Communication and Common Goals in Metastatic Breast Cancer

Transcript

This transcript has been edited for clarity.

Harold J. Burstein, MD, PhD: I'm Dr. Harold Burstein, and this is Care Cues, a conversation about communication in patients with cancer. Today I'm going to be speaking with my patient, Cheryll Plunkett.

She's had breast cancer for over 20 years. She has estrogen receptor-positive, HER2-negative metastatic breast cancer and has been living with metastatic disease for over 9 years. Cheryll, thanks so much for being here today. It's great to have you here.

Cheryll Plunkett: Thank you for having me. I really appreciate it.

Burstein: Cheryll, let's start the conversation the way we always do in clinic. How are you doing today?

Plunkett: I'm doing great. I'm on this new drug, FDA-approved since November 2023, which I know as "capi" [capivasertib]. I've had two cycles of it. And I have to say, I am feeling fabulous. My energy level is off the charts, and I feel really, really good.

Burstein: The idea that you are getting a drug now that didn't exist when you began your journey with metastatic disease is something that's so compelling about being involved in clinical research and academic medicine and bringing those kinds of treatments forward for patients. It's great to see.

Plunkett: Yeah. Very much.

Burstein: Now, for many women with breast cancer, it's a one-time thing. You have a diagnosis. You get treatment. And you had that experience in 2002 and were almost a decade or more out from this when, one day, we had to have a conversation about a recurrence of breast cancer — a diagnosis of metastatic disease. Take us back to that moment, about 9 years ago now, and what that was like.

Plunkett: I remember getting the call that I had what you called metastatic breast cancer. And I remember being out of breath and being like, well, wait a minute. What is metastatic breast cancer? And I was shocked. I really never believed cancer was ever going to come back, much less metastatic breast cancer.

At that point, I went back to my notes from 2002. Sure enough, in writing, I saw that the chance of reoccurrence was 25% to 30%. But I didn't give it much thought, because that's 70% to 75% that I'm good to go. So, the odds were with us, and it had been 13 years. Like, who would have ever thought?

It was one of those surreal moments. And so, you walked me through: OK, this is a reoccurrence, but it has metastasized to other places in your body. At that point, I probably shut down, because for me it was like, what does this mean? Like is this the end? And you did a great job — and thank goodness [my husband] Derek was there — explaining, OK, it sounds really bad, but this is a chronic illness that you can live with. And so you then proceeded to kind of tell us the course of action. And then through communication, it's the ability to just take a deep breath, understand what I have to do, and just start my journey.

Burstein: When it does come back — and, of course, it doesn't come back in most people — but when it does come back, it really feels like you've just kind of been lassoed in a terrible way after all these years.

One of the things I try and do when I talk to patients about advanced or recurrent or metastatic breast cancer — the words kind of all mean the same thing — is to lay out a couple of different ways of thinking about it, because it's not an intuitive problem. So, we often talk about "the journey." You used that word a moment ago, where there will be sort of a starting point, and you sort of know where you want to end up. But there might be bumps in the road. There might be fits and starts. The carburetor might break down. There might be something else you want to do on the way.

You've been living with this now for 9 years, so you've probably heard my spiel way too many times. But is that a useful construct, do you think?

Plunkett: It is. For my husband and I, medical jargon just doesn't equate. We are not medical professionals. You do a great job of giving analogies. You kind of bring it to a level that we can understand. We talk about, what's the analogy we're going to get today?

Burstein: One of the analogies — again, you've heard this many times — is the buffet spread analogy, which is that in the arc of time of the treatment of breast cancer, there are a lot of different treatment options. And like at a buffet table, there might be a salad and then there'll be dessert at the other end. And in between, you've got all these different dishes.

You've been very focused on trying to avoid intravenous therapy, for as much as you can, avoiding that part of the buffet table.

Plunkett: That's my goal. I am literally trying to stay this course for as long as possible. I am young. I live a life where flexibility is awesome. I still work. My husband and I like to travel. We like to do adventurous things with our family. Oral medicine allows for all of that.

Whereas when I think about intravenous therapy, it's much more regimented. It's much more grounded in where I need to be. Now, I don't need to be any specific place except for my monthly check-in point.

Burstein: For a lot of our patients, we try and stretch the oral treatments as far as we can. That's something that you've made very clear is important.

Cheryll, I want to talk about those days when we have to actually confront the need for a new treatment. Oftentimes, as you know, we'll write down, here's one option. Here's another option. Here's a third option. Sometimes we even talk about a clinical trial. From your point of view, how does that feel? Does that work for you, or do you want people to say, like, you had this and now we're going to go to that? Or do you like the menu?

Plunkett: I'd say for Derek and I, we like the menu. We mutually know when we're going to pivot to a new medicine. You always say to me that how I feel is always a key indicator. Cancer markers are a helper, and then the scans, so it isn't a surprise. We know it's happening. It's now making the decision.

You actually explain to us and did a very good job of saying OK, if you choose not to do the clinical trial, then at some point when you do choose it, it may be closed and you can't join it. If you do the clinical trial, this other option will always be there for you. So for Derek and I, that was kind of a no-brainer.

Why not do a clinical trial? I always thought "clinical trial" meant "end of life," so no more options. So in this 9-year journey, I've learned that a clinical trial is a good thing. It extends, for me, extends the oral medicine ability. So sure, I will sign up for that.

Burstein: In the academic literature, they talk about shared decision-making as the approach for lots of serious medical choices. You're obviously a very sophisticated consumer of information and things like that. But do you find that it's possible to really participate in that shared decision, or would you rather at some point say, doc, just tell me what to do?

Plunkett: Shared decision-making 100%. You're not mandating. Here are the options. And it's an open dialogue between the two of us to make that decision.

Burstein: One of the things about having a diagnosis of metastatic cancer, it's obviously a life-altering diagnosis. How has it made you think about things differently in the way of priorities or financial planning?

Plunkett: I'll never forget this. There was one time that I was doing really well on one of my medicines early on. I remember you saying to Derek and I, have you thought about kind of the long-term financial — like putting everything together, making sure you have these difficult conversations? And I remember almost being like, ugh —

Burstein: Killjoy!

Plunkett: Like, killjoy! Like why? Why are you talking about it? Looking back, that was the best thing you could have done. You gave us an opportunity while I was in a really good place — we were in a really good place — to have the conversation. And so it was really nice, and I thank you for it.

Burstein: As far as discussions about end-of-life preferences, estate planning, or wills, I try and structure that on "good news" days. That's the last thing you want to think about if you're changing gears in the treatment plan or not feeling well, or things aren't going right; it's a very awkward time to have that conversation. So when things are on one of those stretches of the journey when you're just kind of traveling along and doing well, I think it's a nice moment to have families think about those kinds of issues.

Plunkett: But in regards to another question you asked: Priority — how did it change? My son Drew will say, when Mom got diagnosed — he was only in seventh grade at the time — we started doing really fun things. So, it makes me wonder, did we not do fun things?

Burstein: The first year is no fun.

Plunkett: Totally. No fun before. But it's fun now. So, I think about that, and it just put things in perspective. It was one of those things that — we've been living this way since. We don't take today for granted. We just enjoy what we can, and we're fortunate that we can.

Burstein: Great advice. This has been Care Cues. And we've been talking about communication and metastatic breast cancer. Thank you for joining us.

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