HBOC Cancer Risks, Part 1

September 30, 2020

Information

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.