Welcome to Yale Cancer Center Answers with doctors Francine Foss and Anees Chagpar.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of The Breast Center at Smilow Cancer Hospital at Yale-New Haven. Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas. If you would like to join the conversation, you can contact the doctors directly.  The address is canceranswers@yale.edu and the phone number is 1-888-234-4YCC.  This week, Dr. Chagpar and Dr. Foss welcome Dr. Ted Tsangaris.  Dr. Tsangaris is Associate Professor of Surgery and Surgical Oncology and Director of Outpatient Breast Services for the Smilow Cancer Hospital Network.  Here is Francine Foss.
 
Foss              Could you start off by telling us a little bit about yourself and what it is you do?
 
Tsangaris      I am a surgeon, and I have been doing this for a very-very long time in the Washington DC area, the Baltimore area, and my most recent place of employment was at Johns Hopkins where I ran the breast program. I have been here since July and it is a pleasure to be here.
 
Foss              Can you tell us a little bit about the outpatient breast services through the Smilow Cancer Hospital Network?  What is the network and what exactly do you encompass within that program?
 
Tsangaris      I have been charged with the task of taking what we do here at the New Haven campus and seeing if we can get this into some of our satellite facilities and our care centers.  Geography has been one of the stumbling blocks to delivering breast care, and actually cancer care in general.  I think the national trend is that we are trying to get cancer care out into the community so that it is accessible to all of our population.
 
Chagpar        Ted, you and I have known each other for a good long while and it was a real treat for me to recruit Ted to be a part of our breast cancer team. Could you tell people a little about some of the exiting things that you see on the horizon for breast cancer, not only here but in our community, but even nationally?
 
Tsangaris      Again, I think the trend and the real emphasis from the National Cancer Institute is that we put cancer care out into the community so that people who might be discouraged based on their geographical location, do not feel like they have to come to a major cancer center to get the kind of care that they would like to get, and so our obligation is to go out into the community.  I think the first goal we would like to achieve is to deliver the care out into the community.  We have great innovations, as Anees has said, both in screening and in treatments and in research and so making those available to the people out in the community is what we would like to see accomplished.
 
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Foss              Can you speak a little bit about the populations that you are trying to reach? Touching on some issues with respect to disparities, which is one thing that we are trying to address now in cancer care.
 
Tsangaris      It sounds like I am beating a dead horse when I keep talking about geography, but it is interesting, geography really is a significant cause of disparity.  There is a very good recent article that was put out by the Center of Disease Control and their cancer prevention program, which looked at, let’s say screening, and that is what the study was about, and what was interesting is that when they measured what we would typically consider the usual benchmarks of disparity like race, ethnicity and socioeconomics, geography was one of the highlights in the stumbling blocks for getting good screening and assumed good cancer care and so it is very fascinating, so we are not targeting any one individual group or ethnicity, we are really targeting the geographical locations.
 
Chagpar        It sounds like you have got a population that is fairly well spread out and it is hard to make sure that the care that you get when you are in a very small center or a very small community is similar to what you would receive at a state-of-the-art center.  How are you going to do that Ted?
 
Tsangaris      It is interesting because the implication is not what we mean to imply, because in fact nothing could be farther from the truth. Connecticut has outstanding health care providers and institutions.  What we are trying to do is pull them together and share both ideas and resources.  I think the challenge is going to be to build relationships and then from those relationships implement systems and when I say system, I am talking specifically about critical pathways so that patients get the same kind of care in their own backyard that they would if they had to travel 100 miles here to New Haven.
 
Foss              Do you have any sense at all about how different the care is for say the common types of breast cancer around the state? Are there significant differences at this point, are we talking about just fine tuning the existing standard of care, which is the same everywhere?
 
Tsangaris      I think that is really what we are going to try to do.  When we try to fine tune the care, as I mentioned, I think there are great surgeons throughout the state and there are great medical oncologists, radiation oncologists, and we know that there is good imaging out in the community, but pulling them together so that they work as a cohesive multidisciplinary group, I think is going to be our real challenge.  That is really where breast cancer needs to be so that patients do not feel like they have a really great surgeon five miles from their home, but they have to go 20 miles to get a great radiation oncologists, and then if they are interested in participating say in a clinical trial, they feel like they have to go 75 miles to come down to say New Haven, or one of the other institutions.
 
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Chagpar        Talk a little bit about that because I think that is a really great point about clinical trials and the fact that clinical trial seems to me to be something that is really driving care to be its very best. How is it that we can export clinical trials so that people are able to participate in their own backyard?
 
Tsangaris      Again, organizing other the resources both in personnel and making available these very innovative clinical trials. I think the days of these large multi-centered organizations, you are seeing that are becoming more of a burden financially and logistically, and so being able to say that Smilow has very intriguing, very provocative clinical trials and then making it available to our local care centers and our affiliates and our partners, I think is very exiting and so again it is providing them with the opportunity to participate in those and I think that is really where we are going so that patients have that access.
 
Foss              When you talk about clinical trials, we have heard a lot recently about some of these newer agents and some of these are targeted therapies and also about the application of molecular techniques to identify tumors and select specific therapies for specific patients.  That has not really made it into the community yet and I am wondering if that is something that you are aiming to do with this initiative?
 
Tsangaris      Absolutely, that is a great point.  What you are going to find not only for breast cancer, but other tumor sites, is that we are going to capitalize on similarities that all people have in any particular tumor site.  So breast cancer certainly is one of those, but where we are going to really make the difference is exploiting the individual differences of a patient.  Your breast cancer would not be the same as your sister’s, your mother’s, or your neighbor’s.  There will be some basic similarities but exploiting those differences is where I think we are going to really see the benefit and get the most out of what we are doing.
 
Chagpar        Is that what people mean when they talk about personalized medicine?
 
Tsangaris      Personalized treatment, personalized medicine, is slightly different for me at least and has a slightly different connotation that implies that we are going to take the individual and address all of their needs, not just their disease, but the treatment, their socioeconomic issues, again geographical issues.  So, these are all things that we are going to address and that is personalizing the medicine to some degree.  Personalizing treatment for me means the question that you brought up earlier, which is, my breast cancer looks the same as everybody else’s, garden variety invasive breast cancer, but in fact based on some of these clinical trials and the studies of the tissues, we know that there is something a little different about "my breast cancer” then yours and that is what we have been trying to exploit.
 
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Foss              Will there be any way to uniformly analyze these tissues between the different care centers? Will there be a standard panel of say markers that are looked that? Will those tissues be reviewed among different institutions, how will that all work?
 
Tsangaris      Though we try to make available all of the treatments, this is where this kind of model works so well because what you want to do is you want to standardize this information.  Having our care centers provide us with the opportunity to accrue patients, but funnel all of that information so that the analysis of that information is standardized here at Smilow, is going to really be key.  Everything that happens out in the community from a research standpoint, the information comes here and we standardize it here.
 
Foss              Does the patient actually need to be on a clinical trial or sign a consent form in order to get their tumor analyzed in this way? Will there be anyone that comes out into the community, say informing patients that this is what is happening?
 
Tsangaris      The goal is to make available all clinical trials including analysis of tissue.  But, nothing can happen without the acknowledgement and the permission of the individual patient.  That is something that patients should always feel comfortable about, that treating physician should always feel comfortable with, this is mandated, this is appropriate, and this is ethical.  We are making available these opportunities but it will ultimately be the physician and their patient that decide whether they want to participate.
 
Chagpar        What I love about what you are talking about, Ted, in terms of getting out into the community and personalizing management from a geographical, socioeconomic as well as a disease treatment basis, is that it really is all about the patient.  Tell us a little bit more about community engagement and how we get people involved in understanding what is going on in cancer and Breast Cancer Awareness month is just around the corner.  How important is it that patients are engaged in this process?
 
Tsangaris      It is really important.  I often think of the patients as being consumers and being knowledgeable about what is available to them both from a treatment standpoint and from the screening standpoint, etc., it is really important. Breast Cancer Awareness month, and you know this as well as I do, is a tiring month. It is the obligation though of health care providers and anyone involved in cancer, particularly breast cancer, during the month of October to get out and do what they can to educate through lectures and fundraising, so that patients and women in general are knowledgeable about what is out there.
 
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Chagpar        We want people to understand what is going with their own bodies so that they can be part of that process.
 
Tsangaris      They need to be part of the process.
 
Chagpar        We are going to take a break for a medical minute, but please stay tune to learn more information about breast cancer screening, community outreach, and all of the exciting things that Dr. Ted Tsangaris is bringing here to our community at Yale.
 
 
Medical
Minute          This year over 200,000 Americans will be diagnosed with lung cancer and in Connecticut alone there will be over 2000 new cases.  More than 85% of lung cancer diagnoses are related to smoking and quitting, even after decades of use, can significantly reduce your risk of developing lung cancer.  Each day, patients with lung cancer are surviving, thanks to increased access to advanced therapies and specialized care.  New treatment options and surgical techniques are giving lung cancer survivors more hope than they have ever had before.  Clinical trials are currently underway at federally designated comprehensive cancer centers like the one at Yale, to test innovative new treatments for lung cancer.  An option for lung cancer patients in need of surgery at Yale Cancer Center is a video-assistant thoracoscopic surgery, also known as VATS procedure, which is a minimally invasive technique.  This has been a medial minute.  More information is available at yalecancercenter.org. You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.
 
Chagpar        Welcome back to Yale Cancer Center Answers.  This is Dr. Anees Chagpar and I am joined today by my co-host Francine Foss and our guest Dr. Ted Tsangaris and we are discussing breast cancer screening and community outreach. Ted is our new director of the outpatient breast cancer network.  Ted, welcome back.
 
Tsangaris      Thank you.
 
Chagpar        We were talking before the break about all the exciting things that are going on in terms of breast cancer and getting out into the network to ensure that breast cancer patients get the same care as they would get anywhere.  One of the things that we always think about in terms of breast cancer is screening and early detection.  Do you want to talk about the importance of that and how you will develop that in the network?
 
 
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Tsangaris      Again, making available good quality screening is really important and coupling it with a multidisciplinary team approach. We have talked about this a lot, but geography is important.  What else is important as we get into this national debate about insurance, is that probably the most significant issue when it comes to not having screening mammography, or utilizing screening mammography, is whether a patient or a woman is insured or uninsured. Believe it or not it trumps ethnicity, race and even to a degree socioeconomic status.  It is a fascinating thing that we need to overcome. How the network can overcome insurance issues, I do not know, but we are certainly going to have to be watchful when we get to this national debate of health care insurance.
 
Chagpar        I think that one thing that you have got in your corner at the network is the fact that the network does participate in the program that is available to all states in the union where uninsured women who are below 250% of poverty can get free screening and if unfortunately God forbid, they are diagnosed with breast cancer, they are eligible for insurance through a State Medicaid Program, so because of the fact that you have this robust network, you will be able to export that to your other sites presumably, right?
 
Tsangaris      That is certainly the hope, I agree.
 
Foss              Anees and Ted, both of you are in the field of breast cancer, can you just refresh our audience about the current screening recommendations? We hear about mammograms, we hear about breast MRI’s and other imaging studies, what are the current recommendations?
 
Tsangaris      As a medical profession, we have not done a great job being as clear as we probably could be on that.  It is sometimes a moving target and it is cyclical depending on where the information comes from, but I would say that most recommend baseline mammogram at the age of 40 and then every year thereafter.  Some of the issues of should you start a little early can be directed to your health care provider based on family history and personal prior history, but to keep it simple, baseline at 40 and then every year there after.  Some key points, quality digital mammography is absolutely a must and then making sure that the people who are interpreting the mammogram are breast imagers by training and by dedication.
 
Anees           I agree completely, and one of the things that has happened in our field is that there have been so many wonderful, exiting, advances in imaging and surgery and medical oncology, radiation oncology, plastics, you name it.  Can you talk a little bit about some of the exciting advances that you have seen and where you think the field is going in the next 5 years or so?
 
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Tsangaris      I think simply we are doing more by doing less, and that is a testament in many ways to quality screening because when we find breast cancers earlier, we are able to get exceptional results.  Women are living more now with breast cancer then they ever have in the past and in doing so we are doing less, we are doing less surgery, we are giving, in many cases, less medications, we are doing less radiation therapy.  So, this is all brought about because the engine which runs this progress is quality screening.  I would say from a surgical standpoint the most interesting and fascinating thing is that we are doing less surgery and accomplishing the same results with breast conservation, in preserving the breast, removing the tumor has been a long standing goal, and is standard now.  We are able to determine staging through lymph nodes by doing less surgery and in many cases not even making an incision in the axilla or under the arm.  Our reconstructive techniques, as you mention Anees, are outstanding.  We can take women who have been told they have breast cancer and after all the treatment is said and done, they can actually cosmetically look better then before they were diagnosed with breast cancers, it is truly remarkable and from our stand point as surgical oncologists, we are very excited by the fact that our mastectomy is not your grandmother's mastectomy anymore.  It is a highly sophisticated, highly effective, yet very much dedicated to preserving cosmetics. I am specifically speaking about skin sparing mastectomies and of course nipple sparing mastectomy, which I personally think is just a marvelous innovation in approach to mastectomies.
 
Foss              These newer techniques, are these available across the state in the different care centers? Are these special techniques that a woman would have to seek say a tertiary care facility to have?
 
Tsangaris      What is really important as a good consumer of your health care and of your upcoming surgery is to ask this same questions that you would ask anybody if you were going out to purchase a commodity which is, is this something you are good at?  Is this something you do a lot of? Specifically you looking for a surgeon whose emphasis is breast surgery.  There are certain things from a reconstructive standpoint that may require you to come to a larger center, some of the more sophisticated reconstructive techniques require special training, special equipment, and they require special postoperative care, so in certain situations I think you do have to go to a specialty hospital, but for the most part it is just a matter of finding out if the surgeon is comfortable, and if they do a lot of these procedures. You want to ask what their succuss rate is, ask to see some results, ask to talk to patients, and that kind of inquiry will hopefully get you into the right hands.
 
Chagpar        Ted, one of the things that you said really intrigued me and I think it is really important for our listeners to understand. You said we are seeing so many breast cancer patients and a lot of women are living with breast cancer.  Tell us a little bit about survival rates after breast cancer and how
 
 
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that has improved over time? Is it still the death sentence that so many patients think or thought that it was?
 
 
Tsangaris      I can’t remember exactly the quote, Anees may be you can remember, but I just recently saw that more women are living with breast cancer than who are dying of breast cancer, obviously that is really remarkable.  No, it is not a death sentence anymore, it is a disease like diabetes, it is a disease like high cholesterol, it is a disease that can be treated, it is a disease that you need to monitor and follow for many years, but we have gotten so good at treating early stage breast cancer now that in fact the old way of dealing with patients where you and your breast surgeon were married for life, that really does not happen anymore because what is happening now is they are being successfully treated for their breast cancer and more and more women still have to deal with the other issues of health care like heart disease, which they are still more likely to die of than breast disease, so it is really interesting.
 
Foss              Is the Survivorship Program here going to integrate with your community out reach program?
 
Tsangaris      Yeah, I think part of what a good cancer program and a satellite program should encompass is that we do survivorship care. It is so important to treat patients initially as close to their home as possible because eventually, as we pointed out, they are going to survive their breast cancer and they need to be put back into the community where they are familiar with their other physicians who are going to take care of their heart disease and the diabetes and other things that they need care for.  So, absolutely, we are hopeful that as we work on our policies for survivorship care, it translates back into the community.
 
Chagpar        Since women are surviving longer with breast cancer, tell us a little bit more about what that transition is like.  Many women think that after breast cancer I have to sit at home or be bound to bed, but other people say no, get out there, be physically active, live your life, what is the right answer?
 
Tsangaris      Even as you are going through your treatment, most of us encourage you to get back in the saddle as best you can and live your life, because the simple fact of the matter is that the studies show that it is actually in your best interest both emotionally and physically to get back into a normal routine. I think survivorship is a little scary.  There is a feeling, it is very common to patients doing well which is at some point we say you really do not need to comes see us anymore and there is this panic and I have to say it’s not only on the patient's part, I think physicians have held on to this belief that patients need us for the rest of their life and I sort of straddle the transition where I was raised and trained in an era where the breast surgeons I knew and respected took care of their
 
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patients forever, but in reality, it is really not necessary, and I think there is that scary moment for both patient and physician when the patients need to get back to their normal life and really do not need to see their breast care specialist for the most part.
 
Chagpar        But then if they ever did?
 
Tsangaris      If they ever did, of course we are always available and I think to some degree we do owe it to them and to the disease to make sure that the physician in the health care system that they are released into in the community is aware of some of the important things that need to be followed and looked at.
 
Foss              One of the other issues that a lot of women with breast cancer face is that there is a multitude of information out there on the internet and there are all these support groups and other political action groups that are trying to raise money for breast cancer.  To what degree are those programs going to be integrated with your community outreach program and how do you actually counsel women about looking at all that information that is out there?
 
Tsangaris      One of the strengths of Smilow is that a lot of the care and information that is given to a patient is really administered by advanced care practitioners.  These are nurses, physician's assistants, nurse practitioners, who really do their job and do it much better than physicians do, and they provide patients with information and guidance on how they are to navigate through all of that information.
 
Dr. Ted Tsangaris is Associate Professor of Surgery and Surgical Oncology and Director of Outpatient Breast Services for the Smilow Cancer Hospital Network.  If you have questions or would like to add your comments, visit yalecancercenter.org, where you can also get the podcast and find written transcripts of past programs. You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.