Melissa K. Accordino, MD, MS, discusses ways to improve the monitoring of patients with metastatic breast cancer.
Melissa K. Accordino, MD, MS
Patients with metastatic breast cancer are monitored via imaging with or without tumor markers. This disease monitoring can be stressful on patients, as it often causes anxiety and discomfort, according to Melissa K. Accordino, MD, MS.
As there are no prospective data analyzing the way in which metastatic breast cancer is monitored, Accordino and colleagues initiated SWOG 1703 (NCT03723928). This is a randomized trial comparing overall survival of patients monitored with serum tumor marker-directed disease monitoring with usual care. SWOG 1703 is enrolling patients with metastatic hormone receptor—positive breast cancer, and is open throughout sites that participate in the National Clinical Trials Network or the National Cancer Institute Community Oncology Research Program.
In an interview during the 2018 OncLive® State of the Science SummitTM on Breast Cancer, Accordino, assistant professor of Medicine, Columbia University Irving Medical Center, Herbert Irving Comprehensive Cancer Center, discussed ways to improve monitoring of patients with metastatic breast cancer.Accordino: I spoke about how we monitor patients with metastatic breast cancer. There are really not a lot of data for how to do this. There certainly are no prospective data at the moment. What we know is that patients are frequently monitored with a combination of imaging with or without tumor markers. They are often done at frequencies that vary from physician to physician. What we also know is that disease monitoring can be very stressful on patients, and there can be a lot of anxiety related to it, because patients are very nervous about progression.
There is a term that Time magazine coined, which is called "scanxiety." This is when patients are so anxious about having scans, they are uncomfortable, and they are often all-day affairs that sometimes require intravenous placement. Then, there is always the delay to get the results. It is a very stressful time for patients, and there are data showing that finding progression as soon as it is there is not associated with better outcomes. We can often stress patients out for all these reasons, and we probably are not doing them any good.
We just launched a study through SWOG, which randomizes patients who have elevated tumor marker levels to be monitored either with tumor markers alone until those markers elevate and then they get a scan, or to have usual care, which involves scans at least every 3 months with or without tumor markers. The outcome is overall survival, but we are also looking at cost of care, patient-reported anxiety, and quality of life (QoL). We think that we probably can minimize what we are doing to these patients, and improve QoL and cost of care without impacting survival.In patients who have elevated markers, as long as their markers continue to downtrend or stay stable, I don't scan them. For some patients, this could be several months; for others, it could be 1 year or even longer. As long as they are not having symptoms, and their tumor markers are stable, I am not in a rush to get imaging. Patients seem to prefer the way that I have been practicing disease monitoring and tumor marker monitoring for a long time.We don't have any data right now to guide us, so hopefully, we can enroll patients onto this study to help us get that data. We are open at a number of community sites, as well as academic sites. In the meantime, it is important to not be a stickler about getting scans every 12 weeks; sometimes we have to be smart about what this information is actually showing us. If patients are having symptoms, that is one thing, but if they are not and we are just checking off boxes, perhaps we could be a little more flexible. It is incredibly important in all aspects of oncology; it is so interdisciplinary. The better we communicate, the more we and the patients are on the same page and get the same message. That is very important.
For patients with metastatic breast cancer, they are mostly followed by medical oncologists and aren't often seeing other types of oncology specialists. Typically, we are the ones ordering the disease monitoring, whereas in the surveillance setting, some of those tests are being ordered by primary care doctors, surgeons, or radiation oncologists. There are no data yet for what we are doing, so it is important to get data because we would never treat a patient with a drug that we don't have data for. It is important to monitor patients in a way that makes sense. It is important to get that data.
I also think it is important for us to use the data that we have. Sometimes people order tumor markers and then they don't do anything with the results, and they still scan the same amount of time. Why are you putting a patient through all these tests and getting them worked up if you are not going to change anything based on the information? We have to be mindful that these interventions, while it is easy for us to check the box on the form or computer, it can have a lot of impact on the patient. There is also a lot of cost associated with these tests too, which can sometimes be passed off onto the patient.