MJA Practice Essentials|
Psychosocial support, treatment of metastatic disease and
Michael A Ashby, David W Kissane, Geoffrey F Beadle, Alan Rodger
MJA 1996; 164: 43-49
Psychosocial support -
Principles of oncological treatment of metastatic breast cancer -
Complementary or alternative therapies -
Palliative care -
Further reading and reference material -
This article deals with four linked but distinct aspects of care for
women with breast cancer, with an emphasis on the pivotal role of the
Modern medicine is fast
recognising the need for psychosocial support of patients; in fact,
for an integrated approach to caring for the whole person at all stages
Oncological treatment of metastatic disease needs to be
individualised and based on realistic expectations of outcome
balanced against side effects.
An open dialogue about the role and appropriateness of
so-called "alternative" or "complementary" therapies is needed.
Despite significant improvements in palliative care
quality and access in Australia in the last decade, many
practitioners still require support and advice in this demanding
area of care (particularly about difficult symptom control).
Women with breast cancer are likely to experience various
psychosocial problems at different stages of their illness (Box 1).
The most useful way of differentiating between a normal grief
reaction and a classifiable psychiatric disorder is to assess the
degree to which the distress is generating undesirable personal,
family and social effects and to monitor intensity of symptoms. To
assist with the diagnosis of depression in the presence of a medical
illness, the Endicott9 criteria (depressed
appearance, social withdrawal or decreased talkativeness,
brooding, self-pity or pessimism, and a lack of appropriate
responsiveness in situations that would normally be pleasurable)
can be used in place of somatic symptoms like fatigue, anorexia,
weight loss and poor concentration.
Psychosocial morbidity can extend throughout the family. It has been
shown that for those women who enter palliative care programs,
substantial psychological morbidity is identifiable in half the
patients, a third of spouses and a quarter of their
offspring.10 Family-centred care that
recognises family members not only as primary care providers but also
as second-order patients is essential.7 There is a clear role for
general practitioners in this process, as an integral part of good
family medicine practice.
The themes which need to be addressed are summarised in Box 2.
Therapeutic interventions should be appropriate to the stage of the
disease and the woman's personal situation (Box 3). Good clinical
care requires that medical, surgical and nursing staff provide
opportunities for patients to express their concerns, anxieties and
preoccupations throughout routine management.
Coping skills and cognitive behaviour therapies11 may be more
applicable to early stage disease, while supportive
psychotherapies which encourage the sharing of feelings about
existential concerns are more suited to patients with metastatic
cancer.12 Another approach
utilises the central concept of loss. Women with breast cancer
grapple with many losses -- their health, breast, sense of
femininity, confidence, dreams and belief in the future. A primary
goal, therefore, is to facilitate adaptive grieving. So-called
grief therapy13 can be pivotal in much
cancer counselling, particularly in the light of the pervasive
pressure on women "to think positively". It is also important to deal
with the possibility of death. Education and clarification of fears
can help promote a sense of realism-based mastery.
Group therapies are cost-effective, provide a supportive network
and are acceptable to about two-thirds of women.
Pharmacological treatments complement psychotherapeutic
approaches (see Box 4). Major tranquillisers and benzodiazepines
can allay anxiety, assist in crises and help to contain distressing
features of delirium. Tricyclic antidepressants and selective
serotonin reuptake inhibitors help in depressive disorders. They
are prescribed for major depression, when sleep disturbance or other
depressive symptoms are moderate in degree and when poor coping and
chronic grief are persisting.
Reduced sex drive2 and reduced frequency of
intercourse invariably follow the initial diagnosis. Open
communication about intimacy and sexuality is desirable and may need
to be initiated by clinicians. The general practitioner should be
approachable for first contact on these issues. Clarification of the
role of altered body image, grief, depression, the nature of the
relationship and adjustment of both partners is necessary before
endocrine assessment is considered.
Although at present psychological interventions are usually
offered only to those who have become symptomatic or are perceived to
be particularly at risk, recent studies suggesting an association
between psychological wellbeing and survival compel us to consider
whether such therapies should be offered routinely.12,14,15 The
experience of stressful life-events, loss of hope, helplessness,
social isolation and failure to share negative emotions have all been
associated with poorer outcome.16 Large multicentre
replication studies of group therapy for women with both early stage
and metastatic breast cancer are currently proceeding in the United
States, Canada and Australia, in the hope of clarifying how critical
this role of support and coping is to overall survival.
Principles of oncological treatment of metastatic breast cancer
Metastatic breast cancer is incurable, but effective palliative
treatment is possible for most patients. The five-year survival is
about 5%-10%. In view of the variable natural history, treatment
plans have to be tailored to the needs of each patient. Surgery,
radiotherapy and systemic treatments have important and varying
roles during the course of the disease. The relative value of each
treatment is influenced by the dominant site(s) and distribution of
metastastic spread, the severity of symptoms, the general condition
of the patient, rate of progression of the disease and response to
previous treatments. It is crucial with all forms of palliative
therapy -- local or systemic -- that the benefits in terms of symptom
control are weighed against the expected toxicities of treatment.
The patient must be involved in these decisions as expectations,
tolerances and wishes will vary. Advice and support of general
practitioners and palliative care staff may be useful to complement
the input of the oncologist.
Approximately 30%-35% of patients with metastatic breast cancer
respond to endocrine treatment and 60%-70% to cytotoxic drug
treatment. Box 5 summarises the principles of selection of these
treatments. The therapeutic effect of endocrine treatment is
mediated through the oestrogen and progesterone receptors, and the
most important single characteristic predicting response to
hormone therapy is the original tumour receptor status (rate of
response 50%-60% if receptors are present, 10% if absent).
Resistance to initial endocrine treatment is associated with a very
small chance of a response to subsequent hormone manipulation, but
progression after a good initial response is an indication to
continue with second and even third line endocrine therapy until the
disease becomes hormone resistant. In practice, patients rarely
respond to more than two sequential endocrine treatments.
Endocrine therapy: For premenopausal patients
ovarian ablation (by oophorectomy or radiation) may be replaced by
medical treatment with the luteinising hormone-releasing hormone
agonists (e.g., goserelin and leuprorelin acetate). For
postmenopausal women the antioestrogen tamoxifen and oral
progestogens (medroxyprogesterone acetate and megestrol acetate)
are the most commonly prescribed treatments. Aromatase inhibitors
(e.g., aminoglutethimide and formestane [4-hydroxy
androstenedione]) have replaced adrenalectomy for those
postmenopausal patients who have exhibited protracted responses to
initial endocrine treatment.
Chemotherapy: The initial high response rate of
metastatic breast cancer to cytotoxic drugs and the eventual
development of resistance raise several important issues in
management. Combinations of cytotoxic drugs offer a better chance of
response than single agents, but do not yield substantially better
survival for most patients. The exception is those patients with life
threatening visceral metastases (normally in liver and lung).
Regimens including anthracyclines (doxorubicin, epirubicin) are
the most effective and are useful for aggressive or life threatening
disease. Less aggressive disease may be treated with less toxic
regimens, frequently based on mitozantrone, although there are a
considerable number of alternative options. Second and even third
line regimens are indicated when disease progresses after an initial
response, but response rate and duration are usually less with each
subsequent regimen. All treatments must be presented to patients as a
balance between a potentially beneficial tumour response and
unwanted cytotoxic effects.
Studies of dose intensification of cytotoxic drugs suggest higher
rates of response but only a minor improvement in survival. The
logical extension of these observations is the application of very
high doses of cytotoxic drugs followed by bone marrow rescue, in an
attempt to achieve maximum tumour control. Initial results indicate
high rates of response, but the ultimate worth of these treatments
awaits further evaluation and their use should be confined to
assessment in randomised controlled trials. Alternative
approaches include constant infusional chemotherapy, such as
fluorouracil given over many weeks, often with low toxicity. Newer
agents such as taxol have been extensively researched and are likely
to be approved for second or third line treatments.
The sensitivity of metastatic breast cancer to both cytotoxic and
hormonal treatments and their different mechanisms of action make
combined treatments attractive. However, the results of a trial
comparing sequential and concurrent administration of tamoxifen
and cytotoxic drugs (doxorubicin and cyclophosphamide) failed to
demonstrate better survival with combined modality
treatment.17 One Australian study
comparing standard (continuous) and less intensive (intermittent
course) cytotoxic drug treatment showed that the control of symptoms
and quality of life were superior in the group receiving continuous
chemotherapy, with a longer time to progression of cancer and better
survival in this group.18 A follow-up study
evaluating the physician's assessment of quality of life showed that
those patients assessed as having better quality of life at the time of
entry into the study also had better survival.19 It remains to be
determined at what point dose intensity and better survival in
metastatic breast cancer will be offset by unacceptable quality of
life, and the study should not be interpreted as justifying the
routine use of chemotherapy for advanced disease in the absence of
defined symptoms. It is also possible that the patients receiving the
more intensive treatment believed (despite information to the
contrary) that they had a better chance of cure or remission.
Patients' beliefs about treatment goals certainly require more
research and understanding, for both standard and alternative
Radiotherapy: Radiotherapy plays a major part in the
palliation of a variety of localised symptoms. Box 6 lists the role of
palliative radiotherapy, which can generally be given in one to five
(daily) fractions, frequently on an outpatient basis, with the
reasonable expectation of a significant impact on symptom control
for most patients. A randomised study of bone pain palliation has
confirmed that short courses are as effective and non-toxic as longer
courses of two weeks or more.20
Complementary or alternative therapies
Interventions such as massage, relaxation, aromatherapy,
hypnotherapy, acupuncture and homoeopathy have gained widespread
acceptance. The use of alternative therapies (such as naturopathy,
nutritional, immunological or physical treatments) is also common,
and may set the patient and clinician on a direct path of conflict which
can be difficult to resolve. Consequently, many patients do not tell
their clinicians that they are using them.21,22|
The need for patients to participate in decisions about treatment
should be emphasised at all times. Doctors should recognise the
limitations of modern oncological treatment, and be prepared to
acknowledge the patient's need to explore other avenues. It is often
helpful for doctors to offer to comment on this issue and such an offer
is rarely rejected. There may be times when doctors feel that they must
advise patients of a dangerous or futile treatment, with the
occasional possibility of real harm being caused, and it should be
pointed out that many therapies are completely untested.
Sometimes it is helpful to differentiate between therapies which
patients believe might cure them and those that help them to live more
comfortably with their disease. Gentle exploration of patients'
beliefs about potential curability of their disease may be
important. Positive thinking strategies which obstruct
appropriate care delivery for a dying patient may also need skilful
Modern palliative medicine offers a model of care which focuses on the
whole person, within their social and emotional context. There is a
difference between the adoption of a palliative approach and the
delivery of holistic, multidisciplinary care appropriate to the
individual patient's needs and wishes. It is not simply a matter of
knowing when to stop oncological treatment, nor of a "cookbook" style
of symptomatic management. The focus must be on the person rather than
the disease, although a good knowledge of the natural history of the
disease and relevant oncological practice is essential.
Active oncological intervention is often required for malignant bone
pain, fungating chest-wall disease or liver, lung or brain
metastases, and can be of value until a very late stage in the disease
process. About 10% of patients with metastatic breast cancer will
develop symptomatic hypercalcaemia (symptoms include nausea,
vomiting, polyuria, drowsiness) and should be treated with
intravenous rehydration, diuretics and a bisphosphonate infusion.
Pleural effusions may require aspiration if symptomatic. If they
recur, pleurodesis with talc, tetracycline or BCG may be required for
control of breathlessness. Meningitic carcinomatosis is very rare
and may respond to intrathecal cytotoxic agents or craniospinal
It is important that the general practitioner be fully informed of the
patient's management and condition. During a long disease course,
often with multiple oncological events, it is all too easy (and
understandable) for patients and families to become attached to a
hospital oncology service and its staff. This may pose problems for
palliative and terminal care at home, as a hitherto relatively
uninvolved general practitioner may have to suddenly take over care.
See Box 7 for definition of palliative care.
Early referral to a specialised palliative care source should be
considered for most patients with metastatic disease, to introduce
future options in palliative care. Although sometimes confronting
for patients and their oncological caring team, a commitment of
future support and proper care planning is of real value in allowing
patients to plan to live until they die. The general practitioner
should be actively involved in this process of communication to
ensure the smoothest possible transitions from curative to
palliative and terminal care.
In psychosocial support, emphasis is often required on issues of
family history (anxieties about daughters developing the disease),
body image and loss of femininity, although concerns about the latter
may be less pronounced than at initial diagnosis. For younger women
with children, death will leave the children without a mother, which
is probably the hardest aspect for a woman to bear. Work on helping to
hand over present and future parenting roles is required.
The proper and appropriate use of opioid drugs is an essential skill
for control of pain and shortness of breath. Nearly 30 years of safe
international clinical experience has led the World Health
Organization to recommend morphine as the opioid of first choice in
cancer pain management.23 Other drugs (either alone
or in combination with morphine) are usually required for deep
somatic pain caused by bone metastases or liver capsule inflammation
(non-steroidal anti-inflammatory drugs and corticosteroids), and
neurogenic pain (antidepressants, anticonvulsants, membrane
stabilising agents). Specialist help is nearly always required for
neurogenic pain, often with the additional involvement of an
anaesthetist with a special interest in cancer pain management.
The regular oral administration of the right dose of an appropriate
drug or drug combination is the cornerstone of modern cancer pain
management. The dose of morphine is adjusted according to the
patient's top-up (or "breakthrough") requirements. The management
of cancer pain with morphine is somewhat unusual in that there is no
absolute upper dose limit. Most patients will achieve initial pain
control on an oral 24-hour morphine dose in the range of 100-200 mg, but
there is very wide individual variation and if the dose continues to
rise without response the cause of the pain and the drug choice should
Advice about anticipated side effects and their prompt and effective
management is essential, together with frequent review of pain
control and analgesic dose. Intermittent subcutaneous injections
or infusions may be used if the oral route is not possible (e.g.,
because of nausea and vomiting), or not effective.
Shortness of breath, anxiety, acute delirium and so-called terminal
restlessness may be managed with anxiolytic drugs such as diazepam,
midazolam or clonazepam (after looking for a specific treatable
underlying cause). Antiemetics also require regular
administration in adequate doses, and may need to be used in
combination (e.g., prochlorperazine 25 mg rectally 3-4 times daily
with metoclopramide 30-90 mg per 24 hours by subcutaneous infusion).
Bowel care is important (and often neglected) throughout the
illness, but particularly towards the end of life. Most patients
taking morphine will require a regular prophylactic aperient.
Intensification of supports and symptomatic treatment will usually
be required as death approaches, particularly if the patient and
family have chosen for this to occur at home with the help of a
domiciliary palliative care team (Box 8).
Doctors are being challenged to focus on the needs of the whole person
and to work collaboratively with colleagues from other disciplines.
Psychosocial support may be required from the time of diagnosis and
should be an intrinsic part of caring throughout the course of the
illness. It is also now widely accepted that there is more to the
management of incurable disease than tumour regression alone, and
therapeutic interventions need to be critically assessed on the
basis of their impact on palliative endpoints, quality of life and
We thank Dr Angela Rutherford, General Practitioner, East Brunswick
Medical Centre, Victoria, for her comments and assistance.
- Walker LG, Cordiner CM, Gilbert FJ, et al. How distressing is
attendance for routine breast screening? Psycho-Oncology
1994; 3: 299-304.
Fallowfield LJ, Hall A, Maguire GP, et al. Psychological outcomes
of different treatment policies in women with early breast cancer
outside a clinical trial. BMJ 1990; 301: 575-580.
Silberfarb PM, Maurer LH, Crouthamel CS. Psychological aspects of
neoplastic disease: 1. Functional status of breast cancer patients
during different treatment regimens. Am J Psychiatry 1980;
Dean C. Psychiatric morbidity following mastectomy:
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Bukberg J, Penman D, Holland JC. Depression in hospitalised cancer
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Maguire P. The repercussions of mastectomy on the family. Int J
Fam Psychiat 1981; 6: 485-503.
Kissane DW, Bloch S, Burns WI, et al. Perceptions of family
functioning and cancer. Psycho-Oncology 1994; 3: 259-269.
Massie MJ, Holland J, Glass E. Delirium in terminally ill cancer
patients. Am J Psychiatry 1983; 140: 1048-1050.
Endicott J. Measurement of depression in patients with cancer.
Cancer 1984; 55: 2243-2248.
Kissane DW, Bloch S, Burns WI, et al. Psychosocial morbidity in the
families of patients with cancer. Psycho-Oncology 1994; 3:
Moorey S, Greer S. Psychological therapy for patients with
cancer. A new approach. Oxford: Heinemann, 1989.
Spiegel D, Bloom JR, Kraemer HC, et al. Effect of psychosocial
treatment on survival of patients with metastatic breast cancer.
Lancet 1989; 1: 888-891.
Worden JW. Grief counselling and grief therapy. 2nd ed. New York:
Fawzy FI, Fawzy NW, Hyun CS, et al. Effects of an early structured
psychiatric invention, coping, and affective state on recurrence
and survival 6 years later. Arch Gen Psychiatry 1993; 50:
Greer S, Morris T, Pettingale KW, et al. Psychological response to
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Mulder CL, Van der Pompe G, Spiegel D, et al. Do psychosocial
factors influence the course of breast cancer? A review of recent
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Psycho-Oncology 1992; 1: 155-167.
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combination. J Clin Oncol 1982; 4: 186-193.
Coates A, Gebski V, Bishop JF, et al. for the ANZ Breast Cancer
Trials Group. Improving the quality of life during chemotherapy for
advanced breast cancer. A comparison of intermittent and continuous
treatment strategies. N Engl J Med 1987; 317: 1490-1495.
Coates A, Gebski V, Signorini D, et al. for the ANZ Breast Cancer
Trials Group. Prognostic value of quality-of-life scores during
chemotherapy for advanced breast cancer. J Clin Oncol 1992;
Price P, Hoskin PJ, Easton D, et al. Prospective randomised trial
of single and multifraction radiotherapy schedules in the treatment
of painful bony metastases. Radiother Oncol 1986; 6:
Downer SM, Cody MM, McCluskey P, et al. Pursuit and practice of
complementary therapies by cancer patients receiving conventional
treatment. BMJ 1994; 309: 86-89.
Eisenberg DM, Kessler RC, Foster C, et al. Unconventional
medicine in the United States. Prevalence, costs and patterns of use.
N Engl J Med 1993; 328: 246-252.
World Health Organization. Cancer pain relief. Geneva: WHO,
Further reading and reference material
- Woodruff R. Palliative medicine. Symptomatic and supportive care
for patients with advanced cancer and AIDS. Melbourne: Asperula,
Raphael B. The anatomy of bereavement. A handbook for the caring
professions. London: Routledge, 1984, reprinted 1990.
Dunlop RJ, Hockley JM. Terminal care support teams. The
hospital-hospice interface. Oxford: Oxford University Press,
Buckman R. I don't know what to say. How to help and support someone who
is dying. Sydney: Sun, 1990.
Derek Doyle. Caring for a dying relative. A guide for families.
Oxford: Oxford University Press, 1994.
Doyle D, Hanks GWC, Macdonald N, editors. Oxford textbook of
palliative medicine. Oxford: Oxford University Press, 1993.
Trevelyan J, Booth B. Complementary medicine for nurses, midwives
and health visitors. London: Macmillan, 1994.
Spiegel D. Living beyond limits. New York: Times Books, 1993.
Palliative Care Centre, McCulloch House, Monash Medical Centre,
Michael A Ashby, FRCR, FRACP, Professor of Palliative Care,
Department of Medicine, Monash University.
Department of Psychiatry, Monash Medical Centre, Clayton, VIC.
David W Kissane, FRACGP, FRANZCP, Senior Staff Specialist, and
Senior Lecturer, Department of Psychological Medicine, Monash
Wesley Medical Centre, Auchenflower, QLD.
Geoffrey F Beadle, FRACP, FRACR, Medical Oncologist.
William Buckland Radiotherapy Centre, The Alfred Health Care Group,
Alfred Hospital, Prahran, VIC.
Alan Rodger, FRCS, FRACR, Director and Professor, Department of
Radiation Oncology, Monash University.
No reprints will be available.
Correspondence: Professor M A Ashby,
McCulloch House, Monash Medical Centre, Clayton, Vic 3168.
1: Frequency of psychosocial problems|
|Psychosocial problems||Phase of illness||Frequency|
|Anxiety disorders||Mammography1|| 20%|
|Adjuvant therapies4||Minor 20%;|
|Sexual disorders||Remission/survival2|| 38%|
|Family relationship problems||Remission6||33%|
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3: Range of psychosocial supports|
|Early stage group therapy||Group therapy is being assessed as an adjuvant to initial medical therapy|
|Advanced breast cancer group therapy||Distress and poor coping; anxiety and depression; routine support|
|Individual supportive psychotherapy||Symptomatic anxiety and
|Family therapy||Family distress and poor coping|
|Couple therapy||Marital and sexual difficulties|
|Community-based self-help groups||General support|
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4: Useful psychotropic agents|
|dothiepin||75-300 mg at night|
|mianserin||20-120 mg at night|
|sertraline||50-200 mg daily|
|paroxetine||20-40 mg daily|
|moclobemide||150-900 mg divided into two daily doses|
|diazepam||2-40 mg divided into two or three daily doses|
|clonazepam||0.5-8 mg divided into two daily doses|
|haloperidol||1.5-10 mg divided into two or three daily doses|
|midazolam||1-5 mg single doses by intravenous injection, as required
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5: Guidelines for selecting systemic treatment|
|Initial systemic treatment|
|Endocrine treatment||Cytotoxic drug treatment|
|Clinically indolent disease||Aggressive disease|
|Long disease-free interval||Short disease-free interval|
|Slow progression||Rapid progression|
|Positive tumour hormone receptor status||Negative tumour hormone receptor status|
|Low tumour bulk/few sites||High tumour bulk/many
|Special site(s): bone marrow, liver, lung (lymphangitis carcinomatosa)|
|Second and subsequent systemic treatments|
|Endocrine treatment||Cytotoxic drug treatment|
|Prior good response to endocrine treatment||Progression after first
endocrine treatment requiring more intensive therapy|
Minimal or no response to previous endocrine treatments
Good response to previous cytotoxic drugs
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6: Indications for palliative radiotherapy |
- ulceration, bleeding
- supraclavicular or axillary nodes
|- localised: external beam localised fields|
|- widespread: hemibody irradiation|
|base of skull/orbital disease|
|impending or pathological fractures|
|- internal fixation and postoperative radiotherapy|
|- surgical decompression and stabilisation rarely indicated|
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7: Definition of palliative care|
Hospice and palliative care is defined as a concept of care which provides coordinated medical, nursing and allied services for people who are terminally ill, delivered where possible in the environment of the person's choice, and which provides physical, psychological, emotional and spiritual support for patients and for patients' families and friends.
The provision of hospice and palliative care services includes grief and bereavement support for the family and other carers during the life of the patient, and continuing after death.
From: Australian Association for Hospice and Palliative Care Inc. Standards for Hospice and Palliative Care Provision, March 1994.
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8: Clinical and practical issues in planning the palliative care of a person dying at home|
- Pain and symptom control
- Place of care and death (home, hospice, hospital, nursing home)
- Role of the team members (who to call for help and when)
- Aids and equipment
- Distressing events (expected and unexpected,
such as terminal confusion, vomiting or
- The actual dying process (explaining to family how death usually occurs)
- What to do at time of death
- What to do after death (funeral arrangements, death certificates)
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