“Cancer can be scary” is an understatement, and choosing the right care team can be just as daunting. “Will they point me in the right direction?” “Can I trust them with my care?” “Will they advocate for me during the fight of my life?” These are just some of the questions you may be considering as you select your oncologist and meet your healthcare team. Taking a closer look at what a breast cancer healthcare team should look like and what role each member plays will hopefully provide comfort to newly diagnosed breast cancer patients and equip them with the knowledge needed to be successful. Every breast cancer journey will vary and should be specific to the individual and their disease. One size fits all does not apply in cancer care anymore.
Members of your cancer care team will be integrated into your cancer journey at different touchpoints. One or all of the care team members can play a key role depending on your specific disease. Mapping out what each healthcare professional brings to the team can hopefully guide you through what a breast cancer journey looks like.
Primary Care Physician/ Gynecologist
Breast cancer is often detected through a suspicious lump found upon examination or through a screening mammogram. Your primary care physician (PCP) or gynecologist may be the one who refers you to an imaging facility for further examination and screening. Once a cancer has been detected, depending on the details of your disease, a referral to a breast surgeon or medical oncologist will take place. It is imperative that you express your wants and needs so you are referred to the physician who fits your needs. If you want a female rather than a male doctor, or if you prefer a doctor who focuses on a more holistic approach, make sure to inform your referring physician so the appropriate referral can be made.
PCPs/gynecologists are brought back into your cancer journey once you transition into survivorship. They will assist in managing your comorbidities, screening recommendations, and caring for any psychosocial issues once treatment is complete.
Radiology is the method through which breast cancer screening is implemented. Certified radiologists provide screenings via mammograms and diagnostic imaging to detect breast cancer. This experience, whether you are coming in for your annual screening or due to a new breast lump, can be intimidating. However, having a mammogram done is vital to women’s health and should remain a part of your comprehensive care.
The radiologist and imaging technicians will explain the process and what to expect at your appointment. If something is found to be suspicious or needs additional imaging, the facility will reach out to schedule additional testing. This may take the form of an ultrasound and possibly a biopsy if it looks like cancer. A breast biopsy is done by the radiologist; a sample of the suspicious area is sent to the lab to determine if cancer is present. The radiologist will inform you of the results and the next steps once they receive the results from the lab. They also remain in contact with your referring physician to keep them informed of the results and recommended next steps.
Although the patient may never meet their pathologist in person, as they are more behind the scenes, they are just as important as the other healthcare team members. Their job is to examine the breast tissue, sent from the radiologist, under a microscope and determine if the sample is cancerous.
If they diagnose the tissue as cancerous, they also look for specifics of that cancer, such as type of cancer, stage, hormone receptor status (is it estrogen, progesterone, or HER2 positive?), grade (growth rate of the cancer), and any other pieces of information that will be needed to successfully treat the cancer. This information is crucial for your healthcare team to map out a treatment plan that is personalized to you and your specific cancer. This information can help your physicians make decisions about the type of surgery, if chemotherapy will be needed, and if you would benefit from certain hormone blockers.
Depending on multiple factors, including stage, hormone receptor status, and recurrence risk, breast surgery is often the primary treatment—which often makes a surgical referral the next step in the patient’s journey. The breast surgeon will have a consult with you to discuss your disease and provide you with surgical options. It is important to give yourself time to make your decision and understand what to expect when evaluating treatment options. The surgeon removes the cancer and any lymph nodes that may be involved until they achieve negative margins (no cancer left behind).
Breast surgery, especially breast cancer surgery, has evolved over the years, allowing patients more options. Surgeries can include a lumpectomy or a mastectomy. “Lumpectomy, also known as breastconserving surgery, is the removal of only the tumor and a small amount of surrounding tissue. Mastectomy is the removal of all of the breast tissue. Mastectomy is more refined and less intrusive than it used to be because in most cases, the muscles under the breast are no longer removed.”1 There are advantages and disadvantages to both surgeries that will need to be discussed with your breast surgeon. Your decision will be based on several factors, including how you feel about losing your breast, the potential for additional surgeries if your margins are not completely clear, the need for radiation after a lumpectomy, the extensiveness of the surgery itself, and the possible need for reconstruction.1 Expressing your wants and concerns, as well as asking questions and viewing photos with your physician, can be helpful in making the right decision for you.
It is also important to remember that you can always seek a second opinion. “A second opinion may confirm your original doctor’s diagnosis and treatment plan, provide more details about the type and stage of breast cancer, raise additional treatment options you hadn’t considered, or recommend a different course of action.”2
Reconstructive surgeons have become key members of the breast cancer care team for many patients. Through various reconstructive procedures, such as implants or autologous “flap” reconstructions, they can help you look and feel comfortable with your new breasts. Implant reconstruction is done by inserting an implant filled with saline or gel. An autologous reconstruction uses tissue transplanted from another part of the body, such as your belly, thigh, or back.3
Some patients choose to have reconstructive surgery, and others choose a different path. This decision is made between the patient and the reconstructive surgeon depending on a multitude of factors, including candidacy of reconstruction, recovery outlook, body image concerns, and peace of mind.
This type of shared decision-making between the patient and their surgeon is essential in making the right decision for the patient. “Shared decisionmaking is a process that informs patients about what available treatments are most effective under particular circumstances, incorporates patients’ needs and values into decisions, and improves the patientclinician dialog about decisions.”4
There are many factors when selecting the surgery that is right for you. Attending an initial consult to view “before and after” photos of varying surgical options can assist you in making your decision. If you are still undecided, you can also seek out a patient who has had a similar surgery to learn more about the surgery itself, recovery time, and follow-up care. Again, there is no wrong or right answer when it comes to reconstruction. This decision can be made easier if you gather as much information as you can.
Whereas surgeons and radiation oncologists aim to treat the cancer locally, medical oncologists focus on the systemic treatment of cancer. Their goal is to rid the body of cancer cells and prevent recurrence with chemotherapy, immunotherapy, hormone therapy, or targeted therapy. Medical oncologists prescribe, administer, and manage your medications and their side effects.
Medical oncologists spend a lot of time with their patients, often monitoring them for years into survivorship. That is why it is so important to have a doctor you trust.
Try to keep an address book of all of your physicians’ phone numbers and addresses. If you are on chemotherapy or taking hormone blockers, you may need to ask the nurse a question regarding a side effect and need quick access to reach them directly. Medical oncology offices often have an afterhours number you can call in case of an emergency.
Radiation therapy is another type of local cancer treatment used in breast cancer. It utilizes high-energy x-rays or other particles to destroy cancer cells. There are different methods of radiation therapy, with the most common being external beam.5 This can be a long process if done traditionally every day for weeks at a time. Radiation has several different side effects based on where the radiation is directed. For example, if you have radiation directed toward your abdomen, you may have gastrointestinal upset as a side effect. If you receive brain radiation, you may have more cognitive disturbances and lose your hair.
For a breast cancer patient, the most common side effects are armpit discomfort; skin changes, such as redness and irritation/peeling; chest pain; fatigue (most common); heart problems; lowered white blood cell counts; and lung problems.6 As with many other treatments, not every patient will experience side effects, as each patient is unique. Usually these side effects have a gradual onset, so it is important to always inform your radiation oncologist or radiation technician of your side effects so they are able to catch it early and manage the side effect.
Palliative Care Specialist
Palliative care specialists are experts at addressing side effects of your treatment and preserving your quality of life. It’s important to know that palliative care is for all patients.
Genetic testing plays an important role in breast cancer for a small number of patients who are appropriate candidates. In fact, in the United States, only 5% to 10% of breast cancers are linked to an inherited gene mutation, and about half of these are linked to a BRCA1 or BRCA2 gene mutation.7 Although not all patients will qualify for genetic testing, the patients who do qualify need to choose a genetic counselor who takes the time to educate them on the complexity of genetics and how it relates to their cancer. Your breast surgeon and/or medical oncologist will determine if you qualify for genetic screening and can facilitate the testing. If you do carry a gene mutation for breast cancer, your referring physician will discuss in detail what your next steps are as it relates to your cancer treatment and will also explain what it means for your family members who may be affected. Preventive measures such as a high-risk surveillance program can be implemented as well.
The nurse navigator serves as your advocate, guiding you and your family through your cancer journey. They provide education, support, and resources. A liaison for your personalized multidisciplinary team, your navigator should be oncology certified and available to address your questions and concerns, help educate you about your cancer, assess for side effects, and assist in the coordination of care.
Although patient navigators do not have a medical background, they will help to support you in many ways. From scheduling your various appointments to providing resources for transportation, a patient navigator will help to ensure a smooth process and that your care is efficiently coordinated.
Social workers can be an asset when it comes to finding you resources and referring you to the appropriate specialists. Situated in a hospital or clinic setting, “A social worker may help people find community resources and support services, and provide counseling and guidance to help with issues such as insurance coverage, nursing home placement, and emotional distress. An oncology social worker is an expert in coordinating and providing help for the cancer patient and family, such as counseling them and helping to manage financial problems, housing or child care issues (such as when treatments are given at a facility away from home), and coping with different types of emotional distress.”8
Support can take a multitude of forms and mean different things to different people. Choosing your support network during this time is important and should be based on your preference and what works best for you. For example, this could include leaning on family, friends, or a support group. Studies have shown the positive effect support can have on a patient’s journey. “An increase in the amount of social contact, representing greater social support, may increase the likelihood of the women’s survival by enhancing their coping skills, providing emotional support, and expanding opportunities for information- sharing.”9 Your support system should be there for you to help decrease stress and offer help when needed. Surrounding yourself with positive and loving people— regardless of how they are connected with you—is the most efficient way to utilize support.
The complex world of cancer care can be distressing and difficult to navigate without the right team in place. When a breast cancer has been diagnosed, it will feel like a whirlwind in the beginning, with appointments and decisions that need to be made. Try to remember that you will have a complete healthcare team surrounding you during this time to lead and guide you through your journey. Each healthcare professional has a role to play in fighting your cancer. Understanding the role each team member plays and what to expect during your cancer journey can help decrease the anxiety of the unknown. Knowing that you can lean on your team and have confidence in their expertise will provide you with the hope and comfort you need to focus on the most important aspect of the cancer journey—yourself.
- Breastcancer.org. Surgery. www.breastcancer.org/treatment/surgery. Updated June 20, 2019. Accessed February 5, 2020.
- Breastcancer.org. Getting a Second Opinion. www.breastcancer.org/ treatment/second_opinion. Updated April 7, 2016. Accessed April 2, 2020.
- Breastcancer.org. Types of Breast Reconstruction. www.breastcancer. org/treatment/surgery/reconstruction/types. Updated December 9, 2019. Accessed January 14, 2020.
- Bellavance EC, Kesmodel SB. Decision-making in the surgical treatment of breast cancer: factors influencing women’s choices for mastectomy and breast conserving surgery. Front Oncol. 2016;6:74.
- Cancer.net. Understanding Radiation Therapy. www.cancer.net/navigatingcancer- care/how-cancer-treated/radiation-therapy/understanding-radiationtherapy. Accessed December 30, 2019.
- Breastcancer.org. Radiation Therapy. www.breastcancer.org/treatment/ radiation. Updated July 22, 2019. Accessed February 5, 2020.
- Susan G. Komen. Genetic Counseling and Genetic Testing. ww5.komen. org/BreastCancer/GeneMutationsampGeneticTesting.html. Accessed February 5, 2020.
- American Cancer Society. Health Professionals Associated with Cancer Care. www.cancer.org/treatment/finding-and-paying-for-treatment/choosing-yourtreament- team/health-professionals-associated-with-cancer-care.html. Accessed January 14, 2020.
- Chou AF, Stewart SL, Wild RC, Bloom JR. Social support and survival in young women with breast carcinoma. Psychooncology. 2012;21:125-133.