Julie Fisher, MD

I would like to pivot a little bit and talk in our remaining minutes about everyone’s favorite topic: COVID-19. How has that affected your process? How has that affected the care that I offer my patients? You mentioned that the pandemic influenced your decision-making about working.

: Yes, very much so. I don’t know that I would’ve worked in any situation because in preschools, they’re precious little babies. However, they’re Petri dishes; that would’ve been a little risky. The other thing is, I’m alone during my infusion. Like I had mentioned before, I had gone with a friend a couple of times when she had her treatments, but I can’t have anybody with me because of COVID-19. When I come to see you, I get a COVID-19 test. It didn’t impact my choice of treatment in any way, and it didn’t change anything as far as the duration of my treatment. I don’t know if it will change my treatment down the road. I know I will have surgery in December, and then some reconstructive surgery. I don’t know what the timing on that will be, or if COVID-19 will affect that because of elective versus necessary surgery. That’s still to be determined, I think. One of the things I want to stress is, my breast cancer was found on an annual screening mammogram. I had no idea there was a problem. I would believe that a lot of people are pushing off appointments like that right now because of COVID-19. It’s very safe to go in and get these tests done. If I had waited and thought, “Oh, it’ll be fine,” my situation could be very different than it is. I have HER2-positive breast cancer. It’s aggressive, and I hope that women are going and getting their screening regardless of the pandemic.

 Absolutely. Thank you for emphasizing that. You’d have to be deaf, dumb, and blind to have been in this country in the last 20 years and not witness the push for routine screening mammograms and the notion that the earlier we catch a breast cancer, the more capable we are of eradicating it. Yes, we’re all concerned about what are going to be the long-term effects of potentially people delaying their screening studies. From the provider perspective, I think there’s good and bad about the way the pandemic has affected us. To me, the good news is I have not been unable to schedule people for their treatment. We haven’t had to alter the interval for treatment, and we haven’t had delays in getting people started in treatment. We’re very fortunate in that in this center. I am very aware that there are other cancer centers, cancer practices, and infusion centers elsewhere that can’t claim that. Thankfully, here, through a combination of diligent and vigilant planning and safety precautions, we’ve been able to treat people throughout. Periodically, there have been interruptions in surgeries, but thankfully again, we’ve not gotten to the point where an oncologic surgery would be delayed. No one’s lumpectomy or mastectomy has been delayed due to the pandemic, but reconstructive surgeries have been. While those are being delayed because they are “elective” or they’re for non–life-threatening issues, clearly that has a significant psychological impact, and we’re all very sympathetic.

Thankfully, as I said, medically, I haven’t really been impacted in terms of having to choose different regimens because, “I can’t use this one because of COVID-19.” Timing hasn’t been altered, which is great, and my monitoring has been pretty similar to before. At one point early on, we were doing more virtual visits and alternating those. For many of my patients on treatment, we were still doing those visits face-to-face when possible; that physical exam is very important. What the negative has been is as you said, I think it’s got to be really hard. I hate that people can’t bring a visitor or a family member with them to infusion. It is a long day to be in there on your own. The stress of having to get a COVID-19 test before treatment and having to come in here a whole extra day to get a COVID-19 test; I think people must feel like they already live here. I hate to have somebody incur yet another visit to this place. This pandemic has been a stressful, frightening time, in general, and having to add that to the significant stress of going through a cancer diagnosis and treatment program, I’m sure that’s challenging. We sure do our best to try to ease the way and make up for people’s lack of ability to have somebody in the infusion suite with them. I know we don’t substitute for a partner, a child, a parent, or a friend. The bottom line is, it’s probably been a lot psychologically harder to go through cancer treatment during this process. However, I’m very thankful that at least here the quality of care hasn’t been affected.

 It will be very interesting down the road, as you alluded to; we’ve got a lot of concerns about people missing out on their routine primary care visits, their routine age-appropriate cancer screenings, and what the downstream effects of that will be. I think we all can agree that much ink will be shed over the years 2020 and 2021. Hopefully, not beyond that.

 Thank you so very much for sharing your perspectives, and for embarking on this discussion this morning with me. To our viewing audience, we hope that you found this 

 program to be rich and informative. Thank you for being here with me today.

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Patient Jocelyn Mueller and oncologist Julia Fisher, M.D., describe some of the adjustments that had to be made to Jocelyn’s treatment for HER2-positive breast cancer due to the COVID-19 pandemic.

HER2-positive Breast Cancer and COVID-19

Are there any questions that I haven’t asked? Is there anything that you think patients who face this process should know?

 The whole process is doable. I will say, reach out to people and take help from people. Ironically, about a month or two before I got diagnosed, I saw this beautiful thing on Facebook that said, if you want to know how much you are loved, get cancer. I have felt that tremendously, and I want to say, let people help you. It’s hard for women, it’s hard for moms; we just want to keep doing everything and taking care of others. We don’t like asking for help. However, people like to feel useful. I think, let people help you and feel what you feel; what you’re feeling is valid. Everyone says, “Oh, a positive attitude goes so far.” Yes, it does, but it’s OK to have days when there’s no way to feel positive about this. I had guilt about that early on, and Dr Fisher, you said to me, “Think about how you would feel if this was your mom or your daughter. Don’t feel guilty about not being able to help, and don’t feel guilty about being sad or being sick. This is just what you have to go through, and show yourself the same compassion you would show the people you love.”

I find myself giving that advice often. I marvel at how hard it is for a lot of us to give ourselves the same compassion and kindness that we are so easily able to give other people. Who is involved in your support network, both here in the office and at home?

 You, [Richard] White, [M.D.,] Callie, and Kathy, primarily. Then any of the nurses I have on the infusion floor. The whole team there is amazing. At home, I have my husband, and my younger daughter, who is 17, has been a terrific help. She shaved my head; she was so happy to help. My older daughter is away at school, but she comes home when she can. My mother lives around the corner, and I have neighbors and work friends. Like I said, I have a support system I wouldn’t have imagined. Unfortunately, I’m in a club now with some people who have been through this, and we’re closer now for it, I would say.

It’s so important to have that network of support. On my side of things, it’s so important to have a network of collaboration, a network of colleagues. I’m very fortunate, at the center where I work, we have a multidisciplinary breast clinic. We have multiple academic conferences where we discuss cases, go over slides, and go over pathology and imaging. It’s a big team. There are a lot of people who are involved in each of my patients’ care, many of whom you might never meet. Your first stop along this path, of course, was with our colleagues in radiology. We’ve got doctors who read the mammograms, and perform the biopsies. Of course, our team in pathology is responsible for making accurate diagnoses. I think we’ve emphasized how important that hormone receptor and HER2/neu status are. Really, they drive what treatments are chosen and what outcomes we see from those treatments; it’s important to have a solid team of pathologists. There is the surgical oncologist, there is me, the medical oncologist, and of course, many patients will also undergo radiation and meet with our colleagues in radiation oncology.

Beyond that, here, we have a whole network of social workers, psychologists, psychiatrists. For women who are interested in preserving fertility, which can of course be affected by chemotherapy, we have a team of reproductive endocrinologists. We’re fortunate to offer a very robust supportive and integrative oncology panel as well. They focus on more holistic aspects of care, things like massage and acupuncture. These days, a lot of people are interested in supplementation, which I support if it’s something that will be helpful. I am not excited about if it’s something that’s going to be potentially harmful. Sometimes supplements can interact with the drugs that I’m prescribing. It’s nice to have people who have real expertise in that to help us tease out what’s appropriate and what’s not. If any of my colleagues are watching and I’ve left you out, I apologize.

I would be remiss not emphasizing what you’ve already touched on, which is the incredible support we get from our nursing staff. My clinic nurses are the backbone of everything, and are available for questions, big and small. It’s a hard process to walk through. Fortunately, you had the benefit of a sister in medicine and a friend who had walked through this before, so at least you had some sense of the vocabulary of cancer treatment. Some people walk in with no exposure to these things. I can’t even begin to imagine how overwhelming it must be. It’s complex concepts, it’s drugs that sound like word salad. It’s got to be a lot to take in if it’s not something you’re familiar with. We have a system of nurse navigators who help navigate, who help people, “OK, where am I going? When? What’s this doctor for? What’s this for?” I can imagine those first visits would just feel overwhelming. The nurse navigation system, when at its best, helps make sense of things for people. Obviously, I’ve been front and center as the person who’s been prescribing the chemotherapy and following up on the chemotherapy, but there is an army of people behind the scenes who have contributed and continue to contribute to your care.

Julie Fisher, M.D., has a conversation with patient Jocelyn Mueller about the importance of good support networks when living with HER2-positive breast cancer.

The Importance of Support Networks for HER2-positive Breast Cancer

On one end of the spectrum, I have patients who have tremendous difficulty, and on the other end of the spectrum, I have patients who seem to get through chemotherapy with minimal difficulty and surprise themselves by how well they feel. I’d say most people fall someplace in the middle; would you say that that’s where you’re lying?

: Yes, very much so. It is hard; I think I said this round has been not as hard as the first but definitely harder than rounds two and three. It’s hard not to focus on the fact that I have two more treatments. I think what I need to focus on is I know, because this is my fourth time doing it, that by the end of these three weeks I’m going to feel pretty normal again. I think that’s what you can’t see in that first round, because you haven’t been through it, you are hit so hard and you’re so wiped out, and you think, “I can’t do this five more times.” However, by the time you get to two and a half weeks you think, “Oh, I actually feel pretty normal. Oh no, now I have to go do this again.” It’s holding onto that feeling that “I know I’m going to feel better again.” I think I didn’t do a great job of focusing on that when I was at my lowest point on this round. But yes, there are ways to mitigate a lot of these issues.

Probably the hardest are the emotional ones. I’m a preschool teacher. You talked about the immune system being suppressed. It was not a great idea in any environment at any time for me to teach preschool while I’m doing this, certainly not in the middle of a pandemic. So not only am I exhausted, but I’m also not working. That’s very hard for me, to feel like I’ve lost part of my identity or part of my purpose in the day. That’s probably another piece that I would think people could struggle with.

Sure. I would imagine that it certainly can be a very consuming process. It depends on the job, and it depends on the person; pre-pandemic it was sometimes a little easier to continue working to some extent. Obviously, the pandemic has changed that depending on people; if you’re working with preschool kids, it’s a different level of risk. The treatment can become a consuming process, and I can very much understand that. I haven’t been through chemotherapy, but goodness knows I certainly empathize with my patients, who I try to walk through chemotherapy. I try to remind people as often as possible: it’s a dark, rainy season and it sometimes can feel like a long, never-ending season, but this is a short season in the grand scheme of things. We’re certainly hopeful that we’re getting the results that we’re seeing at least on your exam.

A great piece of advice I got was, “You didn’t choose this, you can’t avoid it, but in the very near future this is going to be part of your history.”

: “You are going to get through this, and it’s going to be in the rearview mirror.” That thought has helped me a lot.

Obviously, I prescribe the chemotherapy. I am not typically in the infusion suite; I am typically in my office seeing other patients. How frequent are your treatment appointments? How long are you there typically?

: I’m there every three weeks on Tuesdays, and I’m there for usually about six hours. The initial one was about eight hours, I think because you slow down the administration to make sure I’m not having an adverse reaction to any of it; however, I did fine.

For anyone watching who doesn’t know what a port is, it’s implanted, either surgically, or at our center typically, it is placed by the radiologist. I describe it as a semipermanent IV [intravenous line]. It’s under the surface of the skin and accessed via a special needle. It dwells, if you will, in one of the larger veins that leads to the heart. Since it’s in there semi-permanently, it’s a sure thing, instead of coming into infusion and having them looking for a different peripheral vein every time. Are you comfortable with the port? Do you have any difficulties with the port?

: I have a love-hate relationship with the port. I had a friend years ago who I took to chemotherapy a couple of times, and I watched them trying to find a vein. I sat there with her, and she would tell them it was burning as it was going in her vein, so they would have to slow down the flow, and we would be there for longer. I knew I did not want to live that. I also knew with the Herceptin [trastuzumab] and Perjeta [pertuzumab] being a year-long administration, that the port was definitely the route to go. I don’t love feeling it under my skin; I’ve been having a few issues with it. It’s bruised; even with the numbing cream, it really has hurt when they’ve accessed it the last few times. However, I prefer it. I don’t feel anything when the chemo’s going in; there’s no burning sensation, there are no issues at all. They access it one time while I’m there, and then just change out and flush it in between each medication administration. When I leave, they pull the needle out, and I’m good to go.

 We talked about at one of our recent office visits the difficulty that you are experiencing with the port. If we decide that Herceptin/Perjeta is the way to go, this would be a great example of when we would want to talk about, hey, are we going to be able to access the subcutaneous formulation? That might be more pleasant than wrestling with the port for the next six months.

: I strongly encourage women on this same regimen or who have this many treatments, that the port is definitely the way to go.

Jocelyn Mueller details how chemotherapy treatments have affected her daily life and her decision to receive treatment through a port.

The Patient’s Perspective on how Treatment for HER2-positive Breast Cancer impacts Daily Life

 Talking about how we assess response to treatment, we have these post-chemotherapy visits to discuss side effects, how we can optimize people’s health through a very challenging physical process, and where we do a physical examination. How do we know if the chemotherapy is working in the preoperative setting? In the preop setting, we’re primarily reliant on that physical exam. We are looking to see if the tumor is getting smaller, or if it is staying the same size. I am frankly very happy with either of those outcomes. I start to get concerned if I’m able to palpate a tumor that is increasing in size. Again, that would be a reason for me to hold the phone, get some repeat breast imaging, and get the surgeon reinvolved sooner rather than later. We’re going to pivot if we think that the treatment is not working. For the most part, we can expect good responses to this type of chemotherapy, and that complete response rate that we talked and care about, there are different studies that have demonstrated different outcomes; it hovers around 50% for all comers. We see a little bit more of a complete response for people with estrogen and progesterone receptor-negative disease, but that’s OK. For patients who have that hormone-positive disease, we’ve got a whole other leg of treatment in the form of endocrine therapy further down the road.

As far as potential side effects of the regimen that you’re receiving, we use chemotherapeutic agents called Taxotere [docetaxel] and carboplatin, coupled with Herceptin [trastuzumab] and Perjeta [pertuzumab]. Most of the side effects that people experience come from the chemotherapeutic agents. These are nonspecific cancer-killing drugs. Carboplatin and Taxotere are used to treat breast cancer with great benefit. They’re also used to treat a variety of other cancers; they are widely used to treat lung cancer, GI [gastrointestinal] cancer, gynecologic cancer. These are drugs that are targeting a cancer cell’s ability to replicate itself; they’re nonspecific. They’re targeting fast-growing cells, and the side effects that people experience are often a result of that. Hair follicles are quickly dividing, rapidly growing cells, so alopecia or hair loss is something that we commonly see with these drugs. Some patients elect to use an ice cap system that can minimize hair loss or reduce hair loss; that’s a whole different conversation. There are many pros and cons. For some people, hair loss very important, and for other people that is perhaps more trouble than it’s worth; it is a very personal decision there.

Many patients do experience nausea and vomiting with chemotherapy, but thankfully, in the last probably 20 or 25 years we’ve seen such wonderful advances in antinausea medicines. We have a standard antinausea protocol that we give everybody through their port or in their IV [intravenous infusion] before they get chemotherapy, and we have prescription medicines that people take at home as needed. There are some patients who find that works great; for other patients they find that they’re still experiencing nausea or sometimes vomiting, so we fiddle with the regimen and then add things as needed. Many years ago, patients going through chemotherapy spent time in the hospital because they were so dehydrated, and could not keep food and liquids down. Thankfully, this newer age of antinausea medicines has really changed that in a wonderful way.

Something that has always been a priority for oncologists, but is certainly even more so for everyone now, is the effect that chemotherapy can have on the immune system. Chemotherapy temporarily handicaps your immune system by suppressing your bone marrow. The bone marrow is the part of the body that makes blood cells, including the infection-fighting white blood cells. Certainly, during chemotherapy those cells can all become low. If your white cell count is low, your immune system just can’t function as effectively. Again, that’s something that has always been important and has always been a priority, but in this new era of the COVID-19 pandemic, it’s certainly become an area of particular focus and concern, and as much, if not more of a priority than ever to make sure we’re keeping our patients as safe and protected as possible. Taxotere can sometimes cause peripheral neuropathy, which is effectively nerve damage. When people experience that they often describe numbness, tingling, pain, and loss of function that primarily affects the hands and feet. As you alluded to, Jocelyn, sometimes we think that putting your hands and feet in ice may help minimize some of that. The data truly supporting that are still cooking; we don’t know for certain if that’s particularly helpful. However, it’s certainly not harmful so I do encourage my patients to utilize that, what we call cryotherapy, to try to reduce that neuropathy.

Our first HER2-targeted agent, Herceptin, has been shown to sometimes cause a form of heart damage, heart dysfunction that we need to be aware of and that we need to look out for. It happens in a minority of patients, but it happens significantly enough that we want to be aware of it; it’s typically reversible. What we’re really talking about is how well the heart is functioning, how efficiently the heart is squeezing. We can measure that through several tests. Most easily, we do that with an echocardiogram, just like an ultrasound of the heart. What we can sometimes see is that with Herceptin, some patients experience a less efficient and less effective pumping. In most cases with Herceptin, that is temporary, meaning we can stop the Herceptin, wait six to eight weeks, repeat the echocardiogram, and often find that it has gone back to normal. Typically, we are even able to retreat people with Herceptin. However, that is something that we always need to keep in mind. At this center, we check echocardiograms about every three months, whether somebody’s having symptoms or not, just to stay ahead of that curve.

Both pertuzumab and Herceptin target that HER2/neu protein. They hit it at different places, so I think of it as a one-two punch. Interestingly, when pertuzumab was added to the mix, we didn’t notice any increase in the heart issues or the heart toxicity. What we did notice with the addition of pertuzumab was sometimes we see an increase in the incidence of diarrhea. Not everybody experiences that, but I will certainly tell you that a lot of my patients do; I’m going to try to make people aware of that. For people who get stomach bugs due to viruses, the common advice is don’t take anything, you want that virus to run its course and exit your body. Not so with drug-induced diarrhea; we advise people to be generous with things like Imodium [loperamide], prescription strength antidiarrheal medicines, if they need. I would say this is a really broad overview. Clearly, different people are going to have different idiosyncratic side effects.

One thing that I do see that you mentioned previously is this sense of feeling tired and really wiped out. I’d say for most people, that doesn’t last the entire three weeks between administration, but it can be profound and it can really affect people. For somebody like you, Jocelyn, who is young, active, vibrant, and is not used to feeling tired, not used to having to take a rest at the middle of the day, my impression is that it can be very disorienting; it can be upsetting. I know if I get a cold, four days in you start feeling down. It’s hard to not feel well for a protracted period of time. People’s experiences are different; I have patients who struggle mightily with side effects. Sometimes we have to reduce the dose of certain drugs, and sometimes we have to withhold cycles of therapy because people are struggling so significantly. While clearly my priority is to treat the breast cancer as effectively and appropriately as possible, that always has to be balanced against the physician’s mandate to not cause harm.

Julie Fisher, MD, explains how she assesses HER2-positive breast cancer patients for treatment response, what side-effects can occur and how they can be managed.

Julie Fisher, MD

HER2-positive Breast Cancer and COVID-19

The Importance of Support Networks for HER2-positive Breast Cancer

The Patient’s Perspective on how Treatment for HER2-positive Breast Cancer impacts Daily Life

Assessing HER2-positive Breast Cancer Treatment Responses and Managing Side Effects

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