S. Eric Olyejar, MD
Michael Berry, MD, FACS
As patients become increasingly involved in the clinical decision-making process, the significance of information and how it is presented grows as well. For women diagnosed with early-stage breast cancer, advances in treatment like accelerated partial breast irradiation (APBI) have added to the complexity of the decision-making process, putting even greater emphasis on patient education.
Radiation oncologist S. Eric Olyejar, MD, and breast surgeon Michael Berry, MD, FACS, outline their processes for counseling patients on breast cancer treatment options, including addressing misconceptions about breast conservation therapy (BCT) and how to effectively use data in patient discussions.
How informed are patients with regard to their treatment options for early-stage breast cancer?
Dr. Olyejar: I have a preoperative consultation with most (but not all) of my patients, and their level of education varies. Some women are very educated when they come to see me, while others receive very little education prior to our visit.
Dr. Berry: Younger patients or those more comfortable with the internet have typically spent time getting a general idea about their condition. This is often just a cursory knowledge without the full understanding of how their specific situation applies to what they have read. This typically makes my job a little easier with some familiarity with terminology and general prinicpals. There are a fair number of patients, though, that have only spoken to friends or family members for their information. This information tends to be less informative of options and heavily biased on the feelings of those with whom they have spoken.
How do you respond to a patient who is a good candidate for breast conservation therapy but has a preference for mastectomy?
Dr. Olyejar: As with every patient, I review the data with her regarding the equivalence of breast conservation and mastectomy in terms of disease-free and overall survival. I do my best to clear any misconceptions that they carry about mastectomy vs. BCT, the most obvious one being that mastectomy provides them with a greater chance of survival. Another common misconception is the risk of contralateral cancer – many patients believe that a contralateral breast cancer is a certainty. I also find that many patients carry a perception that they will not require chemotherapy if they choose mastectomy over BCT.
Once their perceptions are based on solid data, I then discuss the radiotheraputic treatment options available to them if they were to choose preservation. I also discuss the potential for post-mastectomy radiotherapy. Once I am satisfied that she is well educated on the issues, I fully support whatever decision she feels best about.
Dr. Berry: This patient group generally is the least informed and most biased. I focus on explaining why local therapy has little effect on sytemic disease, and I will refer them to websites and provide literature that confirm their options. Sometimes this is a situation that cannot be overcome. Mastectomy is still an option and while it is not my preference, I have to respect and not belittle my patients’ desires.
When it comes to radiation therapy, how do you present the various options (whole breast vs. APBI, brachytherapy, 3D conformal, IORT, etc.) to your patients? Do you lay out all the options and let the patient decide, or do you guide their decision-making by discussing only a few that you feel are most suitable?
Dr. Olyejar: I do my best to outline the options for her, communicating the supporting data, rationale, risks and benefits of her choices. For women who desire BCT, I tell them that there will likely be two treatment options available for her radiation – whole breast radiation (WBRT) and partial breast radiation. I outline WBRT with her in detail, including the potential for both acute and chronic toxicities, while making it clear that it is considered the standard of care today. In my discussion of partial breast irradiation, I outline the principle, then review the prospective data with her, making it clear to her that level 1 evidence is still outstanding and that a current clinical study is further evaluating this. I communicate that in this setting, which is common in all of medicine, we use guidlines by which we offer the treatment. In the preoperative visit, I make it clear that she may or may not meet the commonly accepted (and admittedly controversial) guidelines, and the option will not be clear until after surgery.
Regarding the modalities of APBI, I’ve made the decision to offer only brachytherapy simply because in my opinion, the other modalies carry a relative paucity of data when compared to brachytherapy. I would estimate that about 95% of my patients who are eligible for APBI will choose that as their therapy when given the option with the above counsel.
Dr. Berry: When discussing breast conserving therapy, I inform the patient that generally radiation is part of the therapy. I broadly cover the rationale, duration of therapy and pros and cons of each option that they will eventually be presented. I want them to be thinking ahead and begin to formulate their desired treatment course, and I generally have an idea of how they are leaning even before surgery. When surgery is completed, we discuss whether or not radiation is necessary. If radiation is needed, we then discuss options that may be available to them based on their age, stage or tumor type. Many patients have already decided that they desire APBI brachtherapy before surgery and are often disappointed if their situation changes to disallow this option.
Do you use data in your discussions with patients? If so, how do you make the science understandable?
Dr. Olyejar: Yes, as above. My patient population ranges from engineers from Intel to women who do not have a high school education, so I believe the way the data is presented has to be tailored to each individual patient and her ability to understand. Patients also tend to make it very clear how much or how little data they need to feel comfortable with their decision. In general, I make the assumption that they do not understand statistics or percentages, so I always try to use whole numbers or ratios in addition to the percentages when discussing statistics. Using simple analogies that are not medically related often help in their understanding. Instead of discussing individual studies, I address similar studies as a group and discuss their general findings.
Dr. Berry: Data is necessary to discuss every aspect of breast cancer treatment and the patient cannot be fully informed without it. The difficulty arises in putting this in an understandable format. One must discern the level of a patient’s understanding and their ablility to navigate the information. I often over-inform the patient and then assess how well they are processing the information. If it is overwheming, then I tend to resummarize in simpler terms. I am almost always the first physician to sit down and explain their cancer diagnosis to the patient. I try to give them an understanding of their entire course of care, not just their surgical options. I’m very specific regarding surgery but spend a fair amount of time discussing radiation, chemotherapy and endocrine therapy. Ultimately, I don’t expect patients to leave my office with a complete understanding of what they are going through but to have a broad knowledge of what is to come.
What tools have you found to be most effective for your discussions with patients – visual aids, videos, presentations, iPad apps, etc.?
Dr. Olyejar: Studies are clear that the majority of women are visual learners as apposed to auditory, so I try to incorporate something that can be looked at as I speak. Maybe I’m pretty old fashioned, but most of my visual aids are drawings that I do on the paper of the exam room table. I also use a booklet provided by the NCI on breast cancer and the breast model provided by SAVI.
Dr. Berry: While there are very nice videos, these tend to be a little inpersonal and don’t allow for patients to ask questions or for us to have a conversation. I tend to use a lot of visual aids and models. For instance, the SAVI device in the breast model is very understandable and appealing to the patients. The fact that it also shows an actual device is nice so there are no surprises later.
What resources do you direct patients to for researching their treatment options?
Dr. Olyejar: The Ironwood Cancer Centerwebsite, which directs patients to the National Cancer Institute website and Breastcancer.org. I also make myself available to my patients by giving them my email for questions. If a woman wants to talk to someone who has previously had the treatment she is considering, I connect her with former patients who have volunteered to discuss their experiences.
Dr. Berry: Breastcancer.org has very nice literature and web based information. It is very accessible to the lay public and not overly encumbered with irrelavent details. Komen and the American Cancer Society have nice websites but a little more difficult to navigate. The resources available to patients today are tremendous and provide much more information that can ever be covered in an office consultation.
About Dr. Olyejar
Dr. Olyejar is Board Certified in Radiation Oncology and has practiced at the Ironwood Cancer Research Centers in Chandler, Ariz. since 2006. He specializes in the treatment of cancer of the breast, prostate, and head and neck. Dr. Olyejar is experienced and has special training and interest in brachytherapy for all sites including breast, prostate, head and neck, gynecologic, esophagus, skin and lung.
About Dr. Berry
Dr. Berry is a Breast Surgical Oncologist at The West Clinic in Memphis, Tenn., and is board certified by the American Board of Surgery. He received his fellowship training in Breast Surgical Oncology through the Susan G. Komen Breast Cancer Foundation fellowship of Breast Oncology at the University of Texas Southwestern Medical Center at Dallas.