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Pro-active management of quality-of-life in breast cancer

Dr Rachel Giles interviewed Dr Ines Vaz-Luis (Gustave Roussy, Paris, France) about her recent work on patient-reported outcomes after adjuvant breast cancer chemotherapy and her vision on personalised care for the future.

Medicom: Thank you so much for joining us. Could you tell me a little bit about your study?

First, I will give you a little bit of context to the study. The research was done within the CANTO cohort, which is a French cohort for patients with breast cancer that is focused on one goal: Predict which patients are at risk for quality-of-life deterioration. The current study aimed to evaluate if we can cluster patients with early breast cancer with respect to their trajectories of quality-of-life deterioration that they experienced.

There are 12,000 patients in the CANTO cohort and for our study we included 4,000 patients, who all had at least four years of follow up. We performed latent class analysis to identify clusters of patients. What we found is that there are four distinctive clusters of patients.

Two clusters, which include the majority of patients, had excellent or very good quality of life before and after treatment. Another cluster of patients had a bad quality of life prior to treatment initiation and they kept this bad quality of life during treatment and after treatment. Finally, there is a cluster of patients that had a very good quality of life in the beginning, but their quality of life deteriorated after cancer treatment and stayed deteriorated for four years, which was the last time point we evaluated. In this particular study we looked at a composed score in terms of quality-of-life, including several functions and several symptoms to create an overall picture of the construct of quality-of-life.

Medicom: So the point was to identify those patients who were likely to deteriorate a priori, so you could intervene?

The idea is to identify clusters of patients and the characteristics of these patients. What we found is that some of the characteristics that are associated with these clusters are modifiable: obesity, smoking, and limited physical activity put a patient at risk for being in a deteriorating cluster in terms of quality-of-life at diagnosis. Next to this, we observed risk factors that are harder to modify, such as ‘low social class’. This demonstrates the need to consider the social determinants of health when we are taking care of patients. A next step would be to build personalised pathways, helping patients from the moment of diagnosis to mitigate symptoms that are already present and preventing deterioration for those that have a very good quality of life but are likely to deteriorate.

Medicom: You found some factors that were associated with these clusters of individuals who deteriorated over time. Were there elements that did not pre-exist at baseline, but accelerated the progress as well?

In general, we looked at baseline and a priori treatment characteristics. However, you get an idea of the behavioural components that are associated with the clusters of the quality-of-life, such as persistent insufficient physical activity. If you look at the clusters descriptively, you see that factors like obesity and smoking are risk factors at baseline and we have the feeling that these bad behaviours are persistent and associated with a further deterioration of the quality-of-life in these clusters.

Medicom: The good thing about bad behaviours is that there are interventions possible.

Exactly. Although it is not easy to change behaviours, there is a way forward. We believe that there is a lot of work that can be done in terms of helping these patients. Self-management is a key term in this setting. We may use the moment of the cancer diagnosis to convince patient to engage in different types of behaviours; behaviours that can mitigate the cancer burden and may alleviate the effects of the cancer treatment. For this purpose, we need to identify patients who are at higher risk for deterioration. Next, a stratification should be made between patients who are likely to easily adopt self-management strategies and those who need extra personal attention to accomplish these goals. In terms of developing pathways of care, the complexity of the patient and the patient’s ability to adopt new behaviours should be considered.

Medicom: Will this be integrated into guidelines for physicians treating patients with breast cancer on adjuvant care? Or is that a dream scenario?

I think that is indeed the dream scenario, but we are working actively on this. We have studies that are going to investigate whether this concept of risk stratification at diagnosis and delivering different pathways of care is acceptable for patients. This would also mean that we will have to be able to communicate the risk of quality-of-life deterioration to the patient at the diagnosis. That is a moment when they are already dealing with a lot of thoughts and emotions. Therefore, this study is co-operating with the patients to answer the question: “How do we do this?” Hereafter our goal is to demonstrate the efficacy on preventing the deterioration of quality-of-life by stratifying patients in these different pathways of care. It’s a dream that I hope to see to come to reality in the next 5 to 10 years.

I want to emphasise that this work is a co-creation with the patients. Traditionally our research team was very focused on hormone-positive stratification, but now we are moving towards the development of an intervention together with the patients. I’m very optimistic that this will be the way. Our previous focus was precision medicine to treat the tumour and our current focus is precision of care, focusing on personalising the tumour treatment and personalising the pathway of care. For this, we need to understand all the determinants of their quality-of-life, their quality-of-life dynamics, and how can we mitigate the dynamics that don’t go in the right direction.

Medicom: Fascinating work. Are there any final messages you wanted to share with your fellow physicians about your research?

I think we have been operating in a reactive system when it comes to quality of life. I would like our work to contribute to a pro-active system, addressing quality-of-life as soon as possible.


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