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The proceedings contain 109 papers. The topics discussed include: dose intensity of palbociclib and initial body weight dosage: implications on progression free survival in 220 patients with ER+/HER2-negative metastatic breast cancer;characteristics of Nirmatrelvir/Ritonavir (Paxlovid) recipients and clinical interventions by oncology pharmacists at a tertiary outpatient cancer center;safe handling of non-carcinogenic drugs in the Ghent University Hospital: development, implementation and communication of hospital-specific guidelines;case series: use of olaparib in uncommon locations in patients with impaired homologous recombination;real-world data evaluation of medicines used in special situations in oncohematology: a retrospective study from a comprehensive cancer institution;Dostarlimab in the treatment of recurrent endometrial cancer: real life experience;medication-related osteonecrosis of the jaws and CDK4/6 inhibitors in breast cancer;and efficacy and safety outcomes of generic imatinib in adults with chronic myeloid leukemia (CML) following the switch from branded imatinib.
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Objective: During the COVID-19 pandemic, cancer patients had restricted access to standard of care tissue biopsy. Liquid biopsy assays using next generation sequencing technology provides a less invasive method for determining circulating tumour mutations (ctDNA) associated with targeted treatments or prognosis. As part of deploying technology to help cancer patients obtain molecular testing, a clinical program was initiated to offer liquid biopsy testing for Canadian patients with advanced or metastatic breast cancer. Method(s): Blood was drawn in two 10 mL StreckTM DNA BCTs and sent to the CAP/CLIA/DAP accredited Imagia Canexia Health laboratory for testing using the clinically validated Follow ItTM liquid biopsy assay. Plasma was isolated using a double spin protocol and plasma cell-free DNA (cfDNA) extracted using an optimized Promega Maxwell RSC method. Extracted cfDNA was amplified using the multiplex amplicon-based hotspot 30 or 38 gene panel and sequenced. An inhouse developed bioinformatics pipeline and reporting platform were used to identify pathogenic single nucleotide variants (SNVs), indels (insertions and deletions), and gene amplification. Included in the panel are genes associated with metastatic breast cancer: AKT1, BRAF, ERBB2, ESR1, KRAS, PIK3CA, TP53. Result(s): To identify biomarkers, 1214 metastatic or advanced breast cancer patient cfDNA samples were tested. There were 15 cases sent for repeat testing. We reported 48% of samples harboring pathogenic ctDNA mutations in TP53 (22%), PIK3CA (19%), ESR1 (18%), AKT1 (2%), ERBB2 (1.5%). Co-occurring variants were identified in samples with ESR1/PIK3CA as well as TP53/PIK3CA (both p-values <0.001). Interestingly, 29% of samples with mutated ESR1 harbored >= 2 ESR1 ctDNA mutations. In 56% of cases, previous molecular testing indicated the cancer subtype as hormone receptor (ER, PR) positive with/without HER2 negative status. In this specific subgroup, 49% harbored ctDNA mutations with 63% of those being PIK3CA and/or ESR1 mutations. Conclusion(s): A population of Canadian women with metastatic breast cancer were tested using a liquid biopsy gene panel during the COVID-19 pandemic for identification of biomarkers for targeted therapeutic options. Over 50% of the samples were identified as hormone positive, with greater than 60% harboring PIK3CA and ESR1 ctDNA mutations. Studies have shown that metastatic PIK3CA mutated ER-positive/HER2-negative tumors are predictive to respond to alpelisib therapy and have FDA and Health Canada approval. Additionally, ESR1 mutations are associated with acquired resistance to antiestrogen therapies, and interestingly we identified 29% of ESR1 mutated samples with multiple mutations possibly indicating resistance subclones. In future studies, longitudinal monitoring for presence of multiple targetable and resistance mutations could be utilized to predict or improve clinical management.
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Breast cancer is the most common form of cancer and the second cancer-causing death in females. Although remission rates are high if detected early, survival rates drop substantially when breast cancer becomes metastatic. The most common sites of metastatic breast cancer are bone, liver and lung. Respiratory viral infections inflict illnesses on countless people. The latest pandemic caused by the respiratory virus, SARS-CoV-2, has infected more than 600 million worldwide, with documented COVID-related death upward of 1 million in the United States alone. Respiratory viral infections result in increased inflammation with immune cell influx and expansion to facilitate viral clearance. Prior studies have shown that inflammation, including through neutrophils, can contribute to dormant cancer cells reawakening and outgrowth. Moreover, inhibition of IL6 has been shown to decrease breast cancer lung metastasis in mouse models. However, how respiratory viral infections contribute to breast cancer lung metastasis remains to be unraveled. Using MMTV/PyMT and MMTV/NEU mouse models of breast cancer lung metastasis and influenza A virus as a model respiratory virus, we demonstrated that acute influenza infection and the accompanying inflammation and immune cell influx awakens and dramatically increased proliferation and expansion of dormant disseminated cancer cells (DCC) in the lungs. Acute influenza infection leads to immune influx and expansion, including neutrophils and macrophages, with increased proportion of MHCII+ macrophages in early time points, and a sustained decrease in CD206+ macrophages starting 6 days post-infection until 28 days after the initial infection. Additionally, we observed a sustained accumulation of CD4+ T cells around expanding tumor cells for as long as 28 days after the infection. Notably, neutrophil depletion or IL6 knockout reversed the flu-induced dormant cell expansion in the lung. Finally, awakened DCC exhibited downregulation of vimentin immunoreactivity, suggesting a role for phenotypic plasticity in DCC outgrowth following viral infection. In conclusion, we show that respiratory viral infections awaken and increase proliferation of dormant breast cancer cells in the lung, and that depletion of neutrophils or blocking IL6 reverses influenza-induced dormant cell awakening and proliferation.
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Introduction and importance: Breast cancer is the most common type of cancer in women, with 30 % being metastatic breast cancer. Cancer is known to be a comorbid Covid-19 infection. Interleukin-6 (IL-6) is one of the findings of inflammatory activity due to Covid-19 infection. We report IL-6 levels as a prognostic factor for survival rate in patients with liver metastatic breast cancer. Case presentation: We report five cases of liver metastatic breast cancer with various types of primary breast cancer. All patients are infected with Covid-19. IL-6 levels were reported to be elevated in all five patients. All patients were treated according to the national guidelines for the care of Covid-19 patients. All patients are reported to have deceased after being treated for Covid-19 infection. Clinical discussion: Metastatic breast cancer has a low prognostic rate. Cancer has been recognized as one of the comorbidities and increases the severity and mortality of Covid-19 infection. Elevated levels of IL-6 are caused by an immune response to infection, and can worsen the outcome of breast cancer patients. Changes in IL-6 levels implicate the survival rate of metastatic breast cancer patients and outcomes during the treatment of Covid-19 infection. Conclusion: Elevated levels of IL-6 can be a prognostic factor of the survival rate of metastatic breast cancer patients during the treatment of Covid-19 infection.
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Background: Breats cancer is a major health problem in elderly ( >= 70 years) women. Increase incidence with age and the progressive increase in life expectancy mean that the numbers in elderly breast cancer diagnosis are increasing. These patients do not always receive the proper treatment and despite this the survival of this population is not always depends on cancer, there are other competing causes of death typical of the aging population. Method(s): A retrospective observational analysis of women >= age 70 diagnosed with breast carcinoma in HUPHM between 2014 and 2020 was made. Clinical, pathological data and stages at diagnosis were analyzed. We checked our patients with the national death center (official national registry) thus obtaining an exact date of death and the cause of death. Data updated in January 2023 , ensuring a minimum follow-up of 24 months. We excluded deaths from Covid or of unknown cause to avoid bias. Result(s): A total of 421 patients were analyzed, mean age of 78.6 years and median follow-up of 48 months. 28% of patients had died at the time of analysis, 11% due to cancer and 17% from other causes. If we analyze the population deceased by cancer, no deaths are detected in patients diagnosed with carcinoma in situ (4% of the population), in stage I (30% of the population) the cumulative incidence of cancer death at 5 years is 3%, 7% In stage II (30% of the population), 15% in stage III (16%) and 70% in stage IV (12%). Death by other causes are more frequent in early breast cancer, the cumulative incidence at 5 years are 10% in stage I, 22% in stage II, 44% in satge III and just 10% in stage IV. The most frequent causes of death in this population were caridovascular events and infections. There are no differences in 5-year mortality according to histological subtypes 20%, 12%, 25% and 12% for triple negative, Rh+/HER2-, RH+/her2+ and RH-/HER2+ respectively. Conclusion(s): Although elderly patients do not receive optical treatments, mortality from cancer in early stages is incidental at 5 years, a different scenario is seen in metastatic disease in which the patient's prognosis depends mainly on the oncological disease, Therefore, an effort should be made in the treatment of these patients with metastatic breast cancer since adequate treatments can have a clearly positive impact on the survival of patients. Legal entity responsible for the study: The authors. Funding(s): Has not received any funding. Disclosure: All authors have declared no conflicts of interest.Copyright © 2023
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Background: The phase III EMERALD trial (NCT03778931) reported significantly prolonged progression-free survival (PFS) and a manageable safety profile with elacestrant vs SoC endocrine therapy (ET) in patients (N=478) with ER+/HER2- advanced or mBC following progression on prior CDK4/6i plus ET. PROs measuring quality of life (QoL) are reported here. Method(s): EMERALD patients (pts) completed 3 PRO tools at prespecified time points: the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30), the PRO version of the Common Terminology Criteria for Adverse Events (PRO-CTCAE), and the EuroQoL 5 Dimension 5 Level (EQ-5D-5L). Result(s): The ratio of PROs tools completed vs. PROs tools expected was 80-90% through cycle 4 and approximately 70% at cycle 6;likely due to clinical study period overlapping with COVID-19 period. Overall, the EORTC QLQ-C30 scores were similar for elacestrant and SoC, with no differences across all time points for both functional and symptom scales. However, PRO-CTCAE results showed that fewer pts who received elacestrant reported very severe nausea (4.0% vs 14.3% by cycle 6) or very severe vomiting (9.1% vs 50% by cycle 6) compared with SoC. There were no clinically meaningful differences across all time points in adverse events typically observed with pts with cancer on ET, such as fatigue, nausea, vomiting, joint and muscle pain and hot flashes. EQ-5D-5L scores were generally comparable throughout treatment for both study arms, with elacestrant showing numerically better outcomes vs SoC for mobility, self-care and usual activities. Similar trends were observed for the full intent-to-treat population and in pts with detectable estrogen receptor 1 mutations (ESR1m). Conclusion(s): This analysis confirmed that QoL was maintained between treatment groups in the EMERALD trial. Together with the previously described statistically significant prolonged PFS and manageable safety profile, these PRO results provide additional evidence that oral elacestrant is clinically meaningful in this patient population with limited therapeutic options. Clinical trial identification: NCT03778931. Editorial acknowledgement: Jeffrey Walter, IQVIA. Legal entity responsible for the study: Stemline Therapeutics/Menarini Group. Funding(s): Stemline Therapeutics/Menarini Group. Disclosure: J. Cortes: Financial Interests, Personal, Advisory Board: Roche, Celgene, Cellestia, AstraZeneca, Seattle Genetics, Daiichi Sankyo, Erytech, Athenex, Polyphor, Lilly, MERCK SHARP& DOHME, GSK, LEUKO, Bioasis, Clovis oncology, Boehringer Ingelheim, Ellipses, Hibercell, BioInvent, Gemoab, Gilead, Menarini, Zymeworks, Reveal Genomics;Financial Interests, Personal, Invited Speaker: Roche, Novartis, Celgene, Eisai, Pfizer, Samsung Bioepis, Lilly, MERCK SHARP& DOHME, Daiichi Sankyo;Financial Interests, Personal, Other, Consulting/advisor: Expres2ion Biotechnologies;Financial Interests, Personal, Stocks/Shares: MedSIR, Nektar Therapeutics;Financial Interests, Institutional, Research Grant: Roche, Ariad Pharmaceuticals, AstraZeneca, Baxalta GMBH/Servier Affaires, Bayer healthcare, Eisai, Guardant Health, Merck Sharp & Dohme, Pfizer, Piqur Therapeutics, Puma B, Queen Mary University of London;Other, Travel cost and expenses: Roche, Novartis, Eisai, Daiichi Sankyo, Pfizer, Gilead, AstraZeneca. F.C. Bidard: Financial Interests, Personal, Advisory Role: Pfizer, AstraZeneca, Lilly, Novartis, Radius Health, Menarini;Financial Interests, Institutional, Advisory Role: Menarini;Financial Interests, Personal, Speaker's Bureau: Pfizer, Novartis, AstraZeneca, Roche, Lilly, Rain Therapeutics;Financial Interests, Institutional, Research Grant: Novartis, Pfizer, Menarini Silicon Biosystems, Prolynx;Financial Interests, Institutional, Other, patents: ESR1 & MSI detection techniques;Financial Interests, Personal, Other, Travel, Accommodations, Expenses: Roche, Pfizer, AstraZeneca, Novartis. A. Bardia: Financial Interests, Personal, Advisory Board: Pfizer, Novartis, Genentech, Merck, Sanofi, Eisa , Lilly, Mersana, AstraZeneca/Daiichi, Menarini, Gilead;Financial Interests, Personal, Royalties: UpToDate;Financial Interests, Institutional, Invited Speaker: Genentech, Novartis, Pfizer, Merck, Sanofi, Radius Health, Immunomedics/Gilead, Daiichi Pharma/AstraZeneca, Eli Lilly.;Non-Financial Interests, Principal Investigator: Gilead, Mersana, AstraZeneca/Daiichi, Novartis, Pfizer, Genentech, Lilly, Merck, Sanofi. V.G. Kaklamani: Financial Interests, Personal, Other, Honoraria: Genentech, Novartis, Pfizer, Genomic Health, Puma Biotechnology, AstraZeneca, Seattle Genetics, Daichi, Gilead Sciences;Financial Interests, Personal, Advisory Role: Amgen, Eisai, Puma Biotechnology, Celldex, AstraZeneca, Athenex, bioTheranostics;Financial Interests, Personal, Speaker's Bureau: Genentech, Novartis, Genomic Health, Puma Biotechnology, Pfizer, AstraZeneca/Daiichi Sankyo;Financial Interests, Personal, Research Grant: Eisai. I. Vlachaki: Financial Interests, Personal, Full or part-time Employment: Menarini Hellas A.E. G. Tonini: Financial Interests, Personal, Full or part-time Employment: Menarini Ricerche S.p.A. N. Habboubi: Financial Interests, Personal, Full or part-time Employment: Stemline Therapeutics;Financial Interests, Personal, Leadership Role: Stemline Therapeutics. P.G. Aftimos: Financial Interests, Personal, Advisory Board: Boehringer Ingelheim, Macrogenics, Roche, Novartis, Amcure, Servier, G1 Therapeutics, Radius, Deloitte, Menarini, Gilead, Novartis, Eisai, Lilly;Financial Interests, Personal, Invited Speaker: Synthon, Amgen;Financial Interests, Institutional, Research Grant: Roche.Copyright © 2023
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The COVID-19 pandemic substantially impacted the delivery of oncology care, particularly for individuals with metastatic cancers. The objective of this study was to qualitatively evaluate the impacts of COVID-19 on metastatic breast cancer (MBC) care among patients. This study consisted of 36 semi-structured qualitative interviews conducted virtually with people living with MBC, who were members of a patient support organization called Project Life. Project Life is an MBC patient-led, web-based wellness community. Responses were analyzed using Phronetic Iterative Analysis. Interviews were conducted from March 14, 2022, to May 31, 2022. Analysis from 36 individual in-depth qualitative interviews revealed the following themes during COVID-19: (1) variable preferences for telehealth (2) disruptions to care, (3) virtualization of social care. Wide variations existed in preferences surrounding telehealth, centered around ideas of convenience. Disruptions to care included delays to diagnostic care, isolation from caregivers, and interruptions associated with COVID-19 infection. These results call for adaptability in oncology care given wide-ranging preferences on telehealth and the shifting of available support services.
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People with metastatic breast cancer face barriers to finding information and support Background FORCE, a national nonprofit organization developed a health communication tool to help patients assess research relevance, key findings, and the quality of media reporting on cancer to support informed and shared health decision-making. People with metastatic breast cancer (mBC) are a priority population. Methods The organization conducted a survey about awareness of and access to breast cancer information and supportive services for people living with metastatic breast cancer. The organization promoted the survey through e-mail and social media, and a network of partner organizations that serve the metastatic breast cancer community. The survey invited respondents to volunteer to participate in focus groups and a follow-up survey in order to support efforts to serve this priority population. Results and Conclusions While interest in clinical trials was high, many users reported that thy do not know how to find an appropriate clinical trial. A majority of the 335 respondents were interested in information about clinical trials, treatment side effects, research findings, long-term health issues, diet/exercise, fatigue, and emotional health. Three quarters of the respondents indicated that they had never participated in a clinical trial, 67% indicated they would be interested in participating in the future, and about 40% indicated they did not know how to find a clinical trial recruiting people with metastatic breast cancer. Approximately one-third of participants were unable to obtain referrals to services they sought. Other barriers to services included lack of insurance coverage, lack of availability, and the COVID-19 public health emergency. Focus group responses indicate that women with mBC find the health communication tool to be useful, and appropriate in language, images, and tone. Results indicate that women with mBC are interested in finding information about clinical trials and other topics related to treatment side effects and quality of life. FORCE and partners are incorporating these results into tailored online resources to meet the needs of the mBC community.
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Problem statement: Those diagnosed with metastatic breast cancer (MBC) have complex supportive care needs and the Australian Government funded 30 new dedicated MBC nurse roles across Australia in 2019 to better meet these needs. A pilot training program was designed to meet the individual learning needs of these nurses to increase their level of expertise in MBC nursing. Initially this program was designed to be delivered in-person, however recurrent COVID-19 restrictions required a change of approach to enable remote participation. Method(s): An expert working group created a curriculum of 20 learning modules addressing key elements of MBC nursing. From these modules a bespoke training program was designed for each participant to address their identified learning needs based on the validated Cancer Nurse Self-Assessment Tool for Metastatic Breast Cancer (CaN-SAT-MBC) and baseline interviews. During the pilot program, four intakes of two nurses (n=8) participated from August 2021 to June 2022. Participants completed a suite of online learning modules, 'attended' a 3-day clinical practicum, and commenced 12 months of bi-monthly clinical supervision for ongoing support. Participants attended the clinical practicum component either in-person or via a telepresence robot. Knowledge, skills and confidence in relation to MBC nursing are being measured by the CaN-SAT-MBC, and learner goals, expectations and experiences are being explored via qualitative interviews at three-time intervals: pre-training;post-practicum;and 12 months post-clinical supervision. Result(s): The final results of the evaluation will be available in 2023. It is hypothesised that nurses will report increased knowledge, skills and confidence in the areas of MBC nursing relevant to their identified learning needs following completion of the training program. Furthermore, it is also hypothesised that remote participation using robot technology will offer an equivalent learning experience to in-person training in this current pandemic environment. Conclusion(s): This study will test an individualised and innovative approach to breast cancer nurse education that may be utilised across Australia to upskill nurses in the provision of supportive care to those with MBC. There is potential for wide-spread adoption of robot technology for cancer education across Australia and beyond. Disclosure of interest: This project is partially funded by Astra ZenecaCopyright © 2022
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Significance and Background: Metastatic Breast Cancer (MBC) or Advanced Breast Cancer (ABC) is multifaceted and requires high levels of support and resource utilization. The ABC Program at MD Anderson Cancer Center began in 2014 with a goal to increase the quantity and quality of life for patients living with MBC. It offers emotional support, personalized visits with a nurse practitioner navigator, access to clinical trials, specialty clinics, tailored patient education and innovative care projects. Prior to COVID-19, the ABC Program held a 90-minute quarterly town hall series featuring 2-3 presenters and topics of patient interest. In response to COVID-19, it pivoted to a weekly virtual 60-minute educational series called "ABCs of Healthy Living in Challenging Times" that is for patients with breast cancer, caregivers, faculty, staff, community members and advocates. Purpose(s): To address COVID-19 social-distancing related isolation and changes to healthcare, build community, empower patients, and educate on diverse topics including patient services, treatment, symptom management and quality of life. Interventions and Evaluation: The series was facilitated by a nurse practitioner navigator via Zoom. A distribution list created from town hall meetings was the basis for the series' notices and has grown by referrals, word of mouth and marketing opportunities;it began with less than 150 people and has grown to more than 550 people. The facilitator offered a format where the attendees and speakers could interact visually and verbally with each other. From 4/2020 to 6/2022, 104 webinars were held for 2,546 attendees for an average of 24 attendees each week. Topics covered were side effect management/quality of life/healthy lifestyle (26%), patient education/empowerment (18%), treatment (19%), clinical trials/research (11%), quality of life related to COVID-19 (8%), COVID-19 (7%), innovation projects (4%), palliative/end of life care (7%), and financial/disability concerns (3%). The series was evaluated using the Qualtrics survey software (n=53). Respondents said that the series has positively influenced their interactions with healthcare providers (65%), how patients with MBC think about their cancer experiences (65%) and provided an opportunity to connect with others like themselves (65%). Respondents stated actions taken based on the series: shared the information with family/friends (77%), joined or remained in a support group (34%), spoke with a provider for information and services (32%), requested an appointment with the ABC Program or other specialty clinics (26%), started a new healthy behavior (21%), joined a clinical trial (11%), or started using a patient reported outcome tool (9%). The series served mostly patients living with MBC (70%), established patients at MD Anderson (38%) or patients at MD Anderson as well as a community cancer center (17%). Most respondents indicated that they attended about half of the time, usually or always (60%) and are very or completely satisfied with the series (92%). Demographics of the respondents were White (77%), Black (13%), Asian (4%) and Hispanic (16%). Discussion(s): The ABC Program pivoted to COVID-19 by offering services virtually. The virtual series has allowed for more digestible patient education, varied presentations, and participation for those living outside of Houston, TX. Peer support and continuing education are imperative dynamics for patients to use their voice to impact their overall quality of life. The series has impacted attendees with a change in behavior when speaking with their clinical team, awareness and utilization of support resources, and starting healthy behaviors. While the series was created in response to demands of COVID-19, it effectively addressed psychosocial and educational needs and overall quality of life of MBC patients. The series was an easy intervention to initiate with lasting changes relative to the effort and resources required.
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Background During the COVID pandemic, we designed and implemented a program, called BQualD, to maintain high quality care for patients with HR+, HER2 negative MBC who were taking oral anti-cancer therapy and needed to shelter at home. This program augmented available clinical resources with (1) trained nurse coaches to manage side effects, improve adherence, monitor for cancer progression and screen for psychological distress via telehealth, and (2) a care coordinator to arrange blood testing at local labs to facilitate timely medication dose adjustments. BQual-D served patients from August 2020 through April 2021. Here, we describe survey results assessing patient (pt) satisfaction with BQual-D. Methods Pt's satisfaction surveys included questions rated on a Likert scale (1 "strongly disagree" to 5 "strongly agree") with questions regarding the following: satisfaction with the quality of the nurse coaching calls;perception that the nurse coach listened to what they were trying to convey;whether or not their needs were met by the nurse coaching calls;whether they felt that they received adequate explanation regarding the nurse coaching calls;whether they would recommend the nurse coaching calls to a friend;perception of whether or not the nurse coach was negative or critical towards them;whether or not they would do it over (i.e., if they would return to the nurse coaching calls);whether or not they felt that the nurse coach was friendly or warm toward them;they were able to more effectively deal with care and symptoms;they felt free to express themselves;they were able to focus on what was of real concern to them;the nurse seemed to understand what they were thinking and feeling. Patients were also asked how much the calls helped with their care and symptoms. Descriptive statistics are reported (i.e., frequencies and means). Results 84 pts were screened and contacted for the BQual-D program. Of the 64 pts who responded, 52 (81.3%) were interested and enrolled in BQual-D;12 (18.8%) declined. Among those who enrolled, 1 voluntarily withdrew, and 7 withdrew due to change in treatment. Participants had a mean age of 65 (range 36 - 88 yrs) and the following racial distribution -Caucasian/White (38, 73.1%), Black or African American (12, 23.1%), American Indian (1, 1.9%) and American Indian or Alaskan Native (1, 1.9%). Satisfaction surveys were received from 32 (50%) pts. Results of surveys regarding patient satisfaction with the nurse coach were generally positive. Pts agreed or strongly agreed that they were satisfied with the quality of the nurse coaching calls (94%), the nurse coach listened to what they were trying to convey (94%), their needs were met by the nurse coaching calls (91%), they understood the purpose of the call (90%), and they would recommend the nurse coaching calls to a friend (88%). The majority (74%) agreed or strongly agreed that they were able to more effectively deal with their care and symptoms after the nurse coach calls. When asked how much the calls helped their care and symptoms, 61% indicated that they made things a lot better, 19% indicated that they made things somewhat better, 16% indicated that they made no difference. One patient indicated that the calls made things somewhat worse. Conclusions During the COVID pandemic, when sheltering at home was encouraged, patient satisfaction with BQual-D, which provided additional health resources (nurse coaches, care coordinator) to support pts on oral therapy for HR+ MBC, was high. Resources needed to implement BQual-D should be explored as a way of providing additional support for pts to minimize the requirement for in-person visits. Funding(s): Supported by a grant from Pfizer.
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Over the last decade we have witnessed rapid advances in the treatment of patients with metastatic breast cancer (MBC) with seminal discoveries in cancer biology, correlative biomarkers and clinical trials leading to multiple new drug approvals. While these milestones have improved survival, the science of survivorship in this population is just beginning. The diagnosis of MBC is life-changing and requires individualized and multidisciplinary support. The NCI defined the areas of epidemiology and surveillance, symptom management, psychosocial research, health-care delivery, and health behaviors as necessary fields to advance the state of the science in advanced cancer survivors. A multifaceted program addressing these domains is needed to assess MBC patients and their unique and ever-changing needs. With input from patients and providers, program components should include: therapeutic clinical trials, multidisciplinary specialty care, individualized patient navigation, peer support, continuing education, and patient reported outcome (PRO) collection to support patients living with MBC. Input for a program for MBC patients can be guided by a multidisciplinary steering committee in which patient advocates are a major voice. Patients can provide insight into what works for them, and what they are facing may be very different from the experience of an early-stage breast cancer patient. Clinical trials designed to advance the current scientific knowledge of breast cancer treatment are essential to patients living longer, more fulfilled lives with MBC. Clinical trials may include systemic therapy, local therapies such as surgery and radiation for MBC patients, side-effect management and quality of life (may put elsewhere). A comprehensive systemic therapy portfolio should include all biological subtypes as well as recommended treatment options (hormonal therapy, targeted therapy, chemotherapy, and immunotherapy). Multidisciplinary care is necessary to diagnose and treat any condition the MBC patient may encounter and is essential in providing quality care. Comorbidities and debilitating side effects arising from cancer treatment are known to be associated with inferior outcomes. MBC patients may experience lack of familiarity of some providers with novel MBC cancer treatment, side effects, and interactions of their cancer treatment with non-cancer conditions and treatment. With the increasing life expectancy of MBC patients, it is important to manage the medical comorbidities in coordination with the MBC patient's cancer treatment. Integrative Medicine helps support the quality of life of patients through providing clinical modalities such as stress management, yoga, meditation, acupuncture, massage and lifestyle counseling. Supportive care helps support cancer related fatigue and sleep challanges, geriatrics and hospice and palliative care for advanced cancer patients. The role of navigation for MBC patients is unique and should be designed to support the patient's many individual needs. Navigation requires assessment of individual knowledge deficit, coordination of care challenges, internal resource utilization, cultural requests, and emotional health. Navigation should also address the patient's financial and disability questions, medication assistance, symptom management, advanced care planning and goals of care discussions. Additional items to be discussed during navigation visits include primary care provider utilization, COVID-19 vaccination, illness and medication questions, and other patient questions as they arise. A comprehensive registry of MBC patient's medical records and histories will assist researchers in designing future therapeutic and quality of life clinical trials. The categories of patient demographics, clinical variables, pathological variables, treatment variables, outcomes of MBC, and PROs will create a robust registry. A comprehensive patient registry can create a rich database which can guide and inspire future innovative research. Peer support through support groups and peer-to-peer matching s pivotal to MBC patients finding and utilizing their patient voice, emotionally supporting each other and learning from other's similar experiences. Connection between patients and the creation of a community of survivors can empower patients to positively impact their care through self-advocacy and self-efficacy. Continuing patient education is also essential to providing quality cancer care. The format of a weekly virtual education webinars are helpful in creating an engaged patient community and a platform to disseminate educational resources in a reoccurring digestible format. Frequent educational webinars covering a wide variety of topics can positively influence patient interactions with their healthcare providers and influence how patients living with MBC view their own cancer experience. Educational webinars provide opportunities for patients to connect with subject matter experts, other patients like themselves, and share information with their family and friends. Informed patients can discuss and ask questions more confidently with their health care providers about information and services presented during the educational webinars. The symptom profile of patients living with MBC are impacted by numerous variables such as disease burden, treatment plan, comorbidities, supportive regimen etc. The collection of PROs has been shown to improve patient satisfaction with his/her care, improve quality of life, decrease emergency room visits and hospitalizations, and increased overall survival. The routine measurement and management of MBC patients' symptoms has been found to be integral in providing comprehensive cancer treatment. The collection of PROs improves patient and provider communication and elicits the outcome to symptoms that matter most to each patient. Patients diagnosed with MBC are living longer because of the recent advancements in therapeutic treatments. A multifaceted and comprehensive program consisting of therapeutic clinical trials, multidisciplinary specialty care, individualized patient navigation, peer support, continuing education, and PROs collection is integral to fully support patients living with MBC.
ABSTRACT
Introduction: Breast cancer is the most common cancer in women and the leading cause of cancerrelated death in women worldwide. The high prevalence of physical and psychosocial suffering among breast cancer patients and their families justifies the need for an early interdisciplinary approach by a palliative care team. The effectiveness of early palliative care for patients with advanced cancer has been demonstrated in many studies. Early referral to outpatient palliative care services improves symptom control, reduces suffering and improves quality of end-of-life care. Aim(s): Evaluation of referral patterns of metastatic breast cancer patients to the outpatient embedded palliative care team. Method(s): We retrospectively retrieved data from electronic medical records of patients who were treated at a private community oncology practice in Brazil who died from metastatic breast cancer during the years of 2018 until 2021.We evaluated the patient's follow-up time by the palliative care team (follow-up > 12 weeks or not) and the year of referral to the service (pre-2020 vs 2020 and later) associated to the service referral type: Late referral (more than 8 weeks of metastatic diagnosis) or early referral. Each group was followed-up by cancer physicians and after referral was also followed-up by a palliative care multidisciplinary team who regularly evaluated cancer patients during their treatments at outpatient setting. During COVID-19 pandemic, some patients were evaluated by telemedicine appointments. We performed univariate comparisons analysis by Fisher's Exact Test. p < 0.1 was deemed as statistically significant. Result(s): Of the 211 patients whose data were assessed, 99 patients were referred to Palliative Care team before 2020 and 112 patients after 2020. 13.1% of patients pre-2020 received early palliative care versus 33.9% of patients in the post-2020 referral group, resulting in a 3.37-fold odds of an early palliative care integration after 2020 (OR 3.37, CI95: 1.61 - 7.45;p< 0.001). Overall, 30.4% of longer follow-up patients were an early referral versus 19.3% of the shorter follow-up, resulting in an 82% greater chance (OR 1.82, CI: 0.92-3.63;p< 0.1) of prolonged assistance with early referral. Conclusion(s): In this analysis, early palliative care integration for patients with metastatic breast cancer has increased after 2019 despite the COVID-19 pandemic, leading to prolonged time of accompaniment by the multidisciplinary palliative care team. This suggests that even in the face of this challenging moment, a mature and consolidated service is offered by the palliative care team. Also, according to previous data in literature, prematurely integration show signs of correlation with better quality of life and death, supporting early palliative care for this group of patients. However, further work is needed to examine the effect of this care model in our cohort.
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Introduction: More than 2 years after the WHO declaration of a pandemic, SARS-Cov-2 still represents a public health problem The pandemic has increased the complexity of cancer treatments including breast cancer. These difficulties were highlighted in adjuvant treatments but above all in metastatic disease. Vaccination has been one of the most important public health factors that has reduced deaths, hospitalizations and the severity of symptoms related to infection. In metastatic breast cancer hormone receptor positive and HER2/neu negative currently the first line of treatment is given by the association between cyclin 4/6 inhibitors and hormone therapy (aromatase inhibitors or fulvestrant) A well-known and frequent side effect of this therapy is the reduction of white blood cell values and neutrophils. The hypothesis that this study is to evaluate whether treatment with cyclin inhibitors initiated before the period of vaccinations may have influenced, due to the reduction in white blood cell values, an increased risk of infection in these patients. Material(s) and Method(s): In our study, we selected patients who had started treatment with cyclin inhibitors before starting the vaccination cycle (in Italy up to the fourth dose in cancer patients) and continue it without evidence of disease progression. All patients were offered a vaccination cycle with mRNA COVID vaccines and were followed during their cancer treatments. All patients, at least 90 days after the last dose of vaccine, have been tested for antibodies against SARS CoV-2 (trimeric spike protein) with a value expressed in binding antibodies unit (BAU) according to international standard WHO During the observation period (starting from the first dose of vaccine administered) the patients were clinically checked and in case of suspicion of infectious pathology with symptoms suggestive of SARS-COV-19 infection, they were tested with molecular swab Results: We evaluated 52 patients who started cyclin treatment before the vaccination course and who are currently without signs of disease recurrence During the study period we found 14 SARSCOV19 infections (28% of patients) and one patient with two infectious episodes. No patients needed treatment in a hospital or resuscitation setting. All patients have fully recovered from the infection and at most after 21 days have resumed the treatment still in place Statistically, a linear regression calculation was applied to evaluate a functional relationship between variables measured on the basis of sample data. We did not find a relationship between spikes or infections compared to the start date of the vaccination cycle;instead we observed a relationship between the value of the spike and the date of last immunization (considered as an active infection or fourth dose of vaccine) with a reduction in the values the further you go away Conclusion(s): The data of the study show that there is a correlation between the time elapsed between the last vaccination and the risk of getting sick. For this reason, the fourth recall represents a strong help to reduce this risk. We did not find any ranges we could refer to regarding the dosage of trimeric spike protein. Considering the positivity rate of infections that does not exceed the general vaccinated population and the absence of serious infectious symptoms with hospitalization, treatment with cyclin inhibitors appears to be a safe treatment even in a pandemic period. (Table Presented).
ABSTRACT
Background: HER2+ mBC remains incurable, with a need for new HER2-directed therapies and regimens, including chemotherapy-free options. Zanidatamab (zani) is a novel HER2-targeted bispecific antibody that binds HER2 in a unique trans configuration, driving multiple mechanisms of antitumor activity, including complement-dependent cytotoxicity. A CDK4/6 inhibitor combined with endocrine therapy is an approved treatment for HER2-negative/HR+ mBC and this combination has also demonstrated encouraging antitumor activity when paired with HER2-targeted therapy(ies) in HER2+/HR+ mBC. Here, we report results from ZWI-ZW25-202 (NCT04224272), an ongoing singlearm phase 2 study of zani combined with palbociclib (palbo) and fulvestrant (fulv) in pts with HER2+/HR+ mBC. Method(s): Eligibility requirements include: HER2+/HR+ unresectable, locally advanced BC or mBC;ECOG PS of 0 or 1;prior treatment with trastuzumab, pertuzumab and T DM1 (additional prior HER2-targeting agents are permitted);and no prior treatment with CDK4/6 inhibitors. Part 1 of the study evaluated the safety and tolerability of the zani/palbo/fulv combination and determined the recommended doses for use in Part 2, where the antitumor activity of the combination is being evaluated. Endpoints include safety outcomes, progression-free survival at 6 months (PFS6), confirmed objective response rate (cORR) per RECIST v1.1;disease control rate (DCR=complete response [CR] plus partial response [PR] plus stable disease [SD]);duration of response (DOR);PFS;and overall survival. Result(s): As of 24 Feb 2022, 34 pts (33 HER2+/HR+ per central analysis) with a median age of 52 (range 36-77) have been treated. In the metastatic setting, pts had received a median (range) of 4 (1-10) prior systemic regimens, including 3 (1-8) different prior HER2 targeted therapies, and 1 (0-4) endocrine therapy. Seven pts (20%) had prior T DXd treatment and 7 pts had prior fulv treatment. All pts received zani (20 mg/kg Q2W) and standard doses of palbo and fulv. Eighteen pts (53%) remained on treatment;median duration of zani treatment was 6.9 mo (range 0.5- 16.3). A dose-limiting toxicity (DLT) of neutropenia occurred in 1 of 7 DLT-evaluable pts in Part 1. Among all pts (n=34), the most common (>20%) treatment (zani, palbo and/or fulv)-related adverse events (TRAEs) were diarrhea (74%), neutrophil count decreased/neutropenia (62%), stomatitis (41%), asthenia (26%), nausea (24%), and anemia (21%). Grade (Gr) >=3 TRAEs in 2 or more pts included neutrophil count decreased/neutropenia (50%), anemia (6%), diarrhea (6%), and thrombocytopenia (6%). AEs of special interest were all Gr <=2 and included 4 pts with cardiac events (LVEF decrease of >=10% from baseline) and 1 pt with infusion-related reaction. There were no treatment-related serious AEs. Palbo was discontinued for 1 pt due to an AE (AST increase);no pt discontinued zani treatment as a result of AEs. Two deaths occurred: 1 due to disease progression and 1 due to an unrelated AE of pneumonia caused by COVID-19. In 29 pts with measurable disease, the cORR was 34.5% (95% CI: 17.9, 54.3), all responses were cPRs, of which 1 is pending CR confirmation. DOR ranged from 2.3 to 14.9+ mo, with 8 confirmed responses ongoing, and the DCR was 93.1% (95% CI: 77.2, 99.2). Interim median PFS was 11.3 mo (range 0.03-16.7;95% CI: 5.6, not estimable). PFS6 analysis is planned following the completion of enrollment. Conclusion(s): Zani in combination with palbo and fulv shows encouraging antitumor activity with durable responses in heavily pretreated pts and a manageable safety profile. This regimen has the potential to be a chemotherapy-free treatment option in pts with HER2+/HR+ mBC. Enrollment in the study is continuing.
ABSTRACT
Background: Supervised exercise programs (SEP) have demonstrated an improvement in quality of life (QoL), cardiovascular health, treatment tolerance and disease outcomes in early breast cancer patients. In metastatic breast cancer (MBC), previous data suggest SEP are safe but no impact on QoL and a low adherence to programs were shown. These studies included a heterogenous population in terms of type of treatments received, numbers of previous lines or comorbidities. From our perspective, MBC profile that could benefit most from SEP needs to be explored. Thus, we conducted a pilot study to assess adherence, safety and impact on QoL of a combined SEP and nutritional program (NP) in a selected population of MBC of patients treated with cyclin-dependent kinase 4/6 inhibitors (iCDK 4/6). Method(s): This is a prospective, single center, single arm pilot study. SEP consisted in a 12-week intervention with twice a week in-person resistance exercise session. Patients also completed weekly aerobic exercise goals in self-managed sessions monitored with activity trackers. SEP was conducted by registered Physical Activity and Sports Science instructors that followed American College of Sports Medicine guidelines. In addition, participants had an initial nutritional assessment and personalized counselling by a qualified nutritionist. Adherence to treatment, biological variables and QoL assessments (FACIT-Fatigue and QLQ-C30 questionnaires) were collected at baseline (B) and week-12 (w12). Primary endpoint was global adherence (>=70% of attended sessions relative to scheduled sessions). Secondary endpoints included safety, changes in biological variables and QoL. Paired samples t-tests (Wilcoxon) were used to assess biological changes and QoL. Result(s): Patients (n=26) were recruited from October 2020 to November 2021. Median age was 47,5 years (45-55);84,6% of patients were ECOG 0. 42,3% of patients were receiving Abemaciclib;34,6% Ribociclib and 23,1% Palbociclib in first (73,1%) or second (26,9%) line treatment. Patients had bone (69,2%);visceral metastasis (57,7%) or both (30,8%). 2 patients did not start the intervention and additional 7 patients discontinued the program prematurely, the majority of them due to COVID-related concerns. Considering all patients who at least attended one session, global adherence was 66% (39-77,5%) and 45,8% of patients achieved an adherence of >= 70%. Patients reported an improvement in QoL [B global QLQ-C30 66,6 (50-75), w12 75 (66,6-83,3);p 0,0121] and fatigue [B FACIT-Fatigue 37 (30-44), w12 42 (38-48);p 0,0017]. Sit-to-stand repetitions in 30-second period also improved [(B 15 (12-17), 19 (15-23);p 0,0002]. Same benefits were seen in patients with adherence >= 70%. No statistically significant changes were seen in body fat or muscular composition and handgrip scores. Importantly, no safety issues related to study intervention were reported. Conclusion(s): Even though the study was conducted during COVID-19 pandemic, global adherence was 66%. For the first time in MBC, SEP and NP combined program demonstrated to be safe and improved QoL in patients with first or second line MBC treated with iCDK4/6. Further research is needed to identify strategies that improve QoL in MBC.
ABSTRACT
Breast cancer is now the most common cancer. Thirty years of increased awareness, early diagnosis, and treatment access contributed to a 40% decline in breast cancer deaths. Yet, in 2021, more than 281,550 new cases of invasive and 49,290 new cases of non-invasive breast cancer will be diagnosed in U.S. women. Black women are 40% more likely to die of breast cancer - the highest breast cancer death rate across racial and ethnic groups. Today, the Black-white breast cancer mortality gap persists, and Black metastatic breast cancer (MBC) patients have a poorer prognosis. The pandemic exacerbated breast cancer disparities. In 2020, delays and avoidance contributed to an 85% breast cancer screening drop while MBC patients' risk of severe illness and death from COVID-19 elevated. Therapy interruptions and abandonment increased, and conversely, clinical trial enrollment decreased. COVID-19 has accelerated the digital platform shift to telemedicine, online psychosocial support programs, virtual patient navigation, and digital engagement across the oncology care continuum. DC Pink Divas Intervening Virtually to Advance Saving Lives (DIVAS) is an award-winning evidence-based training, outreach, and patient navigation program developed to address the educational needs of Black early-stage, MBC breast cancer patients, survivors, and caretakers and provide strategies to educate, empower and impact women by increasing breast health knowledge, decreasing gaps in screenings and access, increasing awareness of MBC to ensure that where a woman lives, will not determine if she lives through a 1-year commitment of attendance in 8 cohort-based education modules where Black breast cancer mortality is highest. The DIVAS Health Behavioral Change Model adapts the Precaution Adoption Process Model, Health Behavior Model, and Social-Ecological Model. DIVAS implements innovative virtual outreach programs, training, and intervention strategies to empower Advocates to educate peers, providers, and policymakers. 3 Cohorts of Black women impacted by breast cancer trained as Lay Breast Health Advocates from 2011, 2020, and 2021 (N = 57;77.5 % 45 years or younger;36.7% early-stage 0-II, 50% late stage III-IV, 10.3% caretakers) self-reported their lifestyle behaviors, breast cancer diagnosis, breast health education, social media use, and interest in a digital-based lifestyle intervention. Participants completed pre-and post-surveys, interviews, and journaling over 10.5+ hours of education modules to understand their breast health, provider-related challenges, and community-related resources. Findings provide evidence that cohort-tailored education is a successful method of supporting Black women in a behavioral-health intervention. The provision of printed culturally attuned information along with the digital-based instruction from a Black woman health care provider or public health expert is effective in helping Black breast cancer survivors transition into patient empowerment, improve QOL and contribute to better patient outcomes. After the intervention and completion of breast health modules, participants reported increased: self-efficacy in communicating with providers (70%) and self-efficacy in making treatment decisions (70%) self-confidence (85%), and a decrease in lifestyle risk factors (87%). Patient-centric behavioral health interventions in breast cancer education must be advanced digitally to address the pandemic's compounded crisis. DC Pink Divas provides insights to combat rising disparities by educating, empowering, and mobilizing Black lay breast health advocates to improve outcomes. Collaborative digital interventions across the care continuum to improve awareness, access, adherence, infrastructure, culturally attuned training, and support are evidencebased methods for navigating the cancer care transformation accelerated by COVID-19 to advance breast health equity. (Table Presented).
ABSTRACT
Early in the pandemic, cancer centers across the nation and Oregon canceled their cancer support programs as non-essential medical care. Breast cancer patients were forced to look elsewhere for essential assistance and community support to move along their cancer journeys. Pink Lemonade Project (PLP), a Vancouver, WA based community based nonprofit, helped fill the gaps and expanded its local support for breast cancer patients. A virtual format allowed PLP to serve more individuals with our psychological, emotional and financial support programs. Next, PLP convened an informal coalition of all the local breast cancer support organizations including those that offer breast cancer support programs, community including dragon boating and rowing, and others that serve broader communities and more people of color. Then, as Komen National announced its restructuring, and closed the Oregon-Southwest Washington affiliate in Spring 2021, Pink Lemonade Project stepped up again to maintain two locally-grown Komen programs that met critical community need-the MBC Dinner Series and the Treatment Access Program (TAP), a transportation assistance program that served all of Oregon and reduced the geographic barrier to care. Through the coalition, PLP heard patients express concern that they were receiving outdated information and were struggling more to find needed support and resources from their providers. Understandably, nurse navigators and social workers could not maintain and/or update patient resources while they assisted COVID patients. The goal of the coalition was to increase communication across the organizations and to share more event schedules for the ease of patients to understand what support programs are available. This session, delivered by an all breast cancer patient panel, will give an overview of Pink Lemonade Project;its programs that helps with psychological, emotional, community and financial support for breast cancer patients, survivors and those living with metastatic breast cancer;and will highlight the results from the patient point of view of the systematic review of the contents of 6 regional health systems new patient binders and present recommendations for consistent, community-wide content for all future breast cancer patients. The project's main strength was that Pink Lemonade Project could draw upon on an existing coalition of local, community-based breast cancer organizations to help update and standardize breast cancer support information from the patient point of view. Then by acting as a neutral convener, PLP could request and receive the binders from all the region's healthcare providers to help standardize and update the community resources across all the region's cancer centers. The result is that any new breast cancer patient, regardless of where their access to care is, can receive consistent community-based information and resources. Another result of this project showed the importance of the partnership of healthcare and human service agencies, especially in a post-pandemic world. As the pandemic continues to strain healthcare, community-based nonprofits have a unique role to help coordinate community resources and improve the quality of life for those affected by breast cancer.
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Background: Integrative therapies are shown to support cancer patients' treatment plans, help with side effect management, and improve patients' quality of life ([1-9]). In 2017, the American Society of Clinical Oncology endorsed the Association of Integrative Oncology's Clinical Practice Guidelines highlighting their importance in breast cancer care. Recent studies suggest that more evidence is needed to bring attention to the role of integrative therapies in advanced breast cancer care [4, 7, 8, 10]. This analysis explores participants' experiences with a wellness program implemented by Unite for HER (UFH), a non-profit organization that delivers integrative therapies and support services such as whole food nutrition services, medical acupuncture, oncology massage therapy, counseling, reiki, meditation, yoga, and fitness classes to patients with breast, metastatic breast, and ovarian cancer. As of April 2022, there were over 1,700 women diagnosed with metastatic breast cancer (MBC) participating in UFH locally and nationally. Method(s): UFH members completed a survey about the impact of the UFH Wellness Program on the overall quality of life, including measures on side-effect management, OTC/prescription drug utilization rate, stress reduction, changes to wellness habits, and the social and emotional challenges associated with living with MBC. In total, 119 unique UFH members with MBC answered online surveys distributed by email in 2020 and 2021. Survey questions were designed to evaluate the impact of the UFH Wellness Program. Descriptive analyses of survey questions and openended comments were conducted to assess program impact. Result(s): All respondents were MBC patients/survivors. No other demographic information was collected. While 2020 respondents received mostly in-person services for part of their program, all 2021 respondents received primarily virtual services due to the Covid-19 restrictions. Despite the inaccessibility of in-person services, the satisfaction levels with the wellness program did not drop significantly in 2021. More than two-thirds of respondents (80% in 2020, 67% in 2021) indicated that the therapies offered through UFH Wellness Program significantly improved the side effects of their treatment for MBC. Notably, more than a quarter of respondents (28% in 2020, 26% in 2021) specified that due to UFH integrative therapies they were able to reduce or eliminate one or more OTC/prescription drugs to manage side effects. At the same time, the majority reported experiencing reduced levels of stress after utilizing integrative therapies offered by UFH (93% in 2020, 81% in 2021), as well as improvements in their emotional wellbeing (95% in 2020, 83% in 2021), and quality of life during or after treatment for MBC (97% in 2020, 96% in 2021). Also, 86% of respondents in both years indicated that UFH services, such as nutrition counseling, cooking classes, and exercise classes, helped them adopt and maintain healthier habits in their life. Furthermore, a qualitative analysis of open-ended comments found that 1) respondents expressed deep gratitude and appreciation for UFH integrative therapies, 2) noted that they would otherwise not be able to access such therapies due to financial barriers, and 3) helped them feel better prepared to cope with the psychosocial aspects of their MBC experience. Discussion(s): These results suggest that integrative therapies such as those offered by UFH can play a significant role in improving patients' outcomes by reducing stress and drug utilization to manage side effects and improving patients' well-being and quality of life during metastatic breast cancer treatment. These findings highlight the importance of choosing integrative oncology programs to support MBC patients' needs in managing the psychosocial and physical side effects of the disease.