Monthly Archives: February 2020

Redefining Hope in Metastatic Breast Cancer

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I had a second post included in the Komen Konnection Blog, this one about hope.

Here is the content of that post.

Image result for hope image

“Hope” is the desire to have something happen or to make something become true.

We hope to be in a meaningful relationship, sharing our lives with someone special.

We hope our children lead happy, healthy and productive lives.

We hope to get to a service station before the gas tank is dry.

Hope for Early Stage Breast Cancer Survivors

In early stage breast cancer, hope is about getting through treatment and eliminating breast cancer in the body.  It’s about wanting to get through therapy without too many life disruptions, eventually putting cancer in the rear view mirror. It’s about wanting to live a cancer-free life.

There are many inspirational memes for early stage breast cancer patients, messages intended to lift spirits and ease anxiety of being a breast cancer patient. For example, “Once you choose hope, anything’s possible.” – Christopher Reeve

For those living with Metastatic Breast Cancer (MBC), the hope-centered memes turn into educational messages like this: “Metastatic Breast Cancer Can Be Treated But Not Cured.”  

Is this a hopeful message?

I’ve been living with MBC since 1998. I think the message is extremely hopeful. When originally diagnosed, there were only seven therapies for MBC. Now there are over 60 with more in clinical trials.

How I’ve Redefined Hope

Hope, for me, isn’t about being cured and putting cancer behind me. 

Hope is that I will live as long as I can while experiencing a reasonable quality of life. 

I also hope that when I die of MBC, it won’t be a long, painful process, one that emotionally rips my family apart. I don’t want to be grasping for treatments when it’s clearly the end, treatments that ruin the quality of whatever time I have left. I don’t want my family to feel guilty that they could have done more.

What is realistic to hope for living with MBC? Should hope even be realistic? Or is what we hope for meant to inspire us?

Dr. Leslie Blackwell explains in her TEDxCharlottsville talk about how hanging on to hope can actually shorten and reduce the quality of life for terminal cancer patients whose bodies can’t tolerate more therapy or who have no viable therapy options. Her talk is called “Living,Dying and the Problem with Hope.” She brings up excellent points about our inability as a culture to see death as the natural conclusion of living.

What Others Living with MBC Say about Hope

I asked MBC group members on FaceBook how the concept of hope has changed for them once diagnosed with stage IV breast cancer. Here is a summary of their words:

Thoughts on Longevity:

“I cling to hope even more now. I want to live as long as possible.”

“I hope to live longer even if my quality of life is low. I want be with my kids as they grow up.”

“My hope at one time was to make it to Christmas. I’m doing much better and believe I will live to see next year.”

“I include hope as an essential part of my cancer treatment.”

Thoughts about Family:

“Hope today centers around my children. I want to do all I can now to set them up for bright futures.”

“I hope my small children remember me after I die.”

“I hope my death won’t traumatize my family.”

Thoughts on Faith: 

“I’ve turned to God as I have no hope in man or science.”

“Hope is like a thread, not a rope. However, my faith, rather than hope, comes from inside and gives me strength.”

Difficulty with Hope:

“I struggle with hope and give a fake smile when people advise me to ‘have hope.’”

“I try to balance hope with the reality of my situation. I used to hope I would be cured.”

Research:

“I hope research accelerates to the point that there will be treatment options for me that provide durable responses:  years versus months or weeks.”

“To me, hope is research to benefit the next generation.”

Other Types of Hope:

“What I hope for changes by the day, week and month. These are short term hopes like getting a good scan report or that I’ll feel better tomorrow.”

“Hope for me is the ability to wake up every day.”

“I hope to enjoy every moment I’m alive.”

“I hope I have the courage to embrace death with acceptance when my times come.”

“Hope gives me the spark to set new goals, learn new things and appreciate life.”

“Hope is the lock that keeps fear in a box. It allows me to enjoy the time I have without living in a state of constant anxiety.”

Like most things in life, hope is complicated. We view hope differently once diagnosed with metastatic breast cancer. Please avoid sharing your version of hope with those living with MBC. If you do, don’t expect to get a big “thank you.”

Hope is personal.

The Right Dose

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I wrote a blog post for Komen about the need for providing the right dose to further individualize treatment in metastatic breast cancer.

Here’s the content of the blog:

Personalized medicine has been hailed as one of the latest big ideas when treating patients. According to the National Cancer Institute Glossary it’s defined as a “form of medicine that uses information about a person’s own genes or proteins to prevent, diagnose or treat disease.”

What’s missing from the personalized medicine definition and practice?

Personalized dosing.

The goal of treating early stage breast cancer is to obliterate cancer in the body and keep it from coming back. In metastatic breast cancer (MBC), the goal is to be on a therapy as long as possible to control the disease while maintaining quality of life. With two distinct goals, you’d think there would be two dosing strategies. One is a sprint, and one is a marathon.

Most FDA approvals for cancer drugs include a maximum tolerated dose (MTD) with at least two lower doses that can be used. All three are shown to be effective, otherwise they wouldn’t have been approved.

The National Comprehensive Cancer Network (NCCN) guidelines list the MTD for most of the approved breast cancer therapies for both early stage and metastatic breast cancer. These guidelines are used by many oncologists to determine dosage.

So instead of personalizing the dose to patients based on drug sensitivities in the past, whether the therapy is for disease control or disease elimination, a standard MTD is administered.

In July 2019, I attended an update on breast cancer therapies for oncologists where I was the only advocate present. During an optional lunch session sponsored by a drug company touting their new drug that I’ll call Drug X,  I publicly suggested that we aren’t properly dosing new cancer meds when there is no difference in outcomes between maximum tolerated doses and stepdown recommended dose reductions in MBC. Pharma reps swooped in on me after the session.

The reps explained that all patients need to start at MTD because if we don’t start there, we will never know if the patient can tolerate the maximum dose. 

Alarms went off in my head. It made no sense to me.

So, let’s say you are a patient with MBC and you’ve been on a few lines of therapy. You have progression and Drug X is your next option. Even if you have low blood counts, have experienced eventual stepdown doses on your other therapies due to sensitivities or side effects, you are to start at the MTD. Why? Because that’s what the guidelines say.

Does this sound right to you? 

It doesn’t make sense to me. Why subject a patient to the highest dose when it’s extremely unlikely they will be able to tolerate it and will likely experience serious or reduced quality of life side effects? And, these side effects may reduce the amount of time the MBC patient can safely remain on the drug.

Furthermore, clinical trials are often quick to establish dose standards without taking time to consider a variety of dosing schedules and amounts. Sometimes it takes a few years for oncologists to see their patients experience intolerable side effects at the MTD before they change their personal practice using reduced dosing. That happened with capecitabine. 

It seems to me that NCCN guidelines should suggest starting at the lowest dose and ramping up if needed or starting at the middle dose and going up or down based on patient reaction. Some oncologists are already doing this, but outside of guidelines. After all, they are “guidelines” not commandments. Yet oncologists may feel uneasy prescribing outside of these guidelines.  

If you are starting a new line of therapy or are on a therapy but experience intolerable side effects, talk to your oncologist about reduced dosing. Your oncologist should be able to explain a good rationale whether to stay at current dose or step down to a lower dose. Make sure you understand the pros and cons. Then it’s your decision how you’d like to proceed. 

Adding individualized dosing to the definition of personalized medicine should be the standard of care.

*The opinions expressed are those of the author.

For more information see:

“A new concept may help us at last abandon one-size-fits-all dosing of cancer treatment drugs”

“Challenging Standard-of-Care Paradigms in the Precision Oncology Era”

“Precision Medicine Is Not Just Genomics:  The Right Dose for Every Patient”