Adam M. Brufsky, MD, PhD: The treatment of metastatic disease, and how we handle patients with metastatic disease is much different. I always remember this case, and I always tell this case to people. This was probably about 15 years ago. I had a new patient come in to see me. She was late for her appointment, like an hour and a half late, which, for my practice, is actually not bad because we’re really busy. When she came in late, I asked, “So, why were you late?” And, she goes, “Because I was picking out my tombstone.”
Lynn Acierno, BSN, RN, OCN, RN-BC: Oh, my goodness.
Adam M. Brufsky, MD, PhD: Yes. She had ER-positive breast cancer with a few bone metastases. That was it. It was not a lot of disease. Part of what we have to do, when people come in the door, is tell people, “You may have something that’s not curable, but you have something that’s controllable for a long time.” The reason people die from breast cancer is that your liver gets filled up with cancer. Or your brain gets filled up with cancer. Or maybe, occasionally, your lungs get filled up with cancer. It keeps growing and you get liver failure. Or you get brain problems.
Having disease in your bone doesn’t kill you. Occasionally, it could, but it usually doesn’t. Having a few scabbed lymph nodes, or 1 or 2 liver metastases that are really small doesn’t kill you. Our job is to keep those stable. We’re not getting rid of all of them, but we can keep them small, for as long as we can, to give you a decent quality of life for as long as we can. That’s what I tell people. They all say, “I’m going to die. That’s it.” What do they tell you about metastatic disease?
Lynn Acierno, BSN, RN, OCN, RN-BC: Patients can be very anxious about upcoming scans.
Adam M. Brufsky, MD, PhD: Right.
Lynn Acierno, BSN, RN, OCN, RN-BC: They are very anxious about what they’re going to find. Most of the time, they want to hear that everything is gone. But, we try to just let them know that, again, stable is good.
Adam M. Brufsky, MD, PhD: Stable is good. That’s right.
Lynn Acierno, BSN, RN, OCN, RN-BC: No spread is good. And, one of my favorite things to say is, “We have a medicine for just about everything.” Again, if we determine that it’s spread to their bones, we have Zometa, zoledronic acid, and Xgeva, denosumab. We will treat as best as we can. Again, we may biopsy the site to make sure we’re choosing the right treatment plan. But patients get very anxious about scans and tumor markers.
Adam M. Brufsky, MD, PhD: Right, they really do. A lot of my colleagues don’t even do tumor markers, for that reason. I tend to be a little bit different. I tend to look at symptoms, tumor markers, and scans. Oftentimes, the scans are kind of the same. Maybe they are a little different, but not that bad, and the markers are going down. It’s very satisfying to tell somebody, “Look, the scans kind of look the same. They may be a touch worse, but your markers are going down. So, it’s likely that the cancer is getting better.” A lot of people don’t like tumor markers. They think they’re just hocus-pocus. But I, personally, in my practice, tend to use the markers.
Lynn Acierno, BSN, RN, OCN, RN-BC: Well I think we see the correlation. I think there’s enough correlation.
Adam M. Brufsky, MD, PhD: Right. I agree with you.
Lynn Acierno, BSN, RN, OCN, RN-BC: It’s merited to keep an eye on them.
Adam M. Brufsky, MD, PhD: Right. People live with metastatic cancer for so long, now. We’re talking, in HER2-positive cancer, at least 5 years, if not longer. Probably, in ER-positive metastatic disease, it may be longer than that: 6, 7, 8 years. What we try to do is give people a good a quality of life for as long as possible. But keeping people on chemotherapy, forever, just doesn’t do it. They always run into problems.
In our practice, we have a nurse practitioner who has been very involved in symptom management for breast cancer, forever. She made a career out of it. One of the things that we have found, and we’ve kind of imparted this on everybody, is it is important to come in every month, or every other month. Do you think that’s important?
Lynn Acierno, BSN, RN, OCN, RN-BC: Absolutely.
Adam M. Brufsky, MD, PhD: Frequency. Now, we’re actually trying to have people come in every 3 months. There’s a big movement because some of the drugs, like Zometa, are now being giving every 3 months, and not every month, any more.
Lynn Acierno, BSN, RN, OCN, RN-BC: We tend to do that with our more stable patients.
Adam M. Brufsky, MD, PhD: Correct.
Lynn Acierno, BSN, RN, OCN, RN-BC: Especially after scans.
Adam M. Brufsky, MD, PhD: But I think that people want to come in every month. Have you found that people want to come in every month? Or they don’t like it? Do they want to come in less frequently?
Lynn Acierno, BSN, RN, OCN, RN-BC: I think it’s a case-to-case basis. For some patients, it can be a financial concern.
Adam M. Brufsky, MD, PhD: Co-pays, right.
Lynn Acierno, BSN, RN, OCN, RN-BC: Also, it could be an emotional need. They need someone to tell them, “You’re doing fine.” So, they like to see somebody every month.
Adam M. Brufsky, MD, PhD: Well, the internet is always available for them, too.
Lynn Acierno, BSN, RN, OCN, RN-BC: One thing we’ve learned through our coworker, who does a lot of work with metastatic disease, is that there’s so many needs beyond the medical aspect of cancer.
Adam M. Brufsky, MD, PhD: Correct, that’s the point.
Lynn Acierno, BSN, RN, OCN, RN-BC: Again, it can be financial. Or they need to work, but the side effects of their drugs prohibit that.
Adam M. Brufsky, MD, PhD: Fatigue, in particular.
Lynn Acierno, BSN, RN, OCN, RN-BC: Right. It’s multifaceted, and we try to cover all of those bases. We involve palliative care. We involve social work. I don’t want to use the word “easy,” but, we make it as “doable” as possible.
Adam M. Brufsky, MD, PhD: You have enough stress having something in you that is probably not curable. I agree, and I think that’s a really important point. I think that as we, oncologists, try to move out the visit frequency of women from monthly to every couple of months, or every 3 months, these are the things we have to keep in mind.