Biologic Therapies for Breast Cancer: Frequently Asked Questions

Ms. Kaplan is a breast oncology clinical nurse specialist at New York-Presbyterian Hospital/Weill Cornell Medical Center, New York City. She received her master’s degree in nursing from the State University of New York, Brooklyn. She has more than 25 years experience in a variety of oncology nursing roles. Ms. Kaplan has also served in editorial roles for the Clinical Journal of Oncology Nursing, Understanding and Managing Oncologic Emergencies: A Resource for Nurses, and the forthcoming Oncology Nursing Certification Corporation certification examination, Certified Breast Care Nurse. She has been recognized for her work for the Reach to Recovery program of the Manhattan office of the American Cancer Society as a recipient of the New York Mets Magic Award. Ms. Kaplan was appointed to the Manhattan Region Board of Advisors of the American Cancer Society in 2006 as their only nurse member.

Marcelle Kaplan, RN, MS, AOCN^®, reported a financial interest/relationship or affiliation in the form of: Speakers’ Bureau, Genentech BioOncolgy.

Biologic Therapy: What's on the Horizon?

Breast Cancer Survivorship Pyschological Support Update

In recent years, cancer survivorship issues have received greater attention and research interest as the number of cancer survivors increases in the United States, and the cancer advocacy movement gains in strength. Cancer survivorship is defined as a continuum from the time of diagnosis to the end of life. It has been conceptualized as a progression through three phases or “seasons” of survival incorporating: (1) surviving the treatment and its side effects, (2) beginning to return to normal life while being monitored for recurrence, and (3) long-term adjustment, when the cancer experience is viewed as an episode in a full life. In 2004, the most recent year with complete Surveillance, Epidemiology, and End Results (SEER) data, there were 10.1 million cancer survivors; of these, more than 2.4 million were breast cancer survivors. Family members, friends, and caregivers of the woman diagnosed with breast cancer are also considered to be cancer survivors.

Psychosocial distress, at varying levels of severity, accompanies the cancer experience. There are calls to consider distress the sixth vital sign; it would then be routinely monitored along with pulse, blood pressure, respiration, temperature, and pain. Periods of highest distress for the woman with breast cancer are associated with transition points in treatment. Completion of treatment may be a cause of increased anxiety rather than joy. There are many potential barriers to meeting the psychosocial needs of women with breast cancer after active treatments ends. The Institute of Medicine of the National Academies has released several reports during recent years describing strategies to acknowledge and meet these needs, declaring that provision of psychosocial services should be a standard of care for survivors of cancer. Oncology nurses play a key role in assessing the patient, family members, and caregivers for signs of distress. In so doing, an atmosphere of compassion and trust is created such that the breast cancer survivor feels free to share psychosocial concerns and have them addressed by appropriate specialists if necessary.

Breast Cancer Survivorship Pyschological Support Update

In recent years, cancer survivorship issues have received greater attention and research interest as the number of cancer survivors increases in the United States, and the cancer advocacy movement gains in strength. Cancer survivorship is defined as a continuum from the time of diagnosis to the end of life. It has been conceptualized as a progression through three phases or “seasons” of survival incorporating: (1) surviving the treatment and its side effects, (2) beginning to return to normal life while being monitored for recurrence, and (3) long-term adjustment, when the cancer experience is viewed as an episode in a full life. In 2004, the most recent year with complete Surveillance, Epidemiology, and End Results (SEER) data, there were 10.1 million cancer survivors; of these, more than 2.4 million were breast cancer survivors. Family members, friends, and caregivers of the woman diagnosed with breast cancer are also considered to be cancer survivors.

Psychosocial distress, at varying levels of severity, accompanies the cancer experience. There are calls to consider distress the sixth vital sign; it would then be routinely monitored along with pulse, blood pressure, respiration, temperature, and pain. Periods of highest distress for the woman with breast cancer are associated with transition points in treatment. Completion of treatment may be a cause of increased anxiety rather than joy. There are many potential barriers to meeting the psychosocial needs of women with breast cancer after active treatments ends. The Institute of Medicine of the National Academies has released several reports during recent years describing strategies to acknowledge and meet these needs, declaring that provision of psychosocial services should be a standard of care for survivors of cancer. Oncology nurses play a key role in assessing the patient, family members, and caregivers for signs of distress. In so doing, an atmosphere of compassion and trust is created such that the breast cancer survivor feels free to share psychosocial concerns and have them addressed by appropriate specialists if necessary.

Dr. Burstein is an assistant professor of medicine at Harvard Medical School in Boston, Massachusetts. He received his doctor of medicine from Harvard Medical School and his doctorate in cellular immunology from Harvard University. Dr. Burstein is also a clinician and clinical investigator at the Breast Oncology Centers for Dana-Farber Cancer Institute, and Brigham and Women’s Hospital. His clinical research interests include novel treatments for early and advancedstage breast cancer. His research has been published extensively in journals such as The New England Journal of Medicine and the Journal of Clinical Oncology. Dr. Burstein also serves on the editorial board of Clinical Breast Cancer and Journal of Clinical Oncology.

Harold J. Burstein, MD, PhD, reported no areas fo conflict.

Adjuvant Breast Cancer: Biological Treatment Update

There are important subsets of breast cancer defined by the expression of molecular markers, including human epidermal growth factor receptor (HER2). Testing for HER2 is critical to therapeutic decision-making as it determines which patients are likely to respond to trastuzumab therapy. However, the precise threshold for treatment remains unclear. This presentation will focus on the role of tumor markers in selecting chemotherapy regimens and evolving trends in the use of adjuvant chemotherapy.

Update on Clinical Trials of Antiangiogenesis Agents in Breast Cancer/Metastatic Breast Cancer Treatment Update

Metastatic breast cancer (MBC) remains a largely incurable disease. However, survival rates continue to increase as advances in the understanding of the biology of tumorigenesis are made. Angiogenesis plays a major role in tumor formation and therefore, agents targeting this process, including the monoclonal antibody bevacizumab, are particularly successful at treating tumors. In addition, the introduction of the monoclonal antibody trastuzumab has dramatically improved outcomes for women with human epidermal growth factor receptor 2 (HER2)-positive MBC and reaffirmed the value of targeting specific cellular proteins as a means of controlling disease. This has led to the development of a plethora of new agents for the treatment of HER2-positive breast cancer in the metastatic setting, though optimal chemotherapy regimens are still under investigation.

Ms. Litsas is a nurse practitioner within the Division of Breast Oncology at the Dana-Farber Cancer Institute, Boston. She received her master’s degree in nursing from Northeastern University, Boston. She is an active member of the Massachusetts Nurses Association, Sigma Theta Tau Honor Society, Oncology Nursing Society, and the Boston Oncology Nursing Society, and lectures regularly on topics related to the care of patients with cancer.

Georgia Litsas, RN, MSN, APRN, BC, AOCNP^® reported a financial interest/relationship or affiliation in the form of: Speakers' Bureau, Genentech BioOncology, AstraZeneca Pharmaceuticals LP, and Pfizer, Inc.

Biologic Therapy Side Effects: Assessment and Management

The use of targeted therapies has emerged as an effective measure in the fight against breast cancer. Although cytotoxic chemotherapy remains an important part of optimal therapy for patients, it is limited by toxicity, nonspecificity, and the seemingly inevitable development of resistance. Targeted therapies, on the other hand, are agents that act on a particular pathway in the growth and development of a tumor. By attacking specific targets, the therapeutic agent helps to fight the tumor itself. As targeted therapies continue to shape clinical advances in the management of breast cancer, it is vitally important for nurses to remain cognizant of the latest therapies and their respective side effects. Approved targeted therapies for breast cancer include trastuzumab, lapatinib, and bevacizumab. Trastuzumab has been utilized in breast cancer therapy for the past 10 years. It is generally well-tolerated and has revolutionized the care of women with HER2-positive breast cancer. Potential side effects include cardiac toxicity, infusion reactions, and pulmonary toxicity. In 2007, lapatinib was approved with capecitabine for use in the metastatic setting. As an oral agent, adherence is a potential issue for patients taking lapatinib, as well as diarrhea, dermatologic toxicity, and cardiotoxicity. Bevacizumab is the most recently approved targeted therapy (2008) in breast cancer. It is also well-tolerated with possible side effects including hypertension, bleeding, and proteinuria. This presentation focuses on the most frequent side effects associated with targeted therapies and recommendations for recognition and management.