Smilow Shares: Breast Cancer Awareness Month: Early-Stage Breast Cancer

Transcript

• 00:00Good evening, and welcome to
• 00:02the SmiloShares
• 00:03early stage breast cancer session
• 00:05entitled what patients and families
• 00:07should know.
• 00:08My name is doctor Rachel
• 00:10Greenup. I'm the chief of
• 00:11breast surgery
• 00:13at the SMILO in the
• 00:14department of surgery at the
• 00:16Yale School of Medicine. And
• 00:17tonight, we have three of
• 00:18our esteemed colleagues, doctor Elizabeth
• 00:20Berger,
• 00:21doctor Siba Haykel, and doctor
• 00:23Maria Rosenblatt.
• 00:24And we're gonna start with
• 00:26doctor Berger who's an assistant
• 00:27professor of surgery in the
• 00:29division of surgical oncology
• 00:31who will talking be talking
• 00:32to us about surgical updates
• 00:34and breast cancer.
• 00:35Doctor Berger, welcome.
• 00:40Thank you so much for
• 00:40that kind introduction, doctor Greenup.
• 00:42Let me share my screen.
• 00:49I get a thumbs up
• 00:51so everyone can see it?
• 00:52Great.
• 00:53So tonight, I I'm gonna
• 00:55spend about ten to fifteen
• 00:56minutes talking about some of
• 00:57the kind of updates of
• 00:58as far as surgical care
• 01:00in early stage breast cancer.
• 01:02And I appreciate the time,
• 01:03and, hopefully, we'll have time
• 01:04for questions,
• 01:05at the end if there
• 01:06are some.
• 01:07So the way we stage
• 01:09breast cancers in just kind
• 01:10of context as far as
• 01:11early stage goes is is
• 01:12multiple different ways. We think
• 01:13about how big the tumor
• 01:15size is, how how many
• 01:16lymph nodes may or may
• 01:17not be involved, and we
• 01:19essentially come up with a
• 01:20stage of breast cancer. And
• 01:21doctor Rosenblatt will probably get
• 01:22into this in more detail,
• 01:24but the biology of tumors
• 01:25now is so much more
• 01:26important than stage. But we
• 01:28still stage breast cancers based
• 01:29upon the staging,
• 01:31schema.
• 01:32And what we'll be talking
• 01:33about tonight is really this
• 01:35category of kind of stage
• 01:36zero, if you will, to
• 01:37stage two breast cancer is
• 01:38considered early stage.
• 01:40Stage zero breast cancer, kind
• 01:42of an enigma and doesn't
• 01:44make that much sense, but
• 01:45we really refer to what's
• 01:46called ductal carcinoma in situ
• 01:48as stage zero breast cancer.
• 01:50Or for a lot of
• 01:51my patients, when I say
• 01:52a precancerous process,
• 01:53it's in situ disease, meaning,
• 01:55you know, the abnormal cells
• 01:56are contained within the ducts.
• 01:58There's no invasion that we've
• 02:00identified.
• 02:01And so,
• 02:03you know, we really think
• 02:04that this is a precancerous
• 02:05lesion or stage
• 02:10We still think that we
• 02:11should take all of DCIS
• 02:12out. We should remove it
• 02:14surgically
• 02:15because we thought all DCIS
• 02:16became an invasive cancer at
• 02:18some point.
• 02:20Now what we know with
• 02:21ongoing clinical trials is maybe
• 02:23some DCIS
• 02:24never becomes invasive cancers,
• 02:26and we can actually safely
• 02:28observe or survey DCIS without
• 02:31actually having to remove it.
• 02:33So stay tuned.
• 02:34Hopefully, in maybe two thousand
• 02:35and thirty, we'll hear more
• 02:37about,
• 02:38stage zero or precancerous lesions
• 02:40such as DCIS
• 02:41being able to,
• 02:43stay in the breast, not
• 02:44have to be removed because
• 02:45of these ongoing clinical trials.
• 02:48So much of breast cancer
• 02:48care as I think everyone's
• 02:50call knows is really based
• 02:51upon really good clinical trial
• 02:53data, which is really exciting
• 02:54for all of us as
• 02:56providers and for patients.
• 02:58So if we're gonna talk
• 02:59about surgery for breast cancer,
• 03:00because surgery for breast cancer
• 03:02is is still important,
• 03:04we think about kind of
• 03:05where we've we've been and
• 03:06where we're going. So
• 03:08doctor Halsted used to perform
• 03:10what's called the radical mastectomy
• 03:11where we'd remove the chest,
• 03:13the the breast, the, pectoralis
• 03:16major and minor muscles.
• 03:17And now we know for
• 03:19breast cancer care that we
• 03:20can really preserve the breast.
• 03:22We can often do what's
• 03:23called lumpectomies where we do
• 03:25breast conservation and not remove
• 03:27the whole breast,
• 03:28and give patients similar, you
• 03:30know, the same outcomes from
• 03:31their cancer care.
• 03:37So and I recognize, but
• 03:39the the point the point
• 03:40of the slide is that,
• 03:42in the nineteen seventies, we
• 03:44started to ask these big
• 03:45questions for surgical care for
• 03:47breast cancer. And we realized
• 03:49that in the nineteen seventies,
• 03:50we didn't have to remove
• 03:52the whole breast,
• 03:53and we could do breast
• 03:54conservation with radiation.
• 03:56We then, if we pivoted
• 03:57towards the nineteen nineties, realized
• 03:59that we didn't have to
• 04:00do so much axillary surgery
• 04:02for early stage breast cancers.
• 04:04The z eleven trial was
• 04:06instrumental
• 04:06in allowing our patients to
• 04:08have less axillary surgery
• 04:10even if they had a
• 04:11few lymph nodes with cancer
• 04:12in it. And now fast
• 04:14forward to the, you know,
• 04:16kind of present time where
• 04:18we can do,
• 04:19maybe even less surgery for
• 04:20DCIS, and we just observe
• 04:22DCIS.
• 04:23So these are some of
• 04:24the really, important,
• 04:27practice changing trials for breast
• 04:28cancer care, especially in the
• 04:30early stage setting.
• 04:33We even may go as
• 04:34far as to say and,
• 04:35again, a little bit more
• 04:36in advanced, breast cancer settings,
• 04:38but we even may as
• 04:39go as to far as
• 04:40to say, if a woman
• 04:41gets chemotherapy before surgery and
• 04:44there's no cancer left in
• 04:45the breast, we may be
• 04:46even able to avoid surgery
• 04:48altogether.
• 04:49This is, I think, too
• 04:50early for prime time, not
• 04:51not ready yet,
• 04:53but something potentially down the
• 04:55pipe.
• 04:58So if we are gonna
• 04:58do surgery for early stage
• 05:00breast cancers,
• 05:01what are some of the
• 05:02updates? And I'll go through
• 05:03these in a kind of
• 05:04brief,
• 05:05review
• 05:06as far as thinking about,
• 05:08we do have noncancerous lesions
• 05:09that we often take out
• 05:10for breast,
• 05:11as breast surgeons. We do
• 05:12a lot of now more
• 05:13oncoplastic work, which I'll touch
• 05:15on, briefly.
• 05:16We have some nipple sparing
• 05:17mastectomy updates as far as,
• 05:19nipple as far as sensation
• 05:21preservation
• 05:22and, potentially, you know, different
• 05:24options for reduction of lymphedema.
• 05:26So a lot of women
• 05:28will get diagnosed
• 05:30with these things called high
• 05:30risk lesions. They're not actually
• 05:31breast cancers, but sometimes,
• 05:34if they're in the breast
• 05:35and we remove it, we
• 05:36may find some underlying,
• 05:38essentially, precancer or DCIS diagnoses.
• 05:41So if a woman gets
• 05:42biopsy and has what's called
• 05:43atypical ductal hyperplasia,
• 05:45it is something that you
• 05:46wanna, consider seeing a breast
• 05:48surgeon for because it may
• 05:50be something we would talk
• 05:51to you you about removal
• 05:52of.
• 05:53Someone may get diagnosed with
• 05:54what's called LCIS or lobular
• 05:56carcinoma in situ, and it's
• 05:58alarming for patients and often
• 06:00get a a phone call
• 06:01from their primary doctor saying,
• 06:02you know, you have an
• 06:04carcinoma.
• 06:05But what we know about
• 06:06LCIS,
• 06:07that we actually don't need
• 06:08to take it out. It
• 06:09doesn't become a breast cancer,
• 06:11and it's something that we
• 06:12can watch,
• 06:13recognizing
• 06:14that it's a marker of
• 06:15risk. And then, you know,
• 06:17further things in the breast
• 06:18that can be diagnosed
• 06:20are the
• 06:21scars and papillomas.
• 06:23All
• 06:25some times,
• 06:26again, considering
• 06:29high risk lesions.
• 06:32Some we recommend,
• 06:34excision for, and some we
• 06:35don't recommend excision for.
• 06:38A lot of women ask,
• 06:39well, how are you gonna
• 06:40find who you're gonna be
• 06:41able to identify to get
• 06:42the the tumor out? And,
• 06:43unfortunately, that little biopsy clip
• 06:44get that gets left is
• 06:46not big enough for us
• 06:47as breast cancer surgeons to
• 06:48find on our own. So
• 06:50we need some help to
• 06:51be able to find that
• 06:52lesion, and it's always disappointing
• 06:53for the patient when we
• 06:54say we have to put
• 06:55in another thing into the
• 06:57breast before surgery, but it's
• 06:59very helpful for us, to
• 07:00be able to find accurately
• 07:01and pinpoint exactly where we
• 07:03need to go. So we
• 07:04used to use wires.
• 07:06And now,
• 07:07because of all the sometimes
• 07:09chaos that can happen with
• 07:10wires, sometimes we'll use what's
• 07:12called a tag or even
• 07:14a smaller device that goes
• 07:16into the breast a few
• 07:17days before surgery,
• 07:18and then often doesn't delay
• 07:20surgeries.
• 07:21A patient can get it,
• 07:22you know, a few days
• 07:23before on their own time,
• 07:25and it allows
• 07:27often
• 07:29to you know, a little
• 07:30bit, at different locations of
• 07:32the breast. Wires are still
• 07:33used. They're great technology.
• 07:35It's a very per, kind
• 07:36of surgeon preference and personal
• 07:38preference for the patient as
• 07:39well, but they're just different
• 07:41ways to, think about localization.
• 07:45Some women will come into
• 07:47our our
• 07:48clinic with, you know, these
• 07:49very large areas of, for
• 07:50instance, calcifications
• 07:52or even a large breast
• 07:53tumor,
• 07:55where, you know, we recommend
• 07:56surgery first.
• 07:58And sometimes, you know, there
• 07:59may be no other option
• 08:01but a mastectomy.
• 08:02But sometimes we have really
• 08:03nice options
• 08:04where we can do a
• 08:04very large resection and work
• 08:06very closely with our plastic
• 08:07surgeons, doctor Hakal and others,
• 08:09where we can do what's
• 08:10called an oncoplastic reduction. And
• 08:12so it allows us as
• 08:13breast cancer surgeons, even an
• 08:14early stage breast cancer, to
• 08:16take out a large piece
• 08:17of tissue,
• 08:18and really reduce or, you
• 08:20know, do what's called a
• 08:21mastopexy lift of the breast,
• 08:23and leave a woman with
• 08:24an amazing, reconstructive result,
• 08:27but still take out a
• 08:28fair amount of breast tissue
• 08:29and and get out the
• 08:30cancer safely.
• 08:32When we are taking
• 08:35out early stage cancers, we
• 08:37all kinda make sure that
• 08:38we get clear margins around
• 08:40the cancer. And I think
• 08:41this is can be a
• 08:42very confusing,
• 08:43for patients to understand.
• 08:45So when we think about
• 08:46clear margins,
• 08:48what essentially what we wanna
• 08:49do is we wanna take
• 08:50out, the cancer,
• 08:52and then we always want
• 08:53some healthy breast tissue
• 08:55around that cancer.
• 08:57And so, you know, unfortunately,
• 08:59when we have what's called
• 09:00a positive margin,
• 09:01what that means is is
• 09:02the what we hope is
• 09:04healthy breast tissue. Again, unfortunately,
• 09:06this is all microscopic
• 09:07disease.
• 09:08What we what a healthy
• 09:09breast tissue margin we we
• 09:11removed
• 09:12comes back underneath the microscope
• 09:13with some cancer on the
• 09:14edge of that margin. And
• 09:16that does often require us
• 09:18to go back to the
• 09:18operating room with the patient
• 09:19to take, again, a little
• 09:21bit more tissue.
• 09:22It doesn't mean that the
• 09:23cancer has spread all over
• 09:24the store. It doesn't mean
• 09:26that,
• 09:27you know, we missed something
• 09:29per se. Unfortunately,
• 09:30you know, we don't have,
• 09:32X-ray vision. If we did,
• 09:33that would be awesome.
• 09:35But since we don't, it's
• 09:36just a matter of where
• 09:37the pathologist, the doctors that
• 09:39look at things underneath the
• 09:40microscope, really have to examine
• 09:41that tissue to make sure
• 09:43that the cancer cells are
• 09:44clean of the edge.
• 09:47We also want cancer cells
• 09:48clean of the edge when
• 09:49we do DCIS,
• 09:51surgeries as well,
• 09:53and we always,
• 09:54kinda shoot for this idea
• 09:55of two millimeters from the
• 09:56edge of the piece of
• 09:57tissue when we take out
• 09:58margins.
• 10:01At Yale, the the study
• 10:03done to look at margins
• 10:05when we do remove breast
• 10:06tissue around,
• 10:08the the,
• 10:11cancer was done,
• 10:12by doctor Chagpar, who's no
• 10:14longer here at Yale, but
• 10:15she led this trial at
• 10:16Yale. And it was a
• 10:17really well done trial to
• 10:20show how we can take
• 10:21these,
• 10:22this healthy breast tissue around
• 10:24the cancer.
• 10:26As far as some of
• 10:27the mastectomy updates for early
• 10:28stage breast cancers, so when
• 10:30we think about mastectomies,
• 10:33there's multiple different ways to
• 10:34do mastectomies, multiple different types
• 10:36of reconstruction.
• 10:37And one of the ways
• 10:38now is what we can
• 10:39do is called a nipple
• 10:40sparing mastectomy.
• 10:42Yes, we know ducts do
• 10:44go into the nipple, and
• 10:45so sometimes there's fear that,
• 10:47you know, that may increase
• 10:48a woman's risk of developing
• 10:49a breast cancer if they
• 10:50have, for instance, the BRCA
• 10:52gene and want a prophylactic
• 10:53mastectomy.
• 10:54Or it may you know,
• 10:55there there may be some
• 10:56fear about risk of recurrence,
• 10:58if a patient has cancer
• 10:59and has a nipple sparing
• 11:00mastectomy.
• 11:01And a lot of really
• 11:02well done trials, you'll see
• 11:03doctor Greenup on this study,
• 11:05I should say.
• 11:07There's been a lot of
• 11:08work done in whether or
• 11:09not nipple sparing mastectomies are
• 11:11safe for our cancer patients
• 11:12in the early stage setting
• 11:13and in the prophylactic setting
• 11:15for our BRCA carrier patients.
• 11:17And what we found from
• 11:18multiple trials now or studies,
• 11:21I guess, I should articulate,
• 11:22is that, it is a
• 11:23very, very safe procedure for
• 11:26women to have done. Not
• 11:27everyone will qualify for a
• 11:29nipple sparing for various reasons,
• 11:32but,
• 11:33you know, in the setting
• 11:34that it's it's, a reasonable
• 11:35operation for a patient, it's
• 11:37safe.
• 11:39Contralateral prophylactic mastectomy. So this
• 11:42is a whole another discussion
• 11:43about when a woman has
• 11:44an affected breast with breast
• 11:46cancer.
• 11:47What about removing the other
• 11:49breast? You know, there's a
• 11:50lot of discussion about whether
• 11:51breast cancer spreads from one
• 11:53breast to the other, and
• 11:54that's actually not the case.
• 11:55We know that breast cancers
• 11:56don't spread from the right
• 11:58breast, for instance, to the
• 11:59left breast, but we do
• 12:00know that a woman's at
• 12:01a higher risk of developing
• 12:03a contralateral cancer if they
• 12:04have a breast cancer in
• 12:05one of their breast.
• 12:07What we do know is
• 12:08that
• 12:09removing the contralateral breast does
• 12:11decrease that woman's risk of
• 12:13getting a breast cancer, but
• 12:14doesn't improve their survival from
• 12:16their actual cancer in their
• 12:17in their breast.
• 12:19It's something to consider. It's
• 12:20definitely a conversation to have
• 12:22with your surgeon.
• 12:24And, you know, some women
• 12:25elect to do it for
• 12:25a very personal reason, and
• 12:27some women don't. It's just
• 12:28something to always kind of
• 12:30think about.
• 12:32As far as nipple sin
• 12:34neurotization
• 12:35now, so,
• 12:36there is some
• 12:38data to suggest that we
• 12:40may be able to reneurotize
• 12:42or essentially give sensation to
• 12:44the mastectomy skin when we
• 12:46remove the breast. Oftentimes, we
• 12:48remove the breast, the skin
• 12:49is innervated or gets its
• 12:50sensation from the breast, And
• 12:52so the skin loses sensation.
• 12:54It becomes numb.
• 12:55And now, you know, there
• 12:57is some,
• 12:58ability
• 12:59to find these nerves along
• 13:01the the outside part of
• 13:03the breast,
• 13:04connect,
• 13:05what's called an allograph. So
• 13:06it's a cadaver nerve,
• 13:08and then so that also
• 13:10into nerves underneath the nipple
• 13:12to try to preserve some
• 13:13sensation.
• 13:15There's
• 13:16some data to suggest that
• 13:18it works and then some
• 13:19data to suggest that it's
• 13:20it's not perfect,
• 13:22and that it doesn't always
• 13:23work. And so, you know,
• 13:25I think this is, you
• 13:26know, kinda two weeks continued.
• 13:29You know, I think often
• 13:30it's worth a try, and
• 13:32then, you know, sometimes,
• 13:34you know, we'll just have
• 13:35to see what the data
• 13:36shows as far as long
• 13:37term outcomes,
• 13:38because it may not, hold
• 13:40true to for every woman.
• 13:44There's been a lot of
• 13:46changes in the way we
• 13:48think about removing lymph nodes
• 13:49underneath the armpit for early
• 13:50stage breast cancers, which is
• 13:52really exciting for patients.
• 13:54We used to have to
• 13:55remove all the lymph nodes
• 13:56underneath the armpit all the
• 13:57time, and it caused a
• 13:58lot of morbidity for our
• 14:00patients. And now what we
• 14:01know, we can really only
• 14:02have to remove a few
• 14:03lymph nodes off in called
• 14:05a sentinel lymph node biopsy
• 14:06and leave the the rest
• 14:08of the lymph nodes to
• 14:09avoid that really, you know,
• 14:10unfortunate risk of what's called
• 14:12lymphedema, the swelling of the
• 14:13arm.
• 14:14As I spoke, earlier on,
• 14:16the z eleven trial was
• 14:17the trial in the early
• 14:18two thousands that showed us
• 14:20that if a woman has
• 14:21only one or two positive
• 14:23lymph nodes at the time
• 14:24of surgery, we don't have
• 14:26to necessarily remove all the
• 14:27lymph nodes.
• 14:29Now we even know
• 14:31that with women who have
• 14:32early stage slow growing cancers,
• 14:35the hormone receptor positive breast
• 14:36cancers,
• 14:37we actually don't even have
• 14:38to remove lymph nodes at
• 14:40all. So we don't even
• 14:41have to do that sentinel
• 14:42lymph node biopsy.
• 14:44If a woman has small
• 14:45cancers, hormone receptor positive,
• 14:48two trials were done, kind
• 14:50of right near each other,
• 14:51one in Europe and one
• 14:53in the UK,
• 14:54that showed us that there
• 14:55was no difference in outcomes
• 14:56whether we actually remove lymph
• 14:58nodes at all.
• 15:00This was just a a
• 15:01little bit more detail on
• 15:02the sound trial that allowed
• 15:04us again to show if
• 15:05a woman has a normal
• 15:06axillary ultrasound before surgery, we
• 15:09do breast conservation.
• 15:11We don't have to remove
• 15:12lymph nodes. And this was
• 15:13the INSEMA trial in Europe,
• 15:15again, showing essentially the same
• 15:17results. As you can see,
• 15:18the surgical complications
• 15:20are real when we have
• 15:22to remove lymph nodes, and
• 15:24they did a really nice
• 15:24job demonstrating that when we
• 15:26omit removing lymph nodes, women
• 15:28have a lot less, surgical
• 15:30complications.
• 15:32We give neoadjuvant chemotherapy, meaning
• 15:34chemotherapy before surgery and sometimes
• 15:37still early stage breast cancers
• 15:38if they're more aggressive, like
• 15:39the triple negative setting and
• 15:41the HER2 positive setting.
• 15:42And now what we know
• 15:43is
• 15:44that if we remove lymph
• 15:46nodes after chemotherapy
• 15:49and there's no cancer left
• 15:50in any of them, we
• 15:52don't have to take out
• 15:52all that lymph nodes underneath
• 15:54the armpit.
• 15:55However, stay tuned because even
• 15:58now, when we have a
• 15:59few lymph nodes that still
• 16:00have cancer in it after
• 16:01chemotherapy,
• 16:02we may not need to
• 16:03take out all the rest
• 16:04of them, and we may
• 16:05be able to, offer the
• 16:07patient radiation alone. So these
• 16:09results are hopefully coming in
• 16:10the next four to five
• 16:11to ten years,
• 16:13but I think this will
• 16:13be practice changing patients
• 16:15as
• 16:16well.
• 16:19And doctor Hickall may get
• 16:20into this in a little
• 16:21bit more detail later, but
• 16:22we now know that if
• 16:23we do have to remove
• 16:24all the lymph nodes, even
• 16:25still for an early stage
• 16:26breast cancer, it can happen.
• 16:28We can do techniques now
• 16:29to hopefully avoid, the horrible
• 16:31complication of lymphedema,
• 16:33where we can connect a
• 16:35vein and a lymphatic, a
• 16:37little channel in the armpit.
• 16:38And, again, I ideally, allow
• 16:40our patients to suffer less
• 16:42from potential complications of lymphedema.
• 16:45There are ongoing clinical trials
• 16:47in this country looking at
• 16:48this very idea to hopefully
• 16:50have to show that there
• 16:52are good outcomes with it,
• 16:54but stay tuned as well.
• 16:56And I think that's all
• 16:57I have. Thank you so
• 16:58much for the time, and
• 16:59I'd love to take questions
• 17:00at the end.
• 17:01Thank you so much, doctor
• 17:03Berger. And we're gonna move
• 17:04on to our two additional
• 17:05speakers. We'll take questions at
• 17:07the end, and I'll be
• 17:08responding in real time in
• 17:09the chat.
• 17:11This is really meant to
• 17:12highlight our multidisciplinary
• 17:13team approach.
• 17:14Next up is doctor Siva
• 17:16Haykal, associate professor of plastic
• 17:18surgery and section chief of
• 17:20oncoplastic
• 17:21reconstruction.
• 17:22Tonight, she'll be talking about
• 17:24breast reconstruction
• 17:25and early stage breast cancer.
• 17:26Thank you, doctor Haykel.
• 17:28Thank you so much, doctor
• 17:29Greenup, and thank you, doctor
• 17:31Berger, for an amazing talk.
• 17:33I'll be sharing my screen.
• 17:42Please let me know if
• 17:43you can see it.
• 17:48Great. Thank you.
• 17:50Okay. Great. So we're gonna
• 17:51talk about breast reconstruction,
• 17:53and,
• 17:55I'm open to questions at
• 17:56the end. Hopefully, I can
• 17:57answer some of the questions
• 17:58by going through,
• 18:00some of the slides and
• 18:01some of the techniques where,
• 18:03breast,
• 18:04breast cancer surgeons are working
• 18:06in collaboration with reconstructive
• 18:09surgeons,
• 18:10in order to achieve a
• 18:11great outcome.
• 18:13So let's talk about breast
• 18:14reconstruction. So it can either
• 18:16be immediate, which is at
• 18:18the time of mastectomy,
• 18:19and we'll talk about lumpectomy
• 18:21as well, or it can
• 18:22be delayed, which is any
• 18:23day after the mastectomy.
• 18:26How do we determine the
• 18:28best options,
• 18:29and, how do we make
• 18:30a decision? So it has
• 18:32to do with patient preference,
• 18:34the need for postoperative treatments
• 18:36such as chemotherapy or radiation,
• 18:39whether we have donor sites,
• 18:40and I'll talk about what
• 18:41that means,
• 18:43other medical issues, and recovery
• 18:45time.
• 18:46So I'll first talk about
• 18:47oncoplastic
• 18:48reconstruction.
• 18:49So doctor Berger mentioned it
• 18:51a little bit, but oncoplastic
• 18:53reconstruction
• 18:54basically involves,
• 18:57rearranging breast tissue after a
• 18:59lumpectomy for breast cancer
• 19:01to achieve a better aesthetic
• 19:03result. So when a portion
• 19:04of the breast is removed,
• 19:06it can cause some dimples,
• 19:08some divots in the breast,
• 19:10and it can cause some
• 19:11asymmetry between the two breasts.
• 19:13So this is a great
• 19:15option for people who have
• 19:17large or very, what we
• 19:18call, tootic or saggy breasts.
• 19:21So a breast reduction is
• 19:22typically done on the other
• 19:24side as well,
• 19:26and or and or a
• 19:28breast lift.
• 19:31Now let's talk about implant
• 19:32based reconstruction.
• 19:34So there are some techniques
• 19:35that involve putting in an
• 19:37implant right away. So that's
• 19:39when we put an implant
• 19:41at the time of a
• 19:42mastectomy.
• 19:43It eliminates the need for
• 19:45what we call a tissue
• 19:46expander.
• 19:48It's a breast reconstruction
• 19:49that can be completed in
• 19:51one step,
• 19:52and people who are good
• 19:53candidates for this are really
• 19:55based on the breast size,
• 19:57the cancer size,
• 19:59and the type of mastectomy
• 20:01required.
• 20:02And frequently, it's done when,
• 20:05we try to keep the
• 20:06nipple areola.
• 20:07However, this is not the
• 20:09gold standard.
• 20:10It can lead to high
• 20:12revision rates.
• 20:14The gold standard for implant
• 20:16based reconstruction
• 20:17is what we call a
• 20:18two stage procedure.
• 20:20So in the first stage,
• 20:22we put either a tissue
• 20:23expander
• 20:24above or underneath the muscle
• 20:26and most commonly now above
• 20:28the muscle.
• 20:29This looks sort of like
• 20:30a balloon. It has,
• 20:32a magnetic port in it,
• 20:34and it's covered by the
• 20:35skin.
• 20:37And this requires
• 20:39filling of that,
• 20:40balloon
• 20:42in clinic every one to
• 20:43two weeks, and we fill
• 20:45it to the size that
• 20:46we're happy with or you're
• 20:47happy with.
• 20:48And it involves the second
• 20:50stage. So that means going
• 20:52back to the operating room,
• 20:54removing the expander, and putting
• 20:56in an implant.
• 20:57Because this is kinda what
• 20:59it looks like. Sometimes it's
• 21:00covered with a special type
• 21:02of mesh.
• 21:03And,
• 21:04in clinic, we use a
• 21:06mag we use a magnetic
• 21:08finder. We find the magnetic
• 21:10port, and we put a
• 21:11needle through the skin
• 21:13into the tissue expander, and
• 21:15we fill up that space.
• 21:16So, typically, we start filling
• 21:19about two to three weeks
• 21:20after surgery.
• 21:21The expansion process can take
• 21:23up to
• 21:36treatment as required.
• 21:39What are the advantages of
• 21:40implant based reconstruction?
• 21:42It's a quicker procedure.
• 21:44It's a shorter recovery time.
• 21:47You get to choose the
• 21:48size of your reconstruction.
• 21:50We're only operating on one
• 21:52side.
• 21:53The disadvantage is it can
• 21:54be more than one surgery.
• 21:56We can sometimes see and
• 21:58palpate the implant.
• 22:00If it's placed under the
• 22:01muscle, the muscle can cause
• 22:03animation.
• 22:04There's always a risk of
• 22:06infection.
• 22:07There's a risk of what
• 22:08we call capsular contracture, which
• 22:10is the body forming
• 22:12a capsule around the implant,
• 22:14which
• 22:15commonly happens. However, sometimes it
• 22:18can become
• 22:19hard and painful
• 22:21and can distort the implant.
• 22:23Implants can also rupture.
• 22:25Any radiation can lead to
• 22:27a higher failure rate, and
• 22:29there's a few things associated
• 22:31with implants that are less
• 22:33common and actually very rare,
• 22:35but we frequently
• 22:36talk about and you should
• 22:37discuss with your reconstructive surgeon,
• 22:40which are anaplastic large cell
• 22:41lymphoma and breast implant illness,
• 22:44which are related to safety,
• 22:46related to some types of
• 22:47implants,
• 22:48which are not always used,
• 22:51in all practices.
• 22:53Doctor Berger alluded to, sensation
• 22:55preservation.
• 22:58So this is frequently
• 23:00done when we can preserve
• 23:02the nipple
• 23:03and the areola,
• 23:04which can which is done
• 23:06in, some patients. Again, the
• 23:08tumor has to be far
• 23:09away enough from the nipple
• 23:11areola so that we can
• 23:12keep it.
• 23:13And then the breast have
• 23:14to has to already has
• 23:15a nice shape,
• 23:17to it so that we
• 23:18can preserve the nipple areola.
• 23:20So when that's done, we
• 23:21can do we can preserve
• 23:23sensation in two ways.
• 23:25One of them by connecting
• 23:27a nerve
• 23:28that comes off the shelf
• 23:30that has been processed,
• 23:32or we can take a
• 23:33nerve
• 23:34from the side of the
• 23:35breast that's not involved in
• 23:36the cancer
• 23:38and transfer it over to
• 23:39try to bring back sensation.
• 23:42Now the sensation is not
• 23:43like normal sensation.
• 23:45It's not erogenous
• 23:46sensation,
• 23:48but, we think with some
• 23:49studies that we can bring
• 23:51back sensation,
• 23:53better than not having this
• 23:54done at all.
• 23:56The other type of re
• 23:58re breast reconstruction is called
• 23:59autologous tissue reconstruction.
• 24:02Can you guys still hear
• 24:03me?
• 24:05Okay. Great. Sorry. I think
• 24:06you lost the signal.
• 24:08And that means using your
• 24:10own tissue. So that can
• 24:12come from different areas.
• 24:14So there it can come
• 24:15from the abdomen, the belly.
• 24:17That's called a deep flap.
• 24:18It can come from the
• 24:19thighs. That can is called
• 24:21the tug flap or the
• 24:22pad flap. It can come
• 24:24from the buttocks, the eye
• 24:26gap, or the s cap,
• 24:27or it can come from
• 24:28the back.
• 24:29So that's using,
• 24:30the patient's own tissues to
• 24:32create a breast mound. It
• 24:34avoids all the complications
• 24:36related to implants,
• 24:37and it's a pretty nice
• 24:38donor site. So let's talk
• 24:40about the options.
• 24:41The most common one is
• 24:43called the deep flap. That
• 24:45stands for deep inferior epigastric
• 24:47perforator flap. That just means
• 24:49the vessels that we actually
• 24:51use.
• 24:52So this is a cross
• 24:53section of the belly where
• 24:54we have skin and fat
• 24:56and the muscle.
• 24:58There's little vessels that are
• 24:59less than one millimeter in
• 25:01size that really penetrate through
• 25:03that muscle
• 25:04and give blood supply to
• 25:06the skin and the fat.
• 25:07So we get a CT
• 25:08scan of the belly first,
• 25:10and during the surgery,
• 25:12we find those little vessels.
• 25:14We follow them all the
• 25:15way down to the groin
• 25:16where they come from, where
• 25:17they become slightly larger, so
• 25:19about two to three millimeters.
• 25:21We disconnect them from that
• 25:23area,
• 25:24and we reconnect them in
• 25:25vessels underneath a small piece
• 25:27of rib.
• 25:29This is called microsurgery.
• 25:31We use loops and a
• 25:32microscope to do this, and
• 25:33it can be a long
• 25:34procedure.
• 25:36You end up with a
• 25:37scar from hip to hip
• 25:38and a scar around the
• 25:39belly button like a tummy
• 25:41tuck.
• 25:42Half of the belly is
• 25:44used for one side, half
• 25:45is used for the other
• 25:47side, and we create a
• 25:48breast out of it.
• 25:50We can also bring in
• 25:51a little nerve to try
• 25:53to bring back sensation
• 25:55and try to,
• 25:57you know, to create the
• 25:58sensation
• 25:59similar to what I talked
• 26:00about earlier.
• 26:02I'm sorry. I have a
• 26:03little child in the background.
• 26:05And we also have,
• 26:07however,
• 26:08it's, again, not like normal
• 26:10sensation,
• 26:12but we do know that
• 26:13with time, even without using
• 26:15a nerve graft, we can
• 26:16bring back since the, the
• 26:19nerves actually grow from the
• 26:20side,
• 26:21of the body to try
• 26:23to bring back sensation into
• 26:25the flap.
• 26:26One side takes about six
• 26:28hours.
• 26:29Two sides takes about ten
• 26:30hours.
• 26:31This admit patients have to
• 26:33admit be admitted for about
• 26:35two to three days. The
• 26:36first twenty four hours are
• 26:38the most important because we
• 26:39watch to make sure that
• 26:41everything is working okay.
• 26:43The advantages are that most
• 26:45of the reconstruction is done
• 26:46at the time of surgery.
• 26:48We're using your own tissues.
• 26:50It's lifelong. It's the best
• 26:52substitute for a natural looking
• 26:53breast.
• 26:54The benefits is a tummy
• 26:56tuck.
• 26:57However, it's a longer procedure.
• 26:59It's a longer recovery time.
• 27:01It's a separate donor site.
• 27:04It may require revision surgeries.
• 27:06There's a possibility of it
• 27:08not working, which is which
• 27:09doesn't happen very often.
• 27:11We can only use the
• 27:12belly once, and there's obviously
• 27:14more scars because we're operating
• 27:16in another area.
• 27:18Other areas that we can
• 27:19take it from is the
• 27:20buttocks,
• 27:21the thighs
• 27:23as well.
• 27:24Now let's talk about using
• 27:26implants with your own tissue.
• 27:28So that is a procedure
• 27:30where we can take,
• 27:31in cases, for example, of
• 27:33radiation,
• 27:34where we can take skin
• 27:36and fat and sometimes the
• 27:38muscle
• 27:39and swing it over to
• 27:40the breast
• 27:41along with a tissue expander
• 27:43of an or an implant,
• 27:45to recreate a breast.
• 27:48Now I also wanna talk
• 27:49about what we call aesthetic
• 27:51flat closure.
• 27:52So plastic surgeon can be
• 27:54involved in after mastectomies
• 27:56in patients who do not
• 27:57want reconstruction,
• 27:59but do not want redundant
• 28:01skin in that area. So
• 28:02we can do different techniques
• 28:04to try to make sure
• 28:05that we have scars,
• 28:08that look aesthetic
• 28:10and to make sure that
• 28:11there are no irregularities
• 28:13in the chest.
• 28:15Now the advantages of implant
• 28:17and autologous based reconstruction, which
• 28:18I mentioned earlier, is that
• 28:20it can be used in
• 28:21patients who had radiation,
• 28:23in patients who are too
• 28:25thin or have had a
• 28:26tummy tuck. The disadvantages
• 28:28is the disadvantages of an
• 28:29implant
• 28:30or using tissue from other
• 28:32part of the body.
• 28:34If we have to remove
• 28:35the nipple areola, then we
• 28:36can reconstruct the nipple areola,
• 28:39and that's usually done by
• 28:40either bunching up some tissue,
• 28:42kinda like origami, to make
• 28:43a nipple or an elevation
• 28:45out of it.
• 28:46And other techniques that we
• 28:47use are,
• 28:49tattooing.
• 28:50One of our APRNs will
• 28:52do that, and we have,
• 28:54they're involved in,
• 28:56clinical and operative care for
• 28:58breast, breast cancer patients.
• 29:00They're certified in tattoo art.
• 29:03Doctor Berger alluded to,
• 29:06a technique that we use
• 29:07for prevention.
• 29:09So one technique is called
• 29:11immediate lymphatic reconstruction,
• 29:13Most importantly, to prevent,
• 29:16to prevent lymphedema,
• 29:17it's the way that we
• 29:18actually remove the lymph nodes
• 29:20by making sure that we
• 29:22try to preserve the lymphatic
• 29:23vessels at the same time.
• 29:25But if all of the
• 29:27lymph nodes are removed and
• 29:28have to be removed,
• 29:30then what we can do
• 29:31is we can try to
• 29:32find those little lymph nodes
• 29:34again by using a microscope.
• 29:36Those are very, very small
• 29:38in size. They're less than
• 29:39one millimeter in size.
• 29:41And we find a vein
• 29:42of equal size, and we
• 29:44reroute them. We perform a
• 29:46bypass.
• 29:47The suture that we use
• 29:48to bring those together is
• 29:49actually finer than a hair,
• 29:51so you can imagine that
• 29:52that's very small.
• 29:54And we our goal is
• 29:56to hopefully prevent lymphedema.
• 29:59This adds about an hour
• 30:00to an hour and a
• 30:01half to the case, and
• 30:02we think by looking at
• 30:04studies that it has the
• 30:06ability to reduce the chances
• 30:07of lymphedema by about fifty
• 30:09percent.
• 30:10It doesn't necessarily mean that
• 30:12absolutely
• 30:13would not have lymphedema,
• 30:15but it definitely
• 30:16is,
• 30:17is worth, worth trying.
• 30:20Thank you very much for
• 30:21listening, and,
• 30:22I welcome any questions that
• 30:24may come at the end
• 30:25of this talk.
• 30:28Thank you very much, doctor
• 30:30Haykel.
• 30:31And, we'll move on to
• 30:32doctor Maria Rosenblatt.
• 30:34Doctor Rosenblatt is an assistant
• 30:36professor of medicine in the
• 30:37division of medical oncology,
• 30:40and she'll be talking with
• 30:41us this evening about updates
• 30:42in systemic therapy.
• 30:44Welcome, doctor Rosenblitt.
• 30:46Thank you so much.
• 30:49Okay. So I'm gonna be
• 30:50talking about systemic therapy for
• 30:52breast cancer.
• 30:55And as we've heard so
• 30:56far,
• 30:57really, the treatment of breast
• 30:59cancer is a multidisciplinary
• 31:00approach,
• 31:01and this involves the breast
• 31:03surgeon, the radiation oncologist, and
• 31:05the medical oncologist.
• 31:07And each part of the
• 31:09team has a slightly different
• 31:11goal. So the goal of
• 31:12the breast surgeon
• 31:13is to remove the known
• 31:14cancer,
• 31:15to obtain negative margins as
• 31:17we heard about, to evaluate
• 31:18the lymph nodes,
• 31:20and
• 31:21to remove involved lymph nodes.
• 31:23The radiation oncologist
• 31:25then tries to mop up
• 31:26any microscopic
• 31:28disease in the breast,
• 31:29and the regional lymph nodes,
• 31:31and this is usually done
• 31:33after surgery, so after a
• 31:35lumpectomy.
• 31:36And sometimes in special circumstances,
• 31:38it might be recommended after
• 31:39a mastectomy.
• 31:40And the goal of that
• 31:41treatment is to reduce local
• 31:43recurrence, so the risk of
• 31:45the breast cancer coming back
• 31:46in the same breast.
• 31:48As the medical oncologist, my
• 31:50goal is to really mop
• 31:51up any microscopic disease that
• 31:53might be anywhere else in
• 31:54the body. And my goal
• 31:56is to decrease the risk
• 31:58of what we call distant
• 31:59recurrence, so the risk that
• 32:00this cancer
• 32:01might come back in other
• 32:02parts of the body.
• 32:04And we call that, the
• 32:06risk of developing metastatic recurrence.
• 32:13Okay. So how do we
• 32:14decide,
• 32:15what kind of medical treatment
• 32:17to offer? And this is
• 32:18a really complex decision that
• 32:20we put a lot of
• 32:20thought into. And we heard
• 32:22a little bit from Doctor.
• 32:23Berger about stage. So we
• 32:25think about what size is
• 32:26the tumor, how many lymph
• 32:28nodes are involved,
• 32:30are we worried about any
• 32:31distant metastatic sites? And then
• 32:34we think about the patient
• 32:35in front of us. What
• 32:36is their age? What are
• 32:37their other medical problems?
• 32:39What is their life expectancy?
• 32:41What are their values?
• 32:43And then we also think
• 32:45about
• 32:46additional characteristics.
• 32:48So just as doctor Berger
• 32:49mentioned, it's not just about
• 32:50tumor size and lymph nodes,
• 32:52it's also about the molecular
• 32:53makeup of that tumor. So
• 32:55we know that,
• 32:57whether it's a hormone positive
• 32:58or HER2 positive or triple
• 33:00negative breast cancer,
• 33:02The type of breast cancer
• 33:03has a very different prognosis.
• 33:06We also think about grade,
• 33:07meaning how aggressive does this
• 33:09cancer look under the microscope,
• 33:11and we sometimes do special
• 33:13types of gene expression testing
• 33:15to try to help us
• 33:16figure out what is the
• 33:17risk of this cancer coming
• 33:18back.
• 33:20So in terms of the
• 33:21timing of the therapy, we
• 33:23think about it, in two
• 33:25large buckets, meaning adjuvant or
• 33:27neoadjuvant
• 33:28approach.
• 33:29When we talk about an
• 33:30adjuvant approach, that's when we
• 33:32have a discussion with the
• 33:33surgeon,
• 33:34and we come up with
• 33:35a plan that we recommend
• 33:37surgery first.
• 33:38After surgery,
• 33:40we think about whether
• 33:42the person would benefit from
• 33:43the addition of chemotherapy,
• 33:46if they have a HER2
• 33:47positive breast cancer, whether they
• 33:49need HER2 targeted therapy,
• 33:51and then if radiation is
• 33:53needed. And then if it's
• 33:54a hormone positive breast cancer,
• 33:56we would add on something
• 33:57called endocrine therapy at the
• 33:59end.
• 34:00Sometimes we prefer a neoadjuvant
• 34:02approach, and this is often
• 34:04when chemotherapy
• 34:06is recommended before surgery.
• 34:08And this is often done
• 34:09in larger tumors
• 34:11where there might be a
• 34:12lot of lymph nodes that
• 34:13we're hoping to shrink before
• 34:15surgery,
• 34:16or if it's a more
• 34:17aggressive cancer like a triple
• 34:19negative breast cancer or HER2
• 34:21positive breast cancer.
• 34:22And sometimes,
• 34:24we recommend
• 34:26systemic treatment first because how
• 34:28the tumor responds to the
• 34:29treatment can actually be very
• 34:31important information for us as
• 34:32medical oncologists.
• 34:35And when the patient gets
• 34:37to surgery,
• 34:38we are looking for something
• 34:39called a complete pathologic
• 34:41response. So if we did
• 34:42systemic therapy first
• 34:44and the whole tumor,
• 34:47was killed off by the
• 34:48therapy and it looks just
• 34:49like scar tissue under the
• 34:50microscope,
• 34:51prognostically, that's very important and
• 34:53predicts a very low risk
• 34:54of recurrence.
• 34:56The radiation,
• 34:57question is up to the
• 34:59radiation oncologist
• 35:00and really depends on,
• 35:02what type of surgery,
• 35:04was recommended.
• 35:05And then once again, if
• 35:06it's hormone positive, we would
• 35:08end,
• 35:08we would add on endocrine
• 35:10therapy at the end.
• 35:12So this is an example
• 35:13of an oncotype, but this
• 35:15is a test that we
• 35:16commonly send for hormone positive
• 35:18breast cancers.
• 35:19And what this does is
• 35:20it takes a small piece
• 35:21of tissue from the original
• 35:23breast tumor
• 35:24and sends it off to
• 35:25a special lab to look
• 35:26at a certain number of
• 35:27genes in the tumor itself
• 35:29that help to predict how
• 35:31aggressive that cancer is and
• 35:33what is the risk of
• 35:33the cancer coming back. And
• 35:35so what the report gives
• 35:37you is a number.
• 35:38And in general, anything above
• 35:40twenty five suggests that there's
• 35:42a benefit to chemotherapy,
• 35:44and it also gives you
• 35:45this number called distant recurrence
• 35:47risk at nine years. And
• 35:49so what that number tells
• 35:50you is over the next
• 35:52nine years,
• 35:53what is the risk of
• 35:54this cancer coming back in
• 35:56other parts of the body,
• 35:57so coming back as a
• 35:58metastatic breast cancer.
• 36:00And,
• 36:01if you take endocrine therapy,
• 36:04it gives you the the
• 36:05risk with the endocrine therapy.
• 36:08In general, we know that
• 36:09endocrine therapy reduces risk by
• 36:11about fifty percent. So if
• 36:13you don't take endocrine therapy,
• 36:15you can double that number.
• 36:17And then it also gives
• 36:18you the number for absolute
• 36:19chemotherapy
• 36:20benefit.
• 36:21And so often if it's
• 36:22a high oncotype,
• 36:24that absolute benefit is usually
• 36:25greater than fifteen percent, and
• 36:27that's when we'll be recommending
• 36:29chemotherapy.
• 36:32Here at Yale, we have
• 36:33developed several different pathways,
• 36:36to help standardize,
• 36:38the decision for when to
• 36:39send Oncotype.
• 36:41And so wherever you go
• 36:43as a patient across the
• 36:44Yale network,
• 36:45the different physicians will be
• 36:47following the same algorithm.
• 36:49And this can be really
• 36:50helpful because for some tumors
• 36:51that are very small, that
• 36:53have very low risk features,
• 36:54we often don't even have
• 36:56to send an oncotype.
• 36:57And then for some tumors
• 36:59that are very large and
• 37:00are very high risk and
• 37:01we know that that person
• 37:02needs chemotherapy,
• 37:04we often don't have to
• 37:05send oncotype either. And then
• 37:07sometimes there are these gray
• 37:08areas, and that's when these
• 37:09pathways can be really helpful.
• 37:11And if you're a physician
• 37:12and you're on the call,
• 37:14and you're
• 37:16looking for some guidance for
• 37:17when to send an oncotype,
• 37:19you can click the pathways
• 37:20tab in epic.
• 37:22And so this has been
• 37:23developed for both premenopausal
• 37:25and postmenopausal
• 37:26women with hormone positive breast
• 37:27cancer.
• 37:28And then in the adjuvant
• 37:30setting,
• 37:31where,
• 37:32somebody has already completed surgery,
• 37:35chemotherapy if they needed it,
• 37:37and radiation,
• 37:38We also think about ways
• 37:39that we can optimize what
• 37:41we call endocrine therapy. So
• 37:42we want to block estrogen
• 37:44in hormone positive breast cancer.
• 37:47And in addition to our
• 37:48estrogen blocking pills, we now
• 37:50have something called CDK four
• 37:52six inhibitors, and these are
• 37:54pills
• 37:54that actually inhibit the cell
• 37:56cycle. So if there's any
• 37:57microscopic
• 37:58cancer cells left over anywhere,
• 38:00it actually inhibits their growth
• 38:02and helps to kill them
• 38:03off, and we often give
• 38:04these in combination with estrogen
• 38:06blockers.
• 38:08And so this is often,
• 38:10saved for patients who have
• 38:12a high risk of recurrence,
• 38:14and so we've developed pathways
• 38:15here at Yale to help
• 38:16with that decision making as
• 38:18well.
• 38:19And oftentimes, it depends on
• 38:21the tumor size. So larger
• 38:22tumors,
• 38:24higher oncotypes,
• 38:26more lymph node involvement at
• 38:28the time of diagnosis.
• 38:31The other thing that we
• 38:32often think about as medical
• 38:34oncologist is whether somebody is
• 38:36eligible for clinical trials.
• 38:38And clinical trials are really
• 38:39important because it's a really
• 38:41great way to
• 38:43try to,
• 38:44optimize therapy for someone that
• 38:46we're seeing
• 38:47and either get a drug
• 38:49early,
• 38:50before it's on the market,
• 38:52or hopefully get, just a
• 38:54better approach to treatment.
• 38:56So one of the big
• 38:57questions currently in the field
• 38:58is, can we think about
• 39:00ways to
• 39:02chemotherapy
• 39:03in young women with hormone
• 39:05positive breast cancer?
• 39:06And the reason why this
• 39:07comes up is because,
• 39:09after doing this for many
• 39:11decades in breast cancer, we're
• 39:12not sure if it's really
• 39:14the chemotherapy
• 39:15drugs themselves
• 39:16that are showing benefit in
• 39:18this patient population
• 39:19or whether it's the chemotherapy
• 39:21putting these women into early
• 39:23menopause
• 39:23and whether it's actually the
• 39:25menopausal status,
• 39:26that is causing the benefit
• 39:28that we see.
• 39:29So there's currently a clinical
• 39:31trial being run by the
• 39:32NRG called BR009,
• 39:35and this is looking for
• 39:36young women who have
• 39:38oncotype below twenty five, which
• 39:40we generally think of as
• 39:42low risk,
• 39:43but they may have a
• 39:44positive lymph node and randomizing
• 39:47them to chemotherapy,
• 39:49which is the standard of
• 39:50care
• 39:51versus
• 39:52not doing chemotherapy, but really
• 39:54optimizing
• 39:55their estrogen blocking and putting
• 39:57them into early menopause.
• 39:59And so this is an
• 40:00important trial and something to
• 40:02think about,
• 40:03especially if if you are
• 40:04a young woman being diagnosed
• 40:06or you know somebody who's
• 40:07being diagnosed,
• 40:08because we're really starting to
• 40:10think that maybe it's not
• 40:12so much the chemotherapy,
• 40:13but the actual menopause status,
• 40:15that may be benefiting
• 40:18these young women.
• 40:20And then we also know
• 40:21that there's probably a subgroup
• 40:23of hormone positive breast cancers
• 40:25that are really high risk,
• 40:27high risk for coming back.
• 40:29And so how can we
• 40:30escalate and optimize treatment for
• 40:32those patients?
• 40:33And so there's a trial
• 40:34being run by Swag here
• 40:36at Yale called, two two
• 40:38zero six that is looking
• 40:39at something called mamaprint, which
• 40:41is very similar to Oncotype,
• 40:43but is a different assay
• 40:44looking at a different set
• 40:45of genes.
• 40:46And for patients who score
• 40:48in the in that really
• 40:49high risk category called high
• 40:51risk two or MP two,
• 40:53they're being randomized to adding
• 40:56immunotherapy
• 40:57to chemotherapy.
• 40:58In general,
• 40:59we don't think of hormone
• 41:01positive breast cancer,
• 41:03as a cancer that's very
• 41:04responsive to immunotherapy,
• 41:06But we think that there
• 41:07might be a subgroup of
• 41:08these very aggressive, fast growing
• 41:11hormone positive breast cancers that
• 41:12may benefit, and that's what
• 41:14that trial is looking at.
• 41:17We also wanna think about
• 41:18how can we tailor chemotherapy
• 41:20for triple negative breast cancer.
• 41:23And so there is a
• 41:24trial also out of SWOG
• 41:26that is looking at,
• 41:28patients with early stage triple
• 41:31negative breast cancer
• 41:32and randomizing
• 41:33to
• 41:35standard of care,
• 41:36chemotherapy,
• 41:38versus standard of care chemotherapy,
• 41:40but without the AC.
• 41:42And the AC drugs,
• 41:44often referred to as the
• 41:46red devil on the Internet,
• 41:48are the ones that have
• 41:49the most toxicity
• 41:50in terms of the chemotherapies
• 41:52that we use
• 41:53and also have a small
• 41:55but significant risk of potentially
• 41:57heart failure in the future.
• 41:59So we would like to
• 42:00avoid them as much as
• 42:01we can, And so we're
• 42:02hopeful that because triple negative
• 42:05tends to be more responsive
• 42:06to immunotherapy,
• 42:08we're hoping that this trial
• 42:09will show that we can
• 42:10avoid anthracyclines
• 42:12or AC in the future.
• 42:16And so the other thing
• 42:17that I think about, for
• 42:18hormone positive breast cancers in
• 42:20particular is how can we
• 42:22tailor our treatments
• 42:23to decrease the risk of
• 42:24late recurrence. So in general,
• 42:26most breast
• 42:27cancers, if they come back,
• 42:29they often come back in
• 42:30the first five years,
• 42:32but hormone positive breast cancers
• 42:34can come back late. So
• 42:35even as far as ten
• 42:37years out sometimes.
• 42:39And we don't really have
• 42:40a good way to detect
• 42:41them
• 42:42besides continuing to screen with
• 42:44our breast imaging with mammograms
• 42:46and ultrasounds.
• 42:47So this is, a trial
• 42:49called KEATS, that is now
• 42:50open at Yale and will
• 42:52be open across several different
• 42:54sites through the TBCRC.
• 42:56And this is looking at
• 42:57using a novel test called
• 42:59circulating tumor DNA,
• 43:02to see whether we can
• 43:03detect
• 43:04cancer coming back at just
• 43:06the microscopic
• 43:07level.
• 43:07And so for patients who
• 43:09are more than five years
• 43:10out from diagnosis with hormone
• 43:12positive breast cancer, who have
• 43:13completed all of their prior
• 43:15treatments,
• 43:17on this trial, they can
• 43:18get the ctDNA test, which
• 43:20is a blood test every
• 43:21three months.
• 43:23And if they end up
• 43:24coming back positive on this
• 43:26test
• 43:27and they don't have cancer
• 43:28yet on their scans,
• 43:30we're gonna be treating them
• 43:31with elocestrant,
• 43:32which is a pill.
• 43:33And it's one of these
• 43:35newer
• 43:36estrogen receptor degraders.
• 43:38So not just a blocker,
• 43:39but actually degrading the estrogen
• 43:41receptor.
• 43:42And we're hopeful that by,
• 43:45intervening
• 43:45at the microscopic
• 43:47state, we can prevent these
• 43:49cells from growing back into
• 43:50a tumor and growing back
• 43:52into a breast cancer recurrence.
• 43:55So thank you very much,
• 43:56and I hope that if
• 43:58you're a patient or a
• 43:59family member or a treating
• 44:01physician that you think about
• 44:02clinical trials or at least
• 44:04discuss clinical trials with your
• 44:06oncologist. Thank you.
• 44:08Thank you very much, doctor
• 44:10Rosenblatt.
• 44:12So we've answered many questions
• 44:14in the chat. This has
• 44:15been a fast and furious
• 44:16overview on updates in early
• 44:18stage breast cancer. We learned,
• 44:20surgical therapy from doctor Berger,
• 44:23options for reconstruction from doctor
• 44:25Hakal as well as updates
• 44:27and systemic therapy
• 44:28from doctor Rosenblit.
• 44:31I think the last thing
• 44:32we'd love to share with
• 44:33our attendees is that we
• 44:35do make decisions as a
• 44:36multi disciplinary cancer team. So
• 44:38patients that
• 44:39come to any site across
• 44:41the Yale Smilow network
• 44:43will meet with a medical
• 44:45oncologist,
• 44:46surgeon, radiation oncologist, and plastic
• 44:48surgeon,
• 44:49and we work as a
• 44:50cohesive united team in patients
• 44:52care.
• 44:53I think there's one last
• 44:55question in the chat, doctor
• 44:56Rosenblatt, about a lobular
• 44:59carcinoma with an oncotype
• 45:01of thirty four
• 45:02and,
• 45:03some concern about how estrogen
• 45:05gene expression,
• 45:08being borderline positive
• 45:10and how that
• 45:12information
• 45:13influences your recommendations for systemic
• 45:16therapy.
• 45:22That's a great question. So
• 45:24Oncotype
• 45:25was really designed to
• 45:27answer the question of, is
• 45:29there benefit to chemotherapy
• 45:31or not?
• 45:32And it really wasn't designed
• 45:34to
• 45:36kind of investigate
• 45:38how hormone
• 45:39positive a breast cancer is.
• 45:41So we still do rely
• 45:42on
• 45:43looking at the tumor under
• 45:45the microscope, and that would
• 45:46be a discussion with your
• 45:49team, including the pathologist
• 45:51in terms of how,
• 45:53how much estrogen positivity you're
• 45:55seeing in that case.
• 45:57In general,
• 45:58even for borderline
• 46:00positive
• 46:01cases,
• 46:02it looks like in this
• 46:03case, it was
• 46:05ninety percent is what I'm
• 46:06understanding
• 46:07from
• 46:08the report.
• 46:10We would go ahead and
• 46:11treat that as an estrogen,
• 46:14hormone positive breast cancer.
• 46:16There are borderline cases where
• 46:18the estrogen positivity is very
• 46:20low, and that becomes just
• 46:21a very complex discussion with
• 46:23your medical oncologist.
• 46:24And in that case, they
• 46:26might
• 46:27tailor the chemotherapy
• 46:28and offer you a slightly
• 46:29different chemotherapy
• 46:31if it's borderline.
• 46:33Thank you very much. There's
• 46:35another question about
• 46:38what we recommend for young
• 46:39women who are
• 46:42thinking about future pregnancy
• 46:44and have an estrogen positive
• 46:46tumor. Unfortunately,
• 46:48the positive trial, which was
• 46:50run out of Dana Farber
• 46:51but included multiple institutions
• 46:53across the country and the
• 46:55world,
• 46:56did look at young women.
• 46:57They were forty two or
• 46:59younger who
• 47:00were treated for hormone receptor
• 47:02positive breast cancer and received
• 47:04between eighteen and thirty months
• 47:06of anti estrogen therapy or
• 47:08hormone,
• 47:10endocrine therapy to target their
• 47:12breast cancer. They went on
• 47:13to take a break for
• 47:14pregnancy and
• 47:16potential breastfeeding, and their pregnancy
• 47:18success was very good
• 47:21as well as the risk
• 47:22of a recurrence
• 47:23was similar to the women
• 47:25who did not go ahead
• 47:26with pregnancy. So the data
• 47:27we currently have
• 47:29is showing great promise
• 47:32that it's safe for select
• 47:33women with hormone receptor positive
• 47:36breast cancers to take a
• 47:38break for pregnancy and,
• 47:40future,
• 47:41breastfeeding.
• 47:42And this is certainly something
• 47:44you should discuss with your
• 47:46oncology team. It's important that
• 47:48you're at a right stage
• 47:49of your cancer treatment and
• 47:51that we can monitor you
• 47:52as well as possible during
• 47:54and after pregnancy.
• 47:57There's another question about,
• 48:00a recent article on spike
• 48:02proteins
• 48:03and the aggressive new cancers.
• 48:05Doctor Rosenblatt, I'd I'd defer
• 48:07to you if you're able
• 48:08to answer this question.
• 48:11I don't see this question
• 48:12about the spike proteins.
• 48:15It says, any comment on
• 48:17the recent article on spike
• 48:18protein and aggressive new cancers?
• 48:22I'm not exactly sure what
• 48:24this article is referring to.
• 48:26There is a lot of
• 48:27research out there trying to
• 48:29figure out,
• 48:30better ways of predicting aggressiveness
• 48:33and recurrence, so that's probably
• 48:34what that's referring to.
• 48:37It's nothing that has reached,
• 48:38you know, standard of care
• 48:40yet. It hasn't entered mainstream
• 48:42practice.
• 48:43But, yeah, I I look
• 48:44forward to reading more about
• 48:45it.
• 48:46Okay.
• 48:47And then there's another question
• 48:49about tracking recurrences
• 48:51and HER2 positive versus
• 48:53hormone receptor
• 48:54positive HER2 negative cancers.
• 48:57I'll dive in very quickly
• 48:58as a surgeon. I think
• 49:00locally, we're examining your skin.
• 49:02We're looking at any changes.
• 49:04There can be there was
• 49:06another comment and question in
• 49:08the chat. There can be
• 49:09ongoing changes in the breast
• 49:10tissue
• 49:11after surgery, reconstruction, and radiation
• 49:14for even a couple years,
• 49:15but most cancer patients should
• 49:17be under surveillance with their
• 49:18oncology team.
• 49:20We decide to survey people
• 49:22for a distant recurrence in
• 49:24the setting of of symptoms
• 49:26or abnormal labs, and doctor
• 49:27Rosenblitz really an expert in
• 49:29ctDNA.
• 49:30So I'll, turn that over
• 49:32to her.
• 49:34Yeah. So the main surveillance
• 49:36mechanism, like we mentioned, is
• 49:38physical exam and then breast
• 49:40imaging.
• 49:42In breast cancer, we have
• 49:43not seen any benefit
• 49:44from PET scans or CAT
• 49:46scans, and so we don't
• 49:47do them because
• 49:49the risk of the radiation
• 49:50from the scans actually outweighs
• 49:52any any benefit in terms
• 49:54of finding a recurrence.
• 49:56And we don't have good
• 49:57blood tests either. There are
• 49:59blood tests out there called
• 50:00tumor markers and we use
• 50:01them for metastatic breast cancer
• 50:03all the time, But for
• 50:04early stage breast cancer, they've
• 50:06been shown to have what's
• 50:08called low sensitivity and low
• 50:09specificity. So they can be
• 50:11negative and there can still
• 50:12be a cancer and they
• 50:13can be positive and there
• 50:14could be no cancer. So
• 50:16they're not very helpful to
• 50:17us. And that's why we're
• 50:18trying to develop this new
• 50:19blood test called circulating tumor
• 50:21DNA.
• 50:22Right now, we're looking at
• 50:23it just in the research
• 50:25setting because we don't know
• 50:27yet how helpful this test
• 50:28is, and we don't have
• 50:30a treatment option. We need
• 50:31to investigate what treatment we
• 50:33can give if that test
• 50:34is positive.
• 50:35So there are trials going
• 50:36on for that for both
• 50:37hormone positive and HER2 positive
• 50:39and triple negative breast cancer.
• 50:41So if you're really interested,
• 50:43please look out for those
• 50:44trials.
• 50:45They're in very early stages,
• 50:47but we'll probably see more
• 50:48of those clinical trials in
• 50:50the next couple of years.
• 50:54Alright. Well, thank you to
• 50:55my esteemed colleagues,
• 50:57for joining us tonight and
• 50:58sharing your knowledge, and thank
• 51:00you to all the attendees
• 51:01for joining us for this
• 51:02Milo shares. We,
• 51:04encourage you to attend our
• 51:06future sessions in the month
• 51:07of October, which as many
• 51:09of you know is breast
• 51:10cancer awareness month. And please
• 51:12reach out,
• 51:14to any member of our
• 51:15program if you or family
• 51:17or friends need to be
• 51:18seen.
• 51:19We wish you all well,
• 51:21and
• 51:21thank you again for joining.