Palliative care in metastatic carcinoma breast

Lets start with a story…
• Mrs Sundari, 33yr old home maker, premenopausal, HBsAg +ve
mother of two young children (4y, 9y), from samasthipur, Bihar
• Diagnosed with carcinoma breast in July, 2019 while she was 4
months pregnant with her 3 rd child
• It was an advanced disease at presentation CT4N3M0, TNBC planned
for MTP NACT  Sx RT  adj CT
• While on RT she developed seVere pain left shoulder
• PET CT suggested florid metastatic disease involving liver, lung, local
LN
• MBC

Palliative Management of
Metastatic Carcinoma Breast
Presenter : Dr Ruparna Khurana
Moderator : Dr Seema Mishra

Overview
• Basic numbers
• Palliative care needs – symptom burden
• Management strategies
• Palliative core issues -:
• Lymphoedema
• Malignant wound
• Psychological issues
• Conclusion

Important Topics (alas!)
• Advanced Care Planning
• End of Life Care
• Bereavement Care
• Pain/other symptom management (MSCC, MBO)
(Opioids/steroids)

Global incidence and mortality

• Globally, breast cancer is the second most frequently diagnosed
malignancy just behind lung cancer
• Accounts for over two million cases each year
• Up to 30% of women originally diagnosed with early breast cancer
will eventually progress to metastatic breast cancer
• 5-10% of women present with primary metastatic disease at initial
diagnosis.
• Over 90% of deaths are due to distal metastasis

Indian data
• Breast cancer ranks as number one cancer among Indian females with
rate as high as 25.8 per 100,000 women and mortality of 12.7 per
100,000 women
• According to estimates, at least 17,97,900 women in India may have
breast cancer by 2020.
AIIMS PCU Data (2019)
149 out of 814 admitted female patients

• The American Cancer Society (ACS) states that the five-year
survival rate after diagnosis for people with stage 4 breast cancer
is 22 percent
Median survival : 19 months 1980
20 months in 1990
23 months in 2000
31 months in 2010
• Better screening tools/ systemic therapies including hormonal and
targeted therapies

Sites of Metastasis in different breast cancer
subtypes

Overview
• Incidence , epidemiology , survivial
lymphoedema
Malignant wound
Psychological issues
Bone mets

Breast Cancer - Targets and
Therapy 2018:10 231–243

Symptom
burden
Physical
Social
Psycholog
ical
Spiritual
Financial
/ Logistics
Treatment related Disease related
Local or Locoregional
Distal
• Pain
• Malignant non healing wound
• Bleeding
• Lymphoedema
• Swelling
Brain
• Seizures
• Personality
• Paraesthesia
• Paralysis
Bone
• Pain
• MSCC
• Fractures
Liver
• Jaundice
• Pruritis
• Ascites
• Anorexia
• Vomiting
• Elevated
enzymes
Peritoneum
Lung
• Dyspnoea
• Haemoptysis
• Cough
Cost of treatment
Cost of hospitalization
Repeated visits to
hospital
Investigation cost
Existential crisis
Meaning of life
Hopelessness
Anxiety
Depression
Worries
Adjustment disorder

Treatment complications
CINV
CIPN
Neutropenia
Alopecia
cardiotoxicities
Mucositis
Dermatitis
Diarrhoea/ constipation
Fatigue/ malaise
Body disfigurement
Body image issues

Overview
• Incidence , Epidemiology , Survivial
• Palliative care needs – Symptom Burden
• Disease Trajectory
• Palliative Core Issues -:
Lymphoedema
Malignant wound

Management
Cancer directed therapies Palliative treatment
• Palliative chemotherapy
• Endocrine therapy
• Targeted therapy Pharmacotherapy and non pharmacotherapy
• Palliative RT
(medication, nutritional changes, relaxation techniques,
emotional and spiritual support)

Overview
• Incidence , Epidemiology , Survivial
• Palliative care needs – Symptom Burden
• Disease Trajectory
• Management Strategies
• Palliative Core Issues -:
Lymphoedema
Malignant wound
Bone mets

CASE VIGNETTE
• Mrs Sundari…
• Presents to Palliative care OPD with chief complaints of
• Swelling of the left upper limb of 2 months duration
• Pain in the upper limb of two months duration
• Restricted range of movement since one month

Lymphedema
• Lymphedema : interstitial collection of protein-rich fluid due to
disruption of lymphatic flow.
• Lymphatic load exceeds the transport capacity of the lymphatic
system, causing filtered fluid to accumulate

Incidence of Lymphedema
• Incidence : 17 percent
• Post Surgery : 30%
• Surgery + RT : 40%
• Some studies report : 60%

Differential diagnosis of Lymphedema
• Deep vein thrombosis (related to central venous access)
• Trauma
• Disease recurrence
• Lymphangitis carcinomatosa

Goals of management Lymphedema
• Reduction in pain
• Reduction in swelling
• Improvement in range of movement
• Improvement in QOL
• Independence in ADL

Management Lymphedema
Prophylactic
Education
Exercises :
Stretching,
Strengthening
Pain
management
Therapeutic
Education
Exercises :
Stretching,
Strengthening
Pain
management
Complete
decongestive
therapy
Prevention is
better than cure

Therapeutic management of Lymphoedema
Patient education
Explain the cause and prognosticate
General self-care measures 
Limb elevation (Positioning operated arm above the level of heart)
Gentle exercises
 Skin and nail care
 No cannulation/ BP measurement
 Avoid trivial trauma
 Keep the skin hydrated
 Protein rich diet

Pain management

Complete Decongestive Therapy
Phase I : Intensive Phase
Phase II : Maintenance phase

Contra- indications
Absolute Contraindication
• Active cellulitis
• Inflammation
• Moderate to severe heart failure
• Acute deep vein thrombosis
Relative contraindications
• Uncontrolled hypertension
• Diabetes mellitus
• Asthma
• Paralysis

PHASE 1 : Intensive phase
• Treatments are administered on a daily basis until the affected body part is
decongested.
• 2- 3 weeks for UL
• 6-8 weeks in severe cases

Phase 1

Manual Lymph Drainage
Goal : re-route the flow of lymphatic fluid back into the
venous system.

Exercises
• Maintaining flow of lymph.
• Increasing the mobility of joints.
• Maintaining muscle strength.
• Controlling weight.
Method:
• Begin with deep breathing.
• Wear compression bandaging while doing
exercises.
• Each exercise is to be repeated 10 -15
times/session and 3-4 sessions/day

b
Shoulder shrugs shoulder rolls shoulder blade
squeeze

Fist clench active finger
movements

Phase 2
Circumferential readings plateau PHASE 2

Self Manual Lymph Drainage
• Technique taught to patient.
Stimulate contralateral axillary LN and ipsilateral
inguinal LN

Compression Garments
• To maintain the results of phase 1
• To avoid recurrence
• They should be used throughout the day and
removed during night.
• To be worn while doing exercises, during air
travel.
• Need to be changed after 6 months

Compression sleeve Gauntlet
compression stockings

• Mrs Sundari…
• Color doppler : rule out DVT
• Etiology : ALND + RT + local recurrence + obesity
• Stage III (skin fibrosis + shoulder and elbow lock)
• Patient education : limb elevation , skin care, exercises
• Manual lymphatic drainage
• Compression stockings

OVERVIEW
• Incidence , epidemiology , survivial
• Disease trajectory
lymphoedema
Malignant wound

Mrs Sundari
• Her lymphoedema was stable
• She developed a fungating wound over her left breast
• Serosanguinous discharge
• Occasional bleeding
• Pain over the entire chest region

CARE OF MALIGNANT WOUNDS
Wound edge Wound
corner
Surface of
the wound
Base of the wound
Cross section of a simple wound
Skin surface
Subcutaneus tissue
Superficial fascia
Muscle layer
Base of the wound
Wound edge
Surface of
the wound
Wound
cavity

• Present major treatment challenges
• Itching
• Painful exudates
• Infection
• Odor
• Social Stigma
• Distress

ASSESSMENT TOOLS
1.Bates Jensen Wound Assessment Tool
2.Toronto Symptom Assessment System for Wounds
4.Wound Symptoms SelfAssessment Chart
5.Hopkins Wound Assessment Tool
6.TELER System
3.Schulz Malignant Fungating Wound Assessment Tool

OTHER TOOLS ITEMS
1.Toronto Symptom Assessment System
for Wounds
Wound-related symptoms, Psychosocial aspects
2.Schulz Malignant Fungating Wound
Assessment Tool
General information about the patient
wound : location, dimensions, shape, appearance of peri-wound skin,
location of oedema, tissue type
questions to assess patients’ perceptions
3.Wound Symptoms Self Assessment
Chart
Wound-related symptoms ,mood, anxiety, alertness, attitudes,
functional abilities and severity of clinical symptoms
4.Hopkins Wound Assessment Tool Wound-classifications (wound colour, hydration, drainage, pain,
odour, tunnelling/undermining).

53
The less is the score , more healthy is the tissue

Components of Wound care
Initial management : debridement and proper wound dressings
• Nonadherent dressings to reduce bleeding and pain
• Special dressings : foams, alginates, or starch copolymers
• Reduce need for frequent dressing changes
Odor : interval mechanical debridement, decrease microbial bioburden on wound surface
• Dressings that incorporate topical metronidazole, hydro foam, Silvers
sulfadiazine, or medicinal honey
Oozing: topical hemostatic agents such as gelatin (Gelfoam) or collagen (Helistat) can be
applied
Gauze saturated with adrenaline or sucralfate paste (1 g sucralfate tablet in 5 mL of water-
soluble gel

Mepilex Ag
• An absorbent, atraumatic polyurethane foam dressing
• The outer surface : vapour-permeable polyurethane membrane,barrier
to liquid and microorganisms including viruses
• The membrane has a wrinkled appearance to accommodate swelling
that occurs as the dressing absorbs exudate
• The foam contains a silver salt : antimicrobial action
• Effect : detectable within 30 minutes and lasts for up to 7 days
• The wound contact surface : coated with soft silicone that makes it non
adherent

Mrs Sundari
• Listened and reassured
• Started her on oral morphine 10mg half tab 4 hrly
• Tab Metrogyl 400 mg thrice a day
• Tab Traneximic acid 500mg thrice
• RT consultation (hemostatic RT)
• Wound care team : mapilex silver dressings

OVERVIEW
• INCIDENCE , EPIDEMIOLOGY , SURVIVIAL
• PALLIATIVE CARE NEEDS – SYMPTOM BURDEN
• DISEASE TRAJECTORY
• MANAGEMENT STRATEGIES
• PALLIATIVE CORE ISSUES -:
LYMPHOEDEMA
MALIGNANT WOUND
PSYCHOLOGICAL ISSUES

Evaluation and management of
common psychological symptoms

• Mrs SUNDARI..
• Spent most of her last few years in the hospital for treatment.
• This time in OPD she appears irritable
• On interviewing she tells about her fear of not being able to make it
because of her advanced disease.
• She has palpitations and excessive sweating when she is talking
about her disease

• She also reports that pain is worse when she is due for next scan to
monitor her disease process
• She has disturbed sleep and feels inability to relax at home
• For the last few months she does not feel like interacting with
family members as it makes her more worried about her illness
• Missed a couple of Chemotherapy sessions due to anxiety

Psychological issues in MBC
Common psychological
syndromes
Anxiety Fear
Sadness /
Depression
Adjustment
disorder
Insomnia Distress
Psychosomatic
manifestations
of stress

• Anxiety is endemic among patients with advanced breast cancer
• Commonly coexists with depressive symptoms
• Anxiety has many expressions and identifiable themes that are
related to their cancer experience

Management
• Benzodiazepines
• SSRIs (Antidepressants)
• Antipsychotics
Pharmacological
interventions
• CBT
• Supportive psychotherapy
• Breathing exercises
Non
Pharmacological
interventions

Drugs used for anxiety in Terminal cancer
Benzodiazepines
• Lorazepam, alprazolam, and
oxazepam (Short acting and
safest)
• Diazepam or clonazepam
breakthrough anxiety/end
of dose failure
• Midazolam (very short
acting): anxiety and
agitation in terminal phases
SSRIs
• For patients with comorbid
depressive symptoms
• Escitalopram
• Sertraline
• For somatic symptoms
(Sleep and appetite)
• Mirtazipine
• Be cautious of
hyponatremia, loose stools
Antipsychotics
• Olanzapine or Quetiapine
• For patients with
persistent symptoms
• For agitation and
irritability not responding
to other two class of
drugs
• Caution: Excessive sedation

Consideration for Initiating Pharmacotherapy
• Patient’s subjective level of distress leading to impairment in daily
life activities
• Problematic patient behaviors such as noncompliance
• Balancing of the risks and benefits of treatment
• Usually administered in conjunction with non pharmacological
interventions

Psychotherapy
• Supportive psychotherapy and behavioral interventions
• Brief supportive psychotherapy
• Crisis-related issues
• Existential issues
• Explore issues of fears, loss, and the unknown that lies ahead
• Help facing illness and treatment with sense of self worth
• Establishes a bond
• Reassure

Remember Mrs Sundari !!
Anxiety
• Interfering with treatment
• Causing significant distress
Supportive psychotherapy session taken
• Listened
• Reassured
• Provide realistic hope
Psychiatric Consult
• Escitalopram 5 mg plus Lorazepam ½ mg twice a day started

Depression
• Less prevalent than anxiety
• Commonly underreported
• More common in family and past history of depression
• Iatrogenic : corticosteroids, hormonal therapies, and whole brain
radiation

DSM 5 Criteria
• At least 5 symptoms
• Present for atleast 2 weeks
• One of them should be
 low mood
Loss of interest/ pleasure

DSM 5
1. Depressed mood – most of the day, nearly every day
2. Markedly diminished interest/ pleasure
3. Significant weight loss (more than 5% in one month)
4. Insomnia / hypersomnia
5. Psychomotor agitation/ retardation
6. Loss of energy
7. Worthlessness/ guilt
8. Inability to think or concentrate
9. Recurrent thoughts of death

Management
• SSRIs (Drug of choice)
• serotonin–norepinephrine reuptake inhibitor: venlaflaxine
• Serotonin-2 antagonists: trazodone
• TCAs
Pharmacological
interventions
• CBT
• Individual
• Group
• Managing Existential issues
Non
Pharmacological
interventions

Pharmacotherapy
SSRIs (Mainstay)
• Major side effects :
loose stools, nausea,
vomiting, insomnia,
headaches, and sexual
dysfunction
• Some may experience
anxiety, tremor, and
restlessness during
initiation
TCA
• Preferred for patients
with agitation and
insomnia
• Anticholinergic side
effects including
constipation, dry
mouth, urinary
retention
Psychostimulants :
methylphenidate
• Rapid onset of action
• Stimulate appetite,
promote a sense of
well-being

Existential suffering
Present
• Concerns of personal integrity and identity
• Changes in body image
• intellectual, social, and professional function
Past
• Profound disappointment from unfulfilled aspirations
• Remorse from unresolved guilt/ matters
Future
• Anticipation of the future : feelings of hopelessness, futility, or meaninglessness
• See no value in continuing to live

Dealing with Existential issues
• Acknowledge these feelings
• Allow ventilation
• Even in the setting of advanced cancer, hope remains important

Realistic hope…
• Hope for time
• Hope for freedom from discomfort
• Hope to maximize the quality of one’s life
• Hope that one’s loved ones will cope with the time ahead
• Hope that in the end, there will be satisfaction with what has been achieved
• Hope for a peaceful death without suffering or indignity

Conclusion
• MBC makes up 5-10% of all diagnosed Breast cancers and has upto 90 %
mortality
• High symptom burden with physical, social, psychological, emotional and
spiritual components
• Palliative care is the cornerstone of management in MBC
• Reassurance, acknowledgement of feelings and realistic hope … is all that the
patients are looking for

Palliative care in metastatic carcinoma breast

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