War and prejudice: the problems faced by pa7ents with advanced breast cancer in accessing appropriate treatments
Lisbon, Portugal: Experts have highlighted the plight of several groups of pa3ents with advanced breast cancer (ABC) for whom the management and treatment of their disease needs urgent a>en3on and improvement.
In the final session of the Advanced Breast Cancer Seventh Interna3onal Consensus Conference (ABC 7) [1] in Lisbon today (Saturday), the experts called for immediate measures to help pa3ents fleeing war or conflict zones and the healthcare professionals who treat them, an end to discrimina3on against pa3ents with serious mental illnesses, and an end to discriminatory prac3ces that can deny pa3ents access to intensive care units based solely on their diagnosis of ABC.
In addi3on, they issued new statements on several groups of pa3ents with ABC where it is difficult to decide on the best treatments and care, such as women who are pregnant, pa3ents with concomitant HIV infec3on, and frail, elderly pa3ents.
Chair of the ABC 7 conference, Dr Fa3ma Cardoso, Director of the Breast Unit of the Champalimaud Clinical Centre, Lisbon, Portugal, and President of the ABC Global Alliance, said: “War and conflict can cause major disrup3on to the delivery of care for pa3ents with advanced breast cancer.
“A lot of pa3ents have completely lost the capacity to be treated, but also all their medical records are lost or destroyed. For instance, our colleagues in Poland, where many Ukrainians have fled, are facing huge difficul3es in trea3ng pa3ents because oYen they don’t even know what type of cancer these pa3ents have, or what type of treatment they’ve been receiving since everything has been destroyed. We cannot wait for wars to end to treat these pa3ents and unfortunately there are always wars or conflicts in the world.”
She said a possible solu3on to this problem could be digital medical cards that pa3ents always carry with them. “If the pa3ent has access to her or his data in electronic form, then it will be easier to share. This is important during war, but also for other situa3ons, for example when a pa3ent is looking for a second opinion. There is an ongoing European Commission project about developing this. However, it does raise issues of confiden3ality.”
Pa3ents with ABC should not be denied access to intensive care units just because of their cancer diagnosis, said the experts. This was an issue that came to prominence at the height of the COVID-19 pandemic. Honorary Chair of ABC 7, Professor Eric P. Winer, Director of the Yale Cancer Center, USA, said: “Just because a pa3ent has metasta3c cancer, they should not automa3cally be denied access to intensive care if they develop a serious illness or infec3on, or a serious side effect from their cancer treatment. During COVID, if a pa3ent had cancer, they were oYen put at the bo>om of the list for access to ven3lators. This happened in many countries, and COVID has not gone away. We have to remember that many pa3ents with metasta3c cancer will live for years. These pa3ents must be reviewed individually and treated according to their needs, with considera3on of their preferences and their oncologists’ input.
“Other examples of prejudice are those shown towards elderly, very frail pa3ents, and those with serious mental illnesses or HIV.”
The panel of experts highlighted that pa3ents with serious mental illnesses were more likely to be diagnosed with cancer when it is at an advanced stage, and they have worse outcomes than people without mental health problems.
Dr Larry Norton, also Honorary Chair of ABC 7, a Senior Vice President at Memorial Sloan-Ke>ering Cancer Center, New York, and Medical Director of the Lauder Breast Center, USA, said: “Comprehensive care of people with advanced breast cancer means a>en3on to all aspects of their health, including mental health. Discrimina3on is of course unacceptable. Furthermore, a mul3disciplinary approach toward special needs – compliance with treatment regimens and monitoring, effec3ve communica3ons, interac3ons between cancer and psychiatric medicines, and appropriate con3nuity of care – is cri3cal.”
The experts agreed that guidelines for trea3ng ABC should be implemented “independently of the age of the pa3ent” and the older, frail pa3ent “should be involved in the treatment decision-making process if they wish to do so, and their preferences should be taken into account”. They also stated that, “independent of age, all eligible pa3ents should be informed about poten3al clinical trials”. They highlighted the poten3al for drug interac3ons for this group as well, as many elderly pa3ents take several medica3ons for several different health condi3ons and diseases.
For pregnant pa3ents with ABC, the panel of experts stated that pa3ents should be managed by a mul3disciplinary team with experience in this extremely difficult clinical situa3on; the preferences of pa3ents should be taken into account, and, where appropriate, those of other people they may want to involve, such as partners, family and friends. The preferred scanning method to assess the cancer should be whole-body MRI, which is less likely to affect the foetus. Among all systemic therapies, only chemotherapy can be given safely, and then only in the second and third trimesters. An3-HER2 therapy and endocrine therapy cannot be given for the dura3on of the pregnancy.
ABC pa3ents living with HIV have worse survival rates than those without HIV and are more likely to develop infec3ons and adverse reac3ons to cancer drugs. The expert panel said mul3disciplinary teams, including an oncologist and an HIV specialist, should manage the care of these pa3ents. They should not be excluded from clinical trials, and doctors should consider reducing doses of an3-cancer drugs that induce immunosuppression, and/or increasing the intervals between doses.
The experts reviewed the newest treatments and issued new guidelines for three sub-types of breast cancer: ER posi3ve/HER2 nega3ve (or endocrine dependent), HER2 posi3ve, and triple-nega3ve disease (that lacks hormonal and HER2 receptors).
They also updated the definition of endocrine sensitivity or resistance. Dr Cardoso said: “These agreed definitions will help to ensure uniformity among clinical trials allowing for a better interpretation of results.”
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[1] This release relates to the ABC 7 consensus session on Saturday 11 November, 08.30-12.45 hrs GMT.
Over 1,100 parJcipants from approximately 90 countries around the world joined this major internaJonal breast cancer conference, including health professionals and paJent advocates.
Advanced breast cancer is defined as cancer that has spread beyond the site of the first (primary) tumour to other sites either within the same breast such as the skin, chest wall and some lymph nodes (locally advanced) or other parts of the body (metastaJc cancer). There are no reliable figures for the numbers of women and men living with advanced breast cancer. However, there are over two million new cases of breast cancer a year in the world and 0.6 million deaths. About 5-10% of cases are either locally advanced or have spread to other parts of the body at diagnosis, and these figures can reach 80% in developing countries. About a third of all early breast cancer cases will become metastaJc even with the best care, and the average overall survival for these paJents is between three and five years.
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