Elsevier

The Breast

Volume 22, Issue 5, October 2013, Pages 616-627
The Breast

Review
Supportive and palliative care for metastatic breast cancer: Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

https://doi.org/10.1016/j.breast.2013.07.052Get rights and content

Abstract

Many women diagnosed with breast cancer in low- and middle-income countries (LMICs) present with advanced-stage disease. While cure is not a realistic outcome, site-specific interventions, supportive care, and palliative care can achieve meaningful outcomes and improve quality of life.

As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert international panel identified thirteen key resource recommendations for supportive and palliative care for metastatic breast cancer. The recommendations are presented in three resource-stratified tables: health system resource allocations, resource allocations for organ-based metastatic breast cancer, and resource allocations for palliative care. These tables illustrate how health systems can provide supportive and palliative care services for patients at a basic level of available resources, and incrementally add services as more resources become available.

The health systems table includes health professional education, patient and family education, palliative care models, and diagnostic testing. The metastatic disease management table provides recommendations for supportive care for bone, brain, liver, lung, and skin metastases as well as bowel obstruction. The third table includes the palliative care recommendations: pain management, and psychosocial and spiritual aspects of care.

The panel considered pain management a priority at a basic level of resource allocation and emphasized the need for morphine to be easily available in LMICs. Regular pain assessments and the proper use of pharmacologic and non-pharmacologic interventions are recommended. Basic-level resources for psychosocial and spiritual aspects of care include health professional and patient and family education, as well as patient support, including community-based peer support.

Section snippets

Supportive and palliative care for metastatic breast cancer

Many women diagnosed with breast cancer in low- and middle-income countries (LMICs) present with advanced metastatic disease, or they may present with locally advanced disease and undergo treatment with curative intent but nonetheless develop metastases. Common sites for breast cancer metastases are bone, brain, liver, and lung; less common sites are intra-abdominal and skin. Cure is not usually a realistic treatment outcome for metastatic disease[1], but site-specific interventions (aimed at

Defining “supportive care” and “palliative care”

The terms “supportive care” and “palliative care” are sometimes used interchangeably[3]. However, supportive care in cancer is the prevention and management of the adverse effects of cancer and its treatment. This includes management of physical and psychological symptoms and side-effects across the continuum of the cancer experience from diagnosis through anticancer treatment to post-treatment care. Enhancing rehabilitation, secondary cancer prevention, survivorship and end-of-life care are

Existing evidence and guidelines

Evidence-based breast cancer clinical guidelines for treatment of metastatic breast cancer from international organizations[6], high-income countries (HICs)[7], [8] and LMICs[9], [10], all recommend supportive/palliative care as part of metastatic breast cancer care. These guidelines expand the concept of palliative care, previously limited to end-of-life care, to include supportive care offered concurrently with curative or life-prolonging treatments for patients with all stages of cancer.

BHGI Global Summit and expert panel consensus process

All three BHGI supportive care consensus statements provide recommendations for breast cancer supportive care program implementation in LMICs. Methods developed by the BHGI for the structured creation of evidence-based, 4-tier resource-stratified guidelines and consensus statements (see Table 1) have been previously described[21], [22]. A systematic literature review was performed in preparation for the 5th BHGI Global Summit, which was held in association with the International Atomic Energy

Key resources needed for supportive care with metastatic disease

The expert international panel identified thirteen key resource recommendations for supportive and palliative care for metastatic breast cancer. The recommendations are presented in three sections 1) health systems resource allocations; 2) resource allocation for organ-based metastatic disease management; and 3) resource allocations palliative care. In each section, a description of a resource category is followed by resource-stratified consensus panel recommendations. Recommendations are also

Special concerns and emerging issues in LMICs

Communication skills for end-of-life care: Effective communication between patients and health professionals has been associated with patient satisfaction with care at end-of-life[119]. However, many health professionals feel that they lack appropriate training to deal with end-of-life issues[120]. In that regard, many oncologists report the communicating of poor prognosis as one of the most challenging and stressful aspects of their profession[121]. Education about effective patient

Discussion

This consensus statement expands on the 2008 BHGI guidelines for resource-stratified treatment of site-specific metastases of breast cancer and palliative care[141]. Palliative care requires interdisciplinary care teams to address physical, psychosocial, and spiritual needs of breast cancer patients and their families. Interdisciplinary teams should include pharmacists, psychologists and psychiatrists, nurses, social workers and spiritual caregivers, with access to the services of

Panel members

Benjamin O. Anderson (BHGI Director, USA), Mohammad A. Bushnaq (Jordan), Rolando Camacho-Rodriguez (Summit Co-chair, Cuba), James Cleary (Co-chair, USA), Joe N. Clegg-Lamptey (Ghana), Stephen R. Connor (USA), Henry Ddungu (Co-chair, Uganda), Msemo B. Diwani (Tanzania), Alexandru Eniu (Romania), Margaret Fitch (USA), Julie R. Gralow (Summit Co-chair, USA), Sudhir Gupta (India), Joe B. Harford (USA), Suresh Kumar (India), Gertrude Nakigudde (Uganda), Mati N. Nejmi (Morocco), M.R. Rajagopal

Conflict of interest statement

BOA received consulting compensation from GE Healthcare and Navidea Biopharmaceuticals. JC received consulting/grant/research support from Procertus, grant/research support from Amgen, and was on the data safety and monitoring committee for KangLaiTe. MN received consulting support from Sanofi-Aventis. All other authors and panel members reported no potential conflict of interest.

Financial Acknowledgments

BHGI received (2012 Global Summit) grants and contributions from Fred Hutchinson Cancer Research Center, Susan G. Komen for the Cure® (Contract ID: INT-3063.0/Tracking No: 221664); International Atomic Energy Agency Programme of Action for Cancer Therapy, National Cancer Institute, The Lancet Oncology, Elsevier, American Society of Clinical Oncology, Sheikh Mohammed Hussein Al-Amoudi Center of Excellence in Breast Cancer, Pan American Health Organization, European Society of Medical Oncology,

References (146)

  • S. Lutz et al.

    Palliative radiotherapy for bone metastases: an ASTRO evidence-based guideline

    Int J Radiat Oncol Biol Phys

    (2011)
  • C.I. Ripamonti et al.

    Decreased occurrence of osteonecrosis of the jaw after implementation of dental preventive measures in solid tumour patients with bone metastases treated with bisphosphonates. The experience of the National Cancer Institute of Milan

    Ann Oncol

    (2009)
  • C.I. Ripamonti et al.

    Efficacy and safety of medical ozone (O(3)) delivered in oil suspension applications for the treatment of osteonecrosis of the jaw in patients with bone metastases treated with bisphosphonates: preliminary results of a phase I-II study

    Oral Oncol

    (2011)
  • M.S. Aapro et al.

    Bone health management in patients with breast cancer: current standards and emerging strategies

    Breast

    (2012)
  • M. Aapro et al.

    Guidance on the use of bisphosphonates in solid tumours: recommendations of an international expert panel

    Ann Oncol

    (2008)
  • C.I. Ripamonti et al.

    Management of malignant bowel obstruction

    Eur J Cancer

    (2008)
  • D.J. Feuer et al.

    Systematic review of surgery in malignant bowel obstruction in advanced gynecological and gastrointestinal cancer. The Systematic Review Steering Committee

    Gynecol Oncol

    (1999)
  • B. Pothuri et al.

    Percutaneous endoscopic gastrostomy tube placement in patients with malignant bowel obstruction due to ovarian carcinoma

    Gynecol Oncol

    (2005)
  • C. Ripamonti et al.

    Role of octreotide, scopolamine butylbromide, and hydration in symptom control of patients with inoperable bowel obstruction and nasogastric tubes: a prospective randomized trial

    J Pain Symptom Manage

    (2000)
  • B.C. Pestalozzi et al.

    Identifying breast cancer patients at risk for central nervous system (CNS) metastases in trials of the International Breast Cancer Study Group (IBCSG)

    Ann Oncol

    (2006)
  • J.C. Flickinger et al.

    A multi-institutional experience with stereotactic radiosurgery for solitary brain metastasis

    Int J Radiat Oncol Biol Phys

    (1994)
  • D. Elias et al.

    Surgery for liver metastases from breast cancer

    HPB: The Off J Int Hepato Pancreato Biliary Assoc

    (2006)
  • C. Ludwig et al.

    Disease-free survival after resection of lung metastases in patients with breast cancer

    Eur J Surg Oncol

    (2003)
  • M.H. van den Beuken-van Everdingen et al.

    Prevalence of pain in patients with cancer: a systematic review of the past 40 years

    Ann Oncol

    (2007)
  • M. Meldrum

    The ladder and the clock: cancer pain and public policy at the end of the twentieth century

    J Pain Symptom Manage

    (2005)
  • M. Nejmi et al.

    Validation and application of the Arabic version of the M. D. Anderson symptom inventory in Moroccan patients with cancer

    J Pain Symptom Manage

    (2010)
  • M. Chinda et al.

    Reliability and validity of a Thai version of the Edmonton symptom assessment scale (ESAS-Thai)

    J Pain Symptom Manage

    (2011)
  • G. Mitera et al.

    Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the Pain Management Index

    Pain Symptom Manage

    (2010)
  • D.F. Haugen et al.

    Assessment and classification of cancer breakthrough pain: a systematic literature review

    Pain

    (2010)
  • K. Mystakidou et al.

    Greek McGill Pain questionnaire: validation and utility in cancer patients

    J Pain Symptom Manage

    (2002)
  • D. Rayson et al.

    Transitions to palliation: two solitudes or inevitable integration?

    Curr Oncol Rep

    (2007)
  • F.D. Ferris et al.

    Palliative cancer care a decade later: accomplishments, the need, next steps – from the American Society of Clinical Oncology

    J Clin Oncol

    (2009)
  • D. Hui et al.

    Concepts and definitions for “supportive care”, “best supportive care”, “palliative care”, and “hospice care” in the published literature, dictionaries, and textbooks

    Support Care Cancer

    (2013)
  • European Association for Palliative Care (EAPC)

    White paper on standards and norms for hospice and palliative care in Europe: Part 1

    Eur J Pall Care

    (2009)
  • WHO. Palliative care: World Health Organization. Available from:...
  • NCCN. National Comprehensive Cancer Network

    Breast Cancer

    (2013)
  • E. Grunfeld et al.

    Clinical practice guidelines for the care and treatment of breast cancer: follow-up after treatment for breast cancer (summary of the 2005 update)

    CMAJ

    (2005)
  • A. Munshi et al.

    Guidelines for locoregional therapy in primary breast cancer in developing countries: the results of an expert panel at the 8th Annual Women's Cancer Initiative – Tata Memorial Hospital (WCI-TMH) Conference

    Indian J Med Paediatr Oncol

    (2012)
  • O. Shamieh et al.

    Modification and implementation of NCCN guidelines on palliative care in the Middle East and North Africa region

    J Natl Compr Canc Netw

    (2010)
  • G. Miccinesi et al.

    Palliative home care reduces time spent in hospital wards: a population-based study in the Tuscany region, Italy

    Cancer Causes Control

    (2003)
  • J. Gaertner et al.

    Facilitating early integration of palliative care into breast cancer therapy. Promoting disease specific guidelines

    Breast Care

    (2011)
  • C. McNeil

    Can guidelines be integrated into everyday practice? The NCCN in year 4. National comprehensive cancer network

    J Natl Cancer Inst

    (1999)
  • J. Gaertner et al.

    Integrating palliative medicine into comprehensive breast cancer therapy – a pilot project

    Breast Care

    (2011)
  • M.H. Levy et al.

    NCCN clinical practice guidelines in oncology: palliative care

    J Natl Compr Canc Netw

    (2009)
  • B.O. Anderson et al.

    Breast cancer in limited-resource countries: an overview of the Breast Health Global Initiative 2005 guidelines

    Breast

    (2006)
  • M.A. Murray et al.

    Nurses' perceptions of factors influencing patient decision support for place of care at the end of life

    Am J Hosp Palliat Care

    (2009)
  • Z. Liao et al.

    Assessment of cancer pain management knowledge in southwest China: a survey of 259 physicians from small city and county hospitals

    J Palliat Med

    (2013 Jun)
  • T. Luckett et al.

    Australian survey of current practice and guideline use in adult cancer pain assessment and management: perspectives of oncologists

    Asia Pac J Clin Oncol

    (2012 Dec 17)
  • M. Silvoniemi et al.

    Physicians' self-assessment of cancer pain treatment skills–more training required

    Support Care Cancer

    (2012)
  • J. Jeba et al.

    Pain assessment and analgesic prescription for cancer patients in a medical ward: the influence of an educational intervention

    Natl Med J India

    (2009)
  • Cited by (39)

    View all citing articles on Scopus

    This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

    View full text