Fighting for Patients: Dr. Rebecca Shatsky on Insurance, Burnout, and Hope in MBC
Live from Stage 4 | Episode # 7 | 11/25/2025 | Interview
Listen to full episode :
Guests
Rebecca A. Shatsky, MD
Board-certified breast medical oncologist and Professor of Clinical Medicine at the University of California San Diego (UCSD). She specializes in treating advanced breast cancer, with a particular focus on aggressive and rare subtypes
Dr. Shatsky focuses her clinical and research efforts on challenging and advanced breast cancer cases, driven by a passion to improve patient care. Her specialties include:
Specialization and research
Stage Four and High-Risk Early-Stage Breast Cancer: Treats patients with advanced disease, including significant lymph node involvement or inoperable tumors.
Lobular Breast Cancer (ILC): Dedicated to improving research and treatment for this subtype, which she notes is underrepresented despite accounting for 15% of all breast cancers.
Triple-Negative Breast Cancer (TNBC): Works extensively with aggressive subtypes, such as metaplastic breast cancer.
Leptomeningeal Disease and Brain Metastasis: Collaborates with neuro-oncology teams to treat these complications, which can affect both triple-negative and lobular breast cancer patients
Quick Summary
In this episode, hosts Victoria Goldberg and Abigail Johnston sit down Dr. Rebecca Shatsky, who leads Breast Medical Oncology at UC San Diego, for a behind-the-scenes look at what it really means to advocate for patients in the world of breast oncology. We talk about the uphill battles with insurance companies—how denials and endless paperwork have an impact on both patients and doctors, and why reform is so desperately needed. Dr. Shatsky shares practical tips for patients, like reaching out to insurance case managers and seeking legal navigation resources, and reminds us that advocacy is a team effort. Dr. Shatsky talks about the emotional toll of oncology—the burnout, the heartbreak, and the resilience it takes to keep going, especially in the face of misinformation and unrealistic expectations. She opens up about the importance of honest conversations, the value of second opinions, and the need for better education for both patients and clinicians. But it is not all heavy—Dr. Shatsky leaves us with hope, highlighting exciting new advances in breast cancer treatment, the power of clinical trials, and her commitment to bringing the latest breakthroughs to her patients. Her passion for teaching, research, and patient care truly shines through.
Key Takeaways
Insurance and Access Challenges:
Dr. Shatsky highlights the increasing difficulties clinicians and patients face with insurance denials, even for treatments that are standard of care. She shares real stories of fighting for patient access and the emotional toll it takes.Burnout in Oncology:
The episode explores the high rates of burnout among oncologists, driven by administrative burdens, emotional strain, and the growing complexity of patient care. Dr. Shatsky discusses the personal impact and the need for resilience in the field.Patient Advocacy and Empowerment:
Patients are encouraged to advocate for themselves, including calling insurance companies and seeking case managers. Dr. Shatsky emphasizes the importance of patients and clinicians working together to navigate the system.Clinical Trials and Research Funding:
Funding cuts and political changes are making it harder to run clinical trials, especially those not sponsored by pharmaceutical companies. Dr. Shatsky explains how this impacts patient access to innovative treatments.Misinformation and Alternative Medicine:
The spread of cancer misinformation and unproven alternative therapies is a growing challenge. Dr. Shatsky stresses the importance of evidence-based care and open, two-way conversations between patients and oncologists.Hope and Progress in Breast Cancer:
Despite the challenges, Dr. Shatsky shares optimism about new breakthroughs in metastatic breast cancer treatment, including advances in targeted therapies and clinical trial opportunities.The Human Side of Oncology:
The episode delves into the emotional connections between oncologists and their patients, the pain of loss, and the fulfillment that comes from making a difference in patients’ lives.Encouragement for Second Opinions:
Dr. Shatsky encourages patients to seek second opinions with thought leaders in the field and stresses that no oncologist should feel threatened by this.Education and Communication:
Dr. Shatsky is passionate about making complex medical information accessible to patients and advocates for clear, jargon-free communication.Collaboration and Community:
The importance of collaboration among clinicians, researchers, and patient advocates is highlighted as key to advancing care and supporting patients.
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[00:01:46] Victoria: So first of all, before we start, I saw that you had been promoted to a full professor.
Thank you. A congratulations.
[00:01:55] Rebecca Shatsky: So Professor Shatsky, it's very nice to have you with us. We are very happy to have you here and welcome to our brand new podcast Live from Stage 4.
[00:02:08] Victoria: So I had some feedback. One of the things they told me that I run right into the interview without letting my guest introduce herself. I'm addressing criticism and I'm so very happy to have you with us.
But , please introduce yourself.
[00:02:27] Rebecca Shatsky: My name is Dr. Rebecca Statsky. I am the Director of Breast Medical Oncology at UC San Diego, where I am also the director of the Inflammatory and Triple Negative Breast Cancer Program and director of Precision Oncology at Sanford Stem Cell Institute.
So that's a research organization, for some of the translational work that I participate in.
[00:02:52] Victoria: So thank you so much again, and you just gave me a number of ideas why I should call you back. This was very useful. Anyway, Abigail why don't you start us off? Sure.
[00:03:08] Abigail: So Dr. Shatsky, you may or may not have heard some of our initial episodes, which are all around this idea of the future at risk because of some of the changes in funding that have happened recently.
And we realized we hadn't actually talked to a clinician about how changes might be affecting the day-to-day clinical practice. And so if we could start there, have you noticed or how has your clinical practice changed?
[00:03:37] Rebecca Shatsky: Certainly, as far as research, I am a high volume clinician.
I also do translational work and clinical trial research. And I will say that the funding from the NIH cuts for some of our clinical research even has affected patients. And trying to get some of our trials up and running that aren't pharma sponsored has been really difficult. Keeping the lights on in the lab is becoming increasingly difficult as well.
And on the day-to-day, as far as patient care, things are very much being affected.
I have seen a lot of insurance switches recently, insurance funding issues and rejections, and denials from insurance companies have become bizarre. . The number of peer-to-peers with insurance companies that I've had to do to get things approved that seem to be so basic has astronomically increased over the past six months.
And starting to see denials for things that are in the National Comprehensive Cancer Guidelines for patients is becoming increasingly worrisome. For example, I'm on the NCCN Breast Cancer Screaming and Diagnosis Panel, and we have added breast MRI in a number of situations,
especially for dense breast tissue, category D , for certain situations as far as neoadjuvant chemotherapy and to see denials of breast MRI, which should be increasing because the clinical utility is very validated and the research and evidence supports, it is really disconcerting. I just heard from one of my colleagues that Tricare, which is a federal insurance for veterans and veterans family is starting to deny breast MRIs for patients.
And I literally just heard that yesterday, which is just crazy to me.
I mean, , it's scary.
[00:05:44] Victoria: I read something today that actually I wanted to ask you about mm-hmm on this topic. You had a patient who was not early stage, but locally advanced with 3C, guess it was triple negative.
It had to have been, and you tried to get an approval for Keytruda for her. You were denied and you were talking loudly enough to an insurance person, and you got a standing ovation for the way you handled it. So I wanted you to tell us that story. I just loved it.
Well,
[00:06:17] Rebecca Shatsky: yeah, so that was a Medscape article from a few years ago. We start as far as peer to peers because sometimes the insurance company does this just to make you jump through hoops because, most oncologists and I give my community oncology folks so much credit because I understand that I am very lucky to be in the academic setting and have more time for some things like this to fight a little bit harder, I would say.
So most oncologists, if they get a denial from insurance, they don't have time to go and fight that. And that's just the nature of the oncology shortage in this country. Really. Like some of these community oncologists are seeing innumerable patients a day, barely making home at night.
I get it, so we go for this first step where basically we'll have either my nurse or one of our physician assistants be on the phone and just make sure that they have the required documentation as far as the reason for denial. Sometimes they're just like, oh, well, I didn't receive the notes, and they deny it.
If we have to take the time to call, and sometimes that's a half an hour or an hour on the phone to figure that out, and then just resubmit the right document that they wanted. By the time it gets to me and my staff are like-- no, it's really being denied. And they're allowing a physician to physician,
or physician to whoever,
peer to peer. And you get on the phone with me. For a physician who is not a breast cancer specialist and especially not a triple negative specialist, which I am, to try to argue with me about their opinion about the clinical utility of some of these therapies in a life threatening situation.
I make it very clear when I communicate about that risk that they are personally putting the patient under, that I will be holding them responsible in the chart for any legal action that the patient chooses to take because of these denials. They should be aware that as an oncologist, if they were in this situation, what would they want as far as what's best for their patient?
I get that there's a lot of burned out oncologists working for insurance companies these days, but to deny possible overall survival improving care to my patient is something that I hope they take home at night and recognize.
[00:08:40] Abigail: Yeah, from a legal perspective let me just say that I love the fact that you hold people responsible in the notes, because as a lawyer, having done a lot of medical malpractice cases, it's so hard sometimes to know exactly
who's at fault, who's to blame for things. So doctors, making that very clear, is always very helpful. But I'm wondering, every insurance policy I've seen has the ability for the physician scheduling those peer-to-peers to ask for an actual peer. Are you not finding that the insurance companies, oh yeah.
That's
[00:09:15] Rebecca Shatsky: changing. Recently. Recently. I can request a peer-to-peer and the insurance of company will say, we don't do that anymore.
[00:09:22] Victoria: Really?
[00:09:23] Rebecca Shatsky: Yeah. Where I'm not allowed to request a peer to peer consultation. Things have been really getting out of control where there are some denials where they're like, no, we are not allowing an appeal.
We're not allowing a physician to physician conversation. And there are definitely companies where I say, I need to speak to a physician, and they'll say, we don't have one available.
[00:09:47] Abigail: Wow. Which makes it even harder to move things forward.
[00:09:52] Rebecca Shatsky: Absolutely. The past year has been enlightening and that article was written a few years ago when I was doing this.
Things are worse since.
I will tell you that since the United Healthcare scandal, United Healthcare is going after physicians that try to argue these days and , so are the other healthcare because they're saying it's putting their staff at risk.
And they're threatening legal actions on physicians basically, who are arguing these denials publicly, and it's quite frightening.
[00:10:26] Abigail: Yeah. As a clinician who is fighting for patients, how can patients partner with you to help your job go a little easier?
[00:10:38] Rebecca Shatsky: So calling your own insurance company and trying to get insurance case manager is actually something I advise patients because that service is available from a lot of different insurance companies where they get basically someone, who's supposed to be on your side to help manage some of your care.
And how much they do or not, I have no idea. But anything the patient can do as far as advocating on their side as well, it helps us do the process together because there's only so far I can get on my own sometimes, and I am known for appealing and appealing and appealing and going to the state insurance commissioner and whatever I have to do because all of these denials in some cases are just totally unjust and they are hurting patients.
We need to reform the prior auth system, which is what many of us have been advocating for as clinicians in oncology, for years. But instead of doing that, things have gotten worse. The United Healthcare scandal and what that unfortunate mentally ill kid did, has made things dramatically worse because now the insurance companies are going after us for advocating for patients.
And so things have become kind of scary on this side.
[00:12:03] Abigail: That's a great idea though. Something very simple for patients to do asking for that other layer potentially of, you know, I don't know what it is, attention maybe. Yeah. And one of the things that I teach in the legal clinics, is for patients never to not call.
So even if they don't feel comfortable potentially advocating, at least calling to make sure that the insurance company is aware that this is somebody who's paying attention. But I'm wondering if you've ever sent anybody to the insurance or the legal and financial navigation programs at Triage Cancer who assist patients in how to file even outside appeals in order to pursue the times when the insurance company is just making an erroneous decision.
[00:12:51] Rebecca Shatsky: I have not, and I would love to learn more about that process. My nurse and I, half of what we do, is just patient advocacy and trying to get our patients what we think they need. And I would love to have additional options there. I mean, the general patient doesn't know too much about health insurance.
You know, I was just trying to help someone today who didn't realize that cancer was a major life event and that sometimes you can get someone enrolled in healthcare or switch plans because of a cancer diagnosis outside of open enrollment. And I don't think the majority of people know that.
And there's a lot that can be done as far as mitigating what insurance you have, what plan you have, what managed care provider group can be switched, and so people feel like they're always beholden only to open enrollment and that's not always the case. I've seen some great things happen on just a little bit of phone call work on the patient's part.
[00:13:52] Abigail: But then of course the energy is always limited for patients and for everyone, which is why I do really like the navigation program where it's staff attorneys. I'm a little biased towards attorneys being the guidance here, but I do think that the staff attorneys at Triage Cancer kind of amazing.
[00:14:10] Rebecca Shatsky: Yeah, that sounds amazing. Yeah, so I think we really need to get the word out because even I don't really know much about that and I need to.
And I would love to use my platform on social media to get the word out as well.
[00:14:23] Victoria: I'll just make a comment. So this podcast is a two-way street, as it turns out. It's a very special, interactive podcast. It's not only we get information from you. Yeah this is great. We give
[00:14:34] Rebecca Shatsky: it back
[00:14:35] Victoria: to you.
[00:14:35] Rebecca Shatsky: I want to know anything that can potentially help my patients. When I'm going to a conference, like every time I'm at ASCO, every time I'm at San Antonio, I visit every little advocacy booth related to breast cancer so that I can learn what else I can offer my patients. And this is so critical that I would love additional resources.
[00:14:55] Victoria: So this is actually a follow up to what you said, how is the current landscape affecting your decisions on clinical trials? What clinical trials you do, what are the problems with the clinical trials right now, and what decisions you make that you may not have had to make in the past?
[00:15:16] Rebecca Shatsky: That is a really good point. So right now, pharma sponsored industry trials seem to still be going, although I will say even in ISpy, we know that especially with tariffs in China and other countries or not getting those contracts maybe, many international companies are wanting less and less to work with the US, and that's a problem.
But at the moment I'm still principal investigator of like 12 different trials and really able to at least offer things that companies wanna develop in the US. It is really difficult. There's less funding for cooperative group trials that sometimes answer big questions that are unanswered.
The current political landscape and funding landscape is making oncology, uh, different. We're also probably waiting a lot longer with the FDA to approve things that would've been improved faster. The government shut down and so that's scaring me there's giant phase 3 data that's been presented.
I've got the publication in my hands and I'm waiting on the FDA and ODAC to meet, being like, what's going on? It's radio silence. We don't really know. There's definitely scary times and both my patients and I share that together in the clinic. All I can do is , say to them is, I know that I will get this to you as soon as I possibly humanly can.
[00:16:35] Victoria: Yeah.
[00:16:37] Abigail: Have you done more applications for compassionate use where people are able to get access to some of those drugs that are not quite FDA approved.
[00:16:45] Rebecca Shatsky: Compassionate use in the entire terminology of it, frustrates me because the right to try legislation is really the right to ask.
And the pharma companies can say no, and they usually do, and so
to get the ones that they'll allow, you go to the Reagan- Udall website and you look and see if your drug is listed on there, and usually it's not. And you can ask the companies, but they usually say no. And so it's quite rarer in this day and age to be able to get anything through compassionate use.
If you have a really good relationship with the drug company and you know the right people, sometimes they'll allow you to do a single patient, what we call a single patient IND investigator. It's often with local biotechs who know me and have a personal relationship with me, and I can describe the situation I'm in the big companies though, Uhuh, so , it's scary.
[00:17:42] Abigail: So those are the kinds of things that patients are talking to each other about, the different avenues or pathways to get access to medication. So it's always good to hear whether or not those are really useful.
[00:17:54] Rebecca Shatsky: Patients believe that they have the right to try something that's on a clinical trial or is not approved, and the current legislation does not support that.
This whole Right to try is the right to ask and usually the answer from the companies is no. And so that's not your physician's fault. That's the other thing, they'll be like, oh, they didn't give me compassionate use. And I'm like, I have no control over that. I ask, I always ask, , if the company says, no, there's nothing I can do to appeal that.
[00:18:25] Abigail: It's such a good point though, that patients are often fully unaware of who is the, I'll say a word that may not be very nice, but who's the villain in the situation? Right. And so, because the doctor is the only person that they have access. Access to have
access to
So it's easy then to maybe conflate the situation or frustration with the situation with the person in front of you.
[00:18:46] Rebecca Shatsky: Yeah there needs to be better education in clinical trials in general. I'm frequently even called by non-oncology physicians about a patient in the ICU and whether they're a candidate for , a clinical trial,you have to be a cancer olympian to get on a trial. A lot of the time. They have really strict inclusion and exclusion criteria.
But I even see on Facebook physician mom groups, doctors reaching out , about their family member in the ICU and wondering why they're not a clinical trial candidate. And it's like, no, that's not how clinical trials in cancer works.
[00:19:18] Abigail: . I wanted to shift gears just a little bit because in addition to the funding stuff that's going on, and certainly patients are watching all of that with concern.
[00:19:29] Rebecca Shatsky: Mm-hmm.
[00:19:30] Abigail: You had commented on social media not too long ago about a situation you had where a patient, and potentially their family was very upset with you and may have been a bit unkind, and you talked about how as a person, as a human being treating
patients who are having very critical, difficult times, can be very difficult as a human being. And so I wanted to ask you about that, if you would be willing to elaborate on the personal toll that you experience.
[00:20:02] Rebecca Shatsky: Yeah, thanks for asking that because there is an enormous rate of burnout in medical oncology right now, and many of us are leaving the field.
And it's sort of twofold of what's going on with that. One , it is very easy, like this has always been a part of oncology where it's much easier, especially for the patient's family, maybe not as much the patient even, when cancer progresses and when cancer's not going as well as we'd hoped to look for a scapegoat and to look for something other than the cancer just being really bad.
And a lot of the times that is my oncologist must have done something wrong and looking to blame and looking to take out that anger on the medical oncologist. And for people like me, I'm a sensitive soul. I really am. I'm super empathetic, but I take things personally. It's hard not to, I work on that.
I work on thickening my skin, but when you know that you've done everything in your power for someone and I have tried as hard and you're just as devastated as they are, that their cancer is progressing , to have that anger directed towards you, it can be a lot. And we take it home at night and it makes the job much harder because we do sometimes really put absolutely everything into our patient care.
But it is a natural human response to want to have something other than just the cancer to blame. And a lot of those emotions, this is a known thing in all parts of medicine, we call this the uninvolved cousin effect, where a patient and their oncologists have been talking about how bad the cancer is and things getting worse for say, years.
They have a great relationship, but when things are getting really critical at the end of life someone who hasn't been involved comes out of the woodwork, attacking the medical team and being like, this must have been done wrong,
and it's also very common when older patients haven't involved their kids in the process or discussions about their own illness because they've been protecting their family member. And then the family member comes out at the medical team, absolutely furious, behaving pretty badly, swearing at us, screaming at us, those kind of things
because they're personally struggling with accepting the situation emotionally. And again, these are all normal human emotions and most of us who have been in this for a while get that and can handle it. But another thing that has affected this and made it really bad, which is really driving an oncology burnout and dropout rate, is the growing cancer misinformation epidemic and alternative medicine epidemic where
patients are hearing misinformation by maybe their alternative medicine practitioner who's not an oncologist, that their cancer can be cured at stage four, that they can just take supplements or change their diet and things will be better. And some of the patients or their families are coming at us, the medical oncologist, even though the patients are still coming to see us, very aggressively, like I've recently had
patient's husband of 300 pounds stand up in the clinic and get in my face yelling and screaming about how I'm wrong about the prognosis. And if I'm just not open-minded enough about the patient's ivermectin or vitamin C or whatever else their alternative medicine provider is pushing as a miracle cure.
And it's becoming a scary situation actually, where many of us are scared for our safety in the clinic. And so that has really been a switch. When I started practicing oncology, it really wasn't like that. And that's been since COVID where alternative medicine situations are becoming dangerous for the medical oncologist.
And it's important to remind patients too that those people purporting miracle clears, when you go to them, you're signing waivers that say that they're not medically responsible for anything that happens to you. But that's not the case with your medical oncologist who is always legally responsible for what happens to you.
And the medical legal risk of when they're doing all of these things, it's a little unfair to us and to be the one blamed and aggressively targeted for some of this in the clinic have gotten a bit scary recently, and it is affecting all of our mental health and feelings of personal safety.
Yeah.
[00:24:51] Abigail: What I hear a lot from patients is that when they bring up out of the box ideas, and I will put myself in this situation because I bring up out of the box ideas all the time. Sometimes , the perception can be that the reaction is a bit dismissive of the things we don't have data on yet.
And I'm wondering, about a patient who might be thinking outside the box, having other ideas, what is a good way for a patient to approach a medical oncologist to say, Hey, let's think outside the box together. Maybe we don't have data yet, but let's think outside the box together.
Would that be more palatable?
[00:25:31] Rebecca Shatsky: Yeah, so I am kind of known for doing things outside of the box as far as therapies going and combine things I do, what I have to do in a patient has stage four disease. It's often the conflicting alternative medicine things that we have a bit of a problem with, because often these are presented by people who have zero oncology training whatsoever, people can call themselves an integrative oncologist these days just by calling themselves that, there's often people who didn't even finish a residency in anything and then have zero data behind,
so I think that a lot of us in medical oncology went into the field because we do tend to have a more scientific mindset where we like to look at data, we like to look at evidence behind some of the things we're doing. And some of the things that are being proposed in the clinic, I can show data saying, this has been studied and this didn't work, it didn't benefit you at all.
But again, these are things that people hang their hat on. And because someone else is giving kind of false hope, it's really tough to have because, I love working with my patients on out of the box ideas. But I have to say I need that to be a two-way street where they're listening to me as well and when I'm showing them like, Hey, we've looked at that in your disease and it didn't help.
As far as outta the box combos of say, cancer drugs, I think that's wonderful. I'm really heavily invested in precision oncology and, think that that is something that I really am open to, but in the alternative medicine world, you know what patients don't know about some of these things too, as far as the supplement industry , is that's the widest growing cause of acute liver failure in young people now because these things are not FDA approved for safety and they're contaminated.
It's something that is of safety concern for medical oncologists a lot of the time because cancer patients aren't liver transplant candidates. And so if something happened to them, because most of us, if we've done an internal medicine residency, have seen someone die of acute liver failure from supplements before, and it's pretty traumatic.
But those candidates usually, if they're young, they get a transplant, but I know my patients can't get that. And so it is a scary thing to, openly accept and participate in, where as far as combining two cancer therapies that maybe aren't approved in your cancer type
[00:28:05] Rebecca Shatsky: that I
think we must be doing. And I think that oncologists need to be open for, and need to be open to things that maybe aren't quite an NCCN guidelines. That's why I love being a super subspecialist in breast oncology because I can tell patients I don't follow guidelines, I make them like I, I really want to be able to do everything in my power, which is why breast cancer is the only thing I do always.
[00:28:31] Victoria: Is that why you spend so much time fighting with insurance companies? Yeah,
[00:28:35] Rebecca Shatsky: because I'm often trying to get off label things that my patients,
[00:28:39] Victoria: okay, there we go.
[00:28:41] Rebecca Shatsky: That's what I'm doing a lot of the time. Just fighting unfair denials, but sometimes it's, I know this is gonna help.
I have the molecular data to say this is very likely going to help. And I've had amazing responses and some of those tumor agnostic pathway combinations that I've used. But I would say, when you're approaching your oncologist about this, just to get back to what you were saying, 'cause I totally hear you, Abigail.
I know exactly what you mean. And I've seen that, I have chronic medical conditions and a lot of people are intimidated with me when I'm the patient as far as bringing stuff. So I think that's one of the reasons I'm fairly empathetic is that I have chronical medical conditions that many of my colleagues know about, that I am often pretty sick and fighting for these things myself.
So, I get my patience on that front. I think the best way to approach is with a wholehearted like, Hey, I think you understand if you were in my situation , like you would wanna do everything in your power, right? And, I'd love to just discuss some of these things, and see your opinion on some of this and why you think this may or may not be beneficial for me.
So, approaching it as a discussion, not approaching it as, Hey, I need you to add this right now because that doesn't go over well too. We have dedicated our lives and I was in school for 26 years to specialize in oncology and I read all day and all night the newest evidence to stay on top of things.
And whoever their non oncologist, integrative physician might be, they don't do that. And they don't necessarily understand cancer. Anyone who's purporting to use the exact same treatment in all types of cancer too, it's a huge red flag. That doesn't even make sense for someone who truly does understand cancer.
And so, having a discussion and being open-minded on both ways, I think is the best way to go about it. And if your oncologist though, is super close-minded about things that there really are evidence for. And that may be time to get a second opinion with a thought leader in the field.
I know you guys know this, but I always highly encourage that no oncologist should be threatened by a patient getting a second opinion. That means their ego has a problem. I'm thrilled when my patients get a second opinion , I do advise them to do it with a thought leader. It is tough when they go get a second opinion with someone who's a community oncologist that doesn't even specialize in breast cancer when that's all I do.
But it's important to know who you're getting an opinion with and their credentials, I would say. But I always encourage patients if you feel like you're not being heard and that you're not getting the discussion that you need surrounding this. Go seek a second opinion with a thought leader in the field and have them communicate with your oncologist too, because I always do that.
When I do second opinions, I try to reach out Hey, I, this is what I discussed with the patient. This is what I think is reasonable because it's my job no matter what situation I'm in to advocate for my patients, and that includes everyone I do a second opinion for.
[00:31:48] Victoria: There's something you mentioned, and it pains me to hear that. I used to go to NYU every year. So they had this program for patient advocates to speak with first year medical students at the NYU Medical School.
The topic was not related to this, but I would always give them advice at the end of my presentation. I would always tell them-- breast oncology, that's where you need to go into. There is so much hope in it. So it pains me to hear that there is such a huge burnout.
So maybe I should just shut up and stop giving advice about their future direction. Yeah.
[00:32:31] Rebecca Shatsky: Medical oncology is... you have to be fairly emotionally resilient. Because you share all of the worry and the grief and everything with your patients. And then, people ask me, even my husband who's emergency medicine every day, I don't know how you do this.
Because there are many nights that I come home and burst into tears and just feel powerless and grief stricken about my patients 'cause I love them so much. Breast oncology is known to be a little bit more difficult as far as patient interactions, and that's more just a female thing.
And this has been documented in that, you know, lung cancer, male oncologist, seeing 70, 80-year-old lung cancer patients, they come into the room and you're like, how you doing? And they're like, fine. Yeah. And then you move on and you give them treatment.
Breast cancer patients, it's a very different, often hour, hour and a half conversation even for the DCIS and so
[00:33:29] Victoria: probably more with DCIS. Yes, exactly. We always
[00:33:32] Rebecca Shatsky: say , the less invasive of the cancer, the longer the visit, , so it's a very different field and you have to be on board for that.
But you get these gratifying, amazing relationships with your patients that I don't know that you do in other things. Like I am closer with my patients than patients are with their primary care doctor by far, because I'm seeing them sometimes weekly or every two weeks. That doesn't happen with a primary care doctor.
It's like they're family, you know? And so that's why it is more emotionally tough when things go south to have someone that you care about so much especially if they direct the blame, or their family directs the blame at you at that point. 'cause you're like, I love this person so much and they hate me now because their cancer progressed, or their cancer relapsed.
And it's tough. But, medical oncologists need to get better and have the tools and training to manage those kind of things because it's just a normal part of the field. And so I do try to teach that in my fellows, the resiliency, like this is normal. When a cancer relapses, you may find that your patient doesn't wanna see you anymore, and that's okay.
Don't take that personally. It's a field that... i'm super committed to teaching. I teach. Medical students, undergraduates, residents, and fellows. And they're in my clinic every single day and doing research with me. I think the best way to encourage people to go into this though is to show them how much you love your job and that something I'm lucky about.
I mean, I love doing what I do and I love my patients and I love the fact that I'm at the cutting edge of things. And the reason I stay in academics instead of getting paid four times as much in the community, yes, I make a fourth of what community oncologists make, is that I love being able to offer my patients through the clinical trials that I run ,something that is better than the standard of care.
The field takes too long to move forward. And in the community, I wouldn't be able to say, Hey, I've got this great clinical trial for you. This is gonna be better and less toxic than what you're getting right now. And even in the curative setting, I'm the clinical trial operations chair of the I-SPY2 trial.
And, um, I able to offer newer and better therapies in the curative setting that no patient could get off trial and to deescalate their therapy and cure more patients at the individual level. I find being a clinical trialist and being an academics, the most rewarding job. And so I try to teach my trainees that every day that, you know, yes, it's a hard job.
And yes, it's emotionally draining, but it is also probably one of the most rewarding things you could ever do.
[00:36:09] Victoria: Well, let me tell you, this has been a pretty depressing conversation.
I'm so sorry. No, I'm so sorry. . But we want to end on a more hopeful note. So I'm gonna ask you, do you see anything positive happening in the world of breast cancer and especially metastatic breast cancer? In terms of treatments? Yes. Yes, yes. Future directions, let's. Let's talk about that.
Hundred
[00:36:36] Rebecca Shatsky: percent. So this past weekend was the European Society of Medical Oncology. It was the biggest breast cancer ESMO that's really, I don't know, in recent history. And we got practice changing data out of there. Like in my belief, there should be a new first line treatment for metastatic triple negative breast cancer.
I've been really vocal about that. 'cause that needs to happen and I need to see people stop using ineffective treatments when the treatment's not going to work, don't do it. Stay on top of the data because antibody drug conjugates should be your first line in metastatic triple negative breast cancer now.
I'm really looking forward to the approval of oral SERD combinations with targeted therapy. I'm not a crazy fan of oral SERDs as a single agent in all patients, that you have to have pretty indolent disease for that.
But combination therapies that are less toxic, I am excited about.
And I think that we are making advances, especially also in CNS disease, which is one of my specialties. So I'm always following brain met and leptomeningeal disease data and trying to present it from my own site. We've created a leptomeningeal disease treatment team at my institution that I'm extremely proud of because it's really rare around the country, and I'm trying to teach other oncology institutions about some of the way we do things to make patients live longer because it matters: the time course, the clinical index of suspicion.
I'm out there educating the emergency medicine community about some of these things so that patients don't get dismissed and sent home from the ER because the doc had no idea that, hey, leptomeningeal disease is gonna be missed on your head ct. Yeah.
That wasn't an appropriate study to make sure that this person with cancer doesn't have CNS disease, things like that.
So I think we are making a lot of progress. I love conference season. It's my favorite time. I am going and presenting data at S-A-B-C-S, I'm doing one of their medical crossfire, nighttime, PER symposium.
I'm doing a fellows forum there to teach the fellows, , I love S-A-B-C-S. It's something that I love getting out there and getting words out and just seeing both the patient advocates there, which is such a joyful thing for me to see them in person when they can come.
Many of my patients are too sick for something like that and I feel for them. So I'm glad there's a virtual option also.
I tell all my patients in the clinic. I'm like, Hey, San Antonio is coming up. ESMO is coming up. I am gonna be there to deliver the latest advances to you.
So get excited because , when I come back from that meeting in the clinic all day, every day, the next few weeks, I'm like, this is what we learn. This is what the new stuff is and so they get excited with me because they can feel my excitement and my hope for the future, because I always tell my metastatic patients, and that is the majority of my practice, about 80% of my practice is metastatic breast cancer.
Which isn't universal amongst breast oncologists. But I say while you're on this, we are looking and finding something better. And so don't lose hope because there is progress. I'm always looking for something better and more novel and less toxic for you. And so while you're on this, there may be a different option when it's time to switch.
Yeah. Yeah. Well, thank you. I think, we've managed to end on a very, very, very positive note. So thank you so much for being here with us. We've taken up a lot of your time and right now, I'm thinking in my head. Okay, so the Leptomeningeal episode, the History of Cancer episode plus the series of Misinformations that we talked about.
[00:40:27] Victoria: I would love to
[00:40:27] Rebecca Shatsky: talk about all of those things.
My whole shtick as a medical oncologist is to disseminate things to patients in a way that they can understand, because that is what needs to happen.
I see it too often, people using jargon that is unintelligible. Not speaking to the patients, not considering what the patient's perspective is, that is what's important to me and so that's really my absolute joy.
[00:40:53] Victoria: Thank you so much. Thank you. So good to see you.
Absolute, you
[00:40:56] Rebecca Shatsky: guys, it's so good to see you. Bye.
.
More on Clinical Trials
According to the U.S. National Library of Medicine, clinical trial sponsors may include:
Government agencies; such as the National Institutes of Health (NIH), the Department of Defense (DOD), and the Department of Veteran’s Affairs (VA)
Private individuals, companies or organizations
Pharmaceutical, biotechnology and medical devices companies
Health care institutions, such as academic medical centers and health maintenance organizations (HMOs)
As a principal investigator she’s the lead clinician at a study site — enrolling patients, overseeing safety and protocol compliance, and liaising with the sponsor. Right now many big international companies are doing fewer U.S.-based trials because rising costs, trade and contract issues in places like China, and an uncertain funding and regulatory climate make the U.S. less attractive for global studies. The FDA is the agency that reviews the safety and effectiveness data companies submit, and the Oncologic Drugs Advisory Committee (ODAC), is an external expert panel the FDA consults on major cancer-drug decisions — their meetings and recommendations can determine how quickly a therapy reaches patients. Dr. Shatsky still runs about a dozen trials, but she says regulatory delays and poor communication are keeping even completed Phase 3 trial data in limbo, leaving clinicians and patients anxious as they wait for decisions.
More on Compassionate Use
There are two main ways patients can try investigational drugs outside clinical trials. Expanded access, often called compassionate use, is when a treating physician asks the drug company to provide the medicine and then submits an expanded access IND to the FDA. An expanded access IND (or Investigational New Drug Application) is basically an emergency or single‑patient application that gives the FDA the data it needs to allow the treatment — it triggers safety review, required reporting, and usually an independent Institutional Review Board (IRB) sign‑off. An IRB is a committee that reviews patient‑facing materials and the treatment plan to protect patient safety and make sure informed consent is valid.
The Reagan-Udall Foundation for the Food and Drug Administration is an independent 501(c)(3) organization created by Congress . The Reagan-Udall Foundation’s Expanded Access Navigator provides physicians, patients, and caregivers with guidance on Expanded Access (EA).
Right to Try, created by federal law in 2018, lets eligible terminal patients request drugs that have completed Phase I without needing the FDA to approve each individual use. It can be faster but comes with far less oversight, no guaranteed IRB review under federal rules, and fewer patient protections; companies still must agree to supply the drug.
Bottom line: “it is the right to ask but not to try.”
