A panel of medical experts explore the impact of breast cancer diagnosis on patient quality of life and how the patient journey is navigated.
Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Sarah, I’ll turn it over to you, I know in terms of quality of life you do a lot of work. How has the quality of life of a patient with breast cancer impacted diagnosis during their treatment journey? Are there things being done to help improve their quality of life? Obviously, one of the big things is that oral oncolytics have allowed us to treat cancer as a chronic disease state, but we know that it comes with a lot of burden. There is an adverse event profile these patients have to deal with and financial toxicities. What does that look like for our patients?
Sarah Sammons, MD: That’s a great question and something I feel very passionately about. Having a diagnosis of high-risk hormone receptor–positive breast cancer, which is what we’re talking about today, is life-changing. Women who are diagnosed often need to undergo chemotherapy if they are high risk from a node-positive standpoint, from a genomically high-risk standpoint. That comes with a lot of quality of life considerations. Alopecia has a dramatic impact on self-image. We have neuropathy and short-term cognitive changes that are incredibly difficult. And that’s what we manage probably every day in clinic, in our survivorship visits. We deplete their estrogen for a minimum of 5 years, and that has incredible implications on their quality of life in terms of sexual health, joint pain, and bone health. And ovarian suppression becomes a very important part of [the lives of] our young women [with high-risk disease]. We abruptly put those women into menopause. That has incredible implications on quality of life, and we can’t have enough research in that space.
Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Absolutely. And you brought up a great point about survivorship and what that looks like in terms of the patient’s course [of treatment]. I’ll tell you all this: My mother was diagnosed with triple-negative breast cancer probably 20 years ago, and she’s doing great, but you can see the adverse events that she has had to deal with, even post diagnosis, post mastectomy, all those kinds of things. So it’s an unfortunate complication. We see a lot of unfortunate complications from the disease, but as you mentioned, I think research in this area would play a significant role. What about in terms of the goals of therapy? Jay, you walked us through the early patient vs the metastatic patient, where we know we’re palliating that patient, not really a cure in sight. What are our goals of therapy? Obviously, from a survivorship perspective, there’s a goal there, but what about in their treatment journey? I know we said it’s a marathon that these patients are running. How does that look?
Jay Andersen, MD: Focusing on the early stage, which is the topic today, it is a journey, and I think every patient comes in frightened and overwhelmed. I think the primary goal they like to hear is that this is a curable disease. That’s the first thing we try to emphasize. Then we start unpacking what that means. For every case, it can be very different. If it’s a patient at low risk, they may have less therapy, of course. [A patient with] higher risk [may have] more complicated therapy. Every visit is a constant balance between that curative intent and managing the toxicities that were just mentioned. So it’s an ongoing, collaborative conversation. After they’re done with their acute management visits, oftentimes patients will transition to a survivorship clinic, and even then, the topics can be very engaging and complicated.
Sarah Sammons, MD: I totally agree. And a journey is one description. I’ve heard a patient describe early-stage and even advanced-stage breast cancer as more of a forced march. Not a journey that they really wanted to go through, but one they were forced to walk through. It’s constantly our job in the clinic to describe these risks and benefits. And risk and benefit ratios change for patients over time, so they continuously need to be reevaluated.
Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: As their medical oncologists, are you finding, after you’ve achieved that goal of cure, [that you are] still seeing these patients on an annual basis? What does that look like, in terms of the longevity part of it?
Jay Andersen, MD: I tend to follow patients as long as they’re on therapy. So if they’re on hormone therapy, that’s at least for 5 years. Many of them [can be on it] up to 10 [years]. At 10 years I talk about graduation from clinic and I give patients the option. Everyone’s different. Some patients are like, “I am ready to be done with this and never come back,” and I’m OK with that at that point. Other patients feel comforted with some ongoing monitoring. I may transition them to annually, for example.
Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: Sam or Heather, is anything different on your end from a monitoring perspective after they’ve graduated? Do they graduate from your clinics?
Heather McArthur, MD: I think it’s up to patient comfort. I adhere to the American Society of Clinical Oncology clinical follow-up guidelines. So I see patients every 3 to 6 months for the first 3 years, and then less frequently thereafter. After 5 years, I see them once a year. And then, after they’re completing their adjuvant therapy, I typically transition them. We are establishing at our site a survivorship and surveillance program that’s run by advanced practitioners, which I think will provide that comfort that a lot of our patients want, because they want to continue to be within the system and have that constant contact but don’t want to be waiting because we are running late from seeing chemotherapy patients. So we want to strike that balance of ensuring that they have an appropriate follow-up, but that the follow-up doesn’t detract from their quality of life as well.
Samyukta Mullangi, MD, MBA: On a similar note, I would also say that we always encourage our patients to plug in with their primary care physicians to really give them the holistic, comprehensive assessments that we just don’t do in a focused way in the breast cancer world. I think oftentimes folks feel such affinity toward their breast cancer oncologist that they want that person to become the guidepost for all aspects of their care, but we’re just not trained to do that.
Heather McArthur, MD: I’m Canadian and we did a study in Canada looking at follow-up, addressing that specific issue, primary care physician follow-up vs specialty follow-up, and patients did equally well if they had a primary care follow-up plan.
Kirollos S. Hanna, PharmD, BCPS, BCOP, FACCC: I think a lot of my medical oncologists practice particularly in the community setting, so they’re seeing all comers. They’ll walk in through their doors and some of my medical oncologists will joke and say, “We become a generalist as well, or a primary care physician,” because they end up caring for everything else for their patient, their blood pressure, cholesterol, and everything else that goes on that we sometimes see.
Transcript edited for clarity.