Tools That Help Guide Breast Cancer Treatment Decisions

Laura Beth Ezzell:

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.