Breast Cancer Community Tumor Board: Innovative Breast Cancer Therapies: New Systemic Therapies and Surgical Options

October 14, 2021

Information

Smilow Shares | October 13, 2021

Presentations by:

Maryam Lustberg, MD, MPH, Chief of Breast Medical Oncology; Director of The Breast Center at Smilow Cancer Hospital

Melanie Lynch, MD, Director of Breast Surgery, Bridgeport

Kathleen Fenn, MD, Assistant Clinical Professor of Medicine

Melissa Mastroianni, MD, Assistant Professor of Plastic & Reconstructive Surgery

Kevin Du, MD, PhD, Associate Professor of Therapeutic Radiology

Pamela Fitzgerald, LCSW, Oncology Patient Navigator

ID7040

To CiteDCA Citation Guide

00:00Answer Community tumor board.
00:02Tonight we look forward to this
00:05conversation with you and welcome
00:07your questions and comments in
00:09the chat box and there will be
00:11plenty of time for interaction.
00:15So to introduce you to the breast
00:18cancer tumor board that takes
00:20place across the Yale network.
00:23These are weekly meetings of breast cancer,
00:26team physicians, nurses, social workers,
00:30physical therapists, nutritionists,
00:31and others engaged in the care of women
00:35and men diagnosed with breast cancer.
00:38These tumor boards allow us to ensure that
00:41the highest quality multidisciplinary
00:44care is taking place in the care of you.
00:49And these meetings also serve to
00:52review available clinical trials.
00:54So today will give you a taste of
00:56what a breast cancer tumor board
00:58might look like and use it as an
01:01opportunity to teach you the latest
01:04about breast cancer management.
01:07And, uh, so.
01:08So in this tumor board,
01:10long will present two cases,
01:13each representing different aspects of
01:16Breast Cancer Care and patients experience.
01:19And we have assembled a
01:21multidisciplinary team from all the
01:23important disciplines that take
01:25care of patients with breast cancer.
01:28And, as I mentioned before,
01:30as questions come to you,
01:32feel free to put them into chat and
01:34we will all take turns answering your.
01:36Questions.
01:39So to introduce you to the members of the
01:45multidisciplinary team who are present today.
01:48I I would like to first present Doctor
01:51Kevin June, who is that associate
01:54Professor of therapeutic radiology.
01:56He has specific expertise and radiation
02:00oncology questions related to breast cancer.
02:03We also have doctor Kathleen sent here
02:06today who who treats a number of men and
02:10women with breast cancer and specializes
02:12in this area as a medical oncology expert.
02:17Max we have Pam Fitzgerald who is a
02:20licensed social worker and oncology
02:23patient navigator and through her
02:26expertise she helps patients navigate
02:29a complex system and the overwhelming
02:32time but better breast cancer diagnosis
02:36can be so that all resources are found
02:39and that your needs are answered.
02:42Next we have Amanda Ganzak.
02:45Who is a genetic counselor and
02:48outreach coordinator in Bridgeport
02:50Hospital as you'll learn,
02:52there are many genetic questions that
02:54come up in the routine care of patients
02:57with breast cancer and she'll be
02:59available today to answer those questions.
03:02Next we have doctor Melanie Lynch,
03:04who is the Director of breast
03:07surgery at Bridgeport Hospital.
03:08She is an amazing resource in
03:11our network and blueberry.
03:12Thrilled to have her expertise in the
03:16management of breast cancer patients.
03:18And next we have doctor Melissa Mastriani,
03:21who's an assistant professor of
03:24plastic surgery who also has extensive
03:27expertise in managing all aspects of
03:31reconstruction and plastic issues
03:33that come up in patients diagnosed
03:35with breast cancer.
03:37So this is our team today and this
03:40same team takes care of patients
03:42in the Trumbull Bridgeport region.
03:44So if if you are a patient in
03:47those areas you may have already
03:50interacted with this seller team.
03:54Since this is breast Cancer Awareness Month,
03:57I will share a few facts with you,
03:59which is that over 300,000 individuals
04:02are diagnosed with breast cancer
04:04annually in the United States through
04:07over three and a half million breast
04:09cancer survivors and long term survival
04:12after breast cancer treatment is common,
04:14with over 8080% of individuals
04:17with breast cancer living more
04:19than ten years after diagnosis.
04:22So with that I will turn
04:23it over to Doctor Lynch,
04:25who will introduce our first case.
04:27Thank you.
04:29Thank you doctor Westburg.
04:32So this team gets to
04:35work together every week.
04:36Which is the best part of my job,
04:38so I'm glad we get to share it.
04:39This tumor board with you tonight.
04:41Our first patient is a 62 year old woman
04:44who has an abnormal screening mammogram.
04:46She was called back and had
04:49diagnostic imaging that identified
04:51a mass in the left breast.
04:52The upper inner part of the
04:54breast near the chest wall.
04:56She's otherwise very healthy
04:58with only osteoporosis and
05:00the only medication she takes.
05:03Is for the treatment of her osteoporosis.
05:06For the next next slide.
05:12Her family history is interesting.
05:13Her mother had breast
05:14cancer at the age of 68,
05:16and her mother's brother,
05:17her maternal uncle,
05:19had pancreatic cancer at the age of 60.
05:22She has a very normal physical
05:24exam except for a very small
05:26mass that can be felt in the
05:28upper inner part of the left
05:29breast and she has no concerning
05:31lymph nodes on physical exam.
05:35So here's a representative this.
05:37These cases are also representative cases.
05:40These are not specific patients,
05:43but here's an example of a.
05:46Mass that would be concerning on a mammogram.
05:49Mammograms are taken in two views and so
05:51the first view looks at the breast from
05:53side to side so you can see that the
05:55masses in the inner part of the breast.
05:57And the second image shows the
05:59breast from top to bottom,
06:01so you can see that the mass is in
06:03the top of the breast as well and very
06:05close to the muscle of the chest wall.
06:10The ultrasound showed this mass and as
06:12you look at the ultrasound you see the
06:14stripes on the bottom of the screen.
06:16That's the muscle of the chest
06:17wall so you can see again that this
06:19tumor mass is close to the muscle.
06:24So she had a biopsy and the
06:26biopsy demonstrated that this
06:28area was was a breast cancer.
06:30It's a ductal cancer grade two and
06:33it's estrogen receptor positive,
06:35which is a favorable tumor biology.
06:44So this is where patients will usually
06:46see a surgeon's first course of treatment,
06:48and so will review medical history,
06:50surgical history,
06:51or social and her family history.
06:53And then we'll make.
06:54Surgeons will make the referral
06:56to the tumor board for discussion
06:58of the primary team in general,
07:00someone with a good early
07:01stage in favorable biology,
07:03cancer will be referred for for surgery
07:07as the first course of treatment.
07:12So I'd like to turn it over to Pam
07:14Fitzgerald, who is our patient navigator,
07:17who will will sit with patients at this
07:22initial consultation and we'll start
07:24start the process of helping patients
07:26work their way through the system.
07:36Right, uhm, can you see me?
07:40Yeah, I'm I'm Fitzgerald and I am
07:42one of the navigators at Smilow,
07:44Trumbull and Fairfield.
07:46I am social worker and what I what I would
07:49do is sit with the patient at initial
07:53consultation with Doctor Lynch and get
07:55to understand a little bit about their
07:57social history and their family history,
08:00who their supports are.
08:02We would also review the distressed
08:04screening tool at this time and see what
08:07in particular this woman generally speaking.
08:10Would indicate where her stressors and we
08:13would try to help problem solve those issues.
08:16So for example in a 62 year old
08:19woman we would talk sometimes
08:22about loss of loved ones.
08:24She may have recently had a family.
08:27Remember,
08:27pass away her children may be moving away.
08:31She may still be working and
08:33worried about financial stressors,
08:35so in that period of time.
08:39Name would talk about what supports
08:43are available to her in the community.
08:46We do have financial grants
08:47that we can help with.
08:48We can also help her with paperwork for work,
08:54whether it be FMLA or short term disability.
08:58We also can refer her to counseling if
09:01it's felt that she would benefit from that.
09:05The Integrated medicine services
09:07that we have available.
09:09Are numerous we have support groups,
09:12dietary counseling.
09:16We you know we have acupuncture
09:20and also most.
09:22Find someone helpful throughout
09:23their course of treatment,
09:25but what's kind of unique to navigation
09:28is that we can travel sort of speak
09:32with the woman throughout her continuum
09:35of care so we can meet with her to
09:37discuss her options for treatment,
09:39but also explain why things
09:41are happening in a certain way.
09:43Sort of in layman's terms, we are available.
09:46We tell them as soon as they walk
09:48out of the office.
09:49If they have a question, please call us.
09:52Call us tomorrow.
09:53Call us next week.
09:54Whatever we can do to alleviate stress.
09:57We can also meet with them with a medical
10:00oncologist and the radiation oncologist,
10:02and again assess at that time.
10:04Oftentimes in radiation oncology,
10:06people have problems with transportation.
10:08We have resources for that as well,
10:11so again,
10:12we're here to eliminate barriers to
10:14care and to also help you from diagnosis
10:17through till survivorship and you know,
10:19we just like to say we're,
10:20you know, a new sort of friend.
10:23That you would make and please
10:24call us if you need us.
10:26And with that I'll turn over to Amanda.
10:36Alright, we can go to the next slide.
10:38I'm Amanda Gann second one
10:39of the genetic counselors,
10:40and we have several who are staffed in
10:44the Bridgeport Trumbull location and
10:46basically what we do is help to review
10:51an individual's personal and family
10:52history of cancer to determine the
10:55likelihood that the cancers are hereditary.
10:58Meaning a gene is running in the family,
11:00placing them and their family
11:01members at high risk for particular
11:03types of cancers and with that.
11:06Information we can then target
11:08and help the providers plan how
11:10to attack those increased risks,
11:12how to offer different surgical approaches,
11:16how to discuss various chemoprevention
11:18or other risk reducing options that might
11:21be available based on those increased risks.
11:24So if we take this case one as our example,
11:27some of the factors that I would be looking
11:30at in terms of assessing for the likelihood
11:33of a hereditary risk for cancer is the.
11:36Patients own breast cancer diagnosis.
11:38Although she was diagnosed
11:40after the age of 50,
11:41so that alone is not something
11:43that would highly be concerning.
11:45For hereditary risk, however,
11:47she has a family history of both breast
11:50cancer in her mother and pancreatic cancer,
11:53in her maternal uncle.
11:54So we see two affected relatives
11:56on the same side of the family,
11:58combining both breast and pancreatic cancer,
12:01which for me are all red flags to see,
12:05you know,
12:06to further assess this family
12:07for potential hereditary risk.
12:10Next slide.
12:13So we utilized the NCCN guidelines,
12:16which are published on an annual basis out
12:19of the National Comprehensive Cancer Network.
12:23These are ever changing and involving
12:25as new data and information is collected
12:28from our hereditary cancer families,
12:31so it can certainly be difficult to
12:32keep a bridge to these year to year,
12:34but that's what we hope to be there for,
12:36and particularly in tumor boards.
12:38So we helped to review these
12:39guidelines in all the cases that are
12:42presented to determine how eligible.
12:43Someone maybe for referral to
12:45cancer genetics for an evaluation
12:47and discussion of genetic testing.
12:50And so if you just hit next for me, please.
12:53In looking at this,
12:54this particular patient was diagnosed
12:56with breast cancer over the age of
12:5950 and she has a close relative with
13:01breast cancer and a close relative
13:03with pancreatic cancer.
13:05So using this these guidelines we
13:07see that she does meet criteria for
13:10consideration of genetic testing.
13:12Next and so historically BRCA one
13:15and BRCA 2 or the genes that we see
13:19most often associated with hereditary
13:21breast cancer.
13:22But these genes called other cancers
13:24like ovarian and pancreatic cancer.
13:26So for me,
13:27kind of top on my radar of assessment for
13:30this patient would be BRCA one and two,
13:33although they are not the only jeans
13:35that link breast and pancreatic cancer.
13:38The other genes that we might think
13:40about in this particular case,
13:41our PAL B2 and ATM.
13:44And so,
13:45in the kind of world of genetic testing,
13:48nowadays we do what's called a multi
13:51gene panel where we can test multiple
13:54genes for hereditary cancer risk,
13:56and I think that would be the best
13:58test suited for this patient.
13:59And she does meet NCCN guidelines
14:01and so more than likely she would
14:03also meet her insurance guidelines
14:04for genetic testing,
14:06and that test would help us determine
14:08does she have a hereditary risk?
14:09Does she have future risks for other
14:11cancers that are higher than we would
14:13expect in the general population?
14:15Turn our other family members at risk
14:17and so that testing comes back in a
14:19couple weeks and we can help facilitate that.
14:22Disclose those results that help
14:23facilitate next steps as needed.
14:26And so pass it along to.
14:31Uh, thank you that Doctor Massaroni
14:35comes back, comes back to surgery.
14:36Oh, OK, so breast surgery is certainly
14:40continuing to evolve as we develop
14:42new techniques to make sure that
14:44we are both curing the cancer and
14:46also providing patients with a good
14:48result and minimizing the morbidity
14:50or complications of our operations
14:52or symptoms associated with them.
14:55And we've moved from mastectomy to
14:57being able to offer breast conservation
14:59or lumpectomy to more patients.
15:01In the pictures in the bottom showed the
15:04difference between axillary dissection,
15:05which was the standard of care
15:07when I was a medical student.
15:08To now Sentinel lymph node biopsy,
15:11removing only one or two lymph
15:13nodes at each operation.
15:14As you've seen the picture
15:16in the lower corner.
15:17Next slide.
15:20And so now we've moved into the
15:22area of Oncoplastic breast surgery,
15:24which is providing the best possible
15:27operation for patients to achieve a good
15:30cosmetic and functional outcome as well
15:33as ensuring that we are providing the
15:36best uncle logic outcome that we are
15:39contributing to the cure of a cancer.
15:42Oncoplastic surgery is often requires
15:44teamwork from a breast surgeon and a
15:46plastic surgeon working together to come
15:48up with the best operation for a patient,
15:51and also making sure that we understand
15:54what the patient's goals are. Next slide.
15:58This is doctor Mastriani slide.
16:00Now I'll jump
16:01in and so uncle plastic breast surgery
16:03is not a cookie cutter operation.
16:06And as you can imagine, based on your
16:08tumor size and the ratio of that tumor
16:11size to the rest of the breast size,
16:14breasts are or come in all shapes and
16:16sizes in many different patients and women.
16:19So typically we're looking at a ratio of
16:21the tumor and that issue that we need to
16:24remove in relation to the rest of the breast.
16:27Simple slam dunks are smaller
16:29tumors in larger breasts.
16:31Patients will hardly notice the
16:32difference if we remove that long,
16:34but we may not necessarily have
16:36to do anything very complicated
16:37to yield you with a normal looking
16:39breast at the end of your operation.
16:41However, as you approach the 20 and 40%
16:46range where you're going to be removing
16:48a significant portion of the breast,
16:49oftentimes,
16:50and the literature shows this too,
16:53it's important to consult with a plastic
16:55surgeon because there are options
16:57that don't involve more surgery.
16:58Or implants or anything that's going
17:01to cause more scars on your body
17:03besides that one. Back to me scar.
17:05Occasionally we can do things
17:07to match the other breast too,
17:08so this is our sort of basic guidelines
17:11where if you have less than 20% of
17:14breast tissue being needed to be removed,
17:17you oftentimes can close very simply
17:19and you're not going to have a very
17:23cosmetic Lee noticeable difference.
17:24As you approach the 20 to 40% range we do.
17:28There are a variety of different
17:30techniques that we can use to
17:33essentially squish tissue from one
17:35area into the area that is now a
17:37whole where the cancer used to be.
17:40Once we go beyond that then you need
17:42to think about volume of replacement
17:44or removing tissue from somewhere
17:46else outside the breast to help fill
17:48in that volume and to make sure that
17:50you're in your own skin look normal.
17:53Next slide, please.
17:55And as you can imagine,
17:56there are nearly limitless possibilities,
17:58so this is one of the fun parts of
18:00my job where I get to talk closely
18:02and work with Doctor Lynch,
18:04or we figure out exactly where
18:05that tumor is and how can we best
18:08design and an incision that's going
18:10to be cosmetically sensitive.
18:11It's not going to be right in the middle
18:13of your face every time you look at yourself,
18:14and that can easily become an clothing.
18:16And also,
18:17how can we make this look nicer for you?
18:20Sometimes this often requires an
18:21operation on the other breast,
18:23two to help it match, so these are just some.
18:25Examples of what we can do.
18:29Next
18:30so this patient had A and a cancer in
18:33the upper inner quadrant of the breast.
18:36And so we planned an operation to excise
18:39that to remove underlying tissue and
18:41to reshape both breasts in a breast
18:45lift type operation. Next slide.
18:50And so many studies have been done to to
18:53demonstrate that this kind of approach
18:56to breast surgery is both safe from
18:59a surgical standpoint and provides a
19:02good uncle logic outcome that we can
19:05ensure that we are also curing the
19:07cancer in the same way that we would
19:10be doing it with a simple lumpectomy.
19:12So two large trials have shown that they're
19:15both safe and effective and next slide.
19:18This is kind of a busy slide,
19:20but if the those two last columns oncoplastic
19:23breast surgery and therapeutic mammoplasty,
19:27the type of operation that we just
19:29showed you also have the best patient
19:32reported outcomes,
19:33including sexual well-being, appearance,
19:35emotional well being and physical well being.
19:39Next slide.
19:41So this was the outcome of the
19:43case for this patient,
19:44where the final tumor was
19:481.8 centimeters in size.
19:49We achieve clear margins.
19:51We did a Sentinel lymph node biopsy,
19:53a limited axillary surgery,
19:55and the lymph nodes were not involved.
19:59Next slide.
20:01He sent to take a test called an
20:04Oncotype and will move from here to
20:06the next slide into Doctor Fenn.
20:13So high, so as a medical oncologist,
20:14I typically will see patients such as this
20:17one who have small lymph node negative
20:19tumors that are hormone receptor positive.
20:22Her two negative to discuss treatments that
20:24we can offer to reduce the risk of recurrence
20:27long term and as a medical oncologist,
20:29and particularly interested at reducing
20:31the risk of distant recurrence that
20:33means cancer outside of the breast,
20:35in the lymph nodes lungs you know
20:38liver to reduce our increase,
20:41the chance that.
20:42Patients will survive long term cancer
20:45free and so for this type of breast cancer.
20:48One tool that we have to assess whether
20:50a patient needs chemotherapy is called
20:53the Oncotype and we'll move to the next
20:56slide and I might go back to this one.
20:59So historically, many patients with
21:02this profile were offered chemotherapy,
21:05but we now know that many patients,
21:07in fact, most patients with node negative
21:10hormone receptor positive breast cancer,
21:12actually don't benefit from post operative
21:14or what we call Advent chemotherapy.
21:17Though there is a subset of patients
21:19that that do benefit in reducing
21:21their risk by receiving chemotherapy.
21:24So our goal is to identify the patients who
21:26will benefit and offer them chemotherapy.
21:28And then you know,
21:29reassure the patients who won't benefit that.
21:31Chemotherapy is not necessary,
21:33and the side effects that potentially
21:34could come there of our our,
21:36you know,
21:36we we need we can avoid them
21:38by avoiding chemotherapy.
21:40So this Oncotype DX test is what we
21:44called 21 gene recurrence score to
21:46test those developed by researchers by
21:48looking at a whole array of genes that
21:52are involved in breast cancer biology
21:55and identifying 16 jeans that are very
21:58strongly associated with breast cancer.
22:00Prints as well as five reference genes.
22:03So when we send this test,
22:04this test is a test sent on the tumor tissue.
22:07It's sent out to a lab,
22:09and the levels of those 21
22:12genes are assessed, and then,
22:14using a mathematical model,
22:16a recurrence score that ranges
22:19from zero to 100 is resulted,
22:22as in that report that you
22:23just saw on the previous slide.
22:26So this test is what we call
22:28both prognostic and predictive.
22:29It can allow us to estimate the
22:32chance that cancer comes back in nine
22:35to 10 years with endocrine therapy,
22:37which I'll talk about in the
22:40next slide alone,
22:41and and then it can also predict
22:45you know how much can we lower
22:46that risk by adding an chemotherapy
22:48to that pill that I'll discuss.
22:51So when this test was developed,
22:53you know it was shown when they looked
22:55at patients treated on previous
22:57clinical trials that there's a subset
22:58of patients with a high recurrence score
23:01who really do benefit from chemotherapy,
23:03whereas patients have lower scores.
23:05You know the benefits less clear.
23:08So with this Oncotype score
23:10result from zero to 100,
23:12we consider up to 10 to be low risk,
23:1511 to 25 B intermediate risk,
23:17and 26 in blood above to be
23:20high risk. And so this you know is validated
23:23in a clinical trial called Taylor Axe.
23:27In which patients who had low recurrence
23:29scores did not receive chemotherapy
23:31and did quite well long term,
23:34whereas those patients who had
23:35high recurrence scores did.
23:37Because we knew that already that these
23:39patients are at high risk of recurrence
23:41and then patients with an intermediate
23:43score between 11 and 25 were randomized
23:46flip a coin to receive chemotherapy and
23:48followed by a pill under current therapy,
23:51or endocrine therapy alone,
23:53and the results of this study
23:55showed that for patients with.
23:57Are a current score of 20
24:01below 25 and below say.
24:04These patients did not,
24:06in general, benefit from additional
24:09chemotherapy after surgery,
24:11and so you know,
24:12I say here post menopausal women,
24:14but really women who are over
24:1650 like our patient here with a
24:19recurrent score at or under 25.
24:21I really don't think benefit from
24:23chemotherapy and you can see that
24:25on the report in the previous slide
24:27they give an estimate of recurrence
24:28risk at 9 to 10 years as patient was
24:319% and they estimated that really
24:33we can't lower it any further.
24:35By giving chemotherapy that was less
24:36than 1% benefit for those patients,
24:40unlike our patients who are
24:41younger under 50 years old.
24:43You know there might be some benefit from
24:45chemotherapy and the high intermediate range,
24:48and often we take into account other features
24:50such as the size of the tumor in the grade.
24:53But again,
24:54for this patient with a recurrence
24:55score of 23,
24:56I would not recommend adjutant chemotherapy.
25:01So that brings us to quick
25:03discussion about endocrine therapy.
25:05So certainly the chemotherapy is not needed.
25:10Agile and endocrine therapy will be
25:12a really important part of this.
25:14Patients care, so by this I mean
25:17a pill that's taken once a day,
25:19for we say at least five
25:21years or five to 10 years,
25:23which yields a really significant
25:24reduction in the risk of recurrence by
25:27about half and death from breast cancer,
25:29and then has a secondary benefit of
25:32reducing the risk of a second breast cancer.
25:34So for post menopausal women,
25:36just a really brief overview,
25:38a class of pills called aromatase inhibitors,
25:40really the preferred.
25:41Therapy to reduce breast cancer recurrence.
25:44Risk pills that many of you may
25:46have heard of in this class include
25:49anastrozole letrozole exemestane.
25:51These pills reduced estrogen levels.
25:54Uhm, and in general these pills can be
25:58quite tolerable in many patients with you.
26:01No, no to few side effects and side
26:04effects are often very manageable
26:06with various strategies,
26:08but it's important to know that they
26:10can carry some side effects for these
26:13particular limitation inhibitors.
26:14Joint stiffness and pain may may occur
26:18as well as some hormonal like symptoms
26:20like hot flashes and mood changes.
26:22We also look out for bone loss.
26:25An aromatisse inhibitors.
26:27This patient had osteoporosis which
26:30is not in and of itself a reason not
26:33to offer an aromatisse inhibitor,
26:35but we would want to make sure that
26:36we are working with her primary
26:38doctor or endocrinologist to make
26:40sure that we're reversing any other
26:42causes of osteoporosis.
26:43Make sure that her vitamin D levels
26:46are optimized and then also potentially
26:48offer an Ivy medication to enhance you
26:52know bone strength and reduce bone loss.
26:56The alternative endocrine therapy
26:58is called tamoxifen.
26:59This can be offered to either
27:01pre or post menopausal women,
27:03but in studies comparing AROMATISSE
27:05inhibitors and tamoxifen is slightly
27:08less effective in post menopausal women.
27:10These pills can have similar hormonal
27:13like symptoms and also carry a small
27:16but increased risk of side effects
27:18such as blood clots and uterine cancer.
27:20So really this is a kind of personalized
27:23discussion with the oncologist and the
27:26patient to decide on endocrine therapy.
27:28But for this patient I would potentially
27:30discuss with her and aromat ACE inhibitor.
27:33And then, really, briefly,
27:34in terms of how long do we treat
27:36patients for,
27:37you know,
27:38our standard is at least five years,
27:41though there are studies,
27:42many studies that are looking at
27:45or have looked at extending this
27:47treatment to 7 to 10 years,
27:49and in general it's an area of controversy.
27:54You know,
27:55these studies generally show that
27:57there's a increased reduction in the
27:59risk of recurrence by extending therapy,
28:02but this?
28:03Benefit might be more significant in
28:05patients who have higher risk disease.
28:08And you know this includes patients
28:10with larger size or lymph node positive
28:13disease who we really might strongly
28:15feel to extend to 10 years for this
28:17patient with a small node negative tumor,
28:20it's an individualized decision.
28:22Depending on you know how well the patient's
28:25tolerating treatment at five years,
28:27and I will mention briefly,
28:28there is a test called the Breast
28:31Cancer Index that is also a gene
28:34expression assay similar in
28:36concept to the Oncotype DX score.
28:39Which can sometimes allow or help for
28:44patients who are on the fence predict
28:46you know the risk of recurrence
28:48in the years 5 to 10 after treat,
28:51you know the treatment and also
28:53predict benefit of extending
28:55treatment and so this is something
28:57that is not right for every patient,
28:59but is something that you know potentially
29:01might be right for this patient.
29:03If she's on the fence and continuing
29:05endocrine therapy at Year 5.
29:13OK, I think
29:14I'm up. My name is Kevin.
29:16Do I'm the radiation oncologist
29:19here at smilow cancer care centers
29:22in Trumbull and you know, I I.
29:26I actually really liked what Pam
29:28said up up at the beginning of this
29:32session about being a friend II.
29:35I think that.
29:36Really, the best thing about
29:40treating patients who are going
29:42through a difficult time it is is
29:44really trying to learn what the
29:47priorities are and what you hope
29:49for and and and really being there
29:51to to help you to try to get there.
29:54And I think that's exactly what friends do.
29:58So thank you for joining us here
30:00for all the attendings for joining
30:02us here and and joining us.
30:05The panelists.
30:06The radiation therapy is is used
30:10in combination with surgery in
30:13order to reduce the risk of the
30:16cancer returning after surgery.
30:19You know it's really enabled.
30:21What Doctor Lynch referred to earlier,
30:23which is a approach called
30:25breast conservation therapy.
30:26That is,
30:27instead of larger surgeries like mastectomy,
30:30enabling patients to preserve their
30:34breasts and to and to still maintain the
30:40same cure rates as larger surgeries.
30:43And so it's been really a big advance in
30:46terms of combination therapy between modern.
30:50Surgeries, chemotherapy,
30:52systemic therapies,
30:53and and radiation therapies,
30:56and that's been a huge advance in
30:59Breast Cancer Care in recent years.
31:02As as I'm showing here on this slide,
31:05you know we use radiation to reduce the
31:07risk of recurrence and to help cure cancer.
31:10But in addition,
31:12and very importantly for radiation
31:14treatment as well as all our treatments,
31:17we also want to reduce the risk
31:19of side effects from treatment,
31:20and so this is very important and
31:23in sort of my earlier comment about
31:27understanding patient priority,
31:29it's a very important thing to understand.
31:33You know the the priorities and
31:35and what a patient is is hoping
31:37for out of treatment and this is
31:40very important to tailor treatment
31:42around the relative benefits and the
31:45relative toxicities of treatment
31:47for radiation treatment.
31:49What we do typically is after
31:52surgery after a systemic therapies,
31:55we treat the breast with X rays
31:59and we use X rays to clean up.
32:03Any possible remaining cancer cells you know?
32:07Maybe just a few cells that no
32:09one can really see,
32:10but we use radiation to to clean
32:14up those cells and and what you're
32:18seeing here is is actually a patient
32:22with similar to the patient that
32:24Doctor Lynch presented with a left
32:27sided breast cancer and what we're
32:30looking at here is a CT scan of the.
32:33Patient laying down on my radiation table,
32:36my treatment table and we're looking
32:39at a CT scan where the patient is
32:42laying down on their back and we're
32:46looking from the feet up through
32:48to the head in kind of bread loaf
32:52slices and in the front at the top
32:55of this image are the patients
32:57breasts and on the back the patient
33:00spine and in the red contours the
33:03patient's heart.
33:04And these black areas to both
33:06sides of the heart or the lungs,
33:08just to kind of Orient you
33:10to what we're looking at.
33:11And you can see that close
33:13to the breasts on the on.
33:16This on the side of the left side,
33:19where the heart is.
33:21The breast is actually very
33:22close to the lungs and the heart,
33:24and these are very important things
33:26that we pay attention to when
33:28we're thinking about how to aim the
33:30radiation and things that we worry
33:32about when we worry about the side effects.
33:34Radiation,
33:35and there's some things that we can
33:38do that are very simple conceptually.
33:41You know, of course,
33:42we need to make sure that we execute
33:45them correctly in order to reduce
33:47the side effects of radiation.
33:48This is one technique where very simply,
33:51we ask the patient to take a deep breath
33:54when we treat them with radiation,
33:56and you can see that by taking a deep breath,
33:59your chest expands and during
34:01the breath hold here on the
34:03right hand side of the screen.
34:05You can see that and I had arrows here.
34:07I apologize,
34:08I don't know where the arrows went,
34:10but you can see in the space between
34:12the breast which is in pink and
34:14the heart which is in red that that
34:17black area the lung expands out
34:19and puts more space between the
34:21heart and the lungs and the breast
34:24where I'm aiming the radiation.
34:27And so this is this pink line is
34:29actually a an actual dose of radiation
34:33that I've delivered to a patient.
34:36And you can see that it
34:37very nicely avoids the lung.
34:39Maybe just a little bit of catching
34:41the lung here and in the in along
34:43the where you can see a little bit
34:46little black area encompassed by the
34:48pink and entirely avoids the heart.
34:51And so this is one technique that we
34:53can use to reduce the toxicities of
34:56radiation while still maintaining cure rates.
34:59Next slide.
35:02And then,
35:02uh,
35:03another technique that we use
35:04commonly to reduce side effects of
35:06radiation is to simply have the
35:08patient lay down on their stomachs
35:10instead of laying on their back.
35:12And you can see in the this is
35:15this pink foam board here,
35:18which which this patient where
35:20this simulated patient is laying
35:22on is is really a is is called a
35:24prone breast board and and there's
35:26an opening here where the breasts
35:28will fall into that opening and
35:30away from the patient.
35:32Body and you can see on the again
35:35on the right side of the screen
35:38where I have my radiation doses
35:41on a on again this CT scan that
35:44treating a patient supine really
35:46while we're treating the breast
35:49well really captures a lot of this
35:51black area the lung and we don't
35:54want that so and you can see that
35:56by simply repositioning the patient
35:58the breast falls away from the body
36:00and the lower panel away from the body and.
36:03And you can actually avoid entirely a long
36:06exposure by simple techniques like this.
36:09So next slide. So I traditionally or
36:16radiation therapy would be delivered by
36:19over six to seven weeks of daily radiation,
36:24and in recent probably the
36:27last ten years or so.
36:29Because of advances in radiation,
36:32how we deliver radiation better,
36:35improved techniques, improved technologies,
36:38improved understanding of breast cancer,
36:42biology that we've been able to actually
36:46shorten that down to, most commonly,
36:49four weeks of daily radiation each day.
36:52Each treatment of radiation is only
36:54about 10 minutes, but Even so with
36:57this reduction from 6-7 weeks to.
37:00Four weeks, you know every day
37:02when I talked to my patients,
37:03I can still tell that four weeks
37:05is a lot of visits for them and I
37:08in recent just the last few years
37:12there have been more of a data,
37:16more of a push, more clinical trial.
37:19Results which supports in fact perhaps
37:22even shorter treatments than that,
37:25potentially even as shortest,
37:28is 5 treatments for radiation treatments,
37:32and I think the discussion here that I
37:36have with my patients is that probably
37:40the most standard treatment is the rather
37:42lengthy four weeks of daily treatment.
37:45However, in selected patients,
37:47and if it's right for them.
37:49You know that, uh,
37:52potentially shorter courses of
37:54treatment would be appropriate
37:56and safe for them to choose,
37:59and I think the the point here is,
38:02as the slide alludes to,
38:04it's it's not a one size fits all
38:06approach for radiation and and a lot of
38:09it is really as just with the surgical
38:13approaches and the chemotherapy.
38:15The medical oncology approach is
38:17that it does depend a lot on the.
38:19Biology, you know,
38:21the discussion between all
38:23the folks on this panel,
38:26the medical oncologists surgeons in order
38:28to come up with a tailored approach.
38:31And most importantly,
38:32the patience and this again goes
38:34back to what I was first saying.
38:36Which is, you know,
38:38it is very important to understand
38:41what the patient hopes for,
38:43what they're looking for out of treatment,
38:45and to be able to help them meet those.
38:50What they need?
38:52So that's my take on the
38:54radiation and and you know,
38:56I think in terms of all
38:59these different approaches,
39:00probably the the four week regimen is
39:02what I would recommend for this patient.
39:08Great. Can go one more ahead.
39:12Will catch up to our next case.
39:14So in summary, this lady was treated with.
39:18Uncle plastic surgery.
39:20Sentinel node biopsy.
39:22She got pulled breast radiotherapy.
39:24She had an Oncotype test and then
39:27was treated with endocrine therapy
39:29with a high expectation of cure.
39:33Uhm? And then.
39:35We can move along to the next next case.
39:39We'll come back to survivorship at the end.
39:41So the second case is a young woman
39:44that she's 38 years old who presented
39:46with a mass that she identified on
39:48her own breast self exam and she
39:51had abnormal imaging and a biopsy.
39:55And her only medical history is
39:58anxiety and depression. Next slide.
40:02Her family history includes a paternal
40:04grandmother with breast cancer,
40:06Gran father with prostate cancer,
40:09and she had a palpable mass
40:11at the edge of the areola,
40:14the pigmented area the breast,
40:16but it wasn't pulling on the skin or
40:18the ****** and she had no lymph nodes.
40:22Next slide.
40:25So the mammogram is done with it.
40:27You can see the triangle on the skin there,
40:30that seems to overlie kind of can
40:32almost see a little triangle underneath
40:35there in the breast tissue next slide.
40:40And on ultrasound there was a small mass
40:43and then another another one right nearby.
40:47Neck and neck slide ****.
40:49Biopsy that showed that
40:50this was a breast cancer,
40:52but this was a different biology.
40:53Breast cancer. This was a higher grade.
40:56It was grade 3.
40:59And it was estrogen receptor negative.
41:03In fact, it was what we call
41:05triple negative breast cancer.
41:06There were no receptors that were
41:09found on the cell surface that
41:11regulating the cell growth and the Ki.
41:1367 shows that this is a.
41:16That's cancer where the cells
41:18are dividing very rapidly.
41:20Next slide.
41:22Breast MRI was done to make sure
41:24that there was no sign of disease
41:27elsewhere and you can see out.
41:30I see your question,
41:31I'll jump in in a minute.
41:32You can see the tumor there that lights up.
41:35It's kind of whitish and you can
41:36see the dark area in the middle,
41:38which is the biopsy clip.
41:40The other slide shows that this tumor
41:43is not close to the ****** though,
41:46even though it's near the
41:47center of the breast.
41:48The MRI is very helpful and
41:51very finely mapping the tumor.
41:53Extent which can help us in surgical
41:55planning down the road and I
41:57saw the question in the chat box
42:00about Grade 3 versus stage three,
42:02which is a great question.
42:05And you'll notice that we we talk
42:06about the stage quite a bit.
42:08In both of these cases,
42:10the stage of the cancer is
42:13determined by the tumor size,
42:15the involvement of local lymph nodes.
42:18Any sign of metastatic disease.
42:22And then we take into account the
42:24the receptors on the cell surface.
42:29The grade is how the cells look
42:32under the microscope and at
42:35how big are the nuclei.
42:37The middle of the cells,
42:39and how rapidly are the cells dividing?
42:41Do we see things like mitosis
42:43and how are the cells organized
42:45next to each other so the stage
42:48takes into account all of these
42:51factors and the grade is just how
42:53it looks under the microscope.
42:58Thanks for that question next next slide.
43:08So this patient is still early stage cancer
43:10like the other one was also stage one.
43:13This is off stage one,
43:14but it's a different tumor biology
43:17and so she then was brought to tumor
43:20board for discussion and the discussion
43:23leaned towards chemotherapy as first
43:26course of treatment next next slide.
43:30Back to Pam.
43:31So when we meet this type of a patient,
43:34what are some of the issues
43:35involved in navigation?
43:38So. Uhm, you know younger
43:40ladies have a little bit other
43:42issues going on as a little
43:44bit different than our other.
43:45Our first case, she may have
43:48issues with finances and working
43:51just like the other lady did,
43:53but but given her age we would talk
43:57to her about fertility preservation.
43:59If she's thinking about having more
44:02children in the future, and if she is,
44:04we would refer her to our interaction.
44:08Reproductive endocrinology clinic.
44:10We would also talk to her
44:12about if she has children.
44:14How do you tell your kids you have cancer
44:18and depending on the age of the child,
44:20we have different resources
44:22to help her to do that.
44:25But we also notice that this lady has
44:27a history of anxiety and depression.
44:29So while we're always assessing for that,
44:33we would really be keeping
44:34a close eye on her,
44:36making sure that her depression
44:38or her anxiety.
44:39Friday aren't a barrier to work here,
44:42and if her to Pressione was getting worse,
44:45we would make sure we would put the
44:47appropriate referrals in whether
44:48it be to social worker psychiatry,
44:50you know,
44:51we would also refer her to the psychologist.
44:54We also have different support groups.
44:56For younger ladies we have triple
44:58negative support groups and we also
45:01know that our percentage of our
45:03triple negative ladies do tend to
45:05be African American and there are
45:07support groups that are specific
45:09to African African American ladies.
45:11UM, so again,
45:13we would follow this woman very closely.
45:16We would meet with her with Doctor
45:19Fenn most likely in a multidisciplinary
45:22clinic and and just make sure she gets.
45:24To the right,
45:25doctors at the right time and meet
45:27any of her needs that may come
45:29up with both ladies would be.
45:31We would also be talking to them
45:33about sexuality and intimacy and
45:35how does breast cancer and the
45:38treatment of it affect them?
45:40Yeah, so next slide please, thank you.
45:44Alright,
45:45so I want to take us into considerations
45:47for this case and whether or not
45:50she has a high chance to have a
45:52hereditary cancer risk, and so first,
45:54let's start with the fact that she
45:56has a triple negative breast cancer,
45:58which is definitely a more rare type
46:00of breast cancer and can be more
46:03highly associated with genes that
46:04cause a hereditary breast cancer risk.
46:07And she's 38 so that alone are two factors,
46:10independent of any other factors in
46:12her family history that would qualify.
46:14Her for an evaluation and genetic testing,
46:16but she also has a family history
46:18of breast cancer in her grandmother.
46:20On her paternal side as well as prostate
46:22cancer. In her Gran father next.
46:26And with triple negative cancers in
46:30particular, as much as 20% of these women,
46:33regardless of family history will
46:35have a hereditary cause for that
46:38triple negative type breast cancer.
46:40So that is one reason which just
46:43within the last month or two,
46:45the NCCN guidelines have changed and
46:48now recommend that all women with
46:50triple negative type breast cancer,
46:52regardless of when they were diagnosed in
46:55regardless of what their family history.
46:57Right,
46:57look like should be referred
46:59and consider genetic testing,
47:00so that is certainly something
47:02that has changed based on our
47:05recognition of how high percentage
47:07of these women have a genetic cause.
47:10Next and so she would meet criteria
47:12and we would definitely recommend
47:14that she come and see us and and
47:16consider genetic testing next.
47:20And so in this particular case,
47:23my suspicion for a hereditary
47:24risk is really high,
47:26and so this patient undergoes genetic
47:28testing before she has surgery,
47:30let's say,
47:31and she's found to have a BRCA one mutation,
47:35which is just a fancy way of saying she
47:37has a genetic risk and BRCA one is the
47:40gene in which that defect was identified.
47:43And so for this woman who has this new
47:46diagnosis of a triple negative breast cancer,
47:48these genetic test results now.
47:50Tell us that she has an additional
47:53risk to get a new primary cancer,
47:57so separate then from this new triple
47:59negative breast cancer and that
48:01lifetime risk for her is 20 to 40%.
48:03To that, she'd get a second breast cancer.
48:06Given how young she is,
48:07she's probably on the higher
48:09end of that risk range,
48:10so maybe even closer to the 40% risk,
48:13and so her options based on this
48:15risk might include increased
48:17screening of remaining breast tissue
48:19depending on what surgical.
48:21Option is decided or she might meet with
48:24Doctor Lynch and the plastic surgeon
48:26that decide that the best approach is
48:29to undergo a bilateral mastectomy.
48:32We're removing both breasts,
48:34and I'm including the cancer that's there,
48:36removing the rest of the healthy
48:38breast tissue to reduce as much
48:40as possible that risk for the
48:41second primary breast cancer.
48:43Now BRCA one is also associated
48:45with ovarian cancer,
48:46and that risk ranges between
48:48a 40 to 60% chance.
48:50The hard part is is that there's no effective
48:53screening to identify ovarian
48:55cancer at an early stage,
48:57meaning we caught it where we
48:59can easily treat it and have long
49:01term survival for that woman.
49:03And so in the absence of effective
49:06ovarian cancer screening,
49:07we strongly encourage and recommend that
49:10women with a BRCA 1 mutation elect to
49:13have their ovaries and both of their
49:16fallopian tubes surgically removed
49:18between the ages of 35 to 40 or whenever.
49:21They're done with their family planning,
49:24and so certainly the breast cancer diagnosis
49:26is first and foremost in our priority
49:29and her care right now at this time.
49:31But this is information for future
49:33planning for us to think about after
49:35we get her through this stage that
49:37ovarian cancer risk is the next
49:39thing that we should be focusing our
49:42attention on and then with BRCA one,
49:45you can see a less than 5% risk
49:47for individuals to die.
49:49Be diagnosed with pancreatic cancer.
49:51In their lifetime,
49:53although it's still rather low in
49:55almost individuals with the BRCA
49:58one mutation will not go on to be
50:01diagnosed with pancreatic cancer,
50:03and so pancreatic cancer screening
50:05has its limitations. It has its risks.
50:08We're still trying to prove benefit,
50:10and so we really reserve pancreatic
50:12cancer screening.
50:13Individuals who have a BRCA one mutation
50:16but who also have a family history
50:18of pancreatic cancer in a close relative.
50:21So in this case.
50:22Since she did not have a family
50:24history of pancreatic cancer,
50:26we would not strongly encourage
50:28consideration of pancreatic
50:30cancer screening in her case.
50:36And next slide for the next.
50:39So this is someone who in medical
50:43oncology I would meet, you know,
50:44before surgery and with an
50:46eye on time I'll go through.
50:48You know how we treat systemically
50:50triple negative breast cancer
50:52and our thoughts about you.
50:54Know timing of chemotherapy?
50:56So as we had mentioned, you know,
50:59triple negative breast cancer is
51:01a subtype of breast cancer that
51:03can have a particularly aggressive
51:05biology and have a propensity to
51:07spread elsewhere in the body quickly.
51:09So this is something a diagnosis
51:12where unfortunately because it's not
51:14expressing the estrogen receptors
51:16or another protein called her two,
51:19we don't have traditionally targeted
51:21therapy such as under current therapy
51:23that I mentioned in the last case to to.
51:26Treat these patients with and.
51:28So what we think of as traditional,
51:30quote, unquote, cytotoxic chemotherapy.
51:32So traditional Ivy chemotherapy is
51:34really the mainstay of systemic
51:36treatment for triple negative
51:37breast cancer and the vast majority
51:39of patients with triple negative
51:41breast cancer will need chemotherapy
51:43as part of their treatment.
51:45When we know that someone is
51:47going to need chemotherapy,
51:49you know we think about whether they would
51:51benefit from chemotherapy before surgery,
51:53which is called neoadjuvant therapy
51:56versus going to surgery first and
51:59doing chemotherapy afterwards.
52:01But for patients with triple
52:03negative breast cancer,
52:04there are particular advantages of giving
52:07chemotherapy upfront prior to surgery,
52:10so these advantages include
52:12for certain patients,
52:13especially those who have
52:15more advanced tumors.
52:16We can shrink the tumor with
52:19chemotherapy and may allow for less
52:21extensive surgery and improved
52:23surgical and cosmetic outcomes.
52:25But from my perspective in medical
52:27oncology and more relevant to
52:29this case in this woman who has
52:31a relatively small tumor.
52:32Is that giving chemotherapy before
52:34surgery allows us to assess the response
52:37to chemotherapy at the time of surgery?
52:40You know,
52:41we know a proportion of patients
52:43will have what we call a pathologic
52:45complete response or no active viable
52:48cancer cells in the pathology tissue
52:50at the time of surgery and those
52:52patients you know generally have a
52:55good prognosis for patients who have
52:58residual disease or active tumor
53:00still leftover after preoperative
53:03chemotherapy.
53:04We know those patients may benefit
53:06from additional therapy after surgery,
53:08but we wouldn't be able to identify
53:11those patients unless we gave the
53:13chemotherapy upfront and assess the response.
53:16So
53:16when we think about who
53:17should receive neoadjuvant
53:18chemotherapy for triple
53:19negative breast cancer,
53:21certainly this is the standard of care
53:23for more advanced early stage breast
53:25cancers such as stage two and three.
53:27But we we know, you know,
53:29patients are going to need chemotherapy.
53:31We will certainly consider it
53:33preoperatively for patients who
53:35have slightly smaller tumors,
53:37including this patient who has a
53:38tumor between one and two centimeters.
53:40Certainly, you know she's young.
53:41She has aggressive biology,
53:43she's a candidate for chemotherapy, I would.
53:46Advocate for her to receive chemotherapy
53:48before surgery so we can assess response
53:50and in my next I'll explain you know,
53:53potential options for her after chemotherapy.
53:55If she doesn't have the optimal
53:57response at the time of surgery.
54:00And so when we think of postoperative
54:06therapies for residual disease
54:09after neoadjuvant chemotherapy.
54:12You know,
54:13I wanted to mention you know two
54:16options just to make aware of,
54:19you know,
54:19options that would be available to
54:21her if she did have a suboptimal
54:23response at the time of surgery.
54:24This concludes briefly at oral
54:27chemotherapy called Xeloda,
54:28which we know improves disease
54:30free and overall survival,
54:32and triple negative patients
54:34with residual disease.
54:35But for her situation in particular,
54:37where she has a germline,
54:38BRCA one mutation that she
54:41inherited from her family members.
54:43There is a drug called Elappara
54:46or brand name Lynparza.
54:47That's when the class called apart inhibitor,
54:50which prevents general terms,
54:52prevents cancer cells from
54:54repairing DNA damage,
54:55leading to cell death and the
54:58patients with BRCA mutations
55:00are particularly susceptible.
55:02Their tumors are susceptible to
55:04this drug and so we have a recent
55:07study that came out just over this
55:09summer called the Olympia trial
55:11that notes that Advent elaborate
55:13can improve disease free survival.
55:15In patients with high risk early
55:17breast cancer and BRCA one mutation
55:19and so if she had residual disease
55:22at the time of surgery,
55:23she could potentially benefit from this drug,
55:26and that's pretty pretty new development.
55:29That's all. Say to preserve time.
55:32It's very exciting. Those changes.
55:34I mean, thinking about in the course of
55:36my career hub treatment of women with
55:38triple negative breast cancer has has
55:40improved is really, really thrilling.
55:42So this patient because
55:43she has a BRCA mutation.
55:46Elected to have a bilateral mastectomy.
55:47I just wanted to comment briefly
55:49on ****** sparing mastectomy
55:50which she is a candidate for.
55:52This is a technique for both
55:55treating breast cancer and for doing
55:58prophylactic surgeries and it allows
56:00us to preserve the entire skin of
56:02the breast including the ******.
56:04This picture which is from a research
56:07publication I think really gives a
56:09wonderful picture 'cause patients
56:11often don't understand how we do the
56:14operation through a very small incision.
56:16Underneath the breast,
56:17where we're able to remove all of
56:19the breast tissue and maintain all
56:20of the skin and provide exposure so
56:23the plastic surgeon, my partner,
56:24Dr Mastriani,
56:25who have done a few of these cases
56:28with can then place an implant
56:30or can even use the patient's own
56:33tissue to create a reconstruction.
56:35These really require the breasts
56:37can't be too large,
56:39so we have to choose the right
56:40patient for the right operation.
56:42And it's also better for patients
56:44that are not smokers next next slide.
56:50And the outcomes are safe and so there
56:53is both a registry and a large review
56:55of multiple studies with multiple
56:57patients that show that these are
56:59both safe from a surgical perspective
57:02and from a cancer perspective,
57:04and that we can still achieve a cure using
57:06these these new operations next slide.
57:11Doctor mastriani
57:16I forgot I was on mute.
57:19So in general, when we remove the the
57:23whole gland which you're left with is
57:25a skin skeleton or a shell basically.
57:28So we have two different options currently
57:31available to fill up that skin envelope.
57:34One is with using an implant,
57:36and that's something that
57:37we make synthetically.
57:38It is made of silicone.
57:41All of them have silicone shells.
57:43Some of them can be filled
57:45with silicone gel itself.
57:46Or they could also be filled with saline,
57:49but all of the shells have silicone
57:51on the outside and it's something
57:52that we've studied for the past 50
57:54years and we know that it's safe.
57:56The other option is that we can fill in
57:58your skin envelope with your own tissue,
58:00and this is not an implant you don't have
58:02to take any rejection medications for this,
58:04it's your body.
58:05It's going to feel the most
58:07natural next slide, please.
58:15The two different kinds of
58:16implants that we can do.
58:17You'll notice on that former slide,
58:19there was a one stage in a two stage.
58:21The two stages where I have
58:22to put in a tissue expander,
58:24which is the device you see on the
58:26left that is an inflatable expander.
58:28It allows me to add more volume
58:31or take it away as we need to.
58:34Based on how your wounds heal
58:36when we do remove most of the
58:38breast to removing about 80 to 90%
58:40of the blood flow to that skin.
58:42So I want to make sure that you heal
58:44well so this it I guess adjustable
58:48implant allows me to tailor make
58:51your reconstruction for you.
58:52It also gives you an opportunity to
58:55try on the size and you can walk
58:57around with that size in your body and
59:00decide if that's what you really like.
59:02Oftentimes and more and more often.
59:04We're able to go directly to the implant,
59:06which is what you see on the right.
59:08And as you'll notice,
59:10it's not a round sphere like a water balloon.
59:13We've also come along way as far
59:15as implant technology to make it
59:17more breast shaped and to help it
59:20move more fluidly with you and to
59:22feel more natural under the skin.
59:24Next slide.
59:26And then finally,
59:27I just wanted to talk briefly
59:29about using your own skin.
59:30This is probably the OR your
59:32own tissue to reconstruct.
59:33This is probably the most popular option,
59:35and it's been around for more than a decade,
59:37but we are now becoming more facile
59:40and and it's becoming more mainstream.
59:42More people are training to do
59:44this kind of procedure.
59:45It is a bit more involved.
59:47We can't just move up skin and
59:49fat from anywhere.
59:50It actually has to come with
59:52a blood supply to it.
59:53We need to nourish that that area.
59:55So one common place.
59:56That we take this extra tissue
59:58from it's the lower abdomen.
01:00:00Often times women have a little
01:00:02bit of extra fat down there.
01:00:03Perhaps they've had pregnancies and
01:00:05they have a little extra skin down
01:00:08there that is hard to exercise the way.
01:00:11So those kinds of patients
01:00:13are ideal candidates for this.
01:00:14Even if you've had a caesarean section,
01:00:16you're still a candidate for this,
01:00:18so we are able to trace all of
01:00:20the blood vessels down into your
01:00:21groin and reconnect them up in
01:00:23your chest using a microscope,
01:00:25and we use sutures as fine as her,
01:00:28so this is an intensive operation.
01:00:30It does require special training.
01:00:31But a place like?
01:00:32Yeah, we can offer services like this.
01:00:34We can offer a whole range of
01:00:37reconstruction options and
01:00:38then the beauty of this kind of
01:00:40reconstruction is you don't need any
01:00:42long term follow-up with implants.
01:00:44I tell my patients it's a lot
01:00:45like getting an oil change.
01:00:46You're going to come in every 10 to
01:00:4815 years to get the implant switched out.
01:00:50And while it's an outpatient surgery,
01:00:52it's still another surgery.
01:00:53Whereas if you undergo this option,
01:00:55you're done with reconstruction
01:00:56for the rest of your life.
01:00:58You don't need to come in for oil
01:00:59changes or anything like that.
01:01:04Next
01:01:09so our patient had that operation,
01:01:12she had an implant based
01:01:14reconstruction next next slide.
01:01:18And she had a complete pathologic response.
01:01:20So at she had a tumor.
01:01:22There she received her chemotherapy,
01:01:25and then at the time of the
01:01:26surgery the tumor was gone,
01:01:28which tells us that she will
01:01:30have a very good prognosis of it.
01:01:32Doctor fed.
01:01:35Saved her life so next slide.
01:01:40So I work at the end of our time,
01:01:43and so maybe let's make sure we've answered
01:01:45any questions and then we can talk
01:01:47about issues in in cancer survivorship.
01:01:52Were there any other questions
01:01:54in the Q&A or in the chat box,
01:01:56or any questions you'd like
01:01:58to ask us now? One question
01:02:00was whether the video will be
01:02:03available, and it will absolutely
01:02:05be available on the on the cancer.
01:02:12Cantyalecancercenter.org website
01:02:13so you guys can have access to
01:02:16this video and you can review it.
01:02:18And if you have other questions you can
01:02:22email us at cancer answers at yale.edu.
01:02:26You can also call the Trumbull team at
01:02:35203-254-2381.
01:02:37And those were the only
01:02:39other questions I saw.
01:02:40We had a few too na that we answered.
01:02:44Yeah, by writing them into the answers.
01:02:48Come to the panelists.
01:02:49Any remaining words before
01:02:51we break for the night.
01:02:58Good job, so proud to be part of this team.
01:03:02I think come. What what,
01:03:05what you all did tonight is
01:03:08highlighting how multidisciplinary
01:03:10Breast Cancer Care is and how we
01:03:12all need each other's expertise to
01:03:14deliver the best and most optimal care.
01:03:17And at the center of the
01:03:19team is our patients.
01:03:20So I want to thank all the audience
01:03:23members tonight who joined us
01:03:24and feel free to email call.
01:03:30We want to hear from you and thank you again.
01:03:35Have a great night.
01:03:38Thank you everyone. Thank you.