Third line chemotherapy in patients with metastatic breast cancer: an evaluation of quality of life and cost

Many patients with metastatic breast cancer receive several types of chemot herapy, although it is recognized that there is a declining probability of response. A major problem confronts oncologists in deciding when to recomme nd to patients that no further chemotherapy should be given. To address thi s problem we have assessed prospectively, health-related quality of life (H RQL) and costs of health care for 35 patients with metastatic breast cancer receiving third line chemotherapy in a representative clinical situation. HRQL and utilities were measured longitudinally using the EORTC QLQ-C30 que stionnaire and the time trade-off method. Patients received a median of 2 c ycles of chemotherapy and lived a median of 4.3 months. Twelve patients (34 %) had substantial (> 10 points) improvement in the Global QL subscale and more than 30% of patients had similar changes in emotional and social funct ion. The median baseline utility score was 0.9 and utilities correlated poo rly with HRQL subscale. Eighteen patients had measurable disease and one pa tients experienced a partial response. Grade 3/4 toxicity occurred in 30% o f patients. The average cost of management from study entry to death was CD N$ 17,260 (similar to US$ 12,000). Sixteen percent of this cost was associa ted directly with chemotherapy while hospital admissions and outpatient vis its accounted for 50% and 14% of the total cost respectively. We conclude t hat: (a) many patients receiving third line chemotherapy maintain or improv e indices of HRQL despite short survival and a low response rate: this migh t be due to chemotherapy, paclebo effect, or a shift in frame of reference for HRQL; (b) patients were unwilling to trade quantity for quality of life ; and (c) response rates and survival may be overestimated in patients sele cted for clinical trials.