I believe that oncology care should be integrated with the way patients feel and how they process information about their cancer. This is a delicate and nuanced exercise, and I don’t always get it right. Knowing how much individuals are prepared to take in regarding facts and logistics in a given visit is a skill and inherently biased. A desire to cultivate hope may conflict with transparency about worst case scenarios or typical natural histories. I have reflected on whether I omitted or failed to completely inform in my efforts to tend to emotional distress and parcel information in proportion to perceived comprehension.
Many oncologists focus solely on relaying and documenting objective facts. They stress worst case scenarios to be certain patients have considered them. There is value to that; clarity and competence is often the most compassionate and skilled oncology care we can provide.
Some appreciate a fact-based, data-forward approach more than others. A caregiver may be looking for black and white, but the patient may want to engage more superficially. A hybrid approach, where some visits focus on pure oncologic science and others on emotional support (with most a bit of both) works well for me and my practice.
Recently, a patient with newly diagnosed liver metastasis asked me to go back to the beginning. She wanted me to explain the path of diagnostic studies and treatments; to review it in context so she could best explain everything to her children and process her new reality. This exercise provided a distinct level of collaboration for us. I share it below:
It started in the right breast and was detected on self-exam, confirmed with a mammogram and ultrasound guided biopsy eight years ago. An ultrasound technician controlled the probe while a radiologist took a cored needle to draw out fluid and cells which were spread on a glass slide; the cells were dried and stained with various materials to highlight proteins. A distinctive subtype was identified-invasive ductal carcinoma, grade 2, ER/PR positive, HER2 negative, ki-67 15%. Surgery was recommended.
A surgeon took out the breast mass and injected a blue dye into the lymph system which traced a path to draining lymph nodes. Those lymph nodes were removed and sectioned into slices on more glass slides. A pathological stage, based on the measurements of the removed cancer, created a blueprint for the personality, treatment options, and prognosis of the cancer-T1cN0M0 invasive ductal carcinoma, grade 2, ER/PR positive, HER2neu negative, ki-67 15%.
Some of the cancerous breast tissue was released from the local pathology lab and sent to a facility in California where it was analyzed based on a 21 gene signature, generating a recurrence score and personalized statistics about the efficacy of chemotherapy and hormone therapy as adjuncts to surgery to reduce the risk of recurrence. Chemotherapy was deferred based on this analysis after discussion of risks versus benefits. Radiation to area of the breast where the tumor was removed was done daily for 20 days, largely to prevent local recurrence. A hormone pill, to decrease circulating estrogen and reduce overall recurrence by 40% was suggested for 5-10 years.
Seven years later, she developed pain after horseback riding and a fractured rib was discovered on X-ray. A nuclear bone scan was done, injecting contrast labeled with a radioisotope through an IV to light up where bones are activated or compromised- suggesting cancer involvement. Beyond the ribs, areas in the spine and hips lit up. Another biopsy was done from the illuminated area in the hip, and its pathologic signature was similar to the original- invasive carcinoma, ER/PR positive, HER2 negative. She was told she had Stage IV breast cancer, that it was treatable but not curable.
From a regular blood draw, done simultaneously, the amount of circulating tumor DNA (ctDNA) in her body was quantified. In addition, a “liquid biopsy” was done on the blood to identify new mutations in drivers of cancer pathways. She had a low level of circulating tumor DNA and a mutation in a protein conferring resistance to hormone therapy, known as ESR1. Local radiation to the painful rib area was done for 3 days. The original hormone pill was stopped. A new hormone therapy, a monthly injection to degrade estrogen, and a new oral pill that targeted cell proliferation, the CDK 4/6 pathway, was started. IV medicine to strengthen the bones was started monthly, shifted to every 3 months after a year of bone stability. Labs including tumor markers and scans every 6 months were ongoing to track the state of the metastatic cancer.
Two years later, she noted mild nausea and weight loss and her scheduled CT scan showed multiple hypodense lesions in the liver. A liver biopsy was done, again ultrasound guidance with a large hollow needle. Tissue was sent for routine pathology and for next generation sequencing (NGS) of the genome. Routine pathology was similar, ER/PR positive, however now HER2neu protein stained the cells conferring a status of HER2 1+. The NGS did not reveal any genetic mutations or gene fusions linked to known treatment options. IV therapy with an Antibody Drug Conjugate (ADC) was suggested, chemotherapy backbone attached to a protein targeted to the HER2neu protein, given every 3 weeks through a port placed under her collarbone in the radiology suite. Bone strengthening medication was continued every 3 months.
The real-time update is that she is doing well today on her treatment with stable disease on scans and normal tumor markers.She tells me she would not have wanted to know more. She admitted to understanding little about the procedures and diagnostic details in the moment but was glad to understand them fully now.
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