Making A New Treatment DecisionRachel Yung, MD

Dana-Farber Cancer InstituteSeptember 24,2016

Our time today• When is it time for new treatment?• How do I make a decision? – Shared decision making– What are my options?• Standard therapies• Clinical trials• Intensive symptom management & palliative care

– Considerations:• Goals, trade offs, expected/possible benefits

When is the right time to make a change in treatment?

1) When the cancer treatment isn’t working any longer (Progression)

2) When the side effects of the treatments outweigh the benefits (Quality of Life)

Shared Decision Making

Shared Decision Making

“An approach where clinicians and patients share the best available evidence when faced with the task of making decisions, and where patients are supported to consider options, to achieve informed preferences.”

Elwyn et al 2010

How do I make a decision about treatment changes?

• Communicate about what is most important to you (which can change)

• Goals of treatment: – Effectiveness against cancer– Minimize side effects from treatment

• Body effects: Hair loss, nausea, fatigue• Life effects: Schedule, monitoring, finances

• Strategizing about ordering of treatments– Use a treatment as long as it is working and it is tolerable

Types of Treatments - examplesStandard treatments Clinical trials

Hormone therapies Letrozole + PalbociclibFaslodex

Bazodoxifeme + PalbociclibFaslodex + investigational agent

Targeted therapies Kadcyla (TDM-1) Enzalutamide

Chemotherapies TaxolEribulin

Taxol + Investigational agentInvestigational agent alone

Immunotherapies ** Pembrolizimab + EribulinPembrolizimab

What are clinical trials?• Research evaluating novel agents or a new uses of approved treatments

– Medications/Therapies– Supportive treatments

• Acupuncture, supportive medications

• Goal is to identify new/better treatments– less toxicity – more effective

• Shifting paradigms– From last ditch to front line

Some Clinical Trial “Lingo”

• Phase of trialsPhase I : safety of promising agentsPhase II : evaluating efficacy Phase III : proving efficacy

• Eligibility– Subtype of disease– Prior Lines of therapy– Location of disease (bones, organs, brain)

Is a clinical trial right for me?Personal Considerations

• Potential benefits: Effectiveness• General feelings about clinical trials• Side effects• Schedule of treatment/monitoring• Financial issues• How it effects your treatment options for

further lines of treatment

Communicating your priorities• Common Fears

– Losing control– Experiencing pain, fatigue, nausea– Losing the ability to do daily activities– Changing appearances– Financial concerns

• Goals– Participation in an important life event– Quality of life, symptom management

• Information gathering– Asking about prognosis– Asking about options

Conversation GuideGoals: If your health situation worsens, what are your most important goals?

Fears: What are your biggest fears and worries about the future with your health?

Function: What abilities are so critical that you can’t imaging living without them?

Trade offs: If you become sicker, how much are you willing to go through for the possibility of gaining more time?

Family: How much does your family know about your priorities and wishes?

Bernacki, 2013

Talking about side effects and symptoms

Reasons that patients may not discuss side effects: – Not explicitly asked– Fear of stopping medication/dose reductions if honest

reporting– Feeling that it isn’t important enough to discuss

Reasons you should discuss side effects: – Safety– Often treatments to mitigate – Better treatment – Better quality of life

What is Palliative care?

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.World Health Organization

Who is palliative care?

• PPC doctors• Acute pain doctors• Chaplains• Hospice• Oncologists• Physical therapists• Social workers

“Scanxiety”• Definition: anxiety surrounding scans and results

• Recognizing what particular issues are anxiety provoking– Anticipation before scans– The actual scans– Waiting on results after

• Methods to manage Scanxiety: – Make a plan with your clinical team – Timing of scans, apts, how results will be shared – Distraction (music), Mindfulness, Support– Social Worker support– Open communication with doctors

For persons who share care with local oncologists

• Through Embrace, we are working to improve 2-way communication with local oncologists

• Ideal timing for repeat consultations at DFCI– When you anticipate a treatment change

In Closing• There are a lot of options for treatment of

advanced breast cancer• Know thyself• Communication with your providers is key• Shared decision making is standard