What tools can help breast cancer patients elevate their care? Expert Dr. Daniel Silbiger explains the importance of shared decision making, reviews current and emerging breast cancer treatment options, and shares strategies for managing symptoms and side effects.
Dr. Daniel Silbiger is a hematologist/oncologist at the Cleveland Clinic. Learn more about Dr. Silbiger.
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Transcript
Laura Beth Ezzell:
Hello, and welcome. I’m Laura Beth Ezzell. Today’s webinar is part of PEN’s Elevate series, and the goal is to help patients elevate their care and make confident decisions with their healthcare team. Today, we’ll hear advice directly from an expert, but before we meet our guest let’s review a few important details. The reminder email you received about this program contains a link to a program resource guide. If you haven’t already, click that link to access the guide to follow along during the webinar. Now, at the end of this program you will receive a link to a program survey, please take a moment to provide feedback about your experience today in order to help us plan future webinars.
And finally, before we get into the discussion, please remember that this program is not a substitute for seeking medical advice. Please refer to your healthcare team about what might be best for you. Okay. Let’s meet our guest. We have Dr. Daniel Silbiger. Welcome. Can you please introduce yourself?
Dr. Daniel Silbiger:
Absolutely. Thanks for having me. I’m Dan Silbiger, I’m a medical oncologist at Cleveland Clinic. I work primarily in the East region, and I’m the breast program director for our East region as well. Thanks for having me.
Laura Beth Ezzell:
We are glad to have you here. And so, since the goal of this series is to help improve the quality of life of patients, can you please explain how would you define living well with breast cancer?
Dr. Daniel Silbiger:
I think that’s important. There are a lot of aspects to it. First of all, it’s mental well-being and having really a strong understanding that yes, we can do this, we can get on top of this cancer, and we can get on a road to an ongoing journey of recovery. And one that really is calm and one that patients really should seek that they are feeling well about their journey itself.
And I think that is one of the biggest first steps for my patients, is mental well-being. And yes, understanding this was a terrible challenge and a terrible experience to begin with in their life, that this was a sudden change of an event. But that we have a plan for them and that we cannot only care for the actual cancer itself but all of the things that come alongside it, the emotional, the physical, nutritional changes and the like. So, I think that’s one of the things that I really define for my patients.
Laura Beth Ezzell:
Yeah. Well said there. And let’s start at the beginning. What testing should take place following a breast cancer diagnosis, and what is the purpose of that?
Dr. Daniel Silbiger:
Absolutely. When someone’s diagnosed with a breast cancer, they’ve obviously gone through a number of breast imaging studies.
Depending on the type of breast cancer and where it was, how large the tumor is, if lymph nodes are involved, that might then dictate if we need to do more imaging such as whole-body imaging like PET scans or CTs of the chest, abdomen, pelvis, and bone scan. Based on that then we have to make a decision of surgery, radiation, and those types of treatments for my area called medical oncology ones. And usually when I meet with patients for the first time, I discuss with them that each of these steps is unique for that individual, the type of the breast cancer, and, of course, the extent of any new symptoms that that patient may come with.
Laura Beth Ezzell:
Yeah. And thank you for explaining that because everybody wants to know the steps right away and how quickly they’re going to move through those steps. So, what questions should the patients ask to make sure they get an accurate diagnosis?
Dr. Daniel Silbiger:
I think it’s really important to understand, first of all, the stage; right? So, I think patients really need to understand from their providers, “Hey, doc, is this a localized cancer, has this spread elsewhere?” I think that is foundation. And to understand too what type of a breast cancer is this? Is this hormone-positive? We call it estrogen-, progesterone-positive. Is this HER2-positive? These are the three features that we always need to know about the breast cancer as we’re coming up with an ideal plan. So, I think those things are really important to know the stage, and then to know what options do I have?
From a surgical perspective, can we conserve the breasts or not, or do we have to do a more aggressive mastectomy? How aggressive of a lymph node assessment do we need to have? So, that’s that surgical discussion, and then a radiation piece discussion as well comes along.
And then afterwards comes my piece typically of discussing what types of treatments. I know folks are really scared about words like chemotherapy, you know, do I need to get those kinds of IV medicines or not? And, of course, if it’s hormone-positive, what type of estrogen-blocking medicines may or may I not need?
Laura Beth Ezzell:
Yeah. Great points there. And can you talk about second opinions? What’s the value for patients there?
Dr. Daniel Silbiger:
Absolutely. People get so nervous to ask me and say, “You know, my family really wanted me to seek a second opinion,” and I’m not trying to boast here, “I really like you and I like your opinions.” And I say to them, “That’s okay. I talk to my colleagues all the time and I get second, third, fourth opinions on how I’m treating my patients sometimes because that’s what we do, we’re a team.” And so, what I tell folks is, it’s a very reasonable idea to get a second opinion if it gives you reassurance and comfort. Perhaps your provider might say, “I’d like you to get an opinion and see if there is a clinical trial available at another institute,” or “This is in the pipeline, this drug, for getting approved, but I’m not sure I should use it on you just yet.”
And so, I tell folks that sometimes it’s good to seek a second opinion outside of where they live too. So, if someone lives in Texas, for instance, maybe go outside of the area, perhaps come here to Cleveland Clinic as an example and get the opinion. Because a lot of times, it’s good to hear differences geographically on opinions too. I really think overwhelmingly, thanks to national guidelines and national and international meetings we have, we really have similarities amongst how we treat patients. But the nuances are: are there, for instance, studies available at certain institutions that may not be at the initial institute that one seeks their care at? Or perhaps there are some unique approaches to integrative health and so forth in other institutions as well.
Laura Beth Ezzell:
Yeah. Great points, though. And going back to your first point about their mental health, I think sometimes getting that second opinion helps them mentally just to talk to someone else. So, I appreciate your honesty there.
Dr. Daniel Silbiger:
Yeah.
Laura Beth Ezzell:
And let’s talk about treatment now. What are the goals of treatment and how they vary by type and stage?
Dr. Daniel Silbiger:
Sure. It’s a long answer to the question, but let’s simplify it first to localized, so if this is a curative intention breast cancer, or if it is one that has, unfortunately, spread to other parts of the body. Not merely to the localized axel area, that’s still a curative setting. But what if it has spread to other parts? So, let’s start with the localized setting. Our hope and prayer is that we do go for cure. Those staging, that’s called stage I, II, or III breast cancers. And our hope with combining surgery, radiation, and systemic treatments like chemotherapies, estrogen blocking therapies, we’re hoping to come up with a definitive plan for patients.
If it is an estrogen hormone-positive breast cancer, these involve, beyond the surgery/radiation, these involve upwards of 10 years for some patients of estrogen-blocking therapies. I tell patients we’re not trying to give more treatments just to give more side effects, no, we’re giving more treatments to give longevity and survival because that’s what some of the studies have suggested to us that longer duration treatment may be important. If, for instance, though we’re looking at the hormone-negative, HER2-negative, triple-negative type of breast cancer, those are cancers that do traditionally involve chemotherapy, perhaps other immunotherapies to awaken the immune system. But the flip side is that those are shorter courses of therapy, six months to one year, and after we’re done with those therapies some of those folks are no longer in need of more systemic therapies. So, it contrasts.
And then, of course, the last point of stage IV, which is, unfortunately, incurable breast cancers that have spread to other parts of the body, we are then in those discussions focusing on long-term systemic treatments to shrink the cancer and minimize chances of it spreading to other parts of the body. I’m hopeful that that helps to lay the foundation for our discussion.
Laura Beth Ezzell:
No, I thought that was really well done. So, thank you for that, doctor. Can you provide an overview of the currently available treatment options? Let’s start with surgery here. When is this necessary?
Dr. Daniel Silbiger:
Yeah. So, surgery is usually a cornerstone to any locally or locally advanced disease, so stage I, II, or III. The order of events – I don’t want to confuse or overwhelm, it can be a little bit tricky. But in general, for most, certainly traditional hormone-positive cancers, we do start with surgery. And the surgery though has evolved for the better. It used to be, not that long ago, a few decades back that we were doing radical, aggressive mastectomies and full dissections on all our patients; that is now a rarity.
We now really focus on really trying to minimize toxicity or side effects from surgery. And so, a lot of folks are able to do breast conservation lumpectomies and that is accompanied with what’s called a sentinel lymph node biopsy, which spares aggressive dissection of the armpit area to avoid lymphedema and swelling. I want to share with the program too, is that we now are even in some cases omitting lymph node sampling in some of the smaller hormone-positive tumors even in patients that are in their 50s to 70s that are postmenopausal. And this is what is important, to be at an institute where we’re keeping up with the guidelines and the studies. So, we really are deescalating surgeries when appropriate as well for patients.
And it’s exciting to share, here at the clinic we’re even doing some endoscopic mastectomies and so forth for folks to minimize time and the surgical incisions as well. So, lots of stuff is evolving in this area of surgery. I’ll start with those points for us.
Laura Beth Ezzell:
No, no. I appreciate you starting there. So, what are the other treatment classes for breast cancer care?
Dr. Daniel Silbiger:
Sure. So, beyond surgery then of course we have radiation therapy, lots of progress here too. And I really think this is important because many institutions are not keeping up with some of the newer radiation schedules and protocols. There are options for partial breast radiation in some cases, especially for smaller tumors, hormone-positive. You can see schedules that are five sessions of treatment alone now, daily for a week, once a week for five weeks. It used to be that everyone was getting five, six weeks of radiation treatment.
So, I think it’s really important to have these good discussions with radiation oncology about what’s the right thing for me? It’s not a one size fits all of doing whole breast and complex five, six weeks of radiation anymore. The other category, of course, are some of the medicines I had been talking about, so hormone endocrine therapies, estrogen-lowering therapies for patients. This can range from, in postmenopausal women receiving medicines called aromatase inhibitors like anastrozole (Arimidex), letrozole (Femara), or tamoxifen’s (Nolvadex) another class of medicines. For some of our patients that are still menstruating, we have perhaps some opportunity to do ovary suppression when it’s appropriate with more aggressive hormone-positive tumors or lymph node-involved tumors. And so, that’s an important class of medications that provides a cornerstone of our systemic therapy. And then, of course, I’ve mentioned the one that I know brings a lot of anxiety to our patients, chemotherapy.
And chemotherapy has evolved tremendously. I’m fortunate that my mom is a retired oncology nurse, and she was giving chemotherapy for many years. And I’m proud to share that she has seen tremendous improvements in how we give chemotherapy now. Supportive medicines, nausea support medicines, we have tremendous changes in our regimen now that make them much more tolerable. And I tell patients it’s not one size fits all, we look into other health issues, age, and we balance out the type of cancer they have, and we really tailor that to then the aggression of chemotherapy strategy we have for them.
Laura Beth Ezzell:
Yeah. And what about maybe new and emerging therapies or clinical trials? What can you share about those?
Dr. Daniel Silbiger:
Absolutely. And I think that’s why it’s so important to really – this is where folks can maybe benefit at times, depending on where they’re at, from second opinions to see what trials are out there.
At Cleveland Clinic, we just had finished an early-stage study on looking at breast cancer vaccines that look at harnessing the immune system to try and fight off a recurrent triple-negative breast cancer, for instance, or new breast cancer from developing. So, there’s a lot of research and opportunity in that space and setting for that. I think also what we’re seeing now as well as is using the immune system called immunotherapy, and one of the drugs called pembrolizumab (Keytruda) is now approved for awakening the immune system in triple-negative breast cancer. And there’s a whole host of new endocrine- or estrogen-blocking therapies that are out there now. We just had a recent meeting publication in San Antonio of what’s called oral selective estrogen receptor degrader, using those types of medicines early on to try and reduce our changes of metastatic disease as well.
There’s also a whole other class of these cyclin DK 4/6 inhibitors that help to reduce chances of metastatic disease that are now coming to earlier stage setting. And we’re really excited to be offering so many of these treatments to patients. I always tell folks it’s a good thing when an oncologist who trained 10 years ago has a whole new set of medicines to use than we had at that point. And I think that’s exciting and promising for our patients as well.
Laura Beth Ezzell:
Yeah. You definitely have an upbeat spirit about this, so I appreciate your enthusiasm. You clearly care about your patients. And this really helps us understand what’s available. So, with all of these options, what helps determine that best approach for an individual patient?
Dr. Daniel Silbiger:
You know, I think that it really has to be an open dialogue with their providers. Because I always tell folks, leave it all on the table. Let me know your concerns. I need to know your health issues. Do you have neuropathy at baseline? Do you have some undiagnosed heart issues? Are there some ambulatory issues?
Am I really understanding your functional status when I’m meeting with that patient? I think that really helps us. We tailor all of the treatments we provide to our patients based on what we learn about our patients; right? And so, I think it’s really important, that open honesty with providers out front. I think also being open about work schedules, family schedules.
We obviously want to give the best treatment possible to our patients, but maybe there’s an option where you can come once every three months for an ovarian suppression shot, for instance, for a patient that needs to be suppressed rather than once a month. Maybe there’s a pill option or a trial option for a pill that might make it a more palatable schedule for a patient than coming in for weekly infusions. And so, I start with that, Laura, as an important point for my patients, that open honesty, telling us about concerns and sharing.
I think we’ve been talking a lot about mental health and well-being too. It’s so important to know on the onset, where is your anxiety level and stress? Because for me, those things are underground, those things are hidden at times, and we need those things to be brought to the forefront and we need – we have breast psychologists at our institute, for instance. We have integrated medicine opportunities, if folks are worried about nutrition and weight management, we could get those folks involved early on. Maybe there’s some financial issues or home issues, we could get our social workers involved. So, I think, Laura, leaving those things on the table right at the beginning is so important to get that right treatment planned for each patient.
Laura Beth Ezzell:
Yeah. And it kind of leads into the next question about why it’s so important for patients to speak up and share their preferences, and what are your thoughts there? And just to give a reference, I have a friend who, she wanted the preference of a treatment option to be able to save her hair, that was her thing. So, kind of talk about that.
Dr. Daniel Silbiger:
Yeah. Absolutely. I think, and again, it’s not one size fits all, right? As we’ve been discussing.
Laura Beth Ezzell:
Right.
Dr. Daniel Silbiger:
And breast cancer’s not breast cancer … every individual has a different breast cancer. But absolutely. Getting those opinions to us right away is important because we do have standards, but sometimes there’s a couple options in that sense. And we do have certain chemotherapy regimens, for instance, that do have less likelihood of alopecia or hair loss. And so, I think knowing those is really important.
I’m always open and honest with my patients as well, though. If I feel that choosing that regimen that, for instance, preserves the hair is not as strong of an option, I’m very open. But I would rather, then, do that option, for instance, than not do treatment at all in that situation. So, I think those things are really important for patients. I think when they’re meeting with – I’ll give you another good example, Laura.
When you’re meeting with your surgeon, if one of the most important things is breast conservation and you do not want to have a mastectomy, is there anything we can do from a systemic standpoint? The surgeon will come to me as a medical oncologist and say, “You know, if you can shrink this tumor enough, maybe I can spare that mastectomy and do that.” So, I think open dialogue’s important. But I also feel that all of my colleagues certainly here at Cleveland Clinic have the same approach: we are going to be honest and say, “Look, that may not be our first choice, but here’s what we could do to work and try and keep your preferences in mind.”
Laura Beth Ezzell:
Yeah. And I love that response and that you do listen. But what about those who feel that they aren’t being heard?
Dr. Daniel Silbiger:
I think this is where we have a team approach. So, if the physician-to-patient dialogue, for instance, if there is some concern – we have MyChart and we have an Epic message, so we have a system where people can email or message us to respond, sometimes that’s a nice way. My nurse often will help and read that; sometimes we can redirect questions through that channel.
Phone calls to us to regroup after a meeting in person is good. Sometimes it does require, you know, if, for instance, somebody met with a surgeon or a plastic surgeon provider and they’re meeting with me and say, “I just … maybe I didn’t click as well or maybe I just misunderstood them.” Sometimes it requires another physician provider to call that person or message to reengage and to just clarify to make sure. So often it’s not a lack of respect and thought about that individual’s concern, maybe it’s just a misunderstanding, right? And so, reengaging with that team and those providers is really helpful. Occasionally, people do seek second opinions as well in those situations.
I think though, I always say, try your best to kind of go through with your team to make sure there wasn’t any misunderstandings first using some of these other channels, the nurse support, social work sometimes will get involved too and I’ll get a message here or there and say, “Oh, I think they might’ve misunderstood this schedule or this treatment recommendation. Can you circle back with them?” as well.
Laura Beth Ezell:
Yeah. Yeah. That’s great advice. And another part of living well with breast cancer though is managing those side effects. So, can you walk us through some common treatments, side effects, and strategies for managing them?
Dr. Daniel Silbiger:
Sure. I’m starting with the one that I know women are very anxious about is hair loss. So, with any chemotherapy ones, you know, we do have certain regimens that we can use cold caps, so we do have safety with that, and many of our centers have cold capping available. So, working with provider, discussing that concern upfront, I think that is an important one. It’s not a 100 percent success with hair preservation, but certainly with certain regimens like our docetaxel-cyclophosphamide (Taxotere-Cytoxan) TC it’s called chemo regimen, there’s a strong likelihood, 60 plus percent for hair preservation.
You know, we mentioned fatigue, tiredness, that’s very common amongst all of our categories of treatments. For some of my patients it’s developing an exercise program, a better sleep regimen, a psychology care, you know, emotional wellbeing, psychological well-being, that can contribute to fatigue and burnout. I think some of my folks really how meditation has been effective for them, yoga, reiki, I’ve seen a lot of these integrative strategies be particularly helpful as well. And some of my folks have challenges with nausea, I think that one we have tremendous medications, ondansetron or Zofran, we have those. We have anti-psychological medicines like olanzapine (Zyprexa) have helped tremendously in that field too.
So, I think there are a number that those are a couple of things, for instance. I think we’ve talked about anxiety and depression, I think discussing with psychology is a great way, meeting with psychiatrists, optimizing antianxiety and antidepressant medicines can be very effective. I know people are worried sometimes about going on medication and that’s not always the right strategy either. Having psychology one on one discussions, we have group sessions that folks can engage in as well that can be effective. And as I mentioned, some of these other strategies with meditation and yoga as well. I have seen tremendous benefits of these support services too.
Laura Beth Ezzell:
Yeah. And you kind of answered some of the next question about just lifestyle approaches that can help, right?
Dr. Daniel Silbiger:
Absolutely. And there is some redundancy, but it really is incredible how much burden some of these issues we discussed can be on all facets of breast cancer care. And so, I think that mental health and well-being, I will tell you, it is a huge, huge barrier for some of my patients.
And that’s why I do spend so much time, including on this program mentioning that is because it really is a major factor. But I think getting a good sleep regimen. You know, balancing that work-life balance too, I think that’s important. If you’re requiring chemotherapy or more aggressive therapies, should you and can you reduce your workload? Can you take some time away during that? I think that’s a really important part. And being honest with family and maybe can the spouse or other family member or parents, can they help with a bit more of the childcare and some of the other activities? I think it’s that open honesty with support system that really goes a long way for success with the treatments.
Laura Beth Ezzell:
Yeah. And why is it so important for patients to mention those side effects or new systems to their care team?
Dr. Daniel Silbiger:
Oh, absolutely. Because as we mentioned with some of the underground ones, if it’s underground, your provider’s not going to know about it, right?
Laura Beth Ezzell:
Yeah.
Dr. Daniel Silbiger:
So, I know about blood counts; we take blood work. Right? We can learn some things from patients. How’s the kidneys doing and the liver doing and the blood counts? But if you’re nauseous, I won’t know unless you’re telling me right in front of me, that’s why I have to ask, obviously, we have to have good questions. If we’re developing numbness or neuropathy, that’s a quiet symptom oftentimes.
And so, I need to know about those things, and approaching that is really important. Anxiety … it’s really important because we can also make adjustments if there is tremendous amount of, going back to neuropathy, we can adjust the treatment dosing, we can space out some of the cycling. There’s a lot we can do, but if we don’t know about it, it will perhaps create more of a burden in the end because then nothing is being changed right away. So, open dialogue is really, really important.
Laura Beth Ezzell:
Yeah. Yeah. Great advice there. And let’s get to a few questions that were sent in prior to the program. This first one says, Marie asked, “Is chemo brain real and how can I manage it day to day? Is there any way to prevent it?”
Dr. Daniel Silbiger:
You know, I would say that there’s … it would be unfair to say that there is an absolute way to prevent. But what I’ve noticed is that for my patients, some of the things we’ve addressed, exercise is really helpful, meditation.
Laura Beth Ezzell:
Yeah.
Dr. Daniel Silbiger:
I think also having a little bit more structure. I think we often take for granted our memory and just the quick recall. I think writing things down, writing a schedule down. If you’re going to the grocery store, maybe it is a good idea, use those cellphones, document those things that you need to get. I think having some order to the day helps my patients. Structuring the day and writing things down has – I know it sounds like a simple thing, but it’s really an elegant, simple thing to help as well.
I have had some of my patients also – I think I mentioned meditation can be something I’ve seen beneficial too. But it is something that is overwhelmingly temporary for my patients who are in a curative setting on short courses of chemotherapy, for instance, but it takes time to recover, six to 12 months. It can take time –
Laura Beth Ezzell:
Yeah.
Dr. Daniel Silbiger:
– to recover that chemo processing or that brain fog or processing capabilities.
Laura Beth Ezzell:
Yeah. And then another question here says Amy wrote, “What should I do if my side effects are making it hard to stick to treatment?” And a great question there.
Dr. Daniel Silbiger:
This is very important because –
Laura Beth Ezzell:
Yeah.
Dr. Daniel Silbiger:
– we talk at our meetings a lot about do we really need that full dose? I’ll give one example. A medicine’s out there now called ribociclib (Kisqali), abemaciclib (Verzenio), some of these medicines we use for two to three years in curative breast setting or even in metastatic setting.
And we have data that shows, yes, we try to use the full dose, but maybe people are having too much fatigue. Maybe they’re having too much loose stools, or perhaps they’re just having too much muscle aches or pains. We have data that shows thoughtful reductions of the dosing seems to show equivalent outcomes. So, I always tell patients, don’t be afraid or alarmed to let us know those things because we have some data that shows dose reductions may not be a wrong strategy. Or sometimes taking a treatment break from some of these estrogen-blocking pills that folks are on, taking a month off, eight weeks off, it can recharge the body and allow one to tolerate those treatments better for five to 10 years that we need those treatments for ideally in many of our patients.
So, I think it’s really important and I think it is okay to be – not okay – it’s necessary to be honest, and that reductions or pauses on treatment are not always the wrong thing to do.
And, in fact, I mentioned neuropathy as another example. If we have to reduce chemotherapy, it’s essential because we don’t want to leave one with debilitating side effects in the long run.
Laura Beth Ezzell:
Yeah. Great answer there. Another one here, it says Elise asked, “I’ve been through treatment, and I’m worried about recurrence. How can I put my mind at ease, and are there ways to prevent a recurrence?”
Dr. Daniel Silbiger:
I think this is the importance of getting a really strong breast-dedicated team for a patient, having comfort in that surgeon, radiation doctor, medical oncologist. Because you need that confidence and trust in your team from the beginning to give you the best treatment to get the lowest, lowest, lowest chances of recurrence. I think that’s one of the foundations that I really feel is critical to the success for patients because that leads to the answer to this question is, we know that recurrence is the number one concern that patients have.
By using these newest and best options for patients, we are trying to lower that recurrence to as small a number as possible. I am never hiding from my patients I can never bring down that number to 0 percent. And that’s not to share with your audience to keep the anxiety high, but many of these newer facets of treatment, extending, for instance, in hormone-positive breast cancer, extending estrogen-blocking therapy longer, adding these medicines like Kisqali or Verzenio, changing some of these chemo strategies really have proven to lower the recurrences to as low as we have ever seen in these state. Triple-negative breast cancer, we’ve seen the best outcomes that we’ve ever seen. But the reality is that regardless, it’s having that team for you to reassure.
And if new issues come up, then we prepare accordingly. We order imaging to make sure that things are okay, to make sure we’re not seeing recurrences. We use the latest and greatest tools to monitor for that. I know one of the tools that people are talking about is circulating tumor DNA, it’s called ctDNA and whether to use these tests. They’re not ready, in my opinion, for prime time, but some folks are seeing these available commercially and wanting to order them. It’s a blood test to see if there’s any cancer cells remaining in the blood stream. The challenge is, we don’t know what to do yet with that information.
But I wanted to share that with your audience because there’s a lot out there right now, there are a lot of platforms out there. We do have ongoing studies available, and certainly on a trial it’s reasonable to look for those things. But that is something that I know that folks are looking at. But we just don’t know yet how to handle a positive result or, quite frankly, how to reassure with a negative result on those tests too.
Laura Beth Ezzell:
Yeah. Great response, though. And thank you for those thoughtful responses.
And keep sending in your questions to question@powerfulpatients.org. Something else I wanted to ask you, you know, financial concerns can also contribute to stress. So, where can patients find financial assistance or resources?
Dr. Daniel Silbiger:
I think there’s a tremendous amount of – I’m blessed; I have a tremendous team around me of social workers, and we have a really integrated specialty pharmacy program that helps our patients to really look for grants. There are many foundations that have been set up to help folks. Especially … these medicines are not cheap. There are lots of these medicines, and a lot of the pharmaceutical companies have what’s called patient assistance programs that are linked to that. And so, I do work with my social worker team, pharmacy colleagues and team, my nurse support team, to really find those best options.
I know that finances are barriers for patients, but I always try to tell patients that I don’t want that to be the barrier that suddenly changes our management. Can we use all of these avenues before we give up on that “best” standard of care treatment? And I think once we go through each of these outlets, I think that’s really where we find success. I know some of my folks have gotten Komen grants, Susan Komen Foundation grants. Depending on the state you live in, there are sometimes foundational supports there too. So, it’s complex, the answer to it, but what I say is that where there’s a will, there’s a way.
Laura Beth Ezzell:
Yeah.
Dr. Daniel Silbiger:
Let’s try and find you that best – let’s try to keep you on that best, model standard of care for that individual patient if at all possible and not let finances get in the way if we can help it.
Laura Beth Ezzell:
Yeah. Yeah. Great advice there, Dr. Silbiger. And as we begin to close today’s program, why should patients feel hopeful about where we are with breast cancer care?
Dr. Daniel Silbiger:
I think many of the things that – and this is a great way to summarize, too.
I think we’ve learned where can we do less and get equal or better outcomes? We are in an era now where our breast oncology community is not settling for, how much can I throw at the breast cancer and pay no attention to the side effects? No, no. Quite the opposite. We are looking now, our research sites are looking at, can we do as little as possible to get the best outcome? And when we do the least amount possible, we often get many less side effects. And so, that is one area we’re really looking at, it’s called deescalation of care.
And I want the audience to recognize that just because we say, “Hey, we might be able to spare this aggressive breast surgery. We may be able to spare chemotherapy from your plan,” even if a lymph node’s involved in certain situations like hormone-positive postmenopausal patients, that’s not a bad thing, that’s a good thing. We’re suggesting that you’ll do just as well but with less side effects if we have to do less treatments.
At the same time, Laura Beth, we’re also looking at where can we do more treatments for the most aggressive breast cancers? And that’s where the excitement and promise of vaccines are out, immunotherapy, newer age drugs that I’d mentioned before such as Verzenio and Kisqali and some of these other estrogen receptor targeted therapies. And so, there is a lot of hope, not just merely for better outcomes with more treatments, but equal or better outcomes with less treatments for the same outcome.
And I think that’s the big excitement that I share and that’s why I’m so passionate and excited to be a breast medical oncologist in this time, and I hope that the audience recognizes that too. And this is why I’m very passionate that folks get to breast specialists because the data has evolved tremendously and I think it will continue to evolve at three-to-six-month paces that we’re adding treatments and guidance to this area.
Laura Beth Ezzell:
Wonderful advice, Dr. Silbiger. Thanks for joining us today.
Dr. Daniel Silbiger:
Absolutely. It’s been my pleasure. Thanks for having me.
Laura Beth Ezzell:
And thank you to all our collaborators. If you would like to watch this webinar again, there will be a replay available soon, you will receive an email when it’s ready. And then don’t forget to take the survey immediately following this webinar, it will help us as we plan future programs.
To learn more about breast cancer and to access tools to help you become a proactive patient, visit powerfulpatients.org. I’m Laura Beth Ezzell. Thanks for joining us.