Case Presentation: A 52-year-old destitute G6P6006 woman with an advanced stage Inflammatory breast cancer (IBC) presented to the OB/GYN for four-month right breast pain and one-month skin changes. The examination was notable for a diffusely dense and hard to left palpation breast, peau d’orange, medial scarring similar to boils without drainage, absent nipple discharge, and left axillary and supraclavicular lymphadenopathy. She promptly received a mammogram that revealed multiple masses, including the dermis, a dominant 9.2 cm left inferior breast mass, associated subcutaneous edema, and bilateral metastatic axillary lymph nodes-largest node, 3.2 cm. BI-RADS score 5. Tissue examination from the ultrasound-guided punch biopsy confirmed ER/PR-negative, 3+ Her2, 60% Ki67 high-grade IBC with extensive necrosis. Further workup showed no bone metastases.Given her lack of insurance, she was able to receive port-a-cath two months after diagnosis. Unfortunately, it was removed two weeks later due to methicillin-sensitive Staphylococcus aureus port site and bloodstream infection (BSI). Therefore, she was discharged on IV daptomycin and doxycycline but returned with repeated BSI two weeks later. Therefore, she was re-admitted to the hospital, received four days of inpatient vancomycin and piperacillin/tazobactam, and was discharged on oral doxycycline.Four months after diagnosis, the PICC line was placed, and paclitaxel, trastuzumab, and pertuzumab (THP) chemotherapy were initiated. After her fourth THP cycle, she visited with the surgeon who advised against mastectomy because IBC was not controlled with THP, increasing the risk of procedure-associated high morbidity and mortality.Unfortunately, she was lost to follow up after her sixth THP cycle and returned to care four months later. Computed tomography (CT) scan revealed progressive multicentric left breast masses with progressive metastases involving the sternum, lungs, and bilateral axillary and supraclavicular lymph nodes. Given her progression was thought to be secondary to not receiving treatment as scheduled, her chemotherapy was restarted with trastuzumab and pertuzumab. She is currently alive with the disease 13 months after diagnosis, undergoing chemotherapy, and discussions have been initiated to coordinate palliative care.
Discussion: IBC is a rare cancer with a discrete clinicopathologic characteristics portrayed through its rapid onset, aggressive course, and late presentation that further worsen its prognosis. This case is an example of a vulnerable patient fighting an aggressive disease. The patient is homeless, uninsured, has poor health literacy, inability to maintain hygiene, and untrusting the medical system as she refused to disclose her shelter location to coordinate care. Despite these obstacles, she could be seen and have a timely diagnosis. However, she struggled for months with port placement and BSI before initiating chemotherapy, and briefly lost to follow-up.
Conclusions: Lack of insurance further hinders disease presentation and homelessness leaves patients vulnerable to contagious infections given inadequate living situations. Those aspects are understudied in the medical literature. Further efforts to promote increased awareness among people experiencing homelessness congregated with programs to educate and enroll them in health care services are crucial in the fight against cancer to improve its outcomes.