8 Ways Metastatic Breast Cancer Is Different from Stages I-III

Metastatic breast cancer, also referred to as stage IV breast cancer, is the most advanced type of the disease. It occurs when tumors spread to other parts of the body. Unfortunately, it is incurable, and means that a woman who is diagnosed with it must live with cancer for the rest of her life. 

Being diagnosed with stage IV breast cancer can be overwhelming, and yet while there is no cure, many people with metastatic breast cancer can still lead full, rewarding lives and do amazing things. Of course, with the diagnosis comes many changes. Here are some of the ways metastatic breast cancer is different from the other stages of the disease.

8. You’re No Longer Looking for a Cure

As previously mentioned, the unfortunate reality of a stage IV breast cancer diagnosis is that you’ll be living with cancer for the rest of your life, which means your treatment will continue just as long. This will affect every treatment you decide to undergo and what you’re willing to experience. You’re no longer looking for a cure, but you are looking for more time.

7. Other People Will Still Think You’re Curable

The average person doesn’t understand that metastatic breast cancer is incurable — they may be under the assumption that your treatment will end during your lifetime. While you know better, do your best to deal with this. Be clear with your friends and family about your situation.

6. You Have More to Learn About This Type of Cancer

Many people, including those who have metastatic breast cancer, don’t fully understand the disease. Dedicate yourself to learning everything you can. This will not only keep you aware of your options, it will also empower you as you work to manage your care.

5. The Goal of Treatment Becomes to Prolong Life

With each treatment you undergo, you know the objective is now to stay as healthy as you can for as long as possible. Some women with metastatic breast cancer can live several years after a diagnosis with proper treatment and care.

4. Quality of Life Becomes More Important

After your stage IV diagnosis, time becomes much more valuable. A good quality of life is what matters, and you have to decide what treatments are worth it and which ones aren’t. Some treatments may be effective, but may also come with side effects you simply don’t want to deal with. Be honest with your medical team about how you feel to ensure you’re spending your time the way you want to.

3. Palliative Care Becomes Part of Your Treatment Plan

Palliative care deals with treating pain and symptoms related to your disease. It is also referred to as “comfort care” or “supportive care,” as the goal is not to cure, but to manage your symptoms and alleviate any emotional issues. It might include endocrine therapy to relieve pain, or medication to deal with nausea or insomnia. The primary objective is to help improve your quality of life.

2. You Get a Different Group of Breast Cancer “Sisters”

One of the silver linings of your diagnosis is that now, you’re part of an exclusive sisterhood, made up of women who are battling the same cancer as you. Like you, their disease is not curable and their time has become more valuable. Make the most of those sisters you have around you. Maybe you can draw strength from each other.

1. You Learn to Live in the Present

You may have received a tough diagnosis, but now you realize that this moment is yours. Make the most of it and appreciate the small things while they’re happening. Spend time with family, check items off your bucket list, and take each day as it comes.
Learning to live with cancer may be difficult, but you still have life to live. This is YOUR time, and it’s up to you how you’d like to make the most of it.

Breast cancer can turn your world upside down, but as draining as it is, good things can come out of your experience, too.

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Accelerate efforts to eliminate cervical cancer

World Health Organization urged countries in its South-East Asia Region to accelerate efforts to eliminate cervical cancer by 2030.

“Countries need to expand vaccination, screening, detection and treatment services for everyone, everywhere to address the growing problem of cervical cancer,” said the Regional Director WHO South-East Asia.

Cervical cancer is a significant public health problem in the Region. In 2018, an estimated 158 000 new cases and 95 766 deaths were reported due to cervical cancer, which is the third most common type of cancer.

Addressing cancer risk factors and reducing its prevalence has been a regional flagship priority since 2014. All countries in the Region are taking measures for screening and treatment of pre-cancers. Four countries in the Region - Bhutan, Maldives, Sri Lanka and Thailand - have introduced HPV vaccine nationally.

“We need to scale up both our capacities and quality for screening, treatment services and palliative care,” the Regional Director said.

Vaccination against human papillomavirus, screening and treatment of pre-cancer, early detection, and prompt treatment of early invasive cancers and palliative care are proven effective strategies to address cervical cancer.

Member countries are working towards interim global targets - of achieving 90% girls fully vaccinated with the human papilloma virus (HPV) vaccine by 15 years of age; 70% women screened with a high-precision test at 35 and 45 years of age, and 90% women identified with the cervical disease receive treatment and care by 2030.

The Regional Director said there is need to strengthen national cervical cancer control plans, including appropriate strategies and guidelines for immunization, screening, treatment and care, including palliative care.

“It is necessary to include these services in the essential services packages towards universal health coverage to meet the targets,” the  Dr.  said.

WHO is prioritizing cervical cancer elimination as worldwide cervical cancer remains one of the gravest threats to women’s lives.

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When Antibiotics Stopped Working, These Viruses Saved a Girl’s Life

When a girl was discharged from a Hospital in London in 2017, her prognosis was grim. The 15-year-old had undergone a double-lung transplant seven months earlier as a result of her cystic fibrosis, a degenerative condition she was born with. Although there had not been any complications with the surgery, her immune system was suppressed, and an opportunistic drug-resistant infection had taken hold at the surgical site. She was taken off of most antibiotics after she experienced severe side effects, including liver failure, and she left the hospital with a palliative care plan in place.

Thousands of miles away, researchers  were racing to refine a therapy that would ultimately save the teenager’s life. The results of her treatment were published recently in a journal now, the treatment is gaining renewed interest, with some even going as far as to call its effects “miraculous.”

The treatment, called phage therapy, has existed for a century, and its underlying concept is elegant: Co-opt viruses that naturally infect bacteria to treat infections while ignoring human host cells. The use of these viruses, known as bacteriophages or phages for short, proliferated in the Soviet Union in the early 20th century in the absence of antibiotics, but the practice has only recently been rediscovered. It is gaining popularity in the US and Europe, where it is being tested as a way to treat everything from burns to urinary tract infections.

As a last-ditch option, one of her doctors reached out to  a professor whose lab studies bacteriophages that infect the tuberculosis family of bacteria. The girl was infected with a member of this bacteria family, which is known to target immunocompromised patients, and the researchers searched through a library of over 10,000 different phages to find the ones that would attack her strain the best. After identifying three that could infect the bacterium effectively, the researchers had one more roadblock to surmount: One of the phages was programmed to infect, but not kill the bacterium. This behavior is known as the lysogenic cycle, in contrast to the lytic cycle in which a virus copies itself before bursting out of its host cell and destroying it.

To address the issue, the team genetically engineered the misbehaving phage to express lytic behavior. This was the first time that an engineered phage has been used in a clinical setting. After conducting the necessary quality control experiments and obtaining regulatory permission to ship the phages from the US to the UK, the team sent off the three-phage cocktail to the patient's doctors, about six months after they had been first contacted.

But while time pressures were ever-present in the back of the researchers’ minds, the researcher told in an interview that the work began as a purely hypothetical exercise – seeing if their library contained the right phages – and only later morphed into a treatment the girl might actually receive.

The girl started to show improvement within weeks of beginning intravenous treatment with the phages every 12 hours – skin lesions caused by the infection started to clear up, her lung function improved and she gained weight. Still, since her treatment was not conducted like an experiment, it is impossible to be 100% certain that the phage therapy caused her recovery.

After nine days of monitoring in the hospital, Carnell-Holdaway had not reported any adverse reactions to the phages, an outcome “that obviously came as a not insubstantial relief to all of us,” Hatfull says. When her doctors decided to discharge her from the hospital again, they were optimistic about her chances of recovery.

Even with the long history of phage therapy in Eastern Europe, this was the first recorded instance of both a genetically engineered phage used clinically and an infection in the tuberculosis family being treated with phages.

“We’re in uncharted territory,” the researcher says.

But that has not stopped researchers and media outlets alike from speculating that phage therapy may one day replace antibiotics as first-line treatments of drug-resistant infections. This kind of “silver bullet” thinking is misplaced, says the Dr., though he does think phage therapy will likely be the solution to some types of highly resistant infections.

The story of the girl’s treatment is a case study into the difficulties facing widespread clinical implementation of phage therapy and a potential roadmap to solving them.

One problem is the phage’s specificity. From an evolutionary standpoint, it makes sense that a highly specialised phage would perform better than a jack of all trades. This has resulted in highly specific phages that are best at infecting substrains within strains: The three phages Hatfull’s team identified as candidates to treat the girl’s infection were not effective against other isolates of the same bacterium. At the same time, only a tiny fraction of the estimated ten nonillion, or ten phages have been discovered and categorised in a library. And once these massive libraries are established, there needs to be infrastructure in place for quickly and cheaply determining the few relevant phages for any specific infection.

Programs like SEA-PHAGES, run by Hatfull’s lab and the Howard Hughes Medical Institute in the US, are trying to address the latter challenge using crowdsourcing. SEA-PHAGES trains undergraduate researchers from more than 100 colleges and universities around the country to discover and sequence phages over the course of two semesters, and the program will soon reach 3,000 sequenced phage genomes.

The patient will soon reach a milestone, too: One year of continuous phage treatment. During that time, she has returned to a normal life and is busy with schoolwork and A-levels. the Dr.says there is no telling how long the girl will remain on treatment, nor whether the phages will keep the infection at bay permanently.

Nevertheless, future work to engineer and refine phage technology offers great promise for the treatment of disease. “It’s really exciting,” the Dr. says. “We love this idea of being able to creatively think about how you could fine-tune what you might think of otherwise as a relatively crude technology, and the potential is substantial.”

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Congenital Heart Disease Directly Linked to Cancer in Young Patients

Many contemporary discussions on our collective human fight against cancer center on the significance of genetics as related to the onset of this hydra-headed disease.

Swedish researchers have recently established a clear connection between congenital heart disease (CHD) and the risk of cancer development in a controlled study of thousands of children and young adults.

Utilizing data from the national Swedish Patient and Cause of Death Registers to pair subjects with CHD from 1970-1993 with subjects of the same birth year, gender and county without CHD revealed a wealth of comorbidity for those with the genetic heart defect and cancers of varying kinds.

Arguably the most disconcerting piece of evidence yielded in this study suggests that the risk of cancer for the most current birth cohort with CHD remains significantly higher than those observed in older cohorts.

Some of this discrepancy is attributed to the early mortality rates of older CHD cohorts due to noteworthy lacks in medical advancement associated with those times. Many CHD patients in the older cohorts simply did not survive CHD long enough to get cancer.

This study represents the first to probe the long-range occurrence of cancer from birth to 41 years of age in participants with any kind of CHD where surgery was a non-factor. Amid the persistent discussion in the world community of cardiologists about whether the prolonged exposure to ionizing radiation associated with most heart surgeries increases the likelihood of cancer in surgery patients, these recent findings support the notion that cardiac catheterization can be a heavy, but not independent, influence.

Patients who had received a full heart transplant seemed to fare the worst in these new statistics, a fact which encourages the study's conclusion that multifactorial stress and clinical exposure components underly much of the atypically high cancer prevalence in CHD patients. Alongside the obvious stresses of the consistent medical imposition posed by a life with CHD, this study further explicates the impact of the natural limitations associated with the disease as relates to cancer susceptibility.

Commonly offered cancer-preventative advice, such as eating a healthy diet and increasing exercise, given to otherwise healthy individuals can be nearly impossible to apply to the realities of the reduced oxygen intake, lower isotonic muscle tone and greater exercise-intolerance experienced by the typical CHD patient.

With their relative vulnerability to cancer representing twice that of a non-CHD patient, the findings surrounding these Swedish children and young adults suggest that a much more in-depth look at the connections between palliative treatments and procedures concerning all groups is both requisite and urgent. 

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Cancer: Breaking the bad news to patients

For Dr Ranjana Srivastava, who began working as an oncologist in Australia 10 years ago, breaking the news to patients suffering from cancer is part of the job.

"A doctor must be able to read a patient in order to break bad news. I ensure they have at least one close family member present when I tell them. This way, the patient has another pair of ears as well as support after I leave the room," she says, over a telephone call from Melbourne.    

Srivastava's decision to be a cancer specialist, she says, was influenced by her experience of watching her grandmother, who was diagnosed with cancer, slip into a coma and pass away. She was 10 at the time. While the family consulted a reputed doctor in Bhagalpur, Bihar, where she grew up, they were given little information about the disease or what the patient would go through. "I wish that the oncologist had held my grandmother's hand and told her what to expect," she says.

In her book Tell me the truth; conversations with my patients about cancer, life and death (published by Harper Element), Srivastava uses real patient experiences to discuss how different patients deal with the news and how families can cope.

The C-word: According to the World Cancer Report from the World Health Organisation (WHO), nearly seven lakh Indians die of cancer every year, while over 10 lakh are newly diagnosed with some form of the disease. While doctors are consumed by growing queues in hospital waiting rooms, and the churn of diagnosis and treatment, in most cases, patients are left with inadequate knowledge of their condition.

In many cases, patients have a hint about the disease while going through the tests. The prolonged wait to be diagnosed only adds to the stress. Srivastava prefers to tell a patient that she needs to discuss serious news and suggests calling in a family member. It's important to be prompt in organising such a meeting, she says.

"Cancer is a frightening term and countless patients have said that once they hear the word, they are incapable of processing anything more. So, I keep the initial discussion short until the patient has gained some control of their thoughts," she says.

There are many patients, who want to protect their family, and insist on hearing the news alone, Srivastava ensures her staff or a social worker is present to talk to the patient. "This doesn't mean that they will never want their family involved; often it's a matter of time before they let others in," she explains.

Focus on facts: Not all cancer is terminal, especially when the disease is caught in the early stages. "It is vital to inform and educate patients about their particular cancer, available treatment and outcomes," says Srivastava. A large part of her job, she reveals, includes listening to patients who are simply left feeling vulnerable and overwhelmed.

Families go through a particularly hard conundrum. They feel bad for the patient but don't know how to help, she says. Part of her role is also to speak with families about how they can best help the patient.

Ask Questions: The initial shock, patients have revealed, leaves them with a lot of questions but they are unable to articulate them. It's important to tell patients to expect this. Srivastava advises them to write down questions as they come up.

No question is too small or simple to ask, reiterates Srivastava.

"Never be afraid of sounding silly or uneducated in front of your doctor.
Cancer is a highly specialised field and many experts in the profession also aren't able to fully understand the workings of the human body," she offers to families seeking answers. If you are unable to understand medical terms, ask the doctor to simplify it in plain language.

If you are a web junkie, be careful not to trust all the information you find online. Srivastava suggests taking along the research to clarify it with a doctor.

Dealing with pain: When it comes to palliative care, an area of medicine that deals with controlling pain and ensuring comfort of the patient when a disease is not curable, Srivastava's focus includes dealing with anxiety and emotions as well.

For many patients, home-based palliative care is suitable, where trained workers monitor symptoms and provide advice under the supervision of doctors. Patients who are too ill to be managed at home or whose complex symptoms require closer attention may be admitted to an in-patient hospice for stabilisation or end-of-life care.

Barriers to palliative care remain with a lack of awareness and availability of facilities. "When people believe that palliative care equates to just letting a patient die, it is natural to avoid discussing it and even being against such care. But the focus is on making sure the patient lives with dignity," explains Srivastava.

In Melbourne, Srivastava conducts a communication workshop for healthcare professionals on dealing with patients. Key notes include; talk less, listen more; be comfortable in silence; look for and respond to emotion; and avoid information overload.

Her efforts are to allow an open doctor-patient relationship. She says, "It is fundamental to cancer treatment, which relies not only on medications but also on human touch which is vital." 

 

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What is Palliative care ? Why it is important

The WHO defines palliative care as “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.” It has recognised palliative care as an integral and essential part of comprehensive care for cancer, HIV and other health conditions. It has urged countries to take action in three areas — policy making, education and drug availability. 

Most of us still tend to confuse palliative care with tender loving care for someone about to die. This is the reason why we think palliative care is the same as hospice care. But the two are very different concepts. A hospice is a home for the terminally ill in the final stages. Palliative care is about ensuring better quality of life through pain and symptom management and through addressing various emotional, social and spiritual issues.

Palliative care does require passion and commitment. But it is as much a specialised science as any other branch of medicine. The developed world has accepted this and already put it into practice.

For long, it has been our tradition to practise palliative care at home. We believe in the religious care of the dying according to age-old rituals and customs. There was no fear of dying at home because our family ties and bonds were very strong and the family always rallied round to help us tide through difficult situations.

However, times have changed drastically and the “nuclear family” is here to stay. More often than not death happens in hospitals and it is considered as a “failure” of medicine. An aggressive approach towards life preservation with little consideration for the financial and emotional impact on the patient and the family leaves very little scope for palliative care. Perhaps, depending on the diagnosis and the prognosis, it is high time that patients and families started asking for palliative care, possibly along with curative treatment to make things easier for all, especially the patient. Already, some physicians have started recommending palliative care, based on their assessment of the patient and also the overall condition of the family.

Palliative Care respects the fact that every human being is made up of body, mind and soul, and should be treated as a ‘whole person' when disease strikes, as it is not just the disease but also the distress produced by the disease that he (and the family) invariably suffers from.

Palliative Medicine is a specialty which involves the active treatment of patients undergoing chronic and life limiting illnesses. Palliative care is not just terminal care. The main focus is on treating the distressing symptoms caused by these diseases even during treatment of the disease (by the respective specialists). It is much more needed towards the advanced stage. Palliative care also addresses the emotional, psychological, social and spiritual issues which are commonly seen in these patients. The sole aim of palliative medicine is to improve quality of life.

Acknowledging this ‘whole person' concept in treating any patient, the World Health Organisation declared Pain Relief and Palliative Care as the fourth dimension of ‘Total Cancer Care' along with the curative options of surgery, radiotherapy and chemotherapy.

So when can palliative care start? The answer is simple – from the time suffering starts, which could be right from the time the diagnosis of a disease like cancer is made!

Every patient diagnosed to have cancer may not need palliative care; but the care should be available to all those who need it any time during the course of the illness. At the time of diagnosis: How does one feel when a cancer diagnosis is made even if it is curable? The very mention of the word ‘cancer' causes fear and anxiety. With advanced literacy and access to information, even if the treating doctor has explained, people have more and more doubts and uncertainties — “Can it really be cured?”, “Will it come back?”, “Will I suffer in pain?”, “Why did God do this to me?” — Classic examples of emotional, psychological and spiritual pain, besides the physical pain. Palliative medicine addresses these issues which help them cope with the diagnosis and move on.

Early control of pain and other physical problems can help many to get back to their normal life sooner. At a time when ‘Freedom from pain is a human right', it is heart-rending to see patients who have suffered unnecessarily for so long that it is common for them to say, “If you can't take away the pain please just kill me!” They never say this once the pain is taken away!

Pain can also occur during cancer treatment and often patients do not want to continue treatment for this reason. Effective medicine and reassurance of symptom relief help them to resume therapy. Unfounded fears of addiction and misconceptions about pain killers and reserving them for the terminal stage deny the patients the opportunity to lead a pain-free life and improved chances of survival.

Every patient has the right to know about his illness (patient autonomy is an important aspect of medical ethics) but the way to tell them is important – neither telling the diagnosis abruptly nor hiding the truth, but gently breaking the news on a need to know basis. Early and effective communication helps both patient and family ‘digest' and accept the diagnosis and gives them a direction to move in.

Palliative medicine is not meant only for patients with cancer. Those suffering from any prolonged illnesses like HIV/AIDS, diseases of different organs like kidney, liver, lungs, nerves, will also benefit from it. Palliative care is the essence of all good medical practice. Ideally, all doctors should practise the basic principles of pain relief and palliative care. The subject should be incorporated in the basic medical and nursing curriculum because of the impending need to treat the suffering millions in our country. We believe that this day will not be far off.

www.palliativecare.in   this site gives a list of institutes offering palliative care in India.

www.lakshmitrust.org          is an institute run by Dr. Subathra Muthukumaran, who is a palliative care physician, whom you can contact through e-mail-

lakshmipaincare@gmail.com