10 Practices in Metastatic cancer | Cancer Australia

Appropriate to involve a multidisciplinary team to consider effective evidence-based anti-cancer and supportive therapies in the management of patients with metastatic breast cancer. A key contact person should be agreed to support communication and coordination of patient-centred care.

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Supporting Information

Context

Multidisciplinary care is an integrated, team-based approach that is a cornerstone of best practice cancer care. Underpinned by Principles of multidisciplinary care for advanced disease, multidisciplinary care is particularly important for patients with metastatic breast cancer due to their complex management and supportive care needs. Multidisciplinary care helps avoid treatments that may be ineffective or do not add to symptom relief or survival for the patient.

The multidisciplinary team involves all relevant health professionals who collaboratively develop an individual treatment and supportive care plan for each patient at key management decision points along the cancer pathway. For Aboriginal and Torres Strait Islander people, the team should include a health professional with expertise in providing culturally appropriate care to Aboriginal and Torres Strait Islander people¹. There may be variation as to whether a multidisciplinary team meets in person, or by using technology to engage all relevant health professionals.

An agreed key contact person, who may be a breast care nurse or another health professional such as the patient’s GP, is critical to facilitate communication and coordination of care for patients with metastatic breast cancer. Australian surveys have indicated that for many patients with metastatic breast cancer, multidisciplinary care may not currently be available. In addition, many patients reported that they had not seen, or would like to have more contact with, a breast care nurse or cancer care coordinator.

Value to patients

Multidisciplinary care, including a key contact person, enables a coordinated and collaborative response to complex management and supportive care needs for patients with metastatic breast cancer, and consideration of a range of evidence-based treatment or clinical trial options. Multidisciplinary care promotes a patient-centred, individualised approach to management, helps avoid ineffective treatments and supports patient involvement in making decisions about treatment and care that is right for them.

1. A culturally appropriate health professional may be an Aboriginal and Torres Strait Islander Health Worker, Health Practitioner, or Hospital Liaison Officer.

Supporting references

Blaschke SM, Gough KC, Chua BH et al. Implementation of a Multidisciplinary Model of Care for Women With Metastatic Breast Cancer: Challenges and Lessons Learned. Clin Breast Cancer. 2018 Dec 21. pii: S1526-8209(18)30567-6.

Breast Cancer Network Australia (BCNA) Member Survey Report. For public distribution - November 2017 [accessed February 2019]

Cancer Australia. Multidisciplinary care for advanced disease. https://canceraustralia.gov.au/clinical-best-practice/multidisciplinary-...

Cancer Australia and Cancer Council Australia. Optimal care pathway for Aboriginal and Torres Strait Islander people with cancer. 2018. https://canceraustralia.gov.au/publications-and-resources/cancer-austral...

Cancer Council Australia. Optimal care pathway for women with breast cancer. 2015. https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Chirgwin J, Craike M, Gray C et al. Does multidisciplinary care enhance the management of advanced breast cancer?: evaluation of advanced breast cancer multidisciplinary team meetings. J Oncol Pract. 2010;6(6):294-300.

Spence D, Morstyn L, Wells K. (2015) The support and information needs of women with secondary breast cancer. Breast Cancer Network Australia. https://www.bcna.org.au/media/2936/bcn1166-sbc-report-2015.pdf

Watts K, Meiser B, Conlon H et al. A specialist breast care nurse role for women with metastatic breast cancer: enhancing supportive care. Oncol Nurs Forum. 2011;38(6):627-31.

What this practice is about

This practice highlights the importance of having a team of health professionals involved in the care of people with metastatic breast cancer.

Best practice care for people with metastatic breast cancer is likely to involve a number of health professionals and services. Care may involve different treatments, participation in a clinical trial, managing symptoms and providing support. Everyone’s needs are different and can change over time. What is right for one person may not be right for another.

It is important that a team of health professionals with different areas of expertise is involved in the treatment and care of people with metastatic breast cancer. This is called a ‘multidisciplinary team’. The team will usually involve one or more specialist cancer doctors, a nurse and one or more health professionals involved in providing support for people with advanced cancer. The team may also include the person’s GP and an expert in providing culturally appropriate care to Aboriginal or Torres Strait Islander people¹ or people from culturally and linguistically diverse backgrounds.

The multidisciplinary team considers individual needs and preferences and considers suitable treatment and care options. Not everyone in the team is involved in the care of every patient. Different health professionals might become involved as a person’s symptoms and needs change.

When a team of health professionals is involved in the care of someone with metastatic breast cancer, it is important to have a key contact person. This may be the GP, breast care nurse or another member of the team. The key contact person acts as a link between the individual and the multidisciplinary team, helping to provide information, answer questions and coordinate care.

Why this practice might be important for you

If you have metastatic breast cancer, it is important that you receive the treatment that is right for you, and that you and your family have the support you need. Your treatment options and support needs may change over time. Having a multidisciplinary team involved in your care means you can consider all available options and access the care and support you need.

It is important for you to know which health professionals are involved in your care and who your key contact person is. This can help you ask questions and let your team know what is important for you.

Questions to ask

Who is in my multidisciplinary team?
Which health professionals are most relevant to my care at the moment and why?
Who is my key contact person? How can I contact them if I have questions?

1. A culturally appropriate health professional may be an Aboriginal and Torres Strait Islander Health Worker, Health Practitioner, or Hospital Liaison Officer.

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Appropriate to communicate effectively and sensitively in a culturally safe environment with metastatic breast cancer patients and their families, and provide timely, comprehensive, patient-centred information on matters including:

prognosis and the intent of treatment
potential benefits and harms of treatment (including complementary and alternative therapies)
cost and practical implications of treatment
supportive and palliative care.

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Supporting Information

Context

Effective communication is a key element of cancer care and contributes to better patient outcomes. It is important that a relationship of trust and open two-way communication between the treatment team and patients and their families is established early and continued throughout the metastatic breast cancer care pathway.

Communication should be sensitive, with the detail and timing of information tailored to the individual patient and their wishes. It is also important to facilitate collaborative and effective involvement with the patient’s family. Communication skills such as actively listening to patients, using a patient-centred style, and recognising and responding appropriately to patients’ verbal and non-verbal cues, contribute to effective communication and can be improved through communication skills training.

Information should be provided on a range of aspects, including prognosis and intent of treatment, potential benefits and harms of treatment (including complementary and alternative therapies), clinical trials, supportive and palliative care, and costs and practical implications of treatment. Information should be comprehensive, evidence-based and easy to understand.

Guidelines recommend communicating in a culturally sensitive way and providing appropriate information for people from culturally and linguistically diverse backgrounds. For Aboriginal and Torres Strait Islander patients, the multidisciplinary team should include a health professional with expertise in providing culturally appropriate care to Aboriginal and Torres Strait Islander people.

Studies have shown that patients with metastatic breast cancer report difficulty in finding comprehensive information, especially information specific to metastatic breast cancer, and an Australian survey has confirmed patients’ unmet information needs.

Value to patients

Two-way, sensitive and culturally appropriate communication with their treatment team can empower patients to make their preferences and concerns known, and be actively involved in shared decision making about their care. Effective communication and patient-centred information about treatment options, and the availability of supportive and palliative care, helps patients to understand more about their disease and treatment, and to make informed choices about their treatment and care.

1. A culturally appropriate health professional may be an Aboriginal and Torres Strait Islander Health Worker, Health Practitioner, or Hospital Liaison Officer.

Supporting references

Breast Cancer Network Australia (BCNA) Member Survey Report. For public distribution - November 2017 [accessed February 2019]

Cancer Australia. Communication skills training. https://canceraustralia.gov.au/clinical-best-practice/cancer-learning/co...

Cancer Council Australia. Optimal care pathway for women with breast cancer. 2015. https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Cardoso F, Spence D, Mertz S et al. Global analysis of advanced/metastatic breast cancer: Decade report (2005-2015). Breast. 2018 Jun;39:131-138.

Danesh M, Belkora J, Volz S et al. Informational needs of patients with metastatic breast cancer: what questions do they ask, and are physicians answering them? J Cancer Educ. 2013 Mar;29(1):175-80.

Fallowfield LJ. Treatment decision-making in breast cancer: the patient-doctor relationship. Breast Cancer Res Treat. 2008 Dec;112 Suppl 1:5-13.

Gilligan T, Coyle N, Frankel RM et al. Patient-Clinician Communication: American Society of Clinical Oncology Consensus Guideline. J Clin Oncol. 2017 Nov 1;35(31):3618-3632.

Kaser E, Shaw J, Marven M, Swinburne L et al. Communication about high-cost drugs in oncology--the patient view. Ann Oncol. 2010 Sep;21(9):1910-4.

Kemp E, Koczwara B, Butow P et al. Online information and support needs of women with advanced breast cancer: a qualitative analysis. Support Care Cancer. 2018 Oct;26(10):3489-3496.

Laidsaar-Powell R, Butow P, Boyle F et al. Facilitating collaborative and effective family involvement in the cancer setting: Guidelines for clinicians (TRIO Guidelines-1). Patient Educ Couns. 2018 Jun;101(6):970-982.

Peppercorn JM, Smith TJ, Helft PR et al. American society of clinical oncology statement: toward individualized care for patients with advanced cancer. J Clin Oncol. 2011 Feb 20;29(6):755-60.

Ryan H, Schofield P, Cockburn J et al. How to recognize and manage psychological distress in cancer patients. Eur J Cancer Care (Engl). 2005 Mar;14(1):7-15

What this practice is about

This practice highlights the importance of good two-way communication between health professionals and people with metastatic breast cancer. It is about how health professionals talk, listen and answer questions, and about making sure people affected and their families have the information they need at the right time.

Good communication is built on a relationship of trust. It is critical that health professionals communicate clearly and sensitively, taking account of any language or cultural considerations. People with metastatic breast cancer and their families should feel able to ask questions and talk about what is important to them. This can empower people to be actively involved in managing their cancer, and to make informed choices about their treatment and care.

It is important that health professionals provide information about why different treatments or types of care are (or are not) recommended, including possible benefits and harms of treatment (including for complementary and alternative treatments), suitable clinical trials, as well as any out-of-pocket costs. Information about likely prognosis should also be provided if an individual asks for this.

Everyone has their own preference for the amount and type of information given to them. How much information is given and when it is given should take account of each person’s individual preferences, values and beliefs.

Why this practice might be important for you

Clear and trusted information will help you understand your diagnosis of metastatic breast cancer and your treatment and care options. It is important that you are able to communicate openly with your health professionals. Information you are given – in person and in writing – should be easy to understand and take account of your individual preferences, values and beliefs.

You and your family can ask for as much or as little information as you feel you need. Ask questions whenever you need to and check if there are things you do not understand.

Questions to ask

How do I let my team know what’s important to me?
Is it OK to talk about things that I haven’t been asked about?
Where can I find out more information? Is there somebody else I can talk to?

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Appropriate for patients with metastatic breast cancer to have access to effective pain and symptom management and psychosocial support, including multidisciplinary supportive and palliative care services when required.

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Supporting Information

Context

Patients with metastatic breast cancer often have significant symptom-related and supportive care needs, and experience psychological and social distress. Identifying these needs early and managing them proactively with a patient-centred, multidisciplinary approach can reduce distress and improve patients’ quality of life.

Measurement tools such as a problem checklist, distress thermometer and pain scale can assist in identifying and monitoring patient needs and assessing symptoms. Studies have shown that integration of electronic patient-reported outcomes into clinical care can improve quality of life and survival outcomes for patients, and have also shown the benefits of incorporating patient education into cancer pain management.

Supportive and palliative care helps control physical symptoms such as pain for patients with a serious illness that cannot be cured, and also focuses on patients’ emotional wellbeing, relationships and spiritual needs. Palliative care is not just for patients near the end of life and patients may move in and out of palliative care as their needs change. Studies have shown that early initiation of palliative care for metastatic cancer patients has beneficial effects on their quality of life, intensity of symptoms such as pain, satisfaction with care, and reduced depression.

Emotional and psychological care and quality of life have been identified as major areas for improvement by patients with metastatic breast cancer. Australian studies have reported that many patients with metastatic breast cancer have unmet supportive care needs, including insufficient emotional and psychological support. Over one third of patients with metastatic breast cancer surveyed reported that they were not informed that palliative care could support them at any time and not just at the end of life.

Value to patients

It is important to help patients living with metastatic breast cancer to live as well and as fully as possible. Effective management of patients’ symptoms can reduce their distress and disruption of daily living and activities, maintain or restore comfort and quality of life, and help patients adhere to and continue treatment for as long as needed. Early referral to a palliative care team or service and offering supportive care throughout the continuum of care can help address psychosocial needs, improve symptom control and quality of life, and help incorporate patient preferences into treatment decisions.

Supporting references

Basch E, Deal AM, Dueck AC et al. Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment. JAMA. 2017 Jul 11;318(2):197-198.

Breast Cancer Network Australia (BCNA) Member Survey Report. For public distribution - November 2017 [accessed February 2019]

Cancer Council Australia. Cancer pain management in adults. 2016 https://wiki.cancer.org.au/australia/Guidelines:Cancer_pain_management

Cancer Council Australia. Optimal care pathway for women with breast cancer. 2015. https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Cardoso F, Spence D, Mertz S et al. Global analysis of advanced/metastatic breast cancer: Decade report (2005-2015). Breast. 2018 Jun;39:131-138.

Girgis A, Durcinoska I, Koh ES et al. Development of Health Pathways to Standardize Cancer Care Pathways Informed by Patient-Reported Outcomes and Clinical Practice Guidelines. JCO Clin Cancer Inform. 2018 Dec;2:1-13.

Haun MW, Estel S, Rücker G et al. Early palliative care for adults with advanced cancer. Cochrane Database Syst Rev. 2017 Jun 12;6:CD011129.

Kirsten L, Hobbs K. Supportive care in advanced breast cancer. Cancer Forum 2017. Vol 41. https://cancerforum.org.au/forum/2017/march/supportive-care-in-advanced-...

Lovell MR, Luckett T, Boyle FM et al. Patient education, coaching, and self-management for cancer pain. J Clin Oncol. 2014 Jun 1;32(16):1712-20.

Pain Australia. Talking about pain. Language guidelines for chronic pain. 2019. https://www.painaustralia.org.au/static/uploads/files/talking-about-pain...

What this practice is about

This practice highlights the importance of making sure that people with metastatic breast cancer get the care and support they need, when they need it.

People with metastatic breast cancer may need help managing:

physical symptoms, such as pain, nausea, constipation or poor appetite
emotional issues, such as distress or anxiety related to the cancer (including support for family members)
practical issues, such as work, travel or costs of care.

Support can be provided by different health professionals and services. Getting help early can reduce distress and improve quality of life.

One of the services that can help in the care of people with metastatic breast cancer is palliative care. A palliative care team or service can help people manage physical, emotional and spiritual needs. Palliative care is not only for people who are nearing the end of life. It is an option for everyone with advanced cancer, and services can be used when needed.

Early involvement of palliative care services in the care of people with advanced cancer has been shown to improve quality of life and satisfaction with care, reduce symptoms such as pain and depression, and deliver care according to individual needs and preferences.

Why this practice might be important for you

It is important that you have the support you need to help you manage symptoms of metastatic breast cancer and its treatment. If your symptoms are controlled, it is likely that you will continue treatment for longer. You may need help managing physical symptoms, such as pain or feelings such as distress or anxiety. You may also need practical help with day-to-day activities.

Different members of your team can help. Support from a nurse, psychologist, counsellor or social worker, may be helpful for you and your family. A palliative care team can help you manage symptoms and provide you with support. Remember that palliative care is not just for people at the end of their life. You can use the services of a palliative care team when you need extra help and stop when you are feeling OK.

Getting the help and support you need can help with your quality of life. The important thing is to let your health professionals know about your symptoms and any feelings or practical concerns that are affecting your day-to-day life. This includes telling your team if your symptoms change over time.

Questions to ask

Who can I talk to about how I’m feeling?
Who can I talk to about how to manage pain or other symptoms?
Who should I talk to if I have a new symptom or if my symptoms change?
How could a palliative care team help my family and me?

More information

For more information about asking questions and getting the right help and support, you may find it helpful to read Finding the words: Starting a conversation when your cancer has progressed.

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Appropriate for patients with metastatic breast cancer to be offered participation in suitable and relevant clinical trials from the time of diagnosis and throughout treatment.

Information for consumers

Supporting Information

Context

Clinical trials are a priority in the metastatic breast cancer setting as currently available treatments are generally not curative. Clinical trials contribute to improved treatment and care and are vital to inform treatment advances.

National and international guidelines recommend offering patients the opportunity to participate in suitable and relevant clinical trials from the time of diagnosis of metastatic breast cancer and throughout treatment. It is important that clinical trials are considered early in the course of treatment, rather than as a potentially unrealistic option later on, since clinical trials may not be available for heavily pre-treated patients. Studies have shown that patients who participate in clinical trials have improved or similar outcomes compared to those who do not.

Participation rates for patients in cancer clinical trials is low (2-14%), and in an Australian survey in 2017, only about 40% of patients with metastatic breast cancer indicated they had been given opportunities to talk about potentially relevant clinical trials. Effective communication between patients and members of the treating team about relevant clinical trials is an important aspect of best practice care, including provision of accessible information for patients.

Value to patients

Clinical trials can provide patients with metastatic breast cancer access to promising new treatments or treatment combinations in a carefully designed and regulated setting, when suitable clinical trials are available and patients meet the criteria for participating. Patients participating in research and clinical trials also contribute to improved care and outcomes of future cancer patients. Effective communication with patients by their treating team can improve patients’ knowledge and understanding of clinical trials. The Australian Cancer Trials website has information about available cancer clinical trials.

Supporting references

Breast Cancer Network Australia (BCNA) Member Survey Report. For public distribution - November 2017 [accessed February 2019]

Cancer Council Australia. Optimal care pathway for women with breast cancer. 2015. https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Nahleh ZA, Lin NU, Wolff AC, Cardoso F; BIG-NABCG collaboration. Perceptions and needs of women with metastatic breast cancer: a focus on clinical trials. Breast. 2013 Jun;22(3):370-3.

Peppercorn JM, Weeks JC, Cook EF et al. Comparison of outcomes in cancer patients treated within and outside clinical trials: conceptual framework and structured review. Lancet. 2004 Jan 24;363(9405):263-70.

Vist GE, Bryant D, Somerville L et al. Outcomes of patients who participate in randomized controlled trials compared to similar patients receiving similar interventions who do not participate. Cochrane Database of Systematic Reviews 2008, Issue 3. Art. No.: MR000009.

What this practice is about

This practice highlights the importance of giving people with metastatic breast cancer the opportunity to take part in suitable clinical trials.

Clinical trials are an important way of finding new and better ways to care for people with metastatic breast cancer. A clinical trial may involve a new treatment or a different combination of treatments that may be more effective than current treatments.

It is important that health professionals discuss suitable clinical trials with people who have metastatic breast cancer and talk about what the trials involve. Clinical trials should be considered at the time of diagnosis of metastatic breast cancer and during treatment.

Why this practice might be important for you

Taking part in a clinical trial could give you access to a new treatment (or combination of treatments) that is not yet available as part of standard care. Your involvement in a clinical trial can also help improve the future care of other people with metastatic breast cancer.

Not all clinical trials are suitable for everyone. Your health professionals can let you know about trials that may be suitable for you.

Before deciding whether to take part in a clinical trial, it is important to understand what is involved. You may need to have additional tests or appointments and your care may be managed at a different hospital or clinic. There may also be more paperwork to complete. Your health professionals can tell you about any additional tests or paperwork that may be involved.

Questions to ask

The first question to ask is: Is there a clinical trial that may be suitable for me?

There are lots of other questions you can ask to help you understand more about clinical trials. Visit the Australian Cancer Trials website for a list of questions to ask about clinical trials.

More information

For more information about clinical trials for metastatic breast cancer, visit the Australian Cancer Trials website.

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Appropriate to offer biopsy of accessible metastases to assess biological markers (such as oestrogen and progesterone receptors and HER2 status), and to offer germline genetic testing for BRCA1/2, if the result is likely to lead to a change in the management of patients with metastatic breast cancer.

Information for consumers

Supporting Information

Context

Information about the presence of biological tumour markers such as oestrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status and other relevant markers guides the appropriate use of therapies such as endocrine and anti-HER2 therapies. Studies have shown there can be differences in tumour markers between the primary breast tumour and subsequent metastases in the same patient, with median discordance rates of 18% for ER, 31% for PR and 9% for HER2 status reported.

Offering biopsy for accessible metastases enables the assessment of markers that will guide treatment options, especially for patients where the markers were unknown or negative in the primary tumour. Other relevant markers, such as specific genomic changes, may also be assessed using a new biopsy or stored archival tissue from the primary breast cancer.

Testing for germline BRCA1/2 mutations can assess suitability for treatment with a poly-ADP-ribose polymerase (PARP) inhibitor for selected patients such as those with HER2-negative tumours. In selected metastatic breast cancer patients with a BRCA1/2 mutation, randomised trials have shown that PARP inhibitors are associated with improved clinical outcomes and quality of life, and less toxicity compared with chemotherapy.

Value to patients

Biopsy of metastases enables measurement of the markers ER, PR and HER2, which are used to determine if endocrine and anti-HER2 therapies are suitable treatment options. Testing for a germline mutation in the BRCA1 or BRCA2 gene is required to determine the suitability for treatment with a PARP inhibitor in selected patients with metastatic breast cancer.

Supporting references

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Cancer Council Australia. Optimal care pathway for women with breast cancer. 2015. https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways

Litton JK, Rugo HS, Ettl J et al. Talazoparib in Patients with Advanced Breast Cancer and a Germline BRCA Mutation. N Engl J Med. 2018 Aug 23;379(8):753-763.

National Institute for Health and Care Excellence. Addendum to Clinical Guideline 81, Advanced Breast Cancer Clinical Guideline Addendum 81.2 Methods, evidence and recommendations August 2017 https://www.nice.org.uk/guidance/cg81/evidence/addendum-version-81.2-pdf...

Robson ME, Tung N, Conte P et al. OlympiAD final overall survival and tolerability results: Olaparib versus chemotherapy treatment of physician's choice in patients with a germline BRCA mutation and HER2-negative metastatic breast cancer. Ann Oncol. 2019 Jan 23.

Van Poznak C, Somerfield MR, Bast RC et al. Use of Biomarkers to Guide Decisions on Systemic Therapy for Women With Metastatic Breast Cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2015 Aug 20;33(24):2695-704.

What this practice is about

This practice highlights the importance of testing tissue or blood samples from people with metastatic breast cancer, to help guide decisions about treatment.

Treatment options for metastatic breast cancer depend on the biological features of breast cancer cells. This includes whether the cells have certain receptors on them, such as hormone receptors or the HER2 receptor.

When cancer spreads to another part of the body, the receptors on the new cancer cells can be different to those on the original breast cancer cells. This means that treatments that were not recommended for someone with early breast cancer may now be an option. Testing a sample of cancer tissue from another part of the body can be helpful to guide the choice of treatment. This may require a new biopsy or may use tissue from the person’s early breast cancer if it is still available in the pathology department. A blood test may also be helpful to help decide which treatments are suitable.

The choice of treatment may also depend on whether the person carries a gene fault known to affect the risk of breast cancer. Examples include a fault in the BRCA1 or BRCA2 gene. If genetic testing has not been done previously, it may be useful to look for faulty genes.

Why this practice might be important for you

It is important to know as much as possible about the breast cancer cells in your body to make sure you receive the treatments that are likely to be most effective for you. Your doctors may recommend that you have a biopsy and/or a blood test to help make decisions about suitable treatments.

A biopsy may involve taking tissue from an area where cancer has spread to (that is, not from the breast). Depending on what other tests you have had, it may also be helpful to test a sample of the original breast cancer. This is possible if tissue is still available in the pathology department.

Questions to ask

Do you recommend a new biopsy or blood test for me?
What information will a biopsy or blood test provide?
What is involved in having a biopsy?
Is any tissue still available from the original breast cancer? Would it be useful to test this tissue?

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Not appropriate to use chemotherapy in patients with metastatic breast cancer who are unlikely to benefit, such as those who have received multiple lines of prior therapy for advanced disease, and with low performance status (3 or 4) or at high risk of toxicity.

Information for consumers

Supporting Information

Context

Chemotherapy treatment has the potential to improve progression-free survival and overall survival, but can also be associated with toxicity and reduced quality of life. Studies have indicated that in patients with metastatic breast cancer treated with chemotherapy, low performance status (3 or 4) is associated not only with a poor survival outcome but also a poor quality of life, and that the response to second and later lines of chemotherapy is strongly influenced by the response to earlier treatment.

International guidelines recommend that chemotherapy treatment decisions take into account the patient’s performance status, their response to prior treatment lines and balance of likely benefit against toxicity. It is important that the patient's preferences regarding additional chemotherapy be considered in a shared decision-making process.

Other factors to be considered include HER2 status and previous therapies, comorbidities such as those that increase risk of toxicity, the aggressiveness of the patient's disease (e.g. indolent disease versus immediately life-threatening disease) and anticipated adverse events.

Late lines of chemotherapy may be associated with signiﬁcant costs, such as the financial costs of supportive drugs, travel and hospitalisations for any acute treatment-related toxicities, and also psychological costs such as those due to unrealistic expectations, or not adequately considering end-of-life preferences. Ongoing supportive and palliative care that focuses on symptom relief including pain management, and that emphasises quality of life, should be considered as an option to further chemotherapy.

Value to patients

Individual consideration of the potential benefits and harms of chemotherapy supports patient-centred care, informed decision-making and the incorporation of patient preferences. Considering patients’ physical functioning and ability to carry on daily activities, and their response to previous chemotherapy and risk of toxicity, helps avoid treatment that may not provide meaningful benefits or may cause harm.

Supporting references

Anders CK, Peppercorn J. Treating in the dark: unanswered questions on costs and benefits of late line therapy for metastatic breast cancer. Cancer Invest. 2009 Jan;27(1):13-6.

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

National Comprehensive Cancer Network Clinical Practice Guidelines. Breast cancer Version 2.2019 https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

Park IH, Lee KS, Ro J. Effects of second and subsequent lines of chemotherapy for metastatic breast cancer. Clin Breast Cancer. 2015 Feb;15(1):e55-62.

Partridge AH, Rumble RB, Carey LA et al. Chemotherapy and targeted therapy for women with human epidermal growth factor receptor 2-negative (or unknown) advanced breast cancer: American Society of Clinical Oncology Clinical Practice Guideline. J Clin Oncol. 2014 Oct 10;32(29):3307-29.

Schnipper LE, Smith TJ, Raghavan D et al. American Society of Clinical Oncology identifies five key opportunities to improve care and reduce costs: the top five list for oncology. J Clin Oncol. 2012 May 10;30(14):1715-24.

van Abbema DL, van den Akker M, Janssen-Heijnen ML et al. Patient- and tumor-related predictors of chemotherapy intolerance in older patients with cancer: A systematic review. J Geriatr Oncol. 2019 Jan;10(1):31-41.

What this practice is about

This practice is about the use of chemotherapy for the treatment of metastatic breast cancer. It highlights the importance of making sure that chemotherapy is only given to people who will benefit from its use.

Chemotherapy involves using drugs to treat people with cancer. It is often used in the treatment of metastatic breast cancer to slow down the growth and spread of cancer cells. Chemotherapy is associated with different side effects, some of which can affect day-to-day activities and quality of life. The decision about whether to have chemotherapy involves weighing up the benefits of treatment and the risk of side effects. This decision may be different for different people.

For some people with metastatic breast cancer, the potential risk and severity of side effects outweighs the possible benefits of chemotherapy. When making decisions about whether to use chemotherapy, it is important to consider the person’s overall health and any issues that might affect the response to treatment. The decision may also be affected by what other treatments were used previously and whether these were effective.

For some people with metastatic breast cancer, it may be more appropriate to focus on relieving pain and other symptoms rather than continuing to use chemotherapy to try and control the cancer. Involvement of a palliative care team and other supportive care professionals can provide care and support to people in this situation.

Why this practice might be important for you

If you have metastatic breast cancer, it is appropriate for you to only receive treatments that have a reasonable chance of being helpful in treating your cancer. Side effects of chemotherapy can affect your day-to-day activities and quality of life. It is important to limit your exposure to side effects of treatments that are unlikely to be effective. The decision not to have chemotherapy may be the right decision if you have already tried several different drugs and these have not been effective, and if it is likely that the side effects will be difficult for you to tolerate.

Depending on what treatments you have used previously and your general health, your doctors may recommend focusing on helping you relieve pain and managing your symptoms rather than using chemotherapy to control your cancer. Involvement of a palliative care team and other supportive care professionals can provide care and support to help you live as well as possible.

Questions to ask

What is the evidence about the benefits of this chemotherapy for people in my situation?
What are the likely side effects of this chemotherapy? How might this affect my day-to-day activity?
What are my treatment and care options if I decide not to have chemotherapy?
How could a supportive and palliative care team help me and my family?

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Not appropriate to use chemotherapy in preference to endocrine therapy (with or without a CDK inhibitor) as initial treatment for patients with metastatic breast cancer that is hormone receptor-positive and HER2 negative, unless there is visceral crisis.

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Supporting Information

Context

Patients with metastatic breast cancer which expresses oestrogen and/or progesterone receptors (hormone receptor-positive) are suitable for endocrine therapy with anti-oestrogen medications such as aromatase inhibitors (letrozole, anastrozole or exemestane), tamoxifen or fulvestrant.

National and international guidelines recommend that endocrine therapy rather than chemotherapy, is used as initial treatment for patients with hormone receptor–positive metastatic breast cancer, except for patients with rapidly progressing visceral disease and severe organ dysfunction (visceral crisis).

Studies have shown that for patients with metastatic breast cancer there is no difference in overall survival for first-line endocrine therapy compared with chemotherapy, and there is less toxicity and better quality of life. However, for patients with hormone receptor-positive metastatic breast cancer who have rapidly progressing visceral disease or with endocrine resistance, chemotherapy may be considered.

CDK4/6 inhibitors, such as palbociclib or ribociclib, reduce cancer proliferation via the cell cycle. Addition of a CDK4/6 inhibitor to first-line endocrine therapy in patients with hormone receptor-positive, HER2-negative metastatic breast cancer is associated with improved progression-free survival and overall response rate, and in a trial enrolling premenopausal women, a survival advantage has been observed. Patients receiving treatment with a CDK4/6 inhibitor should be monitored for adverse events such as neutropenia.

Value to patients

Initial endocrine therapy for patients with metastatic breast cancer that is positive for oestrogen and/or progesterone receptors is generally less toxic, may be associated with better quality of life than chemotherapy and can be taken orally. In addition, there is no difference in overall survival for first-line endocrine therapy compared with chemotherapy in patients with metastatic breast cancer.

Adding a CDK4/6 inhibitor, such as palbociclib or ribociclib, to initial endocrine therapy in suitable patients with metastatic breast cancer can improve outcomes.

Supporting references

Boyle F, Beith J, Burslem K et al. Hormone receptor positive, HER2 negative metastatic breast cancer: Impact of CDK4/6 inhibitors on the current treatment paradigm. Asia Pac J Clin Oncol. 2018 Oct;14 Suppl 4:3-11.

Cancer Council Australia. Optimal care pathway for women with breast cancer. 2015. https://www.cancervic.org.au/for-health-professionals/optimal-care-pathways

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Hortobagyi GN, Stemmer SM, Burris HA et al. Updated results from MONALEESA-2, a phase III trial of first-line ribociclib plus letrozole versus placebo plus letrozole in hormone receptor-positive, HER2-negative advanced breast cancer. Ann Oncol. 2018 Jul 1;29(7):1541-1547.

Im SA, Lu YS, Bardia A et al. Overall Survival with Ribociclib plus Endocrine Therapy in Breast Cancer. N Engl J Med. 2019 Jul 25;381(4):307-316.

National Comprehensive Cancer Network Clinical Practice Guidelines. Breast cancer Version 2.2019 https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

Rugo HS, Rumble RB, Macrae E et al. Endocrine Therapy for Hormone Receptor-Positive Metastatic Breast Cancer: American Society of Clinical Oncology Guideline. J Clin Oncol. 2016 Sep 1;34(25):3069-103.

Rugo HS, Finn RS, Diéras V et al. Palbociclib plus letrozole as first-line therapy in estrogen receptor-positive/human epidermal growth factor receptor 2-negative advanced breast cancer with extended follow-up. Breast Cancer Res Treat. 2019 Apr;174(3):719-729.

Wilcken N, Hornbuckle J, Ghersi D. Chemotherapy alone versus endocrine therapy alone for metastatic breast cancer. Cochrane Database Syst Rev. 2003;(2):CD002747.

What this practice is about

This practice is about tailoring treatment options for people with metastatic breast cancer according to the individual features of the breast cancer cells. It highlights the importance of initially using endocrine therapy in preference to chemotherapy for most people who have hormone receptor-positive, HER2-negative breast cancer*.

Endocrine therapies (also called hormonal therapies) are drugs used to treat breast cancer cells that have hormone receptors on them. Endocrine therapies have been shown to be as effective as chemotherapy in the initial treatment of hormone receptor-positive, HER2-negative metastatic breast cancer. Endocrine therapies are associated with fewer and less toxic side effects than chemotherapy. For this reason, it is recommended that endocrine therapies are used instead of chemotherapy as the first drug treatment following a diagnosis of hormone receptor-positive, HER2-negative metastatic breast cancer.

There are some situations in which endocrine therapy may not be suitable as the first treatment. For example, if breast cancer is growing rapidly, or if it is severely affecting liver function (a visceral crisis), or if a person has previously not responded to endocrine therapy, then chemotherapy may be recommended.

Other treatments called CDK inhibitors (such as palbociclib and ribociclib) may also be recommended alongside initial endocrine therapy to help increase the likelihood of a response to treatment. If a CDK inhibitor is recommended, additional tests will be needed to monitor the level of white blood cells in the blood.

Why this practice might be important for you

If you have metastatic breast cancer, it is important that your treatment options take account of the individual features of the cancer cells. Endocrine therapy is associated with fewer side effects than chemotherapy and may be taken orally, so it is likely to have less impact on your day-to-day activities and quality of life. If you have hormone receptor-positive, HER2-negative metastatic breast cancer, it is important that endocrine therapy is considered as your first treatment option instead of chemotherapy. Adding a CDK inhibitor to initial endocrine therapy may also be helpful to improve your response to treatment.

Questions to ask

Do I have hormone receptor-positive and/or HER2-negative metastatic breast cancer?
Is endocrine therapy an option for me before chemotherapy?
Would a CDK inhibitor be an option for me? How frequently will I need blood tests if I have a CDK inhibitor?

* Hormone receptors (oestrogen and progesterone receptors) and the HER2 receptor are found on some breast cancer cells. Treatment choices depend on whether or not a person’s breast cancer cells have hormone receptors or the HER2 receptor. If cells do have hormone receptors they are said to be ‘hormone receptor-positive’ and if they do not have the HER2 receptor they are said to be ‘HER2-negative’.

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Appropriate to consider single fraction radiotherapy initially for uncomplicated painful bone metastases in patients with metastatic breast cancer, rather than routinely using radiotherapy with extended fractionation schemes (>10 fractions).

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Supporting Information

Context

Bone is a common site for breast cancer metastases, and bone metastases frequently cause signiﬁcant and debilitating pain. Radiotherapy is an effective pain-relieving treatment for painful bone metastases.

Randomised trials have shown that radiotherapy with a single 8 Gy fraction or dose has equivalent pain relief for uncomplicated painful bone metastases compared with longer courses of multiple fractions (such as 20 Gy in 5 fractions or 30 Gy in 10 fractions). Rates of acute toxicity and pathological fractures at the treatment site are also similar. Retreatment to the same site of bone metastasis is more common for single fraction (20%) than for multiple fraction treatment (8%).

International guidelines recommend that a single fraction of 8 Gy radiotherapy be considered for initial treatment of painful uncomplicated bone metastases. Single fraction radiotherapy is also more cost-effective than multiple fraction treatment of bone metastases.

Value to patients

Radiotherapy requires daily hospital attendance, usually at a specialised centre. Single fraction treatment for treatment of painful bone metastases can provide comparable pain relief to treatment with multiple fractions, but takes less time and is more convenient for patients and their carers. Consideration of initial single fraction treatment can enable patients’ preferences to be taken into account, and can help patients avoid the burden of prolonged treatment courses that may not add to symptom relief or improve survival.

Supporting references

Collinson L, Kvizhinadze G, Nair N et al. Economic evaluation of single-fraction versus multiple-fraction palliative radiotherapy for painful bone metastases in breast, lung and prostate cancer. J Med Imaging Radiat Oncol. 2016 Oct;60(5):650-660.

Fallon M, Giusti R, Aielli F et al. Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Ann Oncol. 2018 Oct 1;29(Supplement_4):iv166-iv191.

Hahn C, Kavanagh B, Bhatnagar A et al. Choosing wisely: the American Society for Radiation Oncology's top 5 list. Pract Radiat Oncol. 2014 Nov-Dec;4(6):349-55.

Lutz S, Balboni T, Jones J at al. Palliative radiation therapy for bone metastases: Update of an ASTRO Evidence-Based Guideline. Pract Radiat Oncol. 2017 Jan - Feb;7(1):4-12.

Rich SE, Chow R, Raman S et al. Update of the systematic review of palliative radiation therapy fractionation for bone metastases. Radiother Oncol. 2018 Mar;126(3):547-557.

Sze WM, Shelley M, Held I et al. Palliation of metastatic bone pain: single fraction versus multifraction radiotherapy - a systematic review of the randomised trials. Cochrane Database Syst Rev. 2004;(2):CD004721.

What this practice is about

This practice is about using radiotherapy to treat breast cancer that has spread to the bones (bone metastases). It highlights the importance of people receiving the shortest duration of radiation therapy needed for their situation.

It is common for metastatic breast cancer to spread to the bones. Bone metastases can be painful, and this can affect a person’s quality of life. Radiotherapy is used to relieve pain in some people with bone metastases. This depends on which bones are affected and what other treatments are being used.

Radiotherapy is usually given over several days or weeks at a specialist centre. In people with bone metastases, a single session with a slightly higher dose of radiotherapy has been shown to be as effective at relieving pain as a lower dose given several times. Having a single radiotherapy session (called ‘single fraction radiotherapy’) is more convenient and usually costs less than having multiple lower dose fractions over several days or weeks. The side effects seen with single fraction radiotherapy are similar to those seen with multiple fraction radiotherapy given over several sessions.

Sometimes radiotherapy has to be repeated to help manage pain. The need to repeat radiotherapy may be more likely after single-fraction radiotherapy.

Why this practice might be important for you

If you have metastatic breast cancer, it is important that you only receive the treatments that you need. If you have bone pain caused by bone metastases, your doctors may recommend treatment with radiotherapy. A higher dose of radiotherapy given in one session is as effective for pain relief as a lower dose given over several days or weeks. This means fewer visits to the hospital for treatment and may mean that your out-of-pocket costs are lower.

Questions to ask

Would radiotherapy be helpful to reduce my bone pain?
What is the shortest number of sessions of radiotherapy that would be effective and safe for me?
What are the out-of-pocket costs of having radiotherapy?
What impact would radiotherapy have (if any) on the use and timing of other treatments?

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Not appropriate to routinely use extensive locoregional therapy in metastatic breast cancer patients with minimal symptoms attributable to the primary tumour.

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Supporting Information

Context

Locoregional therapy may involve surgery and/or radiotherapy to the breast and local region for patients who have metastatic breast cancer at initial diagnosis (de novo metastatic breast cancer), or for patients who relapse with metastatic breast cancer including local recurrence.

There are international and national recommendations to not routinely use extensive locoregional therapy in metastatic cancer patients if there are few symptoms from the primary tumour. The evidence is currently inconclusive as to whether survival is improved by surgery to the breast to remove the primary tumour, or radiotherapy to the breast, in patients with de novo metastatic breast cancer. There is limited high quality evidence from prospective studies, and many studies have been retrospective with potential selection bias.

However, for selected patients with metastatic breast cancer, surgery and/or radiotherapy of the breast may be considered on an individual basis to improve quality of life or palliate symptoms, taking into account the patient’s preferences, such as for patients with complications (e.g. skin ulceration, bleeding, fungation and pain). Locoregional therapy may also be considered on an individual basis for patients such as those with bone-only metastases, or those with oligometastatic disease or low-volume metastatic disease that is highly sensitive to systemic therapy.

Value to patients

Locoregional therapy to the breast is not routinely appropriate for metastatic breast cancer patients with few symptoms due to the primary breast tumour. However surgery and/or radiotherapy to the breast in selected patients, such as those with problematic symptoms in the breast, and with consideration of the patient’s preferences, may help relieve symptoms and improve quality of life.

Supporting references

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Harris E, Barry M, Kell MR. Meta-analysis to determine if surgical resection of the primary tumour in the setting of stage IV breast cancer impacts on survival. Ann Surg Oncol. 2013 Sep;20(9):2828-34.

National Comprehensive Cancer Network Clinical Practice Guidelines. Breast cancer Version 2.2019 https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf

Petrelli F, Barni S. Surgery of primary tumors in stage IV breast cancer: an updated meta-analysis of published studies with meta-regression. Med Oncol. 2012;29(5):3282–90. 48.

Pons-Tostivint E, Kirova Y, Lusque A et al. Survival Impact of Locoregional Treatment of the Primary Tumor in De Novo Metastatic Breast Cancers in a Large Multicentric Cohort Study: A Propensity Score-Matched Analysis. Ann Surg Oncol. 2019 Feb;26(2):356-365.

Royal Australian and New Zealand College of Radiologists: tests, treatments and procedures clinicians and consumers should question. 2016
http://www.choosingwisely.org.au/recommendations/ranzcr#1618

Tosello G, Torloni MR, Mota BS et al. Breast surgery for metastatic breast cancer. Cochrane Database Syst Rev. 2018 Mar 15;3:CD011276.

What this practice is about

This practice is about the use of surgery or radiotherapy to treat the breast and the area around the breast in people with metastatic breast cancer (also called ‘locoregional therapy’). It highlights the importance of only treating the person’s breast if the person has symptoms suggesting that treatment will improve their quality of life.

Surgery and radiotherapy are used routinely to treat early breast cancer with the aim of removing the cancer before it spreads to other parts of the body. In people with metastatic breast cancer, cancer has spread to other parts of the body. Treating the cancer in the breast is unlikely to affect the overall response to treatment. If cancer has spread, it is more important to control the cancer in other parts of the body.

Surgery or radiotherapy to the breast may be offered to some people with metastatic breast cancer – for example, if cancer in the breast is causing significant pain or other symptoms, or significant anxiety. Treatment to the breast may also be an option if the cancer in other parts of the body is only in a small area or is growing very slowly.

Why this practice might be important for you

If you have metastatic breast cancer you may think that it is important to treat the cancer in your breast. However, if you have few symptoms in your breast, treatment to this area using surgery or radiotherapy is unlikely to affect your overall response to treatment. It is more important to focus on controlling the cancer as much as possible in the parts of the body where cancer has spread.

The decision about whether to have surgery or radiotherapy to the breast is an individual one and will depend on your symptoms and overall health. If the idea of not having treatment to the breast is making you anxious, it is important to talk to your doctors about your concerns so that you can make the decision that is right for you.

Questions to ask

What treatment(s) do you recommend and why?
What are my options if the cancer in my breast is worrying me or causing me pain or distress?

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Not appropriate to use whole brain radiotherapy for metastatic breast cancer patients with brain metastases, without considering initial surgery or stereotactic radiosurgery.

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Supporting Information

Context

Brain metastases are diagnosed in approximately 10-15% of patients with metastatic breast cancer, have detrimental effects on patients’ cognitive function and quality of life, and are associated with poor survival.

National and international guidelines recommend that surgery or stereotactic radiosurgery (SRS) should be considered for initial treatment of brain metastases in selected patients, including patients with good performance status, small number and small size of metastases suitable for localised therapies, adequate haematological reserve and well-controlled extracranial disease. Studies have shown that while addition of whole brain radiotherapy (WBRT) to radiosurgery may improve local and distant brain control in selected patients with brain metastases, there are worse neurocognitive outcomes and quality of life, and no differences in overall survival.

It is appropriate to undertake a multidisciplinary approach to treatment of brain metastases that considers the patient’s preferences and use of a prognostic index, such as the Breast-Graded Prognostic Assessment (GPA) index, which includes the patient’s performance status, age and tumour phenotype. For patients with a more favourable prognosis, consideration of long-term toxicity is important, and less toxic local therapy options such as SRS, when available and suitable for the patient, may be preferable to WBRT.

Value to patients

A multidisciplinary, patient-centred approach to the treatment of brain metastases can enable patients’ needs and preferences to be taken into account and support balanced, informed decision making. Use of surgery or SRS as initial treatment in suitable patients can help minimise the toxicities and cognitive effects of treatment of brain metastases, and improve quality of life compared with WBRT.

Supporting references

Cancer Australia. Recommendations for the management of central nervous system (CNS) metastases in women with secondary breast cancer 2014. https://canceraustralia.gov.au/publications-and-resources/clinical-pract...

Cardoso F, Senkus E, Costa A et al. 4th ESO-ESMO International Consensus Guidelines for Advanced Breast Cancer (ABC4). Ann Oncol. 2018 Aug 1;29(8):1634-1657.

Patil CG, Pricola K, Sarmiento JM et al. Whole brain radiation therapy (WBRT) alone versus WBRT and radiosurgery for the treatment of brain metastases. Cochrane Database Syst Rev. 2017 Sep 25;9:CD006121.

Phillips C, Jeffree R, Khasraw M. Management of breast cancer brain metastases: A practical review. Breast. 2017 Feb;31:90-98.

Tsao MN, Rades D, Wirth A et al. Radiotherapeutic and surgical management for newly diagnosed brain metastasis(es): An American Society for Radiation Oncology evidence-based guideline. Pract Radiat Oncol. 2012 Jul-Sep;2(3):210-225.

Tsao MN, Xu W, Wong RK et al. Whole brain radiotherapy for the treatment of newly diagnosed multiple brain metastases. Cochrane Database Syst Rev. 2018 Jan 25;1:CD003869.

What this practice is about

This practice is about treating breast cancer that has spread to the brain (brain metastases). It highlights the importance of using the most effective treatments and minimising side effects.

If breast cancer spreads to the brain, treatment is important to limit its effects on the person’s quality of life.

Traditionally, brain metastases have been treated using radiotherapy to the whole brain, known as whole brain radiotherapy. This can treat the cancer cells but may also affect brain function. For some people with brain metastases, surgery or radiosurgery^* may be recommended. These treatments are more precise and have fewer side effects than whole brain radiotherapy. It also allows further precise radiotherapy to be given to a different part of the brain at a later time if needed.

The choice of treatment depends on where cancer cells are in the brain and the size of the affected area. It also depends on whether cancer has spread to other parts of the body, the person’s general health and their preferences. Whole brain radiotherapy may not be recommended if surgery or radiosurgery are suitable options.

Why this practice might be important for you

If you have brain metastases, it is important to balance the benefits and possible side effects of treatment. Treatment options include surgery, radiosurgery and whole brain radiotherapy. Surgery or radiosurgery have fewer side effects than whole brain radiotherapy.

Talk to your doctors about the different types of treatment and the possible benefits and side effects associated with each of them. This includes any impact on your day-to-day activities, such as driving. It is important for you to be informed about all of the options so that you can make the decision that’s right for you.

* Radiosurgery (stereotactic radiosurgery) is a very precise form of radiotherapy that uses radiation to remove tissue rather than the traditional method of using a surgical blade.

Questions to ask

What are my options for treatment of brain metastases?
Would surgery or radiosurgery be useful for me?
What is involved in the treatment you recommend?
What effect will my diagnosis and treatment choice have on my return to driving?

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