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Hello, I'm Helen Zorbas,
and it's my pleasure to welcome you
to this breast cancer education series
produced by National Breast & Ovarian Cancer Centre,
in collaboration with the Rural Health Education Foundation.
We're delighted to have you, as health professionals
in rural and remote areas of Australia, joining us for this program
focusing on breast cancer care.
In Australia, approximately 30% of women diagnosed with breast cancer
live outside a major metropolitan city.
As well as their cancer diagnosis,
these women face additional challenges including geographic isolation
and limited contact with specialist health care workers.
As rural health professionals, you have a vital role to play
in both the provision of information and the delivery
of best practice clinical and supportive care
for rural women with breast cancer.
We hope that through this series,
we improve your access to evidence-based information
and ultimately benefit the women with breast cancer in your care.
The program has been developed
to be specifically relevant to rural practice
and I would like to thank our facilitator Dr Norman Swan
and the breast cancer experts and rural health professionals
who have contributed their time and expertise to this broadcast.
I hope you enjoy the program.
Thanks to Helen Zorbas, the Chief Executive
of the National Breast & Ovarian Cancer Centre.
And welcome to the program on secondary breast cancer -
finding breast cancer outside the breast.
This is a joint initiative as Helen just said
of the National Breast & Ovarian Cancer Centre
and the Rural Health Education Foundation.
It's also a project of the Supporting Women in Rural Areas
Diagnosed with Breast Cancer program
and it's funded by the Australian Government.
Now most women who present with secondary or metastatic breast cancer
will have already been diagnosed with and treated for early breast cancer.
Although, for some, this will actually be how they present.
Today we're going to consider some of the challenges
in looking after women with secondary breast cancer,
recent developments and treatments
and the psychosocial and supportive care needs
of women and indeed their families.
You'll find a number of useful resources available
on both the National Breast & Ovarian Cancer Website,
nbocc.org.au,
and on the Rural Health Education Foundation's website, rhef.com.au.
I want to introduce our panel to you.
Tony Hobbs is a rural general practitioner
from Cootamundra in New South Wales.
- Welcome, Tony. - Thank you, Norman.
Jane Ingham's Professor of Palliative Medicine, at the University of NSW,
and is also at the Cunningham Centre for Palliative Care in Sydney.
- Welcome. - Thank you.
Chris Keogh is a clinical nurse specialist in palliative care
at the Mercy Care Centre in Young in rural New South Wales.
- Welcome, Chris. - Thank you.
Chris Milross is Head of the Department of Radiation Oncology,
at Royal Prince Alfred Hospital in Sydney. Welcome, Chris.
Very happy to be here.
Nicholas Wilcken is Director of Medical Oncology
at Sydney's Westmead Hospital. Welcome.
- Hi, Norman. - Welcome to you all.
Now, before we start our discussion, let's hear briefly -
'cause we want to be really, as focused as we can on the woman's journey
with breast cancer - and hear from Judy who has metastatic breast cancer.
JUDY: 1993, breast cancer sneaked into our lives like a thief in the night.
Lloyd, Oliver, Kyle and Tara, my greatest wish was to see you grow up,
grow old with your father,
sit on the verandahs, surrounded by grandchildren.
I never wanted our lives to change.
We moved to the country and hoped we'd left breast cancer behind.
Cancer returns to my body - to lung, bone and spine .
My *** are gone - *** that nurtured four children
and gave pleasure.
In their place, a tapestry of the scars and wounds of the last 12 years.
I struggle to make sense of my life.
I hold back the pain and the tears buried so deeply,
feeling dead, dry and hollow, ready to splinter.
Thank you to the Breast Cancer Network of Australia
for providing Judy's story.
Tony, um, unfortunately, not an unusual story.
It's not, but not one that we often see in general practice, Norman,
and I think that's a really important message tonight -
even though metastatic breast cancer
is not gonna be a common presentation in general practice,
we need to think about it in women that present with new or different symptoms
that've had breast cancer in the past, and help them navigate their way forward
with a good management plan in place, working with our specialist colleagues,
and to make sure that we bring a message of hope and support
not only to the woman but also to their family.
Chris Keogh, I mean, it does illustrate though,
the support that such a woman and her family need.
Yes, it does, and it's probably important for these rural women
that can be quite isolated as well,
so there are supports around in the country
and it's important to work, I guess, with the GPs and as a team
with the families to help these women at this time.
We'll come back to more of these things later.
Nicholas, of all women with breast cancer,
what proportion does it come back?
It's difficult to get really accurate figures but broadly speaking,
around about 20% of all women with an initial diagnosis of breast cancer
will ultimately get a recurrence... - So, 80% are cured of it?
So, 80% do not in their lifetimes get a cancer recurrence,
and we sometimes forget that when we concentrate on metastatic disease.
And is that proportion getting lower?
It is getting lower.
As our screening detects cancers early and our adjuvant treatments work better,
we are finding fewer and fewer women developing metastatic breast cancer -
or secondary breast cancer -
and also that where it does recur, it's starting to recur later and later.
And what's the pattern over time?
So, over time, we still mainly worry about the first five years.
I think there's a graphic we're about to see that illustrates that.
We'll see in the first five years the risk of recurrence is highest,
but it never goes away, and if you have a look at that graph
down at the ten-year mark, you'll still see that maybe 0.5%,
1-2% a year, women are getting recurrences,
and at that point, ten years down the track,
it's mainly the women who initially had hormone-receptor-positive disease
who are at risk very late on.
NORMAN: What are the risk factors for recurrence?
Can you predict who's gonna get a recurrence?
You can to an extent although it's an imperfect science,
but essentially, the risk of recurrence
depends on how bad the disease was initially,
largely measured by how big the tumour was,
whether it involved axillary lymph nodes or not and if so, how many,
and then certain aspects of the biology of the tumour -
high grade versus low grade -
hormone receptors there versus not there - and increasingly of course,
we're interested in HER2-positive disease as well.
So, you can put together a kind of a nomogram with that information
that will broadly estimate for you the likelihood of recurrence,
and of course, based on that, we will recommend or not recommend
certain adjuvant treatments that will potentially
prevent or delay that recurrence.
Is there any way of predicting in a woman which organs she may be liable...
Look, only very broadly,
and that is that the lower-grade hormone receptor positive cancers
have a predilection for recurring late, as we said, and also recurring in bone,
so the scenario of widespread bone metastases
but no metastases elsewhere
is very typical of hormone receptor positive cancer.
Hormone receptor negative cancers tend to more recur in the viscera.
- And HER2-positive... NORMAN: It's liver and lung?
Liver and lung, in particular, and HER2-positive breast cancer
has a particular predilection for brain metastases.
And, Chris Milross, women and their families wanna know the prognosis -
it's come back, they wanna know the prognosis.
How accurate is the dark art of prognosis in recurrent breast cancer?
I think the honest answer to that question
is that the dark art of prognostication
is probably not very accurate,
but there are a range of scenarios...
The outcome for the woman diagnosed with metastatic breast cancer
is, uh... perhaps best in the context of a woman
who's had a long disease-free interval.
So, you know, 5 years, 10 years, even 15 years,
from treatment for the primary cancer
through to the presentation with metastatic disease.
The pattern of that metastatic disease at presentation
together with the features of the primary cancer that Nick mentioned
also influence prognosis.
So, fewer secondaries in less disseminated?
Long disease-free interval, bone-only secondaries,
previous hormone receptor positive disease -
those things all portend a better prognosis.
A shorter disease-free interval, high-grade disease,
triple-negative disease and the prognosis is more problematic.
Is local recurrence secondary breast cancer?
- And is contralateral... - You probably say 'no'.
Because, I think, when we say...
There's always a grey zone in these classifications,
but when we say 'secondary' or 'metastatic breast cancer',
what we're saying is
that is recurrence away from the breast, chest wall, axilla region,
such that although as we'll see, there are multiple treatment options,
that disease is ultimately incurable.
I think that's the basic definition.
So, were a woman to get a recurrence in the breast
if she hasn't had a mastectomy or in the chest wall if she has,
that is a potentially salvageable and curable situation.
If a tumour is found in the other breast,
it may or may not be a second primary,
so again, that's a potentially salvageable situation.
What about surveillance, Tony?
How do you... What's your practice in terms of following...
So, a woman's been treated for early breast cancer,
she's now... she's not on any treatment anymore,
she's had her adjuvant chemo and radiation
and she's just being followed through.
What surveillance do you routinely practise
and what do the guidelines say?
I think there's a couple of issues here.
The first is that you need to make sure that
the woman is comfortable with having her surveillance with her GP.
Some people wish to continue seeing our specialist colleagues,
the oncologist or perhaps the breast surgeon, on a regular basis.
And interestingly, the NBOCC -
the National Breast & Ovarian Cancer Council -
is actually doing a trial in four centres about this at the moment.
Certainly, the evidence around surveillance
is to offer the woman who has survived her breast cancer regular follow-up.
So, in the first two years, coming back every three to six months
to take a thorough history and physical examination,
in the next two years, every 6 to 12 months and thereafter, every year.
And you can see this on the follow-up schedule.
It's really important that each of these women have a mammogram
and/or an ultrasound, depending on their age, every 12 months,
but also to make sure that we don't do any other investigations
unless there is good symptomatic suggestions
that there may be a recurrent disease somewhere,
and that's pain or some other change.
Because is there any evidence that early detection of recurrence changes outcome?
No, there isn't.
In fact, the converse is true
that as much as it has been looked at so far,
trials of very intensive surveillance have not shown to be beneficial
and might be actively harmful,
as opposed to what we've just heard from Tony.
And the two problems with doing the kind of imaging that we have available to us
other than mammograms are No.1,
that any abnormality that you find in an asymptomatic woman
is probably likely to be a furphy,
and so you've created a whole lot of anxieties
and extra tests that need to be done.
And secondly, as you implied from your question,
this is ultimately incurable disease,
often slowly evolving, and finding those lung metastases or whatever there are
in month one, as opposed to month three or month four,
does not make any difference.
Jane, given that we're talking about end of life here...
End of life might be ten years from now but it's still...
..it's kind of an end-of-life diagnosis.
Um... are we still seeing referrals that are too late for palliative care
where they could've been helped by being seen earlier?
Well, it depends whether you refer to palliative care
as a palliative-care specialist or a team of people who are addressing
your palliative-care needs -
some of which may be your psychosocial concerns,
your anxiety, your worry, your fears, others may be symptoms.
And I think, um... if a GP, particularly in a rural setting,
and a community nurse and an oncologist who's at a distance
or intimate and visits, are addressing that spectrum of needs,
then I think there doesn't necessarily need to be
a referral to palliative care.
That said, if the symptoms are difficult to control
or the psychological concerns are worrying
and out of the usual realm or out of the skills of the GP
with regard to managing them,
I think that's the time to call a specialist.
But palliative care can play a big role throughout the course of illness,
depending on the patient's needs.
Chris Keogh?
Yes, certainly what Jane said is true.
I think people like this will move in and out of palliative care
as the need arises.
If it's a more complex problem that they may have,
then certainly palliative care might be involved in that
and then referring back to.
Tony, do you think people recognise that palliative care
does not mean that you're gonna die next week
and that this is about complex symptom management and helping you out,
or is that still, if you like, a stigma
or a problem with the name 'palliative care'?
I think there are misconceptions, both from the people in the community
but also among some health professionals about the role of palliative care.
And I would certainly strongly endorse what both Chris and Jane have said
about using the team, but about having the conversation with the woman involved
and her family early in a structured, supportive manner,
and making sure that they understand what palliative care is about.
Some people will choose to engage early, some people won't,
and we need to ensure that people
have the information to make an informed choice.
Let's go to our first case study who's Leah.
NORMAN: She's come to see you previously, Tony,
with aches and pains in her right arm and chest
and has limited mobility on the right side.
You'd sent her to physio, some improvement in her symptoms,
but she's back again, and now there's a bit of upper back pain.
Well, this is a potentially, um... not uncommon scenario
in that we have a survivor from breast cancer
who's been treated quite some time ago,
that you've had an ongoing relationship with them,
that you know the particular person well
and you've got a relationship with their family at some level.
So, it's in that context that she comes with quite a new symptom -
pain which is different from her previous pain
related to her surgery and/or radiotherapy,
it's in a different site, it's keeping her awake at night,
it's worse with movement.
That would raise red flags for me as her treating GP,
and we would need to have a discussion about whether or not
this might be metastatic breast disease
or in fact, whether it might be something else
like a muscle strain perhaps,
or perhaps even as osteoporotic fracture in someone of this age.
So, it's really important to have that discussion up-front -
not to alarm the woman but to say that
this could represent a metastatic disease
and then have a management plan with her
about how you're going to move forward.
And that may be investigating that early with an X-ray and/or a bone scan,
it may well be having a conversation with a previous treating specialist
at the regional centre, but to make sure that the woman understands
that you'll be with her, that you'll have a plan in place,
both to investigate and if necessary treat,
should the diagnosis be confirmed.
Is that your script, Nicholas?
Yes, I think so. And I think it's -
at what's a potentially difficult time for the woman -
good for her to know that the GP is concerned
about the possibility of recurrence, he's going to do some imaging
and has contact with the initial treating specialist,
so that the woman - although she's gonna be very worried -
at least can see a kind of a linear progress of what's gonna happen.
And the initial contact we would hope from the rural GP
is to be able to contact fairly directly
the oncologist - medical oncologist, radiation oncologist, whoever it is -
so that if it turns out that she needs to come to some bigger centre
for either assessment or treatment or both,
that can be done fairly quickly.
Why does it need to be done quickly?
It needs to be done from a psychological point of view.
If she's got severe pain it may need to be done quickly,
but from a purely medical point of view, if there are no obvious complications
and it does turn out that this is a bone secondary with some pain
that's perhaps controlled with some Panadol or Panadeine,
then there's no medical urgency,
but there's usually - with a first diagnosis -
a pretty serious psychological urgency.
So, in a sense, was Tony wrong to have delayed this?
She had symptoms on the right side, now she's come back
with upper-thoracic pain, he sent her off to the physio...
- No... - Should he have responded earlier?
Absolutely not. There's two interesting points there.
One is... which is tricky for all of us - GPs and specialists alike -
is women who've had treatment for breast cancer
and surgery and radiotherapy
often have non-specific symptoms on that side that are tricky to sort out,
and often you've had the third or the fourth complaint,
so you might actually trigger a bone scan in that setting
which will turn out to show nothing and what Tony's responding to
is a new symptom that has persisted and has got worse,
so that's when you investigate,
and investigating beforehand is just gonna lead to a lot of furphies.
- Chris? - Breast cancer...
Previous breast cancer doesn't protect you from the aches and pains
of ageing and life - Tony's not wrong at all.
Did you want to say something, Jane?
No, but I think when you have any symptom,
it's important to look at the symptom
in terms of its aetiology as well as to how you'll treat it.
So assuming Tony's gone through a thought process -
which I'm sure he has -
about what the cause of the right arm pain is
that may have been present for years, came on immediately post-surgery,
and detected that there's something new
and has in his mind a pathophysiology for that first pain
as well as the second pain,
then that's how to think it through - there's no problem with that.
But if there's no... biologically, if there's no urgency... Early detection...
We've already agreed that early detection of spread
is not gonna change the outcome.
That can be quite hard to explain to somebody post-hoc...
'We're not sure what this is,
but I'll send you to the physio, see you in a couple of weeks.'
- I think it's important... - Word gets around town,
'He missed the fact that it had spread' you know?
I'm quite sure... I'd defer a little to Tony and how he deals with that
'cause I don't deal with that commonly,
but there are ways of communicating that...
Comes back to Tony saying usually in the rural setting,
this is someone you already have a relationship with,
and if it turns out that it is someone who is always exceptionally anxious,
well, sure, you may end up doing
more bone scans than you otherwise would've.
I think there's a really important message
that remember, this is an individual patient sitting with us,
and I agree with what Nicholas has said -
we will respond according to the situation.
You might have someone who's really anxious,
you might have someone who's very relaxed and very happy to wait,
and really,... - The issue transparency - be honest.
TONY: Absolutely. - And setting up a clear plan, I think,
so the patient feels confident, as Nicholas said before,
that the team is involved and there's a stepwise plan to sort this out.
Now, a woman in this situation, um... Chris Keogh...
..people say requires support, as indeed she does,
but what does support actually mean?
We talk about psychosocial support, we talk about psycho-oncology.
In a rural town - in a country town - what does support actually mean?
What do you think she needs
that she's not got from the conversation we've just heard with Tony?
- Um... - She hasn't got a diagnosis yet.
- That's certainly right, and... NORMAN: ..which reminds me...
But I think it is important to give these people support,
coming from a community nursing background...
NORMAN: But what does it mean? - To go in, spend time, listen, um...
Sometimes there might be other issues going on at the time -
the family might need some extra help,
she may be not coping well with this pain,
even in the basics of housekeeping or things like that.
So, that early referral to other services
might be appropriate at this time,
even though she hasn't got that palliative care sort of diagnosis yet.
Nicholas, Tony's on the phone to you, asking for advice
about what imaging or what diagnostics would be most appropriate.
What are you gonna say?
I think as Tony said, if we're worried about what sounds like,
I guess, the thoracic spine,
it's probably reasonable to get some plain X-rays, um...
..and unless they're completely and absolutely normal,
you're probably gonna proceed fairly quickly to a bone scan.
Well, let's have a look at Leah's bone scan,
'cause that's, in fact, what she had.
Chris?
CHRIS: Leah's bone scan shows numerous, uh... foci in ribs
in a pattern typical for bone metastatic disease.
And then if we take a look at the next image
which shows us the thoracic spine in more detail,
you can see activity in the 11th thoracic vertebral body.
Taken together, a pattern suggestive of...
..highly suggestive of bone metastatic disease.
And, Chris, would you go on and do CT and look for metastases elsewhere?
Um... I may under certain circumstances
because of one of the most serious consequences
of a metastasis in a vertebral body
which is compression of the spinal chord.
So, what specific circumstances would drive me towards further imaging?
Um... severe pain and... certain neurological symptoms, Norman,
including, uh... a radicular pattern to the pain,
sensory disturbance in the lower limbs,
a feeling of unsteadiness of frank weakness
and/or bladder and bowel symptoms -
those sorts of things taken together
would make me worry about the potential for spinal chord compression,
and I would definitely want more than just an X-ray and a bone scan.
And would be looking at the liver and lungs, um, Nicholas?
I think there are probably two phases of investigation here.
The first is the rural GP determining
whether this is a non-specific ache and pain,
an osteoporotic fracture or indeed metastatic breast cancer,
and for that, as Chris has just said, we want a plain X-ray and a bone scan,
and if there aren't any neurological concerns,
probably don't need any further imaging.
That gets us a diagnosis and we move on to treatment.
After we've - as we'll come to discuss -
after we've essentially calmed things down,
there's probably a role in doing a CT scan then because this woman
is now starting what hopefully will be a very long metastatic journey,
and it's not unreasonable, right at the beginning,
just to establish if there's any other disease that we have to know about.
But not in terms of the initial management.
So, treatment - radiotherapy for this or chemo?
Radiotherapy for this local T11 problem with the aim
of palliating the pain that's present now
and preventing progression of the metastasis in that site
and ultimately the development of neurological consequences of that.
So, yes, radiotherapy,
but radiotherapy as part of a more general approach to the pain.
And what about if she's got other lesions elsewhere?
You wouldn't treat those,
you'd just leave them be if they're not problematic?
We wouldn't treat them with radiotherapy,
but having made a diagnosis of metastatic disease,
we would address those other lesions with a systemic agent.
So, is this where bisphosphonates come in, Nicholas?
Yes, but more importantly, endocrine therapy,
so this is the pattern we mentioned before where her disease has come back
ten years down the track,
the original disease was hormone receptor positive
and this highly likely to be hormone receptor positive disease.
So, there's no immediate indication for chemotherapy,
it's very likely that the rest of her disease will come under control
with some endocrine therapy like...
You could try tamoxifen again or probably an aromatase-inhibitor,
and then, yes, there is a role for bisphosphonates...
I thought they helped prevent spread to bone?
That's a controversial area... issue.
They may but the main indication for bisphosphonates in this setting
is that they've been shown in a number of trials
to minimise the risk of fractures and to help with pain
and to reduce the future need for radiotherapy.
Do they have to be given IV 'cause of the risk of the osteonecrosis?
You have. From a rural setting, there are potent intravenous, um...
..bisphosphonates that only need to be used every few weeks,
and the risk - at least over the first year or so -
of osteonecrosis of the jaw is extremely low.
But there are also effective oral bisphosphonates -
clodronate has been shown in randomised trials
to be helpful for women with metastatic breast cancer.
And if it's a woman who doesn't need to have chemo -
so she's gonna have an endocrine therapy tablet -
then it would be very reasonable for that woman to be on oral clodronate,
so that she doesn't need to be tied to a cancer centre...
What about metabolic problems such as hypocalcaemia
where you get extreme fatigue, flaccidity, that sort of thing?
Hypocalcaemia, because we use bisphosphonates,
is not nearly as common as it used to be,
and is generally seen in a woman with, uh...
heavy, multiple-bone metastases -
more than what we saw on that bone scan -
at a time when her disease is progressing.
So, certainly, a woman with known bone metastases,
a story of getting sick - being nauseous, pain worsening...
Other things could happen - she could develop liver metastases -
but a set of bloods including liver function tests
and calcium would be in order.
What's the course of radiotherapy?
Say, you were just treating the thoracic...
I mean, how many weeks, how many...?
Palliative radiotherapy courses are typically very short,
so for a bone metastasis such as this
where we are satisfied that the bone has solid structural integrity,
then a palliative course of treatment might be as few as five fractions
or even a single fraction.
In fact, the two options
have been compared in a number of randomised trials
and are shown to produce, at least initially,
equally effective palliation of pain.
For a rural patient, my personal bias
is generally to give a slightly more protracted...
..course of treatment
because the one potential advantage of that approach
is to reduce the likelihood that the same area
will need to be subsequently re-irradiated.
So, you just sort of steel belt it?
If you're bringing a person from the country
to the city for radiotherapy treatment,
do it once instead of having to do it twice.
Nicholas, just give us a quick cook's tour through the symptomatology
that a general practitioner needs to look out for in the broad
for metastatic breast cancer?
Again, the key is a new symptom
that persists and gets worse rather than better.
We've seen what happened to Leah with new back pain that got worse.
In terms of visceral disease, uh...
..fatigue, a general, um...
..difficulty in coping with the frenetic pace of the day,
maybe some right upper quadrant tenderness,
being a little bit off the food, um...
..a bit anorexic, maybe a bit of weight loss, um...
If liver function tests are completely normal in that setting
and there's nothing to feel in the right upper quadrant
it's unlikely that's there's a significant load of liver metastasis -
could be something subtle but unlikely to be anything
to be immediately worried about.
Um... and I guess in the era where our systemic therapies
for initial disease are working better and better,
so women are living longer and longer,
we are starting to see occasionally - more than we used to in the past -
brain metastases, so feeling sick every morning,
headache that's not going away or some kind of neurological symptom.
Most of those things won't turn out to be brain metastasis,
but that's the sort of thing where Tony does have the conversation,
'I'm a little bit worried - let's get a CAT scan'.
Occasionally, an optometrist picks it up with a retinal deposit.
Yeah.
And presumably, the investigations you do
are common-sense... Tony...
..investigations arising from symptoms you're seeing
rather than jumping to a CT pulmonary angiogram
with everybody you see with a cough?
Look, that's true. Once again, it's about this individual patient
and her symptoms, and treating those appropriately with a plan in place.
So, not to jump to a conclusion, but to take things forward stepwise...
Although it's easy to forget that thromboembolic disease
is a lot more common in this group of women.
It is, and indeed, if someone turned up in my practice
that had had breast cancer in the past with dyspnea,
perhaps pleuritic pain, maybe a bit of a cough,
you would investigate that appropriately over a period of time,
and would be chest a X-ray, maybe an ECG,
and always thinking of the diagnosis of pulmonary embolism
and maybe using a scan or a CT pulmonary angiogram.
Chris Keogh, what are the psychological reactions
that a woman gets at this time when she's now been told
that, you know...
..her worst fears are confirmed that the cancer has come back?
Um... sometimes these women can be quite angry, um...
..not really understanding why that's happened
when they've understood that some of the treatment
or the treatment they've previously had is curative treatment,
so they can be quite angry about that.
Or just generally anxious and concerned what's actually happening with them
and where that sort of journey's going now.
What I want to talk to you about now
is there is a guide for women with secondary breast cancer
to help understand their diagnosis and treatment options.
This is an updated guide based on the clinical guidelines
and it's available free of charge from the NBOCC,
and that's nbocc.org.au, I think.
So, Leah's bone scan confirms bone metastases...
And you wouldn't jump into chemo here if there are no other, um...?
NICHOLAS: No, and the key points there are
it's been a long time since her primary disease,
so we expect the outlook to be better than average,
that it's a hormone-rec... that the primary cancer
was hormone receptor positive - and not always
but probably 85% of the time, that persists in the metastatic setting -
and also that, as far as we know, the disease is mainly in the bone.
They're all things that would suggest that she'd probably respond well
to endocrine therapy,
and then we can save up chemotherapy for a time when we more need it.
How long would you expect to get a pain response,
an analgesic response to the radiotherapy?
It's a very good question and it's an extremely individual, um... finding.
Some patients will have an improvement in their pain
after the first fraction of treatment,
some patients will need a week or two beyond the end of the course
of the radiotherapy to get an improvement in their pain
and everybody else is somewhere in between the two.
Generally, the pain will improve during the course
of a palliative radiotherapy treatment for bone metastases.
So, what's your approach to the treatment of pain then, in Leah?
Obviously, on the day that the decision's made to give radiotherapy,
they'll be no response to the radiotherapy -
you know, it'd take us a day or two or a week to get that thing organised -
so we need to start with some analgesia in the meantime.
So, what would you do, Tony, before she...
You know she's gonna get her radiotherapy in two weeks time.
What'll you do for her in terms of her pain?
Well, it would depend how severe the pain was
and what I thought was actually causing the pain.
So, you would build on perhaps simple analgesia -
paracetamol, anti-inflammatory agents, for instance -
but you may need to either, at that time, introduce opiates, for instance,
or even other medications, depending on the pain,
and indeed, if you thought there was radiculopathy at the time.
I might well have a conversation at that time
with either the regional oncologist or perhaps even ring someone like Jane,
a palliative care person - an expert in pain control -
just to get another opinion about how best to meet her pain needs.
Clearly that's important
while we're waiting for the more definitive radiotherapy.
I assume the risk here, Chris, is that you dive in too low,
and don't capture the pain and actually deal with it
with the heavy guns,
with the guns that are heavy enough to deal with it at that time,
and that's a matter of judgement.
I'm talking about the pharmacological treatment of her pain,
and the risk of lower rather than just getting rid of the pain.
Well, I mean, I think the medication you choose to deal with the pain
is exactly driven by the severity of the symptoms,
and we've got a large armamentarium and WHO pyramid
that demonstrates the hierarchy if you like, quite well.
But mindful of the fact that we don't necessarily move
from simple analgesia to more complex analgesia.
If it's a serious pain, we'll start with the serious analgesia.
NORMAN: Jane? - Yes.
I would usually emphasise to patients
that this is something that we have to work with them,
possibly intensely over the next few days.
When you start a treatment, you can't always predict
that it's exactly the right treatment for that patient,
because everyone's pain is individual.
Encourage the woman to be following up.
If the pain management you started today is not working,
encourage the person to come back to the GP,
and say, 'Brought the pain from seven to five, but it's still not at three.'
And also the other thing I would add to it
is that aside from a pharmacological approach,
there would be a physical approach that might address the woman's activities
in the setting of this bone metastasis,
and suggest that perhaps some activities might not be optimal this week,
and that some activities might hold back on
until we got the pain better controlled.
NORMAN: Chris?
Another thing I don't want to forget to mention
in the context of a person with a prior diagnosis of breast cancer
just discovered they have bone metastasis,
we were talking before about would we target treatment to other sites.
We need to remember the long bones,
because if there'd been abnormalities in humeri or femora
that were at risk of fracture, had they been assessed,
then those locations certainly would be treated pre-emptively.
Sorry?
I think that's another really important aspect to pain management too
that we have skirted around a little bit,
and that's the psychological support for the patient and her family as well.
If we can validate, you know, fears, listen to them,
and help them in a supportive manner.
Whether that's the GP in isolation or whether it's the broader team,
the palliative care nurse for instance, the specialist,
I think that's going to be really important
in helping to abrogate, lessen that pain as well.
Nicholas, what's your...
Given the standard of care here is multidisciplinary team-based care,
in other words, radiation oncologist has to be involved in this situation,
psychologist, psychosocial support, not to mention the general practitioner,
and it's hard in country towns because you don't have the stuff you've got
in a major metropolitan centre, the resources,
what's your approach to multidisciplinary team-based care
so that women from country areas
get the same sort of standard of care as women from the cities?
I think, you know, that the dry, academic answer would be
that there are studies that show that multidisciplinary care matters,
that it improves outcomes,
but we don't know for sure exactly what component of multidisciplinary care
that is that's doing the job.
As a clinician, anecdotally,
I think that the fundamental, critical thing is communication.
So, Tony doesn't have to be in the same room as I am,
I mean, it might be nice from time to time if he is,
but he doesn't have to be.
But if we know each other,
and we've had previous experience with patient care,
and there's a direct line of communication,
that's the most critical thing.
Similarly, I don't necessarily need to be in the same room as Chris,
although I should know him and bump into him from time to time,
but as long as I know how to get to him...
NORMAN: He's bunkered down. - Yeah.
As long as I know how to get to him and I can say,
'I'm ringing you because there's someone coming from the country
who sounds like they're gonna need radiotherapy sooner rather than later,
and I'm... I'm flagging a warning.'
Then, for this case, that is multidisciplinary care.
And the second component of it is
when that person goes... leaves the hospital,
and goes back to the country, it's vital that...
NORMAN: It's not a scribbled discharge summary.
Exactly. That the GP gets some intelligible communication.
Now, there may be other, more nuanced, more complicated cases
where you do want a number of people in the same room,
but I think it's all about communication.
What's your practice, Chris?
I was sharing earlier that at a recent panel discussion
Tony mentioned in this sort of scenario
that the problems that rural GPs have with accessing the specialist,
how do we form a multidisciplinary team
if the rural doctor responsible for the primary care of the patient
can't find us in order to get urgent radiotherapy treatment,
or a change in the systemic management.
I think the issue for us is one of availability,
and in response to Tony's criticism, constructive criticism,
I mean, I certainly started adding my telephone numbers -
both office and mobile -
to the end of my letter after country clinics.
So the number's there and that really does mean we wanna be called.
So that's reassuring in that sense.
And... you know, Nicholas, Chris, what are the treatment goals
that you tell women in this situation?
Um... Obviously it's gonna vary from disease to disease and person to person.
I think the first thing is that the woman needs to be reassured
that we know what's going on,
or we're going to do some tests to find out what's going on,
and there are treatments we have to help.
If we're talking about more long-term goals,
the goal is to try and get you as much back to normal as we can,
and you need to know that there is a spectrum of outcomes here.
But it is certainly possible that you may be well,
and alive for some years,
rather than just months, even though you've got a metastatic diagnosis.
The other source of variation from city to country
is a very important source of improved outcome,
which is access to clinical trials.
The evidence is that if you're in a clinical trial, you do better,
even if you've got the comparator treatment rather than the new treatment.
What's the access to clinical trials like for women in country areas?
Chris Milross?
And they'll often walk in and ask for them,
because they've been on the internet and they've been to clinicaltrials.gov,
and know what's available overseas.
I think it's a good point.
The only, I guess, comment that I would make is
that it may be a self-fulfilling prophecy
in the sense that women who are selected to participate in clinical trials,
or who seek out clinical trials,
may have a slightly different, somewhat more favourable cancer.
But let's suppose it is actually due to the trial,
and/or the level of involvement with the care team
that is inherent in the delivery of a trial medication,
or the follow-up of a trial patient.
I think that these days, there is good access to clinical trials
through the regional cancer centres that operate.
I suppose that will always be true for fly-in, fly-out service,
and I'm sure that it's increasingly true
for the established regional cancer centres.
And then patients who need to travel to the city for treatment
have got exactly the same access to clinical trials as the patients...
But increasingly they won't be with new regional cancer centres coming onstream,
they'll be treated locally. CHRIS: Yeah.
I should say though, that in all the planning for those centres,
the importance of clinical trials,
and support the conduct of clinical trials
has been acknowledged as being an important component
of the design of those centres.
We also have to probably acknowledge that it is going to be always difficult,
and the level of access is likely to be less,
and that's something we do have to acknowledge.
And increasingly there's clinical trials in palliative care training.
Increasingly. We are investigating the best possible strategies
to manage symptoms,
which can be seen as challenging when you're caring for a very ill population
who may or may not be interested in participating in clinical trials.
But we do see that as crucially important,
because we see this time of life,
and the quality of life during this time of life very important.
So the more we can understand about the best possible strategy
to relieve symptoms, the better for the patient.
Tony, what are you on the lookout here for urgent...
We've heard this is a non-urgent situation,
apart from maybe if there's compression here.
But it's more to actually not allow the woman to fester,
and be psychologically upset about the fact that there's a delay.
But what are we looking for in terms of urgent red-flag signs here,
in a woman like Leah?
Urgent flags, first of all, would be severe pain,
and getting that under control because pain is a medical emergency.
So that would be my No.1 priority,
and as I said, I might need to enlist the help of my other colleagues.
And No.2 would be, particularly with this metastasis,
would be the risk of having spinal cord compression,
and that's really important.
So, we talked a little bit about what that might look like,
it might be expressed as... um...
sphincter disturbance, bowel or bladder change,
maybe radiculopathy,
or even just a sensation of radiation around the trunk.
During the course of treatment, it may well be sepsis.
So fever or blood pressure changes, change in mental status for instance.
And, clearly, there are other circumstances
that may alert to the risk of a secondary somewhere else.
So, for instance, it could be something happening in the chest,
it may suggest that the patient may have a pulmonary embolism for instance.
So dyspnea, pain, cough, those sorts of things are really important.
And less likely would be the suggestion
the patient could perhaps have brain metastases.
And Nicholas spoke about this beforehand -
headaches that are unusual, nausea, vomiting,
perhaps personality change.
And the other risk, of course, may be if there are a lot of bone metastases,
or, in fact, in response to treatment, the risk of hypercalcaemia
to be picked up early.
So, polydipsia, polyuria, excessive thirst, urination, constipation,
perhaps change in mental status, those sorts of things.
So they'd be the things that, as GPs, we should be looking for.
NORMAN: Nicholas? NICHOLAS: I agree with that.
I think it's just worth making a couple of comments
about the issue of sepsis...
because it's different when the patient is on chemotherapy.
So, if the patient is on potentially myelotoxic chemotherapy,
and not all chemotherapy is myelotoxic,
the critical issue is what is the white cell count.
Because if the white cell count is low, if the neutrophils are less than one,
then these people can get very sick very fast.
You're better off overtreating them for their infection,
admitting them to the local hospital,
starting antibiotics before you've got any cultures.
If the white cell count is not low, then you can treat it on its merits.
- Beg your pardon? - Before you've got culture results.
NORMAN: You wanna get cultures, though. - Sure.
But if the white cell count is not low,
then you can treat the sepsis on its merits.
It might still be a serious problem,
but you can treat that person like you'd treat anyone else with sepsis.
So, the white cell count, if you can get one urgently,
is the critical point.
Can I say here I think communication again is really important.
My expectation would be if one of my patients was having chemotherapy,
which might drive a neutropenic situation,
I would expect that that would come as part of the information
back from Nicholas.
NORMAN: So you know what to watch for. TONY: Absolutely.
So, immediately, I'm looking out for that,
and then I would treat that as a medical emergency with a protocol in place.
NORMAN: Jane Ingham?
I'm cognisant of the fact that we've been talking mostly
about the medical complications and the medical things...
things we define as medical, to watch out for.
But there are certain psychological consequences,
and very practical issues that come up in these patients' lives
that can be very urgent.
- And so... NORMAN: Such as?
I think that if the patient has debilitating anxiety,
a depression that's coming on that... that might go unnoticed,
unless enquired about specifically by the GP.
Or very practical family issues that may be interfering with treatment,
such as nobody to mind children so that you can't get to treatment,
and those sorts of things.
They may need that.
The person's in front of the GP, so a broad assessment by the GP,
and I'm sure Tony would acknowledge the importance of this,
of the impact of this illness, as well as medical effects...
NORMAN: Not to mention financial impact and transportation problems.
Especially in rural settings.
I think rural GPs are often very cognisant of those issues and I think...
Even with regional cancer centres coming on,
people are still gonna have to travel to regional cancer centre.
Very much. Someone might have to drive them or that sort of thing.
Let's go to our next case study who's June.
69, lives in a town of 8,000 people.
She's married, her husband's still alive.
She had early breast cancer about seven years ago.
She had a mastectomy and chemotherapy for node positive breast cancer.
She came to you, Tony, three months ago complaining of fatigue and weight loss,
and you referred her to Nicholas, where a CT scan found this.
Let's have a look at her CT scan.
Nicholas?
NICHOLAS: Um... So this... in this case,
does represent liver metastases
secondary to her breast cancer.
Although, if that were
the only abnormality that one found,
you may require further investigation
to determine the diagnosis.
NORMAN: Because it could be a hepatoma...
NICHOLAS: Because it could be something else. That's right.
I mean, the commonest presentation with liver metastasis
would be the story you just told us,
but usually with multiple lesions,
rather than just the one.
But assuming that the diagnosis is secure...
And you'd look for metastases elsewhere?
If that was all I saw, I'd look for metastases elsewhere.
But I... as Tony was, would be very suspicious that that's what it was,
because she started out with a node positive cancer a while back,
that obviously was thought at the time
to be serious enough to merit adjuvant chemotherapy.
So we know she's had significant risk of cancer recurrence.
What would you do for someone like this, assuming that you're convinced that...
Assuming we've got the diagnosis right,
and we're assuming because there wasn't any discussion about endocrine therapy,
that her original cancer was hormone receptor negative.
So endocrine therapy is not gonna be helpful.
We would, nowadays, want to establish whether or not a HER2 test was done,
because it may not have been done seven or eight years ago.
It's done routinely on all breast cancers now.
So, that could be done on previous tissue or it may already have been done.
Assuming that that's... hormone receptor negative and it's HER2 negative,
then this is a situation where chemotherapy does come in.
There's very good evidence of chemotherapy on balance
will improve quality of life, get the cancer under control,
and have a small beneficial effect on overall survival.
So, I would be talking to this woman about the meaning of this diagnosis,
the fact that it was serious and potentially life-threatening,
the fact that chemotherapy, although it has side effects,
may well get the disease under control,
and that if it doesn't, there's time for us to reassess other strategies.
Are these complex chemotherapy regimes that you give?
There are increasingly...
There's increasingly now a range of chemotherapies,
and it would depend a little bit on factors like
the pace of disease development,
but we're talking about either the kind of chemotherapy that's given
every week or every three weeks intravenously.
So that means being close to a cancer centre,
or potentially there are some oral chemotherapies
that are effective as well,
and they allow easier treatment at a distance.
- It's going to be toxic to some extent. - It's potentially gonna be toxic.
It'll require doctor visits, blood counts.
It's gonna significantly interfere with your life.
So she comes back in three months time and here's the CT scan.
NICHOLAS: So, this is thankfully relatively unusual.
This is a devastating development, that is, that despite what we presume...
what we intended to be effective chemotherapy,
right at the beginning of her metastatic disease,
she has substantially progressed.
So that there's now very extensive disease throughout the liver.
Now, in general, as long as the woman is well enough,
and wants to pursue further options,
you can usually find that with trying different chemotherapy
you may be able to get things under control for some time.
But whether it's at the first time or the second time or the third time,
at some point that is going to happen,
and at some point we're gonna need to have the discussion
about whether further chemotherapy is really going to be helpful,
and whether we need to concentrate on other aspects of managing the disease,
and how it affects her life.
And how unwell is she at this stage?
Well, she... I mean, she may not be that unwell.
Would she be in pain because of the liver cancer?
She may be uncomfortable.
She may be on regular analgesics because of liver capsule pain,
and she may be... she probably is feeling a bit anorexic and off her food.
If she... I think...
One of the critical tests
of whether it's a good idea to think about more chemotherapy or not
is... has a lot of data behind it, but it's very commonsensical,
and that is how much time are you up and about.
If most of the day or more than half the day,
you actually really need to be lying in bed.
Probably chemotherapy is... is not going to be terribly helpful,
and you're not going to tolerate it very well.
So that's quite a good, almost over-the-phone-type assessment
that one can make.
And, Chris Milross, radiotherapy's not indicated
unless there's a bone metastasis?
Unless there's a bone metastasis or unless there are cerebral metastases,
and even then, you know,
related to what the elsewhere disease is doing,
and what the combined prognosis is from all of the...
And we should talk about cerebral metastasis for a moment
because cerebral radiotherapy can knock you about a lot, can't it?
Cerebral metastases can knock you about even more.
So, you know, if... if a person is symptomatic
from their cerebral metastases,
and that person's elsewhere disease is such that,
were the cerebral disease controlled,
the person could expect to raise quality of life,
then I think, in that scenario,
cerebral radiotherapy is almost always indicated.
But in the context of a person who has
advanced treatment refractory disease in multiple sites,
whose elsewhere disease is going to progress,
it's not unreasonable to have a discussion with the patient
that says perhaps we shouldn't be treating your cerebral metastases.
NICHOLAS: I agree with that and I think it's important to point out
that as our systemic therapies evolve,
they tend, unfortunately, to not get into the brain terribly well.
So we are seeing weller and weller women with brain metastases,
in which case radiotherapy is definitely indicated.
But also the anaesthetics and surgery has advanced
over the last couple of decades,
and so certainly one, but sometimes even two or three.
If a woman is otherwise well and active,
there's often a role for neurosurgery, followed by radiotherapy.
Let's look at it through the lens of a palliative care physician.
How should we be thinking about this woman now, holistically?
I think, holistically, we should be thinking about this woman
in terms of a spectrum of needs that she has.
Her... She has just received the news that the cancer has spread,
that she has... got to that second scan,
she's heard that the chemotherapy is not likely to offer useful benefit for her.
So this woman's view of life, her priorities, her hope,
everything's been turned upside down right now.
And she's regrouping on how to find meaning,
how to hope for what in this setting,
as well as sometimes being troubled by physical symptoms,
practical concerns about how to break this news to her family,
how to sometimes share this with children,
as well as partners and friends.
So there's a lot of needs.
So the way of looking at it is what are the woman's physical needs,
psychological needs or concerns,
informational concerns, practical concerns.
And in the broader spectrum, in many instances, spiritual concerns.
When you say 'spiritual', what do you mean? Religious beliefs?
It's obviously different for every individual,
the sorts of things that give them hope, meaning.
It may be faith in some instances,
it may be a broader concept, a different concept for other people.
It's going to be different for every individual.
But this woman's world has been turned upside down right now,
and in terms of the palliative care needs,
I think that they would... that spectrum of concerns
clearly would not be addressed by one individual in a medical team.
NORMAN: Chris Keogh.
No, it certainly looks like it's a very multidisciplinary approach now.
Even just things like... simple things like fatigue management,
that might include having an occupational therapist
come into this situation.
Jane mentioned spiritual needs.
There are some pastoral care workers around,
but there's also local ministers and things like that as well.
That may be a time when some counselling might be appropriate as well,
when people are really... challenged, I guess, by some of those...
But give me a sense of the transition to palliative care.
Give me a sense of the sort of conversation a GP should be having,
because GPs - Tony's an exception -
GPs... we've been singularly unsuccessful across Australia
in engaging general practitioners in palliative care.
Although they actually do it, they don't recognise that they do it,
but they're not involved as much as the palliative care people
would like them to be involved,
and certainly as much as our national planning would like it to be,
for lots of different reasons - time, enumeration and so on.
But let's assume the GP is making this transition to palliative,
having this conversation as they often will in a rural setting.
What's the conversation they should be having with the woman?
Well, I think they need to be introducing
the thought of palliative care.
There are some women that actually choose not to take up that option.
So sometimes it is good if it's coming from a variety of sources,
so that might be the oncologist as well as the GP,
or, you know, even simply the community nurses.
So whoever is taking care of that patient at the moment or at that time.
How do you handle it, Tony? That transition to palliative care.
Well, again, I think it's a really very individual discussion to have
with that particular person,
and often they have a partner or other family members with them.
You need to put that in the context of your previous relationship
with this person.
You need to listen to what they would like.
You need to make sure they understand
what you're offering with palliative care,
that it's not that you're saying they're going to be dead within months,
but this is really a... program
that can actually support both a person and their family over time.
And often that becomes a really freeing discussion to have with people,
and they engage in palliative care quite enthusiastically.
And again, it's... from a general practice point of view,
I think it's really important that we actually make sure
that we actually invite other members of the team.
The key here, Jane, is that we tend to think of end-of-life care...
the prejudice... not the prejudice,
the stereotypical approach to end-of-life care is that
you're gonna die in three weeks.
But what we're talking here could be a year or two,
that this is end-of-life care.
And there's all sorts of other things to consider as well.
So it's about helping the... bringing in the appropriate array of experts
to help that person have the best quality of life
in the time that's ahead,
and minimise the burden for themselves and their family
in this setting.
I think that the conversations can be difficult,
and especially the beginnings of conversations can be hard
for patients themselves and for some GPs.
It depends how much you've been taught in your training.
It used to be thought that breaking bad news was a skill you were born with.
It is something that you can be trained and it is something you can learn.
Chris Keogh, how much of your work is supporting health professionals
to support the patient?
In other words it can be stressful and pretty upsetting.
You're a country GP, you've known this woman for most of her life,
you know her family and this woman's dying,
and you're the person who has to look after her.
It's like looking after a friend.
It can be and it often is,
particularly for the GPs that might have an ongoing sort of relationship,
and a lot of the community nurses that are providing that care
are in the same situation.
So, I certainly do quite a bit of consulting to the smaller rural areas,
and part of that is supporting them in looking after the clients,
but also in educational needs.
And there is also, you know, debriefing sessions that are available.
The Cancer Care Network actually has a social worker
that does outreach to some of those areas,
and that's part of the role that she has as well...
To support the isolated health professionals. Jane?
Anything else to add to that?
It's just that you shouldn't be afraid to ask for... Tony ..some support
if you need it, if you're finding it upsetting and hard to deal with.
Absolutely. I mean, this can be confronting as Chris has said.
Often these people are well known over a long period of time,
and so it's not surprising perhaps
that GPs and other health professionals might be quite affected.
Peer support is really important, having discussions with your peers,
whether you're a GP or another health professional.
And, of course, there are resources available as well.
Yeah, I agree. I think that we... the health professionals involved,
I think the more we engage as a team,
the more we're comfortable sharing our concerns with each other the better.
But the only other thing that we haven't touched,
or area we haven't touched on in a great deal here
that I don't wanna miss before we close
is the importance of the support of the family.
And indeed of the husband or the partner.
And, in fact, the NBOCC does actually have a booklet available for...
..a resource for men, so they actually know how to deal,
or can fill some support and knowledge themselves.
TONY: Can I say I listened to some of this in preparation for this, Norman,
and I would really strongly recommend
that GPs actually refer partners
of women with secondary breast cancer to that resource.
I find it a very useful resource to listen to,
hearing men and women share their stories,
with some structured ideas about how to take them forward.
Chris Keogh, if a GP's only been used to referring to palliative care
for the last few weeks of care rather than the last year of care,
how different is it when the woman's still relatively well?
Give me sense of... in an ideal world,
what you do upstream from the terminal care.
So, I suppose I should just clarify too
that palliative care isn't only end-of-life care.
That's a really important point to make. But early referral is always...
So, on that point, it's symptom control, pain control,
there's things you know about the drugs that perhaps other people
haven't quite come to terms with.
That's right, but early referral,
particularly when some of these women are quite stable and well,
it is about forming relationships, getting that trust with people
at that early stage.
And it is also about linking in with some of the other issues
that they might need to look at, if they've got young children.
Some things that they might need planning and help with.
Partners.
Even just, you know, referring them
to things like Centrelink for financial assistance.
And if there's nobody like you in the country town, what do you do?
Well, you know, the community nurses in country towns
do have a lot of expertise in those areas,
and they actually work quite closely with these people,
and the GPs as well.
There is a real team happening there already.
I just guess it's a bonus when you do have someone
that has that expertise in palliative care.
But to know that there are lots of resources out there as well
they can utilise.
Jane? That's the... when does the physician come in?
Um... The physician, in terms of the GP doctor,
is there throughout the course of this illness.
I'm talking about somebody like you.
A specialist palliative care clinician can play a role
when the needs are very complex,
when the symptoms are very difficult,
or not easily controlled with those first-line strategies.
That physician may also assess a complex set of problems.
So, a patient who has multiple symptoms doesn't seem to be coping,
things don't seem right.
A GP may ask for that extra assessment.
And so, I think that we come in when things are difficult.
When things are difficult might be a different level
for one GP versus another.
And as we try to bring palliative care knowledge up in the nation,
we're quite happy to be approached about simple things as well as complex things.
There are resources, in terms of knowledge resources
there's a marvellous resource in a website by the name of CareSearch,
which will also provide...
which has an enormous array of resources for doctors
about symptom control, evidence-base literature, etc.
on various symptoms.
NORMAN: And what about end-of-life planning,
such as what situations you want something done, you know,
resuscitation, treatment of infection, that sort of thing.
Presumably that's an important part of this process.
That's an important part to be sure you're honouring the patient's wishes,
because different people have different wishes,
different people have different hopes, some of which are realistic,
some of which a conversation around them might help clarify.
Again, this often happens in the GP's office
with somebody who's known rather than with a stranger
who's giving an expert opinion, especially in the country setting.
But I'd defer to Tony to answer some of those questions
that are absolutely crucial too.
Again, I think this can be a very useful thing for the woman,
and her family,
having that conversation around an advanced-care directive,
having a conversation about where she might like to die -
in the home, in the local hospital, in a palliative care setting for instance.
Making sure you've got flexibility around that,
because in my experience, people do change their minds,
and you need to be flexible and sensible about this.
Talking about things that you would offer them,
such as interventions.
Talking about the funeral for instance.
and that may happen as part of the conversation
with the broader palliative care team as well.
But certainly doing this proactively, I think, is a really good thing,
and it's good not only for the patient, but also for their family,
and certainly for the health professionals who are involved.
- Do you go to the funeral? TONY: I have.
I don't go to all my patients' funerals to be honest.
But I certainly have been to patients' funerals,
and not only people that have died from cancer, but from other causes as well.
Chris, what about after the woman has died,
what's the role of bereavement counselling?
Because some people say it's overdone.
It's forced on people when they might not need it or want it.
Not everybody needs bereavement counselling.
I think it's important to know that...
you know, grief is a normal expression
that people have after someone they love or care for has actually died.
Um... So we would always contact people after someone has died,
and make sure that they know that we're available
if they need that ongoing support as well.
Um... Same as Tony, I don't always attend funerals,
but in some cases, if it's been a long-term client,
or the family have formed a really close relationship with you,
that might be a time when you might do that as well.
It may not always be appropriate for me personally
to contact people after someone has died.
It may be someone else in the team as well,
if someone's had a close contact with them,
such as even the physio, or something like that.
Just so that they've got that ongoing link.
We also give out information
regarding the Cancer Council's bereavement support group,
and, you know, other brochures.
There are other groups that run around,
like some program called Seasons for Growth,
which deals with grief and bereavement in children and adults.
Um... And, you know, open and honest communication about death and dying
within that family unit is always really important.
To try to get that sort of information across to them,
particularly when it's children that are involved as well.
Thank you all very much indeed.
It's been a difficult subject, but the information is important,
and I was just wondering
what your take-home messages were for the audience.
Nicholas?
I think the two things from my perspective would be
for GP and other health-care professionals in the country to realise
that metastatic breast cancer is an extraordinarily heterogeneous disease.
And as we've seen from our two cases,
situations where a woman may be very well with metastatic disease
for many, many years,
other situations where she may rapidly become unwell and have a lot of symptoms
that need to be dealt with.
And the second thing is, although we did discuss a couple of,
if you like, danger flags,
in need of urgent attention, like suspected spinal cord compression,
or sepsis in a patient on chemotherapy,
predominantly, developments...
either the new development of metastatic disease,
or progression of known metastatic disease,
is not an urgent problem and tends to evolve...
you know, over weeks or months rather than hours or days.
NORMAN: Chris Milross?
In addition to the fact that Nick's already mentioned,
namely that not all metastatic breast cancer is exactly the same,
I would... I'd like to emphasise the importance of communication
between the clinicians involved in the care of the patient.
You know, in recognition of the fact that local problems
will frequently benefit from local treatment such as radiotherapy.
Systemic problems will benefit from a systemic approach to the problem.
And... it's really only that if we talk to each other
that we'll establish what treatment's appropriate for what patient.
NORMAN: Chris Keogh?
Early referral to palliative care services.
That helps to build, you know, form those relationships and build trust,
and it's the same with the palliative care team
to be collaborative and, you know... probably communication really,
keep that trust and develop relationships to provide quality care.
NORMAN: Jane Ingham?
Well, here's a message to doctors, I think.
The message is that we have a patient in front of us who's often come to us.
It's important for us to embark upon a broad assessment
that looks at the individual more than medically,
so that we, including GPs, can refer appropriately,
make sure this person's got the right multidisciplinary team around them
to address the spectrum of concerns that they may have.
Pain and symptom management is a crucial part of the doctor's role.
And one must know one's own spectrum of skills,
have a reasonable armamentarium for the first pass,
and know where to turn for help
if there's extra help needed for symptom management.
And know that most palliative care clinicians would be quite happy to...
would welcome a call or a conversation even if...
And most areas have a palliative care clinician linked somehow with them.
Tony Hobbs.
I certainly endorse all those really strongly.
I think the GP has a really central role here
in diagnosing, in help to manage.
And not only managing physical problems, that is the cancer,
but the psychological response to that.
Thank you all very much indeed.
Hope you got a lot from the program as well,
this program on secondary breast cancer.
Thanks to the National Breast & Ovarian Cancer Centre
for making the program possible, but thanks also to you
for taking the time to attend.
If you're interested in obtaining more information about the issues,
or resources talked about in this program,
there are a number available on the NBOCC website.
That's nbocc.org.au.
And, of course, on the Rural Health Education Foundation website,
that's rhef.com.au.
Don't forget to complete and send in your normal evaluation forms
to register for CPD points.
And also please check the RHEF website for the special post-knowledge survey.
I'm Norman Swan. Goodnight.
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