mBC treatment goals

Metastatic breast cancer remains largely incurable. However, with some patients achieving long-term relapse free survival, discussion is now ongoing as to whether a subset of patients may be curable with a more aggressive multidisciplinary team approach and curable intent (Hattori & Iwata, 2018). However, in the absence of a cure, the goal of treatment must be to extend life and delay disease progression while ensuring that patients continue to have the best quality of life as possible for as long as possible (O’Shaughnessy, 2005). 

Patient involvement in their care has been associated with positive patient outcomes (Kashaf & McGill, 2015). Despite this:

Treatment needs and concerns of patients with mBC.

Figure 5: Treatment needs and concerns of patients with mBC.

It is clear that while many patients struggle to communicate their treatment goals and preferences, most want an active role in treatment decisions. Since the publication of patient survey conducted by Harding et al., several new therapies have become available for patients with mBC including additional anti-HER2 therapies, the CDK4/6 inhibitors and PARP inhibitors. Given the increasing armamentarium in mBC, it is vital that patient–doctor communication is improved, and patients are able to express their preferences when it comes to treatment decisions. This is particularly true in breast cancer where patients have been shown to have a particularly strong wish to be actively involved in their treatment (Gaston & Mitchell, 2005).

Shared-decision making (SDM) involves healthcare providers and patients sharing the best evidence when facing a decision and patients being encouraged to take an active role in the decision-making process. This approach is an important element of good advanced cancer care and most patients prefer to participate in decision making (Spronk et al., 2018). The use of SDM has been associated with positive patient outcomes including increased knowledge of therapeutic options, improved perception of care and better quality of life (Kashaf & McGill, 2015; Kehl et al., 2015; Stacey et al., 2017). A series of tools have also been developed to support SDM in metastatic cancer, and mBC in particular. These tools are aimed at helping patients in advance of a consultation with their physician and have been shown to have positive effects although further study is required to confirm this (Spronk et al., 2018).

Symptom management goals

The symptoms that cancer patients experience has been extensively studied and their management represent a key part of a patient’s treatment goals that directly impact their quality of life (Ahmed et al., 2012; Reeve et al., 2014; Kent et al., 2016). However, patient expectation that treatment will not meet their symptom goals can lead to increased anxiety and depressive symptoms in patients with chronic pain (Yi et al., 2014).

Patient-defined symptom goals, therefore, offer a measure of clinically meaningful improvement and should form a part of the SDM process (Joosten et al., 2008). A survey of 80 women with mBC assessed their symptom severity across 10 symptoms commonly experienced by cancer patients. On average, the severity of symptoms was low to moderate, with fatigue, sleep problems and thinking problems being those worst affected. Patients expected symptom treatment to be successful and mean reductions that would represent treatment success were determined for each symptom (Figure 6) (Tometich et al., 2018).

Amount of change necessary for treatment to be considered successful among women with mBC. PCOQ, Patient-centred outcomes questionnaire.

Figure 6: Amount of change necessary for treatment to be considered successful among women with mBC. PCOQ, Patient-centred outcomes questionnaire (Adapted from Tometich et al., 2018).

It is important to recognise that while these values offer a valuable insight into the patient perceptions of treatment success, individual patients will have their own priorities and perspectives emphasising the need for SDM and tailored patient care. Using a cluster analysis based on the ratings of the importance of symptom improvement, Tometich et al., were able to group the patients into three clusters: (1) those who rated thinking problems, sleep problems and fatigue as highly important, (2) those who rated pain as moderately important, and (3) those who rated all symptoms as highly important (Tometich et al., 2018). Utilising SDM and exploring patients’ treatment expectations and priorities will help ensure goals are set that match their values and needs.