemic treatment. Radiotherapy isof particular value in the management of symptoms arising from bone andCNS lesions.
In general, visceral metastases are lessresponsive to endocrine agents than to chemotherapy, however newerendocrine agents have shown good control in patients with significant visceral involvement.
Response to endocrine therapy is less dramatic in terms of thepercentage of patients achieving a complete or partial response.However, significant numbers of patients also achieve diseasestabilisation on endocrine treatment.
The response tochemotherapy is more pronounced but treatment is generally associatedwith significant toxicity. In general, patients who show a response toendocrine therapy enjoy a longer disease remission than patientstreated with chemotherapy.
Newer agents currently underevaluation offer opportunities for more effective control and thepossibility of sequential treatment on relapse. Some of these agentsmay offer the chance of prolongation of survival in respondingpatients.
Clinical trials are currently underway to evaluatethe effect of dose intensification of chemotherapy, with bone marrowsupport, to achieve greater remission and a more durable response.
Radiotherapy
Radiotherapyis used in association with surgery to the breast or axilla to reducelocal recurrence and is essential after breast conserving surgery.Radiotherapy is more likely to be used after mastectomy where thereare:-
- Large high grade tumours
- Many positive nodes
Palliativeradiotherapy, either alone or in association with systemic treatment,is used to control local recurrence and treat metastatic disease.
Side effects include local reactions such as erythema and itching.
Systemic effects include lassitude. The risk of long term morbidity canbe limited by careful focusing and orientation of the beam and forradical treatments subdivision of the dosing schedule (fractionation).
Patient Information Leaflets: Investigative and surgical procedures
Treatment of elderly patients
Breast cancer in the elderly may be as aggressive as that found inyounger women and since about 40% of all breast cancers occur inpatients over 70 (who could have an average life expectancy of 14years), treatment must be as equally effective as that used in youngerpatients.
For patients unable to tolerate general anaesthesia, surgery such as wide local excision and even mastectomycan be undertaken using local anaesthesia and sedation. Furthermore,radiotherapy treatment is well tolerated by this age group and may beradical.
It is a feature of tumours in elderly patients that alarger proportion are oestrogen/progesterone receptor rich and hence alarger proportion will benefit from endocrine treatment.
The oestrogen receptor status of the tumour should be assessed on thecytology specimens prior to starting treatment. However, the onlypatients who may receive tamoxifen,as sole primary therapy, are the small number of very elderly andinfirm patients who are unfit for other treatments (or do not wantsurgery) and who are oestrogen receptor positive (ER +ve).
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