When is it time for a new cancer treatment, and how should patients make these difficult decisions? Rachel Yung, MD, provides an overview of what to consider when making difficult treatment choices.

1. Making A New Treatment
Decision
Rachel Yung, MD
Dana-Farber Cancer Institute
September 24, 2016

2. 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

3. 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)

4. Shared Decision Making

5. 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

6. 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

7. Types of Treatments - examples
Standard treatments Clinical trials
Hormone therapies Letrozole + Palbociclib
Faslodex
Bazodoxifeme + Palbociclib
Faslodex + investigational agent
Targeted therapies Kadcyla (TDM-1) Enzalutamide
Chemotherapies Taxol
Eribulin
Taxol + Investigational agent
Investigational agent alone
Immunotherapies ** Pembrolizimab + Eribulin
Pembrolizimab

8. 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

9. Some Clinical Trial “Lingo”
• Phase of trials
Phase I : safety of promising agents
Phase II : evaluating efficacy
Phase III : proving efficacy
• Eligibility
– Subtype of disease
– Prior Lines of therapy
– Location of disease (bones, organs, brain)

10. 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

11. 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

12. Conversation Guide
Goals: 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

13. 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

14. 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

15. Who is palliative care?
• PPC doctors
• Acute pain doctors
• Chaplains
• Hospice
• Oncologists
• Physical therapists
• Social workers

16. “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

17. 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

18. 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