The single most scary thing about metastatic breast cancer is that it is unpredictable.
You can live the most healthy life possible – eating right, exercising enough, having no stress, etc – and you may still develop this incurable condition.
Metastatic breast cancer, also known as advanced or stage 4 breast cancer, is when the cancer cells in the breast have spread to other organs in the body.
According to consultant breast surgeon and Universiti Malaya emeritus professor Datuk Dr Yip Cheng Har, the most common organs to be invaded by breast cancer cells are the lungs, liver and bones.
Examples of possible symptoms are difficulty breathing or coughing if the lung is affected, back pain if the spine – a common place for breast cancer bone metastases – is affected, and abdominal pain, abdominal swelling, loss of weight or loss of appetite if the liver is affected.
However, the Breast Cancer Welfare Association (BCWA) exco member notes that breast cancer patients rarely lose weight unless they have already reached stage 4.
In addition, the metastases might be so small that they cause no symptoms, and are only picked up upon a PET (positron emission tomography) scan – currently the most sensitive test for cancer metastases.
She says: “Metastatic breast cancer can occur at diagnosis, where the patient presents immediately with stage 4 breast cancer, or it can occur months or years after the (original) breast cancer has been treated.
“Now, metastatic breast cancer is incurable, but long periods of remission can be achieved with treatment.”
Better treatment options
According to Emeritus Prof Yip, treatment can be divided into local and systemic.
Local treatment includes surgery and radiotherapy, while systemic treatment covers chemotherapy, hormone therapy, immunotherapy and targeted therapy.
As a surgeon, she notes that some people might wonder why there is a need to remove the breast if the cancer has already spread.
But if the breast is adversely affected, e.g. it has a fungating cancerous mass or it is bleeding, surgical removal – also known as palliative surgery – is done for better quality of life for the patient, she says.
Radiotherapy would also be done for the same reason.
Meanwhile, systemic therapy is mainly used to treat the metastases in organs other than the breast.
“The traditional ones are chemotherapy and hormone therapy; previously, that was all that was available.
“If it was stage 2, 3 or 4, we would give chemotherapy, and if it was ER+ (oestrogen receptor positive) – that means they respond to oesterogens – we would give hormone therapy.
“But now, we also have targeted therapy like the anti-HER2 (human epidermal growth factor receptor 2) drugs trastuzumab, pertuzumab, ado-trastuzumab emtansine – these are all really expensive; CDK-4 inhibitors like palbociclib, which is a very new drug for ER+PR+HER- patients (PR is progesterone receptor); and the latest PARP (poly-ADP ribose polymerase) inhibitor olaparib – which I can tell you costs RM24,000 a month – that is for BRCA-associated (breast cancer gene 1) cancers,” she explains.
Treatment, she adds, depends on the molecular subtype of breast cancer the patient has.
These molecular subtypes are determined according to the presence and combination of the ER, PR and HER2 targets, which are pinpointed through special tests.
“Nowadays, it’s not enough to just treat breast cancer. In fact, it is said that you cannot treat breast cancer unless you do all these tests, which are all expensive as well,” says Emeritus Prof Yip.
The four molecular subtypes of breast cancer are ER+PR+HER2- (the most common in Malaysia and most treatable subtype), ER+PR+HER2+, ER-PR-HER2+ and ER-PR-HER2- (known as the “triple negative” and the “worst” subtype as chemotherapy is the only treatment option).
However, she notes that there are ongoing clinical trials to test if and how well immunotherapy can treat the triple negative subtypes.
According to a study conducted by her and her colleagues in three hospitals in Malaysia and Singapore, the average survival of metastatic breast cancer patients had risen from 14 months to 21 months over a period of 15 years from 1996 to 2010.
“And the reason for the longer survival was better treatment options,” she says.
No will, no money
However, having better treatment options does not necessarily mean that patients will want or be able to take advantage of them.
According to Emeritus Prof Yip, some breast cancer survivors who discover that their cancer has returned and spread, just lose their willpower and give up.
“It is very demoralising to have a relapse. I’m sure all patients with breast cancer, despite how many years they have been free of breast cancer, fear a relapse.
“And sometimes when they relapse, they say, ‘I don’t want to have chemo(therapy) again. I’ve had it once, I cannot take it anymore’,” she says.
However. she adds: “But if they have the willpower to go on, depending on the type of cancer they have, they can actually have really miraculous remissions.
“Unfortunately, the treatment options can be very expensive once you have failed the first line (treatments). And the reason why patients give up, besides willpower, is finances.”
She notes that there is not much financial assistance available for breast cancer patients.
Breast cancer treatments in public hospitals, which are available for a minimal fee, are currently limited to chemotherapy, hormonal therapy and the targeted therapy trastuzumab.
Other treatments can cause up to RM20,000 for one cycle, which is usually equivalent to a month, according to Emeritus Prof Yip.
“Even if you ask me, I cannot afford to pay RM20,000 for one cycle,” she shares frankly.
“Some patients will say, ‘Why should I spend all that money? The money can be better spent for my family when I die.’”
She shares the story of one patient who had to decide whether or not to dip into her son’s university fund in order to pay for her metastatic breast cancer treatment.
“Of course she chose not to use her son’s education fund, she would rather go without her treatment than use her son’s education fund. People have to make choices like this in their lives,” she says.
According to the results of the Asean Costs in Oncology (Action) study, 45% of Malaysian cancer patients could not afford to buy medicines one year after their diagnosis.
The same percentage of households with cancer patients were hit with financial catastrophe, i.e. spending 30% or more of household income on cancer treatments.
In a more specific study conducted by Emeritus Prof Yip and her colleagues, it was found that one-third of cancer patients in public hospitals, almost two-thirds (65%) of patients in university hospitals and 72% of patients in private hospitals experienced financial catastrophe one year after diagnosis.
The disparity between public and university hospitals, she notes, is because university hospitals will ask their patients to buy the expensive drugs that are not covered by the Health Ministry, whereas public hospitals are unlikely to.
Advanced breast cancer patients are particularly impacted by this as a 2018 systematic review, published in the PLOS One journal, found that the treatment costs of metastatic breast cancer treatment is 165% higher than that of early or stage 1 breast cancer.
Emeritus Prof Yip says that with the current available drugs, metastatic breast cancer can be considered a chronic disease.
Hence, access to prompt treatment is important for all cases of breast cancer.
She adds that the Government also needs to improve financial risk protection for cancer patients by channelling public funds to those in need.
Emeritus Prof Yip, along with BCWA president and breast cancer survivor Ranjit Kaur, was speaking at the official launching of the Embrace programme by Pfizer Malaysia.
This programme provides a 50% subsidy for palbociclib, which costs about RM10,000-13,000 per cycle.
Any breast cancer patient on this targeted therapy can be enrolled into the programme by their oncologist.