Supportive treatment
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Advice
- Strategies in cancer care
- Pathways for referral and primary disease management
- Surgery
- Radiotherapy
- Drug treatment
- Supportive treatment
Approach to Pain
The control of pain is essential in patients with breast cancer. Painrelief is essential in order to maintain the well-being of a patient.
Pain therapy should be tailored for individual patients. It should bebased on a logical stepwise approach, starting at an appropriate levelfor the patient's degree of pain and progressing to the next step ifthe pain is not adequately controlled on an appropriate dose and afteran adequate trial period.
This stepwise regimen is referred to as the AnalgesicLadder (WHO). Analgesics must be prescribed regularly to control painand prevent recurrence. Breakthrough and incident pain must beconsidered.
Some analgesics may cause constipation and so an appropriate laxative may be required.
The Analgesic Ladder: -
- Step 1 - mild pain - simple analgesics e.g. paracetamol, NSAIDs with or without co-analgesics.
- Step 2 - moderate pain - weak opioid e.g. dihydrocodeine, dextropropoxyphene with or without co-analgesics.
- Step 3 - severe pain - strong opioid e.g. morphine, with or without co-analgesic.
In clinical practice co-analgesics may contribute to the relief of painwithout being classical analgesics e.g. NSAIDs, tricyclicantidepressants, anticonvulsants, muscle relaxants and antispasmodics.
Non-pharmacological interventions may be used to control pain. Theseinclude radiotherapy, chemotherapy, hormonal therapy, neural blockade,surgery and physical therapies, such as transcutaneous electrical nervestimulation (TENS), acupuncture, and massage. Stress management and relaxation techniques may also be used to relieve pain.
Bone pain / bony metastases
Symptomatic disease of the skeleton is present in about one half ofpatients with metastatic breast cancer. Metastases may be present butsub-clinical at diagnosis. Sites of possible metastases may beidentified 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).
Clinical trials
The treatment options for patients with breast cancer will continue toexpand and improve. The application and assessment of these can onlyproceed on the basis of objective clinical data obtained by welldesigned and carefully run clinical trials.
Patientspresenting with early or advanced /recurrent breast cancer may beinvited by the Breast Team to participate in a clinical trial toevaluate the efficacy and /or tolerance to a new treatment procedurecompared with the standard procedures available at the Breast Unit. Allclinical trials have to be approved by Independent Ethical ReviewBoards.
Participation in trials is entirely voluntary and canonly proceed when the trial has been adequately explained to thepatient and when she has consented to participate (informed consent).GPs will usually be sent a summary of the trial outlining what isexpected of the patient and what the potential benefits andisadvantages of the trial treatment may be.
The contributionthat well run clinical trials have made to improvements in surgical,radiotherapy and systemic therapeutic techniques cannot beoveremphasised.
Patient Information Leaflets: Drug Treatment
Hypercalcaemia
Hypercalcaemia is a complication of advanced breast cancer particularly where there are extensive lytic lesions of bone. It can also occur as a transient side-effect of systemic breast cancer therapy.
The main symptoms of hypercalcaemia are vomiting, excessive thirst,constipation, weakness, confusion and coma. This is a life threateningcondition and patients suspected of suffering from hypercalcaemiashould be admitted urgently. Intravenous bisphosphonates with rehydration are the treatment of choice.
The use of steroids should be limited in patients with hypercalcaemia.
Supportive Treatment to Chemotherapy
Chemotherapy by its nature causes side-effects which can be ameliorated by supportive treatments. Hair loss associated with chemotherapy may be avoided or reduced by scalp cooling.
Nausea and vomiting as a consequence of moderately emetogenic chemotherapy (e.g. cyclophosphamide, methotrexate and fluorouracil) may be managed by appropriate antiemetics. The use of 5HT3 antagonists (eg ondansetron, granisetron, tropisetron) has been very helpful. Delayed emesis has been greatly improved by the use of dexamethasone for 3-5 days post treatment.
Breast Units responsible for the administration and supervision ofcytotoxic chemotherapy will use protocols and should provide necessaryanti-emetics.
If nausea and vomiting still occur, then oral orrectal domperidone, oral cyclizine, or oral 5HT3 antagonists may beuseful. Patients should be instructed to inform the Breast Unit attheir next attendance so that appropriate changes to their anti-emeticregimen can be made.
Lassitude is common following chemotherapy. The most problematic toxicity following any form of chemotherapy is myelosuppression and consequent risks of infection or bleeding.
Breast Units should inform patients and their GPs of this risk and ofthe steps that should be taken should infection or bleeding occur. A GPconfronted by a febrile or systemically unwell patient receiving chemotherapy should contact the Breast Unit for advice without delay.
Supportive/Palliative Care
Supportive care includes a range of therapeutic interventions aimed atrelieving distress and improving the quality of life for patients andtheir family/carer. It should be available from time of diagnosis, andnot reserved for just the terminal stage of disease. Supportive carecovers the patient's physical, psychological, social and spiritualneeds.
Several disciplines are involved in delivering supportive care/ palliative care: physicians, nurses; physiotherapist; OT; social worker; dieticians; rehabilitation; religious advisors.
The primary health care team should be informed of all supportive careinterventions and while the patient is at home, GPs, district nurses,Macmillan nurses and Marie Curie nurses play a crucial role inmaintaining the patient's and family's quality of life.
In theterminal stages, it is important to ensure that the patient and familyare aware of the prognosis so that they can make appropriate plans.Wherever possible, the patient should be allowed to die in the place oftheir choice. However, often inadequate home circumstances or familysupport will prevent a patient dying at home.
Palliativetherapies are aimed at relieving physical and psychological distress.There should be a full assessment of the patient's symptoms, andtreatments should be planned by a multi-disciplinary team.
Pain is a dominating symptom and may need intervention from specialistsoutside the team, such as anaesthetists for nerve blocks.
Palliative therapies can be co-ordinated from a hospice orhospital-based team, but the primary care team should be informed ofall new interventions. While the patient is at home, the GP anddistrict nurse, advised by a Palliative Care Physician or Macmillannurse, should take control of medication and the psychologicalmanagement.
Antidepressants
Antidepressants play a role in preserving the mental wellbeing ofpatients suffering from breast cancer. From primary presentation to theterminal stages of disease, depression can inhibit the daily functionof patients.
It is very important to consider the mentalhealth of all women suffering from breast cancer at all times. Simplesymptoms such as insomnia, poor appetite etc. may be relieved by theuse of antidepressants.
More complicated symptoms such as coping with the diagnosis, post-surgery body image problems and psychiatric morbidity relating to treatment can also be treated.
Most patients find counselling and support group therapy helpful inconjunction with medication. Patients should be encouraged to discusstheir mental state with their GP or Breast nurse. Most Breast unitswill have a Breast nurse to counsel patients and many will have anassociated psychiatrist to whom patients can be referred if symptomsare not alleviated with standard treatments.
Self-help groups can be very supportive to patients and their families.
Anti depressants are also useful in the control of chronic pain e.g.lower back pain, irrespective of their anti-depressant function.
Anxiolytics
Anxiety is often present in patients with a diagnosis of malignantdisease. Patients often start being anxious during the screeningprocess and while waiting for their results.
Psychologicalsymptoms can be present at any time during the course of the disease.It is important that the physician reassures the patient that thesesymptoms are normal and understandable.
Usually the symptomsof anxiety can be alleviated with discussion and support. Self-helpgroups and counselling can be very helpful. However, anxiolytics such as benzodiazepines may be indicated, in the short term, especially in insomnia.
In clinical practice, short term benzodiazepines may also be helpful inreducing the effect of anticipatory nausea. Anxiolytics are very usefulin the terminal stages either orally or via a syringe driver.
Hypnotics
Hypnoticsmay be required to treat transient or short term insomnia in patientswho have recently been diagnosed as having a malignant disease or whoare trying to cope with the diagnosis.
Short courses ofbenzodiazepines are indicated in such patients. Any underlyingpsychiatric illness should be considered in such cases. Benzodiazepinescan also be used to help patients with pre-treatment anxiety.
In the terminal stages, hypnotics can be used to help reduce anxiety and, in clinical practice, in combination with analgesics they may help relieve pain. They can be administered orally, using tablets or suspension, or via a syringe driver.
Laxatives
Laxatives are often required to treat constipation which usually occursas a consequence of taking opioid analgesics and other medication suchas 5HT3 (serotonin) antagonists.
Consideration should be given to prophylacticuse in patients who are to be given opioids. Constipation can alsoarise in terminally ill patients probably due to a combination of aninadequate diet and poor mobility. Fluid intake is an important issuein constipation. The types of laxatives are:
- Bulk-forming e.g. ispaghula husk, methyl cellulose
- Stimulant e.g. bisacodyl, senna.
- Faecal softeners e.g. liquid paraffin, docusate sodium (also a stimulant).
- Osmotic e.g. magnesium salts, lactulose, phosphate enemas.
Occasionally, when oral laxatives fail, enemas or suppositories may be necessary to relieve the symptoms of constipation.
Non-opioid analgesics
Non-opioid analgesicsare used to control mild to moderate pain and occasionally forbreakthrough pain. Pain can be controlled with simple analgesics suchas paracetamol provided it is given in appropriate doses and regularly.
It is far easier to control pain with regular medication ratherthan trying to treat pain which has been allowed to crescendo. NSAIDs are often used to control the pain due to bony metastases, being more effective than opiates in many patients.
Combination analgesics e.g. paracetamol and codeine are usuallyprescribed for moderate pain not controlled by simple analgesics, butthe side-effect of constipation can often be a problem, especially inthe terminal patient.
NSAIDs
NSAIDsare often used to palliate the pain associated with bony metastases.The relief obtained is often greater than when using opioid analgesicsalone.
Gastro-intestinal bleeding, ulceration and irritation (causing dyspepsia)may occur with NSAIDs. This can be a problem especially in patientswhose appetites are poor. However this can often be controlled by theuse of proton pump inhibitors, H2 receptor antagonists or misoprostol.
Nutritional supplements
Nutritional supplements are often indicated following treatment, whichmay affect the appetite e.g. chemotherapy or in the terminal stages ofthe disease.
They are indicated when a patient's appetite ispoor or where swallowing is difficult for whatever reason. Patientsshould be encouraged to eat normal food as well as taking supplements.
Often supplements will help maintain body weight and strength since thevarious preparations usually have a high energy and high proteincontent. There are many preparations available which enables thepatient to select those preparations which are most palatable.
Opioid analgesics
Opioid analgesicsare generally prescribed for moderate to severe pain, usually in theterminal stages of disease. Apart from the analgesic effect, opioidscan help to reduce anxiety.
The most common opioid used ismorphine, which is now available in several preparations, so it isusually possible to find a form that is suitable to most patients.Patients have a variable response to morphine, which is generally notwell tolerated in high doses.
It is usual to start with small doses and titratethe increase in dose against the response, this helps keep theside-effects to a minimum. The side-effects include nausea,constipation, sedation and respiratory depression.
Laxativesshould be co-prescribed to avoid the onset of constipation. A faecalsoftener with a peristaltic stimulant or lactulose solution with asenna preparation can be used.
A number of opioid analgesicsare available and there are a variety of preparations e.g. short-actingtablets (given 4 hourly), long-acting (modified-release) tablets(effective for 12 or 24 hours), solutions, suspensions, transdermal patches (effective for 72 hours), suppositories or preparations for use sub-cutaneously via a syringe pump.
The latter three preparations are generally used for patients who areunable to tolerate oral preparations for whatever reasons. Doseequivalence charts are available for converting between differentopioids. It is more usual to use diamorphine in the syringe pumpbecause of its greater solubility than morphine.
Other
Control of lymphoedema
Lymphoedemaoccurs in a small proportion of patients treated by axillarydissection, radical radiotherapy or a combination of both. The highestincidence occurs when both treatments are given.
The most severe symptoms are associated with recurrence in the axilla.There is no curative treatment but relief can be obtained bycompression support hosiery or elastic support bandaging, massage andexercise. For particularly troublesome cases, referral to thelymphoedema service at the Breast Unit or the local hospice can behelpful.
Familial Breast cancer and related malignancies
Although there is no clear genetic element established for the majorityof breast cancers, in patients with one or more first degree relativeswho develop breast cancer early, there is a significantly increasedrisk.
Furthermore, in certain families, there is anassociation between the occurrence of breast cancer and othermalignancies of colon, ovary and prostate. Three genes have beenrecently identified to be associated with familial breast cancer,BRCA1; BRCA2 and p53. The interplay between these genes and otherfactors in the development of breast cancer is the subject of activeresearch.
Patients with a relevant family history are usuallyreferred to a Family History Clinic where they will receive morefrequent screening/evaluation and be offered genetic counselling, whereavailable.
Genetic Counselling
Afamily history is a significant risk factor in breast cancer. There isa 2 to 3 fold increase in risk among first degree relatives, while forpatients who have a relative with bilateral disease, the risk isincreased 5 fold.
Up to 10% of patients with breast cancerhave a genetic abnormality, which predisposes them to develop thedisease. One would suspect a genetic abnormality in patients who have :
- Several cases of disease in a single family
- Early onset of disease in affected relatives
- Presence of multiple epithelial cancers (breast, ovarian, colon, prostate.)
Genes associated with breast cancer (BRCA1, BRCA2 and p53) haverecently been identified. (A woman with a mutation of the BRCA1 genehas a life time risk of up to 80% for developing breast cancer.) Theirrole in the aetiology and risk for the development of disease, are the subject of intense research.
Women with a strong family history can now be referred to FamilyHistory Clinics, which are usually sited in Breast Centres. Theseclinics provide genetic counselling and psychological support for womenat risk.
In practice a woman has to have at least 1 livingrelative (in a family with at least 3 affected cases of breast/ovariancancer) who has had breast cancer from whom blood can be taken, so thatthe genetic mutation can be determined by mutation analysis andsequencing.
Further interventions, such as regular screening and bilateral subcutaneous mastectomies, now appear to reduce risk by as much as 90%.
Pregnancy and Breast Cancer
Approximately 1-2% of all breast cancers occur during pregnancy or lactation(1-3 of every 10,000 pregnancies). 25% of women who develop breastcancer under the age of 35 years do so either during or within 1 yearof pregnancy. There is no evidence to suggest that breast canceroccurring during pregnancy is more aggressive than other breast cancer.
Detection of a breast lump, and hence diagnosis, in pregnancymay be more difficult due to breast distension. 65% of patients haveaxillary node involvement at diagnosis. When matched stage for stage,survival is similar to non-pregnant women.
The treatment ofbreast cancer in pregnancy requires careful planning. In the first twotrimesters, treatment is usually wide local excision or mastectomy,depending on the policy of the local Breast Unit, and axillary nodeclearance.
Radiotherapy should not be given during pregnancy.
Chemotherapy can be problematic but has been used during the second andthird trimester. Treatment of breast cancer occurring in the thirdtrimester may be delayed until 30-32 weeks when the baby may bedelivered followed by surgery and radiotherapy for the mother.
Primary systemic chemotherapy may be required if the tumour is large orlocally advanced. However, if the tumour is found to be increasing insize, treatment (surgery and/or chemotherapy) should be institutedbefore delivery.
The use of any chemotherapy during the firsttrimester may be associated with an increased rate of spontaneousabortion, low birth weight, premature birth and organ toxicity. Therisk of teratogenicity is less in the second and third trimesters compared to the first trimester.
It is important that care is within a multidisciplinary team includingsurgeon, oncologist and specialist in foeto-maternal medicine.
There is only limited information on the effect of pregnancy on theoutcome of a woman with a previous history of breast cancer. It isgenerally recommended that there should be a delay of 2 years betweentreatment and pregnancy, since many relapses occur in the first 2years. There is no evidence for an increased rate of congenital abnormality despite radio or chemotherapy.
Women who have been treated with breast conserving surgery andradiotherapy have been known to breast feed from the treated breastwith no detrimental effects to mother or baby.
All pre-menopausal women who are about to undergo radio- or chemotherapy should be given careful contraceptive advice (tamoxifen is not a contraceptive).
Hormonal contraceptives should be avoided if possible. Barrier methodsof contraception (condoms, cap) or coils (IUDs) are the methods ofchoice especially when the patient is receiving endocrine therapy. Some women or their partners may prefer to be sterilised to prevent the risk of pregnancy.
Rehabilitation
The number of people living with cancer is increasing year by year, asare periods of remission. Psychological support services, availablefrom diagnosis, are now recognised as an important integral part ofgood cancer care, alongside medical treatment.
Each individualresponsible to a life-threatening event should be valued, and withskilled intervention, coping strategies can be enhanced, thus promotingadaption and quality of life, encouraging empowerment for the patientand her family.
Lifestyle advice may be given regarding:
- Smoking
- Alcohol intake
- Diet and exercise
Increased information enables the patient to become more empowered and consequently more confident.
Screening
The aim of screening is to detect breast cancer when the primary lesionis small and before it has had a chance to spread.
Screeningtests should be simple to apply, cheap, easy to perform and interpretand specific, i.e. able to identify women with disease and excludewomen without disease.
Individual tests are reasonably pricedand are reasonably specific, detecting approximately 95% of all breastcancers. Mortality can be significantly reduced by identification andtreatment of tumours detected by mammography and is of benefit in womenover 50.
A general overview of randomised and non-randomisedtrial data suggests a reduction in mortality due to mammographicscreening of 24%.
Patients should be encouraged to attend when invited.
GPs can continue sending patients over the age of 65 for screening if they request this.
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