• Two years ago, this 63-year-old woman presented with a large, ulcerated breast lesion and a palpable supraclavicular node.
  
• Bone scan was positive in multiple locations.
  
• CAT scan of the chest and abdomen were negative.
  
• Breast biopsy revealed ER-positive, HER2-negative, infiltrating ductal carcinoma.
  
• Received pamidronate and docetaxel/doxorubicin x 6 and had an excellent response.
  
• Patient is now on maintenance letrozole.

Key discussion points:
	Psychosocial issues in treating women with metastatic disease
	Goals of treating metastatic disease
	Chemotherapy versus hormonal therapy for patients with locally advanced breast cancer

DR LOVE: Before we continue with the case discussions, let's take a moment to reflect on some of the psychosocial issues in decision-making in the metastatic setting. Maria, how do you approach this?

DR THEODOULOU: From the moment you meet a patient with - or make a diagnosis of - metastatic disease, you're dealing with a life-threatening illness. From the very onset, you define your goals of treatment, hopefully in a team effort with the patient. Together you decide whether the goal is cure, palliation, quality of life or supportive care. We've all listened to the lectures, read the algorithms and talked about it with our patients.

This is not something that's esoteric or sophisticated for any of us. But, we know that we're dealing with a life-threatening disease, and sometimes the patient is willing to take on toxicities and a compromise in quality of life to get to a better place.

DR LIPSHUTZ: One of the reasons meetings like these are so successful is because, as

oncologists, we constantly have competing anxieties. We are worried about so many things: causing harm to our patients, being state-of-the-art, medicolegal issues, psychosocial issues. We are even worried about our own lifestyle, our own ability to assimilate the data that comes down the line and our ability to deliver state-of-the-art care.

We have more options available, which is making consults much lengthier and leading to more difficult discussions. All of that weighs heavily on us. Many of us have been doing this for many years and when we finished our fellowships, we believed that we were going to see cures in our lifetime. I think all of us were optimists and thought we were going to see major advances, and that's why we went into oncology.

However, the advances have been painstakingly slow. They are real, but they require a long-sighted vision over a long period of time to see them. People want the latest, greatest and best therapies immediately, and that causes a tremendous amount of strain. If you add government regulations, bureaucratic demands and difficulty with reimbursements for what we consider to be the best of treatment, there is tremendous strain, stress and anxiety on the oncologist.

DR LOVE: Dr Burris, Dr Theodoulou talked about setting realistic goals for the woman with metastatic breast cancer. Can you talk about how you do that in your practice?

DR BURRIS: As Maria was alluding to, the conversation in the metastatic setting is more difficult in terms of how old the patient is, what her performance status is and whether she is having symptoms. A few years ago, the Southwest Oncology Group was trying to do a trial with two different paclitaxel arms for patients who were symptomatic or asymptomatic.

The asymptomatic arm closed very quickly because there were so many patients who relapsed with relatively asymptomatic disease. This gets to an interesting point: I've recently seen several women with metastatic breast cancer recurrences who have been diagnosed by laboratory, a chest X-ray or something that another physician did to get the test result. These patients were not symptomatic and not feeling poorly. In these cases you are left with the decision of how bad should you make the patient feel to get rid of some tumor to potentially prolong life?

So you sit down and you talk with patients about where they want to be and what they want to do. Some older patients have very short-term goals like living to see a grandchild or to watch somebody get married.

These patients are sometimes easier to work with than those with longer-term goals. I saw a woman the other day who was 47 years old with little girls in junior high school. Her goals were probably unrealistic, but her main focus every day was preventing her family's life from being disrupted by her illness.

DR LOVE: What is it like to take care of a 47-year-old woman who has a couple of teenage kids and an extremely serious, noncurable problem? How do you deal with it as an oncologist?

DR GREENBERG: Personally, the first thing I do is talk with the patient to get a sense of what is important to her. Many times she will want to be able to spend time with her children. Generally I have found that patients fall into two populations. One population says, "I want to live, and I don't care what I have to do."

They will walk on hot coals for you, if you think it will buy them one more week. The other population says, "I'm not having that much of a problem now, so just keep me comfortable and don't disrupt my quality of life. Let me enjoy my family because I don't think you're going to cure me."

You need to discuss what the realistic chances are that you're going to tremendously impact their survival and balance that against what they will have to go through to get what benefit. I think that's an important discussion to have.

DR LOVE: Dr Theodoulou, how does the doctor deal with it, personally.

DR THEODOULOU: One of the things I encountered when I was going through my fellowship was the whole concept of being comfortable with death and dying, and that you are never going to get bonus points or a pat on the back for successfully treating a patient, because that patient will eventually die in your care.

It's important to really identify what your comfort level is. Personally, I'm very comfortable in the arena of death and dying. I knew it as a medical student, an intern and a fellow. I come from an environment where family members die at home with their families around them, so I was never uncomfortable in that situation.

Due to the sadness of it, I don't think this is the kind of work that you can ever leave behind at the office. But we have to be very careful not to let one patient experience -even if it's a devastating or tragic one -influence the next patient experience that we have the following day or the next week.

I don't think there are enough venues like this one where we talk to one another. How many times do we talk about how recently we cried, felt guilty, felt frustrated, felt failure or felt like, "Boy, that was a successful death, and thank God I was around to do something good"? I try to open up these types of discussions at the end of the day with my fellows because it is really a huge topic that needs to be addressed more often.

DR RAJDEV: I actually find that young women with metastatic disease are more complex with more emotional issues. Older people are more resigned to dying, whereas younger women, particularly those who have children, have a harder time. I think younger patients with very advanced disease are more demanding on oncologists, at least to me they are.

I had a patient who was in her fifties and didn't want to die before seeing her daughter get married. Every time I went on vacation, she got sick. She started telling me not to go on vacation. Then, she passed away. Later on, I can recall one time when I was about to go on vacation when suddenly, she came back to me. It was like she was telling me again not to go on vacation. I think oncologists are affected, but you have to pick up and move on. It is a way of life, but patients do have an impact on you.

DR LOVE: How do you personally cope with these kinds of things?

DR RAJDEV: It's hard to brush off people. You realize that these are such important issues that you just sort of make the time and talk to patients about them. You can actually see that the more you treat them, the greater confidence they tend to have in you. They develop a rapport with you, even on a social basis, and the more you treat them the more you learn about their lives.

DR LIPSHUTZ: As oncologists I think we're all very different, just like people are in general. I think we have different psychological makeups, backbones and ways we cope.

Personally, I think hospice was a major advance that has allowed oncologists to continue to practice oncology. In the days before hospice, we used to spend too much time taking care of dying people, and the futility of it from a medical oncology standpoint would be frustrating.

I have hobbies and interests that help me divorce myself from the practice of medicine. I am able to move away from it, and yet devote 100 percent of my attention when I'm in the office. I can make that separation, go home and not think about what's going on until the next day when the next problem arises. Friends, family and neighbors call you all the time and ask you for help or advice, so you're really never away from it even on vacation, but I think you need some other interests.

DR LOVE: Dr Bilsky, would you present your case?

DR BILSKY: This patient is an otherwise healthy 63-year-old who looks like she's 53. In June of 2002, she presented with a large, crusted ulcerating right breast lesion and a palpable right supraclavicular lymph node. The work-up revealed bone metastases on bone scan, but she had no bone pain. Her CAT scans failed to reveal any areas of visceral disease in her chest or abdomen. Her breast biopsy revealed ER-positive, HER2-negative, infiltrating ductal carcinoma. Her performance status was excellent and her past medical history was essentially benign.

DR LOVE: Did you have the feeling that she neglected this breast lesion?

DR BILSKY: Oh, yes. She is an intelligent lady. She is a divorcee with a very supportive daughter. I think she was more concerned about being a mother to her daughter and trying to protect her daughter from the idea that this might be a serious significant illness than she was about her own mortality.

DR LOVE: What were you thinking at that point?

DR BILSKY: After the biopsy I knew what her status was pathologically, and I really wanted to just get rid of this horrible right-breast lesion. I treated her fairly aggressively and started her on pamidronate and six courses of docetaxel and doxorubicin. She responded beautifully. The right breast lesion and the ulceration absolutely dried up and the crusting disappeared. Her right supra-clavicular lymph node became barely palpable.

In December of that year, I switched her to maintenance letrozole. I never recommended radiation therapy. I felt that I had controlled the primary tumor pretty well systemically, and I was concerned that the amount of radiation therapy she would require might cause radiation-induced vasculitis that would have been a problem - particularly if she were to ulcerate again.

DR LOVE: I want to go back to your decision to use combination chemotherapy and ask Skip Burris how he would have thought through this case, because another alternative would have been to try hormonal therapy first and see what would happen.

DR BURRIS: I would have probably gone with the same approach as Dr Bilsky. In situations where you can see a tumor like this one in front of you, I think the goal is usually to get rid of it as quickly as possible. In Europe and other parts of the world, hormonal therapy certainly would have been considered. I know that the BCIRG has been trying to get some neoadjuvant hormonal therapy trials rolling, but our doctors in

Nashville didn't think they would ever enroll a patient in that type of study. I don't know if the trial is still moving forward - maybe it's more of an American reaction.

I think docetaxel and doxorubicin are two very active drugs, and the odds of responding are 60, 70, 80 percent and up. Within two or three treatments you're going to have a dramatic response, so I think that was a very logical approach. It's probably what I would have done.

DR LOVE: She is in good condition and this is not an emergent situation, but she does have a disturbing breast lesion. Maria, what about neoadjuvant endocrine therapy?

DR THEODOULOU: I think hormonal therapy is the foundation of our treatment and the gold standard in metastatic disease. But hormonal therapy is slow. It doesn't kick in for three, four or five weeks; sometimes it takes two months or even 10 weeks. Here we have a fairly significant ulceration and a crusted lesion that's going to be amenable to infection and oozing, which could make it all the more difficult to treat.

I probably would have been inclined to use chemotherapy for local control, and then once I got the response I needed, switched over to hormonal therapy. I have used hormonal therapy in Stage IV de novo locally advanced breast cancer, but this is the kind of lesion that would have pushed me to treat with chemotherapy.

SOURCE: Nabholtz JM. Docetaxel-anthracycline combinations in metastatic breast cancer. Breast Cancer Res Treat 2003;79(Suppl 1):3-9. Abstract

SOURCE: Nabholtz J-M et al. Docetaxel and doxorubicin compared with doxorubicin and cyclophosphamide as first-line chemotherapy for metastatic breast cancer: Results of a randomized, multicenter, Phase III trial. J Clin Oncol 2003;21(6):968-75. Abstract

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