Abstract
Background
The presence of a breast nurse is recommended to advise and guide early breast cancer patients before and during chemotherapy/radiation therapy, and at the end of planned treatments. Nevertheless, some patients will need extra guidance. Little is known about the predisposing factors for additional requests.
Aim and Objective
Determine time, reasons, and risk factors for breast nurse unplanned solicitations.
Design and Methods
This monocentric retrospective study included all early breast cancer patients treated with chemotherapy during 1 year. Unplanned solicitations (in person, by phone, or by e-mail) were recorded in the medical file. They were extracted and stratified in four categories: treatment adverse events, medical condition, psychological support, and counselling.
Results
368 unplanned solicitations were observed for 265 patients, 140 patients (52.8%) asked for at least one unplanned solicitation and 57 (21.5%) asked for at least three. There was no significant difference between the four categories. Most of unplanned solicitations occurred significantly during chemotherapy, essentially after first docetaxel infusion (57% of calls). In univariate and multivariate analyses, anxiolytic treatment was significantly associated with more unplanned solicitations (OR = 2, p = 0.02), while a personal breast cancer history was associated with fewer unplanned solicitations (OR = 0.49, p = 0.05).
Conclusion
Breast nurse unplanned solicitations during adjuvant or neoadjuvant chemotherapy in early breast cancers are frequent. Even if patients with anxiolytic treatment have a slightly higher risk of solicitation, no typical profile of a patient who will need extra support exists. Because of its known toxicity, the first cycle of docetaxel is associated with a clear increase in solicitations. Despite physicians' consultations, breast nurses guidance, and leaflets on supportive care and treatments side effects, optimal patient management during early breast cancer remains challenging. Further randomized studies testing more customized tools are required to improve patient support.
Keywords: Breast nurse, Chemotherapy, Early breast cancer, Unplanned solicitations, Cancer care, Phone solicitation
Introduction
Breast cancer (BC) is the leading cause of cancer-related death with an incidence rate per year in 2020 of 2,261,419 cases worldwide and 684,986 deaths. In patients diagnosed with an early BC (EBC), the treatment is usually based on multimodal therapy combining surgery, radiation therapy (RT), chemotherapy (CT), and/or endocrine therapy. The growing complexity of this multimodal therapy claims for the development of supportive care as a backbone measure throughout EBC management. In addition to physicians consultations, the ESMO guidelines recommend that a breast nurse (BN) or a similarly trained and specialized health care practitioner should be available to act as a patient navigator [1]. The concept of a specialist role in BC care has started in the United Kingdom and has led to the development of “Breast Care Nurse (BCN).” But the roles, titles, and activities of BNs vary across countries due to variations in practice settings and training programmes [2]. To date, the availability and role of BN are heterogeneous among BC centres. Usually, BN interventions are in addition to physician's consultations. These BN interventions are based on visits synchronized with the treatment schedule (before, during or after surgery, CT, radiotherapy), or calls based on patient demand. In most of cases, the BN interventions are focused on various symptoms, including treatment-related toxicity, anxiety, and general counselling regarding weight intake or physical activity. BN may interact with patients using both face-face and/or telephone interactions which is an easy and accurate approach for patients symptoms self-management and quality of life improvements [3, 4]. Indeed, nurse case management effectiveness has been proven among older BC patients [5, 6, 7]. Despite these planned interventions, some patients still need specialized advices due to anxiety, misunderstanding of treatments goals, or side effects. Unplanned BN solicitations are mostly made by phone calls or e-mails from the patient with systematic recall by the BN. These unplanned solicitations are time consuming and may be related in some cases to the patient condition. In particular, EBC patients treated by CT are of particular interest. CT can be delivered in a neoadjuvant or an adjuvant setting and is based on a combination of anthracyclines and taxanes [1, 8]. Although this combination of CT is associated with an overall improvement in survival [9], this treatment may be responsible for a spectrum of related toxicities that may affect patient well-being and quality of life. Indeed, the sequential addition of docetaxel to doxorubicin − cyclophosphamide − methotrexate and 5 fluorouracil (D-CMF) or to 5 fluorouracil − epirubicin − cyclophosphamide (FEC) is associated with a significantly increased rate of any grade III-IV adverse event (febrile neutropenia, infection, asthenia, diarrhoea, myalgia, stomatitis) [10, 11]. To our best knowledge, no data are available regarding the number of unplanned solicitations, reasons, and patient characteristics associated with unplanned solicitations. BN interventions analysis may be relevant to identify these elements to better optimize and personalize support to patients and thus offer them better health care. In that context, this study aimed to describe BC unplanned solicitations in patients treated for EBC including CT and to analyse baseline characteristics associated with these solicitations.
Patients and Method
Study Design
This was a monocentric, retrospective, observational study conducted during over 1 year. All the patients treated for an EBC and who had received at least one cycle of CT in the neoadjuvant and/or adjuvant setting were included. CT was based on an anthracycline and taxane combination, usually three cycles of (F)EC (5 fluorouracil 500 mg/m2, epirubicin 100 mg/m2, cyclophosphamide 500 mg/m2), followed by three cycles of docetaxel (100 mg/m2) or 9 to 12 cycles of weekly paclitaxel (80 mg/m2). Patients with metastatic disease, male sex, age inferior to 18 years old, those who refused CT or had contra indications for CT (i.e., WHO performance status >3, or cardiac contraindication to anthracyclines), were not included.
BN Interventions
At our centre, two nurses were dedicated to BN interventions specifically for patients treated with CT for an EBC. For each patient, the BN interventions were based on physical visits at four planned times in the case of an adjuvant course and at 5 times in the case of neoadjuvant course (Fig. 1). These interventions occur in addition to the physicians (surgeon, medical oncologist, and radiation therapist) consultations. For the adjuvant course, the first meeting occurred in the postoperative setting and before the CT initiation on the same day of the oncologist visit (Fig. 1). This first meeting was dedicated to patient understanding about disease and treatment modalities and related toxicities (duration of the consultation: around 45 min). A second meeting occurred during the middle of the CT course and was planned between the (F)EC and taxane cycles (around 20 min). The third meeting occurred at the end of the CT cycles before RT initiation, if planned (around 20 min). The fourth meeting occurred 4 months after RT completion (around 45 min). For the neoadjuvant course, the interventions were based on the same schedule: the first meeting was planned before CT initiation (around 45 min), the second between (F)EC completion and taxane initiation (around 20 min), the third between taxane completion and surgery (around 20 min), the fourth after surgery (around 20 min) and the fifth immediately after or 4 months after RT completion (around 45 min). The aim of these planned meetings was to assess the understanding of the treatment modalities, to answer issues arising after the physicians' consultations, and to identify social frailty. The length of the meetings varied according to the needs of the patients: anxiety, amount of treatments side effects, referral to more specific supportive care practitioner. Leaflets on supportive care (nutrition, pain management, adapted physical activity) and the side effects of treatments (CT, endocrine therapy) were given at each consultation and according to the needs of the patients. At each visit (planned or unplanned), the patient characteristics were collected using a systematic questionnaire specific to the centre included in the medical file of all our patients, including age, personal history of treatment for invasive or in situ BC with specific oncological treatments, histological findings, modalities of other treatment (e.g., surgery, radiotherapy, hormonal or targeted therapy), biometrics (body mass index, BMI), oncogenetic exploration, smoking status, physical activity, and comedications (treatments taken by patients: pain killer, anxiolytic, or other). In addition to these planned interventions systematically performed for each patient, the BN may receive unplanned solicitations, which are the subject of this study. These unplanned solicitations occur mostly by phone call and sometimes via an e-mail. In this case, patients are systematically called back by the BN. These calls are time consuming since they require to identify the purpose of the call, then plan the management of the issue with the dedicated caregiver and complete the medical record. Overall, each unplanned solicitation requires between 30 and 60 min. In this study, number and reasons of these unplanned solicitations were collected. We defined four types of unplanned solicitations: (1) usual treatment-related adverse events (e.g., nausea, vomiting, granulocyte colony-stimulating factor adverse events, mucositis and management of febrile neutropenia), (2) medical condition without a link to CT (e.g., pain, thromboembolism, and fever), (3) psychological support (e.g., fear, stress, anguish, anxiety, sleep disorders and psychological distress), and (4) general counselling (requirement of a consultation with a general practitioner, psychologist, dietitian, or hygienic-dietetic rules.)
Fig. 1.
Planned BNCM interventions during EBC management in the adjuvant (top) or neoadjuvant (bottom) setting. (F)EC: 5-fluorouracil, epirubicin, cyclophosphamide; D: Docetaxel; RT: radiation therapy.
Statistical Analysis
The primary objective was to describe frequency and reasons of unplanned solicitations addressed to BNs by EBC patients under CT. The secondary endpoint was to identify the patient's baseline characteristics associated with unplanned solicitations. For each patient included, the times and reasons for unplanned solicitations were retrospectively collected using computerized medical records. Support for data collection included consultation reports generated by the BN at each unplanned solicitation. Consultation reports were classified into four subtypes: (1) usual treatment-related adverse events, (2) medical condition without a link to CT, (3) psychological support, and (4) general counselling. When patients called for multiple reasons at the same time, only one report was generated. The category in which extra solicitation was retained was the most problematic. The sample characteristics were expressed as numbers and percentages for qualitative variables, and as medians and extreme values for quantitative variables. Comparisons of the characteristics according to requests for unplanned solicitations were established by a χ2 test (or Fisher's exact test) for qualitative variables, and the nonparametric Wilcoxon Mann-Whitney test for quantitative variables. Risk factors for asking for unplanned solicitation one time and at least three times were identified by logistic regression models, in univariate and then multivariable analyses. Stepwise analysis was performed to select only variables statistically associated with the endpoint in the multivariable model. Statistical analyses were performed using R software, version 4.0.2.
Results
During the 1-year study, 265 patients were included. The baseline characteristics are detailed in Table 1. Overall, 41 patients (15%) had undergone neoadjuvant CT (NACT), 54 patients (20%) had a Her2-amplified tumour, 195 patients (74%) had a hormone receptor-positive tumour, and 248 patients had undergone RT (94%). Regarding the number of BN solicitations in addition to the 4 planned interviews, 368 unplanned solicitations for the 265 patients were observed. The median number of unplanned solicitations was 1 (min: 0; max: 17), the mean number of unplanned solicitations was 1.4 (SD: 2.18), 140 patients (52.8%) asked for at least one unplanned solicitation, and 57 patients (21.5%) asked for at least three unplanned solicitations (Fig. 2). Most unplanned solicitations were observed during CT (Fig. 3; p < 0.001): indeed, 31/369 (8%) unplanned solicitations occurred before or immediately after surgery; 289/369 (78%) occurred during CT; and 48/369 (13%) occurred after the end of CT, when patients were treated by RT, HER2-targeted therapy, or endocrine therapy.
Table 1.
Baseline characteristics
| Total N = 265 | Unplanned sollicitations N = 140 | No unplanned sollicitations N = 125 | p value | |
|---|---|---|---|---|
| Patients characteristics | ||||
| Age | 0.711 | |||
| Median [min-max] | 58.4 [22.2–82.3] | 58.9 [22.2–77] | 57.7 [35.6–82.3] | |
| ≤50, n (%) | 73 (27) | 39 (28) | 34 (27) | |
| [50–65], n (%) | 126 (48) | 79 (49) | 57 (46) | |
| >65, n (%) | 66 (25) | 32 (23) | 34 (27) | |
| BMI | ||||
| Median [min-max] | 25.4 [17–48] | 25.2 [16.9–43.3] | 25.7 [19.1–47.6] | 0.460 |
| ≤25, n (%) | 124 (47) | 69 (49) | 55 (44) | |
| >25, n (%) | 141 (53) | 71 (51) | 70 (56) | |
| Personal history of BC | ||||
| Yes, n (%) | 37 (14) | 14 (10) | 23 (18) | 0.073 |
| No, n (%) | 228 (86) | 126 (90) | 102 (82) | |
| BC history in first degree | ||||
| Yes, n (%) | 56 (21) | 24 (17) | 32 (26) | 0.130 |
| No, n (%) | 209 (79) | 116 (83) | 93 (74) | |
| Other cancer history | ||||
| Yes, n (%) | 81 (31) | 43 (31) | 38 (30) | 1 |
| No, n (%) | 184 (69) | 97 (69) | 87 (70) | |
| Anxiolytic treatment | ||||
| Yes, n (%) | 59 (22) | 39 (28) | 20 (16) | 0.030 |
| No, n (%) | 206 (78) | 101 (72) | 105 (84) | |
| Antidepressive treatment | ||||
| Yes, n (%) | 32 (12) | 18 (13) | 14 (11) | 0.822 |
| No, n (%) | 233 (88) | 122 (87) | 111 (89) | |
| Tobacco use | ||||
| Yes, n (%) | 47 (18) | 24 (17) | 23 (18) | 0.920 |
| No, n (%) | 218 (82) | 116 (83) | 102 (82) | |
| Included in a clinical trial | ||||
| Yes, n (%) | 36 (14) | 21 (15) | 15 (12) | 0.590 |
| No, n (%) | 229 (86) | 119 (85) | 110 (88) | |
|
| ||||
| Social situation | ||||
| Living alone | ||||
| Yes, n (%) | 42 (16) | 24 (17) | 18 (14) | 0.660 |
| No, n (%) | 223 (84) | 116 (83) | 107 (86) | |
| Having a dependant | ||||
| Yes, n (%) | 55 (21) | 31 (22) | 24 (19) | 0.660 |
| No, n (%) | 210 (79) | 109 (78) | 101 (81) | |
|
| ||||
| Tumours characteristics | ||||
| Histology | ||||
| Lobular, n (%) | 37 (14) | 22 (16) | 15 (12) | 0.488 |
| Ductal, n (%) | 228 (86) | 118 (84) | 110 (88) | |
| Her2+ | ||||
| Positive, n (%) | 54 (20) | 34 (24) | 20 (16) | 0.090 |
| Negative, n (%) | 211 (80) | 106 (76) | 105 (84) | |
| Inflammatory | ||||
| Yes, n (%) | 11 (4) | 6 (4) | 5 (4) | 1 |
| No, n (%) | 254 (96) | 134 (96) | 120 (96) | |
|
| ||||
| Therapy | ||||
| Mastectomy | ||||
| Total, n (%) | 112 (46) | 55 (49) | 57 (43) | 0.430 |
| Partial, n (%) | 132 (54) | 57 (51) | 75 (57) | |
| CT | 0.775 | |||
| Neo-adjuvant, n (%) | 41 (15) | 23 (16) | 18 (15) | 0.214 |
| FEC/D and FEC/D/paclitaxel, n (%) | 36 (88) | 22 (96) | 14 (78) | |
| FEC/paclitaxel and weekly paclitaxel, n (%) | 3 (7) | 1 (4) | 2 (11) | |
| Others, n (%) | 2 (5) | 0 (0) | 2 (11) | |
| Adjuvant, n (%) | 224 (85) | 117 (84) | 107 (85) | 0.208 |
| FEC/D and FEC/D/paclitaxel, n (%) | 189 (84) | 102 (87) | 87 (81) | |
| FEC/paclitaxel and weekly paclitaxel, n | (%) 12 (6) | 7 (6) | 5 (5) | |
| Others, n (%) | 23 (10) | 8 (7) | 15 (14) | |
| Radiotherapy | ||||
| Yes, n (%) | 248 (94) | 133 (95) | 115 (92) | 0.460 |
| No, n (%) | 17 (6) | 7 (5) | 10 (8) | |
| Endocrine therapy | ||||
| Total, n (%) | 195 (74) | 105 (75) | 90 (72) | 0.680 |
| Tamoxifene, n (%) | 69 (35) | 36 (34) | 33 (37) | 0.840 |
| Aromatase inhibitor, n (%) | 126 (65) | 69 (66) | 57 (63) | |
| No endocrine therapy, n (%) | 70 (26) | 35 (25) | 35 (28) | |
(F)EC, 5-fluorouracil, epirubicin, cyclophosphamide; D, Docetaxel; RT, radiation therapy; TT, targeted therapy.
Fig. 2.
Distribution of unplanned solicitations during therapeutic sequence. For each sequence, the number of solicitations is detailed regarding the four subtypes. (F)EC: 5-fluorouracil, epirubicin, cyclophosphamide; D: Docetaxel; RT: radiation therapy; TT: targeted therapy.
Fig. 3.
Overall repartition of unplanned solicitations regarding therapeutic sequence. (F)EC: 5-fluorouracil, epirubicin, cyclophosphamide; D: Docetaxel; RT: radiation therapy; TT: targeted therapy.
Regarding the subtypes of unplanned solicitations, no significant difference was found in the total number of solicitations among the four categories (Fig. 4). By decreasing frequencies, unplanned solicitations concerned the medical condition (33.1%), CT-related adverse events (25.5%), counselling (25.2%), and support (16.3%). However, the subtype of unplanned solicitations varied during treatment. Unplanned solicitations for general counselling and psychological support repartition were well-balanced during treatment (Fig. 3, 4). By contrast, most unplanned solicitations for medical condition or treatment-related events occurred during CT (Fig. 3; p < 0.0001). In particular, the first cycle of docetaxel (D) was responsible for 57% of all the extra solicitations for related adverse events (Fig. 4).
Fig. 4.
Reparation of unplanned solicitations regarding therapeutic sequence among the four subtypes of solicitations.
Regarding the profiles of the patients' solicitations, the median age of patients requiring unplanned solicitations was 58.9 years and 57.7 years for those not requiring unplanned solicitations. When comparing patients with or without at least one unplanned solicitation, the only baseline characteristic associated with a significantly higher risk of unplanned solicitation was anxiolytic treatment at diagnosis (28 vs. 16; Table 1), both in univariate and multivariate analyses (odds ratio [OR]: 2.03 [1.12–3.77], p = 0.02 and 2.04 [1.12–3.81], p = 0.02, respectively). By contrast, personal BC history was the only baseline characteristic associated with no unplanned solicitations (10 vs. 18%; Table 1), in univariate and multivariate analyses (OR: 0.49 [0.24–0.99], p = 0.05 and 0.49 [0.23–1.04], p = 0.051, respectively). Notably, age, BMI, antidepressive treatment, living alone, tobacco use and family cancer antecedents were not significantly associated with more unplanned solicitations. Considering the 57 patients who called at least three times, having an inflammatory BC was the only risk factor associated with a higher risk of unplanned solicitations in univariate and multivariate analyses (Table 2, OR: 3.24 [0.90–11.16], p = 0.06 and 3.9 [1.06–13.9], p = 0.034, respectively). However, having a BMI >25 kg/m2 was the only factor associated with a decreased risk for unplanned solicitations in both univariate and multivariate analysis (Table 2 and 0.52 [0.28–0.93], p = 0.029 and 0.48 [0.26–0.88], p = 0.018, respectively).
Table 2.
Factors associated with at least one unplanned solicitation (top) or at least three unplanned solicitations (bottom) in univariate and multivariate analyses
| Univariate |
Multivariate |
|||||
|---|---|---|---|---|---|---|
| OR | 95% CI | p value | OR | 95% CI | p value | |
| Unexpected call | ||||||
| Age (ref <50) | ||||||
| 50–65 | 1.050 | [0.59–1.88] | 0.860 | 1.100 | [0.60–2] | 0.760 |
| >65 | 0.820 | [0.42–1.60] | 0.560 | 0.920 | [0.45–1.87] | 0.810 |
| BMI sup 25 | 0.810 | [0.50–1.31] | 0.390 | 0.810 | [0.48–1.36] | 0.420 |
| Neo-adjuvant CT | 1.170 | [0.60–2.31] | 0.650 | 1.110 | [0.51–2.43] | 0.790 |
| Hormonotherapy | 1.170 | [0.67–2.02] | 0.580 | 1.160 | [0.66–2.04] | 0.600 |
| Anxiolytic treatment | 2.030 | [1.12–3.77] | 0.020 | 2.040 | [1.12–3.81] | 0.020 |
| Inflammatory disease | 1.070 | [0.32–3.81] | 0.910 | 1.260 | [0.31–5.27] | 0.740 |
| History of cancer | 0.490 | [0.24–0.99] | 0.050 | 0.590 | [0.23–1.04] | 0.051 |
|
| ||||||
| ≥3 Unexpected calls | ||||||
| Age (ref <50) | ||||||
| 50–65 | 0.710 | [0.37–1.38] | 0.300 | 0.770 | [0.39–1.55] | 0.460 |
| >65 | 0.340 | [0.13–0.81] | 0.019 | 0.450 | [0.17–1.14] | 0.100 |
| BMI sup 25 | 0.520 | [0.28–0.93] | 0.029 | 0.480 | [0.26–0.88] | 0.018 |
| Neo-adjuvant CT | 2.180 | [1.03–4.46] | 0.035 | 1.550 | [0.62–3.67] | 0.330 |
| Hormonotherapy | 0.720 | [0.38–1.39] | 0.320 | 0.770 | [0.40–1.54] | 0.450 |
| Anxiolytic treatment | 1.500 | [0.75–2.89] | 0.240 | 1.810 | [0.88–3.64] | 0.100 |
| Inflammatory disease | 3.240 | [0.90–11.16] | 0.060 | 3.90 | [1.06–13.9] | 0.034 |
| History of cancer | 0.400 | [0.12–1.06] | 0.097 | 0.440 | [0.12–1.25] | 0.160 |
BMI, body mass index; CI, confidence interval; OR, odds ratio.
Discussion
The results of this monocentric, observational, retrospective study showed that during adjuvant or neoadjuvant CT, unplanned solicitations are required by more than half of the patients (52.8%). The profile of these solicitations varied during treatment, with most of solicitations for medical conditions occurring during the first cycles of CT, while most of unplanned solicitations for treatment-related events occurred after the first cycle of taxanes. The latter result was expected because taxane exposure, particularly docetaxel exposure, is associated with an increase in haematological and nonhaematological toxicities compared with anthracycline-based CT [10, 12]. Anxiolytic treatment at diagnosis was associated with more unplanned solicitations in univariate and multivariate analyses (p = 0.02 for both), while personal BC history was associated with fewer unplanned solicitations (p = 0.05). Inflammatory BC is a risk factor and a BMI >25 kg/m2 is a protective factor for patients calling at least three times. Although nurse support during adjuvant CT is recommended [1], adequate determination of the type of support and how to personalize patient support remain challenging. Several studies have already investigated these issues [13, 14]. However, high heterogeneity regarding the primary tumours included, CT regimen, oncological perspective (curative/palliative), and the type of standard support at each cancer centre prevented any definitive conclusion. For example, the overall benefit of nursing intervention on symptom burden during CT was assessed by [15]. In this prospective non-randomized sequential study, nursing intervention based on multiple face-to-face or phone interventions was effective in reducing overall symptom distress and severity (p = 0.01 for both) burden during CT among 143 patients (72 in the intervention group and 71 in the control group) with various tumour types and oncological perspectives. However, [16] reported the results of a monocentric phase III randomized controlled trial that included 120 nonmetastatic patients initiating CT (60 BCs, 30 colorectal cancers, and 30 lung cancers). This study assessed the benefit of proactive telephone calls to reduce patient-reported symptoms. Symptom burden was determined using standardized scales (MSAS-SF, FAMCARE-P, and PHQ-4). The patients were randomly assigned to receive standard care (control group) or intervention (four proactive calls during the first two CT cycles). Symptom burden, higher satisfaction with care and depression, or anxiety symptoms was not affected by the intervention. A recent Cochrane review [4] concerning telephone symptom management in adults with cancer (any type and any stage, 6,250 patients and 32 studies included) emphasized the conflicting results published. The overall aim of this review was to assess the effectiveness of telephone-delivered interventions to reduce symptoms associated with cancer and treatment side effects, and which symptoms were most responsive to telephone interventions. Telephone interventions were mostly performed by trained nurses. Telephone management effectiveness was observed for 4 symptoms − anxiety, depressive symptoms, fatigue, and emotional distress − but with a very low certainty of the evidence. For other symptoms (uncertainty, pain, sexual symptoms, and general symptom experience), effectiveness was not determined because of huge heterogeneity. Notably, the authors renounced performing a meta-analysis because of the high heterogeneity of the studies included. Our study highlights that despite proactive nurse support, most patients will ask for unplanned solicitations, and the identification of these patients remains difficult. Similarly, emotional distress induced by an EBC diagnosis and CT side effect burden is linked to a highly personal process: symptom management depends on internal factors (e.g., the patient's family role, treatment perspective, the way they experience their cancer, and self-involvement in their care) and external factors (professional support or attitudes) [15, 17]. Thus, a “one-size-fits-all” support program may not be the solution. Recently, a systematic review by the Cochrane database [18] evaluated the effects of individuals interventions made by specialist breast care nurses (SBCN) for women with EBC. This review included 14 randomized controlled trials and 2,905 patients. Interestingly, this review highlighted that data are heterogeneous regarding the different indicators considered (quality of life, anxiety, depression, and participant satisfaction) with an overall small improvement of patients quality of life and a low quality evidence. Of note, SBCN-led telephone follow-up interventions were equally as effective as standard care. Our results are in line with these data and claim for the evaluation of self-administered support tools in association with SBCN interventions. Our study also highlighted that most unplanned solicitations for treatment side effects occurred after the first cycle of docetaxel, among patients who had already completed three cycles of anthracycline-based CT and benefited from both preventive medical and nurse interventions. Adding another intervention in that setting seems futile. However, we speculate whether a personalized tool such as a smartphone application that would ask about symptom burden and recall how to manage them may facilitate patient reinsurance. Real-time electronic symptom management was shown to improve well-being and self-efficacy in symptom management in patients undergoing CT [19]. Perhaps improving supportive care during adjuvant CT will not come from what is explained and prescribed to patients, but from the key information, they will receive to manage their symptoms. Our study has some strengths: patients included in this study were highly homogeneous, already undergoing an active support intervention by trained nurses in a cancer centre specialized in BC management, and reflecting daily practice. This study also has limitations. Because of the retrospective monocentric design of this study, we cannot exclude that some data may have been incomplete, and our results may not be applicable to centres using another support protocol. Additionally, important issues were not explored in our study, such as sexual life, asthenia, sleep disorders, and cognitive impairment, which can considerably affect patient quality of life. Finally, the collected data were in part subjective, and not based on validated patient-reported outcome scales. In that context, a dedicated prospective multicentre trial based on validated outcomes would be valuable to determine the key components necessary to optimize patients guidance.
Conclusion
BN unplanned solicitations during adjuvant or neoadjuvant CT in EBCs are frequent. Even if patients with anxiolytic treatment have a slightly higher risk of solicitation, no typical profile of a patient who will need extra support exists. Because of its known toxicity, the first cycle of docetaxel is associated with a clear increase in solicitations. Despite physicians consultations, BNs guidance, and leaflets on supportive care and treatments side effects, optimal patient management during EBC remains challenging. Further randomized studies testing more customized tools are required to improve patient support.
Statement of Ethics
This study was conducted following French method recommendations for retrospective studies (MR-004) and was validated by the Centre Institutional Review Board (registering number N°2009B). All patients provided informed consent for participation and publication.
Conflict of Interest Statement
The authors have no conflicts of interest to declare.
Funding Sources
None.
Author Contribution
Roman VION: data collection and analysis, drafting and proofreading of manuscript, and submission of manuscript; Patricia FLEURY and Valérie BLAZEJEWSKI: data collection and proofreading of the manuscript; Olivier RIGAL: drafting and proofreading of the manuscript; Maxime FONTANILLES and Frederic DI FIORE: writing and proofreading of the manuscript; Justine LEQUESNE: statistical analysis and figures; Florian CLATOT: data collection and analysis, writing and proofreading of the manuscript.
Data Availability Statement
All data generated or analysed during this study are included in this article.
Further enquiries can be directed to the corresponding author.
Funding Statement
None.
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Associated Data
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Data Availability Statement
All data generated or analysed during this study are included in this article.
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