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Case history

image A 53-year-old woman with metastatic breast cancer presented to hospital with worsening back pain and suicidal ideation. She had recently contacted the breast care nurses and her GP several times with non-cardiac chest pain, severe anxiety attacks and other non-specific symptoms. She had no other medical illnesses apart from depression, for which citalopram and diazepam had been prescribed. She was still working as a chief flight attendant. She was divorced and lived alone, but had a good relationship with her mother and a few close friends.

The patient was initially diagnosed with oestrogen receptor (ER)-positive human epidermal growth factor receptor 2 (HER2)-negative left breast carcinoma at age 38 years. Although radically treated, she subsequently relapsed with multifocal ipsilateral breast carcinoma 12 years later. Unfortunately, 2 years after her second adjuvant treatment, she developed metastatic liver and bone disease. She then progressed through four lines of treatment in short succession: tamoxifen; fulvestrant and a protein kinase B (Akt) inhibitor (Fulvestrant Akt Inhibition in Advanced Aromatase Inhibitor-Resistant Breast Cancer [FAKTION] trial); capecitabine; and everolimus and exemestane. She was devastated to learn about her most recent progression and did not turn up to any clinic appointments or engage with any members of her oncology team. She wanted to run away from facing her advanced, progressing disease. She feared further chemotherapy would disfigure her and make her look ill, and she would therefore lose her professional identity. This was compounded by her recent relationship breakdown and the news that her best friend had died of breast cancer. She also started having flashbacks of her two maternal aunts dying painfully from breast cancer in their forties. She felt overwhelmed. Indeed, she had formed plans on how she would commit suicide and considered Dignitas, but had been held back by the thought of hurting her loved ones.

During this acute admission, she was hypercalcaemic and had worsening liver function. She was managed medically and was urgently seen by the psychooncology team. She had a prolonged hospital stay and, after much consideration, decided to proceed with paclitaxel, with major input and support from the breast and palliative care nurses. At last follow-up, she had an excellent partial response to treatment and began coming to terms with her diagnosis.

What is the evidence behind recommending second and subsequent lines of chemotherapy in metastatic breast cancer?

What can you do if a patient decides not to have any further treatment?

Is there any practical guidance in managing patients with advanced, progressing disease?

Is there evidence for earlier supportive and palliative care in metastatic breast cancer?

How common is suicidal ideation and thoughts of euthanasia among patients with metastatic cancer?

What is the legal position regarding euthanasia in cancer patients in the UK?

What is the evidence behind recommending second and subsequent lines of chemotherapy in metastatic breast cancer?

Despite the remarkable progress seen in breast cancer treatments over the past 30 ...

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