Nurse helps guide breast cancer patients through treatment

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Treatment options for breast cancer have changed over the years, and today we'll hear about what may lay ahead after diagnosis from nurse Maureen Garvey. She's the breast cancer navigator for the Upstate Cancer Center. Welcome to "The Informed Patient," Ms. Garvey.

[00:00:29] Maureen Garvey: Good morning, Amber. Thank you for inviting me to speak on something that's so passionate to me.

[00:00:35] Host Amber Smith: So what is a breast cancer navigator?

[00:00:38] Maureen Garvey: As the breast navigator here at Upstate Cancer Center, I'm the liaison. So I introduce myself to all the patients that are referred to the breast cancer program here at Upstate. Our breast cancer program here at Upstate is very unique. We have the ability to meet as a multidisciplinary team. So when a patient is seen at our breast cancer program here at Upstate, they see almost everyone involved in their cancer treatment -- the breast surgeon, the medical oncologist, the radiation oncologist, we offer genetic testing to all of our patients, as well as our integrative medicine provider.

[00:01:18] Host Amber Smith: So by the time they meet you, they've been diagnosed with a biopsy. They know they have some form of breast cancer, right?

[00:01:26] Maureen Garvey: All of the patients that come through the breast cancer program have been diagnosed with breast cancer. When they come to us, they're coming from all aspects. They're coming from primary care providers. They're coming from their OB/Gyn (obstetrician/gynecologist) providers. Or they may be coming from our breast and endocrine center. So they're coming from very many other aspects of understanding and knowing about their diagnosis.

[00:01:52] Host Amber Smith: So what happens after diagnosis? What do you do with these -- and then I assume it's mostly -- women?

[00:01:58] Maureen Garvey: The majority of our patients are women. Here at the cancer center at Upstate, we've hadover a handful of men come through the program.

When they come to me and I introduce myself, they have a general idea that they have breast cancer. They don't really know their staging. And a lot of it is confusing because many of our primary care providers and our OB/Gyns, are not specialists. So when they come here, it's a lot of working with them and trying to make them understand.

One of the first questions that the patients ask is, what stage am I? And when I talk to them, I explain to them that the staging is very difficult based on a biopsy. We need more information. And when we come in, we go over everything with them to explain staging and what it entails.

[00:02:50] Host Amber Smith: So there's other testing that may be involved to get the right staging. And the staging is kind of telling them how far advanced the cancer is, right?

[00:03:00] Maureen Garvey: Yes. Staging is how far it's advanced. What is very confusing is now, with modern technology, many of our patients receive their pathology reports before they come here. Many of them are trying to research what certain things mean. When they're looking at a pathology report, there's things in there that may be confusing to them. Like if a pathology says "invasive," invasive can mean many things. We don't know unless they've had a lymph node biopsy if that cancer has spread anywhere else. Invasive means it's established and invaded into that part of the breast. So that's very confusing for patients.

They also now can see other things on their pathology report, like estrogen and progesterone receptors, as well as HER2 (human epidermal growth factor receptor 2) receptors and what we call a Ki-67 (a nuclear protein associated with a proliferation of cancer cells.)

And they can see the grade. People get confused. The grade of their pathology report can be grade 1, 2 or 3. That tells the provider if it's -- I don't want to use the word aggressive -- but the tumor is a little, maybe less slower growing, a little bit less aggressive. Middle is middle of the road. And grade 3 lets the provider know that it's a little bit more aggressive, and we need to keep an eye on it. People get very confused between grade and stage.

When we talk about stage, we talk about the progression of the disease. That tells us about the tumor, where the cancer may have gone, the size of the tumor, if it went to the lymph nodes. That is the stage. That helps with the treatment plan.

So if you are stage 0, which is typically ductal carcinoma in situ, which is, I guess if you want to talk about a tree, it's like seedlings. So it's seeding, and it's sitting around there. When we talk about invasive, like I said before, it's established itself -- either in the ducts, in the lobes -- so that's considered invasive.

Then you're moving on to a stage 1, and then stage 1 can vary depending on the size of the tumor. Then we move up to 2, which could be bigger size tumor and maybe some lymph nodes. Stage three, a little bit more, a little bit bigger, maybe a few more lymph nodes.

When we get to stage 4, it has left the breast and the axillary lymph nodes and travelled to another part of the body -- the liver, the bones, the lungs, or the brain. Stage 4, there still is treatments that can be given. And with our technology, we have a lot to offer patients. So stage 4, for people before, when they hear stage 4 makes them feel like, "oh my, it's my end of life." And you know, we never know when the end of our life will be, but we know now with stage 4, we have so much more to offer.

When we talk about grade of the tumor, that would be on the pathology report. Grade goes 1, 2 and 3, and it looks at different parts of the tumor, like a Nottingham scale is what they use for how aggressive the tumor may be. It tells them that if you come in and it's ductal carcinoma in situ, grade 1, ER- PR-positive (estrogen and progesterone positive), they know that that's an early tumor, hopefully early treatment, as long as the ductal carcinoma isn't somewhere else.

They come in stage 2, ER- PR-negative, HER2-negative, and their grade is grade 2, we know that we got to keep an eye on that. It's getting a little bit more. Grade 3, they're always keeping an eye on because it's the top of the grade. So it makes it a little bit more -- and I hate to use the word aggressive -- but they know that it's a more serious tumor with a grade 3.

[00:07:01] Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with the Upstate Cancer Center's breast cancer navigator, nurse Maureen Garvey.

So it sounds like there's a lot to consider in just getting the full diagnosis. There's a lot of factors.

[00:07:20] Maureen Garvey: There are a lot of factors. A lot of factors are what we see when we talk about their imaging, what is the next step that they need. If we do an MRI, the patients -- because MRIs are so sensitive, some people like them, some people don't -- but we don't want to pedal backwards in the treatment of our patients. If something shows up on the MRI, and someone's recommending on the opposite side of the breast, or if they see something in the affected breast, do we need to go in and do another biopsy? And very often that's happening. But we want to make sure if we see something else that we're not going back six months later and finding something different. Not that that can't happen, but we want to know upfront before we've scheduled them for surgery or we've started their treatment plan.

[00:08:04] Host Amber Smith: I see. So at what point might you recommend or help facilitate a second opinion? Does that ever come up?

[00:08:13] Maureen Garvey: It does come up. It comes up a lot. I can very often tell when a patient feels uncomfortable and they're not understanding or they're hesitant. I always tell my patients, you need to feel comfortable no matter where you go. The most important thing for their care and their treatment is that they feel comfortable. So I always offer to them, is there someone else you'd like to see? Is there somewhere I can set you up? Have you got an idea of maybe who you want to see.

In the world of technology and communication, people really communicate back and forth, and sometimes they have an idea that they would like a second opinion somewhere. So I help facilitate that, getting them their records and things like that. But I like to get a feel of where they're considering. I don't like to say where they should go, but sometimes they have an idea.

[00:09:06] Host Amber Smith: So in terms of thinking about treatment, do you need to know the stage and the grade before the patient knows what their options are?

[00:09:15] Maureen Garvey: So when we talk about staging, there's clinical staging and there's pathological staging. Clinical staging is based on the information that we obtain. It talks about the size of the tumor. Are there lymph nodes involved? The estrogen and progesterone receptors? So that's important as far as that goes.

The pathological staging is when the surgery is actually done and they can look at all of those things. Many times patients come in and had a breast biopsy, and only a breast biopsy, because maybe they didn't see anything in their lymph nodes or something like that.

When they meet is our multidisciplinary approach. Before they come in for that visit, the providers all sit down. We have a breast radiologist that goes through all of the images. The staff talks. The providers talk amongst each other and say, "do we need more testing?" "Do I see something different there?" "Do they need an MRI?" Not everyone gets an MRI. It's all how they talk about what needs to be done, the density of the breasts.

If they' ve had a lymph node that's positive, do we need to do staging scans? And staging scans will tell us if the cancer has went outside the axillary lymph nodes. The first place that breast cancer travels to is the lymph nodes, so that helps us. If, depending on their cancer type, do they need to have what we call a sentinel node biopsy? And that's when the surgeon goes in and does surgery. They take an injection into the breast, that the injection in the dye leads to that portion of the breast that the drain it drains to in the lymph system. Then they'll take -- hopefully if they don't see anything or worry about anything -- they'll take one or two lymph nodes. And that will give them more of a idea about the staging and stuff like that.

It's very complicated because there's so many directions now. There's so much more that we know about breast cancer. The biggest thing that I tell people is that your breast cancer is your breast cancer. Years ago, we used to treat very much the same: Biopsies for surgery if it was positive, then you go back. Now we know by looking at the receptors, looking at all the things that we have, we treat that patient based on their tumor.

A lot of the patients will get feedback from other people, and I say, that's great. Support is great. If you have any questions why Mary Smith may have had this, this, and this, please reach out and ask us. Because we do want people to have support from other people, but we want them to understand why their treatment plan may be different.

[00:11:57] Host Amber Smith: So as the navigator, do you set up appointments and make sure that the patients get where they need to go on the right day and time?

[00:12:07] Maureen Garvey: So I am like the liaison. I help them through this process or journey, because it's definitely a process and definitely a journey. It's ups and downs. Before, you'd follow one path. Now we may get a report that's good or bad. We may need to proceed. I may sure that if they have questions on who to call, because the team is confusing to them. They've got three or four different providers. They're not all in the same office. The patients don't always know who to call. So I always say to them, as long as it's not a medical emergency, please reach out to me. I can figure out where to go, who to call. Get your forms to me, and we'll figure out everything.

I don't always set up appointments. I have our multidisciplinary team that will schedule anything that we need done from that visit. But I also make sure that they get to where they need to go if they need help. Do they need transportation? We'll figure out transportation. Do they need funds to get somewhere? We have a lot of people coming from out of the (Onondaga) county, a lot of people that are limited resources, and we here at Upstate really try and help them meet those barriers. So a lot of what I'm doing is helping them with their barriers.

When they come in to visit us, I give them a sheet of all their doctors from the cancer center, so they have the numbers, they have the locations, because after they leave here, they go to the other offices. I make sure that moving forward, we're following their plan. If something changes, I may change the appointment. I no longer just set up appointments for them. We make sure that we have everything for that next visit. If they have surgery, did all their tests come back? Are they going to radiation oncology first, or are they going to medical oncology first?

So that's kind of what I do. I'm here. They call, they talk to me, if they are upset about something or they're angry about something or they don't know where to turn, they all have my work cell phone number or can text me. And so I'm kind of their liaison.

[00:14:07] Host Amber Smith: So you keep things organized, and you prevent things from falling through the cracks and and just kind of navigate.

[00:14:14] Maureen Garvey: Yeah. It's like navigating the waters. It's hard for the patients. It's very overwhelming. There is so much as far as breast cancers out there, and our treatments and what we can offer patients, and the technology has changed so much, and it's ever changing.

[00:14:29] Host Amber Smith: Is surgery usually involved?

[00:14:32] Maureen Garvey: Surgery is usually involved. Our stage 4 patients generally don't go for surgery. The research and the providers say that it's not a benefit. And stage 4 is metastatic breast cancer that's gone outside of the axillary lymph nodes. So, local metastatic is just to the lymph nodes. Anything past the lymph nodes, in the bones or liver, brain, lungs is considered stage 4.

[00:15:02] Host Amber Smith: I see. And then radiation, chemo, those are still options for a lot of women, right?

[00:15:09] Maureen Garvey: Yep. It depends on the surgery that the women are having. Lumpectomy, depending on what their pathology shows, ductal carcinoma in situ, depending on if -- nothing is standard anymore; it's all individual -- but if they have ductal carcinoma in situ and they have a lumpectomy, they'll have a lumpectomy, most likely radiation, and then if they're estrogen- and progesterone-positive, they may get what we call a aromatase inhibitor, which blocks estrogen and progesterone.

Women don't understand that post-menopausal women still make estrogen and progesterone in our bones and in our muscles. We know that with estrogen- and progesterone-positive cancers that the tumor feeds off of estrogen and progesterone, so our goal -- not that we start with it right away, unless surgery's going to be delayed -- we know that these women benefit in survival rate of getting a recurrent breast cancer.

[00:16:06] Host Amber Smith: Is chemotherapy part of the treatment for most women as well?

[00:16:10] Maureen Garvey: Amber, chemotherapy can be a large part of a patient's treatment, depending on their, once again, their pathology, their estrogen receptor results, as well as their HER2. The HER2 receptor tells us a little bit about if they're at increased risk for recurrence. So that's another way that we treat patients a little bit differently.

And the other thing that we now have is what we call genomic testing. Genomic testing is genetics on the surgical sample, not the patient's blood, but the actual tumor itself. That recurrence score tells us if the patient is at high risk or low risk for distant metastatic disease in the future. So we know now that these women that are high risk, or many young premenopausal women that we can give chemotherapy, or some of the immunotherapies to help prevent. So, like the flu shot, a little bit different, but we're looking to prevent future occurrences.

So the thing about chemotherapy is that it's improved from what it did in the past, but there's still patients that have trouble with taking the therapy -- nausea, vomiting and things like that. Here at Upstate, we have our palliative care team. I know it sounds very scary because people think of palliative care as hospice or end of life. That is not the fact here at Upstate. Our palliative care team here is amazing. They help with symptom management, so if you're having a hard time with your chemotherapy, you know you've got a decreased appetite, marijuana medication and stuff to help them get through that, other medications that may help get them through that. So we are at Upstate really trying to encourage our palliative care team to meet with the patients. Patients become very anxious about when we mention palliative care, but I like to share that because it's very important that there are means out there for patients.

And in chemotherapy there's some new technology. Some of the chemotherapies -- not all of them in breast cancer -- we can give mitts and booties they wear on their hands and feet because it helps with the neuropathy and pain from some of the taxane medications that we give for chemotherapy. Here at Upstate we also offer -- for certain chemotherapies, not all of them -- the cooling cap. We actually have a grant for the cooling cap that they can wear that helps them from losing their hair. They will still lose some of their hair. I've worked with a lot of patients. It's a commitment. It adds to your time. But a lot of women said their hair has grown back quicker, and it gives them another option, maybe, to feel a little bit better about themselves.

So, as far as chemotherapy, we have options here. They just need to ask. Ask any questions that you have.

[00:19:07] Host Amber Smith: The newer forms of treatment, the targeted therapy and immunotherapy, how often are those used?

[00:19:15] Maureen Garvey: The immunotherapy and the targeted therapy depends on the, once again, the pathology report. Triple negative women, which means their estrogen and progesterone and HER2-negative patients, sometimes can benefit from these targeted therapies. And they're immunotherapy, so it's actually working on your immune system to fight off these cells.

Triple negative breast cancer, we don't have the ability to give estrogen and progesterone blockers because the tumor with triple negative breast disease is not, it won't work for them. Because we don't know that avenue of treating the breast cancer, as far as the estrogen, progesterone receptors.

[00:20:01] Host Amber Smith: You're listening to Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith. I'm talking with Upstate Cancer Center's breast cancer navigator, nurse Maureen Garvey.

Are the treatment options the same for men who are diagnosed with breast cancer?

[00:20:17] Maureen Garvey: Yes. Many of the treatments are very similar for men. If they needed to have surgery, they would have mastectomy, lumpectomy, depending on where the cancer was. If they had a lumpectomy, radiation, and then men still, their body still makes estrogen and progesterone. You know, their pathology is tested the same way that a female's is.

[00:20:45] Host Amber Smith: What advice do you have for someone who's going through breast cancer treatment?

[00:20:50] Maureen Garvey: The biggest thing is that: Ask your questions. Anything people don't understand, it's prying on them. They're thinking about it constantly. To them, it may seem silly. But if it's something that is pressing in their mind, they can't move forward.

And the other thing that I tell people is it's one step at a time. One test at a time. One office visit at a time. You know, in the beginning of your breast cancer journey and your diagnosis, depending on how many tests you need to have, it's going to be a lot of visits. It'll be a lot of visits, something new, and then all of a sudden things -- depending on your diagnosis and your staging -- things calm down a little bit.

Sometimes the patients feel like all of a sudden they're just kind of left. But they're not. We are hoping that they're transitioning into being a little bit more independent, starting to feel better and things like that. So my biggest thing is ask your questions.

[00:21:52] Host Amber Smith: Any advice for the best ways loved ones can help?

[00:21:57] Maureen Garvey: For loved ones, it's hard. Because breast cancer is so advertised and so much in the media, people are beginning to think that, oh, it's not as bad. Well, our technology is better. People are living longer. Our treatments are better. But I've had many women -- because I run our Pink Champion support group -- that say once they got that diagnosed, their whole life changed. Everything that they looked at and the way they felt about things were different.

And I think that for family members, it's difficult because they don't know what to say. They don't know what to act and what to do. People will shy away because they don't know what to say. The biggest thing for many of the patients is you got to talk about it. If they're willing to talk about it, you got to talk about it. You got to share. The person that's helping care for that person needs to share what they're feeling as well.

And the other thing is, keep your loved ones active. My thing I tell patients all the time, if you're having a bad day, you don't feel good, chemo's not going good, get up, take a walk, even if it's to the end of the driveway, come back. It's proven that exercise and getting up and moving will make you feel better.

[00:23:10] Host Amber Smith: Well, that's good advice. Thank you, Ms. Garvey, for making time for this interview.

[00:23:14] Maureen Garvey: Thank you very much for inviting me.

[00:23:17] Host Amber Smith: My guest has been Nurse Maureen Garvey, the breast cancer navigator for the Upstate Cancer Center. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. If you enjoyed this episode, please tell a friend to listen too. And you can rate and review "The Informed Patient" podcast on Spotify, Apple podcasts, YouTube, or wherever you tune in. This is your host, Amber Smith thanking you for listening.