Nursing Network News - Breast Cancer Now · 2015-12-10 · 4 Nursing Network News 5 A view from…...

www.breastcancercare.org.uk 1

ISSUE 19 NOVEMBER 2015

IN THIS ISSUE

6-7

14-16

19-23

What’s on your bucket list?

Nursing Network News

Bisphosphonate news

Electrochemotherapy

2 Nursing Network News

Section


References1. Paik S et al. N Engl J Med 2004; 351: 2817-2826; 2. Dowsett M et al. J Clin Oncol 2010; 28: 1829-1834; 3. Paik S et al. J Clin Oncol 2006; 24: 3726-3734; 4. Albain KS et al. Lancet Oncol 2010;11: 55-65.

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This piece is intended to educate physicians on the clinical utility of the Oncotype DX® Breast Cancer Assay and should not be provided to patients. Genomic Health and Oncotype DX are registered trademarks of Genomic Health, Inc. © 2015 Genomic Health, Inc. All rights reserved.

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Contact uswww.breastcancercare.org.ukFree Helpline 0808 800 6000(Text Relay 18001)

Calls may be monitored for training purposes. Confidentiality is maintained between callers and Breast Cancer Care

Nursing Network and professional developmentTelephone 0345 092 0802Email [email protected]

Scotland and Northern IrelandTelephone 0345 077 1892Email [email protected]

Wales, South West and Central EnglandTelephone 0345 077 1894Email [email protected]

East Midlands and the North of EnglandTelephone 0345 077 1893Email [email protected]

London and the South East of EnglandTelephone 0345 077 1895Email [email protected]

Contents News

4 A view from…

Catherine Priestley, Clinical Nurse Specialist (secondary breast cancer) at Breast Cancer Care

5 New cancer strategy

Emma Lavelle, Policy Manager at Breast Cancer Care, talks about the strategy and what it means for people diagnosed with breast cancer

6-7 What’s on your bucket list?

Find out about our bucket list campaign, developed in conjunction with people with secondary breast cancer

8-9 Brand campaign

Breast Cancer Care is here from day one. Read Nicky’s story and find out more about our brand campaign

Sharing practice

10 Nursing Network Awards

The Nursing Network Awards celebrate best practice in specialist breast care nursing

12-13 Supporting people with secondary breast cancer

We’ve made some important changes to our secondary breast cancer resource pack, with the help of patients

14-16 Bisphosphonate news: new meta-analyses, old drugs

Emma Pennery CBE talks about the latest bisphosphonate news and the impact on practice

Learning Together

17-18 Exercise interventions for upper limb dysfunction due to breast cancer treatment

A summary of the Cochrane Review

19-23 Electrochemotherapy for skin metastases in breast cancer

A report on eletrochemotherapy and its implications for health professionals and patients

About Breast Cancer CareBreast Cancer Care is the only UK-wide charity providing specialist support and tailored information for anyone affected by breast cancer.

Editorial boardDr Emma Pennery CBE, Clinical Director; Katie Parsons, Editor.

FeedbackThis is our 19th issue of Nursing Network News and we’d love to know what you think. Please email [email protected]

Your viewsWe’re also looking for contributions for future issues. If you’d like to write an article or have an idea you’d like to share with network members, please get in touch using the above email.

Contents

www.breastcancercare.org.uk 54 Nursing Network News

A view from…

Catherine Priestley, Clinical Nurse Specialist (secondary breast cancer) at Breast Cancer Care. Catherine talks about her experiences and the importance of support services for people living with secondary breast cancer.Being a CNS at Breast Cancer Care has been an amazing career move for me. I have worked for the charity in different roles for nearly seven years, having returned to the organisation as a full time Secondary Breast Cancer CNS just over a year ago. This was a role I never thought I would want to do, but the influence of others can be a powerful thing. In this case a fellow CNS changed my perspective and revealed a new opportunity.

A brief return to the NHS gave me first hand insight into how valuable Breast Cancer Care’s information and services are to patients. The pressure and workload for specialist breast care nurses is phenomenal, and to have a safe place to direct patients to for additional support made a positive difference to my patients – and my workload!

Now, I’m learning how our Living with Secondary Breast Cancer (LWSBC) services across the country make a difference to those diagnosed with secondary breast cancer. Despite organisations such as Breast Cancer Care campaigning to strengthen the importance of secondary breast cancer on the health agenda, for most patients their needs go unaddressed – this can make peer support opportunities incredibly invaluable.

Attending some of the 20 LWSBC services is really satisfying. Meeting this client group is a real privilege and most

are passionate, determined and vocal women who get enormous support from each other. Sadly, all too often I hear how women wish they’d had the opportunity to attend far sooner. Raising awareness in clinical practice of the LWSBC service and other secondary breast cancer groups is paramount in providing support from someone who can truly empathise. The benefits of a LWSBC meeting can be as simple as ‘the opportunity to both give and receive support from people who know how I feel’, as one attendee stated.

The CNS I mentioned in my introduction spent some time with a relative of mine. In a frank discussion she seized the opportunity to sensitively but positively change his care experience. Not only did her forthrightness help the whole family, it also made me reflect that working with people with advanced cancer can be as rewarding for the nurse as it is crucial to the patient and their family.

It can take just a few minutes out of our busy schedules to promote the benefits of LWSBC. In the face of something as devastating as secondary breast cancer, that opportunity can make a world of difference to our patients and those who love them.

You can find out where your patients can attend our LWSBC services at www.breastcancercare.org.uk/lwsbc

New cancer strategy

In July, a new cancer strategy for England, Achieving world-class cancer outcomes: A strategy for England 2015-2020, was launched by the Independent Cancer Taskforce.The Taskforce was established by NHS England in January 2015 to develop a new five-year strategy for cancer. If the recommendations in the report are implemented and its ambitions realised, the Taskforce estimates that 30,000 additional patients will survive cancer by 2020.

We’ve outlined what we see as some of the most important points.

A strong focus on quicker diagnoses and improving survival There’s recognition that cancers can, and should, be diagnosed earlier. The report recommends that the time it takes from GP referral to communication of results should take a maximum of four weeks. We know that this will go some way in helping to reduce some of the anxiety that so many people feel while waiting to find out if they have breast cancer, and it’s a recommendation we very much welcome. There’s also a recommendation that supports patients to self-refer for a first investigative test, via a nurse telephone service. This would be where a patient has a ‘red flag’ symptom, such as a breast lump.

Importance of patient experienceThere’s a desire to put patient experience on a par with clinical effectiveness. The focus on online access to test results and treatment records for patients is one we welcome.

Crucially, there’s also the recommendation that all patients should have access to a clinical nurse specialist (CNS) or other key worker. But we know many secondary breast cancer patients don’t have this support. Breast Cancer Care has campaigned for a while on this very issue so it’s great that it’s recognised in the strategy.

Living with and beyond cancerThe strategy highlights that some progress has been made in developing support for people living with, and beyond, cancer, but acknowledges that there’s still much to be done. The strategy calls for every person with cancer to have access to a range of information and support.

For secondary breast cancer patients, there’s also important attention given to the area of palliative care; an issue we raised last year for Secondary Breast Cancer Awareness Day.

Preparing for the futureThere’s also detail on:

• the need to modernise cancer services

• dealing with gaps in the workforce (particularly in oncology, radiology and specialist nursing provision)

•updating out-of-date equipment.

We’re optimistic about the vision of the new strategy. What we need to see now are detailed action plans for how the report’s recommendations will be taken forward, alongside an assurance by government to provide the funding needed. Only then will we be on track to realise the government’s commitment to being a world-leading cancer service.

The full report is available at www.cancerresearchuk.org/about-us/cancer-taskforce

NewsA view from...


and years with families (as well as ticking off those all-important bucket list items). Well co-ordinated care means patients can maintain a good quality of life for as long as possible and a good death.

There are of course other issues, most notably the funding required to achieve all of this. But with the new cancer strategy, we have the best opportunity to campaign together for the changes that we know are so desperately needed.

That’s where you come in. Join our campaign and help us raise awareness of secondary breast cancer. Find out more about the five women and their stories, as well as how to share your own bucket lists at www.breastcancercare.org.uk/secondary

What’s on your bucket list?

Public Affairs and Campaign Manager, Andy Glyde, tells us about Breast Cancer Care’s new bucket list campaign.If you were living with an incurable disease, what are the things that would make up your bucket list – the things you really want to do before you die? Would you want to travel the world, jump out of an aeroplane, run a marathon, or something different entirely?

We know one way that people who’ve been diagnosed with secondary breast cancer cope with having an incurable disease is to have a bucket list. That’s why Breast Cancer Care has just launched its new bucket list campaign. We’re asking for people to share their bucket lists to help raise awareness of secondary breast cancer and ensure that everyone living with the disease gets the care and support they need.

Our campaign, developed in conjunction with people with secondary breast cancer, sees five women – Angie, Emma, Frances, Heather and Letitia – who are living with the disease sharing their stories. They explain what it’s like to be diagnosed with secondary breast cancer and how it affects them day to day.

The women also share what’s on their bucket lists. They each take a personal approach to this. For some of them, it’s about spending time with family. Heather wants to conduct an orchestra at the Royal Albert Hall, while for Angie, the most important thing on her bucket list is making sure her cancer does not define her.

The final part of each woman’s story is something that they think the government should be doing for people living with secondary breast cancer. Those five things form the basis for Breast Cancer Care’s bucket list. We are calling on the government to implement our bucket list to significantly improve care for secondary breast cancer.

Our bucket list is big and ambitious, but that’s exactly what bucket lists are supposed to be. If it were to be implemented, it would go a long way in improving care. If data collection on secondary breast cancer happened consistently and robustly, this would help inform commissioners about patient needs and what services are required, both in terms of specialist nursing and palliative care. A reformed drug appraisal system would mean better access to crucial life-extending drugs that allow people to spend precious extra months

I think what the government needs to do is recognise secondary breast cancer and the people living with it because I don’t think it gets enough recognition. Letitia

‘ ‘I have a 10 year-old daughter. I want to be there when she goes to secondary school. When she gets her GCSE results. When she goes to her first prom. Those are all on my bucket list. Emma

‘ ‘Our bucket list includes:

1. No one living in unnecessary pain

Pain is one of the most common symptoms, but too few people are being referred to palliative care services for symptom control and pain management. Everyone should be offered referral to palliative care at the point of diagnosis.

2. Everyone having access to the treatments they need

Some people are being denied access to clinically effective drugs because they’re not available through routes such as NICE or the Cancer Drugs Fund. The whole system of treatments and drug appraisal should be reformed to make sure patients can receive life-lengthening treatments.

3. All patients have a clinical nurse specialist as part of their care

A secondary breast cancer patient is far less likely to have access to a clinical nurse specialist than a primary breast cancer patient. A CNS can provide invaluable support and help guide patients through the health system. Everyone should have a CNS involved in their care.

4. Hospitals are able to plan services to meet their patients’ needs

Despite it being mandatory in England for hospitals to collect data on secondary breast cancer, this is not happening consistently. This means that commissioners are not able to understand their patients’ needs and plan services to meet these needs.

5. Everyone’s care is co-ordinated and joined up

Multidisciplinary teams (MDTs) are not consistently discussing secondary breast cancer patients, missing a clear opportunity to ensure patients are receiving the best possible integrated care.

NewsNews

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Please watch and share Nicky’s video with friends, family and colleagues so they can knowaboutthesupportthatweoffer.Wealsohavepostersandflyersthatyoucangive to your patients – you can order copies at breastcancercare.org.uk/publications Tofindoutmoreaboutthecampaign,visitwww.breastcancercare.org.uk/dayone

Support from day one made a huge difference

Two years after she was diagnosed with breast cancer, Nicky Sherwood is now the face of Breast Cancer Care’s ‘Here from day one’ campaign.Nicky clearly remembers the day she noticed a lump in her breast.

She was lying in bed when her fingers brushed against the pea sized lump. Her GP reassured her it was probably a cyst, but referred Nicky for tests anyway.

A mammogram and ultrasound told a different story: it was likely to be breast cancer. ‘I was told I’d have to come back in a week for the results of a biopsy,’ says Nicky. ‘I went out in a daze.’

While waiting for her test results, Nicky called Breast Cancer Care. ‘I wanted reassurance that what had happened to me was normal, and that I hadn’t imagined it all.’ Nicky found speaking to someone about it all incredibly reassuring. She felt more equipped to deal with the results.

Help from day oneThe theme for Breast Cancer Care’s ‘Here from day one’ campaign is days and time. Breast cancer changes everything, even the things in your diary. Time becomes measured in appointments: the next scan, the next results, the next challenge.

‘Breast cancer becomes an interloper, a stranger, occupying a space at home,’

says Sarah Ross, Assistant Director of Communications and Marketing.

‘We know that the support we provide makes a very real difference. Yet too often we hear people say they wish they’d known about us sooner.

Our new “Here from day one” campaign addresses this issue, and raises awareness that Breast Cancer Care can offer care, support and information every day, from day one.

‘From the day you notice something’s not right to the day you begin to move forward, Breast Cancer Care is here to help you through.’

Support every day ‘Having access to Breast Cancer Care’s services from day one made a huge difference,’ says Nicky, who appears in the new campaign adverts.

As well as calling several times, Nicky used the online Forum, patient information booklets and website, Someone Like Me telephone service, and went to a Younger Women Together event.

‘I felt quite in control during treatment,’ says Nicky, ‘and a large part of that was down to the help I received from this amazing charity.

‘I’ve benefited hugely from Breast Cancer Care’s support, and I can’t imagine going through treatment without it. I would have missed out on a huge amount of information, friendship, and the chance to meet people in the same boat as me.’

News


Our Nursing Network Awards champion best practice in specialist breast care nursing, and recognise individuals or teams who have demonstrated innovative and successful nurse-led initiatives that have made a positive difference to patient care.

Thank you to all our members who applied this year!We were delighted to receive a wide range of applications spread across the treatment pathway, from family history to metastatic disease.Winners will be announced at our Annual Conference on Friday 6 November 2015.More information about our top placed entries and their projects will be available in the next issue of Nursing Network News (March 2016).

Nursing Network Awards

Celebrating the success of you and your team

Sharing practice

Information and support for people with an inherited altered BRCA gene

Being a gene carrier

Hear from expert speakers and meet other BRCA gene carriers. Free sessions held on Saturday mornings 10am – 1pm in central London. Talks on key topics followed by a chance to chat to others in a relaxed, supportive environment. 16 January 2016 – Risk reducing surgery6 February 2016 – Talking to children and family5 March 2016 – BRCA related cancers Refreshments provided. You’re welcome to bring someone with you to the themed talk. Call 0345 077 1893 or email [email protected] to book.

breastcancercare.org.uk

registered charity in England and Wales 1017658 and in Scotland SC038104


Supporting people with secondary breast cancer

Acting Head of Publishing, Ali Raven, tells us about working with a group of patients to revise Breast Cancer Care’s secondary breast cancer resource pack.Breast Cancer Care has produced a resource pack for people with secondary breast cancer for a number of years. However, as care and treatment for secondary breast cancer improves, it’s become apparent how much these patients value information that can be tailored to their specific situation to help them manage what, for some, is a chronic condition that remains so for a number of years.

WorkingwithpatientsThe Christie NHS Foundation Trust in Manchester contacted the Publishing team last year. They have a group of women with secondary breast cancer who meet regularly as a focus group working with the secondary breast care nurses. Initially they had come together to work on the Secondary Breast Cancer Pledge – a joint initiative between Breast Cancer Care and Breast Cancer Now (formerly Breakthrough Breast Cancer) – to improve the care provided to people with secondary breast cancer. Following this, the patients wanted to find ways they could better monitor their condition and the outcomes of appointments, scans and tests. They had devised their own patient record sheets and wanted to be able to share them more widely and help empower others in the same situation.

A couple of Breast Cancer Care representatives met with the group, discussed the patient record sheets and spoke to them (and their secondary breast care nurses) more widely about what they’d like from a resource pack.

We used this insight to revise the secondary breast cancer resource pack. Members of the group, alongside one of their secondary breast care nurses, commented on the draft contents. We also sent a ‘mock up’ to the group to see what they thought of the proposed format, and some specific questions we wanted to ask them.

Consulting with the group at the Christie helped us make some changes to the pack. When Breast Cancer Care first produced information for secondary breast cancer patients, the focus was very much on information and support. While we wanted to retain this, we also recognised these women very much wanted a tool to help monitor their condition.

The new pack consists of three parts.

• A loose-leaf section dedicated to medical information and focused on helping people to monitor their condition. It includes a number of patient record sheets (with the opportunity to order/download more), a diary to help monitor energy levels plus a diary to help monitor pain levels (again further copies can be ordered or downloaded).

• A booklet in the back of the pack on living with secondary breast cancer. This looks at how someone may feel and features the experiences of others with secondary breast cancer. We made this a separate booklet so it can be removed from the pack to make it lighter to carry around.

• A short guide to difficult decisions and choices at the end of life. We felt it was important to include this information, but recognise that people will choose when it’s the right time for them (if at all) to look at it.

We hope the new format of the pack will allow patients to choose the information they want to read, when they are ready, and be a tool to help them monitor and record interactions and appointments in one place.

The pack will be available to order from the end of November from www.breastcancercare.org.uk/publications

We’re grateful to Claire Gaskell and Sharon Foy, Macmillan Secondary Breast Cancer Nurse Specialists, and the Christie NHS Foundation Trust secondary breast cancer focus group for all their help in updating and refining this pack.

Sharing practice Sharing practice


Bisphosphonate news New meta-analyses, old drugs

Dr Emma Pennery CBE, Clinical Director at Breast Cancer CareThe Early Breast Cancer Trialists’ Collaborative Group (EBCTCG) was established in the mid 1980s and has since periodically published meta-analyses of randomised trials of adjuvant treatments (dubbed the Oxford Overviews).

In July, one edition of The Lancet published two new EBCTCG meta-analyses, both of which are likely to impact on practice.

Aromatase inhibitors versus tamoxifen in early breast cancer (9 trials, data on 31,920 patients)

This meta-analysis included data from post-menopausal women with oestrogen receptor positive (ER+) primary breast cancer in randomised trials of aromatase inhibitors (AIs) and/or tamoxifen, alone or sequentially, as follows:

•5 years AI versus 5 years tamoxifen• 5 years AI versus 2-3 years

tamoxifen, then an AI to year 5• 5 years tamoxifen versus 2-3 years

tamoxifen, then an AI to year 5

The findings confirm those from previous trials – compared to tamoxifen alone, taking AIs in the first five years (either for the full five years or switching after two-three years of tamoxifen) reduces the risk of recurrence by about 30%, while treatments differ.

Importantly, they also show reduced breast cancer mortality and improved overall survival at 10 years (such gains have previously been elusive and

optimum scheduling uncertain). This reduction in breast cancer mortality is expected in an already good-prognosis population, but persists during years 0-4 and 5-9, significantly reducing 10-year breast cancer mortality.

Compared to tamoxifen alone, AIs reduce the risk of dying from breast cancer by around 15% in the first decade after beginning treatment.

The benefits were seen regardless of progesterone receptor status, HER2 status, lymph node involvement, tumour size and grade; and regardless of patient characteristics such as body mass index and age. They were also independent of which AI was taken, suggesting there’s no distinction between brands.

For women starting on an AI, there appeared to be no significant benefit from continuing to five years, rather than switching to tamoxifen mid-way. This will be reassuring for women who don’t tolerate AIs.

AIs are not without side effects, notably bone health issues (which makes the second meta-analysis below especially relevant). Tamoxifen and AIs can result in significant side effects that adversely impact on quality of life and, therefore, compliance.

There were fewer endometrial cancers with AIs than with tamoxifen (10-year incidence 0·4% vs 1·2%) but more bone fractures (5-year risk 8·2% vs 5·5%), and the absolute excess of fractures increased with age.

Summary Aggregating all three types of comparison, recurrence rates favoured AIs during the time period when treatments differed but not significantly thereafter. Breast cancer mortality was reduced both while treatments differed and subsequently.

Implications for practiceAbout two thirds of all women with breast cancer are post-menopausal with ER+ disease. The meta-analysis raises the possibility that all post-menopausal women with ER+ breast cancer consider AI-based therapy within the first five years of their adjuvant treatment, either alone or sequentially before or after tamoxifen. AIs are inexpensive, widely used, generic drugs but do have side effects that can reduce compliance.

It’s not yet known how longer durations of endocrine therapy (extending from five to ten years) might impact on these findings and on practice.

Adjuvant bisphosphonate treatment in early breast cancer (26 trials, data on 18,206 patients)

This meta-analysis included data from trials over the past 20 years that randomised women with early breast cancer to bisphosphonates (taken for two to five years) or a control group. Previous studies on adjuvant bisphosphonates have produced mixed results – some showed benefits, others didn’t. But a more definitive picture emerges from bringing the data together in a meta-analysis.

Overall (irrespective of age or menopausal status) bisphosphonates resulted in reductions at 10 years in distant recurrence (20.4% versus 21.8%) and breast cancer mortality (16.6% versus 18.4%), but these were just borderline significant. The only significant effect of adjuvant bisphosphonates overall was a reduction in bone metastases (7.8% versus 9.0%).

However, when analysis was done by menopausal status and age, the results were more striking.

For pre-menopausal women, taking bisphosphonates had no apparent effect on any of the outcomes. This may be because reproductive hormones limit the efficacy of bisphosphonates, but more research is needed to understand this finding.

But in post-menopausal women (irrespective of whether the menopause was natural or treatment induced), bisphosphonates resulted in highly significant reductions in bone metastases, all other sites of distant spread and the risk of dying from breast cancer during the first decade after diagnosis.

In absolute terms, post-menopausal women taking adjuvant bisphosphonates gain a 2.2% reduction in bone metastases (6.6% versus 8.8%) and a 3.3% reduction in breast cancer mortality (14.7% versus 18.0%).

These benefits were seen regardless of ER status, lymph node involvement, tumour size and grade and whether or not the person had chemotherapy. They were also largely independent of the type of bisphosphonates (oral or intravenous) or the duration they were taken for. Ongoing trials are comparing different bisphosphonate drugs so we might learn more about which, if any, are superior when these report.

Sharing practice Sharing practice


An additional benefit was that in women with available fracture data (n=13,341), bisphosphonates also reduced the risk of fracture from 7·3% to 6·3%.

Notably, there was no effect on local or regional recurrence or contralateral breast cancer so the evidence provides no support for bisphosphonates as a breast cancer chemoprevention strategy.

If you’re wondering how bisphosphonates can prevent distant spread as well as bone metastases – circulating tumour cells are attracted to surfaces within the bone, and they can then remain dormant for years before exiting and spreading elsewhere. The theory is bisphosphonates reduce osteoclast activity, making bones less favourable for metastatic cells to grow and survive in, and so reduce the risk of recurrence both in bones and other organs.

Bisphosphonates have two potential serious side effects – impaired renal function and osteonecrosis of the jaw. The meta-analyses found these to be rare, affecting only 1-2 % of patients.

Summary In post-menopausal women, adjuvant bisphosphonates prevent around a quarter of bone recurrences and 1 in 6 of all breast cancer deaths in the first decade of treatment. All bisphosphonates appear to be effective, as long as they are given for at least two years.

Implications for practice Bisphosphonates are currently used to treat bone loss or fractures (usually in women taking aromatase inhibitors) and bone metastases. So they improve bone quality and density and also reduce fracture rates. And they are inexpensive, generic drugs, so should now be considered for a wider range of post-menopausal women with breast cancer.

About 80% of all women with breast cancer are post-menopausal so bisphosphonates could potentially be prescribed to around 40,000 newly diagnosed women each year. One potential barrier to this is they’re not licensed in this setting.

References: 1. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Adjuvant bisphosphonate treatment in early breast cancer: meta-analyses of individual patient data from randomised trials. Lancet 2015; published online 24 July, 2015. http://dx.doi.org/10.1016/S0140-6736(15)60908-4 2. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Aromatase inhibitors versus tamoxifen in early breast cancer: patient-level meta-analysis of the randomised trials. Lancet 2015; published online 24 July, 2015 http://dx.doi.org/10.1016/S0140-6736(15)61074-1

Exercise interventions for upper limb dysfunction due to breast cancer treatmentThis is a summary of a Cochrane Review. The researchers who conducted the Review are listed in the reference section at the end.

BackgroundAfter treatment for breast cancer, women can experience a range of side effects including upper limb dysfunction. This can present as decreased shoulder range of motion, decreased shoulder strength, pain, and lymphoedema that can extend to tissues of the hand, arm, breast or trunk. These side effects affect a significant number of women following treatment, can persist for many years and have been found to decrease quality of life.

Exercise interventions are used to minimise or improve these problems and are commonly prescribed by therapists following surgery. Studies in this area have shown benefits including improved joint mobility, reduced pain, and improved movement and strength in upper limb muscles. However, there is controversy regarding the optimal timing and intensity. Some studies advocate early intervention with modification to the type of exercise and attention to the intensity and progression of therapy. Other studies favour delaying exercises because of the potential for early aggressive exercise, which can impair wound healing and contribute to the incidence of long term lymphoedema. It is also important to understand the advantages of exercise for late onset or persistent upper limb dysfunction.

Nurses are ideally placed to advocate for their patients; they act as communicators between family members, liaison between healthcare professionals, interpreters of clinical

information, educators and caregivers for their patients. As educators, they are in a position to inform patients regarding exercise interventions and endorse interventions that are evidence based. Understanding the outcomes of this review will provide nurses with valuable information.

ObjectivesThe purpose of this systematic review was to examine the evidence of effectiveness generated from randomised controlled trials involving exercise interventions for preventing, minimising and/or improving upper limb dysfunction due to breast cancer treatment.

Interventions/methods This review includes only randomised controlled trials with breast cancer patients (unless there were subgroup data available for other cancer studies). Studies were grouped together according to the type of comparison and timing of the exercise. The participants in the studies all had confirmed breast cancer diagnoses; surgical removal of the breast tumour; axillary lymph node dissection; and were adults aged over 17 years.

Four types of therapeutic exercises were included in the interventions for this study:

1. Active or active-assisted range of movement exercises

2. Passive range of movement or manual stretching exercises

For more information about the topics discussed in this article, you can download or order the publications pictured from our website www.breastcancercare.org.uk/publications

Learning togetherLearning together

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Treatment and side effects

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3. Stretching exercises (including yoga and Tai Chi Chan)

4. Strengthening or resistance exercises.

The primary outcomes were upper extremity range of movement, muscular strength, lymphoedema and pain. Secondary outcomes included upper-extremity/shoulder dysfunction and quality of life. Information was also sought regarding post-operative complications and wound healing. A range of electronic databases were searched, including grey literature and hand searches of reference lists. The data collection analysis and quality assessment were all conducted according to Cochrane’s protocol. Data were extracted using standardised forms and included all identified variables. Analysis included meta-analysis of quantitative data and a narrative account.

Results A total of 24 studies involving 2132 participants were included in the review. Ten studies related to early versus delayed exercises. These studies introduced exercises at various times and there was considerable variation between these studies. Six studies examined the effects of exercise versus usual care. Three studies examined the effects of exercise versus usual care during adjuvant cancer treatment. Five studies examined the effect of exercise versus usual care following cancer treatment. Only 10 out of the 24 studies were considered to have an adequate risk of bias. Meta-analysis was undertaken for eight outcomes. Results favour early exercise to restore shoulder flexion and abduction range of movement in the early post-operative

weeks. A small, to moderate, negative effect of increased wound drainage was associated with early exercise.

ConclusionsThe evidence from this review supports the early introduction of exercise. However, this is associated with increased wound drainage, therefore some patients or clinicians may prefer to delay exercise for one week to minimise this. There is evidence to support exercise interventions that include structured instruction and supervision as opposed to more passive forms of instruction. Of note, greater benefits were found for patients with shoulder range of movement problems and function when exercise was introduced earlier in the recovery period. There was no evidence of a negative effect from upper limb exercise on upper limb lymphoedema at any point following surgery. Because of the risk of bias in studies, and the heterogeneity between studies, more research is needed that considers the advantages of exercise relative to patient demographics and treatment variables. In particular there are more studies needed with older individuals.

Implications for practiceNurses should encourage patients to be active during their recovery period and engage with physical therapy to achieve optimal outcomes. Side effects can be reduced with appropriate management and nurses are well placed to advise and educate patients.

Author

Natalie Bradford, RN MPH PhD, The University of Queensland, Centre for Online Health

References: McNeely, Margaret L., et al., Exercise interventions for upper limb dysfunction due to breast cancer treatment. The Cochrane Library (2010) http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005211.pub2/abstract For the full review, go to www.cochrane.org.uk

Electrochemotherapy for skin metastases in breast cancerBackgroundBreast cancer is the most common cancer to affect women worldwide [1] with 1 in 8 women developing breast cancer in their lifetime. In 2011, there were more than 50,000 new cases of breast cancer, affecting 95 per 100,000 women in the UK [2]. While it is becoming increasingly treatable and associated with a falling mortality, 1-5% of patients who have breast cancer recurrence develop skin metastases [3].

The clinical problemPresentations of skin metastases include ulcers, inflammatory changes, rashes and palpable nodules [4]. If left untreated, uncontrolled local disease can cause bleeding, exude a discharge and become infected, causing pain and an unpleasant smell [5]. This can lead patients to socially isolate themselves, causing further psychological distress. Patients often feel too embarrassed to talk to relatives or healthcare professionals about the lesions until they have become well established.

Surgery and radiotherapy is the first line of treatment for localised disease – however, as the lesions have a high risk

of recurrence these options may not be available at subsequent treatments. Systemic treatment with chemotherapy or endocrine therapy is currently the first line treatment option for widespread skin lesions. This sometimes results in a temporary halt in the progression of the disease. Unfortunately resistance is common with continued treatment.

Simple palliation alone often involves daily dressing of the wounds, opiate analgesia for painful lesions and frequent admissions to hospital if the wounds become infected. Until recently, treatment options for lesions were limited to these choices. Electrochemotherapy (ECT) is a new treatment modality that is changing the approach to treating cutaneous metastases.

Electrochemotherapy and why it worksThe principle of ECT is to combine the administration of non-permeable or poorly permeable chemotherapeutic agents with electric pulses in order to allow drug delivery into the cancer cells. The electric pulses are delivered directly over the skin lesions to be treated.

References: [1] Global Health Estimates, WHO 2013 [2] Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 Lyon, France: International Agency for Research on Cancer; 2013. [3] Krathen RA, Orengo IF, Rosen T. Cutaneous metastasis: a meta-analysis of data. South Med J. Feb 2003; 96(2):164-7. [4] 16. De Giorgi V, Grazzini M, Alfaioli B et al. Cutaneous manifestations of breast carcinoma. Dermatologic Therapy 2010; 23: 581-89. [5] The National Institute for Health and Clinical Excellence. Advanced breast cancer: diagnosis and treatment. Full guideline February 2009.



This is done with the help of a specially designed needle probe, so that treatment is targeted to where the lesions are. The direct effects of this treatment are:

• Formation of a high-intensity electric field inducing cancer cell suicide (apoptosis) [6]

• Formation of ‘reversible pores’ in the cell membrane – a process known as electroporation [7] increases permeability of cancer cells up to 8000-fold, which improves drug delivery [7]

• Production of a ‘vascular lock’ in the treatment area, which reduces blood flow in tumour vessels and reduces the oxygen supply to the cancer cells

• Disruption of tumour vessels due to endothelial damage.

The European Standard Operating Procedures of Electrochemotherapy (ESOPE) study in 2006 [8] evaluated and confirmed the efficacy and safety of ECT using bleomycin and cisplatin. They found an objective response rate of 85% on the ECT treated nodules, regardless of tumour histology. They demonstrated ECT is also suitable for treatment in previously irradiated skin.

The ESOPE study showed that ECT was a highly effective and safe approach for the treatment of skin metastases, could

be given as repeated treatments and was quick to perform. However it does not alter disease progression. Patients reported only minor and acceptable side effects, with most willing to have repeat treatments [8]. In 2014 Spratt et al showed that ECT was as effective as other treatments including radiotherapy [9].

Electrochemotherapy in the UK ECT as a treatment option for breast cancer is still in its infancy in the UK. Its use to date has been limited to a small number of institutions across Europe and the UK, and to those patients who have advanced or recurrent disease. This may reflect that it is relatively uncommon to develop cutaneous metastases from breast cancer.

Another factor may be the lack of awareness of its potential as a treatment modality. Research on its use in breast cancer has been restricted to where other therapies have failed or there are no other options. More research is yet to be done regarding the timing of this procedure relative to other treatments.

In 2013 the National Institute for Health and Care Excellence (NICE) recommended its use in non-skin cancer related skin metastases including breast cancer [10]. Prior to this, the

References: [6] Weaver JC, Chizmadzhev YA (1996). Theory of electroporation: a review. Bioelectrochem Bioenerg 41:135–160 [7] Robert E. Neal II, Ravi Singh, Heather C. Hatcher ,Nancy D. Kock, Suzy V. Torti, Rafael V. Davalos. Treatment of breast cancer through the application of irreversible electroporation using a novel minimally invasive single needle electrode. Breast Cancer Res Treat (2010) 123:295–301.DOI 10.1007/s10549-010-0803-5 [8] Michel Marty, Gregor Sersa, Jean Rémi Garbay, Julie Gehl,Christopher G. Collins, Marko Snoj et al. Electrochemotherapy – An easy, highly effective and safe treatment of cutaneous and subcutaneous metastases: Results of ESOPE (European Standard Operating Procedures of Electrochemotherapy) study. EJC. EJC SUPPLIMENTS S4.(2006) 3-13. [9] Daniel E. Spratt, Elizabeth A. Gordon Spratt, Shenhong Wu, Antonio DeRosa, Nancy Y. Lee,Mario E. Lacouture, and Christopher A. Barker. Efficacy of Skin-Directed Therapy for Cutaneous Metastases From Advanced Cancer: A Meta-Analysis. JCO.2014.55.4634

first centre in the UK to start using ECT was James Cook University Hospital, Middlesbrough, in 2010. Then six other Hospitals in the UK, including our institution, also started using the technology on a trial basis.

Currently there are 15 centres in the UK offering this treatment.

Indications of treatment and the procedureNICE guidelines indicate that electrochemotherapy should be used when other standard treatments are unsuitable or ineffective. Advanced age is not a contra-indication to treatment, however the presence of multiple co-morbidities and poor performance status increases risk of poor outcome [11][12]. Patients need to be counselled about the treatment being palliative and not curative. All patients who are suitable for treatment should have a life expectancy of at least three months and show no evidence of disease progression at distant sites.

The table on page 22 shows the types of cancers treated by ECT.

Patients receive general anaesthesia with low inspired oxygen concentrations intra-operatively to reduce the risk of pulmonary fibrosis, which can be a side effect of bleomycin, the chemotherapy

agent that’s given intravenously as fast bolus [13]. Eight minutes after giving bleomycin, treatment starts with Cliniporator, which delivers electrical pulses via an electrode inserted through the skin’s surface. Patients are usually admitted for a minimum of one night for observation post treatment.

The patient’s experience of electrochemotherapy Following the procedure, most patients have no pain or discomfort. Patients who have been treated on extensive areas on the chest wall may complain of prolonged stiffness and pain [14]. Most patients are discharged the day after treatment.

The treatment sites become slightly red and swollen initially but gradually this reduces. There is increase in pigmentation in the treated areas which does not disappear. In the first 2-4 weeks most patients have some low grade symptoms of discomfort, skin tightness and aches and pains. In most cases this settles after 4-6 weeks.

Supportive measures recommended for electrochemotherapy All patients should have access to physiotherapy post ECT treatment as an in patient and at their local hospital.

References: [10] Electrochemotherapy for metastases in the skin from tumours of non-skin origin and melanoma. https://www.nice.org.uk/guidance/ipg446 [11] Luca G. Campana , Sara Valpione ,Cristina Falci ,Simone Mocellin , Michela Basso Luigi Corti, Nicola Balestrieri, Alberto Marchet, Carlo R. Rossi. The activity and safety of electrochemotherapy in persistent chest wall recurrence from breast cancer after mastectomy: a phase-II study. Breast Cancer Res Treat (2012) 134:1169–1178. [12] Luca G. Campana, Sara Galuppo, Sara Valpione, Antonella Brunello, Christina Ghiotto, Alessia Ongaro and Carlo R. Rossi. Bleomycin Electrochemotherapy in metastatic breast cancer patients: clinical outcome and management considerations. J Cancer Res Clin Oncol (2014) 140:1557–1565. [13] DuBois D; DuBois EF: A formula to estimate the approximate surface area if height and weight be known. Arch Int Med 1916 17:863-71. [14] Quaglino P1, Matthiessen LW, Curatolo P, Muir T, Bertino G, Kunte C, Odili J, Rotunno R, Humphreys AC, Letulé V, Marenco F, Cuthbert C, Albret R, Benazzo M, De Terlizzi F, Gehl J. Predicting patients at risk for pain associated with electrochemotherapy. Acta Oncol. 2015 Jan 16:1-9. [Epub ahead of print]



Patients should continue with analgesics prescribed by the treatment centre. After two weeks post ECT patients have found that applying a cream or oil used for scars has relieved the symptoms of skin tightness.

Authors

Miss S.M. Banerjee1 Senior Clinical Fellow, Department of Surgery, Royal Free London NHS Foundation Trust

Prof. M.R.S. Keshtgar1,2* Professor of Cancer Surgery and Surgical Oncology, Royal Free NHS Foundation Trust and University College London

Cancer type/site

Centre for treatment in the UK Publications related to cancer type

Breast Royal Free London breast unit, London

Nottingham City Hospital, Nottingham

Campana et al. Bleomycin Electrochemotherapy in metastatic breast cancer patients: clinical outcome and management considerations. J Cancer Res Clin Oncol (2014) 140:1557–1565.

Spratt et al 2014. (see below)

Marty, Sersa et al 2006. (see below)

Melanoma Royal London Hospital, London

Nottingham City Hospital breast unit, Nottingham

Moriston hospital, Swansea

Preston General Hospital, Preston

Testori et al. Utility of electrochemotherapy in melanoma treatment

Current opinion in oncology 2012, Vol.24 (2), pp.155-61


Marty, Sersa et al 2006. (see below)

Non- melanoma skin cancers

Royal London hospital, London

Moriston hospital, Swansea

Preston General Hospital, Preston

Nottingham City Hospital, Nottingham

Spratt et al (see below)

Marty, Sersa et al 2014 (see below)

Campana et al 2014 (see below)

Head and neck cancers

Royal London Hospital, London

Royal Marsden, London

Campana et al

Electrochemotherapy in non-melanoma head and neck cancers: a retrospective analysis of the treated cases. British Journal of Oral & Maxillofacial Surgery, 2014, Vol.52 (10), pp.957-964


Marty, et al 2006. (see below)

All above types

St. Georges Hospital, London

Christie Hospital, London

James Cook Hospital, Middlesborough

Whiston Hospital, Wirral

Nine Wells Hospital, Dundee

Leeds General infirmary, Leeds

Bristol South Mead Hospital, Bristol

Castle Hill Hospital, Hull

Royal Devon and Exeter Hospital, Devon

Southampton General Hospital, Southampton

Marty, Sersa et al Electrochemotherapy – An easy, highly effective and safe treatment of cutaneous and subcutaneous metastases: Results of ESOPE (European Standard Operating Procedures of Electrochemotherapy) study. EJC. EJC SUPPLEMENTS S4.(2006) 3-13.

Spratt et al. Efficacy of Skin-Directed Therapy for Cutaneous Metastases From Advanced Cancer: A Meta-Analysis. JCO.2014.55.4634

Key Points

• Electrochemotherapy is a safe and effective treatment for cutaneous metastases.

• Appropriate patient selection for treatment, pre-emptive analgesia, post treatment support and follow-up is essential.

1

Bleomycin is given intravenously

2

Electrochemotherapy commences 8 minutes after IV administration of bleomycin

3

The electrodes are inserted through the skin surface directly over the lesions and in the area for treatment

4

The Cliniporator is activated using pedals

5

The procedure is completed after 30 minutes


The electrochemotherapy process

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