Brain metastasis,secondary to breast cancer,and strategies for improving quality of life

Abstract

There are more than 2.3 million cases of breast cancer that occur each year, which makes breast cancer the most common cancer among adults. In 95% of countries, breast cancer is the first or second leading cause of female cancer deaths (World Health Organization, 2023). Breast cancer is a heterogeneous disease and may metastasize to distant organs, leading to a poor prognosis. Metastasis is a complex process that involves various cellular and molecular mechanisms, including migration, invasion, angiogenesis, and immune evasion.

Brain metastasis refers to the spread of cancer cells from a primary tumor in another part of the body to the brain. Breast cancer is one of the most common types of cancer that can lead to brain metastasis, with up to 10–15% of patients with advanced breast cancer developing brain metastasis during their disease course (Chakrabarti et al., 2020). The metastatic process involves cancer cells breaking away from the primary tumor, entering the bloodstream or lymphatic system, and traveling to the brain where they can form new tumors. When comparing brain metastasis, secondary to breast cancer, to brain metastasis from other sources, brain metastasis secondary to breast cancer is more often associated with symptoms such as headache, seizure, cognitive impairments, and focal neurological deficits whereas brain metastasis from lung cancer, for example, may present with symptoms like a persistent cough, difficulty breathing, or unexplained weight loss, in addition to neurological symptoms (Chakrabarti et al., 2020).

Brain metastasis, secondary to breast cancer, can have a significant impact on a patient’s quality of life (QoL) and occupational functioning (Chakrabarti et al., 2020). Research studies have shown that brain metastasis, secondary to breast cancer, can impact occupational functioning, as patients may experience physical and psychological symptoms that affect their ability to work. For example, a study by Johnsson et al. (2023) found that breast cancer survivors with metastatic disease reported greater impairments in work ability and productivity among other daily activities compared to those without metastasis. Although research has shown that occupational therapy interventions can significantly improve the QoL for patients with symptoms of brain metastasis, secondary to breast cancer, by addressing physical, cognitive, and emotional needs (Fleege et al., 2023), occupational therapy has remained underused (Pergolotti et al., 2016). Barriers to patients receiving occupational therapy are (a) poor awareness of occupational therapy, (b) lack of knowledge of whom occupational therapy would benefit, and (c) practical accessibility to the service. As such, it is important that patients with this condition receive appropriate and timely occupational therapy interventions to support their wellbeing and help them maintain their independence.

The cognitive and psychological effects of brain metastasis, secondary to breast cancer, can be significant and can impact QoL for patients and their caregivers. Psychological distress, encompassing conditions like depression and anxiety, frequently manifests (Soffietti et al., 2017) alongside cognitive impairments characterized by memory loss, attention deficits, and executive function challenges, a pattern frequently observed among patients suffering from brain metastasis, secondary to breast cancer (Meyers et al., 2004). Radiation therapy for brain metastasis can induce cognitive decline and fatigue (Lehrer et al., 2022) impacting QoL. Additionally, chemotherapy as systemic treatment can cause mood disturbances and cognitive impairment (Das et al., 2020). Overall, the cognitive and psychological effects of brain metastasis, secondary to breast cancer, are significant and should be considered in patient management.

The occupational therapy practice framework

Occupational therapy is essential for individuals with brain metastasis, secondary to breast cancer. According to the Occupational Therapy Practice Framework (American Occupational Therapy Association, 2020), the overarching goal of occupational therapy is to enable full participation in daily life through engaging and meaningful activities. For these individuals, occupational therapy aims to enhance their ability to perform daily living activities. Additionally, it provides emotional support, helps them maintain a sense of purpose and identity, and facilitates meaningful occupations despite illness challenges. Table 1 outlines primary and secondary domains impacted, problems that commonly arise and occupational therapy input for individuals with brain metastasis, secondary to breast cancer.

Table 1.

Domains impacted, common problems, and occupational therapy input for individuals with brain metastasis, secondary to breast cancer.

Domain name	Domain type	Area/problem	Occupational therapy input
Functional cognition	Primary	Cognitive deficits (i.e. memory loss, attention problems, problem-solving difficulties) create difficulty remembering recent events, retaining new information, sustaining attention, switching between tasks, analyzing complex situations, making decisions, and finding effective solutions.	Cognitive rehabilitation, compensatory strategies, and environmental modifications
Physical	Primary	Impaired physical function (i.e. mobility deficits, endurance limitations, coordination challenges, balance issues) impact functional movement. Endurance limitations result in decreased endurance levels, leading to fatigue during daily tasks and physical activities. Impaired coordination affects precise and coordinated movements, impacting fine motor skills and hand-eye coordination.	Therapeutic exercise, therapeutic activities, assistive devices, and activities of daily living retraining
Emotional	Primary	Common emotional challenges include depression, anxiety, fear, and uncertainty. Individuals may experience persistent sadness, loss of interest or pleasure, changes in appetite and sleep patterns. Anxiety can lead to restlessness, irritability, difficulty concentrating, and physical manifestations like a racing heartbeat, or shortness of breath. Heightened stress levels and emotional distress can arise due to concerns about prognosis, treatment, and the future.	Counseling, relaxation techniques and stress management
Social	Primary	Social isolation, difficulties with social participation and other factors (physical limitations, changes in appearance, speech, reduced energy levels) may lead to loneliness and a reduced sense of connection. Difficulties with social participation arise from cognitive deficits, physical limitations, communication challenges, or emotional distress. Interacting, communicating, and maintaining relationships can be challenging for individuals.	Social skills training, community reintegration, and peer support groups
Activities of daily living	Secondary	Basic activities of daily living (i.e. bathing, dressing and grooming) may be impacted due to cognitive impairments and motor deficits. Feeding issues can arise from swallowing difficulties and impaired motor control.	Assess and provide interventions to improve skills impacted or compensate for loss.
Instrumental activities of daily living	Secondary	Various cognitive and physical symptoms impact instrumental activities of daily living (i.e. cooking, cleaning, finance management and driving). Cognitive impairments hinder cooking by affecting memory, following recipes, and maintaining kitchen safety. Cleaning is affected by impaired organization, planning and multitasking. Managing finances becomes challenging due to difficulties with financial planning, budgeting, and decision-making. Impaired attention, memory, reaction time, decision-making skills and coordination compromise safe driving.	Assess and provide interventions to improve or adapt skills impacted to support a person’s independence with complex activities of daily living.
Vocational	Secondary	Cognitive and physical limitations, fatigue and treatment side effects impact vocational skills. Cognitive impairments (i.e. memory problems, poor concentration) hinder learning retention and complex job duties. Physical limitations like weakness and coordination problems affect manual dexterity and mobility. Cancer-related fatigue reduces energy and work productivity. Treatment side effects (i.e. nausea, fatigue, cognitive issues) affect vocational tasks. Recovery and rehabilitation following treatment may require time off work or adjustments in work hours and responsibilities.	Vocational rehabilitation services to support a person’s return to work or to identify alternative employment options.
Leisure and recreation	Secondary	Cognitive and physical challenges, fatigue, and emotional/psychological factors impact participation in leisure activities. Cognitive impairments limit engagement, particularly in mentally demanding activities that require learning new skills or following complex instructions. Physical impairments restrict participation in physically exerting activities. Cancer-related fatigue affects energy, stamina, and motivation for leisure activities. Emotional distress and mood changes impact motivation and pleasure in previously enjoyed hobbies.	Assess and provide interventions to help individuals identify deficits and participate in meaningful leisure activities, despite their limitations.
Environment	Secondary	Cognitive impairments, motor deficits, sensory changes, and impaired communication skills impact navigating and functioning in the community. Cognitive impairments hinder safe navigation, motor deficits make daily activities (walking, climbing, getting in/out of vehicles) harder, sensory changes increase accident risks, and communication challenges hinder expressing needs and understanding instructions (Fleege et al., 2023).	Assess the environment and provide modifications or adaptations to improve accessibility and safety (American Occupational Therapy Association, 2020).

Transactional process approach

The transactional process approach collaboratively identifies goals, concerns, and priorities of individuals with brain metastasis, secondary to breast cancer. In occupational therapy, this approach addresses physical, cognitive, emotional, and occupational needs within this population. Recognizing the dynamic nature of living with brain metastasis, secondary to breast cancer, individuals may undergo changes in occupational performance and wellbeing over time (Moss et al., 2022). This approach emphasizes the importance of flexible and responsive occupational therapy intervention to meet evolving individual needs. It acknowledges the need for continuous support and intervention to sustain occupational performance and QoL amidst the physical, cognitive, and emotional challenges of living with brain metastasis, secondary to breast cancer.

Nine evidence-based strategies to improve QoL

Occupational therapists can employ diverse evidence-based strategies to enhance the QoL for patients with brain metastasis, secondary to breast cancer. These interventions effectively address physical, cognitive, emotional, and social needs, while promoting functional independence, symptom reduction, and overall wellbeing (Molitar et al., 2023).

Mind–body interventions: Mind–body interventions such as mindfulness meditation, yoga, and tai chi can help improve physical and psychological symptoms, reduce stress, and promote relaxation and overall wellbeing (Islam et al., 2022).

Fatigue management: Fatigue is a common symptom experienced by brain metastasis secondary to breast cancer patients. Occupational therapists can work with patients to develop strategies for managing fatigue, such as scheduling rest breaks, pacing activities, and engaging in relaxation techniques (Phipps et al., 2018).

Assistive technology: Assistive technology such as smartphones, tablets, and wearable devices can be used to support cognitive and physical function, promote safety, and enhance independence for brain metastasis breast cancer patients (Pilegaard et al., 2022).

Palliative care: Occupational therapists can provide palliative care interventions to improve symptom management, optimize function, and promote QoL for patients with advanced cancer (Talbot-Coulombe et al., 2022).

Energy conservation techniques: Occupational therapists can work with patients to develop strategies for conserving their energy throughout the day. These techniques may include pacing activities, taking rest breaks, and using assistive devices to reduce the physical demands of daily tasks (Talbot-Coulombe et al., 2022).

Cognitive rehabilitation: Brain metastasis can cause cognitive deficits, such as memory loss, difficulty with attention and concentration, and impaired problem-solving skills. Occupational therapists can provide cognitive rehabilitation interventions to improve these deficits and promote functional independence (Molitar et al., 2023).

Adaptive equipment: Occupational therapists can assess patients’ functional abilities and identify assistive devices or modifications to improve their independence and QoL. Examples may include mobility aids, shower chairs, raised toilet seats, and other adaptive equipment (Molitar et al., 2023).

Psychoeducation: Occupational therapists can provide psychoeducation to patients and their families to promote understanding of the disease process, treatment options, and strategies for coping with the emotional and psychological effects of brain metastasis breast cancer (Pilegaard et al., 2022).

Graded motor imagery: This is a therapy approach that uses visualization and other techniques to help patients improve their movement and reduce pain. Occupational therapists can use graded motor imagery to help patients with brain metastasis breast cancer improve their physical function and reduce pain (Islam et al., 2022).

Implications for the future of the profession

Occupational therapy is crucial in enhancing the QoL for individuals with brain metastasis, secondary to breast cancer. This condition poses various challenges, encompassing cognitive and psychological deficits alongside physical impairments and emotional distress. These difficulties significantly hinder patients’ engagement in daily activities and independent living. Regrettably, occupational therapy remains underutilized in addressing these occupational tasks. By raising awareness and knowledge among practitioners and employing evidence-based strategies, occupational therapy can be tailored collaboratively to meet the distinct needs and goals of individuals with brain metastasis, secondary to breast cancer, and thus improve quality of life.

Footnotes

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author declared no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Sabina Khan

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