Care For Metastatic Breast Cancer Research Articles

Patient-reported outcomes to assess symptoms in patients with metastatic breast cancer: Pilot implementation project.

177 Background: Use of patient-reported outcomes (PRO) to evaluate symptoms improves clinical outcomes. Best practices for implementing PROs into routine care may vary according to clinical scenario, site-specific resources and programmatic goals. Patients with metastatic breast cancer (MBC) often experience a variety of symptoms. Methods: As a quality improvement project, we are pilot testing incorporation of a battery of PRO measures into routine care for patients with MBC at Johns Hopkins in order to gain experience that will guide future broader implementation of PROs across our program. Participants complete the PROs on paper at baseline (BL), 3, and 6 months (mo). Measures include NCCN Distress Thermometer (BL only), Patient Health Questionnaire-8 (PHQ-8), Generalized Anxiety Disorder-7 (GAD-7), PRO-CTCAE Insomnia questions and a modified version of the revised Edmonton Symptom Assessment System (r-ESAS) questionnaire with 3 extra symptom domains. Project team members alert clinicians by email of scores that exceed severity thresholds as follows – Distress: ≥4, PHQ-8: ≥8, GAD-7: ≥10, any item on r-ESAS: ≥4 and PRO-CTCAE Insomnia: severe/very severe or quite a bit/very much. Results: From May 29, 2020 and April 5, 2021, 67 patients were approached for participation, and 40 (59.7%) completed the BL PROs. Median age was 64 (range 36-85). Most participants were White (70%), non-Hispanic (90%) and had hormone receptor-positive (93%) MBC. At BL, 22 (55%) had visceral disease and most were receiving endocrine-based regimens [21 (53%)] or chemotherapy [16 (40%)]. 27 (68%) participants had ≥1 BL alert. The most common BL alerts were for symptoms on the r-ESAS [23 participants (58%)]. The most frequent items on the r-ESAS for which participants had BL alerts were pain, tiredness, well-being, tingling/numbness and rash. Other BL alerts were: Distress [9 participants (23%)], PRO-CTCAE Insomnia [5 participants (13%)], PHQ-8 [4 participants (10%)] and GAD-7 [2 participants (5%)]. To date, 24 of 35 (69%) and 15 of 28 (54%) participants who have reached the 3 and 6 mo time points have completed the respective follow-up (FU) PROs. Most common FU alerts to date are on the r-ESAS [3 mo: 14 participants (58%), 6 mo: 9 participants (60%)]. The project team has successfully notified providers of all alerts to date. Clinical actions (phone calls, provider visits and/or referrals) have been taken within 30 days of notification for > 75% of alerts. Conclusions: Implementation of a PRO battery for patients receiving routine care for MBC led to detection of a range of symptoms, the majority of which were clinically actionable. Restrictions on in-person interactions during the COVID-19 pandemic may have contributed to low rates of PRO completion in this pilot project. Prior to broader implementation, we will consider strategies such as an electronic platform and a shorter battery to enhance patient engagement.

Evaluating specialty referral, research involvement, and PROs in a CNS-involved metastatic breast cancer care coordination program.

47 Background: Central nervous system (CNS) metastases are associated with decreased survival and quality of life for patients with metastatic breast cancer (MBC). Multi-disciplinary care can optimize outcomes. This project aims to improve access to coordinated care for patients with MBC and CNS metastases while assessing patient-reported outcomes (PROs) in the context of the multidisciplinary care experience. Methods: Patients with MBC and CNS metastases are referred and offered to enroll in our care coordination program. A team of specialists (breast medical oncology, breast cancer genetics, radiation oncology, neurosurgery, neuro-oncology, physical medicine and rehabilitation (PM&R), neuropsychology, and palliative care) supports a dedicated program coordinator who provides navigation, education, specialty referral, and clinical trial screening. A unique intake form developed for the program creates personalized, coordinated, and expedited referrals. PROs and caregiver assessments are collected on a voluntary basis using the following validated questionnaires: PROMIS Cancer Function Brief 3D Profile, MD Anderson Symptom Inventory Brain Tumor (MDASI), and Short Form Zarit Burden Interview (ZBI-12), a screening tool for caregiver burden. Results: Since May 2020, 43 patients were referred and a total of 40 patients (93%) were enrolled – 2 (5%) declined due to perceived burden of participation and 1 (2%) died before enrollment. The majority of patients were White (n = 34, 85%). Median time to program intake was 1 day (range: 0-8 days). Of the 43 patients referred, 17 (40%) consented to research studies in the metastatic setting. 11 were for an interventional trial (65%), while 9 consents were for non-interventional studies (53%). In addition to the initially referred specialty, 56 referrals were made across 7 sub-specialties; 37 patients (66%) were subsequently seen by a sub-specialist, most commonly radiation oncology (n = 9), PM&R (n = 9), neuro-oncology (n = 8), and neuropsychology (n = 8). Of the nine patients seen by PM&R, 5 completed the PROMIS Profile (55%). Similar completion rates were seen for the MDASI (13 of 23 surveys given, 56.5%) and ZBI-12 (13 of 26 surveys given, 50%) questionnaires. Conclusions: Implementation of a care coordination program for patients with MBC and CNS metastases allows for improved access to care across sub-specialties and supports participation in clinical research for a group of cancer patients historically underrepresented in research studies. Though completion of questionnaires is optional in this program, the rate of completion raises the question of whether this patient population faces unique challenges that make it difficult to complete questionnaires that are often required in research studies. Funding source: National Comprehensive Cancer Network Oncology Research Program from financial support from Pfizer.

A mixed-methods study of cyclin-dependent kinase 4 and 6 inhibitor symptom burden and quality of life among metastatic breast cancer patients and providers.

BackgroundCyclin‐dependent kinase 4 and 6 (CDK4/6) inhibitor targeted therapies dramatically improve survival outcomes for metastatic breast cancer (MBC), but they are associated with significant symptom burden that can impact patients’ health‐related quality of life (HRQOL) and treatment outcomes. This study is the first to describe CDK4/6 inhibitor symptoms from the lived perspectives of MBC patients taking CDK4/6 inhibitors and healthcare providers involved in MBC care. This study also explored patients’ symptom management and HRQOL concerns, and gathered feedback about developing supportive interventions for MBC.MethodsMBC patients taking CDK4/6 inhibitors (N = 20) and MBC healthcare providers (N = 12) participated in semi‐structured interviews that were analyzed for qualitative themes. MBC patients completed surveys about HRQOL, symptoms, and unmet needs.ResultsPatient and provider perceptions of CDK4/6 inhibitor symptoms did not align with patients perceiving symptoms as more burdensome. Patients reported that supportive resources (e.g., support groups, blogs) that are not specific to MBC do not adequately meet their needs. Patients and providers were enthusiastic about developing supportive interventions specifically for MBC and offered considerations for designing such interventions.ConclusionsFindings highlight differences in perceptions of CDK4/6 inhibitor symptom burden between MBC patients and providers. Results will inform the development of supportive interventions to assist MBC patients in managing CDK4/6 inhibitor symptom burden and maintaining HRQOL. Such interventions could also improve treatment outcomes.

Real-world practice patterns in treatment of metastatic breast cancer in Washington State.

e13038 Background: Evidence-based, national guidelines for the management of metastatic breast cancer (MBC) recommend numerous treatment options that do not capture the nuances of real-world practice. Disparities may exist across Washington State with financial implications for patients and health systems. The objective of this study was to assess practice patterns around treatment of ER+/HER2- MBC in actual clinical practice. Methods: We collaborated with Hutchinson Institute for Cancer Outcomes Research (HICOR) to link enrollment and insurance claims records with Washington State cancer registries from 2008-2017. Our cohort comprised of women >18 years old with de novo ER+/HER2- MBC who met enrollment criteria in one of four payors (Premera, Regence, Medicare, or Medicaid). We identified receipt of first line treatment, categorized as CDK4/6 inhibitors plus endocrine therapy (CDKi+ET), chemotherapy (CT), or endocrine therapy alone (ET). We examined factors influencing treatment selection using Fisher's and Kruskal-Wallis tests. Total costs (defined as costs from inpatient and outpatient claims one year after diagnosis) was estimated for patients and payors. Results: We identified 140 patients with de novo ER+/HER2- MBC with median age of 64 (range 28-95). The majority of the cohort were Caucasian (90%) with the rest comprising of Asian, Black, American Indian, and Hispanic patients. Based on the Rural Urban Commuting Area (RUCA) classification, patients predominantly lived in metropolitan neighborhoods (96%). Over 20% of patients lived in areas of high deprivation (area of deprivation index, ADI, 8-10). Patients had either Commercial (40.7%), Medicaid/Medicare (43.6%) or multiple (15.7%) insurance. Our data show that 17 patients (12%) received first line therapy with CDKi + ET, 64 patients (46%) with CT, and 59 patients (42%) with ET alone. Factors influencing treatment selection include age, co-morbidity score, and payor type. Older patients (>65 years old) were more likely to receive ET alone compared to younger patients (56% vs 44%, p value <0.001). Patients with high co-morbidity score were more likely to receive ET (30%) compared to CT (5%) or CDKi + ET (23%), p value <0.001. Patients with commercial insurance made up over 50% of patients in our cohort who received CDKi +ET, while Medicare-insured patients were most likely to receive ET alone (p value <0.001). We estimated the mean cost of receiving first line therapy with CDKi +ET ($20,368 and $175,932), CT ($10,624 and $117,847) and ET alone ($13,292 and $60,338) for patients and payors, respectively (costs inflated to December 2019). Conclusions: Our study shows substantial variation across Washington state in treatment selection and costs for patients with metastatic breast cancer in the first-line setting. Our findings demonstrate the need for initiatives to standardize quality of care relative to clinical guidelines in metastatic breast cancer care.

The Quality of End-of-Life Care for Women Deceased From Metastatic Breast Cancer.

Metastatic breast cancer (MBC) carries unique disease burdens with potential for poor-quality end-of-life (EOL) care. It is the purpose of this article to explore the association of poor-quality EOL care indicators according to key tumor, demographic, social, and clinical factors. End-of-life quality indicators were based on Emanuel and Emanuel's good death model in conjunction with Earle et al (2003). A single-institution retrospective chart review of women deceased from MBC between November 2016 and November 2019 with double-verification chart review was completed. Data were analyzed with descriptive, correlative, and comparative statistics. Total sample was N = 167 women, with 14.4% (n = 24) Black and 85.6% (n = 143) White. Mean (SD) age was 55.3 (11.73) years. Overall, MBC survival was 3.12 years (SD, 3.31): White women, 41.2 months (3.4 years), and Black women, 19 months (1.6 years). A total of 64.1% (n = 107) experienced 1 or more indicators of poor-quality EOL care. Patients more likely to experience poor-quality EOL care were older (P = .03), estrogen negative (P = .08), human epidermal growth factor receptor 2 negative (P = .07), from more deprived neighborhoods (P = .02), married (P = .05), and with physical (P = .001) and mental (P = .002) comorbidities. Understanding sociodemographic and clinical factors associated with poor EOL MBC care may be useful for proactive patient navigation.

Abstract PD9-12: Concordance and use patterns of tissue and cell-free based genomic testing in metastatic breast cancer

Abstract Genomic testing has transformed clinical care in metastatic breast cancer. Cell-free DNA (cfDNA) has made sequential testing feasible, however, concordance between tissue and cfDNA, sensitivity of cfDNA, and optimal sampling frequency have not been examined on large data sets with clinical annotation. Of the 648 genes in the tissue NGS Tempus xT assay, 105 genes are also included in the Tempus xF cfDNA plasma-based test. Both platforms are run on Illumina and detect SNVs, indels, CNVs, and rearrangements/fusions with high sensitivity and specificity (>90%). This study used the Tempus Labs LENS™ tool to identify the most recent ~3,300 metastatic breast cancer patients who underwent clinical testing and had either tissue-based testing, cfDNA testing or both. Of the 212 patients with xF and xT testing, 87 had xT before xF, 135 had xF before xT, and 7 had the testing performed at the same time. The most common pathogenic germline versus somatic alterations on tissue-based testing and their concordance will also be reported. In summary, this data suggests a variable amount of concordance between tissue-based and plasma-based assays. Timing of assay performance and inclusion of germline DNA might play an important role in contributing to these differences which need further exploration. Table: Count of Reported Variants and xT/xF Concordance by GeneSomatic GenesxF frequency (n)xT frequency(n)Concordance Between xF and xTTP5313911043%PIK3CA848058%ESR1584141%BRCA238217%ERBB2372629%NF1322113%RB1272416%ATM30165%GATA3213441%FGFR13353%PTEN193036%ARID1A251823% Citation Format: Minetta Liu, Jeff Schaffer, Aneta Piwowarczyk, Nike Beaubier, Kimberly Blackwell, Ben Park. Concordance and use patterns of tissue and cell-free based genomic testing in metastatic breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PD9-12.

Using a Twitter Chat to Rapidly Identify Barriers and Policy Solutions for Metastatic Breast Cancer Care: Qualitative Study.

BackgroundReal-time, rapid assessment of barriers to care experienced by patients can be used to inform relevant health care legislation. In recent years, online communities have become a source of support for patients as well as a vehicle for discussion and collaboration among patients, clinicians, advocates, and researchers. The Breast Cancer Social Media (#BCSM) community has hosted weekly Twitter chats since 2011. Topics vary each week, and chats draw a diverse group of participants. Partnering with the #BCSM community, we used Twitter to gather data on barriers to care for patients with metastatic breast cancer and potential policy solutions. Metastatic breast cancer survival rates are low and in large part conditioned by time-sensitive access to care factors that might be improved through policy changes.ObjectiveThis study was part of an assessment of the barriers to care for metastatic breast cancer with the goal of offering policy solutions for the legislative session in California.MethodsWe provided 5 questions for a chat specific to metastatic breast cancer care barriers and potential policy solutions. These were discussed during the course of a #BCSM chat on November 18, 2019. We used Symplur (Symplur LLC) analytics to generate a transcript of tweets and a profile of participants. Responses to the questions are presented in this paper.ResultsThere were 288 tweets from 42 users, generating 2.1 million impressions during the 1-hour chat. Participants included 23 patient advocates (most of whom were patients themselves), 7 doctors, 6 researchers or academics, 3 health care providers (2 nurses, 1 clinical psychologist), and 2 advocacy organizations. Participants noted communication gaps between patient and provider especially as related to the need for individualized medication dosing to minimize side effects and maximize quality of life. Timeliness of insurance company response, for example, to authorize treatments, was also a concern. Chat participants noted that palliative care is not well integrated into metastatic breast cancer care and that insurance company denials of coverage for these services were common. Regarding financial challenges, chat participants mentioned unexpected copays, changes in insurance drug formularies that made it difficult to anticipate drug costs, and limits on the number of physical therapy visits covered by insurance. Last, on the topic of disability benefits, participants expressed frustration about how to access disability benefits. When prompted for input regarding what health system and policy changes are necessary, participants suggested a number of ideas, including expanding the availability of nurse navigation for metastatic breast cancer, developing and offering a guide for the range of treatment and support resources patients with metastatic breast cancer, and improving access to clinical trials.ConclusionsRapid assessments drawing from online community insights may be a critical source of data that can be used to ensure more responsive policy action to improve patient care.

A Qualitative Study on the Needs of Women with Metastatic Breast Cancer.

Few studies have investigated the needs of patients with metastatic breast cancer (MBC), and none have been conducted in Italy. Three categories of needs have been identified from the literature: information, support, and practical resources. The present study aims to achieve an in-depth understanding of the patients' needs related to the MBC care pathway. In-depth interviews were conducted and analyzed by thematic analysis. The participants were 9 women with MBC (age range 36-74) who were enrolled atthe Fondazione IRCCS Istituto Nazionalde dei tumori, in Milan. The analysis enabled us to identify four themes (which reflect the needs of the participants), each divided into numerous sub-themes: (1) the need for clinical recognition, (2) the need for more attention from healthcare professionals, (3) the need for more and better services to be available at the hospital, (4) the need for specific public health policies. Since the metastatic phase of breast cancer seems to elicit additional, specific needs and multi-level management, changes in attitudes and multidisciplinary practices should be tested in order to ascertain how these needs can be met.

Optimal Supportive Care for Patients With Metastatic Breast Cancer According to Their Disease Progression Phase.

The clinical progression patterns of metastatic breast cancer (MBC) are heterogeneous; patients experience acute and stable phases at different time points. The acute phase consists of rapid progressive symptomatic changes, whereas in the stable phase, patients have relatively low symptom burden. Therefore, personalized interdisciplinary care is essential. The optimal palliative or supportive care in MBC is to provide comprehensive care that is individually prioritized to the patient's disease status. The purpose of this review is to provide a practical guide for oncologists to understand the priorities for supportive care for patients with MBC in the two phases. We note that for better decision making in patient care, performance status should be broadened to consider not only physical status but also psychosocial needs and cognitive condition. We summarize the clinical importance of physical symptom control, psychosocial support, physical activity, nutrition support, and advance care planning. For optimal care, we present palliative or supportive care checklists according to the disease progression phase, combining the limited evidence with expert input. In the acute phase, close monitoring of the patient's status and symptom management take priority. In the stable phase, the focus can shift to maintenance or improvement of physical strength and emotional condition. Finally, we discuss future directions and unmet needs in providing the best supportive care for patients with MBC.

Metastasis: A Bane of Breast Cancer Therapy

The underlying mechanisms of metastasis in patients with breast cancer is still poorly understood. Approximately 6% of patients with breast cancer present with metastasis at the time of diagnosis. Metastatic breast cancer is difficult to treat and patients with breast cancer with distant metastasis have a significantly lower 5-year survival rate compared to patients with localised breast cancer (27% and 99%, respectively). During breast cancer progression, tumour cells first metastasise to nearby draining lymph nodes and then to distant organs, primarily bone, lungs, liver, and brain. In this brief review, the authors discuss breast cancer metastasis, the role of epithelial–mesenchymal transition and the contributions of the immune system to the metastatic process. The authors also briefly discuss whether there is any relationship between tumour size and metastatic potential, and recent advances in treatment for metastatic breast cancer. The studies highlighted suggest that immunotherapy may play a more significant role in future patient care for metastatic breast cancer.

Diagnosis and Treatment of Bone Metastases in Breast Cancer: Radiotherapy, Local Approach and Systemic Therapy in a Guide for Clinicians.

The standard care for metastatic breast cancer (MBC) is systemic therapies with imbrication of focal treatment for symptoms. Recently, thanks to implementation of radiological and metabolic exams and development of new target therapies, oligometastatic and oligoprogressive settings are even more common—paving the way to a paradigm change of focal treatments role. In fact, according to immunophenotype, radiotherapy can be considered with radical intent in these settings of patients. The aim of this literature review is to analyze available clinical data on prognosis of bone metastases from breast cancer and benefits of available treatments for developing a practical guide for clinicians.

International retrospective cohort study of locoregional and systemic therapy in oligometastatic breast cancer (OLIGO-BC1).

1025 Background: Systemic therapy is the standard care in metastatic breast cancer (BC). However, retrospective studies demonstrated survival benefits of locoregional and systemic (combination) therapy in oligometastatic BC. To clarify it, the Federation of Asian Clinical Oncology conducted an international retrospective cohort study (OLIGO-BC1) (UMIN No.000030047). Methods: Oligometastatic BC patients diagnosed from 2007 to 2012 were registered. “Oligometastases” is defined as low volume metastatic disease with limited number and size of metastatic lesions up to five and not necessarily in the same organ by the ABC guidelines. Overall survival (OS) from the diagnosis of oligometastases was the primary endpoint and compared between combination and systemic therapy using a log-rank test. Assuming the 5-year OS of 50% and 40%, respectively, 698 patients were required to achieve 80% power to detect the superiority of combination therapy, at a two-sided significance level. A multivariable Cox regression model with stratification by country was performed to estimate hazard ratio (HR) for therapy and other risk factors. Results: While 1,262 cases had been registered from February 2018 to May 2019, 1,200 remained for analysis after exclusion of unavailable cases. Among them, 573, 529 and 98 cases were registered from China, Japan and Korea, respectively. Luminal BC was recorded in 526 cases (44%), luminal-HER2 BC in 189 (16%), HER2 BC in 154 (13%), triple-negative BC in 166 (14%) and others in 165 (13%). One oligometastatic BC was found in 578 cases, 2 in 289, 3 in 154, 4 in 102 and 5 in 77. Bone metastases were recorded in 301 cases, visceral metastases in 387, locoregional recurrence in 25, local recurrence in 83 and multiple metastatic sites in 404. Combination therapy was performed in 595 cases and systemic therapy in 404. At median follow-up of 4.9 years, 5-year OS was 59.6% and 41.9%, respectively (p < 0.01). An adjusted HR was 0.61 (95% CI: 0.51, 0.74). Type of systemic therapy, younger age, ECOG performance status 0, stage I BC, non-triple negative subtype, fewer metastatic sites, local recurrence and longer disease-free interval were significantly favorable prognostic factors. Discussions: Oligometastatic BC under some conditions seems to be curable. Taken together with recent molecular targeted therapy, locoregional therapy will be advantageous to conquer it. Conclusions: Combination therapy is a promising strategy for patients with oligometastatic BC.

Linking insurance claims across time to characterize treatment, monitoring, and end-of-life care in metastatic breast cancer.

7063 Background: Treatment and monitoring options for metastatic breast cancer (MBC) are increasing, but little is known about patterns or predictors of their use. Insurance claims are potentially informative, but tracking patient care timelines using episodic claims data has been cumbersome. Methods: We used an advanced cohort engine, implementing a temporal query language, to link IBM Marketscan claims over time for > 125 million US individuals from 2007-2014. To select the most common MBC subtype (ER+, HER2-), our criteria were: ≥2 MBC ICD codes, ≥1 year of follow-up, and ≥1 CPT or medication code for endocrine therapy and 0 for HER2-targeted therapy. We defined aggressive MBC as ≥1 ICD code for visceral or central nervous system metastasis < 1 year after the first MBC code. Geographic area was defined by 9 Census-Bureau designated regions. End-of-record was used as a surrogate for death in a Cox regression. We used multivariate logistic regression to determine correlation of factors, including disease aggressiveness and geography, with treatment, monitoring, and end-of-life events. Results: 7,335 women met criteria for ER+, HER2- MBC, with median age 59. Nearly half (46%) had aggressive disease, which correlated with shorter survival (hazard ratio (HR) 1.5 [1.4-1.6], P < 0.001). Treatment: first-line was endocrine therapy for 64% versus chemotherapy for 36%. Monitoring: 79% were imaged mostly by CT versus 21% by PET-CT, with median between-scan interval of 81 days; 63% received CA 15-3 serum tumor markers. End-of-life: 10% had a hospice code, of whom 19% had an ICU stay and 34% chemotherapy in the prior 3 months. Correlates of care: Disease aggressiveness correlated with first-line chemotherapy (odds ratio (OR) 2.0 [1.8-2.2], P < 0.001), PET/CT (OR 1.6 [1.4-1.8], P < 0.001), more frequent scans (OR 2.3 [2.1-2.6], P < 0.001), and chemotherapy < 3 months pre-hospice (OR 1.2 [1.1-1.4], P < 0.001), but not with CA 15-3 monitoring or ICU stay. Disease aggressiveness did not vary by region (χ2 P = 0.8), but region was significantly associated with treatment, monitoring, and end-of-life care (P < 0.001). Conclusions: Approximately two-thirds of ER+, HER2- MBC patients receive first-line endocrine therapy and are monitored with CA 15-3 serum tumor markers; 10% had evidence of hospice use, a likely underestimate due to differential follow-up. MBC care patterns vary by geography while disease aggressiveness does not, suggesting that care is not optimally tailored to individuals. These insights from claims data can inform quality improvement for MBC care.

Redrawing the Lines: The Next Generation of Treatment in Metastatic Breast Cancer

Although not considered curative in nature, new therapeutic advances in metastatic breast cancer (MBC) have substantially improved patient outcomes. This article discusses the state-of-the-art and emerging therapeutic options for management of MBC. BC systemic therapy targets multiple key pathways, including estrogen receptor signaling, HER2 signaling, and phosphoinositide 3-kinase (PI3K)/protein kinase B (AKT)/mammalian target of rapamycin (mTOR) signaling. Other therapeutic strategies include targeting DNA repair, inhibiting immune checkpoints, and developing antibody-drug conjugates. Although surgery historically was reserved for palliation of symptomatic, large, or ulcerating masses, some data suggest a possibly expanding role for more aggressive locoregional therapy in combination with systemic therapy. As technology develops, biomarker-specific, line-agnostic, and receptor-agnostic treatment strategies will redraw the current lines of MBC care. However, tumor heterogeneity remains a challenge. To effectively reshape our approach to MBC, careful consideration of the patient perspective, the costs and value of novel treatments, and accessibility (especially in developing countries) is paramount.

The Support, Education, and Advocacy (SEA) Program of Care for Women With Metastatic Breast Cancer: A Nurse-Led Palliative Care Demonstration Program.

Women with metastatic breast cancer (MBC) experience unique symptom management and psychosocial needs due to aggressive, yet palliative treatment with a progressive, chronic illness. This article describes the effect of a quality improvement project for coordination of supportive care in MBC. Program evaluations included referral rates for supportive services, patient-reported outcomes of symptom distress, generalized anxiety, and overall well-being. An interdisciplinary Support, Education and Advocacy Program (MBC-SEA) was developed. The 1-hour, weekly, patient review included collaborative assessments to determine needs for social service, psychological counseling, and palliative care. A prospective pre- and postexperimental cohort design with convenience sampling was used. Analysis was conducted with paired t test analysis of pre- and postimplementation outcomes. Program outcomes of 118 women with MBC visiting an urban outpatient breast cancer clinic during September 2016 to November 2016 (pre) and January 2017 to March 2017 (post) were evaluated. Referral rates to social work and palliative care, symptom, anxiety, and overall well-being scores. Following program implementation, referrals to palliative care and social work supportive services increased significantly including patient-reported outcomes symptom distress scores mean difference 1.4 (95% confidence interval [CI]: 0.4306-2.6428), P = .004; generalized anxiety scores mean difference 1.5 (95% CI: 0.5406-2.5781), P = .003; and overall well-being mean difference of -0.7 (95% CI: -1.3498 to -0.0570), P = .03. Purposeful nurse-led assessment for social service and palliative care needs increases referrals with improvement in patient-reported outcomes.

Building Evidence for Advocacy: Improved Services for MBC Patients in Romania

Background and context: More than 9000 women are diagnosed each year with breast cancer in Romania and one third of them will develop advanced disease. The metastatic breast cancer (MBC) management aims to optimize disease control while ensuring the best possible quality of life (QoL). In Romania, the new MBC treatments made possible longer survival, but social and psychological support is still extremely limited, and specific guidelines and standards for these services have not been developed. No study regarding distress level, quality of life and specific unmet need of metastatic breast cancer (MBC) patients in Romania was ever carried so no data are available to substantiate introduction of support services for these patients. An evidence based standard of care for support services, based on specific MBC patients needs, has to be developed to ensure an harmonization of support services in Romania. Aim: To improve quality of care for metastatic breast cancer (MBC) patients through the implementation of a standard of care for support services. Strategy/Tactics: The project uses an action research approach that starts with a qualitative study to identify both metastatic breast cancer (MBC) patients' specific needs (regarding information and support services when facing the challenges of diagnosis, treatment, and prognosis) and also their health and social providers' knowledge, experiences and perceptions about MBC. In-depths interviews will be performed with both patients and providers followed by data analysis. Based on the identified needs and literature, specific information materials for metastatic breast cancer (MBC) patients and support services guidelines will be developed. To build support, the materials (the study report, the information materials and the guidelines) will be disseminated among providers and patients through a Web page, a workshop with medical providers representatives from hospitals in the northwest region of Romania, presentation in different scientific events and collaboration with the other cancer patient associations in Romania. A policy proposal regarding the introduction and use of specific support services guidelines within the standard of care for metastatic breast cancer patients in Romania will be developed and presented to the Ministry of Health. Outcomes: An evidence based standard of care for support services and adequate information materials will create a basis for improved service provision for MBC patients; implementing a standard of care in the daily routine of service provision for MBC patients will support health and social providers to ensure better communication and patient empowerment that will have a direct impact on the treatment's efficiency as it increases patients' participation; it will also help MBC patients to better cope with the disease, to make personal decisions regarding treatment options and also to participate to the improvement of their quality of life.

First person: George Sledge, Jr, MD: Former ASCO president leads breast cancer research and mentors Stanford faculty.

First person: George Sledge, Jr, MD: Former ASCO president leads breast cancer research and mentors Stanford faculty.

Advances in treatment and care in metastatic breast cancer (MBC): are there MBC patients who are curable?

Metastatic breast cancer (MBC) remains a largely incurable disease. The goals of treatment for MBC are still to maintain quality of life and prolong survival. However, some cases of MBC with a long-term relapse free survival occurs, implying that a small subset of MBC patients could become curable. Although it is a controversial issue of whether MBC can be cured, a more aggressive multidisciplinary approach to MBC with a curable intent may help improve MBC patient outcomes. The Earlier detection of metastatic disease by using modern imaging technologies may allow the detection of metastasis before cancer cells spread widely. This brief review focuses on the potentials of clinical response at initial therapy of MBC and early detection of metastatic disease of the possibility of cure of MBC patients.

Preface for special issue "Advances in treatment and care in metastatic breast cancer".

More than 70% of patients with operable breast cancer who received the modern standard of care can be cured. On the other hand, patients with metastatic breast cancer (MBC) are still incurable and have poor prognosis with approximately 3 years of median survival time. However, the prognosis of MBC is gradually improving in step with advances in life science and technology and changes in the social environment.

The availability and effectiveness of tools supporting shared decision making in metastatic breast cancer care: a review

BackgroundShared decision-making (SDM) in the management of metastatic breast cancer care is associated with positive patient outcomes. In daily clinical practice, however, SDM is not fully integrated yet. Initiatives to improve the implementation of SDM would be helpful. The aim of this review was to assess the availability and effectiveness of tools supporting SDM in metastatic breast cancer care.MethodsLiterature databases were systematically searched for articles published since 2006 focusing on the development or evaluation of tools to improve information-provision and to support decision-making in metastatic breast cancer care. Internet searches and experts identified additional tools. Data from included tools were extracted and the evaluation of tools was appraised using the GRADE grading system.ResultsThe literature search yielded five instruments. In addition, two tools were identified via internet searches and consultation of experts. Four tools were specifically developed for supporting SDM in metastatic breast cancer, the other three tools focused on metastatic cancer in general. Tools were mainly applicable across the care process, and usable for decisions on supportive care with or without chemotherapy. All tools were designed for patients to be used before a consultation with the physician. Effects on patient outcomes were generally weakly positive although most tools were not studied in well-designed studies.ConclusionsDespite its recognized importance, only two tools were positively evaluated on effectiveness and are available to support patients with metastatic breast cancer in SDM. These tools show promising results in pilot studies and focus on different aspects of care. However, their effectiveness should be confirmed in well-designed studies before implementation in clinical practice. Innovation and development of SDM tools targeting clinicians as well as patients during a clinical encounter is recommended.