HBOC Cancer Risks, Part 1
September 30, 2020Information
Breast Cancer: Risks, risk reduction, surveillance, prevention
Dr. Erin Hofstatter
Gynecologic Cancer: Risks, risk reduction, surveillance, prevention
Dr. Elena Ratner
Facilitator: Ruth Ann Ornstein
ID5688
To CiteDCA Citation Guide
- 00:00In a wearying cancer risk tonight
- 00:02will be having two speakers,
- 00:04doctor Erin Hofstatter and doctor
- 00:05Lena Ratner, who will be sharing
- 00:07a lot of information with us.
- 00:09There will be an opportunity to answer
- 00:12questions at the end of the evening.
- 00:14Please post it in the chat room.
- 00:16I now like to take a moment out
- 00:19to introduce Doctor Hofstetter.
- 00:20Doctor Hofstetter is abreast
- 00:22ecologist and associate professor of
- 00:24Medicine on the adjunct faculty at
- 00:26Yale and she helps to run
- 00:28the breast cancer genetics
- 00:29and Prevention Program.
- 00:30Doctor Hofstetter,
- 00:31thank you so much now.
- 00:32This is where the technology comes in.
- 00:35Joanna, did you have my yay oh thank God.
- 00:39Don't think it's been six months,
- 00:41but it still takes some getting used to.
- 00:44Can you guys hear me OK?
- 00:47I'll take that as a Yes.
- 00:49OK, well let me know if you
- 00:51if the audio has trouble,
- 00:53but thank you so much to everybody
- 00:55who has taken time out from their
- 00:57evening to talk about hereditary
- 00:59breast and ovarian cancer syndrome.
- 01:01This is the second part
- 01:02of a four part series,
- 01:04and so I'm honored to be able
- 01:06to give this part of the talk.
- 01:09And I'll be focusing today on
- 01:11breast cancer risk and management
- 01:12options for women at high risk
- 01:14due to a credit Terry syndrome or
- 01:17who may be at high risk due to.
- 01:19Family history to next slide please.
- 01:25Perfect, so I think many of you,
- 01:27many people in general are
- 01:28surprised to find out that most
- 01:30breast cancer is not hereditary.
- 01:32I know that's the topic of this evening
- 01:34is obviously an important topic,
- 01:36but I even when families have alot
- 01:38of breast cancer and they think
- 01:40gosh this is running in my family.
- 01:42Many times we send folks for genetic
- 01:45testing just to find out they test
- 01:47negative and we sort of are puzzled
- 01:49as to try and figure out why.
- 01:51Why a family may have more
- 01:53breast cancer than average.
- 01:54In fact, 75% of patients who are
- 01:56diagnosed with breast cancer are
- 01:58due to unknown reasons essentially.
- 02:00Considered sporadic,
- 02:01another 15 to 20% of patients may have
- 02:04more young breast cancer that appears
- 02:07to be more common in a given family.
- 02:10Perhaps that's due to shared risk
- 02:12factors such as smoking or alcohol,
- 02:15perhaps obesity only about 5 to
- 02:1710% of all breast cancers are
- 02:19considered to fall into that truly
- 02:21hereditary genetic predisposition.
- 02:23And of that,
- 02:24five to 10%.
- 02:26About half of that green piece
- 02:28of pie can be attributed to.
- 02:31The genetic syndromes we know best,
- 02:33specifically BRC A1 and B RCA two.
- 02:35Now that doesn't seem like that much,
- 02:38but when you consider that there's over
- 02:40250,000 diagnosis of breast cancer
- 02:42every single year in the United States,
- 02:44you know 5% of that number turns
- 02:46out to be anywhere between 12
- 02:49and 25,000 women per year,
- 02:51so it's a lot of women out there who might
- 02:54benefit from a more enhanced screening,
- 02:56surveillance or prevention options.
- 02:59Next slide.
- 03:00So obviously beer,
- 03:01see one and two is what I'm
- 03:03going to focus on tonight.
- 03:05Those are their breast cancer
- 03:07genetic syndromes that we know
- 03:09best and arguably our most.
- 03:11Common if you will,
- 03:12in terms of in terms of
- 03:13guidelines and what we know to do,
- 03:16but beer so you wanted to are
- 03:17only two of several breast cancer
- 03:19susceptibility genes only.
- 03:20Only two of the genetic syndromes
- 03:23that are out there on this graph
- 03:25you can see in the upper left hand
- 03:27corner BRC A1 and B RCA two in.
- 03:29On this graph it shows on the Y axis
- 03:31that the risk that these genetic
- 03:33syndromes confer is actually pretty high.
- 03:36You know if you have one of
- 03:38these gene mutations,
- 03:39your risk of breast cancer can
- 03:40approach anywhere between 50 and 85%,
- 03:42and I'll talk about that in a bit.
- 03:45But if you see on the X axis,
- 03:48they're pretty rare in the
- 03:50population that those two with
- 03:53what we call TP 53 or Li Fraumeni
- 03:56syndrome P10C DH ones STK 11.
- 03:58These are very very rare genetic syndromes,
- 04:00but because a lot of risk on the other
- 04:04hand there are common but very low
- 04:07strength gene alleles if you will,
- 04:09that's in the lower right hand
- 04:12corner of this graph.
- 04:13These things like you can see your FG FR2.
- 04:17EQ Cascade.
- 04:17They're pretty common in the population,
- 04:19but each one in and of themselves
- 04:21confers only very,
- 04:22very small risk, and there's a lot of
- 04:24research going on right now to figure out.
- 04:26How do we put all these comments?
- 04:28We call them snips? How do we put
- 04:30all these together to explain risk?
- 04:32And then in the middle of the
- 04:34graph you can see here Pal Beach.
- 04:36Do ATM check to brick one.
- 04:38These are what we call moderate penetrance.
- 04:40Genes there still pretty rare,
- 04:41but a little more common than B or C-12.
- 04:44And they confirm what we call moderate or
- 04:46medium risk instead of a 10 fold risk.
- 04:48Maybe they confer perhaps a two
- 04:50or three fold risk over average.
- 04:51So the take home point here is
- 04:53that there's more to hereditary
- 04:54cancer syndromes than just beer.
- 04:56See one and two,
- 04:57and there's a lot of a lot more to
- 05:00learn about these other gene mutations.
- 05:02Next slide.
- 05:04So let's focus on bigger stage
- 05:05one and two you've seen.
- 05:07For those of you who attended last week,
- 05:10perhaps you recall seeing
- 05:11similar slides talking bout risk,
- 05:13but I wanted to go over those risks briefly.
- 05:15Again,
- 05:16for those who may have missed last week.
- 05:18So no woman who has breast tissue is
- 05:21has a zero risk of breast cancer.
- 05:23In fact,
- 05:24the average woman walking around
- 05:26in the US has about a 12 to 13%
- 05:28chance during her lifetime to
- 05:30be diagnosed with breast cancer.
- 05:31However, if you carry a beer CA,
- 05:34one mutation or VRC A2 Mutation.
- 05:36Those risks increase to anywhere
- 05:38between 50 and upwards of 85%,
- 05:40perhaps little bit higher.
- 05:41With beer CA one than be RCA 2.
- 05:45For second primary breast cancer,
- 05:47what that means is,
- 05:48once you've had a breast cancer,
- 05:50what are your odds of developing
- 05:52a whole brand new one later on?
- 05:54And so for the general for the
- 05:56general population,
- 05:57the average person who gets a breast cancer,
- 05:59their risk for a whole nuther
- 06:01breast cancer is somewhere on the
- 06:03order of let's say,
- 06:044% up test 11% during their lifetime,
- 06:07whereas those risks are much
- 06:08higher for BRC A1 and B or C,
- 06:11A2 and with ovarian cancer that you hear
- 06:13more about later with Doctor Ratner.
- 06:16Average person's risk is actually pretty low.
- 06:18It's only about a 1 to 2% chance,
- 06:20but with beer stay one or two,
- 06:22those risks can approach 40 to maybe
- 06:24even as high as 60% next slide.
- 06:28Well,
- 06:28there's more to hereditary breast
- 06:30and ovarian cancer syndrome then
- 06:32just press in ovarian cancer.
- 06:33In fact, the the more time that goes by,
- 06:36the more we're learning.
- 06:37There are other cancer types
- 06:39associated with PRC,
- 06:40one and two male breast cancers,
- 06:42exceedingly rare.
- 06:42There's only about 2000 men diognosed
- 06:44every year with male breast cancer,
- 06:46but those risks appear to be higher
- 06:49if you are a B or C A2 carrier.
- 06:52The risk of prostate cancer.
- 06:54We're recognizing his increased
- 06:55again upwards of, say, 30 to 40%,
- 06:58perhaps higher with beer.
- 06:59See one and two and pancreatic
- 07:02cancer as well,
- 07:03is increasingly recognized
- 07:04as part of these syndromes.
- 07:06Particularly beer stayed too.
- 07:07There's some question about whether
- 07:09melanomas associated perhaps some
- 07:11other gastrointestinal cancers,
- 07:12but male breast cancer,
- 07:14prostate cancer, and pancreatic cancer
- 07:16certainly recognized next slide.
- 07:18So we do about it, right?
- 07:20You know, once you know your risk,
- 07:23the questions, what do you do day-to-day?
- 07:25An for those women with a beer,
- 07:27see one or two mutation with some of
- 07:29these other mutations I've mentioned,
- 07:31such as ATM or chek, two palb,
- 07:33two others.
- 07:34Or for those women with a very very
- 07:36strong family history you have options
- 07:38and that's my take home message.
- 07:40You do have options.
- 07:41One size does not fit all and
- 07:43some of the things we will talk
- 07:45about tonight are screening.
- 07:47Enhanced screening is an option.
- 07:49Or what can you do to reduce that risk?
- 07:52Meaning preventive surgery taking
- 07:53medications called Chemo Prevention
- 07:55or what lifestyle changes can you
- 07:57do everyday to help lower your risk?
- 07:59So we'll talk about that tonight so key
- 08:02points as I go through each of these things.
- 08:05Ultimately again,
- 08:06there is no one quote right answer.
- 08:08Every patient who I might see in my
- 08:11clinic comes out arguably with a
- 08:13different answer to their questions,
- 08:15because every patient is different.
- 08:17Management truly should be tailored to
- 08:19that patient that's sitting in front of me.
- 08:22It does turn on.
- 08:23How old is that person?
- 08:25Not to say that we should like,
- 08:27be ageist or anything.
- 08:28But what's right for somebody
- 08:29who's 25 might be different than
- 08:31what's right for somebody who's 80.
- 08:33You know,
- 08:33we have to consider what is
- 08:35the short term risk.
- 08:36What are the long term risks?
- 08:38What are the other health issues are
- 08:40you currently fighting another cancer?
- 08:41Do you have other competing risks that
- 08:43might threaten your health even more than,
- 08:45say, breast cancer risk?
- 08:47You know it's important to understand
- 08:48what are the risks and benefits of
- 08:50the options were talking about.
- 08:51Are we talking about quality of life or
- 08:53we talking bout quantity of life or both?
- 08:56And Lastly, what are?
- 08:57What are your goals?
- 08:58Because again, what we care about?
- 08:59I mean,
- 09:00I'm in my mid 40s with a character,
- 09:02but when I was 25 is probably
- 09:04a little different now and will
- 09:06be different again when I'm,
- 09:07you know, 6070 eighty 80 years old.
- 09:09So again, your goals may change overtime.
- 09:12Next, next slide.
- 09:14Can't believe I told you I'm in my mid 40s.
- 09:17Whatever again.
- 09:17Keypoint lifetime risks do
- 09:19change overtime so I know I just
- 09:21showed you statistics like OK.
- 09:23BRC A1,
- 09:23you've got a lifetime risk
- 09:25of breast cancer at 85%,
- 09:27but that's not true for your whole life.
- 09:29When you show up as a 30 year old lady,
- 09:32you have your whole life ahead of you.
- 09:35A 30 year old woman with a beer stay.
- 09:38One mutation does probably have a
- 09:4050 to 85% chance of dealing with
- 09:42a breast cancer sometime between.
- 09:44Age 30 and stay age 80 or 85.
- 09:47But if you are woman,
- 09:48have managed to get to say age 65
- 09:51without getting a breast cancer.
- 09:52You've eaten away at the lot of
- 09:55that risk and your remaining risk
- 09:57of your life is not 85% anymore.
- 09:59It's much lower. Then that's what's
- 10:01demonstrated here on this graph,
- 10:03and if you'll play along with me
- 10:05if you can see in that Gray row,
- 10:08the risk of breast cancer for,
- 10:10say, a woman with a beer CA,
- 10:12one Mutation who says 60 years old her,
- 10:15let her lifetime risk between
- 10:17age 60 and 70 is not 85%.
- 10:19In fact, it's 19%.
- 10:21So again, what I mean to say is
- 10:23the more you go through your life
- 10:25and your healthy without cancer,
- 10:27the more your overall risk goes down.
- 10:30Risk is confusing.
- 10:31Well, in Covid age, so we're here,
- 10:33but risk all the time.
- 10:34But risk evolves overtime so
- 10:36it's important to make sure you
- 10:37understand where you fall on a risk
- 10:39category when you're considering
- 10:41the risk conferred from a mutation.
- 10:43So again, this is this.
- 10:44The take home point is 1 size
- 10:47does not fit all next slide.
- 10:49So what do we do about it?
- 10:51It's fine to assign a number,
- 10:53but you know,
- 10:54how can we be proactive
- 10:56about managing risk and so?
- 10:57First, I'll talk about screening.
- 10:59So next slide.
- 11:01So the the guidelines that we rely
- 11:04heavily upon or called the NCCN guidelines,
- 11:07it's National Cancer consortium network,
- 11:09and it's basically the thought
- 11:11leaders in the cancer academic
- 11:13community coming together and really
- 11:15putting their heads together and say
- 11:18what is the best way that we can.
- 11:20We can treat and manage these women,
- 11:23so the NCCN recommends for those
- 11:25would be RCA and againest.
- 11:27Extrapolates to those with other mutations,
- 11:30or at very very high risk.
- 11:32Doing a once a year, mammogram,
- 11:34Anna once a year MRI of the breast,
- 11:37alternating every six months,
- 11:38so you get a mammogram six months later,
- 11:41MRI, six months later mammogram,
- 11:42and that continues starting at age 25.
- 11:45We typically start with the MRI.
- 11:47We do that once a year until age 30
- 11:49and then once H 30 comes around.
- 11:52It's MRI mammogram, MRI mammogram.
- 11:53We do that up until a woman 75 and
- 11:56then once a person 75 we say, OK,
- 11:59we have the option to let the MRI go.
- 12:02We can continue on with mammograms
- 12:04once a year.
- 12:05Because again,
- 12:06the risk has gone down by that point.
- 12:08It's not zero, but it's gone down,
- 12:10so that's a typical screening recommendation.
- 12:12We also recommend breast exams,
- 12:14and so folks with beer see mutations
- 12:16will often come to see myself.
- 12:18My nurse practitioner.
- 12:19Perhaps their Gynecologists for
- 12:20breast exam every six months,
- 12:22and so throughout the year you're
- 12:24getting breast exams twice a year.
- 12:25You're getting image Ng twice a year,
- 12:28so you're getting kind of four
- 12:30assessments spread out over
- 12:31the course of the year,
- 12:32and the whole point of this
- 12:34intensive screening.
- 12:35Remember, it doesn't prevent breast cancer,
- 12:37but the idea is early detection and
- 12:39there's been research that shows with
- 12:41this kind of intensive screening,
- 12:43breast cancers can be caught very,
- 12:45very early at a very curable stage,
- 12:48either at stage zero,
- 12:49before they become invasive or at stage one.
- 12:52More than 95% of the time.
- 12:54So in a very curable setting, so next slide.
- 12:58And so again, why MRI?
- 13:00Why not just mammogram?
- 13:01Well, the MRI and mammogram together
- 13:03again as I just showed you detects
- 13:06breast cancer at a very early stage and
- 13:09has been shown to be cost effective.
- 13:11And it's more sensitive.
- 13:12The MRI is the mammograms basically
- 13:14an X Ray and what it's looking
- 13:17for are calcifications which
- 13:18commonly conform into cancer.
- 13:20MRI instead is looking more
- 13:21at blood flow in our things.
- 13:23Lighting up in the breast.
- 13:25It's a little more vague,
- 13:27but it is more sensitive.
- 13:29The trade off is that they see stuff and
- 13:31then that opens up this whole can of
- 13:33worms and they see some enhancement in.
- 13:35Should we call the person back for a six
- 13:37month follow up or should we get a biopsy?
- 13:40You know, so it is a can of worms.
- 13:42But if you can put up with that risk of
- 13:44false positives and put up with that
- 13:46risk of me calling you back for a biopsy,
- 13:49I would say the pros outweigh the cons.
- 13:51If you're a woman at high risk
- 13:52but it but I appreciate MRI,
- 13:54it's not just going for a scan,
- 13:56it's it is a whole ball of wax X side.
- 14:00So screening does go beyond
- 14:01just breast cancer screening,
- 14:02so and it goes beyond women.
- 14:04So remember,
- 14:05men are equally likely to inherit
- 14:07these mutations as women,
- 14:08it just manifests different
- 14:09differently because they are men
- 14:11aren't at quite high of risk.
- 14:12As for breast cancer,
- 14:13and obviously aren't going to ovarian cancer,
- 14:15so sometimes it can hide in men,
- 14:17but if you know that one of your male
- 14:20relatives has a B or C Mutation,
- 14:22they too should learn how to do a
- 14:24breast self exams starting at around age 35.
- 14:27In fact,
- 14:27I have some men in my clinic.
- 14:30Clinic who come in once a year for
- 14:32chest wall exam.
- 14:33Prostate cancer risk starts to
- 14:35weigh in at around age 45 from men
- 14:38and screening should be discussed,
- 14:40particularly if that gentleman
- 14:41is a B or C A2 carrier.
- 14:43Remember I mentioned the possible
- 14:45increased risks of pancreatic cancer
- 14:47and Melanoma an again, though,
- 14:49the data is not quite as definitive,
- 14:51we will recommend consideration
- 14:53at least of a full body exam once
- 14:56a year to look for Melanoma and
- 14:58eye exam every year to look for.
- 15:00Dark freckles in the back of the eye
- 15:02to make sure that there's no Melanoma
- 15:04freckle in the back of the eye.
- 15:05Pancreatic cancer,
- 15:06for those people who have a family
- 15:09history of pancreatic cancer,
- 15:11you can consider enrolling into
- 15:12a study called the caps five
- 15:14study that's looking at whether
- 15:17aggressive screening with ultrasound
- 15:19endoscopic ultrasound.
- 15:20For an eye or the combination
- 15:22can catch something early.
- 15:23It is not been proven yet.
- 15:24It's still a research study,
- 15:26but is something that you can consider.
- 15:28And of course,
- 15:29there's ovarian cancer screening,
- 15:31but I'll leave the ovarian cancer
- 15:33screening to doctor Ratner next slide.
- 15:36So there are, as I mentioned,
- 15:38other gene mutations aside from
- 15:40just bearcity one and two for
- 15:42hereditary breast cancer risk,
- 15:43and there's many many of them.
- 15:45But perhaps the ones that you,
- 15:47perhaps some folks in the
- 15:49audience have heard more about.
- 15:51Are these moderate penetrance mutations,
- 15:52ATM chek, two palb two?
- 15:54These are the ones that that aren't
- 15:56quite as strong as Pearcey one and two,
- 15:59but still puts a person at increased risk.
- 16:02And I show you this,
- 16:03this graph here this just
- 16:05to show that the NCCN.
- 16:07We care about those people to an you
- 16:09can see here there's specific guidelines
- 16:10about what do we do about breast cancer risk?
- 16:13What do we do about ovarian cancer risk?
- 16:16What do we do about other cancer
- 16:17risks like pancreatic cancer,
- 16:19colon cancer,
- 16:19and the like?
- 16:20So these guidelines are very similar to beer,
- 16:22say one and two.
- 16:23An I show you this,
- 16:25if only to say there are guidelines and
- 16:27people thinking about this and that
- 16:29these guidelines are subject to change.
- 16:30You'll notice at the top it says
- 16:32one 2020 this set of guidelines
- 16:34came out in January of this year,
- 16:36and I fully expect they're
- 16:37going to be updated next year.
- 16:39So it's important to keep in touch
- 16:41with your genetic counselor and
- 16:43your providers to know what's the
- 16:45latest and greatest in terms of
- 16:47screening and Prevention options.
- 16:49Next, slide.
- 16:50That screening,
- 16:50so I would argue as a as a person
- 16:54with a genetic syndrome screening,
- 16:55I would recommend as a bare minimum
- 16:57for what you should do for management,
- 17:00but then you have options for risk reduction,
- 17:02so we'll talk about that next.
- 17:04So next slide.
- 17:06So of course,
- 17:07thinking about breast cancer,
- 17:08the thing that comes to mind
- 17:10immediately is preventive,
- 17:12mastectomies or prophylactic removal of
- 17:13the breast to help prevent breast cancer.
- 17:16Now, to be fair, it is the most
- 17:18effective way to reduce their risk.
- 17:21In fact,
- 17:21it reduces the risk by more than 90%.
- 17:24Nothing is 100%.
- 17:25Remember,
- 17:26it's a surgery.
- 17:27There's a small but possible
- 17:29chance of breast cancer developing,
- 17:30and actually the lymph nodes of the armpit,
- 17:33or perhaps way over on the side of
- 17:35where the breast was removed because
- 17:38the breast tissue does continue.
- 17:40Up into the armpit.
- 17:41So there's a very small chance that
- 17:43you could get a breast cancer even
- 17:45though you've got the preventive surgery.
- 17:47That said,
- 17:47it's still a very,
- 17:48very effective way to go.
- 17:50Another advantage is you don't have to do
- 17:52the mammograms in the screenings anymore.
- 17:54So instead of showing up every six months,
- 17:56you don't have to do that anymore.
- 17:58If you choose implant
- 17:59reconstruction and I'll go into that
- 18:01in a minute, this silicone implants do
- 18:03need to get checked every once in awhile,
- 18:05maybe every 2 three years,
- 18:06either by MRI or ultrasound,
- 18:08not to look for a cancer,
- 18:09but just to make sure that the.
- 18:11Implant is intact, but no more screening.
- 18:14And the other thing to consider
- 18:16with mastectomies is that you don't
- 18:18have to do breast reconstruction.
- 18:19In fact, it makes it a much simpler procedure
- 18:22if you choose not to get reconstruction,
- 18:25but I would argue most women choose
- 18:27to do breast reconstruction,
- 18:28so the major advantage,
- 18:30no screening, very low cancer risk.
- 18:32However, it's not for everybody.
- 18:33It is a big surgery.
- 18:35It's not like getting breast augmentation,
- 18:37you know,
- 18:38like the plastic surgery shows you see on TV,
- 18:41this is surgical removal of the breast.
- 18:43Anet is surgical reconstruction of
- 18:45that breast. It's a big surgery.
- 18:47There is recovery time,
- 18:48typically quoted as anywhere
- 18:49between 4:00 and six weeks.
- 18:51Where you're, you know you're at home.
- 18:53You're not working if you've got little kids,
- 18:55we've got to figure out who's
- 18:57going to carry the baby around,
- 18:59and things like that.
- 19:00So it is a big surgery.
- 19:02Cosmetics can be beautiful,
- 19:04but most of the time you can tell a
- 19:07person has had surgery and it can
- 19:09take a long time to get it perfect.
- 19:11So I usually tell folks to plan
- 19:13on taking 6 to 12 months.
- 19:15Sort of as a mindset to know that
- 19:18you're going to be kind of tweaking
- 19:21along the way before your done,
- 19:23so it's a It's a process from
- 19:25a body image intimacy issue.
- 19:27Sometimes women really mourn if you will,
- 19:30for lack of a better term,
- 19:32the loss of a major part of their
- 19:34body in for you do lose nipple
- 19:37sensation in breast sensation and
- 19:39that can be difficult for some women.
- 19:42And I think one of the major points is.
- 19:46Many people say, Well, you know,
- 19:47I don't want to die of breast cancer,
- 19:49so I need to get this done or my doctor
- 19:52told me I have to get this done,
- 19:54but one of the things to realize is
- 19:56remember I told you with screening we
- 19:58catch breast cancer very very early.
- 20:00Breast cancer. It went stinks.
- 20:01Don't get me wrong.
- 20:02I would not wish it upon anybody but
- 20:04many times we can treat that breast
- 20:06cancer cure, that breast cancer,
- 20:08and if that person is destined
- 20:10to live to age 85,
- 20:11then they will do that with
- 20:12or without a mastectomy.
- 20:13Statistically speaking,
- 20:14mastectomy doesn't make a person live longer.
- 20:16It may make him live better,
- 20:18but it may not make them live longer.
- 20:20So again,
- 20:20that's where you need to
- 20:22understand what you're buying,
- 20:23what bang for your Buck are you
- 20:25getting with such a big procedure?
- 20:27Next slide.
- 20:28So if you choose mastectomies,
- 20:30you have any choose reconstruction,
- 20:32you've got two ways to approach
- 20:34is to reconstruct the breast,
- 20:36either by putting in a silicone
- 20:39or Saline implant,
- 20:40or by doing what we call
- 20:42an autologous or flat
- 20:43procedure where you
- 20:44literally can take belly fat.
- 20:47Sometimes you can take from
- 20:48the thigh or the buttock,
- 20:50but you take belly fat and you literally
- 20:53use that fat to reconstruct the breast,
- 20:56the breast mound? The implant procedure?
- 20:58Typically is done in two stages,
- 21:00where the first stage,
- 21:02the surgical, the surgeon,
- 21:03the breast surgeon removes the breast
- 21:05tissue in the plastic surgeon,
- 21:07puts in what's called an expander,
- 21:09which is an envelope that gets you know,
- 21:12sewn in place and then gets filled
- 21:14week after week after week,
- 21:16until you get to the appropriate
- 21:18size and then you go in for a
- 21:20second stage and it's exchanged
- 21:22for a silicone or Saline implant.
- 21:24The second procedure is much
- 21:26easier than the first occasion.
- 21:28I'm learning more and more
- 21:29that some plastic surgeons are.
- 21:31Able to go straight to implant
- 21:33but depends a lot on the breast
- 21:35size and other nuances.
- 21:37I'm not a surgeon so I won't
- 21:39get into that too much,
- 21:41but on occasion I hear that some people
- 21:43can do immediate reconstruction.
- 21:44Implants don't last forever.
- 21:46Typically they get exchanged at
- 21:48your 10 or year 15,
- 21:49so eventually they need replacement.
- 21:51Now with a flat procedure,
- 21:53some people like that procedure
- 21:54because it's not a foreign body
- 21:56going into their to their body
- 21:58doesn't need exchange if you will,
- 22:00but it is a bigger upfront procedure
- 22:02because you're getting surgery up
- 22:04top and you're basically getting
- 22:05a hip to hip incision,
- 22:07almost like a C-section to get the
- 22:09abdominal fat removed so you have
- 22:11two places to recover from instead of 1.
- 22:13So many people like it,
- 22:15but it again not for everybody.
- 22:17Next slide.
- 22:19So like I said before,
- 22:20there isn't any magical age,
- 22:21but you, so it's not like you can't
- 22:23do it after a certain age.
- 22:25But what I always cringe as when my
- 22:27patients come and see me and they say,
- 22:29Well, Gosh,
- 22:30I just found out I have a beer see Mutation.
- 22:32So I have to get my breast removed and
- 22:35everyone's telling me I have to do it.
- 22:37We don't have to do it.
- 22:38Or if you choose to do it doesn't
- 22:40mean you have to do it right away.
- 22:43So for example,
- 22:43it may not be the ideal thing to
- 22:45do for a woman who's 25 because at
- 22:47that point she may want to have kids.
- 22:50She may want to breastfeed.
- 22:51Per year to year risk may may actually
- 22:53still be quite low at that age.
- 22:55Conversely,
- 22:55if you've made it to age 75
- 22:57without a breast cancer,
- 22:59per maybe have competing health issues,
- 23:00maybe that's more aggressive
- 23:01than you need to be in perhaps
- 23:03aggressive surveillance may be
- 23:05just as reasonable way to go,
- 23:06so there's no magical age that you
- 23:08can't do it, or you should do it.
- 23:11It's a personal issue.
- 23:12And then thinking of surgeries,
- 23:14I don't want to forget and again
- 23:16I'll let Elena talk a lot about this.
- 23:19But getting your ovaries removed
- 23:21is recommended as part of
- 23:22care for women with beer.
- 23:24See mutations in other mutations.
- 23:25If you get your ovaries out at a young age
- 23:28when you're premenopausal that actually
- 23:30reduces your breast risk by up to half,
- 23:33even if you go on hormone
- 23:34replacement therapy in again.
- 23:36I'll refer to doctor Ratner on this one.
- 23:38We encourage women to go on
- 23:40hormone replacement therapy,
- 23:41and it doesn't undo that risk reduction.
- 23:43So bear in mind some of the
- 23:45routine care you might get lowers
- 23:47your breast cancer risk as well.
- 23:49Next slide.
- 23:50So that surgery in a nutshell,
- 23:53and I'm keeping my eye on the time I've got
- 23:57another 5 minutes or so Elena I'll hand over.
- 24:00I promise.
- 24:01Medicine, Chemo Prevention.
- 24:02Now that I want you to know that there
- 24:05are medications that have been approved
- 24:07for reducing risk of breast cancer
- 24:10and those medicines are listed here,
- 24:12namely tamoxifen, relax,
- 24:14sophine, SMS, Deignan Astras.
- 24:15All now I use these medications all the time.
- 24:18They are most effective
- 24:20in women whose risk is.
- 24:22Is related to having atypical cells in their
- 24:25breast or DCIS or something like that?
- 24:28They probably work in be RCA carriers.
- 24:30It's just the data is so limited
- 24:32it's difficult for me to sit here
- 24:34and say they definitely work.
- 24:36It's certainly worth considering
- 24:37if you're a woman who's choosing
- 24:39to keep your breast tissue there.
- 24:41The data that we can get suggest
- 24:43that there is.
- 24:43Is that tamoxifen of any of these
- 24:45tamoxifen is the one with the most data,
- 24:48so again,
- 24:48I will offer this to my patients likely
- 24:51to be more effective in those women
- 24:53with beer c82 then beers day one.
- 24:55So I want you know it's an option about it.
- 24:58Again, may not be for everyone.
- 25:00Next slide.
- 25:01And the reason it may not be
- 25:03for everyone is because there's
- 25:05no such thing as free lunch.
- 25:08Now, while it might lower breast cancer risk,
- 25:11an it can be some of these medications
- 25:13can be helpful for your bone health.
- 25:16Most have side effects,
- 25:17including hot flashes, leg cramps,
- 25:19night sweats, vaginal dryness, weight gain.
- 25:21Rarely tamoxifen can cause
- 25:23uterine cancer and blood clots.
- 25:24The Aromat Ace Inhibitors like XML
- 25:26stain can cause bone thinning,
- 25:28so again on balance it's not a free lunch.
- 25:32They've not been proven to
- 25:33make people live longer.
- 25:34You can't use them at the same time as birth
- 25:36control pills or hormone replacement therapy.
- 25:39And remember,
- 25:39I just told you I'm actually recommending
- 25:41that in a lot of my patients and remember,
- 25:43you get a significant reduction in breast
- 25:45cancer risk by having your ovaries removed.
- 25:47That's what DSO means.
- 25:48Bilateral salpingo oophorectomy.
- 25:49So there's some debate in the in
- 25:50the community right now is how
- 25:52much does it actually help you
- 25:53beyond what we're doing already,
- 25:55so again worth a discussion.
- 25:56Don't get me wrong,
- 25:57but it's not like I'm handing this
- 25:59stuff out every single patient.
- 26:01Next slide.
- 26:02And then Lastly, remember yes.
- 26:04Of course,
- 26:05if somebody inherits a beer,
- 26:06see a mutation that puts you
- 26:08at increased risk for cancer.
- 26:10But remember that very first
- 26:11slide I showed you most people
- 26:13who get cancer don't have a beer.
- 26:15Stay one or two mutation.
- 26:17In fact there's alot of things that
- 26:19go into risk of developing a cancer,
- 26:21so of course it's whatever genes you inherit.
- 26:24But it's what we call modifier genes.
- 26:26How are all your different genes interacting?
- 26:28How? What carcinogens have you been
- 26:30exposed to over your lifetime,
- 26:31such as smoking, alcohol, obesity?
- 26:33What are some hormonal reproductive factors?
- 26:35Even things you can't control in
- 26:37terms of how old are you were
- 26:39when you had your periods?
- 26:40How late was your menopause?
- 26:41How many kids did you have?
- 26:43How old were you when you had your kids?
- 26:46A lot of these things you can't control,
- 26:48but everything adds up to sort of,
- 26:50you know,
- 26:51get a person to the brink of
- 26:53developing a cancer next slide.
- 26:55So what can you do about it?
- 26:57What factors can you control so specifically
- 26:59within the beer see a positive another?
- 27:02Specifically hereditary cancer syndromes.
- 27:04It's difficult to tease out how much
- 27:06lifestyle change can affect risk at
- 27:08the same time we know on a population
- 27:11level it can matter and it can add up.
- 27:13So in general re recommend these
- 27:15lifestyle changes for everyone
- 27:17from the American Cancer Society.
- 27:19So if you go to my I think one of my last
- 27:22slides here you outline here this is.
- 27:25This really applies to all of us,
- 27:28especially during kovid,
- 27:29as were all like sitting at
- 27:31our computers all day.
- 27:33But in general we recommend
- 27:34obviously avoiding tobacco,
- 27:35limiting alcohol to one serving
- 27:37a day or less.
- 27:39For women, two servings a day or less.
- 27:42For men diet, dietary changes,
- 27:43getting plenty of fruits and vegetables
- 27:46were talking like 5 servings a day,
- 27:48weighing towards whole grains like
- 27:50Brown Rice instead of white rice,
- 27:52Brown wheat bread instead of
- 27:54refined and limiting Redden.
- 27:56This meets be careful of portions.
- 27:58Again, this is what we all we all know,
- 28:01but I'm just trying to reinforce it and
- 28:03aim for lots of just a plant based diet.
- 28:06No exercise,
- 28:07move move, move right.
- 28:08Especially now during covid,
- 28:09but what we're looking for is about 150
- 28:12minutes a week of moderate activity,
- 28:14or 75 minutes that we can vigorous
- 28:16activity like jogging or like
- 28:18really really getting sweaty.
- 28:19So that translates to about 30 minutes
- 28:21a day of walking a brisk walking.
- 28:24And it doesn't have to be consecutive.
- 28:26Even 15 minutes in the morning
- 28:28in 15 minutes at night.
- 28:30Just trying to accumulate and
- 28:31moving as much as possible.
- 28:32Another way I kind of think about it is
- 28:35shooting for about 7 or 8000 steps today.
- 28:38And then Lastly,
- 28:39and perhaps most importantly,
- 28:40is really to do all of these things with
- 28:42the goal of achieving a healthy weight.
- 28:45We do know that obesity does
- 28:46increase the risk of cancer.
- 28:48Many types of cancer,
- 28:49including breast cancer,
- 28:50uterine cancer,
- 28:51colon cancer in the US population.
- 28:52So that does matter. Next slide.
- 28:56So in summary, right at 7:30.
- 29:00I want you to come away from this
- 29:02talk knowing that you have options.
- 29:04It is not one size fits all.
- 29:07You know it is a mix and blend of screening,
- 29:10lifestyle modifications,
- 29:11medications, surgeries, an it may.
- 29:13It may vary over the course of
- 29:15your life so you do have options.
- 29:17These whatever approach is right
- 29:19for you can be tailored to you
- 29:22and what's right for you may not
- 29:24be right for another person,
- 29:25so don't let anyone else tell you otherwise.
- 29:28I think that's it, I think.
- 29:31Yeah, that's it.
- 29:31So thank you so much for the opportunity.
- 29:34Here is where I handed off to Doctor Ratner.
- 29:37Thank you doctor hofstetter.
- 29:38I'd like to now introduce doctor Ratner.
- 29:41Doctor Ratner is an associate professor
- 29:43in the Department of obstetrics,
- 29:45gynecology and Reproductive Sciences Co.
- 29:47Chief section of gynecological oncology
- 29:48in the director of discovery to cure.
- 29:51Thank you Doctor Ratner.
- 29:54Thank you so much for 10,
- 29:56so Joanna would you like to
- 29:58whoever has whoever has the.
- 30:00Control of the of the screen.
- 30:02Can you share the screen
- 30:03and then I'll take it over?
- 30:05Or you can do the slides.
- 30:14Oh, why don't you just
- 30:15go ahead and then just.
- 30:18Stop. To be here with you.
- 30:24Thank you attend and Joanna for
- 30:26doing all this work and getting
- 30:28all of us together here tonight.
- 30:30And I could have said or what a pleasure
- 30:33it is to do these talks with you and how
- 30:37amazing you are and how much I miss you.
- 30:40And it's just amazing that we're back
- 30:42together doing this even though it's virtual.
- 30:44But it feels the same.
- 30:46It feels like we all together
- 30:48so that they have to.
- 30:50They did an amazing job discussing here
- 30:52editori breast cancer prevention screening.
- 30:55Who is at risk and what can be done?
- 30:58And now I will do similarly
- 31:02for ovarian cancer.
- 31:04As you guys already heard,
- 31:06there's of course a lot of interaction
- 31:09between ovarian cancer and breast cancer,
- 31:11and This is why these talks
- 31:14so frequently discussed.
- 31:15Both of these sites.
- 31:18Um?
- 31:20So it is very important to understand
- 31:23what your family history is.
- 31:25It is so important to understand what you
- 31:28would risk for because once you understand,
- 31:31and once you know,
- 31:33then you take life into your hands
- 31:36and you do prevention and screening
- 31:38and you don't allow things to happen.
- 31:41This is one of the examples of somebody
- 31:45who had a lot of family history and
- 31:49unfortunately did not appreciate it.
- 31:51And then once that's only
- 31:53history was really understood.
- 31:55We appreciate it how they would risk and
- 31:59that I Love Prevention could be done.
- 32:06Alright, so the driving hypothesis,
- 32:08which is what doctor hofstetter
- 32:10begin talking about,
- 32:11is that many patients may be
- 32:13at risk for cancers depending
- 32:15on many different factors,
- 32:18family history, genetic status,
- 32:19personal history and it is very,
- 32:22very important to know because
- 32:24different women with different risk
- 32:26factors and that's all part of this
- 32:30individualized care personalized
- 32:31care that we so argue for have to
- 32:34be monitored differently depending
- 32:35on what their specific risk.
- 32:37Yes, and of course our theory is also
- 32:40is that these women should be cared
- 32:43not by piece meal but different providers,
- 32:47but by somebody who truly understands
- 32:49what kind of risks they have and is
- 32:53able to do monitoring and screening.
- 32:57Aaron talked about different cancers where
- 33:00we believe the genetics are are factor
- 33:02and there's multiple different things,
- 33:04such as early age of onset,
- 33:07multiple affected family members,
- 33:08related cancers and again
- 33:10like Aaron talked about,
- 33:11it's not just ovarian and breast,
- 33:14cancer is also very important to
- 33:16remember that there's many other
- 33:18cancers that thin to the family.
- 33:20It is not enormous.
- 33:22Like Aaron said, it is prostate cancer.
- 33:25In males it is pancreatic cancer.
- 33:28So it is very important to remember
- 33:30that these cancer clusters do
- 33:32not just affect women.
- 33:33They also affect men.
- 33:35And then there's just something that
- 33:37really can resonate with the families
- 33:40and go from generation to generation.
- 33:42As Doctor Hoster said,
- 33:44male breast cancer plays a huge role.
- 33:46You know in the older days we used
- 33:48to think that Ashkenazic Jewish
- 33:50ancestry was so so important.
- 33:52It's explained genetic
- 33:53mutations in most populations,
- 33:55but now we know the same case
- 33:57that there's a lot of other
- 33:59populations that are similarly
- 34:00at risk for genetic mutations.
- 34:02But of course we continue to
- 34:05believe that Ashkenazic Jewish
- 34:06women have a higher risk.
- 34:11So Aaron already discussed these.
- 34:14There's multiple different genetic mutations,
- 34:16and there's many different ones that we see.
- 34:19But Baraka Wanna bracket?
- 34:21Two are the ones that were
- 34:23most concerned about,
- 34:25and in particular for ovarian cancer
- 34:28they carry as high as 40 to 60%
- 34:31risk of developing ovarian cancer,
- 34:33and the general population.
- 34:35The risk of being cancer is 1.4%,
- 34:38so these risks.
- 34:39For women with broken one in bracket two,
- 34:42I certainly significantly increased,
- 34:44and again,
- 34:44that is why it's so important
- 34:46to know if I'm the history so
- 34:48that testing can be done that if
- 34:50you do carry one this mutations
- 34:53they're diagnosed properly.
- 34:54So then then decisions can be
- 34:56made accordingly.
- 34:59And then that brings us now to to
- 35:03the important issues ovarian cancer.
- 35:06So the trouble with appear in cancer remains
- 35:11that it continues to be very deadly. And.
- 35:19East for freeze. One is that this
- 35:21cancers learn how to mutate and they
- 35:24learn how to resist the treatment,
- 35:27chemotherapy treatment that we give that
- 35:29were treated with and because of that,
- 35:32so many of them return later in life and
- 35:35become more and more difficult to treat.
- 35:38And that is why would everything
- 35:40that we do right now.
- 35:42It's so important where we do
- 35:44personalized care, individual care.
- 35:45Where we studied tumors where we treat
- 35:47women they differently depending on what
- 35:50kind of mutations they have in their tumor.
- 35:52You know nowadays we do not treat
- 35:54two women the same just because
- 35:56they have the same kind of cancer.
- 35:59We are much better now.
- 36:01Much smarter.
- 36:01We know how to understand what
- 36:03drives the cancer.
- 36:04And we know now how to target it better.
- 36:08That is true true meaning of this
- 36:11personalized individualised care
- 36:12that I was discussing before.
- 36:14But the second trouble with the
- 36:16variant cancer is that unfortunately
- 36:18it continues to be diagnosed quietly.
- 36:21Great majority.
- 36:2285% of these cancers is still diagnosed
- 36:25in stage three and stage four,
- 36:28which makes it a little bit more
- 36:31challenging or significantly more
- 36:32challenging to treat women with stage
- 36:35one and two cancers do really well manicured.
- 36:38That is why it is so important to find
- 36:41these cancers early at earliest stage.
- 36:44In the older days,
- 36:46few years back we used to say, you know,
- 36:49there's just nothing you can do.
- 36:51OK in cancer is the cancer, the whispers.
- 36:54There's no symptoms,
- 36:55there's just no way to find it early.
- 36:58But we now know that that is not the
- 37:01case or brain cancer is not the cancer,
- 37:04the whispers.
- 37:04Ovarian cancer is just the cancer
- 37:06that nobody's listening to.
- 37:08There's been multiple studies that showed,
- 37:10even though great majority of women with
- 37:12stage three and four cancer have symptoms.
- 37:15That are described here,
- 37:17but we now know that its highs in I
- 37:21percent of women with stage one and two
- 37:25cancer similarly had these symptoms
- 37:28and the symptoms are abdominal distention,
- 37:31abdominal discomfort,
- 37:32some GI symptoms, some vague pain,
- 37:35constitutional symptoms,
- 37:36urinary symptoms and pelvic pressure,
- 37:39and of course,
- 37:40listening to these symptoms.
- 37:42We all have these symptoms and most common.
- 37:46Cause of the symptoms are really just
- 37:49normal hormonal symptoms that all of
- 37:52us women experience but with separates
- 37:54the normal symptoms from those that
- 37:57actually were precursors or signs
- 37:59of early cancer was the women had
- 38:02more than one and they had it every
- 38:05single day for two weeks and that
- 38:08is how is distinguished between the
- 38:11normal hormonal symptoms that is very,
- 38:13very normal for all of us to expect.
- 38:17And the ones that actually
- 38:20wore pathologic symptoms.
- 38:22The other trouble with ovarian
- 38:24cancer is not only that it is very
- 38:27difficult for women to diagnose
- 38:30these symptoms or to really feel that
- 38:33their body is going through something
- 38:35and that is not part of the normal,
- 38:39especially when these symptoms
- 38:41happened during time of menopause or
- 38:43some other hormonal fluctuations.
- 38:45It is also that providers are not
- 38:48good in diagnosing ovarian cancer.
- 38:51Um? Many women who are diagnosed
- 38:54with Varian cancer see a great number
- 38:57of providers prior to actually
- 38:59finally being appropriate diagnosed.
- 39:02There's a study that was done relatively
- 39:05recently that showed that when the woman
- 39:08finally is treated for Varian cancer,
- 39:11she likely has had this cancer
- 39:13for 24 months and she likely has
- 39:16seen at least six other providers
- 39:19prior to getting to the right one.
- 39:22And that's because.
- 39:23As you see,
- 39:24the symptoms are so big and women
- 39:26are seen by gastroenterologists and
- 39:28by urologist and by chiropractors
- 39:31and those specialists,
- 39:32all very good at what they do
- 39:35and they rule out there parts
- 39:37of the disease that it could be,
- 39:40but nobody pieces together that these
- 39:43vague symptoms could mean some sort
- 39:45of pathology in the ovaries and that
- 39:48is why so much research is being done.
- 39:51So much work is being done.
- 39:54To educate providers,
- 39:55not just educate women and not
- 39:57just to increase awareness about
- 39:59listening to your body.
- 40:00It's annoying when something
- 40:02doesn't feel right,
- 40:03but also educating providers about
- 40:05science and symptoms and not just ruling
- 40:08out what it is that that's your field,
- 40:10but also understanding that there
- 40:13could be some sort of correlation
- 40:15between the kind of logic organ.
- 40:19It's.
- 40:21And the biggest lesson of the biggest advice,
- 40:23of course,
- 40:24that that idea of two women
- 40:26during these talks is to demand
- 40:28the care that you deserve.
- 40:29So many of my patients that come to me say,
- 40:32you know,
- 40:33I went from one to another and everybody
- 40:35was saying that everything was normal
- 40:36and I was just going through menopause.
- 40:39But I knew that something was wrong,
- 40:41and when I do multiple
- 40:42lectures for providers,
- 40:43I always say listen to the women,
- 40:45listen to the patient if they
- 40:47tell you that they know that
- 40:49something is wrong in their bodies,
- 40:51do not feel right.
- 40:52Then then you need to listen and you need
- 40:55to do whatever it takes to diagnose it.
- 40:57So the biggest thing prior to a few
- 41:00years back it used to be that we used
- 41:03to say there's just nothing you can do.
- 41:05OK in cancer is just get diagnosed
- 41:07late and that's just what it is.
- 41:09But we now know that that's not
- 41:12the case and that is why it's
- 41:14so important that we do so much.
- 41:16Again,
- 41:16patient education or women awareness and
- 41:18then provide education for the symptoms.
- 41:20And we know that when women actually
- 41:22present with symptoms of ovarian cancer.
- 41:24The most common physicians or providers
- 41:27that see them get into Rolla gist urologist,
- 41:31chiropractors,
- 41:31and psychologists.
- 41:32And these are really the groups that
- 41:36were doing so much education with.
- 41:40Because of this.
- 41:46So. As I mentioned previously,
- 41:4921,000 cases in 2020 in the United States,
- 41:51but unfortunately a lot of deaths is
- 41:54the most common cause of cancer death,
- 41:56and we were going to logic answers
- 41:59and the 5th leading cause of
- 42:01cancer death in women in the US.
- 42:04As Aaron already mentioned,
- 42:06you know this is.
- 42:07This is still what we believe,
- 42:09even though we know this is not
- 42:11to be the case.
- 42:12You know we used to say that 10% of Herod's
- 42:15overbearing cancer hereditary we now
- 42:17think it's significantly higher than that.
- 42:19We think it's probably 20%,
- 42:20and I think as the time goes,
- 42:22and as we meet again,
- 42:24have these talks over years,
- 42:25I will be able to demonstrate to you
- 42:28that this number is going to be higher
- 42:30and higher as we're learning more and
- 42:32more about genetics and predispositions,
- 42:34were there in cancer?
- 42:36But as at the hospital said,
- 42:39he has great majority continue at
- 42:41this point to be something called
- 42:43spontaneous where we do not know a
- 42:45genetic mutation that is associated.
- 42:48But again,
- 42:48similarly,
- 42:49just because we don't know it
- 42:51doesn't mean it doesn't exist.
- 42:53There is unquestionably families
- 42:54that have a lot of cancer that
- 42:57runs through them that even though
- 42:59we cannot diagnose mutation,
- 43:01we know some mutation exists
- 43:02and that's what predisposes them
- 43:04to increase risk of cancer.
- 43:08So let's again briefly talk about,
- 43:11so we're talking about risks.
- 43:13So it is very important to
- 43:16understand who is at risk,
- 43:18because for women who are at risk,
- 43:21the methods of screening and Prevention and
- 43:24things that we can do a very different.
- 43:28So I already talked about the biggest risk.
- 43:31The biggest risk is genetics,
- 43:34but what other risks are there?
- 43:36Besides cancers that run your family or known
- 43:40genetic mutations and run in the family.
- 43:43So early age of 1st measure period.
- 43:47Late age of menopause.
- 43:49Women who have never had pregnancies with,
- 43:52including breastfeed women who had
- 43:55infertility all at higher risk and
- 43:59the reason for this is Twofold.
- 44:02That brings me to the discussion
- 44:04of of how do we in Kansas happen,
- 44:08and where do they come from?
- 44:10And there's two different theories.
- 44:12There is the older traditional
- 44:14theory and a little bit of newer
- 44:17theory that I will discuss.
- 44:19So the traditional theory is that the
- 44:22more time times that the woman ovulates,
- 44:25the more is the risk of this
- 44:28Custer Genesis and ovary.
- 44:30So every time she ovulates.
- 44:32There's increased risk of discussion
- 44:35Genesis and the less time shall be
- 44:37late for somebody who has not had
- 44:40who started their periods late,
- 44:42who had their menopause early,
- 44:44who had a lot of children, who breast it all?
- 44:48The older children who use birth control
- 44:50pills and we'll talk about that shortly.
- 44:53As one of the things that we can
- 44:56do for risk reduction that these
- 44:59women have an increased risk if
- 45:02they were ovulating alot.
- 45:04The second theory of getting cancer,
- 45:07the more recent one.
- 45:08Is there a bank answers actually
- 45:10not appearing cancers at all?
- 45:12There are varying cancers, actually.
- 45:14Fallopian tube cancers,
- 45:15and that's where these cancers.
- 45:18He always wear their their caught and we
- 45:22definitely think that these kind of theory,
- 45:25or fallopian tube cancers is little
- 45:28bit more associated with genetic
- 45:30mutations such as Baresi mutations.
- 45:32Infertility is a risk factor
- 45:35with two fold reasons.
- 45:37Infertility is a risk factor one
- 45:39because women is continues to obvia
- 45:42late and doesn't have that period of
- 45:45time where the ovaries arresting,
- 45:48but also because endometriosis,
- 45:50which is very common cause.
- 45:52Common common disease in women in
- 45:55itself predisposes you to certain
- 45:57kinds of ovarian cancers,
- 45:59such as clear cell cancer and
- 46:02Anthony Jewett cancer,
- 46:03so that is the reason for the for
- 46:06infertility to be significant risk factor.
- 46:11So. Now that we know who who is at risk,
- 46:16then what can can be done and this
- 46:19is very similar to what I have said.
- 46:22The talked about previously there is a
- 46:25cancer that you have. There's always 3.
- 46:30Three risk management options,
- 46:32so surveillance chemoprevention
- 46:33and then surgery.
- 46:34And of course you can see that
- 46:37they are going from the least
- 46:40aggressive to the most aggressive.
- 46:42So let's start with.
- 46:45Surveillance, actually not before
- 46:47we talk about surveillance.
- 46:49Let me talk a little bit about prevention so.
- 46:53There is. There are things that
- 46:56one can do to decrease their risks.
- 46:59Ovarian cancer.
- 47:00We certainly cannot prevent it entirely,
- 47:03but we can certainly risk reduce.
- 47:06So somebody who has had five
- 47:09children and breast fed each of
- 47:12those children for one year each.
- 47:15That was the plan that I was working
- 47:19on decreases the risk by 50%.
- 47:22So if somebody's risk is 1.4%,
- 47:24then there is becomes point 7%.
- 47:26But more importantly,
- 47:28for somebody who has Beyoncé Mutation
- 47:30an let's say their risk was 20% of 40%,
- 47:33they can decrease that risk to have.
- 47:36So somebody had a 40% risk
- 47:38can now have a 20% risk.
- 47:41Similar kind of reduction can be
- 47:43done also by birth control pills.
- 47:46So for any woman who takes birth control
- 47:49pills for five years during their lifetime,
- 47:52they decrease their risk by five years.
- 47:55Anybody who take birth control pills
- 47:58for 10 years decreases advice highs
- 48:0180 percent 15 years as high as 90%.
- 48:04So if you hear anything today out of
- 48:07my talk that you are going to remember.
- 48:11It's this and this is a point that
- 48:13I make not going to where I am
- 48:16where I'm being interviewed for.
- 48:18Something completely different than
- 48:19completely completely separate from this.
- 48:21I always make this point because
- 48:23this really can save lives.
- 48:25The women who can take birth control
- 48:27pills for at least five years
- 48:29during their time their lifetime.
- 48:31It doesn't have to be consecutive,
- 48:33could be at any point of their lives
- 48:36significantly decreased their risks.
- 48:37It has to be birth control pills,
- 48:39or it can be Nueva ring.
- 48:41It cannot be Marina or it cannot
- 48:44be now you deep as it has to be
- 48:47something that stops your ovulation.
- 48:49And then the third thing that can be
- 48:52done to significantly decrease your
- 48:54risk is removing your fallopian tubes,
- 48:57and there's currently studies that are
- 48:59going on for women who are significant risk,
- 49:02like women would be RC mutations.
- 49:05Whether we can preventatively remove
- 49:07their fallopian tubes once they're done
- 49:10with trying to conceive as a risk reduction,
- 49:12an end in those cases able to
- 49:15leave their ovaries in place for
- 49:17longer so they benefit from the
- 49:20hormones released by the ovary.
- 49:22But fallopian tubes by themselves
- 49:24do not really have a purpose.
- 49:26The only purpose of Philippine
- 49:28tubes is for pregnancies.
- 49:29For the egg from the ovary to get
- 49:31into the uterus for implantation.
- 49:34So once childbearing is complete,
- 49:35or if a patient decides she's
- 49:37going to IBF no matter what,
- 49:40then what we would do is we would remove
- 49:42the Flippin tubes and that significantly
- 49:44decreases risk of ovarian cancer,
- 49:47likely secondary to the second.
- 49:50Causality over being cancer discussed
- 49:53that these cancers happen in
- 49:56the fallopian tubes first.
- 49:58So that now brings us to surveillance.
- 50:01Unfortunately. This is different
- 50:05from what they could have said.
- 50:08I was discussing in her breast cancer
- 50:11surveillance talk as mammograms
- 50:13and breast MRI's are very effective
- 50:16in diagnosing ovarian cancers.
- 50:18We do not have effective screening method.
- 50:23What is done now is that we do
- 50:28ultrasounds for for cancer risks combined
- 50:32with a tumor markers such as C125.
- 50:39Unfortunately, these tests are.
- 50:42Not as good as they are in breast cancer,
- 50:47and unfortunately,
- 50:48even if we do this test,
- 50:50they frequently we still can.
- 50:52Unfortunately Miss Erin cancer, so,
- 50:54but it is better than nothing and we
- 50:57a lot of literature has been done
- 51:00that the best way of doing this kind
- 51:03of screening is the combination
- 51:05of the ultrasound and the scene
- 51:08with 25 to a marker or some newer
- 51:11markers that are now on the market,
- 51:13such as over one.
- 51:15Once a year it is important to note
- 51:19that this is not for everybody.
- 51:21This is not for low risk women
- 51:24because the risk of finding something
- 51:26abnormal ovaries in needing surgery
- 51:28is unfortunately somewhat high,
- 51:30so this kind of a methods of attempted
- 51:34screening is truly for women with high risk.
- 51:38Who are high risk for wearing
- 51:40cancer and for those women would
- 51:42recommend this kind of screening.
- 51:46Now the that brings us to the most aggressive
- 51:51kind of risk reduction which is surgery.
- 51:55So surgery give you 2 fold as I started
- 51:58discussing previously nowadays against a lot
- 52:02of studies are being done about benefits
- 52:05of removing just you fallopian tubes.
- 52:09Once childbearing is completed as
- 52:12as a method of the risk reduction.
- 52:16However, because unfortunately we do
- 52:19not have a great screening method,
- 52:22the current guidelines are such that
- 52:25we recommended over his envelope
- 52:27in tubes are removed at a certain
- 52:30age for women at significant risk.
- 52:33At this point,
- 52:35this significant risk really just
- 52:37means genetic mutations such as Braca,
- 52:40one rocker two, and Lynch syndrome,
- 52:43for example, and the.
- 52:45Age at which the surgery is
- 52:47recommended depends on what kind
- 52:49of Mutation the woman has.
- 52:52What is her risk, what?
- 52:54What kind of family history does she have?
- 52:57What age was her family members diagnosed?
- 52:59If they have in cancer and also of
- 53:02course so importantly on whether they
- 53:05have completed childbearing or not.
- 53:08That being said,
- 53:09I have a number of women who,
- 53:12for whom we took we remove the ovaries
- 53:15and fallopian tubes in their early 40s,
- 53:18and then they still were able to get
- 53:21pregnant with the eggs and embryos that
- 53:23they were able to save and freeze previously.
- 53:27So I think that's a very important point.
- 53:30I believe you guys actually have a
- 53:32whole session where you discussing
- 53:34the importance of fertility,
- 53:36sparing treatment.
- 53:37Sanford fertility modalities
- 53:38that are now available.
- 53:40To the women to be able to both risk reduce,
- 53:44reduce their risk of cancer,
- 53:45but at the same time be able to
- 53:48have the families that they want.
- 53:51For women who do not have genetic mutation,
- 53:54this love debates on whether over he
- 53:57should be removed prophylactically or not.
- 53:59An award age in the older days,
- 54:02you know, five years back,
- 54:0410 years back,
- 54:05we used to always remove ovaries at
- 54:08approximately age 5052 if the woman
- 54:10was having some sort of a surgery for,
- 54:13let's say,
- 54:14fibroids or pelvic pain.
- 54:16And this is one of the studies that
- 54:18showed from Doctor Schwarz from
- 54:20Yale that showed that approximately.
- 54:2312% of women might avoid developing
- 54:25ovarian cancer if this kind of
- 54:28prophylactic removal of ovaries was
- 54:30done routinely at the time of hysterectomy.
- 54:33For women in their 50s.
- 54:35Subsequently,
- 54:36there's been some studies that
- 54:38showed that there is likely some
- 54:41benefit to the ovaries up to age 65,
- 54:44so we now much more careful
- 54:46with these decisions,
- 54:47and we truly again same as I started before.
- 54:53Talk to the women and truly provide
- 54:55personalized individualised care.
- 54:56Depending on what their risk factors are,
- 54:59do they have?
- 55:00Do they have a risk factor over
- 55:02there in cancer or breast cancer?
- 55:05In which case of course,
- 55:07removing ovaries makes a lot of sense.
- 55:09Or do they have none of those cancers
- 55:12or no cancers at all in the family?
- 55:15But they do have cardiac risk.
- 55:19Which is greatly,
- 55:21um,
- 55:21protect against even again until age
- 55:2565 or so, and then those women the
- 55:28benefits of keeping overs in place
- 55:31outweigh the risks of of that.
- 55:34So again, truly personalized treatment
- 55:37from that perspective as well.
- 55:40Removing ovaries and Philippine tubes
- 55:42in women is very, very effective,
- 55:45so this is one of the studies in Bercy.
- 55:49Ape Revivers, where women underwent
- 55:52this risk reducing remove ovaries and
- 55:55tubes versus control and we can see
- 55:58the women who were controls and had
- 56:01their ovaries still in place had almost
- 56:046% chance of ovarian cancer over this
- 56:08follow up of six years versus only one.
- 56:11Percent of something called
- 56:14primary peritoneal cancer?
- 56:16What is very important to talk about?
- 56:20And I still have two minutes and
- 56:22this is what I want to talk about
- 56:25it because it is so, so important.
- 56:28There's a lot of misconception in the
- 56:31community about hormones in women who
- 56:33are at higher risk for Varian cancer or
- 56:36at high risk ovarian cancer and join,
- 56:38and I see numerous patients and it
- 56:41really breaks our heart who are in their
- 56:4330s or the 40s in their super young
- 56:46and their ovaries in Philippine tubes
- 56:49are removed for this risk reduction.
- 56:51And because there's this misconception of
- 56:54hormones causing increased risk of cancers,
- 56:56these women after that at that very
- 56:59young age and not placed on hormones,
- 57:02and there's been a great number of
- 57:04studies and a lot of literature that
- 57:07exists that not only is it safe for
- 57:10the woman to be placed on supplemental
- 57:13hormones after their risk reduction,
- 57:15and the removal always,
- 57:17but it's actually detrimental
- 57:19for them not to be on hormones.
- 57:22Ann is Doctor Hofstetter,
- 57:24said and noted when they always
- 57:26remove prior to menopause and
- 57:29women are placed on hormones,
- 57:31they have a risk reduction of
- 57:33breast cancer that is 50%.
- 57:35You know so incredible risk
- 57:38reduction in breast cancer,
- 57:39not increase with the hormones and
- 57:42hormones are so important for the
- 57:45heart and the bones in the mind
- 57:47and how the woman feels that right
- 57:50now the standard absolutely is to
- 57:53place women on hormonal therapy.
- 57:55After they always have lookin terms removed,
- 57:58my patients get get a Patch before
- 58:00they even would leave the hospital.
- 58:03We don't have too much time unfortunately
- 58:06in this at this junction to discuss
- 58:08progesterone versus estrogen.
- 58:10Besides that,
- 58:11I would just say that if there's one
- 58:14hormone that we sometimes try to avoid
- 58:17this progesterone and that's why a
- 58:19lot of stuff that happens is whether
- 58:22we put in Marina in at the time of
- 58:25surgery or we do some other things,
- 58:28is for for the fact that we really
- 58:31want women to be on estrogen.
- 58:34But and try to avoid progesterone
- 58:37is possible.
- 58:38And I'm sure we're going to talk
- 58:40about this a little bit more in
- 58:43in during the question therapy.
- 58:45So the most important point that I
- 58:48would like to to to mention in my
- 58:50last minute available is that so
- 58:53much innovation cancer has changed
- 58:55and is changing and the future is
- 58:57bright and the presenters right,
- 58:59there's so much more that we
- 59:01now understand Wednesday and so
- 59:03much more about detection and
- 59:05Prevention and who is at risk and
- 59:08how we should look for this women.
- 59:10And how we it's so important
- 59:12to understand your history?
- 59:13Understand where you come from,
- 59:15how it's so important to
- 59:17listen to your bodies,
- 59:18and when you don't feel right to
- 59:21insist and demand to get the care
- 59:23that you need and you deserve.
- 59:25But also so much has changed
- 59:27in the treatment over there.
- 59:29In cancer, you know,
- 59:30I began with saying that the
- 59:32treatment nowadays is very different.
- 59:34We don't treat women the same.
- 59:36We truly now study every single cancer
- 59:38we understand with mutations driving it.
- 59:40And the care is truly given in a
- 59:43personalized individual fashion.
- 59:44And you know,
- 59:45not only does it increase how
- 59:47well the chemotherapy works,
- 59:49but it also improves the lifestyle
- 59:51and gives the women the quality of
- 59:53life and allows them to return to
- 59:55their lives that disrupted by this.
- 59:58So thank you so much for this opportunity.
- 01:00:00You still wonderful to be with
- 01:00:02all of you today and I'm looking
- 01:00:04forward to the questions.
- 01:00:29Doctor Ratner and Doctor Hoffstetter.
- 01:00:30Thank you for your time today and we
- 01:00:32have a question here from one of the
- 01:00:35panelists for one of the participants
- 01:00:37are hormone safe for women who have
- 01:00:39had a PR positive breast cancer.
- 01:00:41So I'll ask Doctor Hofstetter
- 01:00:42maybe to start with that one.
- 01:00:49I think you're on mute Doctor Hofstetter.
- 01:00:53Find a dollar for every time I was told that.
- 01:00:57I was going to say the answer to that
- 01:01:01question and probably every question in
- 01:01:03this forum is going to be. It depends.
- 01:01:06The short answer is probably not,
- 01:01:09but of course it depends on how strongly
- 01:01:12Pierre positive that breast cancer was.
- 01:01:14So, for example, it was estrogen
- 01:01:17receptor negative or ER, negative,
- 01:01:19and progesterone receptor like 1% positive.
- 01:01:21I think that would be it would
- 01:01:24be considered in that case.
- 01:01:26If it were, for example,
- 01:01:28was a pre invasive breast cancer like
- 01:01:30a DCIS and a person at a mastectomy,
- 01:01:33I would say yes.
- 01:01:34That's probably safe.
- 01:01:35So the short answer to that question
- 01:01:37is it depends.
- 01:01:38Probably not,
- 01:01:39but there are certain situations
- 01:01:40where it might be considered.
- 01:01:43And I just want to 2nd very much without.
- 01:01:46Perhaps they're saying then this is again
- 01:01:49resonates with what I was saying before
- 01:01:51that everything truly is personalized.
- 01:01:53Again, there's a lot of literature,
- 01:01:55for example, that vaginal estrogen is.
- 01:01:57It is very safe even when women have PR
- 01:02:00positive or ER positive breast cancers.
- 01:02:02Alot of women live their lives with
- 01:02:04vaginal dryness and with atrophy.
- 01:02:06And there was difficulty
- 01:02:07with having intercourse,
- 01:02:08and there's a lot of literature that
- 01:02:11very small amount of vaginal estrogen
- 01:02:13gets absorbed into the bloodstream.
- 01:02:15And the great majority of medical
- 01:02:17colleges believe that it is safe to use
- 01:02:20vaginal estrogen in this population.
- 01:02:21And I also wanted to make a point
- 01:02:24that estrogens is just one of
- 01:02:26the mentalities that we used to
- 01:02:28treat these kind of symptoms.
- 01:02:30Hormones that there is herbal
- 01:02:31medicines and there's occupying turn.
- 01:02:33There's a lot of other things
- 01:02:34that can be done specifically for
- 01:02:36women with breast cancer,
- 01:02:38for whom like that perhaps ever mentioned,
- 01:02:40estrogen should not be the first option.
- 01:02:46So we have another question and an ladies.
- 01:02:48Feel free to ask her questions in
- 01:02:51the chat box. The next question is,
- 01:02:53are there any new findings correlating
- 01:02:55the rad 51 D gene to breast cancer?
- 01:02:59The short answer to that is yes, and again,
- 01:03:02that's one of the areas where I rely
- 01:03:04on the NCCN guidelines to stay updated,
- 01:03:07because if you would ask me that question,
- 01:03:09even as recently as a year ago,
- 01:03:11I would have said no, no, no,
- 01:03:14we don't need to do anything.
- 01:03:16But on this rendition there's some
- 01:03:18evidence that suggests perhaps notice
- 01:03:19all the caveats that red 51 C&D may
- 01:03:21have increased risks for specifically
- 01:03:23triple negative breast cancer,
- 01:03:25but the data is murky enough at this
- 01:03:27point that they are not yet recommending.
- 01:03:29Enhanced screening,
- 01:03:30like MRI and things like that.
- 01:03:32That's one of those things
- 01:03:33where you have to stay tuned.
- 01:03:35It may very well be in a year
- 01:03:37that I'm going to be recommending
- 01:03:38breast mris for these folks,
- 01:03:40but not yet so possibly, but stay tuned.
- 01:03:46Thank you doctor half Sir.
- 01:03:51And I just want to take a minute
- 01:03:53if there are any other questions.
- 01:03:56Will certainly take them as well.
- 01:03:58We do have two more weeks
- 01:03:59of our web and R series.
- 01:04:01Next week will be talking about
- 01:04:03male cancer risks and also the
- 01:04:05breast reconstruction options
- 01:04:06with one of our plastic surgeons.
- 01:04:08We have also our pancreatic
- 01:04:10cancer discussion and then the
- 01:04:12following week we will have a
- 01:04:13full session on sexuality and
- 01:04:15menopause and hormone management.
- 01:04:16So we'll go into more depth about
- 01:04:18the different types of hormone
- 01:04:20replacement therapy that we use so.
- 01:04:22Stay tuned for those on the
- 01:04:24following Tuesday nights.
- 01:04:29That there's another question about
- 01:04:31the age of taking birth control pills.
- 01:04:33Does anybody want to take that one about
- 01:04:36how old girls or women should beat
- 01:04:38when they take birth control pills?
- 01:04:42Elena, I'd be happy to let you
- 01:04:45start with that one. I think that
- 01:04:47question actually,
- 01:04:48I think the victorious question
- 01:04:49is not the age because they age
- 01:04:52is totally fine. You can have.
- 01:04:54You can start birth control pills,
- 01:04:56super young and the family
- 01:04:57history right and you know.
- 01:04:59As I have a 16 year old now and I
- 01:05:02don't want to think Oh my 16 year
- 01:05:04old taking birth control pills,
- 01:05:06just reality and so but people
- 01:05:08take it for different reasons
- 01:05:09and yeah for the for just minari
- 01:05:11and that periods it is very very
- 01:05:13common and very normal to take
- 01:05:15it at age 16 even younger. Uh.
- 01:05:21That action was more for family history
- 01:05:24of breast cancer when it's safe. Yeah,
- 01:05:27that's what I was thinking.
- 01:05:29Yeah, I think picture.
- 01:05:30I mean the amount of risk that birth control
- 01:05:34pills theoretically adds to underlying
- 01:05:37breast cancer risk is exceedingly small.
- 01:05:40So there's a difference between statistical
- 01:05:42significance and clinical significance,
- 01:05:44and so even those studies that show a
- 01:05:46statistically significant increased risk,
- 01:05:48you have to understand what that
- 01:05:49translates to is, you know, point.
- 01:05:51Like again, I'm just making up these numbers,
- 01:05:54but the difference is like
- 01:05:56even if you double your risk,
- 01:05:58if your risk is .01% and it goes to .02%,
- 01:06:01you've just doubled your risk.
- 01:06:03And yet the absolute risk remains very small,
- 01:06:05so without getting too lost in the numbers,
- 01:06:08big picture is.
- 01:06:09That's where you have to tailor it.
- 01:06:11If you've got a young woman
- 01:06:13in her teens despite a fam.
- 01:06:15Family history of breast cancer.
- 01:06:17If it is, if it is right for whatever reason,
- 01:06:21control of her periods and symptoms,
- 01:06:23birth control, whatever.
- 01:06:24If it's the right thing to do for
- 01:06:27those reasons, she should do it.
- 01:06:29The potential additive risk,
- 01:06:31if it even exists at all,
- 01:06:33is exceedingly small.
- 01:06:34Even at that age,
- 01:06:36even with beer CAE mutations.
- 01:06:37So I would do is
- 01:06:39right for that particular young woman.
- 01:06:41And also remember the benefit
- 01:06:43of reduction in ovarian cancer.
- 01:06:45You know so well, what about the hostel?
- 01:06:48Talked about the small risk,
- 01:06:49but a very, very significant
- 01:06:51reduction risk in ovarian cancer?
- 01:06:52You know. 50% again,
- 01:06:54like I mentioned, 50% in five years.
- 01:06:56Very very significant. Really.
- 01:06:57The only thing that we can
- 01:06:59really do to reduce her risk.
- 01:07:01Yeah, and I'm so I saw that
- 01:07:03chat just pop up there.
- 01:07:05Sounds like the women are
- 01:07:06ranging in age from 18 to 22.
- 01:07:08I would say if that's what's
- 01:07:09right for them, that's fine.
- 01:07:11That doesn't floor me at all.
- 01:07:12In fact, we don't even test for beer.
- 01:07:15See mutations until womans 25 so
- 01:07:17they should do whatever is right for them.
- 01:07:20You're welcome.
- 01:07:22I was a chef.
- 01:07:23Feature is so fun.
- 01:07:25Let's try to get all the
- 01:07:27questions answered before 8:30,
- 01:07:29so next question is about the Bard.
- 01:07:31One mutation for breast cancer risk.
- 01:07:33Doctor Hofstetter, can you
- 01:07:34talk about that? Yeah, so I that's
- 01:07:37graph that I show in the beginning.
- 01:07:39I feel like I wish I could edit it
- 01:07:42because Bard one is still in the grey
- 01:07:45zone in terms of depending on the study.
- 01:07:48Look at it is associated.
- 01:07:49It's not associated is.
- 01:07:51It's not even less so than Route 51 C&D.
- 01:07:54It's still not clear that it's
- 01:07:56definitively linked to risk.
- 01:07:57So I almost wish I could take it off of that,
- 01:08:00that graph. Remember,
- 01:08:01a lot of times people come to genetic
- 01:08:03counseling with a family history of
- 01:08:05breast cancer an then we might randomly find,
- 01:08:07let's say a Bard.
- 01:08:09One mutation.
- 01:08:09In those situations,
- 01:08:10I would actually look back
- 01:08:11to the family history.
- 01:08:13I mean, the reason they came in the 1st
- 01:08:15place is probably because of family history.
- 01:08:17So you have to take the mutation into
- 01:08:19contact with the family history.
- 01:08:21So if a person had a Bard, one mutation,
- 01:08:23but they had like a million breast
- 01:08:25cancers at young ages in their family.
- 01:08:27I'm going to recommend an MRI
- 01:08:29based on that family history,
- 01:08:30not necessarily because of the mutation.
- 01:08:32So again,
- 01:08:32this is where everybody comes in
- 01:08:34with an individual history in
- 01:08:35an individual family history,
- 01:08:36and the Mutation is just one piece of that.
- 01:08:41Join and I wanted to make sure
- 01:08:43that we answer Roses question,
- 01:08:44but I think roses question was
- 01:08:46a little bit different and
- 01:08:48we kind of skipped around it.
- 01:08:49So first of all rows.
- 01:08:51Congratulations that is so amazing
- 01:08:52to hear but I think this question is
- 01:08:55what is the advice to her kids now
- 01:08:57that she's seen negative so you know
- 01:08:59rose is very difficult question and.
- 01:09:02Everything depends on the family
- 01:09:04history and really on you you know.
- 01:09:06So if a patient had a beer,
- 01:09:09see Mutation and then the children do not,
- 01:09:11then they have nothing to worry about
- 01:09:14so that you know if a patient woman
- 01:09:16has a broad communication and to
- 01:09:19develop severe in cancer then that'll
- 01:09:21be accounts is explained by the
- 01:09:23Braca Mutation and then the children.
- 01:09:25If they don't have it,
- 01:09:27just have a population risk
- 01:09:29so they live normalize.
- 01:09:30If the woman doesn't have a.
- 01:09:32The same mutation and the
- 01:09:34children don't as well.
- 01:09:35Then it's not as helpful because
- 01:09:37you know we don't know why the
- 01:09:39woman got in the 1st place and we
- 01:09:42believe that their risk is doubled.
- 01:09:44But exactly as like I have to sell,
- 01:09:46we won't even test them till
- 01:09:48till they're older anyway.
- 01:09:50And there's a lot of debate back and
- 01:09:52forth whether we would scream them and
- 01:09:54whether we do ultrasounds them later in life.
- 01:09:57Right now I will tell you that no,
- 01:09:59we do not.
- 01:10:01Everything depends on additional
- 01:10:02family members you know is a
- 01:10:04really some sort of risk or some
- 01:10:06sort of a thought that there's
- 01:10:08some other genetic mutation that
- 01:10:10runs through your family.
- 01:10:11And again,
- 01:10:12so truly kind of individualized
- 01:10:14personalized decisions.
- 01:10:16Arizona period. 4.
- 01:10:24You just broke up there a little bit,
- 01:10:26but I don't have anything to add to the
- 01:10:28explanation that you just mentioned.
- 01:10:30I will admit, enjoying.
- 01:10:31I'll let you drive the questions
- 01:10:32here 'cause I'm seeing that
- 01:10:34there's questions in Q&A,
- 01:10:35and I'm seeing that there's chat,
- 01:10:36so I'll let you join in.
- 01:10:38Tell me what we're
- 01:10:39supposed to do next,
- 01:10:40so the next the next question
- 01:10:42that will go to is about Melanoma,
- 01:10:44and I screening and I think
- 01:10:45will touch a little bit about
- 01:10:47this next week as well.
- 01:10:48With the other cancer risks.
- 01:10:49But Ginny's question was,
- 01:10:50is there anything special to do
- 01:10:52for prevention of eye melanomas?
- 01:10:53Or do we just do the monitoring with
- 01:10:56an eye exam once a year?
- 01:10:58Yeah, I mean, I think this is
- 01:11:00where just general public health.
- 01:11:02Sun protection comes in,
- 01:11:04so obviously limit your exposure to the
- 01:11:06sun in between 10:00 and 2:00 o'clock.
- 01:11:08Sunscreen in terms of
- 01:11:10special things for the eye.
- 01:11:11To be honest, I'm not in opthamologist,
- 01:11:14but I think that's where it makes sense to,
- 01:11:17you know. Wear sunglasses and
- 01:11:18things like that and UV protection,
- 01:11:21but there isn't any special
- 01:11:23recommendation beyond.
- 01:11:24You know common sense skin
- 01:11:25care and seeing the eye doctor.
- 01:11:27Let me emphasize, ocular Melanoma
- 01:11:29is exceedingly exceedingly rare.
- 01:11:30It's like a fraction of a percent
- 01:11:32of people per year.
- 01:11:33So it's very, very rare.
- 01:11:38OK. And next question,
- 01:11:42this one might be a tough one.
- 01:11:44There's an article about Staten's
- 01:11:46that are inhibiting an enzyme in a
- 01:11:49pathway involved in tumor growth.
- 01:11:51Can anybody comment on that?
- 01:11:55Elena, do you want to take this one I have?
- 01:11:58Old small amount to say, but not a lot.
- 01:12:01Go ahead, sure, sure.
- 01:12:03So yes, the answer is Staten's like
- 01:12:05these are cholesterol medications
- 01:12:07and there is some research,
- 01:12:10at least in the breast cancer
- 01:12:12literature that there's something
- 01:12:13about cholesterol synthesis,
- 01:12:15and I think it's the AH MG Coenzyme Pathway.
- 01:12:19Don't quote me on that, but again,
- 01:12:22it's where my brain is starting
- 01:12:24to turn the cholesterol synthesis
- 01:12:26pathway that does appear to increase
- 01:12:29risk of breast cancer incidence.
- 01:12:32And may actually, in combination with some.
- 01:12:37Chemotherapeutic agents may
- 01:12:38actually enhance treatment.
- 01:12:39If you put a cholesterol medication
- 01:12:41together with certain chemotherapies,
- 01:12:43it's still very early.
- 01:12:44There was actually a breast cancer
- 01:12:46prevention trial that closed early a few
- 01:12:48years ago trying to look at particular
- 01:12:50statin and preventing breast cancer,
- 01:12:52but it closed early 'cause they
- 01:12:54had a hard time recruiting 'cause
- 01:12:56so many people are on statins that
- 01:12:58they couldn't recruit enough people.
- 01:13:00But I think that there is some
- 01:13:03data that there is some data there
- 01:13:05and I would again stay tuned.
- 01:13:07I don't think it's at the point where
- 01:13:09I would tell people to go take a step,
- 01:13:12and if they don't need it,
- 01:13:13but it's certainly not going to be
- 01:13:15sad if you're on it.
- 01:13:16I'll be honest, so yeah,
- 01:13:18so I feel very similarly.
- 01:13:19Aaron, I feel like a lot of those I
- 01:13:21get asked this question all the time
- 01:13:23nowadays because of those of just
- 01:13:25the news that talks about the stands,
- 01:13:26but I very much agree with you.
- 01:13:28I think a lot of women need it,
- 01:13:30or even if they have a low threshold
- 01:13:32at a much like for them to be honest,
- 01:13:35the literature is very is very new
- 01:13:36and the research is very young.
- 01:13:38But there's definitely some
- 01:13:39some plausible mechanisms.
- 01:13:40It seemed like it would be.
- 01:13:42It would be helpful,
- 01:13:43and I guess the other
- 01:13:44the other plug I will put in for
- 01:13:46lifestyle is I would much rather
- 01:13:48somebody like exercise and lose weight
- 01:13:50and get off of their blood pressure
- 01:13:52medicines and off of their Staten,
- 01:13:54like eat your Cheerios and exercise.
- 01:13:55Then be honest and if that makes sense.
- 01:14:01So we'll do a few more in the next 10 to
- 01:14:0515 minutes that we have left.
- 01:14:07The next one is about hormone
- 01:14:10replacement after a cancer,
- 01:14:11so we talked a little bit about,
- 01:14:13you know, being careful with
- 01:14:15hormone replacement therapy
- 01:14:16after breast cancer is Doctor
- 01:14:18Ratner. What about after gynaecologic cancers
- 01:14:20is hormone replacement therapies safe?
- 01:14:22So it depends what kind of cancers.
- 01:14:25Definitely safe after being cancers
- 01:14:26there is just very rare few cancers
- 01:14:29in the cold endometrioid appear in
- 01:14:31cancers that might have high estrogen.
- 01:14:33Receptors that would be the one cancel
- 01:14:36that we would look and and consider other
- 01:14:38options prior to starting estrogen,
- 01:14:40but cervical cancer.
- 01:14:41It is totally fine and the meet
- 01:14:44real cancer is the cancer will use.
- 01:14:46We usually like to wait at least a
- 01:14:49couple years for the woman to get away
- 01:14:52from the diagnosis because most of these
- 01:14:54have a very high estrogen receptors.
- 01:14:56And again, you know there's many
- 01:14:59different things that we can do,
- 01:15:01and the great majority of women get
- 01:15:03relief with herbal medicine with
- 01:15:05acupuncture with other interventions
- 01:15:06with other non hormonal interventions.
- 01:15:09And again, everything is very personalized.
- 01:15:11I have women with very high
- 01:15:14estrogen receptors, but so so.
- 01:15:17Quality of life.
- 01:15:21About last last message in that we
- 01:15:24absolutely do use estrogen in those women.
- 01:15:27But if women have the mutual
- 01:15:29cancer or very rare subtype,
- 01:15:31called Anthony Chuter,
- 01:15:32there in cancer would like to check
- 01:15:35hormone receptors in the hormone.
- 01:15:37Receptors are high.
- 01:15:38We like to try other alternative
- 01:15:40methods prior to starting
- 01:15:42estrogen to see relief can be
- 01:15:44obtained without the hormones.
- 01:15:50And I think we'll probably
- 01:15:52end with this great question.
- 01:15:54And there's a question about after
- 01:15:56somebody has all of the risk reducing
- 01:15:58surgeries if they have a mastectomy,
- 01:16:00and if they have ovaries and tubes removed,
- 01:16:03what do they need for surveillance?
- 01:16:06For breast or gynecological cancers.
- 01:16:10So it's a great question, and so I'll take.
- 01:16:13I'll take the top half and Elena can
- 01:16:15take the bottom half in terms of what
- 01:16:18you need to do about breast cancer.
- 01:16:21Remember your risk at this point?
- 01:16:23You're the remaining lifetime risk is
- 01:16:25less than 5%, so technically speaking,
- 01:16:27you could probably disappear from a
- 01:16:29breast exam forever and probably be fine.
- 01:16:31But that said, This is where I kind of
- 01:16:34leave it to the discretion of the patient.
- 01:16:37It's not unusual for a patient
- 01:16:39to come in CS once a year.
- 01:16:42Once every couple years or get a
- 01:16:44breast exam from their doctor looking
- 01:16:46specifically along the scar lines,
- 01:16:48and to examine the axilla.
- 01:16:50Is it necessary?
- 01:16:51Technically, it's not necessary there
- 01:16:52risk at this point is less than mine.
- 01:16:55Quite frankly, does it?
- 01:16:56Is it nice to touch base and
- 01:16:58keep up to date and do a breast
- 01:17:00exam and provide reassurance?
- 01:17:02Of course it is,
- 01:17:04so it's it's never wrong to go back.
- 01:17:06Of course if it's a if it's a hardship
- 01:17:09to come in and see your provider.
- 01:17:12That's one area where you can rest
- 01:17:14assured that your risk remains quite low.
- 01:17:18So from the standpoint of the
- 01:17:20gang cancer prevention screening,
- 01:17:21women who who have had their ovaries
- 01:17:24and looking tubes removed very much
- 01:17:26should still be seeing a gynecologist,
- 01:17:28and that is for the sake
- 01:17:31of physical examinations.
- 01:17:32If you have a uterus still in place,
- 01:17:35and certainly you need to get pap
- 01:17:37smears and and exams like that,
- 01:17:39but there's also a very small chance of
- 01:17:42something called primary peritoneal cancer,
- 01:17:44which is a cancer that's
- 01:17:46that's like Woodbury.
- 01:17:47Cancer, but it comes on the lining of
- 01:17:50the abdomen called pair appeared to name.
- 01:17:53Their risk is small.
- 01:17:54You know the literature shows
- 01:17:56you with one point 6%.
- 01:17:58You know, anecdotally,
- 01:17:59I believe that's actually even less nowadays,
- 01:18:01because we do surgeries in a much more
- 01:18:04radical way to remove all remnants,
- 01:18:06fallopian tubes, ovaries.
- 01:18:07But Yes,
- 01:18:08you should have a physical examination,
- 01:18:10and there's also a lot of debate whether
- 01:18:13you should also have a blood test blood test,
- 01:18:16like a C125 or over one.
- 01:18:18And that's more debatable in my practice.
- 01:18:20Yes,
- 01:18:21in Joanna's in my practice,
- 01:18:22yes we do physical examinations
- 01:18:23once a year and we would do a blood
- 01:18:26test called CA 125 once a year.
- 01:18:28C 125 is not a good test,
- 01:18:30it's bad text that has a lot of false
- 01:18:32positives, allow false negatives.
- 01:18:33I was going to say it's a crappy test,
- 01:18:36but I saw Joanna previously saying that
- 01:18:38this is all going to be state somewhere.
- 01:18:40So now actually,
- 01:18:41gotta watch how I say things,
- 01:18:43but it's not a good test.
- 01:18:45You know this love,
- 01:18:46false positives, lawful Stega Tibbs,
- 01:18:47the highest number I've ever
- 01:18:49seen with somebody who have cold.
- 01:18:50Who's number was, you know,
- 01:18:52thousand fifteen,
- 01:18:5316,000 and then a few weeks
- 01:18:55later came down to 7,
- 01:18:56but what matters is that the test
- 01:18:58so that says it doesn't matter
- 01:19:00where the absolute number is,
- 01:19:01it matters what that number is for you.
- 01:19:04So it's a trend.
- 01:19:05It's only specific for you, so for you,
- 01:19:08if we watch 725 once every year,
- 01:19:10then we would know if anything is out
- 01:19:12of ordinary to what it is usually.
- 01:19:14So yes, that is what we would recommend.
- 01:19:17How we will do surveillance.
- 01:19:24OK, well thank you doctor Ratner and
- 01:19:26Doctor Hofstetter for a wonderful session.
- 01:19:29Are there any other final questions?
- 01:19:45There's anybody else, any other final
- 01:19:47thoughts from the speakers at all tonight?
- 01:19:54Other than thank you know this has been
- 01:19:57really great to be able to to know.
- 01:20:00Touch based everybody.
- 01:20:02An talk about these issues and
- 01:20:05thank you for the invitation.
- 01:20:08Yeah, I guess I guess that's it.
- 01:20:10How about you,
- 01:20:11Elena? My point of course is very similar.
- 01:20:14But also my point. My last point has
- 01:20:17to be better empowerment that we.
- 01:20:20Who lives, but you know,
- 01:20:22we take care of ourselves.
- 01:20:23You are you best advocate.
- 01:20:25The fact that you here means that
- 01:20:27you are doing everything you can
- 01:20:29to protect yourself from whatever
- 01:20:31whatever can happen and getting jeans,
- 01:20:34jeans tested, financial value,
- 01:20:35family history,
- 01:20:36understanding your risks,
- 01:20:37understanding what you can do to
- 01:20:39risk reduce is what it's all about.
- 01:20:41This way you make sure that nothing happens
- 01:20:44to you and that you take care of yourself.
- 01:20:47And we're here as a family to help you and.
- 01:20:51Do whatever we can to do PC risks.
- 01:20:55And I will echo that that even though
- 01:20:57Doctor Hofstetter's group is at the
- 01:20:58Saint Rayfield Campus and Doctor
- 01:21:00Ratner's group is at the Smilow campus,
- 01:21:01we very much work together.
- 01:21:03And we're here for your
- 01:21:04whole family were here.
- 01:21:05For your you know,
- 01:21:06all the women in your family and
- 01:21:08all the men in your family are
- 01:21:10genetic counselors are close by.
- 01:21:11We can answer any questions that you have,
- 01:21:13or if we can't answer then we
- 01:21:15can get you to the right person.
- 01:21:18So thank you to everybody who
- 01:21:20joined us tonight, and Ruth Ann,
- 01:21:22thank you for coordinating and organizing.
- 01:21:24Ruth Ann's are discovery to
- 01:21:26cure program manager and she
- 01:21:28does a wonderful job on the fund
- 01:21:30raising side and patient support.
- 01:21:31So if you need any extra support
- 01:21:34from Ruth Ann,
- 01:21:35she's wonderful as well and we hope
- 01:21:37to see you next week for more.
- 01:21:39Once Milo shares.
- 01:21:42Thanks everybody.