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Patient Communication in EBC
Strategies for Optimizing Patient Communication: Focus on Early Breast Cancer

Released: May 30, 2023

Erika P. Hamilton
Erika P. Hamilton, MD
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Key Takeaways
  • Shared decision-making incorporates the patient’s views and goals in treatment decisions.
  • Healthcare professionals should foster patient relationships that encourage open communication, incorporating a variety of tools to promote effective communication.
  • The patient and patient’s family or caregivers all contribute to developing individualized treatment plans for early breast cancer.

The concept of shared decision-making (SDM) can be intimidating, but is relatively simple. Fundamentally, SDM means involving the patients in the decisions that affect them. SDM is important because it allows patients to be an integral part of the care team and decision-making process. In the setting of high-risk hormone receptor–positive/HER2-negative early breast cancer several therapies should be considered: endocrine therapy, adjuvant abemaciclib, and chemotherapy.

The healthcare professional’s (HCP’s) role in the SDM process includes explaining potential treatment strategies to the patient. The HCP also helps patients estimate the risk of various management options, the rationale for each option, why patients may want to make different treatment decisions based on the risk, and how these decisions affect risk.

It is important to ensure that patients comprehend the information they receive, including understanding their diagnosis and the risk of recurrence. Some of the factors patients should consider when choosing a treatment include adverse event profiles, therapy duration, expected outcomes, and social factors (eg, family, work, and other obligations) that affect—and will be affected by—their disease and therapy choice.

Understanding the Risk of Recurrence and Potential Therapy Benefit in Early Breast Cancer
Although I try to describe risk to patients and provide examples, it is difficult for patients to understand what a 6% decrease in recurrence risk means based on the monarchE trial of adjuvant abemaciclib. Drawing a picture can help patients visualize risk. Although I am not a great artist, I may draw a picture of 100 women and explain that among these women, 10 will have a recurrence regardless of the treatment strategy. An additional 6 women will not have a recurrence if they receive abemaciclib plus endocrine therapy vs endocrine therapy alone. The remaining 84 patients will not have a recurrence, regardless of the treatment strategy.

Patients’ desire for therapy varies and should be considered when determining a treatment strategy. When gauging each patient’s desire for therapy, it is important to discuss how much patients want to reduce their recurrence risk, to assess their comfort level with each treatment option’s risk, and to weigh the risks against the potential benefits of the therapy. An individual patient’s risk tolerance, therapy goals, and perception of and willingness to accept adverse effects to achieve a perceived benefit may differ from another patient’s idea. One example is when we look at the patient’s age. A 30-year-old with a young child may make different treatment choices compared with an 82-year-old with comorbidities because of their individual perceptions, goals, and situation.

Communication to Foster Adherence to Therapy
Data show that patients sometimes hesitate to admit to missing doses or to say that they are not doing well because they think that they might be perceived as complaining. HCPs need to ensure that they foster a relationship with their patients that allows patients to feel comfortable talking about these issues. Patients need to know that their HCP wants to hear about the adverse effects they are experiencing because the HCP may be able to improve patients’ experience.

Tolerability and adherence are separate but equally important issues for any cancer therapy. For patients who are not tolerating their treatment well, it is important to understand why they are not tolerating the treatment and what “tolerable” looks like for them. The next step is determining whether the patient’s idea of “tolerable” is feasible and how it can be achieved. This may include dose reduction or modification. Although patients and HCPs worry about dose reductions, accumulating data indicate that, for many therapies, dose reductions are not necessarily associated with inferior outcomes. Dosing should be individually tailored, but most HCPs typically initiate all patients on the same dose. Therefore, it is important that patients understand that there is not something “wrong” with them if they cannot tolerate the current dose. Rather, because different patients metabolize therapies differently, some patients receiving lower doses may have the same exposure and benefits as other patients who receive higher doses. Accumulating data regarding oral therapy dose reductions—including some from patient-led research—indicate that patients want their HCPs to talk to them about potential dose reductions. Discussing dose reductions and open communication with patients is important in achieving a good quality of life while receiving treatment. Patients who feel well are more likely to adhere to the therapy regimen.

Patient Education Tools
I try to make information relatable by putting everything into perspective. For example, I may explain that endocrine therapy decreases breast cancer recurrence risk by one half. In comparison, depending on the regimen, chemotherapy only decreases breast cancer recurrence risk by 20% or 30%. Therefore, compared with chemotherapy, it is even more important to complete the entire endocrine therapy regimen.

Take-home handouts and patient information allow patients as much time as they need to review and thoroughly digest information and to discuss it with family and other trusted people. This may increase understanding and allow them to formulate follow-up questions for their next office visit.

Follow-up visits can be very helpful because when patients are presented with a lot of information at once, they may become overwhelmed and unable to think of all the questions that they have. Follow-up visits or phone calls from the HCP team give patients the opportunity to get answers to their outstanding questions.

A Team Approach
Patient’s treatment plans are typically managed via a team approach. Most patients with breast cancer have at least 3-4 HCPs on their team including a medical oncologist who manages systemic risk; a radiation oncologist who delivers radiation for local risk; a surgical oncologist who resects the tumor; and possibly a plastic surgeon for reconstruction. The team may also include pharmacists, who explain new medications, adverse effects, and cost and facilitate patient adherence by ensuring that prescriptions are refilled on time; breast oncology nurse navigators who coordinate care among the team members and offices; nurse practitioners and physician associates; and schedulers who ensure that appointment and procedure times are as convenient for the patient as possible.

Caregivers and Family Members
Incorporating family members and other caregivers into the treatment process can be difficult. Although well-meaning, the patient’s supporters can inadvertently overwhelm the already-stressed patient with, for example, information and articles they have found that relate to the patient’s disease and treatment. This may leave patients wondering if they should employ the suggestions or how they can ask their well-meaning supporters to stop sending information without injuring feelings. On the other hand, caregivers and family members can be quite supportive. I notice that when confronted with a decision, patients often look to the supporters who are accompanying them for guidance. In these cases, it is important to remind patients that, ultimately, the choice is theirs alone and that they must do what is best for them regardless of their loved ones’ preferences.

There are other times when patients are afraid to make decisions. An example is when I tell a patient that a specific therapy is associated with an 8% benefit and I am met with silence. In these situations, I try to normalize that either decision—for or against taking the therapy—is valid. I might explain that some patients may want the 8% benefit provided by the therapy and be willing to do anything to lower their recurrence risk. Then I might explain that other patients may focus on the 92% of cases where therapy does not affect the outcome and these patients may decide that the risk of adverse effects outweighs the potential 8% benefit.

Your Thoughts?
How do you incorporate SDM into your clinical practice? Answer the polling question and join the conversation in the discussion box below.

 

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What tools do you use in your practice to assist with SDM and patient education?

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