I have been preparing a talk for our oncology fellows about metastatic breast cancer. The slides are full of Kaplan–Meier curves, sequencing strategies, resistance pathways, and the latest drug approvals. All of that matters and is necessary. It is our responsibility to know the science.
But what I keep thinking about is how to teach them the intangibles of oncology. What is it REALLY like to take care of someone with metastatic breast cancer ?
I am, by nature, an eternal optimist. I have always believed that the best possible outcome could happen. That instinct has overall served me well in oncology. When you sit across from someone whose life has just shifted in a single sentence, hope is not something that you can fake.
When I started fellowship at Mayo Clinic, one of the senior attendings, Dr. Robert Phyliky, was preparing to retire. He gave me a tour on one of my first days. At one point, he stopped, looked at me with very kind eyes and a grin, and said he was jealous. Jealous that I was beginning my career at the moment I was.
“You are going to see remarkable advances,” he told me. “You are going to see so many more cures. It’s going to be an exciting time to be an oncologist/hematologist.”
I can still see exactly where we were standing. I can hear his voice. It was a five-minute interaction, but it imprinted on me in a way few moments do. I think about his words on my hardest days. I have now been an attending for twenty years. That alone feels surreal. But he was right.
During fellowship, I witnessed one of those moments in oncology. The development of trastuzumab for HER2-positive breast cancer changed everything. At the time, HER2-positive disease was among the most aggressive and deadly subtypes we treated. I had been seeing patients enrolled on the trial showing dramatic reductions in recurrence. There was a buzz in the clinic even before the data were formally presented.
When the results were unveiled at the American Society of Clinical Oncology annual meeting in 2005, the presentation was described as electric. Progression free survival curves separated widely. They had to close the study early because the new treatment was so good we didn’t want to withhold it from others. As the researcher presented the study there was thunderous applause. A standing ovation. Nurses and physicians crying and high-fiving one another. I was told it was likened to a rock concert.
When my attendings came back and told us what it felt like to be in that room, I remember the tears welling up in my eyes. I felt the magnitude of it. The privilege of being part of something that would permanently alter the future for thousands of people.
We often say metastatic breast cancer is incurable. For many subtypes, that remains true today. But I do not say that reflexively for patients with HER2-positive disease anymore. I have seen too much change. I have seen nearly all of my metastatic her 2 positive patients have no evidence of disease or progression for years. What drug are we currently testing or working on that will be that for the other subtypes and other cancers for that matter? It could be next year or even tomorrow..
See how the hope comes in and is honest?
So when I think about what I want fellows to take away from a lecture on metastatic breast cancer, it is not just which drug to use in the second line.
It is this.
1. We Never Know When the Next Breakthrough Will Come
Life expectancy in metastatic breast cancer is now often measured in years. How many years? We do not know. Uncertainty is hard to talk about with people but get good at doing it without taking hope away.
Keep enrolling patients in clinical trials and pushing science forward. The cure for other subtypes I believe will come in your career. It may come because of someone sitting in your clinic today who agrees to participate in research. Helping to create the next rock-concert moment.
Remain hopeful, for your patients and for yourself.
2. Long-Term Relationships Are a Gift
Because of the advances in treatment, we now walk alongside patients for years. That changes the nature of our work.
Val and I have been together for sixteen and a half years. She was diagnosed with metastatic Her2 + breast cancer at the outset, when our children were very young. She went through chemotherapy. We navigated a recurrence and chemo again. And for the past decade, she has had no evidence of disease.
Oncology allows you to witness lives in motion and see resilience up close. Sixteen and a half years of conversations, of scans and birthdays, graduations and setbacks, fear and relief. Of watching her children grow up and now her having grandkids! Val is the epitome of resilience and she continues to teach me each day how to live life through adversity.
I want the fellows to know how important it is to find moments of real connectivity with each patient. Last week I learned about an awesome new Pilates studio, how cold pressed sunflower oil is made and how it healed up a farmer’s cracked hands, and a 7 exercise routine that my 88 year old has such buff arms. It is one of the most meaningful parts of our field and makes the day joyful.
3. Learn Resilience from Your Patients
If you pay attention, your patients will teach you how to live. Ask them how they cope. Ask them what helps on the hard days. Ask them how they hold uncertainty.
You will need those same tools.
There are parts of oncology that are breathtakingly beautiful. There are also parts that are devastating. The cumulative weight of loss is real. I liken it to war. Borrow the coping strategies of the people you care for. They often become experts in living with uncertainty.
4. Build Your Own Support Team
Do not try to metabolize the emotional weight of this work alone. This I can not stress enough. Please do not make the same mistake I did waiting for things to get very low before having objective, professional help.
It is very hard for people not to instinctively feel so sorry for you when they hear about the lows of your day. I learned that too much sympathy or “cheerleading” was not helpful for me. It made me close up. I also found that people not in the arena held back on sharing their life because they felt their hard wasn’t as hard as my hard. What I needed was perspective, space to process, and tools.
Find a small group of people with whom you can speak honestly about both the joyful and the heartbreaking parts. You need a work partner who can commiserate in a very real way. I also highly recommend including someone objective like a therapist, counselor, or coach.
It is very hard for others to know how to “help” in these situations when someone hasn’t had training.
Hope is powerful. But processing grief ALLOWS you to remain hopeful.
So while I want them to know all of the drugs and side effects and pathways, I also want them to know that taking care of people with metastatic breast cancer is not just about protocols and progression-free survival curves. It is about standing in exam rooms on the worst day of someone’s life and choosing to believe that more is possible.
It is about remembering that five-minute conversation early in your career and allowing it to shape how you practice medicine for decades.
It is about the art and science of humans and that these two things are equally important.
