You’re listening to Breaking Boundaries in Breast Cancer, sponsored by Lilly.
From the shock of diagnosis to the stress during treatment, the trauma faced by patients with breast cancer can greatly impact their quality of life. For these patients, the importance of communication with their physicians cannot be underestimated, as it has a great impact on how they cope with these difficult emotions. That’s why on today’s program, we’ll be taking a look at the role of this patient-physician relationship along with some strategies we can use when counseling our patients with breast cancer.
Welcome to Breaking Boundaries in Breast Cancer on ReachMD. I’m Dr. Jennifer Caudle, and joining me to explore the role of communication when caring for our patients with breast cancer is Dr. Stephanie Graff, Director of the Breast Program at the Sarah Cannon Cancer Institute.
Dr. Graff, it’s great to have you with us today!
To start us off, Dr. Graff, can you briefly share your career experience and your clinical background in the field of breast cancer?
So, I am a breast medical oncologist. I trained at the University of Kansas and now am the Associate Director of Breast Cancer Clinical Research for the Sarah Cannon Research Institute and the Director of the Breast Cancer Program for the Sarah Cannon Research Institute at HCA Midwest Health. I am also the Director of Clinical Trials for HCA Midwest Health, Sarah Cannon Cancer Program. A lot of job titles. I have been exclusively seeing patients with breast cancer and caring for breast oncology patients for about a decade now, and I also run our high-risk program and have helped develop our high risk and risk reduction program nationally for The Sarah Cannon Cancer Network.
Great, thanks for sharing that with us, Dr. Graff. Now you had actually written an article that was published in the Journal of Clinical Oncology titled “The Cattle Don’t Care,” and in this, you reflected on your personal experiences in the role of a supportive family member rather than a physician after your dad was diagnosed with cancer. So did that new perspective impact your approach at all?
Yeah, being a daughter to my father really opened my eyes to a bunch of different ways to be a better oncologist. And some of those are first when patients are coming to me to get a sense of what their best treatment plan looks like regardless of what setting that’s in. If it’s curative or early stage disease or metastatic disease, everybody that’s supporting that patient is coming in with their own experiences. So, what my dad understands about cancer treatment as the patient, what my mom understands about the cancer treatment and what she would do if it were her, and what I understand as a physician daughter and what I would do if it were me. We’re all three very different situations, and I think that there’s an opportunity for us as cancer physicians to address everybody’s concern. And so now I very pointedly, as we’ve talked about the plan with a patient, make sure that I turn to each family member that that patient has chosen to bring into the appointment and include in their plan and say, what specific questions do you have? Or, I saw you, you know, rolling your eyes or grimacing or whatever when your loved one was expressing this feeling, how does that make you feel? Let’s all make sure that we’re on the same page together. And often family members in that moment tell me that they had an experience with their husband’s parents or their best friend’s sister and that has given them this outside experience that is coloring what they’ve brought into their family member’s experience. And having the opportunity to get that background of my patient support system and to be able to address that, I think helps all of us, me and that patient’s family members, provide the best care for that patient. Because really, you know, I’m with a patient for a very short amount of time relative to how much time their family is with them as they do most of the work of recovering from every chemo, experiencing the side effects of every chemotherapy at home, it really kind of falls to their family, so it’s important that everybody is aligned.
The other thing that I learned being my father’s daughter is that everybody’s experience around cancer is so uniquely shaped by who they are as an individual, and my dad is stubborn and just not that into doctors. And so for him to find out that he was going to need a treatment that was going to need repeated visits to a hospital, that it would be sort of a protracted treatment course, not just a one and done. Like, I think he thought cancer was like having your appendix out. Once it’s done, it’s done, and it happens on a single day. It’s really hard to change some of those hard-held beliefs about how you receive healthcare and so, it’s helped me understand that if a patient comes out of the gate at our first visit saying there’s no way I’m ever going to consent to this. Whether that’s surgery or chemotherapy or losing their hair or getting a medicine that makes them throw up, I then can ask why they have that belief. Sometimes it’s something that we can talk through and come to a better understanding, me as them, them as me. And sometimes it’s something that I can acknowledge, okay, yeah that’s a really big deal to you, I understand your perspective and why you’re coming to me with that concern. Let’s talk about maybe the next best thing that could meet you where you’re at.
Thanks so much for sharing your story with us, Dr. Graff, it certainly seems to have had an effect on your approach for the better. Coming back to your breast cancer patients, then, what communication strategies do you use to help boost their quality of life?
I have two comments about quality of life. My first is that I pretty regularly tell patients that I feel like most people’s first chemotherapy is their hardest chemotherapy because they have no idea what to expect. It doesn’t necessarily mean that out of your 3 or 10 or 400 drug chemo regimen that that’s actually the hardest one is that you don’t know when you’re going to get nauseated. Is it going to be 3 hours later or 42 hours later? You don’t know if you’re going to have diarrhea or constipation because most drugs can cause both.. And so, what I tell patients all the time is you can’t cry wolf. You can call my nurse triage line, my office, our electronic system 100,000 times and we are still going to call you back the 101st. I tell patients all the time, they will never be my worst patient. I want patients to know that they’re not bothering us. I think people are so polite that they’re worried that they’re creating a burden somehow by asking questions or saying that they don’t understand or reporting symptom. So, don’t be afraid to cry wolf; that’s not a thing.
My second comment was that I also think that patients, you know, they get their chemo, for example, a regimen that might be given every 14 days or once every two weeks. So, they’ll get their chemo and they’ll go home. And their yucky days will be day 3 or 4 and then when they come back 14 days later for cycle number 2 and I ask how they’re feeling and what sort of symptoms they have, they say oh, well, everything’s better now – it’s okay. And they don’t want to go back and tell me about the time that it’s bad. And I don’t know if nobody wants to remember the bad time or if they’re worried that if they complain too much, that somehow we will alter their chemotherapy in a way that’s less effective, but I have to know about problems in order to fix them. So, if you on day 4 were so tired that you couldn’t get out of bed or if on day 3, you had terrible uncontrolled diarrhea, tell me. Because chances are I have a tip or an idea that will make that better with the next round that will not in any way alter the success of your chemotherapy. And what’s more, having good symptom control improves the likelihood that you’re going to finish the chemo that we planned for you. So, the more you’re able to report, the more you’re able to sort of modify in order to keep you on track with your planned chemo regimen, the better it’s going be. So, just like I don’t feel that a physician can over communicate with a patient, I don’t feel that a patient can over communicate with a physician.
For those just tuning in, you’re listening to Breaking Boundaries in Breast Cancer on ReachMD. I’m Dr. Jennifer Caudle, and joining me on the topic of counseling strategies to improve quality of life for breast cancer patients is Dr. Stephanie Graff.
So Dr. Graff, staying on this track for communication strategies, what are some of the most common challenges or barriers you come across that can make counseling more difficult for these patients?
I think that the biggest barrier to quality cancer care is the unknown. I think a lot of patients are afraid to talk about socioeconomic barriers if they don’t have good access to transportation or food or if they’ve missed any more than, you know, 10 days of work a year, they’ll get fired and lose their health insurance. Whatever that might look like, I have a team for that. I have a licensed social worker. I have an amazing collection of resources, whether it’s gas cards or a free transportation shuttle for some of my patients. We just have so many resources at our disposal, but it’s hard for me to screen every patient for every situation. And so I want patients to not feel ashamed or embarrassed or rushed to disclose those things to us because I think it will help your care team overcome barriers if we know what the ones are that are hidden from us.
Absolutely. Now before we wrap up, Dr. Graff, I want to ask you about another important aspect of breast cancer care and counseling, and that’s regarding our patients’ sexual health. What are some takeaways you’d like other clinicians to know about guiding patients through sexual issues?
My vision of perfect cancer care is care that ultimately cures your cancer and restores your life to normal. And our sexual identity, our sexual health, is a part of normal. And it’s a part of normal that a lot of people are uncomfortable talking about. I think that the best way to optimize sexual health during and after cancer treatment is to be able to talk about it early. Because, like any injury or illness, it’s easier to recover from a mild case than a severe case. And so, as a woman, who is a breast cancer survivor or newly diagnosed with breast cancer, our breasts are a part of our sexual identity for better or for worse. And to have them operated on, maybe removed completely, we’re talking about a change in the way that they might feel of loss of sensation. There may be pain or tenderness. And if – if your breast health is a part of your body image, that can affect your overall mood and your sense of sexuality. It can affect your relationship with your partner.
Then there’s all the other issues with medicines and breast cancer. Often they can cause vaginal dryness, which can make sex and intimacy more uncomfortable. So, patients might need different lubricants, different moisturizers. They might need to use medical therapies or even surgical therapies to optimize their vaginal health. And so, I think some patients feel awkward discussing that with their physician. I think some patients feel awkward discussing that with their partner or their family members in the room. And so, one of the things that’s important to me for sexual health is you could always say, can I ask you a few questions privately? Sometimes patients are more comfortable. Like they might have a male oncologist and be more comfortable asking that question to a woman. There might be a nurse practitioner or just a nurse in the clinic base or even, you know, social workers, somebody with a special skill set that you can introduce that conversation to. Sexual health is, at the end of the day, health, and it’s a part of our job to care for every aspect of health and that includes sexual health and intimacy.
Those are all great things for us to keep in mind, and as that brings us to the end of today’s program, I want to thank my guest, Dr. Stephanie Graff, for providing insights on counseling strategies to help improve quality of life for patients with breast cancer.
Dr. Graff, it was great having you on the program.
The preceding program was sponsored by Lilly. Content for this series is produced and controlled by ReachMD. This series is intended for healthcare professionals only. To revisit any part of this discussion and to access other episodes in this series, visit ReachMD.com. Thank you for listening to ReachMD. Be Part of the Knowledge.