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War and Prejudice: Problems Faced by Advanced Breast Cancer Patients in Accessing Treatments

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Experts have highlighted the plight of several groups of patients with advanced breast cancer (ABC) for whom the management and treatment of their disease needs urgent attention and improvement.

In the final session of the Advanced Breast Cancer Seventh International Consensus Conference (ABC 7) in Lisbon, held on November 11, 2023, the experts called for immediate measures to help patients fleeing war or conflict zones and the healthcare professionals who treat them, an end to discrimination against patients with serious mental illnesses, and an end to discriminatory practices that can deny patients access to intensive care units based solely on their diagnosis of ABC.

In addition, they issued new statements on several groups of patients with ABC where it is difficult to decide on the best treatments and care, such as women who are pregnant, patients with concomitant HIV infection, and frail, elderly patients.

Chair of the ABC 7 conference, Dr Fatima Cardoso, the director of the Breast Unit of the Champalimaud Clinical Centre, Lisbon, Portugal, and the president of the ABC Global Alliance, said: “War and conflict can cause major disruption to the delivery of care for patients with advanced breast cancer.

“A lot of patients have completely lost the capacity to be treated, but also all their medical records are lost or destroyed. For instance, our colleagues in Poland, where many Ukrainians have fled, are facing huge difficulties in treating patients because often they don’t even know what type of cancer these patients have, or what type of treatment they’ve been receiving since everything has been destroyed. We cannot wait for wars to end to treat these patients and unfortunately there are always wars or conflicts in the world.”

She said a possible solution to this problem could be digital medical cards that patients always carry with them. “If the patient has access to her or his data in electronic form, then it will be easier to share. This is important during war, but also for other situations, for example, when a patient is looking for a second opinion. There is an ongoing European Commission project about developing this. However, it does raise issues of confidentiality.”

Patients with ABC should not be denied access to intensive care units just because of their cancer diagnosis, said the experts. This was an issue that came to prominence at the height of the Covid-19 pandemic.

Honorary Chair of ABC 7, professor Eric Winer, director of the Yale Cancer Center, USA, said: “Just because a patient has metastatic cancer, they should not automatically be denied access to intensive care if they develop a serious illness or infection, or a serious side effect from their cancer treatment. During Covid, if a patient had cancer, they were often put at the bottom of the list for access to ventilators.

“This happened in many countries, and Covid has not gone away. We have to remember that many patients with metastatic cancer will live for years. These patients must be reviewed individually and treated according to their needs, with consideration of their preferences and their oncologists’ input.

“Other examples of prejudice are those shown towards elderly, very frail patients, and those with serious mental illnesses or HIV.”

The panel of experts highlighted that patients with serious mental illnesses were more likely to be diagnosed with cancer when it is at an advanced stage, and they have worse outcomes than people without mental health problems.

Dr Larry Norton, also an honorary chair of ABC 7; a senior vice president at Memorial Sloan-Kettering Cancer Center, New York; and medical director of the Lauder Breast Center, USA, said: “Comprehensive care of people with advanced breast cancer means attention to all aspects of their health, including mental health. Discrimination is of course unacceptable. Furthermore, a multidisciplinary approach toward special needs – compliance with treatment regimens and monitoring, effective communications, interactions between cancer and psychiatric medicines, and appropriate continuity of care – is critical.”

The experts agreed that guidelines for treating ABC should be implemented “independently of the age of the patient” and the older, frail patient “should be involved in the treatment decision-making process if they wish to do so, and their preferences should be taken into account”.

They also stated that “independent of age, all eligible patients should be informed about potential clinical trials.” They highlighted the potential for drug interactions for this group as well, as many elderly patients take several medications for several different health conditions and diseases.

For pregnant patients with ABC, the panel stated that patients should be managed by a multidisciplinary team with experience in this extremely difficult clinical situation. Also, the preferences of patients should be taken into account, and, where appropriate, those of other people they may want to involve, such as partners, family, and friends.

The preferred scanning method to assess the cancer should be whole-body MRI, which is less likely to affect the foetus. Among all systemic therapies, only chemotherapy can be given safely, and then only in the second and third trimesters. Anti-HER2 therapy and endocrine therapy cannot be given for the duration of the pregnancy.

ABC patients living with HIV have worse survival rates than those without HIV and are more likely to develop infections and adverse reactions to cancer drugs. The expert panel said multidisciplinary teams, including an oncologist and an HIV specialist, should manage the care of these patients. They should not be excluded from clinical trials, and doctors should consider reducing doses of anti-cancer drugs that induce immunosuppression, and/or increasing the intervals between doses.

The experts reviewed the newest treatments and issued new guidelines for three sub-types of breast cancer: ER positive/HER2 negative (or endocrine dependent), HER2 positive, and triple-negative disease (that lacks hormonal and HER2 receptors).

They also updated the definition of endocrine sensitivity or resistance. Dr Cardoso said: “These agreed definitions will help to ensure uniformity among clinical trials allowing for a better interpretation of results.”

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