Being Involved in Decision-Making Through the Multidisciplinary Approach to Metastatic Breast Cancer Care

Kristie L. Kahl: Can you explain how a care team works together in determining a patient's treatment plan?

Dr. Nancy Lin: So just to give an example, you know, if I see a patient who has newly diagnosed brain metastases, the first thing I want to do is assess whether they would be potentially a candidate for surgery. And if I think that there could be some chance of that, I will refer them to a neurosurgeon. Also thinking about whether there would be a candidate for radiation and what type, I refer them to a radiation oncologist who specializes in treating cancer in the brain. And not everybody has to see every specialist, but once everyone has seen the groups that they need to see, we confer among ourselves as to what we think among the various options might be good options to think about. And then we communicate that back to patients. It's really a multidisciplinary discussion that's really required. And sometimes the options might be to give some focused radiation versus switching the chemotherapy or systemic therapy around. Sometimes there may be options for whole brain radiation, or options that we could use to avoid whole brain radiation. And there are pros and cons of each of those. So these are all things that require all the different specialties to weigh in. And then for the patient to be involved in the decision-making process to figure out what's the right step forward.

Kristie L. Kahl: Can you explain what treatment sequencing is? And then, why do we do it in metastatic breast cancer?

Dr. Nancy Lin: So there's a couple different kinds of treatment sequencing. One is the sequencing of different chemotherapy, systemic treatments. There usually is a set order that we go through, different treatments for metastatic breast cancer. It's not always the same order for all patients. But there are some general principles there. And then the other is sequencing around the types of treatments. And so, for cancer in the brain, we might first, in many cases, start with radiation, but not always. But then when the cancer worsens, again, we would then be thinking about the right thing to do another course of radiation versus switching the systemic therapy around versus sending somebody to neurosurgery to consider removing a tumor, if a patient goes to surgery, then typically there's radiation that follows the surgery. And then we have to think about what chemotherapy or systemic therapy we're going to use afterwards. So there are all these kinds of sequencing decisions. And we have to obviously coordinate with each other so that we're not stepping on each other's feet, and that everything proceeds in a way that makes the most sense for the patient's treatment.

Kristie L. Kahl: Wo we have the multidisciplinary approach, and that being a shared decision making process, and then we also have the patients being a part of the shared decision-making process. What factors go into treatment planning with all those moving parts?

Dr. Nancy Lin: So the factors include, for example, if we're trying to decide between radiation therapy versus switching the systemic therapy in the hopes that it would treat the brain metastases, we need to understand what is the potential benefit of radiation? Has somebody had radiation to that location before? What are the risks? And then, from the systemic therapy side, we need to understand what is the likelihood that the cancer will respond to that systemic treatment, which gets very different from one subtype to another, and one treatment to another? And what would the downside be? And then what goes into that also is, where are the spots in the brain? How big are they? Are they causing symptoms? What would happen if we tried a systemic therapy and it didn't work? What would happen if we did radiation therapy in the patient, live for a long time afterwards, because that's something we worry, we want to happen, but then it makes us more worried about the side effects of hormone radiation.

So all of those things go into the consideration. And then from the patient perspective, patients also have very strong preferences. So for some people, the security of whole brain radiation, meaning patients are almost guaranteed to respond, at least initially, the brain tumors will shrink, is very appealing; and taking a chance on systemic therapy, not so appealing. And for other patients, the chance to avoid whole brain radiation is really appealing and worth the potential downside of trying a systemic therapy that may or may not work. And those are very personal decisions that we try to help people work through. And why I think it's so important that these processes are shared decision-making between the providers and patients.

Kristie L. Kahl: Why is it important, especially based off some of those factors, for patients to make sure they have an active voice, and what's a great way for them to make sure that they're being heard when it comes to planning their treatment?

Dr. Nancy Lin: Letting your doctor know what kind of voice you want in your care is really important. Sometimes when we try to suss it out, or we try to guess, but it's always easier if somebody just tells us. Some people want to be really involved. And some people, they want our advice, they kind of don't want to be so involved. And it's okay either way. You just have to know who you are and communicate that.

And then the other thing is, if you feel like you're not being heard to speak up, because, for better or worse, many oncologists run busy practices, and sometimes, your voice might not be acknowledged or heard in that moment. And if you're feeling that way, I certainly don't want my patients to feel that way. And I would really want them to speak up and I'm sure I speak for other oncologists as well, we really want to hear from patients. And so, if you feel like you're not being heard, if you feel like your concerns are not being heard, to really speak up about it. It's just really important. I think sometimes people are worried their oncologist is busy, or they don't want to bother them, or maybe it's a stupid question or all sorts of different things. But you just have to advocate for yourself and feel like that's the right thing to do. And I want people to do that.