Breast cancer patients need personalized follow-up care

Breast cancer patients need personalized follow up care after breast cancer treatment due to a wide spectrum of varying health burdens, according to a study presented at the European Society for Medical Oncology’s ESMO Breast Cancer Virtual Congress 2021.¹

The study was conducted by Kelly de Ligt, PhD, of the division of psychosocial oncology and epidemiology at the Netherlands Cancer Institute at the Antoni van Leeuwenhoek Hospital in Amsterdam, Netherlands, and colleagues.

“We wanted to measure the overall burden on their health-related quality of life and see if any patterns emerged that would better inform us on which individuals require active symptom management,” de Ligt said in an ESMO press release.

Women were selected from the Netherlands Cancer Registry and were 1 to 5 years out from a stage I to stage III breast cancer diagnosis that was surgically treated with or without adjuvant treatment. Researchers asked 404 breast cancer survivors about their post-treatment experience with pain, nausea, fatigue, shortness of breath, appetite, constipation, diarrhea, insomnia, and cognitive and emotional symptoms.

Researchers analyzed women’s answers, and reported 3 subgroups based on women's responses, classifying them as having low, intermediate, or high symptom burdens. Nearly 1/3 of women belonged to the low burden group and were less affected than the representative sample of 1,300 Dutch women who had filled out the researcher’s questionnaire.1 In the ESMO press release, de Ligt said she was pleasantly surprised that this group of women was doing better than that representative sample.

Fifty-five percent of women fell into the intermediate burden category, researchers said, adding that their results were similar to the representative sample. However, the intermediate group reported slightly worse insomnia, fatigue, and cognitive symptoms.¹

Fifteen percent of the women were in the high burden group, with 1 in 6 reporting worse symptoms than the representative sample.1 “The differences, ranging between 15 and 20 percentage points, were large enough to be considered not just statistically significant, but clinically relevant as well,” de Ligt said in the release. Patients with heart disease, diabetes, and other comorbidities were more likely to be in the high burden group, researchers said.¹ de Ligt said the association was so strong that researchers were unable to connect the level of symptom burden with the type of treatment patients had received.

“However, because we measured symptom burden and comorbidities at the same time in the study, we cannot draw conclusions from these findings alone. Future research should attempt to measure patients’ health-related quality of life through Patient Reported Outcome Measures (PROMs) before the start of treatment for breast cancer and afterward to allow us to measure the effect of the therapy,” de Ligt commented.

Another study that looked at 621 breast cancer survivors treated between 2003- 2013 at Oulu University Hospital in Finland showed the need for personalized care.² That study found only 25% of cancer recurrences were detected during pre-planned control visits, according to the ESMO release. In addition, more than half of recurrences in 95 cases were found when the patient contacted their physician with new symptoms, most often pain.

Breast cancer expert Nadia Harbeck, MD, PhD, head of the Breast Center at LMU University Hospital of Munich, Germany, and who is unaffiliated with either study, commented in the ESMO press release on the findings. She said, “Gathering data from a larger group of women could help us to gain more insight, and it would be interesting to see this study reproduced in other countries to ascertain whether there are also cultural and social factors impacting patients’ answers.”

In an interview with Contemporary OB/GYN®, de Ligt said that while previous studies have examined these symptoms as separate, independent items, survivors usually experience multiple symptoms that can add up. “We therefore studied the overall symptom burden in breast cancer survivors and tried to identify patterns in this. We believe this may be more relevant, as currently the needs of breast cancer survivors are not fully met and there is a growing demand for personalized follow-up care,” de Ligt said.

De Ligt noted that the first practical step towards care personalization is that providers need to be able to detect these needs. “Regular assessment with Patient Reported Outcome Measures (PROMs) before the start of treatment for breast cancer and afterwards up can play an important part of regular clinical care in detecting bothersome symptoms in patients. We are currently implementing regular PROM assessment in our daily clinical practice at the Netherlands Cancer Institute in Amsterdam,” she said.

For next steps in research towards personalized care, de Ligt said that finding out which patient and treatment characteristics are associated with symptom burden would be helpful. “Ideally, health care providers would want to know early in the care process which follow-up arrangements would probably serve their patients. Patients with comorbidities may be served better by follow-up arrangements that are sensitive to their more complex, comorbid health status. However, because we measured symptom burden and comorbidities at the same time in the study, we cannot draw conclusions from these findings alone. Regular assessment with PROMs before the start of treatment for breast cancer and afterwards up to several years will also allow us to better measure the effect of treatment,” de Ligt said.

References

1. de Ligt KM, de Rooij BH, Walraven I, et al. Towards tailored follow-up care for breast cancer survivors: cluster analyses based on symptom burden. Presented at: ESMO Breast Cancer Virtual Congress 2021. Abst # 134P_PR. https://bit.ly/3b1bgHN
2. Myller S, Jukkola A, Jääskeläinen A, Roininen N, Karihtala P. How breast cancer recurrences are found? - a real-world, prospective cohort study. ePoster: ESMO Breast Cancer Virtual Congress 2021. Abst #140P Annals of Oncology, Volume 32, Supplement 2, May 2021.https://doi.org/10.1016/j.annonc.2021.03.154