The blog was adapted from an interview with Maria Malloy, BSN, RN, OCN, CBCN, a nurse navigator in Penn Medicine’s Breast Cancer program.
What happens after a breast cancer diagnosis?
I always prepare patients with the information that a breast cancer diagnosis involves a multidisciplinary approach. The team includes plastic surgery, medical oncology, and radiation oncology, and at times other providers based on specific patient needs such as fertility or genetics). I always stress that that doesn’t mean they will personally get all three treatment modalities. I try to emphasize that although some breast cancer centers encourage patients to meet all three doctors in the same day, in my experience it’s not always beneficial due to each treatment plan relying on full information from the other doctors — so you don’t want to see a provider too soon. Once we have a surgical plan, we then think about the right timing for the other specialties.
How can patients organize and schedule these appointments?
Patients are either referred to call directly to breast surgery or are referred to me to facilitate the process, either by their primary care provider, radiology, or our scheduling staff. I explain that I will help walk them through each step by providing information about what to expect as well as coordinating the appointments needed. Our breast team also refers to me for both patients already at Penn or those coming here from the outside. Then once the surgical consultation happens and the surgeon recommends whether they will go to surgery first or whether they’re referred to to medical oncology for consideration of up front chemo — I connect with the patient and schedule the medical oncology and radiation appointments at the appropriate timing
The timing of surgery can vary depending on what surgery is planned, but we try to schedule the medical and radiation oncology appointments within two weeks after surgery. Keep in mind that the timing of appointments and what is needed is based on the patient’s individual plan.
How will my primary care provider be involved?
Primary care providers or OBGYNs typically work through the process for the initial diagnosis, because they write the orders for the mammogram, and subsequent script for biopsy if needed. Most primary care physicians will tell a patient the results and that they will need to see a breast surgeon. A lot of the primary care physicians here at Penn know my role and know to direct the patients to me or another nurse navigator for next steps. Basically any positive breast cancer diagnosis, whether you are a patient here already or not, first leads to a consultation with breast surgery.
What advice do you give patients on how to best process all the information they get at these early appointments?
It can be very overwhelming. I explain that they’ll have a conversation with the three different providers that I mentioned earlier, but the other thing that they need to understand is that a core biopsy still has more information that doesn’t come right away. The receptor status — estrogen or progesterone positive, or HER2 protein positive or negative — takes a few more days to come back and this will help inform the treatment plan. Until then, they can educate themselves by looking at the different options, such as surgery options, but until they meet with the surgeon to go over their imaging and pathology, they won’t really know what they’re dealing with. And then we can give them more specific resources, answer their questions, and guide them properly. OncoLink or the American Cancer Society are great resources to start for general information. But the crux is really that surgery consultation for specific recommendations.
What if someone wants a second opinion?
Most of my patients do come from the outside the Penn system seeking a second opinion. I assess the patient’s needs and connect with the new patient office to retrieve the records including breast imaging and the biopsy slides. These are reviewed by radiology and pathology in advance of the consultation, so the physician can review complete information and recommend a plan. The only thing that jeopardizes that process of obtaining records is when patients are going to multiple places at once, because records may not be readily available. I do explain to patients that records must be reviewed prior to having surgery. This is common practice at many institutions. And getting a second opinion is not only about meeting with a Penn surgeon (or medical oncologist) — we have their imaging reviewed by radiology and we have their biopsy slides examined by a pathologist. Again, it’s a multidisciplinary approach.
What kind of support do you recommend for patients who have received a breast cancer diagnosis?
We have resources in Patient and Family Services to help offer support during this time. We can refer to one of our social workers or to our counselor. Some patients also find it helpful to talk to a cancer survivor. Of course, I also support them if they have any questions — I get a lot of multiple, repeat phone calls, sometimes up to three or four times in a week to go over some of this new, often overwhelming information. I also recommend they talk to their primary care physicians if they’re having a hard time with the diagnosis.
I suggest patients to nominate someone in their family or community who can support them and come to appointments with them. If they don’t have anyone, I refer them to one of our social workers or I go to consultations with them myself. It’s important to have someone strong and supportive who can come to the consultations and help them process all the information and navigate these difficult decisions.
Advice for caregivers?
We also have caregiver support through Patient and Family Services, through social work and cancer counseling. Caregivers are important members of the patient’s team, helping with support at home, advocating for their family member, and attending appointments. It’s important that caregivers also are aware of their own stress during this time in order to be in the best position to support their loved one.