Oncology

HER2+ Breast Cancer

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Reducing the Burden of Breast Cancer Treatment

clinical topic updates by Ian Krop, MD, PhD

Overview

Treatment burden is an important dimension of the overall experience of patients with breast cancer. Increasingly, the oncology community is recognizing this burden and is seeking ways to reduce the impact of cancer treatment on the daily lives of patients.

Expert Commentary

Ian Krop, MD, PhD

Professor of Internal Medicine, Section of Medical Oncology
Associate Cancer Center Director, Clinical Research
Chief Clinical Research Officer
Yale Cancer Center
Yale School of Medicine
New Haven, CT

“We have to consider the treatment burden when deciding between treatment A vs treatment B, and we need to make sure that patients understand what is involved in these various treatments, not only from a toxicity standpoint but also from the sheer logistics of receiving their treatment.”

Ian Krop, MD, PhD

I think that the burden of treatment and the impact of treatment on the daily lives of patients are overlooked components of patient care in oncology, but the oncology community is starting to address these challenges. Of course, we should take patient preference into consideration when making treatment-related decisions, but it goes beyond that, especially in terms of treatment burden for patients. It is important for clinicians to remember that treatment burden is a real issue for most patients, with some individuals being able to manage their treatment more effectively than others.

The demands that patients with cancer face by coming into the clinic on a regular basis could be disruptive to all of the other responsibilities in their lives, and clinicians are increasingly concerned about these aspects of the patient experience. In fact, the numbers are quite eye-opening. One study compared the burden for patients with different stages of breast cancer. Researchers reported that the median number of appointments during the first 18 months after diagnosis for patients with stage III breast cancer was 77, which is an incredibly high number within a fairly short period of time. Meanwhile, these individuals are also trying to balance work and the responsibilities related to taking care of their families and their activities of daily living. In addition, commuting and costs associated with commuting are other burdens, with the authors reporting a median cost of commuting for those with stage III breast cancer of approximately $1400. Further, the challenge of treatment burden may be compounded if the patient has comorbidities that require visits to other specialists, if their travel to the clinic is long or complicated, and/or if their financial status is not ideal. We have to consider the treatment burden when deciding between treatment A vs treatment B, and we need to make sure that patients understand what is involved in these various treatments, not only from a toxicity standpoint but also from the sheer logistics of receiving their treatment.

Accordingly, there is interest in reducing both the amount of time that patients are spending in the clinic and, hopefully, the number of patient visits. For example, there is the new formulation of pegfilgrastim, a long-acting granulocyte colony-stimulating factor, with an on-body autoinjector that helps patients avoid coming into the clinic an additional day of a cycle just to receive their dose of growth factor. There are also subcutaneous formulations of trastuzumab and trastuzumab plus pertuzumab, which cut down the infusion time and enable patients to get in and out of the clinic faster. Finally, studies in Europe are exploring the home injection of these subcutaneous formulations, again, to try to reduce the burden of commuting for patients. 

Ultimately, all of these potential burdens need to be factored into the care of patients with breast cancer, especially those who have additional issues such as medical comorbidities and financial concerns, to ensure that these individuals are receiving the full course of treatment. These issues can affect psychosocial health, and those patients would likely benefit from extra support. As clinicians, we have to think beyond the familiar consideration of the efficacy of treatments and ensure that the logistics for patients to receive these treatments are effective as well.

References

Anderson RT, Eton DT, Camacho FT, et al. Impact of comorbidities and treatment burden on general well-being among women’s cancer survivors. J Patient Rep Outcomes. 2021;5(1):2. doi:10.1186/s41687-020-00264-z

Cheng AC, Levy MA. Measures of treatment workload for patients with breast cancer. JCO Clin Cancer Inform. 2019;3:1-10. doi:10.1200/CCI.18.00122

De Oliveira Brandao, Lewis S, Sandschafer D, Crawford J. Two decades of pegfilgrastim: what have we learned? Where do we go from here? Curr Med Res Opin. 2023 Apr 8;1-12. doi:10.1080/03007995.2023.2196197

O'Shaughnessy J, Sousa S, Cruz J, et al; PHranceSCa Study Group. Preference for the fixed-dose combination of pertuzumab and trastuzumab for subcutaneous injection in patients with HER2-positive early breast cancer (PHranceSCa): a randomised, open-label phase II study. Eur J Cancer. 2021;152:223-232. doi:10.1016/j.ejca.2021.03.047

Wardley A, Canon J-L, Elsten L, et al. Flexible care in breast cancer. ESMO Open. 2021;6(1):100007. doi:10.1016/j.esmoop.2020.100007

Ian Krop, MD, PhD

Professor of Internal Medicine, Section of Medical Oncology
Associate Cancer Center Director, Clinical Research
Chief Clinical Research Officer
Yale Cancer Center
Yale School of Medicine
New Haven, CT

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