Supportive Care for Breast Cancer

Transcript

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00:13 --> 00:43Welcome to Yale Cancer Answers with doctors Anees Chagpar and Steven Gore. Yale Cancer Answers features the latest information on cancer care by welcoming oncologists and specialists who are on the forefront of the battle to fight cancer. This week, it is a conversation about supportive care for breast cancer with Elspeth Knill Selby, an Advanced Practice Nurse in the Breast Center at Smilow Cancer Hospital. Dr. Chagpar is a Professor of Surgery at the Yale School of Medicine.
00:43 --> 00:51<vChagpar>So, Elspeth, why don't we start with you telling us a little bit about yourself and what exactly is an advanced practice nurse?
00:51 --> 01:28<vKnill Selby>An advanced practice nurse is collaborating with a physician so that we are able to provide collaborative care for patients such as breast cancer patients where the term at one point was physician extender, but that is not the term that we use now. We use advanced practice provider. So, we are available potentially when the physician is not. For instance, with a surgeon, the surgeon might be in the operating room and we are available in the clinic if there is an issue with a patient.
01:28 --> 01:42<vChagpar> So, tell us a little bit about the background to that. How do you become an advanced practice nurse, what is involved, what kinds of things do you do, what kinds of things do you not do?
01:42 --> 04:04<vKnill Selby>Well, the way I went about it is quite interesting actually because my background, my bachelor's degree is from Mount Holyoke in Massachusetts in psychobiology. But I always had an interest in medicine and nursing because my father was a physician. But I started thinking about it and thinking the best mix might be to become a nurse practitioner so that I was able to not only have a life kind of outside of my work, but to really provide a good balance. I thought, I will go and get a bachelor's in nursing. So, I debated, and elected to get a broad-based background, a liberal arts background, a recommendation of my dad's, and then decided that I would go and become a nurse practitioner, so I could practice but hopefully I would be able to really have a work-life balance. So, I went down to Vanderbilt actually and did a degree in family practice and fell into oncology actually. I decided that was really the area that I could make a difference in. So, I did some basic nursing and then someone asked me to work in radiation oncology as a nurse practitioner. It was establishing a role there which was quite interesting because physicians were not really aware of that. We collaborated basically and alternated between visits. I would see the patients some visits, they would see them some visits, so they really felt like they were getting to know several different people and if need be, they knew who to connect with if a person was not available. I did research nursing for a time in New Jersey and then came up to Yale, did research nursing again for a time and then started in surgery.
04:04 --> 04:47<vChagpar>Tell us about the differences in role between a practice nurse, an RN, and an advanced practice provider or an APRN, or a nurse practitioner. Are there differences in terms of scope, in terms of education, in terms of what you do, what they do, those kinds of things? I can imagine that some of our listeners who may not be used to having multiple different providers with different kind of credentials, may be confused what the difference is between a physician assistant versus a nurse practitioner versus a practice nurse versus a patient care associate?
04:47 --> 06:54<vKnill Selby>I approach it as we are all people going to care for the patient. Again, I am repeating myself and saying it is collaborative, but it truly is. The PCA or the ACA as now the term is, they are the ones that take the vital signs and put the patients in the room. But they set the tone for the visit. They put them in the rooms, the RN, now she may have a diploma, she may have a certificate or even a bachelor of nursing, you can never assume, but they will take a history, talk to them about their medications and their allergies and that kind of thing and kind of a bit of their history as well and present that to the physician typically. And the nurse practitioner role is kind of, we are like a bridge between everybody. So, if the physician is not available; often times, the nurse or maybe even the PCA comes to us and may say so and so is having an issue, the doctor that we both work with is not available, what are your thoughts? So, the nurse practitioner or the physician assistant as far as I am concerned work in the same way that we are able to provide care when a physician is not present. You know, we are able to practice independently. I am not as clear on physician assistants, I think it varies actually state to state as to if you can prescribe and those kinds of things. But, bottomline is that we can see a patient, evaluate them, we can prescribe medications and depending on your area of expertise, you may be doing particular procedures and things like that.
06:54 --> 07:08<vChagpar>So, working very much in partnership with the rest of the team and the surgeon or the physician in this case to really provide care in a seamless kind of way.
07:08 --> 07:09<vKnill Selby>That's correct.
07:09 --> 08:08<vChagpar>You know, Elspeth, the other thing that strikes me especially in the care space is how important the whole team is in terms of supporting the patient and being there through that whole journey. Talk a little bit about that and what you do to help patients kind of get through this because for many people, I can imagine that you are diagnosed with cancer, your doctor tells you about the diagnosis and maps out this whole treatment plan, which at that time probably sounds like blah, blah, blah, blah, cancer blah, blah, blah, blah, blah, blah.... and you just come out of the room feeling completely overwhelmed and devastated, and I feel like that is often times the space where the whole team gets together to support that patient. Talk a little bit about that and some of the tools that you use to help patients to get through that.
08:08 --> 10:17<vKnill Selby>Well, it can be challenging because there are times where I am seeing the pathology first, that the individual has a cancer and certainly I will discuss that with the physician or the surgeon before I phone the patient and so I will phone them and I will say, unfortunately I am the one that is going to deliver this news to you and it is part of my job that I hate, but you know, this is what we found and you just sense that their brain turns off after you have said cancer. And there is kind of a pause and I am kind of waiting to see how they are processing things. And so, I will say to them, yes this is what it is and we need to move forward, we need to get you back into see the breast surgeon and talk about a plan and I might briefly go over the pathology and say, this is what we are seeing, we may not have a size or a design, but we may know some of the characteristics, so I will briefly talk to them about that, but I will say you will be coming in, please write down all the questions that you have, otherwise you get in there and it just slips your mind, please bring us a second set or a third set of ears because we want you to ask the questions. You are not really hearing what I am saying right now, but again that is what we are here for and that is what I am here for, we are a team, no question is a silly question. Sometimes, I have not met them and I am telling them of their diagnosis, but I say I am making a point to meet you and so it kind of goes from there.
10:17 --> 10:47<vChagpar>I think that is a really good point for people out there who are listening is that you want to advocate for yourself and you want to make sure that you are asking all of the questions that you have, writing them down, thinking about them in advance, bringing some extra people, taking notes. And if you have questions after the visit, feel free to call your team and it sounds like there are a lot of people on a team who can answer those questions.
10:47 --> 11:23<vKnill Selby>What is wonderful too is that we have this binder now that we give patients that are newly diagnosed, and it is great because they have a place to put their pathology because when the patient comes in, we give them a copy of it so they have a place for that, they have a list of who is on their team from the patient care associate, the nurse, the nurse practitioner, the physician. So, they have a sense that it is a team collaborative effort. And that we are all there to support them.
11:23 --> 11:58<vChagpar>And I can imagine that as a patient goes through that journey, they get the phone call or they are called into the office, they get the diagnosis, they map out this treatment plan, they ask the questions, they go home and then life sets in. And the idea that oh! my gosh, this is a real diagnosis, this is something that is going to effect me, it is going to affect my kids, how am I going to tell my kids what is going to happen to my work, all of those things come into play. How do you help patients through all of that?
11:58 --> 12:49<vKnill Selby>So, we have a wonderful social work department that helps. It helps in that process and that is certainly something that is identified right at the first visit, and so, the social workers are aware, we offer that to the patient and a relationship is started right at that point because it is a critical point, it is a critical time, and again, they are trying to process all this information and how are they going to tell their daughter who is 5 or their daughter that is 13, or their son that is 13 or 5 or what not, because developmentally too, they are different stages. And so, that is a wonderful thing too because the social worker can really talk to them about, okay what do you say to your child or what do you say to your spouse?
12:49 --> 13:13<vChagpar> Yeah. And then, I can imagine that the other piece that comes in in terms of emotional support and so on is the guilt that comes with the diagnosis, what did I do? Was it something I did, did I eat something, should I eat something different, was it because I have not exercised, is it all of that? How do you talk to the patients about that?
13:13 --> 13:41<vKnill Selby>So, I bring them back to the present. I say, we need to look forward and not back and there is nothing that they could have done differently necessarily because it is not a blame game. It is really again moving forward, do not look back and it is a journey. I also say it is marathon, it is not a sprint.
13:41 --> 14:04<vChagpar>And it is a marathon that many patients do not want to go on, but it certainly is something that I think becomes a lot more liveable when you have got a good team helping you through it. We are going to take a short break for a medical minute. Please stay tuned to learn more about support and resources for patients diagnosed with breast cancer right after this.
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15:18 --> 16:40<vChagpar>Welcome back to Yale Cancer Answers. This is Dr. Anees Chagpar, and I am joined tonight by my guest Elspeth Knill Selby who is here talking about supportive care and resources for patients with breast cancer. Elspeth is an APRN, who works in the breast center at Yale, and right before the break, we were talking about how people going through the journey of breast cancer that this is really a marathon, not a sprint and a marathon that nobody really wants to go through. Elspeth, another topic that often comes up as people are going on this journey is the whole idea of genetics. You talked about it not being a blame game, but nowadays, many patients are being sent for or getting genetic testing where in fact they discover that they may have a genetic mutation that predisposes them to breast cancer. I can imagine that that does a number of things for patients. #1, it may incite in them some sense of guilt blame, oh! my gosh, am I putting my kids at risk and #2, this whole conundrum of what am I going to do now? Talk a little bit about how you counsel patients who are facing genetic mutations.
16:40 --> 18:45<vKnill Selby>Well, it is quite interesting because over the years, I have had people, patients approach it differently. For instance, I encountered one patient that had undergone the testing, had actually had ovarian cancer but did not want to know the results of her genetic testing, which I thought was quite interesting, but again, I give them information and I let them make their decision, because it is daunting, especially if you have children, girls or boys, because men get breast cancer as well. My thought and my training as a nurse practitioner is primary prevention, being proactive, not being reactive, being able to kind of have a sense of plotting out things. There are a number of patients I follow with the carrier mutation and want to be followed initially and particularly women that are considering having children and all of that, they are trying to plot things out and they may have an egg retrieval or go through that as well, have the eggs tested to see if they carry the mutation, do they not and go from there. I mean, we have had some really young women recently that have either carried the mutation or carried the mutation in addition to having a breast cancer. And as far as I am concerned, it is daunting at that time in your life to have to try to plot out the rest of your life in terms of what you are looking for, what you want. So, again, try not to overwhelm the individual but put it out there for them.
18:45 --> 19:43<vChagpar> Yeah. I can imagine that for a young patient particularly right. You are 30, 40 years old, you are thinking about having kids, you have just now been told not only do you breast cancer, but you also have a gene mutation, so this increases your risk of breast cancer, it increases your risk of ovarian cancer, should you have your ovaries out, should you have your breasts removed, what about having kids because if you are going to undergo breast cancer treatment, you need to think about fertility preservation first, that is a lot. How do you help patients map that out and to take a breath and to put one step in front of the other and to really bring together and coalesce a team around that patient to support them through what is undoubtedly a very complicated, very daunting, very challenging time in their life.
19:43 --> 20:46<vKnill Selby>Well, again, you know, we are collaborating not only with our team, but with the other specialities too, so for instance, the fertility-infertility people. Certainly medical oncology comes into play as well, if the patient needs to have chemotherapy because that is going to impact childbearing and all of that. Also, genetics, they are excellent. They do the testing and then the genetic counselors counsel the patient as to how this individual should proceed and what their options are. What we are trying to do is make sure that they make informed decisions. So, providing the information, it is a delicate balance between too much and too little information. So, we have to kind of try to hit it in between those two.
20:46 --> 20:52<vChagpar>Yeah. And I would suspect that some patients want more information and some patients want less.
20:52 --> 21:18<vKnill Selby>Exactly and you can never assume. As I have said to patients, you drive the bus, you tell me what it is you want, are you feeling overwhelmed, is it too much information or are you not getting enough, and again, I let them direct their care and really encourage them to be their own advocates.
21:18 --> 22:19<vChagpar> Yeah. And I think the other piece is that, as you mentioned, this is really an interdisciplinary team and so making patients really feel supported with all aspects of their care so that they understand that this is really a coordinated effort that yes they are at the center of this effort and "driving the bus" but it is not like they are driving the bus without a map and without a crew on board who is helping them every step of the way. You know, a lot of patients as they go through this, and we talked a little bit about this blame game that often goes on in the psychology of patients, will ask questions like, so now that I have had breast cancer and I am going through treatment, what can I do? You know, what kind of diet should I have, should I take certain nutritional supplements, what can I do? What do you tell patients?
22:19 --> 23:09<vKnill Selby>There is a nutritionist, but also too, depending on where they are, we have a survivorship program as well and they address things such as diet and exercise and all of those types of things so that it is neatly packaged up so they walk away thinking okay, I have had these things addressed because how do I move forward because obviously I need to move forward and get on with my life and do things that I would have done before my diagnosis and hopefully during the diagnosis.
23:09 --> 24:44<vChagpar>Yeah. I mean, I think certainly having those kinds of resources and talking to people about,eating healthy, just taking this as a teachable moment in life to really make some positive changes in your life, I have found so many patients have really taken the diagnosis of breast cancer and once they have gotten through, kind of the tumultuous part of oh! my gosh this is a real diagnosis and I have to get through treatment, really take it becomes how I am really going to live my life, I am going to suck the marrow out of life because I can and because I now realize that there is more to life than I had thought before and I want to live my best life. And kind of getting to that point I think is something that is really wonderful to see with patients. So, talk a little bit about, can patients get back to doing everything they normally do because some patients may feel like I have had cancer, I am not sure that I can do what I used to do, I am not sure I can go to the gym like I used to, I am not sure that I am going to be perceived the way I used to, I am not sure about whether my friends and my loved ones are still going to love me after this diagnosis and I can imagine how while we say move forward, people may not feel like they can move forward always. How do you help them through that?
24:44 --> 26:11<vKnill Selby>Well, this sounds kind of silly, but one of the things I do is make people laugh, humor I think is important but to make people laugh I say, think about me with pom-poms and I am cheering you on through all of this because of the number of years that I have been in this, I have been on lots of journeys and I have been privileged to meet all kinds of different people and all kinds of situations. And there are so many success stories and that is the exciting part is to see people, you know, 2, 3, 4 years, 5 years out and be able to for instance congratulate them and just say, you are walking around and there are probably a lot of women out there that have gone through what you have gone through and you would not have a clue. And that there certainly is life after cancer, and you can do any of those things you used to do. And I encourage that and as one of my colleagues said, yI do not ask them about exercise, I ask them if they move and I think that is a good way of approaching it. So, it is just a more kind of natural way to ask a question that it does not have to be in a gym, a very structured activity, it can be outside going for a walk in the park.
26:11 --> 26:41<vChagpar>Absolutely. And as we are approaching breast cancer awareness month, as we wrap up here in the last few minutes, talk a little bit about kind of the advice that you would give breast cancer patients #1, and #2 - people who have not yet been diagnosed, but advice that you would give men and women in terms of taking care of their health so that maybe they reduce their risk of developing breast cancer or other cancers.
26:41 --> 27:37<vKnill Selby>I talk about it being really a lifestyle change and basically not a diet or not necessarily an exercise regimen, but, you know, again as you had mentioned, living your best life. So, again, another thing I tell patients is, everything in moderation. You do not have to never drink a glass of wine again, you do not need to never have a piece of chocolate again, those kinds of things because I think that people come out of this and think okay I need to do this, this and this and I need to exercise 7 days a week for 30 minutes at a time and no fat, no sugar, nothing processed, and I think that becomes very limiting and very overwhelming in itself. So, again, I guess my message is everything in moderation.
27:37 --> 28:17<vChagpar>Yeah. And really, you know, get out there and do the things that you want to do. Don't really think about this is a limiting diagnosis, but something that you can really take hold of and participate in all the things that you would want to without really thinking about your diagnosis as a limiting factor. You know, in terms of reducing risk, do you have advice for people because I am certain when they come to see you and they bring their family, often their family members are going to say well, okay what should I be doing?
28:17 --> 29:11<vKnill Selby>Yeah. That is an interesting question. Prevention is key, so routine screening, and again it depends on the age for instance that a woman is diagnosed, but certainly for just general population, we say first mammogram at 40, and at this point,I typically will say annually and an annual breast exam at least as just the very basic recommendation, and then again a well-balanced diet, fruits, vegetables, protein, low fat and moving, doing some type of exercise, it can be just walking at lunchtime or something like that as long as you are moving, that is important.
29:11 --> 29:33Elspeth Knill Selby is an Advanced Practice Nurse in the Breast Center at Smilow Cancer Hospital. If you have questions, the address is canceranswers@yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org. We hope you will join us next week to learn more about the fight against cancer here on Connecticut Public Radio.

Information

Supportive Care for Breast Cancer with guest Elspeth Knill-Selby July 7, 2019 Yale Cancer Center visit: http://www.yalecancercenter.org email: canceranswers@yale.edu call: 203-785-4095