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Case history

image A 48-year-old woman attended a screening mammogram which demonstrated an 8 mm right breast lesion and suspicious axillary lymph nodes. Biopsy of the breast lesion confirmed grade 3 invasive ductal carcinoma, oestrogen receptor (ER) 7, progesterone receptor (PR) 8, human epidermal growth factor receptor 2 (HER2) 1+, with positive axillary nodes. She had a medical history of stage IB malignant melanoma of the upper chest that had been excised 2 years previously. A staging CT revealed a possible solitary bone metastasis in the L5 vertebra, later confirmed on MRI. Biopsy of the L5 lesion confirmed metastatic breast cancer.

During her first medical oncology consultation, her previous mental health issues came to light. She had received treatment for acute psychosis, following a series of family difficulties and a road traffic accident 3 years previously. She had recently been weaned off risperidone and was under psychiatric follow-up. It was clear at this initial consultation that her expectations of treatment were of curative intent and she found discussions of the diagnosis of secondary breast cancer and palliative treatment extremely difficult. The secondary breast care nurses, introduced as part of an integrated palliative care initiative, were able to offer her additional psychological support.

She began first line endocrine therapy with tamoxifen and goserelin, along with denosumab, in view of her low-volume ER-positive metastatic breast cancer. She remained well on endocrine therapy and had no evidence of disease progression in the first 4 months. Given that she had small-volume metastatic disease, a more radical treatment approach was considered. She underwent spinal vertebroplasty followed by surgery to the primary breast tumour. This was followed by postoperative radiotherapy to her right breast.

While undergoing radiotherapy, the patient reported increasing back pain. Restaging investigations unfortunately confirmed rapidly progressive bone disease throughout her spine. Her systemic treatment was changed to first line palliative chemotherapy with capecitabine; she continued bone-directed therapy with denosumab. Her disease remained stable for 6 months; however, she required treatment breaks for palliative radiotherapy and pain control. At the point of progression, her treatment was changed to second line palliative chemotherapy with paclitaxel. A restaging scan after three cycles confirmed further disease progression in her bones.

What was the goal of cancer treatment?

What was the role of the secondary breast care nurse?

What is the evidence for her first line therapy?

What is the evidence for bone-directed therapy?

What is the next step in her metastatic breast cancer management?

What was the goal of cancer treatment?

Metastatic breast cancer is an incurable but treatable disease with average life expectancy of 2-3 years. Some patients with ER-positive, non-visceral metastatic disease may, however, have a better prognosis measurable in terms of several years.

Around 5% of all breast cancer patients are diagnosed with metastatic disease at presentation, and bone metastasis is the most common site. Goals of care in metastatic breast cancer patients are to optimize ...

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