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Palliative care: needs of advanced breast

cancer patients
This article was published in the following Dove Press journal:
Breast Cancer - Targets and Therapy

Nathan I Cherny Abstract: Advanced breast cancer is characterized by many physical manifestations with the
Shani Paluch-Shimon potential to undermine the quality of life (most related to the cancer and some to treatments), as
Yael Berner-Wygoda well as substantial impact on psychosocial well-being. Patients with advanced breast cancer and
their families have complex needs that have to be addressed in order to minimize severe distress
Integrated Oncology and Palliative
Medicine Department, Breast and deterioration in the quality of life of patients and their family members. This task requires
Oncology Unit, Shaare Zedek Medical the full engagement of an interdisciplinary approach to palliative care with strong emphasis on
Center, Jerusalem, Israel
the assessment of needs and anticipated needs, patient expectations, skilled therapeutics, and
commitment to continuity of care. In this review, we address four issues: 1) organizational and
conceptual issues in palliative care of patients with breast cancer, 2) common physical symptoms
among patients with breast cancer and their management, 3) common psychological issues among
patients with breast cancer, and 4) common challenging palliative care problems in breast cancer.
Keywords: psychooncology, supportive care, goal setting, quality of life

Introduction
Breast cancer is the most common cancer in women and is the leading cause of cancer-
related death in women in both developing and developed regions. Approximately
5%–10% of newly diagnosed patients with breast cancer are metastatic at diagnosis; of
these, approximately one-fifth will survive for 5 years. Among patients diagnosed with
early stage disease, depending on the risk factors, as many as 30% of node-negative
and up to 70% of node-positive breast cancers will develop metastatic disease.1,2
Since the survival of women with metastatic breast cancer is often prolonged, the
prevalence of metastatic disease is high, and indeed, the care for women with metastatic
breast cancer is a major challenge for oncologists and palliative care teams.1 The natural
history of breast cancer is variable – those with aggressive subtypes, such as triple
negative breast cancer, may have very fulminant courses leading to death within a few
months or years while those with hormone receptor-positive and Her-2-overexpressed
metastatic breast cancer will have a prolonged course of illness.1
Breast cancer is characterized by many physical manifestations with the potential
to undermine the quality of life (most related to the cancer and some to treatments), as
well as substantial impact on psychosocial well-being.2,3 Antineoplastic treatment with
Correspondence: Nathan I Cherny hormonal therapy, chemotherapy, and biological therapies can modify and relieve physical
Integrated Oncology and Palliative
Medicine Department, Department, manifestations of the disease, and indeed, besides their impact on prolongation of survival,
Breast Oncology Unit, Shaare Zedek these treatments are a cornerstone of palliation for women with advanced breast cancer.
Medical Center, Shmu’el Bait St 12,
Jerusalem, 9103102, Israel
With the passage to time and sequential lines of treatment, the therapeutic window
Email Chernyn@[Link] narrows down and the likelihood of achieving substantial benefit from disease-­modifying

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therapies is diminished until such a time that further trials of team, including a palliative medicine expert for backup in
disease-modifying treatments are either no longer helpful or difficult cases.
have greater likelihood of harm than benefit, at which point
palliation and support become the central focus of care. Concurrent model
All of this is reflected in the goals of care, whereas for In this model, patients with advanced cancer are jointly cared
patients with early metastatic cancer, the goal of prolonga- for by both an oncologist and a palliative medicine special-
tion of survival may sometimes even take precedence over ist (working in the context of an interdisciplinary palliative
considerations of comfort; as the disease progresses and care team) in a similar way in which medical, surgical, and
the likelihood of life prolongation diminishes and issues of radiation oncologists traditionally work together.6 The rela-
comfort and function take greater precedence. In all cases, the tive role of the oncologist or palliative medicine physician
prevailing goals of care need to be discussed with the patient is determined by the prevailing problems, and indeed, case
and their family, and all stakeholders should be aware of the management responsibilities may be handled by either and
prevailing priorities since these set the context for decision- are usually determined by the circumstances of the patient.
making and care planning.4 Successful implementation of this approach requires close
A complete review of all the aspects of palliative care for cooperation and open communication between the oncol-
cancer patients is beyond the scope of what can be reviewed ogy and palliative medicine clinicians. This approach is
in a single paper. In this review, we will focus on four issues: strongly supported by data demonstrating improved patient
1) organizational and conceptual issues in palliative care of outcomes.7–12
patients with breast cancer, 2) common physical symptoms
among patients with breast cancer and their management,
Assessing patient needs for palliative care
3) common psychological issues among patients with breast
An appreciation of the complete diversity of factors that
cancer, and 4) common challenging palliative care problems
may contribute to patient distress underscores the need for
in breast cancer.
a methodical approach to the assessment of each individual
case.13 This role should be assumed by a case manager, who in
Organizational and conceptual many cases is both the clinician and the coordinator of the health
issues in palliative care of patients care professionals, that is, physicians, nurses, social workers,
with breast cancer and therapists. The evaluation must incorporate the following.
Models of care for patients with
advanced breast cancer Patient assessment
The high prevalence of physical and psychosocial distress The early establishment of good symptom control conveys
among patients with breast cancer underscores the need for concern, builds the trust of patients and their families, and
an approach to care that incorporates clinical approach to facilitates the ability to address other important issues.
address these issues in parallel to usual anticancer therapies. Patient variables that must be assessed include the dis-
There is no one best way for oncologists and specialist ease status, expected disease progression, present functional
palliative care services to work together. Rather a number of level, symptoms, current therapies, and anticipated future
different models have been developed.5 problems. Of particular importance is the patients’ level of
function, reflecting their mobility, ability to communicate,
Oncologist-based palliative care ability to perform activities of daily living, bowel and blad-
In this model, the oncologists assume the role of coordinat- der function, and level of alertness. The use of validated pain
ing care and providing both anticancer and palliative care and symptom assessment instruments can provide a format
services, thus seeing the patients through from diagnosis for communication between the patients and the health care
until death. This approach emphasizes the importance of professionals, and these instruments can also be used to
the oncologist-patient relationship and the notions of con- monitor the adequacy of therapy.
tinuity of care and nonabandonment. The success of this It is important to ascertain the patients’ and their families’
model is dependent on the level of palliative care skills and understanding of the nature and extent of the illness and their
sophistication of the oncologists and their ability to balance expectations of treatment and outcome. As a part of this
competing intellectual and practical interests. This approach process, the case manager must develop an understanding
is augmented by having a strong relationship with a care of the patients’ prioritization of the sometimes conflicting

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Dovepress Palliative care: needs of advanced breast cancer patients

goals of care: optimization of comfort, function (interactional Since care for the palliative care patients is a longitudinal
function in particular), and duration of survival. commitment, assessment must be repeated at appropriate
intervals which will be determined by the rate of change in
Family assessment the patients’ clinical conditions or at points of major change
Family assessment should encompass medical variables, in goals, care plan, or the patients’ conditions.
psychosocial concerns, and the adequacy and availability
of supports. Evaluation of the willingness and ability of Family meetings and goals of care
home carers to provide home care, and the availability of Family meetings, with relevant members of the professional
supports are essential. Concurrent medical problems in a health care team, provide a useful format for discussing the
family member, particularly a primary caregiver, need to needs of all parties involved, clarifying care goals, sharing
be evaluated since the viability of the home care plan may and exploring concerns, and developing a therapeutic plan
depend upon the family members’ ability to participate in that adequately addresses those needs.15,16 The participants
care. Since the ability of families to cope with home care is should be determined on an individual case basis.
largely determined by the nature of the available home care Since family is an appropriate unit of care, and its
supports, family assessment must include an assessment of members have a right to confidentiality, it may be appropri-
available health care professional and community supports. ate, occasionally, to meet without the participation of the
Discrepancies between what is known and understood by patient to address their concerns and needs. Meetings with
the patients and their families should be identified, and the the participation of all persons who are involved can open
reasons for these discrepancies should be tactfully explored. communication, improve coordination in the formulation of
Knowledge deficits may have been deliberately maintained: a care plan, and facilitate better personal coping for each of
the family or patient not wanting information overload, the the individuals involved.
patient protecting the family from the knowledge of poor The case manager is responsible for monitoring the degree
prognosis, or the family protecting the patient from the impact to which care needs are being met and for facilitating change
of such information.14 when necessary. Similarly the well-being and function of
the health care professionals must be monitored, ensuring
Health care professional assessment the availability of appropriate manpower and expertise to
To effectively plan for ongoing care, the case manager must effectively manage the prevailing problems. For security and
understand the limitations of the involved health care profes- safety in the event of a clinical crisis, it is essential that the
sionals (knowledge, experience, and availability for home patients and their families have access to a contact person
care), their difficulties in coping with the situation, and their with 24 hour availability. This model represents a family
perceived needs to improve the care outcome. cantered, multidisciplinary, collaborative approach between
Based on this assessment, one can formulate a care plan physicians, nurses, social workers, other therapists, and
that addresses all aspects of the care trilogy: patient, family, community supports.
and health care professionals. The formulation can be sum-
marized in a document or report that describes: Evaluation and management of
1. The medical condition of the patient and the goals of care common physical symptoms
2. Description of the involved family members and health Pain
care professionals Overwhelmingly, the most common causes of cancer-related
3. Patient issues: physical, psychological, existential, social, pain in women with breast cancer are bone metastases and
communication, understanding their sequelae including impending and actual fractures and
4. Family issues: physical, psychological, existential, social, compression of adjacent neural structures.17,18 Other pain
communication, understanding syndromes that are less common include tumor pain from
5. Professional carer issues: staffing, training, resources, chest wall infiltration, brachial plexopathy, headache from
resource/need match, emotional coping brain metastases or leptomeningeal metastases, and abdomi-
6. Coping assessment: patient, family, health care nal pain from hepatic capsular distension.17
professionals Bone metastases are very common in breast cancer.18
7. Contingency planning: anticipated contingencies, planned They most commonly involve the axial skeleton,19 these
interventions lesions may be either blastic or lytic; however, when caused

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by bone marrow infiltration, the disease may not be evident metastasis to the epidural space. Occasionally, epidural
on conventional imaging and may require either MRI or PET compression is caused by tumor extension from the posterior
CT imaging.18 arch of the vertebra or infiltration of a paravertebral tumor
The vertebrae are the most common sites of bony through the intervertebral foramen.
metastases. More than two-thirds of vertebral metastases Untreated, epidural compression leads inevitably to
are located in the thoracic spine; lumbosacral and cervical neurological damage. Effective treatment can potentially
metastases account for ~20% and 10%, respectively. The prevent these complications and thus underscores the
early recognition of pain syndromes due to tumor invasion importance of early diagnosis. Since pain usually precedes
of vertebral bodies is essential, since pain usually precedes neurologic signs by a prolonged period, it should be viewed
compression of adjacent neural structures and prompt treat- as a potential indicator of epidural compression, which can
ment of the lesion may prevent the subsequent development lead to treatment at a time when a favorable response is most
of neurologic deficits. likely. Some pain characteristics are particularly suggestive
The pelvis and hip are common sites of metastatic of epidural extension: rapid worsening of back pain and
involvement. The weight bearing function of these structures, radicular pain (particularly if it is exacerbated by recumbence,
essential for normal ambulation, contributes to the propensity cough, sneeze, or strain). Weakness, sensory loss, autonomic
of the disease at these sites to cause incident pain with walk- dysfunction, and reflex abnormalities usually occur after a
ing and weight-bearing.20 period of progressive pain.
The management of pain requires an integrated approach Patients with suspected epidural encroachment require
including antitumor therapies (including disease-modifying urgent axial assessment of the epidural space with either
agents: hormonal, chemotherapeutic and biological, radio- MRI or CT imaging. MRI offers accurate imaging of the
therapy, and surgery), analgesic therapy, and rehabilitation vertebrae, intraspinal, and paravertebral structures.22,23 CT
and psychological care.18,19,21 Analgesic pharmacotherapy imaging is a good option if urgent MRI cannot be arranged.
must be cognoscente of the mechanism of pain (somatic Patients with identified epidural encroachment will need
vs neuropathic) and must be appropriate to the severity of treatment with either radiotherapy with steroids or a combina-
the pain. Opioid analgesic therapy will be needed for most tion of surgical compression and stabilization followed by
patients with strong pain, and this should incorporate the radiotherapy.22,23 There is conflicting data as to whether the
background around the clock dosing for chronic pain as well later yields better neurological outcomes.22,24,25
as provision for as needed “rescue doses” using a rapidly
acting opioid. Opioid analgesic therapy must be titrated to Iatrogenic chronic pain
effect with close follow-up both for the adequacy of analgesia Iatrogenic pain is a major cause of patient distress even
and for the emergence of adverse effects such as drowsi- among patients with early stage disease. Three iatrogenic
ness, confusion, nausea, itch, myoclonus, or constipation. pain syndromes are extremely common and a major cause
If either inadequate analgesia or excessive adverse effects of patient distress; these include: 1) post axillary dissection
are observed, the treatment strategy will need revision until neuropathic pain,26 2) taxane-induced painful peripheral neu-
adequate and acceptable balance is found between the provi- ropathy,26 and 3) aromatase inhibitor (AI)-induced multifocal
sion of relief and adverse effects. When the mechanism of joint pains.27 The risk of postoperative neuropathy is reduced
the pain is neuropathic, patients may benefit from the addi- with the application of more limited dissection approaches
tion of an agent with specific efficacy for this mechanism of such as sentinel lymph node dissection, but even with these
pain such as a tricyclic, an SNRI, and/or an anticonvulsant. approaches, there remain a subgroup of patients who will
Radiotherapy may be particularly important for patients with endure an ongoing neuropathic pain syndrome.
poorly controlled pain from bone metastases and for patients Taxane-induced peripheral neuropathy is a common con-
with compression or infiltration of neural structures. sequence of breast cancer treatment in both the adjuvant and
metastatic settings.28,29 The risk of chronic neuropathy must
The special case of back pain and epidural be discussed with all patients considering taxane therapy and
compression must be considered in any risk–benefit evaluation regarding
Epidural compression of the spinal cord or cauda equina is the potential role of these agents.30 Treatment of established
a common neurologic complication of breast cancer. Most neuropathy is challenging and often requires an interdisci-
often it is caused by posterior extension of vertebral body plinary approach including occupational therapy to assist

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Dovepress Palliative care: needs of advanced breast cancer patients

with functional issues, pharmacotherapy for neuropathic Table 1 Potentially treatable causes of breathlessness
pain,31 and physiological and social support. Pharmaco- Underlying cause Potential treatment
therapy approaches should be evidence based and will com- Anemia Blood transfusion
monly require sequential trials of therapy to optimal benefit Acidosis HCO3
Bronchospasm Bronchodilator therapy
and minimize adverse effects.31 Pneumonia Antibiotic therapy
AIs can cause arthralgia, joint stiffness, and bone pain, Pulmonary embolus Anti-coagulate
which can be severe in up to 30% of patients. The pain and Pneumonitis Steroids
Atrial fibrillation Anti-arrhythmic
stiffness typically involve the hands, arms, knees, feet, pelvic
Congestive cardiac failure Diuretic
and hip bones, or back. It is usually symmetrical and may Pericardial tamponade Drainage
be associated with mild soft-tissue thickening.27 There is Pleural effusion Thoracentesis
limited evidence to suggest that some patients may benefit Endobronchial tumor Endobronchial laser
Extrinsic compression of bronchus Radiotherapy
from a change to a different AI formulation. There is limited
Carcinomatous lymphangitis Steroids (anecdotes only)
anecdotal evidence support of vitamin D supplementation, Lung metastases Chemotherapy/hormonal therapy
nonsteroidal anti-inflammatory medications, yoga, exercise,
acupuncture, or SSRI antidepressants. In some cases, this
becomes an intractable problem that necessitates a therapeutic be adequately assisted by nasal prongs or a face mask. Some
compromise including reversion back to tamoxifen. patients may benefit from either BiPAP or high-flow oxygen
to maintain adequate oxygenation and comfort. Patients with
Breathlessness (dyspnea) severe hypoxemia that is caused by a potentially reversible
Dyspnea is defined as a subjective sensation of difficulty acute problem such as pneumonia or pneumonitis may
in breathing. It is a common symptom among patients with require ventilatory support to enable them to overcome an
advanced breast cancer.32 Among patients with breast cancer, acute episode. Consequently, it is helpful to evaluate patients’
there are many potential causes of breathlessness (Table advanced directives should they have an acute life-threatening
1). Since many of these are amenable to specific therapies, but potentially reversible event.
optimal treatment requires careful evaluation which must be Opioids are the preferred symptomatic therapy for
cognoscente of the patients’ premorbid state, current therapy, dyspnea at the end-of-life as well as dyspnea that is not
and known extent of disease. adequately relieved by the treatment of the underlying cause
Except in situations where dyspnea is anticipated because and correction of hypoxemia. In the opioid naïve patients,
of the extent of disease or in the setting of imminent antici- low doses of oral (5–10 mg) or parenteral morphine (2–4
pated dying, dyspnea ought to be carefully evaluated includ- mg) may be adequate for most of the patients. Importantly,
ing a careful physical examination, pulse oximetry, and chest patients on chronic opioid therapy may need higher doses.
X-ray. Other investigations including ECG, echo cardiogram, Continual opioid therapy can be provided using long-acting
CT, or CT angiography may be needed, and these should be oral or transdermal formulations or by continuous infusion.
judiciously selected on the basis of the differential diagnosis Patients with severe dyspnea should also have access to a
suggested by the medical history and physical examination rescue dose analogous to the treatment of breakthrough pain.
findings.
Symptomatic management of dyspnea uses nonphar- Fatigue
macological and pharmacological approaches.32 Sitting the Fatigue is one of the most common symptoms among
patient upright, increasing air flow over the face using a fan patients with breast cancer. It is a major cause of distress to
or open window, and use of bedside relaxation techniques both patients and their family members. It has immediate
are all helpful. Treatable precipitants may benefit from impact if it interferes with the patients’ ability to maintain
specific therapies. Large symptomatic pleural or pericardial a normal lifestyle, additionally it is often perceived to have
effusions should be drained. Recurrent pleural effusions, a substantial symbolic consequence in so far as it suggests
particularly in patients with a very refractory disease may persistent morbidity that is a reminder of the risk of death.
require pleuradesis or a permanent drainage device (such as a Fatigue is the most common adverse effect of chemother-
PleurX catheter). Oxygen supplementation may help relieve apy, and it is a common complaint among women receiving
dyspnea for patients who are hypoxemic. Most patients will hormonal and biological therapies for breast cancer. In many

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instances, however, there may be underlying factors, acute In that situation, it is our common practice to administer
or chronic, that may be precipitating or exacerbating fatigue dexamethasone 10–20 mg at 12 hours before the event.
and tiredness. These may include anemia, infection, fever,
dehydration, electrolyte imbalance, cachexia, hypothyroid- Delirium and confusion
ism or hypogonadism, depression, sleep disturbance, and Delirium can be described as alteration in attention and
centrally acting sedating medications. awareness fluctuating in severity across time. It is sometimes
A rational treatment approach should be three pronged:33 accompanied with neurological deficits such as aphasia,
first addressing underlying reversible factors, second using disorientation and hallucinations, and psychomotor changes.
nonpharmacological, and finally pharmacological approaches. Delirium is a common complication of advanced cancer. Inci-
Four nonpharmacological approaches are presented in dence estimates range from 43% in the general cancer popula-
Box 1. tion to 85% in patients in the terminal stages of their illness.36
Energy expenditure planning involved the planning of Three clinical subtypes of delirium, based on arousal
daily activities or prioritizing activities to be undertaken at disturbance and psychomotor behavior, have been described
times of leased fatigue and maximal energy. Energy restora- as follows:
tion strategies include ensuring adequate rest and nutrition,
1. Hyperactive subtype – hyperaroused, hyperalert, or
reducing stress through techniques such as meditation or
agitated.
relaxation. Physical exercise has been endorsed as a use-
2. Hypoactive subtype – hypoaroused, hypoalert, or
ful approach in many clinical trials.34 The level of physical
lethargic.
exercise needs to be tailored to the underlying performance
3. Mixed subtype with alternating features of hyperactive
status and general well-being of the patients.
and hypoactive delirium.
Fatigue patients who are anemic with a hemoglobin of
<8 g/dL can be considered for blood transfusion,35 aiming Neurologic abnormalities may be present during delirium,
to maintain a hemoglobin level between 10 and 12 g/dL. including cortical abnormalities (dysgraphia, constructional
There are some limited data that patients with persistent apraxia, and dysnomic aphasia); motor abnormalities (tremor,
fatigue may benefit from a low dose of either methylpheni- asterixis, myoclonus, and reflex or tone changes); and elec-
date or modafanil. Methylphenidate is generally initiated at troencephalogram abnormalities (typically global slowing).
a dose of 5–10 mg in the morning and may be titrated up to The extent of evaluation is very much determined by the
40–60 mg per day.33 The most common side effects with this patients’ prognosis.36 When delirium occurs in an ambulatory
approach include agitation, nervousness, sleep disturbances, patient, it should generally be evaluated urgently. Compre-
nausea, or diarrhea. hensive initial evaluation should be performed to identify
Though steroids are not useful in the long-term manage- and address the contributing factors, including obtaining the
ment fatigue, they may have a role to play in the short-term history with corroboration from family or staff, medication
management of fatigue for a patient who wants to have review, physical and neurological examination, and specific
optimal alertness for an important occasion or family event. laboratory tests or imaging, as appropriate to the patients’
goals of care.
Common precipitating events include sepsis, medication
Box 1 Nonpharmacological approaches to fatigue side effects, and metabolic aberrations (particularly hypercal-
Energy expenditure Planning of daily activities or cemia, hyponatremia, uremia, dehydration, brain metastases,
planning prioritizing activities to be or cerebrovascular events).36 Less common causes include
undertaken at times of leased fatigue leptomeningeal metastases or status epilepticus.
and maximal energy
Delirium is a medical emergency that must be managed
Energy restoration strategies Ensuring adequate rest and nutrition,
reducing stress through techniques with compassion, reassurance, and clear explanation of the
such as meditation or relaxation impact of pharmacological and nonpharmacological strate-
Physical exercise Endorsed as a useful approach in gies to improve symptom control.36 Nonessential centrally
many clinical trials34
The level of physical exercise needs
acting medications that may contribute to delirium should
to be tailored to the underlying be stopped.
performance status and general well- Medications for treating agitation and delirium in the
being of the patients
terminal phase include antipsychotics: the newer agents such

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Dovepress Palliative care: needs of advanced breast cancer patients

as olanzapine, quetiapine, and aripiprazole appear less likely Table 2 Common expressions and themes of anxiety and their
to be associated with extrapyramidal side effects than earlier clinical manifestations
generation antipsychotics such as haloperidol, chlorproma- Expression of anxiety Common clinical
presentations
zine, levomepromazine, or risperidone.36 Benzodiazepines
Fearfulness Often characterized by
may be required for more rapid control of agitation and
apprehension and dread
anxiety, but they can occasionally cause paradoxical agita- When severe, may become
tion if used alone.36 even more exaggerated and
manifest as panic or alarm
Physical reactions not attributable to Hyperventilation
Evaluation and management of organic disease or drug reactions Sensation of lump in throat
common psychological symptoms Palpitations
Breast cancer places considerable psychological stress Tightness in chest or stomach
Nausea
on patients and their families.3 These stresses, similarly, Thought confusion Difficulty in concentrating
amplify the emotional content of the contact with health care Difficulty in assimilating or
providers, particularly with oncologists. In order to be able recalling information
Altered perceptions such
to effectively care for cancer patients, oncology clinicians
as seeing the environment,
must be familiar with common psychological syndromes procedures or treatments as
experienced by patients and their families. threatening
Restlessness Hyper vigilance about new

Anxiety treatments or symptoms

Phobic avoidance of feared
Anxiety is endemic among patients with advanced breast procedures or situations
cancer.37 Among patients, it commonly coexists with depres- Paralysis of effective coping
sive symptoms, and it is very common among the family Indecision and poor sleeping
Poor sleeping
members of cancer patients. Anxiety has many expressions Themes of anxiety Common clinical
and identifiable themes that are related to their cancer experi- presentations
ence37 (Table 2). Uncertainty Anxiety about outcome of
treatments
In deciding whether to treat anxiety in a patient with
Anxiety about likelihood of
cancer, the patient’s subjective level of distress is the pri- cure or relapse
mary consideration for the initiation of treatment. Other Anxiety about duration of
considerations include problematic patient behaviors such survival
Anxiety about unfamiliar
as ­noncompliance due to anxiety, family and staff reactions
treatments and procedures
to the patients’ distress, and the balancing of the risks and Life under siege Fear that their lives have
benefits of treatment. Anxiolytic pharmacotherapy should been surrounded and
usually be administered in conjunction with supportive overtaken by forces that
threaten both the present
psychotherapy or cognitive therapy approaches.39 The phar- and possibly the future too
macotherapy of anxiety in terminal illness typically involves Fear of progression Fears with respect to the
use of benzodiazepine or nonbenzodiazepine anxiolytics.39 progression of their illness
and its possible sequellae38
Benzodiazepines are the mainstay of the pharmacologi-
cal treatment of anxiety in patients with cancer. The shorter
acting benzodiazepines, such as lorazepam, alprazolam, and
oxazepam, are the safest in this population. Longer acting alone or in combination. Brief supportive psychotherapy,
benzodiazepines such as diazepam or clonazepam are usually by a skilled therapist, is often useful in dealing with both
reserved for patients who experience breakthrough anxiety or crisis-related issues and existential issues confronted by
end of dose failure. Midazolam, a very short acting is useful the terminally ill.39 The goals of psychotherapy with the
in controlling anxiety and agitation in terminal phases of patient are to establish a bond that decreases the sense of
illness. For patients with persistent symptoms, neuroleptics isolation experienced with terminal illness; to help the
such as olanzapine or quetiapine sometimes are indicated. patient face their illness and its treatment with a sense of
Nonpharmacological interventions include supportive self-worth; to correct misconceptions about the past and
psychotherapy and behavioral interventions that are used present; to integrate the present illness into a continuum of

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life experiences; and to explore issues of fears, loss, and the Antidepressant pharmacotherapy is the mainstay of
unknown that lies ahead. The therapist should emphasize management in the treatment of cancer patients with severe
past strengths and support previously successful ways of depressive symptoms. 40 This should almost always be
coping. This helps the patient mobilize inner resources, accompanied by some form of psychotherapy by a skilled
modify plans for the future, and perhaps even accept the therapist.40,41 There are five selective serotonin re-uptake
inevitability of death. inhibitors including fluoxetine, sertraline, paroxetine,
The oncology clinicians can contribute greatly to alle- citalopram, and fluvoxamine. Fluoxetine and paroxetine
viating anxiety by attending to the emotional and informa- may accelerate the metabolism of tamoxifen and are not
tional needs of patients and their families during the cancer preferred for patients on hormonal therapy. These drugs are
experience and by ensuring open lines of communication as effective in the treatment of depression as the tricyclics
and a commitment to rapid response in times of distress but have a lower likelihood of major side effects. That
or concern. is not to say that these drugs are free of adverse effects.
Many patients complain of loose stools, nausea, vomit-
Depression ing, insomnia, headaches, and sexual dysfunction. Some
Depression is less prevalent than anxiety. However, it is patients may experience anxiety, tremor, and restlessness
a common symptom and may well be underreported by particularly when starting treatment. A third generation of
patients.3,37 It is more common among patients with a family antidepressants includes the serotonin–norepinephrine reup-
history of depression and history of previous depressive epi- take inhibitor, venlaflaxine, and the serotonin-2 antagonists/
sodes. In some cases depression may be iatrogenic; and cor- serotonin reuptake inhibitors, nefazodone and trazodone.
ticosteroids, hormonal therapies, and whole brain radiation These agents share the improved therapeutic index of the
have all been implicated as potential causes of depression. SSRI drugs.
Treating clinicians should be alert to common symptoms The role of tricyclic antidepressants is limited because of
of depression (Table 3). their anticholinergic side including constipation, dry mouth,
Depression in cancer patients often requires an approach and urinary retention. They may be a good option for the
combining supportive psychotherapy, cognitive-behavioral depressed patient who also suffers from agitation and insom-
techniques, and antidepressant medications.40 Psychotherapy nia. Psychostimulants such as methylphenidate are a useful
and cognitive-behavioral techniques –in the form of either alternative and effective approach to the treatment of depres-
individual or group counseling – are useful in the manage- sion particularly when a rapid onset of action is needed.41
ment of psychological distress in cancer patients and have Occasionally, treatment with SSRI and a psychostimulant
been applied to the treatment of depressive and anxious may be initiated concurrently so that patients with depression
symptoms related to cancer. may receive the immediate benefits of the psychostimulant
drug until the 1–2 weeks necessary for an SSRI to begin to
Table 3 Common symptoms of depression
work pass. In relatively low dose, psychostimulants stimulate
appetite, promote a sense of well-being, and improve feelings
Symptoms of depression Common clinical presentations
of weakness and fatigue in cancer patients.
Mood alteration Persistent sadness
Flatness of affect
Emotionally withdrawn and Existential suffering
unresponsive In addition to the well described psychological syndromes,
Ruminative negative thoughts Preoccupation with intrusive
thoughts about the illness and its
existential issues are also common among patients with
implications cancer. For patients with advanced cancer, these include
Distracted and unable to focus on concerns related to hopelessness, futility, meaninglessness,
other tasks at home or at work
disappointment, remorse, death anxiety, and disruption of
Passivity Disengagement from usual activities
and interests personal identity.42,43
Low motivation to do anything Existential distresses may be related to past, present, or
Lack of interest in the other issues future concerns.
going on in their lives
Poor sleep and appetite Poor sleep and appetite unrelated 1. Present: Current personal integrity and identity can be
to the illness or its treatment.
disrupted by changes in body image; somatic, intellec-

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Dovepress Palliative care: needs of advanced breast cancer patients

tual, social, and professional function and in perceived maladaptive responses to their illness that undermine the
attractiveness as a person and as a sexual partner. efficacy of their coping. Some “resign and withdraw” with
2. Past: For some patients, retrospection can trigger pro- a progressive and biologically premature invalidity which,
found disappointment from unfulfilled aspirations or in itself, may alienate their families and care givers. Some
remorse from unresolved guilt or unsolved matters. “Reject and Rage”51,52 expressing their anger as if they are try-
3. Future: If life is perceived to offer, at best, comfort in the ing to make everyone around them as miserable as possible.
setting of fading potency or, at worst, ongoing physical Maladaptive coping needs to be recognized and addressed by
and emotional distress, anticipation of the future may the care team to minimize both patient and family distress.
be associated with feelings of hopelessness, futility, or
meaninglessness such that the patients see no value in Common challenging palliative care
continuing to live.
problems in breast cancer
Existential issues are universal and independent of reli- Fungating chest wall tumors
gion and religious practice although their content is often In many instances, patients initially presenting with ulcerated
influenced by one’s culture.44 Patients with existential and or fungating chest wall tumors will respond to anticancer
spiritual distress may often be helped with skilled chaplaincy therapies.53 In some situations, especially with initial presen-
or spiritual care. Cognitive therapists have developed specific tation, anti-tumor therapies (hormonal, chemotherapy, and
programs to enhance dignity45,46 and meaning.47,48 biological) or radiation therapy also enhance local control.
There is a place for the treating clinician to engage with Persistent chest wall and skin lesions after several lines of
some of these issues.49 For many patients, a lack of understand- therapy present major treatment challenges.53 These lesions
ing about their illness and its treatment enhances feelings of may be complicated by problems of itch, pain exudates,
vulnerability, uncertainty and helplessness. Often informa- infection, and odor54 and are a major cause of distress to
tion is obfuscated with vague language with the intention of patients and their caregivers.54 These patients need meticulous
“protecting the patient” but this is often counterproductive. By wound care, adequate supports, and analgesia particularly
sharing knowledge and information in a sensitive and appropri- for wound care and open lines of communication with the
ate manner, the treating clinician can often help to empower professional care team.
the patient to take command of their lives as much as possible. For patients with good performance status and a life
The discussions are often underscored by a wealth of feelings: expectancy of more than 6 months, surgical management
anxiety, fear, sadness, and distress are all common. These with resection with appropriate flap or graft reconstruction
discussions need to be accompanied by the opportunity to is occasionally helpful,55 but for most patients this will not be
work through the emotional response, to prevent an emotional an option. These patients and their caregivers need education
backlog which can undermine the process of coping. This and support to assist with washing, asepsis, dressing changes,
requires that the treating clinicians acknowledge these feelings control of odor, itch and bleeding, pain management, and
and allow the patients to ventilate them to release emotional dealing with the most troublesome chronic wound problems
energy that is essential in the process of re-establishing coping. that affect the patients physically and emotionally.56,57
Even in the setting of advanced cancer, hope remains Initial management includes debridement and proper
important.50 Clinicians can help the patients shift the focus to wound dressings. Nonadherent dressings should be used to
achievable and meaningful hope such as hope for time, hope reduce bleeding and pain with dressing changes, that is, spe-
for freedom from discomfort, hope to maximize the quality of cial dressings such as foams, alginates, or starch copolymers
one’s life in the setting of threatened duration of survival, hope which reduce the need for frequent dressing changes. Odor
that one’s loved ones will cope with the time ahead, hope that as can be controlled with interval mechanical debridement to
one approaches the end of one’s days that it will be with the feel- decrease the microbial bioburden on the wound surface and
ing of satisfaction with the quality of what has been achieved, dressings that incorporate topical metronidazole, hydro foam
and hope for a peaceful death without suffering or indignity. with silvers sulfadiazine, or medicinal honey.58 When there
Talking about coping can be important and helpful.3 To is oozing from the lesions, topical hemostatic agents such as
some degree, the challenge of living and coping with cancer gelatin (Gelfoam) or collagen (Helistat) can be applied. Other
is related to attitude: giving all of the uncertainties associ- approaches that have been described include gauze saturated
ated with the disease patients can see themselves as “living with adrenaline or sucralfate paste (1 g sucralfate tablet in 5
with cancer” or as “dying of cancer.” Some patients develop mL of water-soluble gel) may decrease widespread oozing.57,59

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Cherny et al Dovepress

The management plan should be considerate of esthetics more targeted approaches to adjuvant radiotherapy including
including attention to dressings that protect clothing from hippocampal sparing radiotherapy or stereotactic surgery to
discharge and that preserve symmetry as much as possible. the resection cavity.
Isolated bleeding points may be treated with silver nitrate Stereotactic radiotherapy (sometimes called radiosur-
sticks; however, more active bleeding may necessitate more gery or gamma knife surgery) is recommended when there
aggressive approaches including transcatheter embolization is a small number of brain metastases (usually <5) and for
of bleeding arteries59,60 and direct puncture sclerotherapy in patients who have a single metastasis but who are not can-
which the tumor is injected with sclerosing agent, radio- didates for surgery.63 There is no evidence that subsequent
therapy, or rarely reconstructive surgery.59 Keeping the skin brain radiotherapy reduces the risk of recurrence or improves
moisturized and protected will help reduce itching, and, if overall survival.
necessary, topical corticosteroid creams can be applied. Whole brain radiotherapy may be appropriate for symp-
Chronic pain should be treated in accordance with the tomatic patients who have a very poor prognosis and for
standard guidelines for chronic cancer pain. Dressing changes patients who have multiple metastases not amenable to focal
will often require premedication with a short-acting opioids therapy.63,64 For patients with HER2 overexpressing breast
and, occasionally, may even require sedation. cancer, the trial of therapy with lapatinib and capecitabine
may provide adequate control and allow for the deferral of
Brain metastases whole brain radiotherapy.64,65
Brain metastases are a common complication of breast can- In the setting of recurrent disease, patients with a good
cer which occurs in ~15% of patients with metastatic breast performance status and a limited number of recurrent lesions
cancer.61 The risk of breast brain metastases is very low may be treated with stereotactic radiosurgery even if they
among patients with luminal A breast cancer and is substan- have previously received whole brain radiotherapy.63,66
tially higher among patients with luminal B, Her2-positive,
and triple-negative breast cancer.61,62 Leptomeningeal metastases
Common symptoms associated with brain metastases Leptomeningeal metastases that are characterized by diffuse
include headache, confusion, and new onset of focal seizures. or multifocal involvement of the subarachnoid space by
Diagnosis is made through axial brain imaging using either metastatic tumor occur in a small proportion of patients with
contrast-enhanced CT scan or gadolinium enhanced MRI breast cancer usually late in the evolution of the disease.67,68
scanning.63 Given the more limited diagnostic resolution This is a poor prognostic situation with a median overall
of CT scanning, when a small number of brain metastases survival of <4 months.69
are identified that may be amenable to localized therapies, a Leptomeningeal metastases present with focal or multifo-
subsequent MRI scan is indicated for more accurate staging cal neurological symptoms or signs that may involve any level
of the true extent of cerebral metastases.63 of the neuraxis.67,68 The most common presenting symptoms
Symptomatic patients with extensive vasogenic edema are headache, cranial nerve palsies,70 and radicular pain in the
axial imaging should be treated with dexamethasone.63 low back and buttocks.71 More than one-third of patients pres-
Moderate- to high-dose steroids can cause a reduction in ents with evidence of cranial nerve damage, including double
intracranial pressure and reduction in symptoms within hours vision, hearing loss, facial numbness, and decreased vision.70
of administration. A starting dose of 10–20 mg can be used. Gadolinium-enhanced MRI of the neuroaxis is the
This can be gradually tapered down after a clinical improve- investigation of choice when leptomeningeal metastases are
ment is achieved. Anticonvulsant therapies are indicated suspected. Compared to cerebrospinal fluid (CSF) cytology
for patients who have had a seizure associated with their examination, MRI probably is more sensitive but is less
metastasis. Routine seizure prophylaxis is not recommended. specific as false-positive cytologies are rare.72 Gadolinium-
Among patients with a relatively well preserved per- enhanced spinal MRI may be positive in almost 50% of
formance status, the treatment strategies are influenced by patients without clinical findings related to the spinal region
the number of involved metastases. When there is a single and in 60% of patients with negative CSF cytology.73 The
lesion, this is best managed with the surgical resection if this CSF analysis may reveal elevated pressure, elevated protein,
is technically possible.63 Postoperative radiotherapy ought depressed glucose, and/or lymphocytic pleocytosis. Ninety
to be considered. There is increasing data to indicate that percent of patients ultimately show positive cytology, but
the problems of cognitive decline may be reduced by using multiple evaluations may be required. Despite these measures,

240 submit your manuscript | [Link] Breast Cancer - Targets and Therapy 2018:10
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Dovepress Palliative care: needs of advanced breast cancer patients

CSF cytology is persistently negative in as many as 20% of 3. Brunault P, Champagne AL, Huguet G. Major depressive disorder,
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The authors report no conflicts of interest in this work. for the treatment of metastatic extradural spinal cord compression in
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