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Case history

image A 54-year-old woman presented with a history of anorexia and fatigue. Seven years previously, she had had a diagnosis of right breast invasive ductal carcinoma, T2 (35 mm), grade 3, N1 (1/11), oestrogen receptor (ER) 75%, progesterone receptor (PR) 24%. Human epidermal growth factor receptor 2 (HER2) was not assayed at that time. She had undergone a right mastectomy and axillary node clearance, followed by adjuvant chemotherapy with epirubicin, cyclophosphamide, methotrexate and fluorouracil, and adjuvant endocrine therapy with tamoxifen. A restaging CT scan confirmed liver metastasis and chest wall recurrence. Biopsy of the chest wall lesion confirmed invasive ductal carcinoma grade 2, ER 7, PR 0, HER2 2+, fluorescence in situ hybridization (FISH)-negative. Her liver function test showed mild transaminitis. She was still on tamoxifen at the time of relapse. The patient was well with performance status (PS) 1. Discussions took place about the palliative nature of any treatment that might be considered. Options for available therapy were discussed and she commenced first line palliative chemotherapy with capecitabine.

She was seen by the secondary breast care nurse in clinic, where psychosocial concerns were discussed in detail. This highlighted her anxiety over her husband's mental health and coping mechanisms, as well as her desire to continue to work and maintain 'normality' for as long as possible. She declined community palliative care team support, but regular telephone follow-up by the nurse was offered to identify any additional supportive care needs as she progressed through her treatment course.

A restaging scan after 3 months showed a partial response and she was tolerating capecitabine well. She underwent regular CT and clinical surveillance. Four months later, she developed deranged liver function tests. A restaging CT scan and MRI of the liver confirmed diffuse infiltration of disease in her liver, with new ascites. She became jaundiced and her PS declined rapidly. Discussions took place around what active treatment may be possible in the context of severe liver dysfunction and the patient's wishes and preferred place of care in the event of her continued decline. Reduced-dose weekly paclitaxel was considered and the risks associated with its administration were discussed carefully with the patient. She received one dose but, given her rate of decline, further chemotherapy was ultimately considered futile. She passed away peacefully at home several days later.

What was the aim of treatment in this patient?

What is the evidence base for repeat biopsy in metastatic breast cancer?

What is the evidence for the use of paclitaxel in liver impairment?

What was the role of the supportive care team in this patient's care?

What was the aim of treatment in this patient?

In cases of metastatic breast cancer, patient and clinician goals should be identified to enable joint decision making. The patient's aim was clearly identified: she wished to commence palliative treatment with minimal toxicity, enabling her to maintain 'normality'. At her disease relapse, chemotherapy was chosen over ...

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