Breast Cancer Metastasis To Liver

hello, i'm helen zorbas, and it's my pleasure to welcome you to this breast cancer education series produced by national breast& ovarian cancer centre, in collaboration withthe rural health education foundation. we're delighted to have you,as health professionals in rural and remote areas of australia,joining us for this program focusing on breast cancer care. in australia, approximately 30% of womendiagnosed with breast cancer

live outside a major metropolitan city. as well as their cancer diagnosis, these women face additional challengesincluding geographic isolation and limited contactwith specialist health care workers. as rural health professionals,you have a vital role to play in both the provision of informationand the delivery of best practiceclinical and supportive care for rural women with breast cancer. we hope that through this series,

we improve your accessto evidence-based information and ultimately benefit the womenwith breast cancer in your care. the program has been developed to be specifically relevant torural practice and i would like to thankour facilitator dr norman swan and the breast cancer expertsand rural health professionals who have contributed their timeand expertise to this broadcast. i hope you enjoy the program. thanks to helen zorbas,the chief executive

of the national breast& ovarian cancer centre. and welcome to the programon secondary breast cancer - finding breast canceroutside the breast. this is a joint initiativeas helen just said of the national breast& ovarian cancer centre and the rural healtheducation foundation. it's also a project of thesupporting women in rural areas diagnosed with breast cancer program and it's funded bythe australian government.

now most women who present withsecondary or metastatic breast cancer will have already been diagnosed withand treated for early breast cancer. although, for some,this will actually be how they present. today we're going to considersome of the challenges in looking after womenwith secondary breast cancer, recent developments and treatments and the psychosocialand supportive care needs of women and indeed their families. you'll find a numberof useful resources available

on both the national breast& ovarian cancer website, nbocc.org.au, and on the rural health educationfoundation's website, rhef.com.au. i want to introduce our panel to you. tony hobbsis a rural general practitioner from cootamundra in new south wales. - welcome, tony.- thank you, norman. jane ingham's professor of palliativemedicine, at the university of nsw, and is also at the cunningham centrefor palliative care in sydney.

- welcome.- thank you. chris keogh is a clinical nursespecialist in palliative care at the mercy care centrein young in rural new south wales. - welcome, chris.- thank you. chris milross is head of thedepartment of radiation oncology, at royal prince alfredhospital in sydney. welcome, chris. very happy to be here. nicholas wilckenis director of medical oncology at sydney's westmead hospital. welcome.

- hi, norman.- welcome to you all. now, before we start our discussion,let's hear briefly - 'cause we want to be really, as focusedas we can on the woman's journey with breast cancer - and hear from judywho has metastatic breast cancer. judy: 1993, breast cancer sneaked intoour lives like a thief in the night. lloyd, oliver, kyle and tara,my greatest wish was to see you grow up, grow old with your father, sit on the verandahs,surrounded by grandchildren. i never wanted our lives to change.

we moved to the country and hopedwe'd left breast cancer behind. cancer returns to my body -to lung, bone and spine . my breasts are gone -breasts that nurtured four children and gave pleasure. in their place, a tapestry of the scarsand wounds of the last 12 years. i struggle to make sense of my life. i hold back the painand the tears buried so deeply, feeling dead, dry and hollow,ready to splinter. thank you to thebreast cancer network of australia

for providing judy's story. tony, um, unfortunately,not an unusual story. it's not, but not one that we often seein general practice, norman, and i think that's a reallyimportant message tonight - even though metastatic breast cancer is not gonna be a common presentationin general practice, we need to think about it in women thatpresent with new or different symptoms that've had breast cancer in the past,and help them navigate their way forward with a good management plan in place,working with our specialist colleagues,

and to make sure that we bring a messageof hope and support not only to the womanbut also to their family. chris keogh, i mean,it does illustrate though, the support that such a womanand her family need. yes, it does, and it's probablyimportant for these rural women that can be quite isolated as well, so there are supportsaround in the country and it's important to work, i guess,with the gps and as a team with the familiesto help these women at this time.

we'll come back to moreof these things later. nicholas, of all womenwith breast cancer, what proportion does it come back? it's difficult to get really accuratefigures but broadly speaking, around about 20% of all women withan initial diagnosis of breast cancer will ultimately get a recurrence...- so, 80% are cured of it? so, 80% do not in their lifetimesget a cancer recurrence, and we sometimes forget that whenwe concentrate on metastatic disease. and is that proportion getting lower?

it is getting lower. as our screening detects cancers earlyand our adjuvant treatments work better, we are finding fewer and fewer womendeveloping metastatic breast cancer - or secondary breast cancer - and also that where it does recur,it's starting to recur later and later. and what's the pattern over time? so, over time, we still mainly worryabout the first five years. i think there's a graphic we're aboutto see that illustrates that. we'll see in the first five yearsthe risk of recurrence is highest,

but it never goes away,and if you have a look at that graph down at the ten-year mark,you'll still see that maybe 0.5%, 1-2% a year,women are getting recurrences, and at that point,ten years down the track, it's mainly the women who initiallyhad hormone-receptor-positive disease who are at risk very late on. norman: what are the risk factorsfor recurrence? can you predictwho's gonna get a recurrence? you can to an extentalthough it's an imperfect science,

but essentially, the risk of recurrence depends on how badthe disease was initially, largely measuredby how big the tumour was, whether it involved axillary lymph nodesor not and if so, how many, and then certain aspectsof the biology of the tumour - high grade versus low grade - hormone receptors there versusnot there - and increasingly of course, we're interestedin her2-positive disease as well. so, you can put together a kind ofa nomogram with that information

that will broadly estimate for youthe likelihood of recurrence, and of course, based on that,we will recommend or not recommend certain adjuvant treatmentsthat will potentially prevent or delay that recurrence. is there any way of predicting in awoman which organs she may be liable... look, only very broadly, and that is that the lower-gradehormone receptor positive cancers have a predilection for recurring late,as we said, and also recurring in bone, so the scenarioof widespread bone metastases

but no metastases elsewhere is very typicalof hormone receptor positive cancer. hormone receptor negative cancerstend to more recur in the viscera. - and her2-positive...norman: it's liver and lung? liver and lung, in particular,and her2-positive breast cancer has a particular predilectionfor brain metastases. and, chris milross, women and theirfamilies wanna know the prognosis - it's come back,they wanna know the prognosis. how accurate is the dark art ofprognosis in recurrent breast cancer?

i think the honest answerto that question is that the dark art of prognostication is probably not very accurate, but there are a range of scenarios... the outcome for the woman diagnosedwith metastatic breast cancer is, uh... perhaps bestin the context of a woman who's had a long disease-free interval. so, you know, 5 years, 10 years,even 15 years, from treatment for the primary cancer

through to the presentationwith metastatic disease. the pattern of that metastaticdisease at presentation together with the features of theprimary cancer that nick mentioned also influence prognosis. so, fewer secondariesin less disseminated? long disease-free interval,bone-only secondaries, previous hormone receptor positivedisease - those things all portenda better prognosis. a shorter disease-free interval,high-grade disease,

triple-negative diseaseand the prognosis is more problematic. is local recurrencesecondary breast cancer? - and is contralateral...- you probably say 'no'. because, i think, when we say... there's always a grey zonein these classifications, but when we say 'secondary'or 'metastatic breast cancer', what we're saying is that is recurrence away fromthe breast, chest wall, axilla region, such that although as we'll see,there are multiple treatment options,

that disease is ultimately incurable. i think that's the basic definition. so, were a woman to geta recurrence in the breast if she hasn't had a mastectomyor in the chest wall if she has, that is a potentially salvageableand curable situation. if a tumour is foundin the other breast, it may or may not be a second primary, so again, that's a potentiallysalvageable situation. what about surveillance, tony?

how do you... what's your practicein terms of following... so, a woman's been treatedfor early breast cancer, she's now...she's not on any treatment anymore, she's had her adjuvantchemo and radiation and she's just being followed through. what surveillancedo you routinely practise and what do the guidelines say? i think there's a couple of issues here. the first is that you needto make sure that

the woman is comfortable withhaving her surveillance with her gp. some people wish to continueseeing our specialist colleagues, the oncologist or perhapsthe breast surgeon, on a regular basis. and interestingly, the nbocc - the national breast& ovarian cancer council - is actually doing a trial in fourcentres about this at the moment. certainly, the evidencearound surveillance is to offer the woman who has survivedher breast cancer regular follow-up. so, in the first two years,coming back every three to six months

to take a thorough historyand physical examination, in the next two years, every 6 to 12months and thereafter, every year. and you can see thison the follow-up schedule. it's really important that each of thesewomen have a mammogram and/or an ultrasound,depending on their age, every 12 months, but also to make sure thatwe don't do any other investigations unless there is goodsymptomatic suggestions that there may bea recurrent disease somewhere, and that's pain or some other change.

because is there any evidence that earlydetection of recurrence changes outcome? no, there isn't. in fact, the converse is true that as much as it has beenlooked at so far, trials of very intensive surveillancehave not shown to be beneficial and might be actively harmful, as opposed to whatwe've just heard from tony. and the two problems with doing the kindof imaging that we have available to us other than mammograms are no.1,

that any abnormality that you findin an asymptomatic woman is probably likely to be a furphy, and so you've createda whole lot of anxieties and extra tests that need to be done. and secondly,as you implied from your question, this is ultimately incurable disease, often slowly evolving, and finding thoselung metastases or whatever there are in month one, as opposedto month three or month four, does not make any difference.

jane, given thatwe're talking about end of life here... end of life might be ten years from nowbut it's still... ..it's kind of an end-of-life diagnosis. um... are we still seeing referralsthat are too late for palliative care where they could've been helpedby being seen earlier? well, it depends whetheryou refer to palliative care as a palliative-care specialistor a team of people who are addressing your palliative-care needs - some of whichmay be your psychosocial concerns,

your anxiety, your worry, your fears,others may be symptoms. and i think, um... if a gp,particularly in a rural setting, and a community nurseand an oncologist who's at a distance or intimate and visits,are addressing that spectrum of needs, then i think there doesn't necessarilyneed to be a referral to palliative care. that said, if the symptomsare difficult to control or the psychological concernsare worrying and out of the usual realmor out of the skills of the gp

with regard to managing them, i think that's the timeto call a specialist. but palliative care can play a big rolethroughout the course of illness, depending on the patient's needs. chris keogh? yes, certainly what jane said is true. i think people like thiswill move in and out of palliative care as the need arises. if it's a more complex problemthat they may have,

then certainly palliative caremight be involved in that and then referring back to. tony, do you think peoplerecognise that palliative care does not mean thatyou're gonna die next week and that this is about complexsymptom management and helping you out, or is that still, if you like, a stigma or a problem with the name'palliative care'? i think there are misconceptions,both from the people in the community but also among some health professionalsabout the role of palliative care.

and i would certainly strongly endorsewhat both chris and jane have said about using the team, but about havingthe conversation with the woman involved and her family earlyin a structured, supportive manner, and making sure that they understandwhat palliative care is about. some people will choose to engage early,some people won't, and we need to ensure that people have the informationto make an informed choice. let's go to our first case studywho's leah. norman: she's come to see youpreviously, tony,

with aches and painsin her right arm and chest and has limited mobilityon the right side. you'd sent her to physio,some improvement in her symptoms, but she's back again, and nowthere's a bit of upper back pain. well, this is a potentially, um...not uncommon scenario in that we have a survivorfrom breast cancer who's been treated quite some time ago, that you've had an ongoing relationshipwith them, that you knowthe particular person well

and you've got a relationshipwith their family at some level. so, it's in that context thatshe comes with quite a new symptom - pain which is differentfrom her previous pain related to her surgeryand/or radiotherapy, it's in a different site,it's keeping her awake at night, it's worse with movement. that would raise red flags for meas her treating gp, and we would need to havea discussion about whether or not this might be metastatic breast disease

or in fact,whether it might be something else like a muscle strain perhaps, or perhaps even as osteoporotic fracturein someone of this age. so, it's really importantto have that discussion up-front - not to alarm the woman but to say that this could representa metastatic disease and then have a management planwith her about how you're going to move forward. and that may be investigating that earlywith an x-ray and/or a bone scan,

it may well be having a conversationwith a previous treating specialist at the regional centre, but to make surethat the woman understands that you'll be with her,that you'll have a plan in place, both to investigateand if necessary treat, should the diagnosis be confirmed. is that your script, nicholas? yes, i think so. and i think it's - at what's a potentiallydifficult time for the woman - good for her to know thatthe gp is concerned

about the possibility of recurrence,he's going to do some imaging and has contact withthe initial treating specialist, so that the woman -although she's gonna be very worried - at least can see a kind of a linearprogress of what's gonna happen. and the initial contactwe would hope from the rural gp is to be able to contact fairly directly the oncologist - medical oncologist,radiation oncologist, whoever it is - so that if it turns out that she needsto come to some bigger centre for either assessmentor treatment or both,

that can be done fairly quickly. why does it need to be done quickly? it needs to be donefrom a psychological point of view. if she's got severe painit may need to be done quickly, but from a purely medical point of view,if there are no obvious complications and it does turn out that thisis a bone secondary with some pain that's perhaps controlledwith some panadol or panadeine, then there's no medical urgency, but there's usually -with a first diagnosis -

a pretty serious psychological urgency. so, in a sense,was tony wrong to have delayed this? she had symptoms on the right side,now she's come back with upper-thoracic pain,he sent her off to the physio... - no...- should he have responded earlier? absolutely not.there's two interesting points there. one is... which is tricky for allof us - gps and specialists alike - is women who've had treatmentfor breast cancer and surgery and radiotherapy

often have non-specific symptoms onthat side that are tricky to sort out, and often you've hadthe third or the fourth complaint, so you might actually triggera bone scan in that setting which will turn out to show nothingand what tony's responding to is a new symptom that has persistedand has got worse, so that's when you investigate, and investigating beforehandis just gonna lead to a lot of furphies. - chris?- breast cancer... previous breast cancer doesn'tprotect you from the aches and pains

of ageing and life -tony's not wrong at all. did you want to say something, jane? no, but i thinkwhen you have any symptom, it's important to look at the symptom in terms of its aetiology as wellas to how you'll treat it. so assumingtony's gone through a thought process - which i'm sure he has - about what the causeof the right arm pain is that may have been present for years,came on immediately post-surgery,

and detected that there's something new and has in his minda pathophysiology for that first pain as well as the second pain, then that's how to think it through -there's no problem with that. but if there's no... biologically, ifthere's no urgency... early detection... we've already agreedthat early detection of spread is not gonna change the outcome. that can be quite hardto explain to somebody post-hoc... 'we're not sure what this is,

but i'll send you to the physio,see you in a couple of weeks.' - i think it's important...- word gets around town, 'he missed the fact that it had spread'you know? i'm quite sure... i'd defer a littleto tony and how he deals with that 'cause i don't deal with that commonly, but there are waysof communicating that... comes back to tony sayingusually in the rural setting, this is someone you alreadyhave a relationship with, and if it turns out that it is someonewho is always exceptionally anxious,

well, sure, you may end up doing more bone scansthan you otherwise would've. i think there's a reallyimportant message that remember, this is anindividual patient sitting with us, and i agree withwhat nicholas has said - we will respondaccording to the situation. you might have someonewho's really anxious, you might have someone who'svery relaxed and very happy to wait, and really,...- the issue transparency - be honest.

tony: absolutely.- and setting up a clear plan, i think, so the patient feels confident,as nicholas said before, that the team is involved and there'sa stepwise plan to sort this out. now, a woman in this situation, um...chris keogh... ..people say requires support,as indeed she does, but what does support actually mean? we talk about psychosocial support,we talk about psycho-oncology. in a rural town - in a country town -what does support actually mean? what do you think she needs

that she's not got from the conversationwe've just heard with tony? - um...- she hasn't got a diagnosis yet. - that's certainly right, and...norman: ..which reminds me... but i think it is importantto give these people support, coming from a community nursingbackground... norman: but what does it mean?- to go in, spend time, listen, um... sometimes there might beother issues going on at the time - the family might need some extra help, she may be not coping wellwith this pain,

even in the basics of housekeepingor things like that. so, that early referralto other services might be appropriate at this time, even though she hasn't got thatpalliative care sort of diagnosis yet. nicholas, tony's on the phone to you,asking for advice about what imaging or what diagnosticswould be most appropriate. what are you gonna say? i think as tony said,if we're worried about what sounds like, i guess, the thoracic spine,

it's probably reasonableto get some plain x-rays, um... ..and unless they're completelyand absolutely normal, you're probably gonna proceedfairly quickly to a bone scan. well, let's have a lookat leah's bone scan, 'cause that's, in fact, what she had. chris? chris: leah's bone scan shows numerous,uh... foci in ribs in a pattern typicalfor bone metastatic disease. and then if we take a lookat the next image

which shows us the thoracic spinein more detail, you can see activityin the 11th thoracic vertebral body. taken together,a pattern suggestive of... ..highly suggestiveof bone metastatic disease. and, chris, would you go on and do ctand look for metastases elsewhere? um... i may under certain circumstances because of oneof the most serious consequences of a metastasis in a vertebral body which is compressionof the spinal chord.

so, what specific circumstanceswould drive me towards further imaging? um... severe pain and...certain neurological symptoms, norman, including, uh...a radicular pattern to the pain, sensory disturbance in the lower limbs, a feeling of unsteadinessof frank weakness and/or bladder and bowel symptoms - those sorts of things taken together would make me worry about thepotential for spinal chord compression, and i would definitely want morethan just an x-ray and a bone scan.

and would be lookingat the liver and lungs, um, nicholas? i think there are probablytwo phases of investigation here. the first is the rural gp determining whether this is a non-specificache and pain, an osteoporotic fractureor indeed metastatic breast cancer, and for that, as chris has just said,we want a plain x-ray and a bone scan, and if there aren't anyneurological concerns, probably don't need any further imaging. that gets us a diagnosisand we move on to treatment.

after we've - as we'll come to discuss - after we've essentiallycalmed things down, there's probably a role in doinga ct scan then because this woman is now starting what hopefullywill be a very long metastatic journey, and it's not unreasonable,right at the beginning, just to establish if there's any otherdisease that we have to know about. but not in termsof the initial management. so, treatment -radiotherapy for this or chemo? radiotherapy for thislocal t11 problem with the aim

of palliating the painthat's present now and preventing progressionof the metastasis in that site and ultimately the developmentof neurological consequences of that. so, yes, radiotherapy, but radiotherapy as part of a moregeneral approach to the pain. and what about if she's gotother lesions elsewhere? you wouldn't treat those, you'd just leave them beif they're not problematic? we wouldn't treat themwith radiotherapy,

but having made a diagnosisof metastatic disease, we would address those other lesionswith a systemic agent. so, is this where bisphosphonatescome in, nicholas? yes, but more importantly,endocrine therapy, so this is the pattern we mentionedbefore where her disease has come back ten years down the track, the original disease washormone receptor positive and this highly likely to behormone receptor positive disease. so, there's no immediate indicationfor chemotherapy,

it's very likely that the rest of herdisease will come under control with some endocrine therapy like... you could try tamoxifen againor probably an aromatase-inhibitor, and then, yes,there is a role for bisphosphonates... i thought they helpedprevent spread to bone? that's a controversial area... issue. they may but the main indicationfor bisphosphonates in this setting is that they've been shownin a number of trials to minimise the risk of fracturesand to help with pain

and to reduce the future needfor radiotherapy. do they have to be given iv'cause of the risk of the osteonecrosis? you have. from a rural setting,there are potent intravenous, um... ..bisphosphonates that only needto be used every few weeks, and the risk -at least over the first year or so - of osteonecrosis of the jawis extremely low. but there are alsoeffective oral bisphosphonates - clodronate has been shownin randomised trials to be helpful for womenwith metastatic breast cancer.

and if it's a womanwho doesn't need to have chemo - so she's gonna havean endocrine therapy tablet - then it would be very reasonable forthat woman to be on oral clodronate, so that she doesn't needto be tied to a cancer centre... what about metabolic problemssuch as hypocalcaemia where you get extreme fatigue,flaccidity, that sort of thing? hypocalcaemia,because we use bisphosphonates, is not nearly as commonas it used to be, and is generally seenin a woman with, uh...

heavy, multiple-bone metastases - more than what we sawon that bone scan - at a time when her diseaseis progressing. so, certainly, a womanwith known bone metastases, a story of getting sick -being nauseous, pain worsening... other things could happen -she could develop liver metastases - but a set of bloodsincluding liver function tests and calcium would be in order. what's the course of radiotherapy?

say, you were just treatingthe thoracic... i mean, how many weeks, how many...? palliative radiotherapy coursesare typically very short, so for a bone metastasis such as this where we are satisfied thatthe bone has solid structural integrity, then a palliative course of treatmentmight be as few as five fractions or even a single fraction. in fact, the two options have been comparedin a number of randomised trials

and are shown to produce,at least initially, equally effective palliation of pain. for a rural patient, my personal bias is generally to givea slightly more protracted... ..course of treatment because the one potential advantageof that approach is to reduce the likelihoodthat the same area will need to be subsequentlyre-irradiated. so, you just sort of steel belt it?

if you're bringing a personfrom the country to the city for radiotherapy treatment, do it once insteadof having to do it twice. nicholas, just give us a quick cook'stour through the symptomatology that a general practitionerneeds to look out for in the broad for metastatic breast cancer? again, the key is a new symptom that persists and gets worserather than better. we've seen what happened to leahwith new back pain that got worse.

in terms of visceral disease, uh... ..fatigue, a general, um... ..difficulty in copingwith the frenetic pace of the day, maybe someright upper quadrant tenderness, being a little bit off the food, um... ..a bit anorexic,maybe a bit of weight loss, um... if liver function testsare completely normal in that setting and there's nothing to feelin the right upper quadrant it's unlikely that's there'sa significant load of liver metastasis -

could be something subtlebut unlikely to be anything to be immediately worried about. um... and i guess in the erawhere our systemic therapies for initial diseaseare working better and better, so women are living longer and longer, we are starting to see occasionally -more than we used to in the past - brain metastases,so feeling sick every morning, headache that's not going awayor some kind of neurological symptom. most of those thingswon't turn out to be brain metastasis,

but that's the sort of thingwhere tony does have the conversation, 'i'm a little bit worried -let's get a cat scan'. occasionally, an optometristpicks it up with a retinal deposit. yeah. and presumably,the investigations you do are common-sense... tony... ..investigations arisingfrom symptoms you're seeing rather than jumpingto a ct pulmonary angiogram with everybody you see with a cough?

look, that's true. once again,it's about this individual patient and her symptoms, and treating thoseappropriately with a plan in place. so, not to jump to a conclusion,but to take things forward stepwise... although it's easy to forgetthat thromboembolic disease is a lot more commonin this group of women. it is, and indeed,if someone turned up in my practice that had had breast cancerin the past with dyspnea, perhaps pleuritic pain,maybe a bit of a cough, you would investigate that appropriatelyover a period of time,

and would be chest a x-ray,maybe an ecg, and always thinking of the diagnosisof pulmonary embolism and maybe using a scanor a ct pulmonary angiogram. chris keogh,what are the psychological reactions that a woman gets at this timewhen she's now been told that, you know... ..her worst fears are confirmedthat the cancer has come back? um... sometimes these womencan be quite angry, um... ..not really understandingwhy that's happened

when they've understoodthat some of the treatment or the treatment they've previously hadis curative treatment, so they can be quite angry about that. or just generally anxious and concernedwhat's actually happening with them and where that sort ofjourney's going now. what i want to talk to you about now is there is a guide for womenwith secondary breast cancer to help understand their diagnosisand treatment options. this is an updated guidebased on the clinical guidelines

and it's available free of chargefrom the nbocc, and that's nbocc.org.au, i think. so, leah's bone scanconfirms bone metastases... and you wouldn't jump into chemo hereif there are no other, um...? nicholas: no,and the key points there are it's been a long timesince her primary disease, so we expect the outlookto be better than average, that it's a hormone-rec...that the primary cancer was hormone receptor positive -and not always

but probably 85% of the time, thatpersists in the metastatic setting - and also that, as far as we know,the disease is mainly in the bone. they're all things that would suggestthat she'd probably respond well to endocrine therapy, and then we can save up chemotherapyfor a time when we more need it. how long would you expectto get a pain response, an analgesic responseto the radiotherapy? it's a very good question and it'san extremely individual, um... finding. some patients will havean improvement in their pain

after the first fraction of treatment, some patients will need a week or twobeyond the end of the course of the radiotherapy to getan improvement in their pain and everybody elseis somewhere in between the two. generally, the pain will improveduring the course of a palliative radiotherapy treatmentfor bone metastases. so, what's your approach to thetreatment of pain then, in leah? obviously, on the day that thedecision's made to give radiotherapy, they'll be no responseto the radiotherapy -

you know, it'd take us a day or twoor a week to get that thing organised - so we need to start withsome analgesia in the meantime. so, what would you do, tony,before she... you know she's gonna get herradiotherapy in two weeks time. what'll you do for herin terms of her pain? well, it would dependhow severe the pain was and what i thoughtwas actually causing the pain. so, you would build onperhaps simple analgesia - paracetamol, anti-inflammatory agents,for instance -

but you may need to either, at thattime, introduce opiates, for instance, or even other medications,depending on the pain, and indeed, if you thought therewas radiculopathy at the time. i might well havea conversation at that time with either the regional oncologistor perhaps even ring someone like jane, a palliative care person -an expert in pain control - just to get another opinionabout how best to meet her pain needs. clearly that's important while we're waiting for the moredefinitive radiotherapy.

i assume the risk here, chris,is that you dive in too low, and don't capture the painand actually deal with it with the heavy guns, with the guns that are heavy enoughto deal with it at that time, and that's a matter of judgement. i'm talking about the pharmacologicaltreatment of her pain, and the risk of lower rather than justgetting rid of the pain. well, i mean, i think the medicationyou choose to deal with the pain is exactly driven by the severityof the symptoms,

and we've got a large armamentariumand who pyramid that demonstrates the hierarchyif you like, quite well. but mindful of the factthat we don't necessarily move from simple analgesiato more complex analgesia. if it's a serious pain,we'll start with the serious analgesia. norman: jane?- yes. i would usually emphasise to patients that this is somethingthat we have to work with them, possibly intenselyover the next few days.

when you start a treatment,you can't always predict that it's exactly the right treatmentfor that patient, because everyone's pain is individual. encourage the woman to be following up. if the pain management you started todayis not working, encourage the person to come backto the gp, and say, 'brought the pain from sevento five, but it's still not at three.' and also the other thingi would add to it is that aside froma pharmacological approach,

there would be a physical approach thatmight address the woman's activities in the setting of this bone metastasis, and suggest that perhaps some activitiesmight not be optimal this week, and that some activitiesmight hold back on until we got the pain better controlled. norman: chris? another thing i don't want to forgetto mention in the context of a personwith a prior diagnosis of breast cancer just discoveredthey have bone metastasis,

we were talking before about would wetarget treatment to other sites. we need to remember the long bones, because if there'd been abnormalitiesin humeri or femora that were at risk of fracture,had they been assessed, then those locations certainly would betreated pre-emptively. sorry? i think that's another really importantaspect to pain management too that we have skirted arounda little bit, and that's the psychological supportfor the patient and her family as well.

if we can validate, you know, fears,listen to them, and help them in a supportive manner. whether that's the gp in isolationor whether it's the broader team, the palliative care nurse for instance,the specialist, i think that's going to bereally important in helping to abrogate,lessen that pain as well. nicholas, what's your... given the standard of care hereis multidisciplinary team-based care, in other words, radiation oncologisthas to be involved in this situation,

psychologist, psychosocial support,not to mention the general practitioner, and it's hard in country towns becauseyou don't have the stuff you've got in a major metropolitan centre,the resources, what's your approach tomultidisciplinary team-based care so that women from country areas get the same sort of standard of careas women from the cities? i think, you know, that the dry,academic answer would be that there are studies that showthat multidisciplinary care matters, that it improves outcomes,

but we don't know for sure exactly whatcomponent of multidisciplinary care that is that's doing the job. as a clinician, anecdotally, i think that the fundamental,critical thing is communication. so, tony doesn't have to bein the same room as i am, i mean, it might be nicefrom time to time if he is, but he doesn't have to be. but if we know each other, and we've had previous experiencewith patient care,

and there's a direct lineof communication, that's the most critical thing. similarly, i don't necessarilyneed to be in the same room as chris, although i should know himand bump into him from time to time, but as long as i knowhow to get to him... norman: he's bunkered down.- yeah. as long as i know how to get to himand i can say, 'i'm ringing you because there's someonecoming from the country who sounds like they're gonna needradiotherapy sooner rather than later,

and i'm... i'm flagging a warning.' then, for this case,that is multidisciplinary care. and the second component of it is when that person goes...leaves the hospital, and goes back to the country,it's vital that... norman: it's not a scribbled dischargesummary. exactly. that the gp getssome intelligible communication. now, there may be other, more nuanced,more complicated cases where you do want a number of peoplein the same room,

but i thinkit's all about communication. what's your practice, chris? i was sharing earlierthat at a recent panel discussion tony mentioned in this sort of scenario that the problems that rural gps havewith accessing the specialist, how do we form a multidisciplinary team if the rural doctor responsible forthe primary care of the patient can't find us in order to geturgent radiotherapy treatment, or a change in the systemic management.

i think the issue for usis one of availability, and in response to tony's criticism,constructive criticism, i mean, i certainly started addingmy telephone numbers - both office and mobile - to the end of my letterafter country clinics. so the number's there and that reallydoes mean we wanna be called. so that's reassuring in that sense. and... you know, nicholas, chris,what are the treatment goals that you tell women in this situation?

um... obviously it's gonna vary fromdisease to disease and person to person. i think the first thing is thatthe woman needs to be reassured that we know what's going on, or we're going to do some teststo find out what's going on, and there are treatments we haveto help. if we're talking aboutmore long-term goals, the goal is to try and get you as muchback to normal as we can, and you need to know that there isa spectrum of outcomes here. but it is certainly possiblethat you may be well,

and alive for some years, rather than just months, even thoughyou've got a metastatic diagnosis. the other source of variationfrom city to country is a very important sourceof improved outcome, which is access to clinical trials. the evidence is that if you'rein a clinical trial, you do better, even if you've got the comparatortreatment rather than the new treatment. what's the access to clinical trialslike for women in country areas? chris milross?

and they'll often walk inand ask for them, because they've been on the internetand they've been to clinicaltrials.gov, and know what's available overseas. i think it's a good point. the only, i guess,comment that i would make is that it may bea self-fulfilling prophecy in the sense that women who are selectedto participate in clinical trials, or who seek out clinical trials, may have a slightly different,somewhat more favourable cancer.

but let's supposeit is actually due to the trial, and/or the level of involvementwith the care team that is inherent in the deliveryof a trial medication, or the follow-up of a trial patient. i think that these days,there is good access to clinical trials through the regional cancer centresthat operate. i suppose that will always be truefor fly-in, fly-out service, and i'm sure that it's increasingly true for the establishedregional cancer centres.

and then patients who need to travelto the city for treatment have got exactly the same accessto clinical trials as the patients... but increasingly they won't be with newregional cancer centres coming onstream, they'll be treated locally.chris: yeah. i should say though, that in allthe planning for those centres, the importance of clinical trials, and support the conductof clinical trials has been acknowledged as beingan important component of the design of those centres.

we also have to probably acknowledgethat it is going to be always difficult, and the level of accessis likely to be less, and that's somethingwe do have to acknowledge. and increasingly there's clinical trialsin palliative care training. increasingly. we are investigatingthe best possible strategies to manage symptoms, which can be seen as challenging whenyou're caring for a very ill population who may or may not be interestedin participating in clinical trials. but we do see thatas crucially important,

because we see this time of life, and the quality of lifeduring this time of life very important. so the more we can understandabout the best possible strategy to relieve symptoms,the better for the patient. tony, what are you on the lookout herefor urgent... we've heard this isa non-urgent situation, apart from maybeif there's compression here. but it's more to actuallynot allow the woman to fester, and be psychologically upsetabout the fact that there's a delay.

but what are we looking for in terms ofurgent red-flag signs here, in a woman like leah? urgent flags, first of all,would be severe pain, and getting that under controlbecause pain is a medical emergency. so that would be my no.1 priority, and as i said, i might need to enlistthe help of my other colleagues. and no.2 would be,particularly with this metastasis, would be the risk of havingspinal cord compression, and that's really important.

so, we talked a little bit aboutwhat that might look like, it might be expressed as... um... sphincter disturbance,bowel or bladder change, maybe radiculopathy, or even just a sensation of radiationaround the trunk. during the course of treatment,it may well be sepsis. so fever or blood pressure changes,change in mental status for instance. and, clearly,there are other circumstances that may alert to the riskof a secondary somewhere else.

so, for instance, it could be somethinghappening in the chest, it may suggest that the patient may havea pulmonary embolism for instance. so dyspnea, pain, cough, those sortsof things are really important. and less likely would be the suggestion the patient could perhaps havebrain metastases. and nicholas spoke about thisbeforehand - headaches that are unusual,nausea, vomiting, perhaps personality change. and the other risk, of course, may beif there are a lot of bone metastases,

or, in fact, in response to treatment,the risk of hypercalcaemia to be picked up early. so, polydipsia, polyuria, excessivethirst, urination, constipation, perhaps change in mental status,those sorts of things. so they'd be the things that,as gps, we should be looking for. norman: nicholas?nicholas: i agree with that. i think it's just worth makinga couple of comments about the issue of sepsis... because it's different when the patientis on chemotherapy.

so, if the patient is on potentiallymyelotoxic chemotherapy, and not all chemotherapy is myelotoxic, the critical issue iswhat is the white cell count. because if the white cell count is low,if the neutrophils are less than one, then these people can get very sickvery fast. you're better off overtreating themfor their infection, admitting them to the local hospital, starting antibioticsbefore you've got any cultures. if the white cell count is not low,then you can treat it on its merits.

- beg your pardon?- before you've got culture results. norman: you wanna get cultures, though.- sure. but if the white cell count is not low, then you can treat the sepsison its merits. it might still be a serious problem, but you can treat that person likeyou'd treat anyone else with sepsis. so, the white cell count,if you can get one urgently, is the critical point. can i say here i think communicationagain is really important.

my expectation would be if one of mypatients was having chemotherapy, which might drivea neutropenic situation, i would expect that that would comeas part of the information back from nicholas. norman: so you know what to watch for.tony: absolutely. so, immediately,i'm looking out for that, and then i would treat that as a medicalemergency with a protocol in place. norman: jane ingham? i'm cognisant of the factthat we've been talking mostly

about the medical complicationsand the medical things... things we define as medical,to watch out for. but there are certainpsychological consequences, and very practical issues that come upin these patients' lives that can be very urgent. - and so...norman: such as? i think that if the patienthas debilitating anxiety, a depression that's coming onthat... that might go unnoticed, unless enquired aboutspecifically by the gp.

or very practical family issuesthat may be interfering with treatment, such as nobody to mind childrenso that you can't get to treatment, and those sorts of things. they may need that. the person's in front of the gp,so a broad assessment by the gp, and i'm sure tony would acknowledgethe importance of this, of the impact of this illness,as well as medical effects... norman: not to mention financial impactand transportation problems. especially in rural settings.

i think rural gps are often verycognisant of those issues and i think... even with regional cancer centrescoming on, people are still gonna have to travelto regional cancer centre. very much. someone might have to drivethem or that sort of thing. let's go to our next case studywho's june. 69, lives in a town of 8,000 people. she's married,her husband's still alive. she had early breast cancerabout seven years ago. she had a mastectomy and chemotherapyfor node positive breast cancer.

she came to you, tony, three months agocomplaining of fatigue and weight loss, and you referred her to nicholas,where a ct scan found this. let's have a look at her ct scan. nicholas? nicholas: um... so this... in this case, does represent liver metastases secondary to her breast cancer. although, if that were the only abnormality that one found,

you may require further investigation to determine the diagnosis. norman: because it could bea hepatoma... nicholas: because it could besomething else. that's right. i mean, the commonest presentationwith liver metastasis would be the story you just told us, but usually with multiple lesions, rather than just the one. but assuming that the diagnosisis secure...

and you'd look for metastases elsewhere? if that was all i saw,i'd look for metastases elsewhere. but i... as tony was, would bevery suspicious that that's what it was, because she started out witha node positive cancer a while back, that obviously was thought at the time to be serious enoughto merit adjuvant chemotherapy. so we know she's had significant riskof cancer recurrence. what would you do for someone like this,assuming that you're convinced that... assuming we've got the diagnosis right,

and we're assuming because there wasn'tany discussion about endocrine therapy, that her original cancerwas hormone receptor negative. so endocrine therapyis not gonna be helpful. we would, nowadays, want to establishwhether or not a her2 test was done, because it may not have been doneseven or eight years ago. it's done routinelyon all breast cancers now. so, that could be done on previoustissue or it may already have been done. assuming that that's... hormone receptornegative and it's her2 negative, then this is a situationwhere chemotherapy does come in.

there's very good evidence ofchemotherapy on balance will improve quality of life,get the cancer under control, and have a small beneficial effecton overall survival. so, i would be talking to this womanabout the meaning of this diagnosis, the fact that it was seriousand potentially life-threatening, the fact that chemotherapy,although it has side effects, may well get the disease under control, and that if it doesn't, there's timefor us to reassess other strategies. are these complex chemotherapyregimes that you give?

there are increasingly... there's increasingly nowa range of chemotherapies, and it would depend a little biton factors like the pace of disease development, but we're talking about either the kindof chemotherapy that's given every week or every three weeksintravenously. so that means being closeto a cancer centre, or potentially there are someoral chemotherapies that are effective as well,

and they allow easier treatmentat a distance. - it's going to be toxic to some extent.- it's potentially gonna be toxic. it'll require doctor visits,blood counts. it's gonna significantly interferewith your life. so she comes back in three months timeand here's the ct scan. nicholas: so, this is thankfullyrelatively unusual. this is a devastating development,that is, that despite what we presume... what we intended to beeffective chemotherapy, right at the beginningof her metastatic disease,

she has substantially progressed. so that there's now veryextensive disease throughout the liver. now, in general, as long as the womanis well enough, and wants to pursue further options, you can usually findthat with trying different chemotherapy you may be able to get thingsunder control for some time. but whether it's at the first timeor the second time or the third time, at some point that is going to happen, and at some point we're gonna needto have the discussion

about whether further chemotherapyis really going to be helpful, and whether we need to concentrate onother aspects of managing the disease, and how it affects her life. and how unwell is she at this stage? well, she...i mean, she may not be that unwell. would she be in painbecause of the liver cancer? she may be uncomfortable. she may be on regular analgesicsbecause of liver capsule pain, and she may be... she probably isfeeling a bit anorexic and off her food.

if she... i think... one of the critical tests of whether it's a good idea to thinkabout more chemotherapy or not is... has a lot of data behind it,but it's very commonsensical, and that is how much timeare you up and about. if most of the dayor more than half the day, you actually really needto be lying in bed. probably chemotherapy is...is not going to be terribly helpful, and you're not going to tolerate itvery well.

so that's quite a good, almostover-the-phone-type assessment that one can make. and, chris milross,radiotherapy's not indicated unless there's a bone metastasis? unless there's a bone metastasisor unless there are cerebral metastases, and even then, you know, related to what the elsewhere diseaseis doing, and what the combined prognosis isfrom all of the... and we should talk aboutcerebral metastasis for a moment

because cerebral radiotherapycan knock you about a lot, can't it? cerebral metastasescan knock you about even more. so, you know,if... if a person is symptomatic from their cerebral metastases, and that person's elsewhere diseaseis such that, were the cerebral disease controlled, the person could expect to raisequality of life, then i think, in that scenario, cerebral radiotherapyis almost always indicated.

but in the context of a person who has advanced treatment refractory diseasein multiple sites, whose elsewhere diseaseis going to progress, it's not unreasonable to havea discussion with the patient that says perhaps we shouldn't betreating your cerebral metastases. nicholas: i agree with thatand i think it's important to point out that as our systemic therapies evolve, they tend, unfortunately,to not get into the brain terribly well. so we are seeing weller and weller womenwith brain metastases,

in which case radiotherapyis definitely indicated. but also the anaesthetics and surgeryhas advanced over the last couple of decades, and so certainly one,but sometimes even two or three. if a woman is otherwise well and active, there's often a role for neurosurgery,followed by radiotherapy. let's look at it through the lensof a palliative care physician. how should we be thinking aboutthis woman now, holistically? i think, holistically, we should bethinking about this woman

in terms of a spectrum of needsthat she has. her... she has just received the newsthat the cancer has spread, that she has... got to that second scan, she's heard that the chemotherapy is notlikely to offer useful benefit for her. so this woman's view of life,her priorities, her hope, everything's been turned upside downright now. and she's regroupingon how to find meaning, how to hope for what in this setting, as well as sometimes being troubledby physical symptoms,

practical concerns about how to breakthis news to her family, how to sometimes share thiswith children, as well as partners and friends. so there's a lot of needs. so the way of looking at it iswhat are the woman's physical needs, psychological needs or concerns, informational concerns,practical concerns. and in the broader spectrum,in many instances, spiritual concerns. when you say 'spiritual',what do you mean? religious beliefs?

it's obviously differentfor every individual, the sorts of things that give themhope, meaning. it may be faith in some instances, it may be a broader concept,a different concept for other people. it's going to be differentfor every individual. but this woman's world has been turnedupside down right now, and in terms ofthe palliative care needs, i think that they would...that spectrum of concerns clearly would not be addressedby one individual in a medical team.

norman: chris keogh. no, it certainly looks like it'sa very multidisciplinary approach now. even just things like... simple thingslike fatigue management, that might include havingan occupational therapist come into this situation. jane mentioned spiritual needs. there are somepastoral care workers around, but there's also local ministersand things like that as well. that may be a time when some counsellingmight be appropriate as well,

when people are really... challenged,i guess, by some of those... but give me a sense of the transitionto palliative care. give me a sense of the sort ofconversation a gp should be having, because gps - tony's an exception - gps... we've been singularlyunsuccessful across australia in engaging general practitionersin palliative care. although they actually do it,they don't recognise that they do it, but they're not involved as muchas the palliative care people would like them to be involved,

and certainly as much as our nationalplanning would like it to be, for lots of different reasons -time, enumeration and so on. but let's assume the gp is makingthis transition to palliative, having this conversationas they often will in a rural setting. what's the conversationthey should be having with the woman? well, i think they needto be introducing the thought of palliative care. there are some women that actuallychoose not to take up that option. so sometimes it is good if it's comingfrom a variety of sources,

so that might be the oncologistas well as the gp, or, you know, even simplythe community nurses. so whoever is taking care of thatpatient at the moment or at that time. how do you handle it, tony?that transition to palliative care. well, again, i think it's a reallyvery individual discussion to have with that particular person, and often they have a partneror other family members with them. you need to put that in the context ofyour previous relationship with this person.

you need to listento what they would like. you need to make sure they understand what you're offeringwith palliative care, that it's not that you're sayingthey're going to be dead within months, but this is really a... program that can actually support both a personand their family over time. and often that becomes a really freeingdiscussion to have with people, and they engage in palliative carequite enthusiastically. and again, it's...from a general practice point of view,

i think it's really importantthat we actually make sure that we actually inviteother members of the team. the key here, jane, is that we tendto think of end-of-life care... the prejudice... not the prejudice, the stereotypical approachto end-of-life care is that you're gonna die in three weeks. but what we're talking herecould be a year or two, that this is end-of-life care. and there's all sorts of other thingsto consider as well.

so it's about helping the... bringing inthe appropriate array of experts to help that person havethe best quality of life in the time that's ahead, and minimise the burdenfor themselves and their family in this setting. i think that the conversationscan be difficult, and especially the beginningsof conversations can be hard for patients themselvesand for some gps. it depends how muchyou've been taught in your training.

it used to be thought that breakingbad news was a skill you were born with. it is something that you can be trainedand it is something you can learn. chris keogh, how much of your workis supporting health professionals to support the patient? in other words it can be stressfuland pretty upsetting. you're a country gp, you've knownthis woman for most of her life, you know her familyand this woman's dying, and you're the personwho has to look after her. it's like looking after a friend.

it can be and it often is, particularly for the gps that might havean ongoing sort of relationship, and a lot of the community nursesthat are providing that care are in the same situation. so, i certainly do quite a bit ofconsulting to the smaller rural areas, and part of that is supporting themin looking after the clients, but also in educational needs. and there is also, you know,debriefing sessions that are available. the cancer care networkactually has a social worker

that does outreachto some of those areas, and that's part of the rolethat she has as well... to support the isolatedhealth professionals. jane? anything else to add to that? it's just that you shouldn't be afraidto ask for... tony ..some support if you need it, if you're finding itupsetting and hard to deal with. absolutely. i mean, this can beconfronting as chris has said. often these people are well knownover a long period of time, and so it's not surprising perhaps

that gps and other health professionalsmight be quite affected. peer support is really important, havingdiscussions with your peers, whether you're a gpor another health professional. and, of course, there are resourcesavailable as well. yeah, i agree. i think that we...the health professionals involved, i think the more we engage as a team, the more we're comfortable sharingour concerns with each other the better. but the only other thingthat we haven't touched, or area we haven't touched onin a great deal here

that i don't wanna miss before we close is the importanceof the support of the family. and indeed of the husbandor the partner. and, in fact, the nbocc does actuallyhave a booklet available for... ..a resource for men,so they actually know how to deal, or can fill some supportand knowledge themselves. tony: can i say i listened to someof this in preparation for this, norman, and i would really strongly recommend that gps actually refer partners

of women with secondary breast cancerto that resource. i find it a very useful resourceto listen to, hearing men and womenshare their stories, with some structured ideasabout how to take them forward. chris keogh, if a gp's only been usedto referring to palliative care for the last few weeks of carerather than the last year of care, how different is itwhen the woman's still relatively well? give me sense of... in an ideal world, what you do upstreamfrom the terminal care.

so, i suppose i should just clarify too that palliative care isn't onlyend-of-life care. that's a really important point to make.but early referral is always... so, on that point, it's symptom control,pain control, there's things you know about the drugsthat perhaps other people haven't quite come to terms with. that's right, but early referral, particularly when some of these womenare quite stable and well, it is about forming relationships,getting that trust with people

at that early stage. and it is also about linkingin with some of the other issues that they might need to look at,if they've got young children. some things that they might needplanning and help with. partners. even just, you know, referring them to things like centrelinkfor financial assistance. and if there's nobody like youin the country town, what do you do? well, you know, the community nursesin country towns

do have a lot of expertisein those areas, and they actually work quite closelywith these people, and the gps as well. there is a real teamhappening there already. i just guess it's a bonuswhen you do have someone that has that expertisein palliative care. but to know that there arelots of resources out there as well they can utilise. jane? that's the...when does the physician come in?

um... the physician,in terms of the gp doctor, is there throughout the courseof this illness. i'm talking about somebody like you. a specialist palliative care cliniciancan play a role when the needs are very complex, when the symptoms are very difficult, or not easily controlledwith those first-line strategies. that physician may also assessa complex set of problems. so, a patient who has multiple symptomsdoesn't seem to be coping,

things don't seem right. a gp may ask for that extra assessment. and so, i think that we come inwhen things are difficult. when things are difficultmight be a different level for one gp versus another. and as we try to bring palliative careknowledge up in the nation, we're quite happy to be approached aboutsimple things as well as complex things. there are resources,in terms of knowledge resources there's a marvellous resourcein a website by the name of caresearch,

which will also provide... which has an enormous array of resourcesfor doctors about symptom control,evidence-base literature, etc. on various symptoms. norman: and what aboutend-of-life planning, such as what situations you wantsomething done, you know, resuscitation, treatment of infection,that sort of thing. presumably that's an important partof this process. that's an important part to be sureyou're honouring the patient's wishes,

because different peoplehave different wishes, different people have different hopes,some of which are realistic, some of which a conversation around themmight help clarify. again, this often happensin the gp's office with somebody who's knownrather than with a stranger who's giving an expert opinion,especially in the country setting. but i'd defer to tony to answersome of those questions that are absolutely crucial too. again, i think this can bea very useful thing for the woman,

and her family, having that conversation aroundan advanced-care directive, having a conversation aboutwhere she might like to die - in the home, in the local hospital, ina palliative care setting for instance. making sureyou've got flexibility around that, because in my experience,people do change their minds, and you need to be flexible and sensibleabout this. talking about thingsthat you would offer them, such as interventions.

talking about the funeral for instance. and that may happenas part of the conversation with the broader palliative care teamas well. but certainly doing this proactively,i think, is a really good thing, and it's good not only for the patient,but also for their family, and certainly for the healthprofessionals who are involved. - do you go to the funeral?tony: i have. i don't go to all my patients' funeralsto be honest. but i certainly have beento patients' funerals,

and not only people that have died fromcancer, but from other causes as well. chris, what about afterthe woman has died, what's the roleof bereavement counselling? because some people say it's overdone. it's forced on peoplewhen they might not need it or want it. not everybody needsbereavement counselling. i think it's important to know that... you know, grief is a normal expression that people have after someone they loveor care for has actually died.

um... so we would always contact peopleafter someone has died, and make sure that they knowthat we're available if they need that ongoing supportas well. um... same as tony,i don't always attend funerals, but in some cases,if it's been a long-term client, or the family have formeda really close relationship with you, that might be a timewhen you might do that as well. it may not always be appropriatefor me personally to contact peopleafter someone has died.

it may be someone elsein the team as well, if someone's had a close contactwith them, such as even the physio,or something like that. just so that they've got thatongoing link. we also give out information regarding the cancer council'sbereavement support group, and, you know, other brochures. there are other groups that run around, like some program calledseasons for growth,

which deals with grief and bereavementin children and adults. um... and, you know, open and honestcommunication about death and dying within that family unitis always really important. to try to get that sort of informationacross to them, particularly when it's childrenthat are involved as well. thank you all very much indeed. it's been a difficult subject,but the information is important, and i was just wondering what your take-home messages werefor the audience.

i think the two thingsfrom my perspective would be for gp and other health-careprofessionals in the country to realise that metastatic breast cancer is anextraordinarily heterogeneous disease. and as we've seen from our two cases, situations where a woman may bevery well with metastatic disease for many, many years, other situations where she may rapidlybecome unwell and have a lot of symptoms that need to be dealt with. and the second thing is,although we did discuss a couple of,

if you like, danger flags, in need of urgent attention,like suspected spinal cord compression, or sepsis in a patient on chemotherapy, predominantly, developments... either the new developmentof metastatic disease, or progression of knownmetastatic disease, is not an urgent problemand tends to evolve... you know, over weeks or monthsrather than hours or days. norman: chris milross?

in addition to the factthat nick's already mentioned, namely that not all metastaticbreast cancer is exactly the same, i would... i'd like to emphasisethe importance of communication between the clinicians involvedin the care of the patient. you know, in recognition of the factthat local problems will frequently benefit fromlocal treatment such as radiotherapy. systemic problems will benefit froma systemic approach to the problem. and... it's really only that if we talkto each other that we'll establish what treatment'sappropriate for what patient.

norman: chris keogh? early referralto palliative care services. that helps to build, you know, formthose relationships and build trust, and it's the same withthe palliative care team to be collaborative and, you know...probably communication really, keep that trust and developrelationships to provide quality care. well, here's a message to doctors,i think. the message is that we have a patientin front of us who's often come to us. it's important for us to embark upona broad assessment

that looks at the individualmore than medically, so that we, including gps,can refer appropriately, make sure this person's got the rightmultidisciplinary team around them to address the spectrum of concernsthat they may have. pain and symptom managementis a crucial part of the doctor's role. and one must knowone's own spectrum of skills, have a reasonable armamentariumfor the first pass, and know where to turn for help if there's extra help neededfor symptom management.

and know that most palliative careclinicians would be quite happy to... would welcome a call or a conversationeven if... and most areas have a palliative careclinician linked somehow with them. tony hobbs. i certainly endorseall those really strongly. i think the gp hasa really central role here in diagnosing, in help to manage. and not only managing physical problems,that is the cancer, but the psychological response to that.

hope you got a lot from the programas well, this program on secondary breast cancer. thanks to the national breast& ovarian cancer centre for making the program possible,but thanks also to you for taking the time to attend. if you're interested in obtainingmore information about the issues, or resources talked aboutin this program, there are a number availableon the nbocc website. that's nbocc.org.au.

and, of course, on the rural healtheducation foundation website, that's rhef.com.au. don't forget to complete and send inyour normal evaluation forms to register for cpd points. and also please check the rhef websitefor the special post-knowledge survey. i'm norman swan. goodnight. captions bycaptioning & subtitling international funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�