June 01, 2021
Joanne Mortimer, MD, director of women’s cancer programs at City of Hope, discusses the unique challenges of treating breast cancer, the importance of patient-centered treatment, and what payers can do to better accommodate patient needs while reducing costs.
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Welcome back to PopHealth Perspectives, a conversation with the Population Health Learning Network where we combine expert commentary and exclusive insight into key issues in population health management and more.
Today we are joined by Dr. Joanne Mortimer, director of Women's Cancer Programs at City of Hope. She discusses the unique challenges of treating breast cancer, the importance of patient‑centered treatment, and what payers can do to better accommodate patient needs while reducing costs. Dr. Mortimer?
My name is Joanne Mortimer. I am currently the director of our Women's Cancers Program at City of Hope. I've been taking care of women with breast cancer for 35 years, so I've had the opportunity to watch a great deal of change over time.
After I finished training, we used to get a drug every 10 years. In the '70s, it was Adriamycin. In the '80s, it was Cisplatin, and then it was etoposide. The rapid change in the landscape of how many new drugs we have is both exciting and very sobering and it makes it very complex to be able to keep up with the treatment of breast cancer patients.
What are some common challenges in treating breast cancer that make it unique compared to other types of cancer, and where do you see the future going in terms of care?
It's an incredible challenge, no matter what specialty of oncology you're in, to keep up. There are so many new targeted agents that have very different side effects than the ones we're used to. You have to not only learn what the drugs are, what their indications, and what the unique side effects are.
Additionally, we have a number of molecular tests. These are wonderful, they help us to define who needs chemotherapy and who does not, how long to give treatment for, and importantly, germline testing tells us who is at risk for certain types of cancer and how we should follow them over time.
Another challenge with breast cancer, which is somewhat unique is that breast cancer is a chronic disease. While there are subtypes of breast cancer which can be very aggressive, like triple‑negative breast cancer, for the majority of breast cancer, it's diagnosed at an early stage.
The cure rate is incredibly high for those women diagnosed at an early stage. This makes understanding the patient experience so much more important because survivorship and the problems that women experience during survivorship have become the purview of the medical oncologist.
How we manage the side effects of estrogen deprivation at very young ages is a component of the care of breast cancer patients. For women who have metastatic disease, again, this can be a very chronic process.
Women with estrogen‑positive breast cancer are on and off different endocrine therapies that may keep them in and out of remission for years and even decades, in some cases. For women with HER2‑positive breast cancer, there are so many new HER2‑directed agents that this also has become a very chronic disease that women live for years, even with metastatic disease.
Some of the new challenges that come up are brain metastases. That's true, certainly in the HER2‑positive arena because as women with breast cancer, especially HER2‑positive and triple‑negative breast cancer live longer, they are at increased risk for developing brain metastases. Again, we're balancing the toxicity of surgery and radiation with quality of life.
In the past, where we used to give whole brain radiation to most women with brain metastases, now, our treatments tend to be more local with surgery and radiation and stereotactic radiation, because we want to avoid the long-term complications of whole brain radiation as these women have the opportunity to live longer and longer, and we want to maximize their quality of life.
As far as the future, we continue to understand the genetic makeup of cancer and the biology of cancer, which allows us to get new drugs for the treatment of breast cancer. Another area that's important is understanding the patient and their own immune system. That may not be the right term, but their own biologic makeup.
Right now, younger women with breast cancer have worse outcomes stage for stage, even when they're treated appropriately. What is about the makeup of a younger patient that makes their cancer behave more aggressively, have more recurrences, and a greater likelihood of dying of breast cancer than the older woman?
The future is understanding the biology of cancer and developing new drugs, understanding the genetic makeup of who's at risk for getting breast cancer, and understanding the inherent makeup of individuals, whether it's by age or by individuals themselves, that may impact the side effects of drugs and how the drugs are handled in that individual patient and how the cancer behaves in that environment.
Another aspect in the future and I want to talk about, the importance of advocacy. Our patients are our true partners in treating them and understanding the disease, and also how they experience breast cancer and the side effects of treatment.
They are incredibly important partners in not only their own treatment, but in our understanding of breast cancer and how to improve therapies in patients. Also to help us to understand what is important, not just the psychosocial but the toxicities of treatment, the financial issues. The continued role of advocacy, I see only increasing in the future.
We often hear about multidisciplinary teams. In your experience, what has it been like navigating through breast cancer with the whole care team?
People always talk about, breast cancer is a team sport. Breast cancer, like all cancers right now, involves the patient and families who are at the center of multidisciplinary treatment team that includes surgeons and medical oncologists, radiation oncologists, radiologists, and pathologists.
Our pharmacists partner with us, and they are important in making sure that we prescribe the right dose of the drug, that we've given the appropriate antiemetics, and increasingly, our pharmacists are called upon to navigate the financial landscape of these very expensive oral agents that we use.
These new agents are so incredibly important in improving quality of life and longevity, and yet the cost of them is often prohibitive. The ability to get these drugs for all our patients often takes a team, our financial team as well as our pharmacists.
The other components of the team, which I think are variable across practices are the psychosocial support teams. At City of Hope, we're very fortunate to have a robust psychosocial team who actually see each of our patients and their support person at the time of diagnosis.
During this visit, they talk about what their concerns are, and our social workers work with them to talk about strength‑based support. Women like to process and they like to talk about their cancer and the problems that they're facing, and the emotional issues, and men like to fix things. At these initial visits, we talk about how those different types of personalities can help to support each other.
We discuss how men should just listen to women, you don't have to fix it if they've talked about something, and women should give men tasks to help them direct their energies to task‑oriented activities that help them to feel that they're supporting the woman and are also obviously incredibly helpful. These psychosocial support systems are very, very important.
We all are challenged to work with the payers and to the insurers to make sure that our patients have access to the most effective new agents. That will continue to be a challenge now and in the future as we work with pharma and insurers to help them understand the importance of individual treatments on quality of life and longevity.
How has treatment for breast cancer change during the COVID‑19 pandemic?
Initially, when the pandemic took root, we had a lot of discussion about how to minimize toxicities from treatment that may make a patient myelosuppressed and put them at risk for infection presumably because they were immunocompromised.
We initially started to delay doing surgeries, putting women upfront on chemotherapy or endocrine therapy to delay their surgery. As time went on, it became apparent that that strategy was not necessary because we were not putting women at increased risk.
In fact, knowing what their appropriate stage and treatment was, was more important than worrying about any possible complications related to COVID. For women with breast cancer, there hasn't been a lot of change. All along, the women who had metastatic breast cancer continued to receive their treatment because that's their lifeline. During COVID, that did not change.
Where we see the difference in breast cancer care has been in the screening. Nationally, we see significant decreases in the number of women who underwent their screening mammographies.
What we're seeing now, and this is just the beginning of what we're going to see throughout the next year, is an increase in women with locally advanced breast cancer, so cancers that were in place and ignored or not picked up on screening and therefore presented as a greater stage when they're finally diagnosed.
The impact of COVID has been on new diagnoses of breast cancer and the use of screening mammography.
What are some of the biggest areas of breast cancer care and management you think both providers and payers should know about?
I would like the payers to have a better appreciation of the patient experience and the impact on the family and the importance of psychosocial support. I mentioned earlier that we have what we call our couples program where our psychosocial support people or social workers meet with our patients and their family members to talk about psychosocial support throughout the treatment course.
What we've demonstrated is that women in our couples programs actually have shorter length of stays in the hospital than the women who were not part of our couples program. What this says is that ultimately having that type of support at home, and that sort of strength of the support does translate into cost savings.
I wish that our payers and our providers would actually study this because, although this is soft science, the psychosocial support, ultimately, it can translate into cost savings.
Is there anything else you'd like to add?
The importance of the patient in decision‑making cannot be overstated. Over my years, I have learned so much from my patients, whether it's the patients who are not advocates, or our patient advocates who tell us what's important to them.
Because in treating the patient, if we don't know what's important to the patient, we get caught up in the biology and the science, which is fascinating, and it's incredibly important at making advances, but ultimately, does it help the patient in the long run? The importance of advocacy and incorporating the patient into the decision‑making process cannot be overstated.
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