In this Expert Perspectives, we spoke with Editorial Board Member Don Dizon, MD, Director of the Oncology Sexual Health Clinic at the Gillette Center for Gynecologic Oncology at Massachusetts General Hospital in Boston, MA about some issues that have come to the forefront for patients with breast cancer.
Do you believe women are too quick to select mastectomy versus breast conserving surgery when they are diagnosed with breast cancer? Why or why not?
Dr. Dizon: That’s a hard question to answer because it’s not generalizable. The decisions regarding breast surgery after being told “it’s cancer” are complex and each person brings to it their own prior experiences (for example, a relative or a friend who had breast cancer), their fears, goals, and preferences. In addition, so much goes into it from the medical perspective—whether or not it’s a familial breast cancer due to BRCA 1/2 mutation, the size of the tumor in relation to the breast, clinical stage (ie, whether the lymph nodes are involved), and even the tumor’s characteristics.
What I would say is that oncologists should try to understand more fully what is motivating the decisions women make when it comes to breast surgery. It means having a conversation about the surgical options several times and addressing any questions related to the specific treatment. Physicians have a responsibility of making sure each decision is “informed” by the evidence, but at the end of the day, we cannot dictate the choices our patients make.
How do you empower your patients with breast cancer to make decisions regarding their treatment?
Dr. Dizon: The empowerment comes from engagement. To me, even patients who do not know “what to do” still want to know what their options are. I think our role as physicians is to present each available option while keeping in mind both the present and their future. I will present standard therapies and their associated with risks (or side effects) and also the clinical trials that are relevant to each situation.
It may take more than one visit, but it’s so important that the approach be a shared decision, even if at the end of the day, uncertainty is still present. So much in medicine (and in oncology) requires good communication and trust—it’s really a partnership, and that’s where the engagement becomes so important.
How essential is personalized treatment in managing patients with breast cancer? What opportunities does it offer the patient and the clinician that were not previously available?
Dr. Dizon: Breast cancer has led oncology in the field of personalized treatment, and hopefully we will continue to do so. From the recognition that hormone receptors are important predictors of the role of endocrine therapy, to the breakthroughs of HER2-directed treatments for HER2-positive breast cancers, these developments have allowed us to identify appropriate treatment strategies aimed at subgroups of patients, rather than a “one size fits all” approach. Hopefully, with a deeper understanding of tumor biology and the identification of molecular drivers of specific subsets of breast cancers, we will continue to make progress in selecting the best treatment approach for the specific patient.
How much of a role does genetic testing play in this era of individualized therapy for the disease?
Dr. Dizon: As of right now, genetic testing isn’t impacting current treatment paradigms. However, most of us believe that the knowledge of certain mutations (eg, BRCA 1/2 mutations) will be used to select patients for specific therapies (ie, PARP inhibitors). At our institution we are discussing genomic testing of tumors in the context of various phase 1 molecularly targeted clinical trials we have ongoing at any one time.
So, I see it more as a powerful research tool to drive the completion of the next generation of clinical trials that are testing a specific mutation in an enriched patient population. It’s exciting work and hopefully, very soon, we will begin to see the benefits of this strategy.