DR LOVE: We’ve been doing patterns of care studies with oncologists for several years via national telephone surveys and using keypads and laptop computers at meetings. We’ve been gathering information on how oncologists practice — or how they say they practice. The information we gathered led to this new publication called Patterns of Care.

We conducted a national telephone survey of 200 medical oncologists from approximately 37 states randomly selected from the ASCO mailing list of oncologists in practice. Each question was asked of either 100 or all 200 physicians, so we are fairly confident in the numbers.

I’d like to present and discuss some of the results with you. According to the data (Figure 2) — and we have seen this from several other studies as well — about one third of general oncology practice is dedicated to breast cancer. Does that surprise you?

DR CARLSON: It doesn’t surprise me based on the number of therapies that are available to women with breast cancer and the intensity of the interactions that are required. My expectation is that we are going to see those numbers decline over the next year or two as information about the advances in colorectal cancer and lung cancer are distributed throughout the community.

DR LOVE: That’s a good point. I imagine that adjuvant therapy is creating a lot of the office visits for breast cancer patients, and it seems that adjuvant therapy for colon cancer and lung cancer is changing very rapidly.

DR CARLSON: I am sure a lot of it is adjuvant therapy but a lot of it is the weekly therapies we use for recurrent disease. Add in bisphosphonates and all the growth factors we are now using in the metastatic setting and it equals a lot of office visits.

DR LOVE: Before we discuss clinical scenarios, I’d like to ask you some questions that we asked the surveyed physicians relating to more psychosocial and quality-of-life aspects of patients with metastatic breast cancer and their predictions for how patients would rate their experiences with oncologists and oncology nurses.

Joyce, how many breast cancer patients in your practice have died in the last three months (Figures 3 and 4)?

DR O’SHAUGHNESSY: Oh, it has been terrible. I have lost many patients in the last six months. In the last three months, I would say approximately six patients have died. My practice is all breast cancer so they were all breast cancer patients.

DR LOVE: You said you had a terrible six months. How does that affect you?

DR O’SHAUGHNESSY: I have been in Dallas for seven and a half years. Many of these women have been my patients for five, six, seven years. They live a long time and you get to know them. It is really a complicated question because aside from my love for my family, taking care of breast cancer patients is the most enhancing thing in my life.

I’ve learned over the years — and it has taken me a long time to understand this — that truly caring about somebody, wanting to solve problems on that person’s behalf and struggling to do everything you can to help that person — is the most empowering and energizing emotion I know. It is extremely positive.

Human beings are built for service; we are absolutely hard-wired for it. It is good for us, motivates us, energizes us and brings out the best in us, so getting to know patients, caring about them and seeing these women is absolutely one of the most enhancing things in my life.

Thankfully, in breast cancer, we often have the opportunity to celebrate remissions. But you know darn well, Neil, that patients die. When you see the inexorable progression, start running out of options and watch as the symptoms become debilitating, it is very sad and it makes you feel helpless. It also spurs you to do the very best you can for earlystage breast cancer patients and become the strongest of salespeople when it comes to recommending and keeping women on therapy.

Patients tell me all the time, and it amazes me, that the best palliation by far comes from pills — antiestrogens or capecitabine. For HER2- positive disease, drugs like vinorelbine or trastuzumab provide enormously wonderful palliation for long periods of time as well.

However, in these patients who have prolonged periods of excellent quality of life and then go on to have horrendous difficulty with progression, lots of symptomatology and suffer the side effects of chemotherapy when they die, their families look at me and say, “You gave her five more years.”

I have had several patients, and two come to mind, who died particularly difficult deaths. Both experienced complications from chemotherapy and died in the hospital instead of at home with hospice. However, both families expressed their appreciation for the extra years they had with their loved ones. That is enormously powerful.

DR LOVE: What do you do personally to deal with some of the stress and these feelings of helplessness?

DR O’SHAUGHNESSY: The way I deal with these feelings is to funnel them right back into breast cancer. I listen and give respect to my own evolving observations about patterns of care and what works. I try to outsmart the cancer. I don’t have “willy-nilly” algorithms for how to treat metastatic disease. I try to psyche it out.

The other thing I do is research. For example, these horrendous triplenegative (ER/PR/HER2-negative) breast tumors are very drug resistant. Some we cure in the adjuvant setting but the ones that come back are horrendous. We are hoping to start a new clinical trial of CPT-11/carboplatin with or without cetuximab because about 50 percent of these tumors have EGFR overexpression.

DR LOVE: How many clinical visits do you think the average woman with metastatic breast cancer has over a three-month period of time (Figure 7)?

DR O’SHAUGHNESSY: If we are including visits with the doctor, appointments for hematopoietic growth factors and everything else that patients come in for, I would have to agree with what the physicians said — seven or eight, on average.

DR LOVE: How long do you think the typical patient with metastatic breast cancer spends in your waiting room (Figure 8) and how long do you think she spends at your office from the time she arrives until the time she leaves (Figure 9)?

DR O’SHAUGHNESSY: I think she waits about 45 minutes to see me. When we add in the treatment time, the blood work and the consultation with me, I think each visit is probably two hours in total.

DR LOVE: That leads us to the next question, how long do you typically spend with a patient with metastatic breast cancer (Figure 10)?

DR O’SHAUGHNESSY: I would say a typical, relatively uncomplicated visit would probably last approximately 12 to 15 minutes.

DR LOVE: One of the other interesting aspects of this survey is that we asked physicians how their patients would grade them in terms of their overall care (Figure 12). What makes this so interesting is, in a similar survey we conducted of metastatic breast cancer patients, we asked them to actually grade their oncologists and oncology nurses using a 4-point scale.

We have recently prepared an abstract about this for presentation at the 2004 San Antonio Breast Cancer Symposium. What grade point averages do you think patients gave their oncologists and oncology nurses?

DR O’SHAUGHNESSY: I am going to guess that patients, on average, scored their doctors a 3.8 and their oncology nurses a 4.0.

DR LOVE: They were actually both about 3.5 and support the overall theme of the abstract, which is that patients think very highly of their doctors and nurses. I asked this question in conversations at ASCO and a variety of other places, and I found that at least half of the oncologists I spoke with think their patients would give them a “C”. Many underestimated how much patients appreciate their work.

DR O’SHAUGHNESSY: I think patients love their healthcare team, Neil; I think doctors and nurses become enormously important people in the lives of metastatic breast cancer patients and their entire families. These people spend a lot of time thinking about their doctor and when they see kindness and true caring from the doctor, they truly appreciate it.

DR LOVE: This is another very interesting question. What percent of patients do you think fired their oncologists because they weren’t happy?

DR O’SHAUGHNESSY: A very small number. I would say five percent.

DR LOVE: It was 21 percent.

DR O’SHAUGHNESSY: That is the actual number from the patients?

DR LOVE: Yes. Twenty-one percent of these women left their oncologist because they were not happy. Part of the reason patients are so satisfied is because they seek satisfaction.

DR O’SHAUGHNESSY: They sought out what they needed. Good for them. Wow, that number is very high.

DR LOVE: Which of these characteristics do you think patients would view as most important (Figure 13)?

DR O’SHAUGHNESSY: Wow, these are all important. If I had to rate the highest, I would say it is a toss-up between providing straightforward information and caring, with providing straightforward information coming first.

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