Metastatic breast cancer (MBC) is associated with a poor prognosis, and patients often develop refractory or resistant disease, adverse events, depression, and financial hardship. Mikel Ross, MSN, RN, AGPCNP-BC, OCN®, CBCN®, office practice nurse in the Outpatient Breast Medicine Service at Memorial Sloan Kettering Cancer Center, spoke with i3 Health about challenging patient questions and the importance of multidisciplinary care in the management of patients with MBC.
What are some of the most challenging aspects of managing patients with MBC?
Mikel Ross, MSN, RN, AGPCNP-BC, OCN®, CBCN®: Any patient that has a metastatic diagnosis, whether it's breast cancer or other types of cancer, is a challenging patient. One of the things that's unique to the metastatic breast cancer patient is that they tend to be a very information-seeking group, and they tend to be highly connected, both interpersonally as well as on the internet. Many times in clinic, I get a lot of questions that start off with, "I was talking to someone," or "I read on a blog."
So the challenge is taking what has sparked their interest, positioning that in a broader clinical setting, and encouraging that inquisitiveness and partnership in their care while making sure you are setting their expectations based on their specific situation, as opposed to a general, non-specific one. It can be very challenging, but it's a challenge that makes us do better because no matter how wonderful we would like to think we are, there can be things we could fine-tune. What the patient reads on a blog, what they heard from someone else, and what they ask us in clinic from their own information seeking can be difficult, but it does make sure we do the absolute best with them. Often times, what they have read or heard is not something that applies in their situation, so then we have to help them understand where they are in relation to that information.
What are best practices that you recommend to other oncology nurses who work with MBC patients?
Mr. Ross: You don't have to work with this population long in order to have your own set of best practices. For me, what I challenge myself to do, and what I would always encourage someone else to do, is to have a commitment to be a lifelong learner. Breast cancer is the number one cancer diagnosis in women in the United States. As a result, we have a great wealth of information. There are many clinical trials and drug advances, so the data moves quickly. Challenge yourself to continue to be a student of the data, and learn how to utilize all of the medications we have for MBC patients in the best way for that particular patient. It does take that commitment to lifelong learning.
What questions do you commonly encounter from patients about their treatment and how do you counsel them?
Mr. Ross: An engaged patient is one of your best assets in terms of providing care to someone. There are two points at which patients have a lot of questions that deserve time in terms of providing the information they're looking for, and having sensitivity around those questions.
When they need a new treatment plan, the question is always, "Is this going to work for me?" That is a tough one. I counsel them by being true to the data. In breast cancer we've had many large clinical trials that tell us, "Yes, this is the best way to treat." So I will tell them, "This is the plan. Scientifically, this is why we believe it works in terms of thousands of people that have been treated this way, and how you fit into that group." I try to help them understand where their situation fits within that history of clinical trials and treatment recommendations.
The other time that it can be a challenge is at the time of progression or the time of a new scan. The question I get when a scan begins to hint at progression is, "Do I need to do something else?" How I counsel them is, "When you are a metastatic patient, it is about the marathon, not the sprint. It is absolutely critical that we optimize every single moment of benefit from every single treatment regimen." I help patients appreciate that a scan, which may not show decreased disease burden, is not necessarily a bad thing or time to switch the horse.
What are some of the promising advances in MBC treatment that you expect to see in the near future?
Mr. Ross: When you look at oncology in general, the biggest thing that has changed the way that we treat patients across all tumor types in recent years has been the advent of immunotherapy. Now while it has yielded treatment-changing, paradigm-changing advances in lung cancer, melanoma, renal cancer, and bladder cancer, it has been a bit of a disappointment in breast cancer. We have not quite cracked how to best use immunotherapy in breast cancer treatment. We simply have not had consistently good results. It is probably because the net was cast too broadly. However, we are getting closer. We are beginning to identify patients with particular biomarkers—not necessarily the traditional biomarkers of hormone receptor and HER2—that can be used to strategically select a population that would benefit from an immune-based therapy. As we get better at honing in on that patient, and the biology of their specific cancer, we will find a subset of patients with breast cancer that will more reliably benefit from immunotherapy. I think we are going to bring the benefits we have seen in other tumor types to breast cancer in the not-too-distant future.
What is the role of multidisciplinary care in patients with MBC?
Mr. Ross: It's absolutely critical. We live in an increasingly complex world, and there's so much data and the information moves so quickly. To try to be someone who can deliver and optimize all aspects of care as an individual is a fool's errand.
The need to build and leverage that multidisciplinary team is absolutely critical, and while it does increase the complexity of care for patients, it optimizes how we fine-tune every single aspect of their care. Nursing, medical oncology, radiology, surgery, radiation oncology, occupational therapy, social work, physical therapy and a host of other disciplines are involved in the multidisciplinary care of patients with MBC.
At Memorial Sloan Kettering Cancer Center, there is also an integrative medicine center with physicians and other practitioners who are dedicated to research in complementary treatment modalities. For example, we have research that shows acupuncture can help with taxane-related neuropathies. We have data that shows acupuncture can help with hot flashes, which come with many of the hormonal therapies that breast cancer patients struggle with and are truly significant challenges for those younger women that have now found themselves to be put into an early menopause. We actually find they have modalities of treatment for symptoms that we don't have good solutions for in the traditional model. All of those complementary—not alternative—therapies go hand in hand. It's not either/or. It's "and," and that works well. Many patients benefit from an integrated approach.
Is there anything else you would like to add for oncology nurses caring for patients with MBC?
Mr. Ross: The work you do every day is incredibly important, incredibly rewarding, and at the same time incredibly taxing. My advice, if I could deign to give advice to anyone else, is to work hard but play harder. Make sure you find time for yourself to relax. The only way to continue to give at that level is to continue to find ways to refresh and renew your own well.
About Mr. Ross:
Mikel Ross, MSN, RN, AGPCNP-BC, OCN®, CBCN® is an office practice nurse at the Breast Cancer Medicine Service at Memorial Sloan Kettering Cancer Center, providing nursing leadership and care to breast cancer patients in collaborative practice with medical oncologists. Mr. Ross is a member of the Oncology Nursing Society and was named the 2017 Certified Breast Care Nurse of the Year. He has co-authored several publications in journals such as The Clinical Journal of Oncology Nursing and Oncology Nursing Forum.
Transcript edited for clarity.
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