Breast cancer

Updated: Treatment choices never as simple as ABC


Financial reasons are the most likely explanation for the lack of consistency between clinical practice and clinical guidelines in the management of women with advanced breast cancer.

International guest speaker Professor Fatima Cardoso told the MOGA ASM that endocrine therapy was the preferred option for all hormone receptor positive disease, even in the presence of visceral disease.

Professor Cardoso, who is director of the breast unit at Champalimaud Cancer Clinical in Lisbon, Portugal, said the only exception was when there was a visceral crisis – organ dysfunction due to an abundance of metastases.

Yet clinical practice was clearly not in line with current guidelines.

“About 65% of patients with ER positive disease receive chemotherapy as initial palliative therapy,” she said.

Instead, patients should be treated with sequential endocrine therapy.

Professor Cardoso referenced an editorial published earlier this year in The Breast where she outlined the likely reasons for the discrepancy.

“Perhaps the strongest ones are economically driven. In many countries, the reimbursement rules do not favour the use of oral drugs, in particular, endocrine therapy,” she said in the editorial.

She added that regulators should ensure there were no indirect financial pressures on clinicians and hospital administrators that might skew their practice.

Continuing medical education and multidisciplinary practice could also encourage adherence to clinical guidelines.

Associate Professor Linda Mileshkin, from the Peter MacCallum Cancer Centre told the limbic she felt the problem was more of an issue overseas.

“It is important that care is not driven by reimbursement and I think it is not as much a problem here because of the way our health care system is set up.

“It’s also important with the MBS Review coming up that remains the focus of evidence based practice and doing what’s better for the patients – not trying to optimise individual billing for the doctor.”

She said there would be some oncologists who do give too much chemotherapy but possibly because that was what they had always done.

“It could be a mindset. Certainly when I trained in oncology the teaching was that if you had visceral metastases, so if you had disease in an organ like the liver or the lungs, you should have chemotherapy.”

“It’s only over time we’ve recognised that in some of those patients the disease is not growing that fast and they can do well with hormones and not need chemotherapy.”

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