Caring for HER2+ mBC Patients Through Collaboration and Communication

Dr. Caudle: 
Welcome to Project Oncology on ReachMD. I'm your host, Dr. Jennifer Caudle, and joining me to discuss strategies for HER2-positive metastatic breast cancer multidisciplinary care teams are Drs. Megan Kruse and Marcella Mazo.  

Dr. Kruse is a Breast Medical Oncologist and Director of Breast Cancer Research at the Cleveland Clinic in Ohio. Dr. Kruse, thank you so much for being here today.  

Dr. Kruse:  
Happy to be here. Thank you for having me.  

Dr. Caudle:  
We're looking forward to hearing from you today. And Dr. Mazo is an Assistant Professor in the Division of Hematology Oncology at the University of Texas Health Science Center, San Antonio, and a Breast Medical Oncologist at Mays Cancer Center.  

Dr. Mazo, it's great to have you here as well.  

Dr. Mazo: 
Thank you so much for the invitation. I'm happy to be here with all of you today.  

So, Dr. Kruse, if you wouldn't mind starting us off today, can you tell us who is typically part of the multidisciplinary care team for patients with HER2-positive metastatic breast cancer and how they all work together?  

Dr. Kruse:  
Sure. So oncology is definitely a team sport when you think about it these days. It really requires more than just a medical oncologist to craft an effective and safe treatment plan. And so the key people that I think of in the beginning to help a patient develop their team are really, of course, the patient and their family, the medical oncologist, as well as our nursing care team who would be helping with education and support for these patients, as well as our pharmacist, I think they play a really critical role in terms of helping us to not only educate but also when there are issues that we encounter, if it's a unique medical circumstance that a patient is in or they're having a unique toxicity of therapy, I think our pharmacists are our go-to people. 

And then we think about all of our other support staff members and the key one there is actually, the social workers, who really help the patients put their cancer diagnosis in the context of the rest of their life and figure out how to help them live their lives while they're going through this intense treatment.  

Dr. Caudle:  
You're so right about that. Thank you for sharing that information. And turning now to you, Dr. Mazo, how does the multidisciplinary team help set treatment expectations for these patients?  

Dr. Mazo: 
So it's very important that all the members of the team set expectations with patients from their discipline. So education is key. So for example, for the medical oncologist to discuss what is the nature of the disease, what is the prognosis of the disease, what are the goals of the treatment that we're going to be putting these patients on from the radiation oncologist perspective is what is the goal, for example, of the radiation therapy? Is it to palliate symptoms and decrease pain? Is it to decrease the size of the tumors and maybe alleviate pressure if we're dealing with patients with metastatic disease, for example, in the brain. And also, when it comes to supportive care services or our palliative care doctors, it is important to set up expectations about what will be our strategy to manage the potential side effects that the patient may have, or how we're going to provide supportive care when it comes to pain, managing nausea, for example, discomfort. And I will also highlight that it’s important that we set the expectation of discussing what are the advanced directives of that patient? What are their goals? How are we going to manage things when maybe the disease is progressing and we need to make some difficult decisions. So it's important for each discipline to discuss with the patient what are they going to gain from the interaction from that doctor, so we provide ideal care for them from our little different specialties. 

Dr. Caudle: 
With that in mind, Dr. Kruse, how can the team work together to manage the adverse events that might occur?  

Dr. Kruse:  
When these adverse events come up, I think it's just really critical to have open communication between the different members of the team, and so many times I'm thinking about getting a pulmonologist involved very early for any concern about trastuzumab/deruxtecan-related interstitial lung disease or pneumonitis. And oftentimes, looping in a radiologist into that conversation to really look at prior imaging studies, as well as any current imaging studies of concern as the imaging findings really impact how seriously we take concerns about interstitial lung disease. And I think it's also helpful in those cases, when we're not really quite sure what's going on, and having another set of eyes to think about is this only drug-related or are there other pieces of a patient's history that we might need to take into account while we're figuring out the best way to move forward. 

Dr. Caudle:  
And for those of you who are just tuning in, you're listening to Project Oncology on ReachMD. I'm your host, Dr. Jennifer Caudle, and I'm speaking with Drs. Megan Kruse and Marcella Mazo about HER2-positive metastatic breast cancer care.  

So sticking with the multidisciplinary care team for a moment longer, Dr. Mazo, what are some common communication challenges that occur and how can the team overcome them?  

Dr. Mazo:
So one of the challenges that we have communicating with patients is the fact that we're trying to come up with a strategy to share very complex medical information. It is important also to note that our patients may have different backgrounds, so sometimes their cultural beliefs can be different than the ones from the clinician. It is important to acknowledge that our patients deal with a lot of uncertainty and a lot of anxiety. They don't know how they're going to respond to a certain treatment, so there's going to be an element of anxiety and depression that could be with them at all times.  

How do we overcome those challenges? So basically, clear communication in lay terms with the patients in a language that they can understand, being culturally sensitive and being respectful to their cultural beliefs, and if possible, try to communicate with them in the same language if you have the privilege of having a doctor that speaks the same language as the patient. 

Also, try to ease them into making decisions ahead of time. For example, start planning for advanced directives if the patients are going to struggle with what to do at the very end of things. So having a two-way communication in between doctor and patient is what's going to help us better care for them and better serve them. 

Dr. Caudle: 
And if we come back to you, Dr. Kruse, what advice would you give other clinicians looking to improve patient care in their practice?  

Dr. Kruse:  
I think one thing that you've heard throughout the conversation today is the importance of collaboration and communication, and we really can't manage these patients in the best way on our own. And so I think when we're trying to incorporate best practices for managing these patients. It's really developing your own team network. Who are your go-to consultants that, when you run into a patient who has a particular toxicity, that you can call and run that case by them and have them see the patient quickly. Because oftentimes we're needing to make these decisions relatively urgently to keep the patient on therapy or to act quickly with supportive medications to get them out of a danger zone.  

And I think the other thing from a patient education standpoint is just giving as much proactive guidance as we can and anticipatory guidance. Because I think when patients are prepared for what can happen, it doesn't hit them as much of a surprise, and I find that they are less likely to minimize or find an alternative explanation for something that we would really want to know about and act on right away. So I have found that having recurring conversations with the pharmacist, with our nurses, and having key contact phone numbers for the patients, as simple as it sounds, that's really been the key strategy for success.  

Dr. Caudle:  
Those points are very well put. Thank you for that. And before we close, I’d like to ask you the same thing, Dr. Mazo. Any advice for improving the care journey for patients with HER2-positive metastatic breast cancer?  

Dr. Mazo:
So some of the strategies that we can use to improve the care of these patients is always having open communication with the patient and with the multidisciplinary team that is caring for them. Always discussing what will be the best option when it comes to treatment and involving that patient in the decision-making. Maybe they’ll not be likely to want to deal with a certain side effect, so it's important to have that communication open.  

I will also highlight that it's important for these patients with advanced disease to be enrolled in clinical trials. A lot of patients are motivated to participate in clinical trials because it could help them and because it will help others, so sometimes that gives our patients a sense of purpose or a mission that is encouraging and is empowering for them. And lastly, be very culturally sensitive to their needs and always be respectful of their wishes and the things that they want for them.  

Dr. Caudle:  
Well, those are great pieces of advice to consider as we end our discussion today. And I'd like to thank my guests, Drs. Megan Kruse and Marcella Mazo Canola, for joining me to share how we can take a multidisciplinary approach to HER2-positive metastatic breast cancer care. Drs. Kruse and Mazo, it was great having you both in the program.  

Dr. Kruse:  
Thanks so much.  

Dr. Mazo: 
It is my absolute pleasure. Thank you so much for the invitation and for having me.  

Dr. Caudle:  
You've been listening to Project Oncology on ReachMD. To access this and other episodes in our series, please visit Project Oncology on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening.