Advanced Breast Cancer with oligometastasis. Quality of life in long term survivors following aggressive treatments. Single clinician's experience

Abstract

Background: Management of advanced breast cancer is challenging for treating clinicians. The spectrum varies from oligometastasis (non life threatening) to multiple metastasis (life threatening). Modern treatment protocols give better disease control hence quality of life issues is of prime importance for long term survivors. Patients and methods: Data of metastatic breast cancer patients presented to single clinician from March 1996 to Dec 2010 were collected. Mode of presentation, sites of metastasis, performance status, pathology and prognostic variables, tools for metastatic work up, details of different modes of treatments (surgical, medical, radiation, hormonal or supportive care) were evaluated. Quality of life evaluation was done using linear analogue self-assessment (LASA) in all patients. Results: Total number of patients -165. Age group 29-75. Skin ulceration/ fungation, were present in 64 and larger than 5 cms size tumor in the rest. Oligometastasis in the form of isolated lung lesions (8), liver (5), bones (18), brain (11), visceral (10). Remaining 114 had multiple metastasis. 158 had IDCA, 4 medullary and 3 lobular cancer. 60 were triple negative, 21 were HER2+ve, 84 ER and PR +ve. All received Docetaxel / epirbicin / xeloda combination regimen. Of the 21, HER2+ve cases 10 had Herceptin, 5 Tykerb, 6 could not afford. All together 21 had brain metastasis and received RT to brain. Pleural tapping was required for 25,2 required ventilator support. Ascitic tapping was done in 35.40 /165 based on the extent of disease were treated with palliative intent only. Surgical salvages were attempted in those with oligometastasis in bones. Chest wall resections in 4, excision of sternum in 5, clavicle in 2, spine decompression and stabilization in 2, hip replacement in 3 and humerus conservative resection in 2. 25 patients with bone metastasis as a part of multiple metastasis also received spine decompressions. Local surgeries were done in 130 cases. Flap cover in 80, BCT in 40 and mastectomy in 10. Isolated lung lesions were controlled with 2nd or 3rd line chemotherapies. Premenopausal ER/PR +ve patients received tamoxifen and post menopausal Letrazole. Radiation was offered to all those who had local surgeries or for symptomatic bony lesions. Disease control (risk group), 18 (10.9%)patients survived more than 5 years -very good, 64 (38.7%) patients more than 36 months-good, 71 (43%) patients more than 12 months-average and 15 (9%) succumbed within 12months- was rated as poor-risk group. Conclusions: Therapeutic refinements, technological advancements in surgery, radiation, understanding of tumor biology and modern targeted treatments have resulted in advanced breast cancer patients surviving for more number of years than in the past. Patients with oligometastasis confined to chest wall, manubrium, single bones or isolated lung lesions having salvage surgery performed better. Hence aggressive approach in selected metastatic cases and personalized treatment plans respecting tumor biology may be ideal offering best quality of life, in the current scenario.