Smilow Shares Primary Care: Breast Cancer
October 05, 2022Smilow Shares Primary Care: Breast Cancer
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Information
October 4, 2022
Presenters: Rachel Greenup, MD, MPH, Sarah Mougalian, MD, Wajih Zaheer, MD, Jill Banatoski, MD
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- 00:00People get started now.
- 00:02Thanks for joining us for Smile
- 00:05shares with primary care this month.
- 00:08We're focused on breast cancer
- 00:10because it's certainly breast cancer
- 00:12awareness month and the next slide.
- 00:15Oh, my name is Anne Chang.
- 00:16I'm the deputy CMO and Chief
- 00:19integration officer for SMILO.
- 00:21I'm a long medical oncologist
- 00:24and I developed this this,
- 00:27this series with Karen Brown and EMG
- 00:31and Smiler working together to really.
- 00:33Focus on the primary care perspective
- 00:36on cancer and hematology and the
- 00:39audience for primary care clinicians
- 00:42and we have our primary care
- 00:45panelist and smilo physicians.
- 00:47This is a monthly series.
- 00:49So if you like us then come back.
- 00:52It's always the first Tuesday
- 00:545:00 to 6:00 PM virtually and
- 00:56at some point perhaps in person.
- 00:59We started last month and really
- 01:01this is an opportunity to.
- 01:03To focus on questions that primary
- 01:06care may have about cancer topics
- 01:08and we really felt that it wasn't
- 01:11something that where we wanted the
- 01:12specialist to tell primary care what
- 01:14they wanted to know but really ask
- 01:16primary care what what the topics are
- 01:18that that you you have questions about.
- 01:20So we're going to go into introductions
- 01:23and then we'll go into a case
- 01:26presentation with our experts and
- 01:27really we'll let would like to
- 01:30have about 10 minutes available
- 01:32for questions answers that you.
- 01:33We put in the chat as we're going
- 01:36along or or ask at that time.
- 01:40So I'm going to introduce Karen Brown first.
- 01:44Karen,
- 01:44if you can say a few words and
- 01:47then and and then.
- 01:49Start with the interests of our faculty.
- 01:51Sure. No, I I just want to
- 01:53thank you and and of course,
- 01:54all of our smilo folks for sharing with us.
- 01:59You know, we are always stronger
- 02:02together and new cancer is.
- 02:04Can be a really tough time for our patients
- 02:07and for us to support our patients.
- 02:09So I think the more that we can
- 02:11do to coordinate both officially
- 02:13and unofficially and formally and
- 02:15informally between us that the better
- 02:18care that our patients will receive.
- 02:20And I would also like to point
- 02:22out that this evenings panel is
- 02:24largely on the the New Haven region.
- 02:26So we're hoping to kind of
- 02:29highlight on different regions and
- 02:31I'll introduce Joe Bennett,
- 02:33Toski who is one of our star.
- 02:35EMG primary care clinicians Jill
- 02:37attended medical school at the
- 02:39University of Connecticut and completed
- 02:42residency in primary care general
- 02:45internal medicine at Mass General.
- 02:47She returned to Connecticut to
- 02:49practice general internal medicine,
- 02:51where I met her.
- 02:53She was an assistant clinical
- 02:54professor and working closely to
- 02:56educate a lot of the residents
- 02:58who were training with us at Yale.
- 03:01The ambulatory setting.
- 03:03She and her practice joined a NE
- 03:07Medical Group in 2018 and are clearly
- 03:11provide excellent patient care.
- 03:13We get constant demands to see how many
- 03:17more patients they can follow because
- 03:19people love them and they do such a
- 03:22good job taking care of patients.
- 03:24She's additionally now the medical
- 03:26director for University of New Haven,
- 03:28so engaging in some student health as well.
- 03:32I'll pass it back to you to
- 03:34introduce our specialist.
- 03:35So Rachel Greenup is an associate professor.
- 03:40Surgery. She's a breast surgeon.
- 03:42She's our chief of breast surgery.
- 03:44And she came from, came from Wisconsin,
- 03:48where she did her residency and then
- 03:50went on to do her fellowship at the MGH,
- 03:53Dana Farber and Brigham and actually
- 03:57came before joining Yale from Duke,
- 04:00where she founded that Duke Breast
- 04:03Cancer Outcomes Research Group and.
- 04:05And she has been here how long?
- 04:09Now I think it's Rachel.
- 04:13Yes, and it has a real focus on
- 04:15care of women with young women
- 04:18with breast cancer and early onset
- 04:20breast cancer and health equities.
- 04:22Sarah Shellhorn is a colleague of mine,
- 04:26associate professor of medicine,
- 04:29chief ambulatory officer for for Smilo,
- 04:32and she came from.
- 04:34She did her residency at Beth Israel
- 04:36Deaconess in Boston and and came
- 04:38did her fellowship at MD Anderson.
- 04:40And she is really interested
- 04:42in in lots of things.
- 04:43Around patient care,
- 04:45using technology to help patients optimize
- 04:49adherence to oral therapies and, you know,
- 04:53studying patient reported outcomes.
- 04:55And she's the physician leader of our
- 04:58faculty academic practice and also very
- 05:01interested in early onset breast cancer.
- 05:04Why do you stay here?
- 05:05And another colleague,
- 05:06associate Professor,
- 05:07Professor of medicine,
- 05:08he is the medical director for our
- 05:11Smilow Cancer Care Center in Guildford.
- 05:13And he trained it.
- 05:16Yellow affiliated hospital for residency.
- 05:18He was chief resident and then did
- 05:21his fellowship at Cornell University,
- 05:23met while Medical College,
- 05:24and is a Fellow of the American
- 05:27College of Physicians and also
- 05:29very interested in long term care
- 05:31of patients with breast cancer.
- 05:33So without further ado,
- 05:35but with our Distinguished faculty panel,
- 05:37I'll hand it over to Jill.
- 05:40Good evening, everyone and thank you.
- 05:42Thank you for the introduction.
- 05:43Dan and Karen, we and NMG who are seeing
- 05:48patients see and have conversations
- 05:50with over 100,000 women regarding
- 05:52breast cancer screening annually
- 05:53and we order hundreds of mammograms.
- 05:56So this topic is very important to us.
- 05:59We utilize the health maintenance tab
- 06:00in EPIC as an opportunity to remind
- 06:02ourselves and our patients of when
- 06:04their mammograms are due and to make
- 06:06sure they're done in a timely fashion.
- 06:08And one of the focuses we wanted
- 06:10to make sure.
- 06:11We took on tonight was recognizing
- 06:13those who are at increased risk of
- 06:15breast cancer and might need earlier
- 06:17or more advanced level screening.
- 06:19So with that,
- 06:20I'll start our case with a 35 year old
- 06:23nulliparous female with a history of obesity,
- 06:25PCOS and Raynauds who presents
- 06:27for advice regarding breast cancer
- 06:30screening and prevention as her mother,
- 06:32maternal aunt and premenopausal older
- 06:34sister all have a history of breast cancer.
- 06:38So questions regarding this case are
- 06:40what screening imaging is recommended
- 06:42in light of her family history and at
- 06:45what intervals is genetic testing indicated?
- 06:47What tests and how is it best
- 06:50to arrange that?
- 06:50And what, if any,
- 06:52preventative strategies are recommended
- 06:54regarding prophylaxis or surgery?
- 06:55And so Doctor Greenup is going
- 06:57to take this on.
- 06:58Thank you,
- 06:59Rachel.
- 07:00Thank you for having me.
- 07:02So breast cancer screening has been a
- 07:05topic of great controversy for many years.
- 07:08And it flares up in the lay
- 07:10press every three to five years.
- 07:12Every different society
- 07:13has specific guidelines,
- 07:15but the next slide will show you
- 07:18that the US Preventive Task Force
- 07:20guideline demonstrates that women
- 07:22under 50 screening should be made
- 07:24on an individual basis and take
- 07:26patient context into account.
- 07:28So certainly a strong family history.
- 07:30We recommend women begin screening
- 07:33with annual mammogram and or
- 07:36ultrasound based on the youngest.
- 07:38Age of the individual and
- 07:40their family at diagnosis.
- 07:41So for example,
- 07:42in this 35 year old woman who
- 07:44had a history of a mother,
- 07:46maternal aunt,
- 07:47and premenopausal older sister,
- 07:49we would think about the ages of
- 07:52their diagnosis and recommend
- 07:53screening for her about 10 years
- 07:56younger than that earliest diagnosis.
- 07:59the US Preventive Task Force
- 08:01guidelines were most controversial
- 08:03because they did recommend that
- 08:05screening could be considered in
- 08:07every other year in women 50 to.
- 08:0974 and they actually said that
- 08:11there was potentially no benefit
- 08:13to clinical breast exam patients.
- 08:16Asked us about this a lot.
- 08:18I still encourage women who are
- 08:20comfortable doing a monthly
- 08:21breast exam to do so.
- 08:22Regardless of what the data shows,
- 08:24we still meet many women who
- 08:26find their own breast cancer.
- 08:28The next slide shows the American
- 08:31Cancer Society guidelines,
- 08:32and again, this is what most of
- 08:34us in academic programs adhere to,
- 08:37which includes.
- 08:38Annual screening for women 40 to 44,
- 08:41again lifetime risk should be
- 08:44considered and then switching
- 08:46to mammograms every two years
- 08:48as women are 55 and older,
- 08:50again depending on risk.
- 08:52The next slide shows the American
- 08:54Society of Breast surgeons position
- 08:57statement on screening mammogram and
- 08:59this came out in 2019 in response to
- 09:02differing opinions around frequency
- 09:04and type of imaging for average
- 09:06risk women and these guidelines.
- 09:09Really thoughtful in considering
- 09:11not only family history but also
- 09:13breast density and the value
- 09:15of supplemental imaging.
- 09:16And I recommend if anyone's
- 09:17interested you can go on the SBS
- 09:19website and look at these in detail.
- 09:21But the next slide will outline.
- 09:25When women, certainly who have breast cancer,
- 09:28was,
- 09:28we see a finding on mammogram followed
- 09:31by ultrasound plus minus biopsy.
- 09:33Next slide.
- 09:34If there's any concern about density
- 09:37or family history being exacerbated,
- 09:40inclusion of MRI, 3D mammography screening,
- 09:44ultrasound or supplemental imaging
- 09:46such as contrast enhanced mammography,
- 09:49which is a less common currently
- 09:51across the country,
- 09:52but we're hoping to launch that in
- 09:55our smilow network in the near future.
- 09:58There's opportunities to do so without
- 10:01pushback from insurance coverage.
- 10:04In terms of screening or testing
- 10:07for a hereditary Cancer syndrome,
- 10:09next slide,
- 10:10we typically depended on the NCCN
- 10:13guidelines and these as many of you know,
- 10:16we're really based on both a personal
- 10:19history of breast cancer and a
- 10:21family history of breast cancer.
- 10:23It looked at potential for
- 10:25genetic testing for BRCA one and
- 10:28two mutation carriers,
- 10:29any woman 45 or younger women younger
- 10:32than 50 with first, second or third.
- 10:353 relatives women with family history
- 10:38of both breast and GYN cancers,
- 10:41including ovarian or fallopian
- 10:42tube or primary peritoneal,
- 10:44it did account for.
- 10:47Bilateral breast cancer,
- 10:49triple negative phenotype under age
- 10:5160 and individuals with strong family
- 10:54history of Melanoma and pancreas cancer.
- 10:57Next slide.
- 10:59Again, the American Society of
- 11:02Breast Surgeons did update our
- 11:04genetic testing for hereditary breast
- 11:06cancer guidelines to say that any
- 11:09woman with a known breast cancer
- 11:11should have access to a genetic
- 11:14counseling and potential testing,
- 11:16knowing that a broad genetic testing
- 11:18panels can include variants of
- 11:21unknown significance that can cause
- 11:23difficulty in discussions and are
- 11:26often not clinically actionable.
- 11:28And I think that brings us to
- 11:30our screening key points.
- 11:34And the final is that average
- 11:37risk women who need screening can.
- 11:40Be considered for every other
- 11:42year starting at age 50,
- 11:43but all current guidelines recommend we
- 11:46account for patient family history and
- 11:48personal history including biopsies.
- 11:50We should consider screening
- 11:52every year in women 40 or over.
- 11:56It's important to screen women 25 and
- 11:58over for higher risk of breast cancer
- 12:01and include that on their imaging.
- 12:03That will help our radiology colleagues
- 12:06think about supplemental ultrasound
- 12:08and or MRI related to breast density.
- 12:10And again, we do have a robust program
- 12:13at the breast center that includes
- 12:16breast surgery EP's who can help absorb
- 12:19these patients if they need a medical
- 12:22home for their Breast Cancer Care.
- 12:28Thank you. So now we're we're
- 12:30taking this same patient and moving
- 12:32her through the process here.
- 12:34Now she's presenting at age 49
- 12:37with a palpable breast mass.
- 12:39And so when we come to this case
- 12:41the questions that come up are
- 12:43what are the appropriate imaging
- 12:45orders and what is the appropriate
- 12:47method for referring for biopsy.
- 12:49Should the patient go straight to
- 12:51surgery should be a radiological biopsy
- 12:53and if the if the biopsy is positive?
- 12:56What's the order of referral and
- 12:58when should she see oncology in
- 13:01relationship to her definitive surgery?
- 13:03I believe Rachel is taking this one as well.
- 13:06Yeah. So it's certainly a 49 year old woman
- 13:10with a palpable breast mass initially
- 13:12should undergo diagnostic mammogram,
- 13:14a diagnostic ultrasound and certainly
- 13:17consideration of MRI based on
- 13:19breast density is very reasonable.
- 13:22I typically have this discussion
- 13:24with our radiologist.
- 13:25Sometimes the reports will say
- 13:27things such as extremely dense
- 13:29breast MRI is recommended.
- 13:31Other times it's valuable to think
- 13:32about the pros and cons of the MRI
- 13:35in partnership with the patient.
- 13:36Ourselves at Yale are we do refer
- 13:40these women for biopsy and or second
- 13:43opinion if the imaging is done
- 13:45outside so that women can get both
- 13:48a face to face consultation with a
- 13:50provider in our breast center and
- 13:53also have a formal review of their
- 13:57screening imaging that led to the.
- 13:59The work up or the the area of concern
- 14:03screening imaging being their annual
- 14:05imaging that caught the abnormality
- 14:08and diagnostic being the additional
- 14:10workup that led to diagnosis.
- 14:13When we think about breast surgery
- 14:15and typically our breast surgeons
- 14:17are the first frontline providers
- 14:19that see these patients,
- 14:21there are many options.
- 14:22So women who are eligible with small
- 14:25breast cancers can undergo lumpectomy
- 14:27or mastectomy if they are found to
- 14:30not have a hereditary cancer syndrome.
- 14:32And we know their risk of local
- 14:35recurrence remains very low
- 14:36lumpectomies are shorter surgeries.
- 14:38We can do that in conjunction
- 14:41with Aqua plastic surgery either
- 14:42reduction or a lift we.
- 14:44Typically recommend that women
- 14:46less than 70 years old with a
- 14:49triple negative or her two positive
- 14:52breast cancers have lumpectomy,
- 14:54followed by radiation.
- 14:56There are some exceptions and older
- 14:58women with favorable hormone receptor
- 15:00positive breast cancers where
- 15:01radiation can be safely omitted.
- 15:03The recovery time is shorter.
- 15:05I always tell patients they get
- 15:06back to their lives a little sooner
- 15:09and the complication rate is low
- 15:11when we think about mastectomy.
- 15:12It's a bigger surgery when we add.
- 15:14Reconstruction.
- 15:15That's a second really important layer
- 15:17from a psychosocial perspective,
- 15:19but does not contribute to
- 15:22improve cancer outcomes.
- 15:23Many women with small tumors after
- 15:27mastectomy won't need radiation.
- 15:29They can be exposed to several
- 15:31surgeries and or revisions and there's
- 15:33a higher rates of complications
- 15:35especially if patients are smokers
- 15:38have diabetes or other comorbidities.
- 15:40Next slide and these are just some pictures
- 15:43that everyone on the call is aware of.
- 15:45Lumpectomy means we're removing
- 15:46the tumor with negative margins
- 15:48typically following by radiation.
- 15:50Next slide we used to be very reliant
- 15:53on radiology putting a wire in next
- 15:56slide and now we have the improved.
- 15:59Sophisticated technology like
- 16:00radioactive seeds or tag localizers
- 16:03that women can have placed up to
- 16:06five days prior to their lumpectomy
- 16:08without needing to have the wire.
- 16:12Out of their breasted day of surgery,
- 16:14we also have good data.
- 16:15It's more comfortable,
- 16:16patients have better satisfaction
- 16:18and their margin rates are improved
- 16:21with smaller resection specimens.
- 16:23Next slide when we think about mastectomy
- 16:26obviously that's removing all of the
- 16:28breast tissue that can happen with or
- 16:30without reconstruction.
- 16:31We have a great group of reconstructive
- 16:34surgeons across the region that
- 16:37do both implant based and micro
- 16:39vascular reconstruction and we're
- 16:41doing an increasing number of.
- 16:43Media implant reconstruction,
- 16:44which does consolidate the
- 16:46recovery time for our patients.
- 16:48Next, I think one of the things that
- 16:51comes up a lot when I meet women,
- 16:53especially our younger
- 16:54patients like this one.
- 16:56As the discussion about whether there's
- 16:58benefit of removing their healthy
- 17:00opposite breast through prophylactic
- 17:02mastectomy on the contralateral side
- 17:04and the rates of this has actually
- 17:06tripled in the last few decades,
- 17:08probably related to cultural and
- 17:11kind of pop culture conversations.
- 17:15We know that after one breast cancer,
- 17:17a woman's risk of a contralateral
- 17:19cancer is low.
- 17:20It's between .1 and .5% per year,
- 17:24and that removing a healthy breast
- 17:26outside of a hereditary cancer
- 17:28syndrome does not improve survival.
- 17:30And there is also an associated higher
- 17:32risk when we do more surgery inherent
- 17:35to things like bleeding infection.
- 17:37But ultimately our patients do
- 17:40report that sometimes cosmetic
- 17:42outcomes and a Peace of Mind are
- 17:44reasons that prompt them to.
- 17:46Pursue a double mastectomy.
- 17:49Next slide.
- 17:50When women need radiation,
- 17:52this is external beam radiation.
- 17:54It's painless.
- 17:55They usually get five days
- 17:57a week for one to 10 weeks.
- 17:59It's cumulative, so side effects tend
- 18:01to come later or towards the end.
- 18:03This is things like sunburning,
- 18:05fatigue, low risk of secondary cancers.
- 18:09Next slide.
- 18:11And there can be swelling,
- 18:12redness, cough,
- 18:13shortness of breath.
- 18:14Some of this related to the site
- 18:16that receives the radiation.
- 18:18But our radiation colleagues have
- 18:20improved techniques to avoid
- 18:22Android to heart and lungs,
- 18:23and they continue to work towards shorter,
- 18:26abbreviated courses.
- 18:34Rachel, if we could just go back
- 18:35to the beginning of the case
- 18:36with the you don't have to go
- 18:38all the way back in the slides,
- 18:39but just about how you would advise
- 18:42this woman with regard to options
- 18:45prior to her developing her cancer
- 18:48in terms of surgical prophylactic
- 18:51surgery or medical therapeutics,
- 18:54prophylactic medicine medications.
- 18:56What is the, how do you,
- 18:59how do you phrase that conversation?
- 19:00With her given her risk and whether
- 19:02or not if she hasn't known mutation
- 19:04or does not have a mutation
- 19:06but a profound family history.
- 19:08Yeah, so it's a complicated discussion.
- 19:11I think ideally women will come in
- 19:13early in the process before they're
- 19:15kind of ready to sign up for surgery.
- 19:18I first start by taking a good family
- 19:21history and getting a sense of the
- 19:23level of family member involvement,
- 19:26at what age family members are diagnosed
- 19:29and how those family members have survived
- 19:33or or not survived their breast cancer.
- 19:36We do see families where there's many,
- 19:38many women. With breast cancer,
- 19:39but they're all diagnosed in the
- 19:42postmenopausal setting with screen
- 19:44detected very favorable cancers.
- 19:46And then we see women who have a
- 19:48myriad of young women and their
- 19:50family diagnosed with very highly
- 19:52aggressive breast cancers where the
- 19:54it's probably more time sensitive.
- 19:57As certainly a woman with this strong
- 19:59family history having a mother,
- 20:00maternal aunt and older sister,
- 20:02I would refer her for genetic testing.
- 20:05Ideally,
- 20:05we refer an effective family member first.
- 20:09Because if that person's negative,
- 20:11less likely that the individual in
- 20:13front of us would be a mutation carrier.
- 20:17Again,
- 20:17screening should start about 10
- 20:19years younger than the earliest
- 20:21family member was diagnosed.
- 20:23And my practice for these high risk
- 20:26patients although it it is candidly
- 20:29controversial as to to both a 3D
- 20:31mammogram screening ultrasound
- 20:33alternating with annual MRI.
- 20:36So we're staggering imaging that's
- 20:37being looked at every six months.
- 20:40We do see that some women get fatigued.
- 20:42So it's a shared decision.
- 20:43We work with them together about
- 20:45what what feels good.
- 20:47I have patients that feel very
- 20:49reassured when they're imaging
- 20:50is normal and I patients that are
- 20:53probably overestimate their risk of
- 20:55breast cancer the more imaging we do.
- 20:57So it's important to be thoughtful
- 20:59about how it affects their experience.
- 21:03If she was postmenopausal I,
- 21:06typically the breast tissue becomes
- 21:08fatty or replace we all know
- 21:10that 3D mammography and becomes a
- 21:13becomes easier to interpret and.
- 21:15I think especially if postmenopausal
- 21:17women are nearing end of life or
- 21:19they have multiple comorbidities,
- 21:21discussions around reducing the
- 21:23frequency of imaging is valuable.
- 21:27And we do talk to women about
- 21:29chemo prevention if their family
- 21:31history is very high,
- 21:33certainly if women have both a known
- 21:35BRC 1 mutation and strong family
- 21:38history or bracket 2 mutation.
- 21:40Similarly,
- 21:40we we have good discussions about
- 21:43risk reducing surgery both from
- 21:45a mastectomy perspective and
- 21:47also from a GYN perspective.
- 21:50Thank you. I I think Sarah had her hand
- 21:52raised and she wanted to comment as well.
- 21:54Just wanted, yes, thank you.
- 21:56Jill, I just wanted to add to that,
- 21:57that sometimes in women who are at
- 22:00particularly high risk but don't
- 22:02wish to go the the surgical route,
- 22:04chemo prevention is a possibility and
- 22:07chemo prevention sounds much scarier,
- 22:09scarier than it actually is.
- 22:11But Chemoprevention just basically
- 22:13means tamoxifen or sometimes aromatase
- 22:15inhibitors which reduce the risk of
- 22:18developing a breast cancer somewhere,
- 22:19a relative risk. 30 to 50%.
- 22:24Over whatever time period they're
- 22:25taking it in, even past that time frame,
- 22:28the the issue there.
- 22:33The issue there, excuse me,
- 22:34what is that that relative risk
- 22:36reduction may not translate into a
- 22:39large absolute risk reduction and
- 22:40that can get a little bit complicated,
- 22:43but it's certainly something that we we
- 22:45do on occasion for people who are interested.
- 22:49Thank you.
- 22:51So we'll take our patient who unfortunately
- 22:54has surgery and is found to have a
- 22:57stage 2A invasive ductal carcinoma.
- 22:58The tumor is 2.5 centimeters in grade 3,
- 23:02does not involve any lymph nodes,
- 23:04and is ER PR positive and her two negative.
- 23:07And so we are going to now engage
- 23:10in discussion about treatment.
- 23:11If she's pre menopausal,
- 23:13what is her appropriate adjuvant treatment
- 23:15and what factors are considered?
- 23:18How is this different if she's
- 23:20postmenopausal and how long should she
- 23:22be on adjuvant hormonal therapy and
- 23:25doctor shellhorn's going to take it away?
- 23:28Right.
- 23:28So breast cancer treatment in 10 minutes,
- 23:31no problem.
- 23:32The the,
- 23:33the initial approach and Rachel did a
- 23:36really lovely job going through the,
- 23:39the definitive local management
- 23:41of breast cancer.
- 23:42When we think about breast cancer,
- 23:44they're really three different modalities,
- 23:46each of which has a different concern.
- 23:48And so very broadly speaking,
- 23:50and I know I'm jumping into
- 23:51the next slide a little bit,
- 23:52but very broadly speaking, surgery,
- 23:54the purpose of surgery is,
- 23:55is,
- 23:56is to take out the cancer and the affected.
- 23:58Lymph nodes,
- 23:59the areas that we know contain cancer.
- 24:01The purpose of radiation is to mop up behind
- 24:04the surgeon to to get rid of any micro,
- 24:07micro microscopic disease that
- 24:08might reside in the breast or the
- 24:11OR the XL or other lymph nodes.
- 24:13And then the purpose of medical
- 24:15oncology or systemic therapy is really
- 24:17to reduce the risk of developing
- 24:20metastatic disease in the long run.
- 24:22So we all have very different concerns.
- 24:24The sequencing of treatments can
- 24:26be different depending on the
- 24:29clinical circumstance.
- 24:30Sometimes surgery is done 1st,
- 24:33and this is particularly helpful
- 24:34to figure out what it is exactly
- 24:36that we're dealing with.
- 24:37What's the size of the cancer,
- 24:38how many lymph nodes are involved.
- 24:41You really get a full pathologic
- 24:42picture of the cancer,
- 24:44and if that is going to be used to
- 24:46determine systemic therapy or the need
- 24:47for radiation later on down the road,
- 24:49that can be helpful.
- 24:51Sometimes we use a neoadjuvant approach,
- 24:53meaning before surgery,
- 24:54to give some sort of systemic therapy
- 24:57such as chemotherapy, and this is used
- 24:59in generally and more aggressive.
- 25:01Cancers or very locally advanced cancers
- 25:03when we know that chemotherapy is
- 25:05going to be needed and we don't need
- 25:08that additional pathology to determine
- 25:10what chemotherapy regimen to use.
- 25:12So just wanted to give a quick word on
- 25:14adjuvant versus neoadjuvant and then
- 25:16we'll dive into all of that pathologic
- 25:18gobbledygook that Jill told us about in
- 25:20terms of this patients biopsy results.
- 25:27Before we do that, however,
- 25:28I've already mentioned over on the
- 25:30right what the roles of surgery,
- 25:33radiation and medical therapy are.
- 25:37Patients often want to
- 25:38know what their stage is.
- 25:40In fact, almost 100% of the time and stage
- 25:43can be thought of in one of two ways.
- 25:46There's the anatomic stage,
- 25:48which relies on the size of the tumor
- 25:50and the presence or absence of lymph
- 25:52nodes and their number to determine.
- 25:54How locally advanced a cancer is.
- 25:57More recently we started incorporating
- 25:59some of those things that were mentioned
- 26:02in the biopsy report that Jill that
- 26:04Jill read earlier including the grade
- 26:06which in this case was Grade 3,
- 26:08the estrogen receptor and the progesterone
- 26:11receptor status and the her two status.
- 26:14And we can incorporate those features of
- 26:17the cancer into the tumor size in the
- 26:20lymph node status to come up with what
- 26:22the final stage is and stage correlates.
- 26:25Roughly with prognosis.
- 26:28So it gets us now the patient's
- 26:30going to have surgery,
- 26:31the patients,
- 26:32if the assuming the patient has a lumpectomy,
- 26:34she'll need radiation.
- 26:36How do we decide what kind of medical therapy
- 26:39we're going to recommend for this patient?
- 26:42So next slide?
- 26:44We first look at the grade.
- 26:46Grade is a measure, broadly speaking,
- 26:49of how aggressive the cancer
- 26:50cell looks under the microscope.
- 26:52It's incorporating a couple
- 26:53of different things,
- 26:54including the architecture,
- 26:56nuclear grade and speed of replication.
- 26:59And it gives us a sense the higher the grade,
- 27:02the more aggressive we may need to be,
- 27:04IE the higher grade,
- 27:05the more likely the chemo is that
- 27:08chemo is going to be recommended.
- 27:10Next slide.
- 27:13We get into the estrogen and
- 27:15progesterone receptor.
- 27:15So the vast majority,
- 27:1675 ish percent of all breast cancers are
- 27:19fueled at least in part by the female
- 27:21hormones estrogen and progesterone.
- 27:23And so the presence of estrogen or
- 27:28progesterone near the cancer can
- 27:30lead to more uncontrolled growth.
- 27:33So estrogen and progesterone
- 27:35positive cancers,
- 27:36estrogen and progesterone receptor
- 27:38positive cancers are fueled by hormones,
- 27:41which leads us to.
- 27:43Talk about some sort of anti hormonal
- 27:46therapy and interfering with that
- 27:48interaction between the ligand and the
- 27:51receptor can lead to decreased gene
- 27:53expression and therefore decreased
- 27:54cell proliferation in the long run.
- 27:56So that's the the reason behind
- 27:59these hormone type therapies or
- 28:01rather anti hormone type therapies
- 28:03that we recommend for patients who
- 28:06have this type of breast cancer.
- 28:08You've heard of these drugs.
- 28:10You probably have hundreds
- 28:11of patients on these drugs.
- 28:12Tamoxifen works as a competitive
- 28:15antagonist of estrogen,
- 28:16and progesterone 6 sits in the
- 28:18pocket of the receptor and prevents
- 28:21breast cancers from from growing,
- 28:23or breast cells in general from
- 28:25being able to grow.
- 28:26Aromatase inhibitors, on the other hand.
- 28:30Prevent the peripheral aromatization
- 28:33of steroids into testosterone and into
- 28:37of rather testosterone into estrogen.
- 28:41And prevent the body from being
- 28:43able to make estrogen,
- 28:44and so you remove the leg in
- 28:47entirely so there's nothing to
- 28:48bind to the receptor itself.
- 28:52The final thing that we look
- 28:54at is the her two status.
- 28:55Her two is a member of the EGFR
- 28:58family of surface receptors,
- 29:00and it can be either normal,
- 29:02also called negative,
- 29:04or it can be positive and it can
- 29:06be positive in one of two ways.
- 29:09It can be overexpressed on
- 29:10the surface of the cell,
- 29:12or it can be amplified in the
- 29:15nucleus with lots of additional
- 29:17copies of the her two encoding DNA,
- 29:19her two positive cancers in general.
- 29:22Are more aggressive.
- 29:24They in general require chemotherapy and
- 29:28oftentimes we use chemotherapy first.
- 29:31In this setting, you may have heard
- 29:33of the name triple negative breast cancer.
- 29:37Triple negative just means estrogen
- 29:39receptor is negative,
- 29:40progesterone receptor is negative.
- 29:41Her two is -, 1, two,
- 29:44three, triple negative.
- 29:46Next slide please.
- 29:49Jill in in our preparation for
- 29:52this meeting, Jill shared a risk,
- 29:55shared a story of a patient who came
- 29:58in wanting to discuss her number
- 30:00with her primary care doctor and and
- 30:02number in this case often refers to
- 30:05something called the Oncotype DX,
- 30:07which is a recurrence score.
- 30:09It's a number on a scale of zero to 100
- 30:12and it is a number that is calculated
- 30:16by looking at the gene expression of.
- 30:1921 cancer specific genes.
- 30:21It goes into a patented algorithm by
- 30:24this company genomic health and the
- 30:26number the recurrence scores is spit out.
- 30:29So if that number could be on a scale
- 30:32of zero to 100, it's a complicated,
- 30:35nuanced conversation with patients.
- 30:37But in general,
- 30:38if that number is 25 or lower,
- 30:42patients may not benefit from chemotherapy,
- 30:45and so chemotherapy is likely not to be
- 30:48recommended if that number is higher than 20.
- 30:51UH-5 or 26 and up,
- 30:53there needs to be a more detailed
- 30:55conversation about the use of chemotherapy.
- 30:58So this is a test that that we
- 31:00send to determine whether or not
- 31:02a patient needs chemotherapy.
- 31:04It does correlate a little bit
- 31:07to to prognosis,
- 31:08but the real purpose of this test
- 31:10is to determine whether or not we
- 31:12need to use chemotherapy to reduce
- 31:13the risk of micrometastatic disease
- 31:15and subsequent distant relapse
- 31:17and at some point in the future.
- 31:19Next slide.
- 31:22Umm, I don't expect you to
- 31:23actually be able to read the slide,
- 31:25but the there are a lot of different
- 31:29regimens and your friendly neighborhood rest,
- 31:31oncologist, oncologist would be more
- 31:33than happy to discuss any of these
- 31:35chemotherapy regimens with you.
- 31:37I I put this up just to show that
- 31:39there are a lot of different regimens
- 31:40with a lot of different side effects,
- 31:43a lot of different schedules and that's
- 31:46our job to to really talk through risks
- 31:49and benefits, potential side effects.
- 31:51Potential toxicities,
- 31:52mainstays of treatment for breast cancer,
- 31:55include taxanes, so Taxol,
- 31:59taxotere, ABRAXANE.
- 32:00Those are some commonly used drugs,
- 32:03sometimes adriamycin or doxorubicin
- 32:07and anthracycline.
- 32:08Cyclophosphamide, cytoxan and carboplatin.
- 32:12And then,
- 32:13if the cancer is her too positive trust,
- 32:16who's amab?
- 32:16Also known as Herceptin,
- 32:18as well as other anti her two
- 32:19targeting agents.
- 32:22Next slide. So this particular
- 32:26patient would have had most likely,
- 32:29given that it was a high grade cancer,
- 32:30it was larger. She's premenopausal
- 32:32likely to have a high risk Oncotype.
- 32:35So an Oncotype that's higher than 26,
- 32:37she likely would have been
- 32:40recommended chemotherapy.
- 32:41However, she also needs to
- 32:43go on endocrine therapy.
- 32:46Tamoxifen or an aromatase
- 32:49inhibitor would be indicated.
- 32:50So just to think about
- 32:52who we can use these in.
- 32:54Tamoxifen can be used in in
- 32:56anyone provided they don't have
- 32:58a risk of or a history of venous
- 33:02thromboembolism or endometrial cancer.
- 33:04Aromatase inhibitors can only be used
- 33:07in post menopausal women and that
- 33:10is largely related to its mechanism.
- 33:13It works by blocking the
- 33:15peripheral aromatization.
- 33:16In peripheral tissues, not the ovaries.
- 33:19But what that leads to is
- 33:21deprivation of estrogen in the body,
- 33:23leading to negative feedback and the
- 33:27ovaries ramping up if if used in
- 33:30the absence of ovarian suppression.
- 33:32So aromatase inhibitors can only
- 33:33be used in post menopausal women or
- 33:36women who do not have ovarian function,
- 33:38either surgically, chemically or otherwise.
- 33:41The side effects of the two drugs
- 33:43or the two classes of drugs are
- 33:45are a little bit different.
- 33:46Tamoxifen could cause vasomotor symptoms,
- 33:49such as hot flashes.
- 33:50It can cause mood changes.
- 33:52There is a small risk of venous
- 33:55thromboembolism very small
- 33:56risk of uterine cancer.
- 33:57It can be beneficial in patients
- 34:00with osteoporosis and can can lead
- 34:02to an increase in bone density.
- 34:04Aromatase inhibitors, on the other hand,
- 34:06lead to this low estrogen state.
- 34:08So it's kind of menopause, Part 2.
- 34:10It can cause vasomotor symptoms such as
- 34:12hot flashes, night sweats, vaginal dryness.
- 34:16Accelerated bone loss.
- 34:18And so we monitor bone density
- 34:19very closely in these patients,
- 34:21usually every other year.
- 34:22It can lead to increased cholesterol as well.
- 34:26In terms of monitor monitoring,
- 34:28there's really no monitoring
- 34:29for tamoxifen other than.
- 34:59To determining whether or not
- 35:03we should extend endocrine
- 35:05therapy past five years.
- 35:07The slides have disappeared.
- 35:09I'd be happy to take some
- 35:11questions until the slides return.
- 35:14Or we could just go straight
- 35:16into the next phase of the case.
- 35:21Thank you very much, Sarah.
- 35:24And we're going to move into
- 35:26survivorship and new symptoms.
- 35:27So our patient is now 54 years old.
- 35:29She's tolerating her
- 35:31adjuvant hormonal therapy.
- 35:33And we'd like to have a discussion
- 35:35about what risk should we as
- 35:36primary care physicians be
- 35:37aware of those being endocrine,
- 35:39cardiac, pulmonary,
- 35:40psychological and what testing
- 35:42should the primary care physician be
- 35:44prepared to order for those patients.
- 35:49And in addition, after after that
- 35:52conversation, eight years later,
- 35:54our patient presents with new onset of
- 35:56back back pain of four weeks duration,
- 35:59which she originally attributed to
- 36:00a strenuous session of gardening.
- 36:02But rather than improving as would
- 36:04be expected, the pain is worsening.
- 36:06So this would lead us into discussion.
- 36:08Considering her breast cancer history,
- 36:10what are the appropriate next steps
- 36:12in diagnosis and management of her new
- 36:15onset of symptoms given her history?
- 36:17And Doctor Zahir is kindly going
- 36:19to take this on. Thank you.
- 36:21Thank you for including me in
- 36:22this conversation. So this is,
- 36:24I'll take your second question first.
- 36:26You know, this is, you know,
- 36:27any kind of workup for a patient with
- 36:30history of breast cancer should be
- 36:32based on what was their underlying
- 36:34risk and what are the symptoms
- 36:36and obviously this lady is having.
- 36:38Persistent back pain issues.
- 36:40So we need to have it worked up to make
- 36:42sure that there's nothing you know,
- 36:44we that we work it up for,
- 36:46whether it's related to breast
- 36:48cancer or related to a treatment
- 36:51or related to another etiology.
- 36:53So if she's having persistent back pain,
- 36:57she will have a workup that
- 37:00could include X-rays or well,
- 37:02if there is persistent pain in
- 37:05a particular location and MRI,
- 37:06or if there are diffuse symptoms.
- 37:093D scan or a PET scan?
- 37:11And if we find some abnormality
- 37:13that is highly suspicious based
- 37:16on the radiology data,
- 37:17then we have to biopsy at the time of
- 37:21anytime of anytime we feel that there
- 37:23is a possibility of a recurrence,
- 37:25we need to biopsy that for
- 37:27a variety of reasons.
- 37:29First reason is we want to confirm
- 37:31that this is indeed metastatic breast
- 37:33cancer or is this another malignancy.
- 37:35And also we need to test for all those
- 37:38markers that doctor Mcgillian has mentioned,
- 37:40you know the estrogen receptor.
- 37:41Suggestion receptor,
- 37:42her two receptors and also additional
- 37:46molecular biomarkers that we use
- 37:49these days for metastatic disease.
- 37:51Another issue with the metastasis is
- 37:55that bone metastases are usually seen
- 37:58in estrogen receptor positive patients,
- 38:01whereas brain metastases are
- 38:03more common in her two positive
- 38:05or triple negative patients.
- 38:07And anytime a patient is diagnosed
- 38:09with metastatic disease these days,
- 38:11we have a lot of choices and
- 38:13we have a lot of treatments,
- 38:14additional treatments that can be very
- 38:17helpful and they are still trying to convert.
- 38:21This into a chronic disease rather than
- 38:23a death sentence and then we have to
- 38:25assess the patient for the for distress,
- 38:27which requires a lot of help
- 38:30on part of medical providers as
- 38:33well as home providers.
- 38:37So we all know and that's why we have
- 38:40gathered today that best care for any
- 38:42patient is good collaboration between
- 38:44a primary care and an oncologist,
- 38:47which we do this all the time and
- 38:49I've had the pleasure of doing this
- 38:51with Jill for a number of years.
- 38:53So acute toxicity usually is
- 38:54taken care of by medical oncology,
- 38:56but chronic toxicities are shared
- 38:59between primary care and and medical
- 39:02oncologist and any woman who has been.
- 39:05Treated with endocrine therapy,
- 39:06especially the aromatase inhibitors.
- 39:08We know about bone health,
- 39:09we discuss those issues and many
- 39:11of these patients are placed
- 39:13prophylactically also on bisphosphonates,
- 39:16which is an agent that also that helps
- 39:19with bone health but also may decrease
- 39:23the risk of disease recurrence in the bones.
- 39:26We all know about the side
- 39:28effects of adriamycin.
- 39:29We do not usually reach that dosage
- 39:32that causes problems with the heart,
- 39:33but we usually still check it.
- 39:35In the adjuvant setting,
- 39:37anti herto therapy has a potential
- 39:41for cardiac complications also,
- 39:43but most of those issues are
- 39:46temporary and they resolved with
- 39:48discontinuation of therapy.
- 39:50We have a excellent cardio oncology
- 39:52program that actually helps us
- 39:53out in care of these patients
- 39:55in some decision making process,
- 39:57whether to treat or not to treat.
- 39:59Pneumonitis is another risk that
- 40:02can happen with chemotherapy that
- 40:04can happen with radiation therapy
- 40:07that is happening these days with
- 40:09immune therapy also.
- 40:11It's relatively uncommon but has but may
- 40:15require steroid therapy at some point.
- 40:18Neuropathy is one of the most common
- 40:21chronic side effects that we hear about
- 40:24most commonly in breast cancer patients.
- 40:26Taxol is the is the culprit,
- 40:29although in other malignancies oxaliplatin
- 40:32is more notorious for that side effect.
- 40:35There are certain medications that
- 40:37actually help with some symptoms.
- 40:39We actually have a physical therapy
- 40:41department that actually focuses
- 40:43on neuropathy and has been really
- 40:45successful in helping out with this.
- 40:48Chronic.
- 40:50Problem.
- 40:52Psychological health is very important
- 40:55in any breast cancer or any cancer survivor.
- 40:59And with time as as as we
- 41:02have improved on chemotherapy,
- 41:04we have improved on side effects,
- 41:06we have tried to cut back on surgeries,
- 41:10we have tried to cut back on chemo,
- 41:11certain type of chemotherapy.
- 41:13The financial toxicity continues to
- 41:16increase because of the increased
- 41:18cost of treatment and increased cost
- 41:20of taking care of these patients.
- 41:23So coming back to your first question,
- 41:25how often this person should be followed
- 41:27if they do not have metastatic disease?
- 41:29Normally speaking the NCCN guidelines.
- 41:33Say that we need to see the patients one,
- 41:36one to four times a year per year
- 41:38for five years and decreasing
- 41:41frequency again based on their.
- 41:43Their risk and again based
- 41:46on their symptoms also.
- 41:48We are actually working on a long term
- 41:51care plan at the at the Hill Spyro Center,
- 41:54trying to see what is the best way
- 41:56to transition back to primary care
- 41:58after five years and what type
- 42:00of patient should that be.
- 42:02And based on their original
- 42:04pathology as well as need
- 42:06for continuing care, patients also
- 42:09need periodic screening for family
- 42:11history genetic testing because the
- 42:14genetic testing also can change in a
- 42:16number of years and new additional.
- 42:18Testing may be required.
- 42:19We are all familiar with
- 42:21the lymphedema management,
- 42:23which is which can be a problem,
- 42:26but those problems are decreasing,
- 42:27thankfully, to less invasive surgery,
- 42:31and we have good physical
- 42:33therapists that are available for
- 42:35those management of lymphedema.
- 42:37Again, the one of the required radiology
- 42:40is the yearly mammogram unless
- 42:42patient has had bilateral mastectomy.
- 42:46There's actually no indication for
- 42:48any other testing for routine testing
- 42:50in the absence of clinical signs and
- 42:53symptoms suggestive of a recurrence.
- 42:54And again we have good long term
- 42:57care plans that we are working on
- 43:00and we have a lot of these support
- 43:03services that are available at
- 43:05the SMILO Cancer Center.
- 43:07I will not go into individual details,
- 43:09but all of them are providing
- 43:11additional help.
- 43:12We have the extended care clinic for
- 43:14off hours so that the patient cannot.
- 43:16Should not go to the emergency room and
- 43:19can go and can bypass the emergency room.
- 43:22We have the multidisciplinary care
- 43:24that we are trying to get patient an
- 43:27appointment together with the surgeon
- 43:29and medical oncologist and radiation
- 43:31oncologist and other supportive.
- 43:36Agencies, we are trying to
- 43:38also get next day access,
- 43:39which we have been successful to some extent.
- 43:41And then I want to mention that the
- 43:44oncology pharmacy has been one of
- 43:46the mainstays that are available in
- 43:47almost all of our offices that are
- 43:50readily available to discuss interactions
- 43:52and discuss any changes as needed.
- 43:55And thank you very much.
- 43:58With terrific, I'm going to just
- 44:00leave a question and answer session,
- 44:03although we don't have anybody
- 44:05that's offered any question and
- 44:07answers through our zoom connection.
- 44:09So if you are thinking of asking the
- 44:12question by all means put it in the
- 44:15Q&A and otherwise I I I have a a couple
- 44:19of kind of logistic questions. So.
- 44:22The first thing was in a cancer survivor,
- 44:26a breast cancer survivor who
- 44:28has some new symptoms,
- 44:29whether it's back pain or maybe a lump,
- 44:31they feel subcutaneous lump.
- 44:34Is, you know,
- 44:35you said to assess their risk of
- 44:38recurrence based on their initial
- 44:40cancer and and that is one thing that
- 44:44can really stump us in primary care.
- 44:47So, you know,
- 44:47what I find is whenever I see the name of
- 44:50the oncologist who treated the patient,
- 44:52and I recognized the name,
- 44:54and I pick up the phone,
- 44:56they have this encyclopedic knowledge
- 44:58of exactly what means what as far
- 45:01as what they were treated with,
- 45:02and, you know, their markers.
- 45:04And so I'm, I'm wondering is,
- 45:06is that something that's going to
- 45:08be addressed in this care plan or
- 45:10is that kind of just the right
- 45:12thing to do is to pick up the
- 45:13phone and call an oncologist,
- 45:15how,
- 45:15how should we proceed when we do
- 45:19suspect at late recurrence or of cancer?
- 45:24I Karen, it's a great question.
- 45:26Why did you go ahead.
- 45:27Sorry, go ahead. I basically
- 45:29you know I would say that you know
- 45:31picking up the phone is always very
- 45:33helpful that's it's the best care
- 45:35possible for the patient and again I've
- 45:38known Jill and her group for a long
- 45:40time and I I get these calls all the
- 45:43time and I think that really improves
- 45:45the care that tells that directs which,
- 45:48which test needs to be done and
- 45:50there are and we are actually
- 45:52in a better position in a sense.
- 45:54To tell as to what tests should
- 45:56be done first.
- 45:57That sometimes saves money and
- 45:59as well as unnecessary tests
- 46:00also and unnecessary anxiety.
- 46:02Also looking at certain person,
- 46:04certain patient,
- 46:05we look at a certain abnormality,
- 46:07we will say you know it's highly unlikely
- 46:10related to breast cancer and that
- 46:12may alleviate the anxiety right away.
- 46:15Yeah and I would echo exactly that,
- 46:17that same sentiment it's we love
- 46:20to hear from primary care doctors.
- 46:23You know we recognize that we're not
- 46:25up to date on the latest and greatest
- 46:28antihypertensives antihypertensives
- 46:30and I can't name anti diabetes
- 46:33medications except for metformin.
- 46:35So the Umm it really has to be
- 46:40a collaboration that we do come
- 46:43across any number of patients.
- 46:45Let's say I had cancer.
- 46:47My shoulder hurts.
- 46:49I need all the scans and and so
- 46:52it's a careful balance of what
- 46:54that patient's underlying risk is,
- 46:56which really is our job,
- 46:57and and what's the likelihood
- 46:59that this represents a metastatic
- 47:01or neoplastic process.
- 47:02And the the thing that I find to be
- 47:04helpful when explaining to patients at least,
- 47:06is cancer.
- 47:06Usually if cancer is going to come back,
- 47:09it's going to meet the three P's,
- 47:11it's going to be a symptom.
- 47:12That's perplexing.
- 47:13You don't know why you have it.
- 47:15You you didn't just shovel your
- 47:17driveway for three hours the day before.
- 47:20It's persistent.
- 47:20It's there,
- 47:21it doesn't go away and it's
- 47:23progressive and it's getting worse.
- 47:25And so those are the three things
- 47:27that kind of help us determine what
- 47:29we need to be more worried about.
- 47:31We're not going to worry about
- 47:32something if it's been there
- 47:33for an hour and a half.
- 47:34We're going to worry about
- 47:36something if it's been there for
- 47:37weeks and it really isn't behaving
- 47:39like it should if this were some
- 47:41other non neoplastic process and
- 47:42then deciding what test is best.
- 47:45To do really does kind of require
- 47:47a knowledge about the biology
- 47:48of the cancer and where is this
- 47:51most likely to show up.
- 47:52Some subtypes are more likely to
- 47:54actually show up in the brain and
- 47:56and we have to have that's that's
- 47:57kind of our job to to catch that.
- 47:59So we we love to hear from
- 48:01primary care doctors.
- 48:04And what if I don't know
- 48:06who the oncologist is?
- 48:07Or was the patients moved from out of state?
- 48:10Or perhaps the oncologist has retired?
- 48:13Is there a Kawaji Kawaji?
- 48:17Going out to all of our
- 48:19New Haven clinicians,
- 48:20you've got it all right.
- 48:22That is excellent now.
- 48:24We're always happy to help.
- 48:26All on in basket we're all on my chart
- 48:29and happy to to take a look and we may
- 48:31not be able to give you the right answer,
- 48:34but we're we're especially if we don't
- 48:36have all the information but but that's
- 48:38not a reason we have long-term people
- 48:41who can who who are happy to see and
- 48:43kind of assess their underlying risk.
- 48:45Thank you and that is again it
- 48:47is so helpful to say to a patient
- 48:50you know I'm not concerned that
- 48:52this cancer that this represents
- 48:54recurrent cancer and I also spoke.
- 48:56To your oncologist and they share that
- 48:59it it actually is is incredibly helpful.
- 49:02So thank you for that collaboration.
- 49:06Looks like we don't have other questions.
- 49:08So Jill, maybe you have a
- 49:09question I was going
- 49:10to ask just because in talking about
- 49:13survivorship or even in the process,
- 49:15it is very anxiety provoking and we
- 49:18are often called upon to prescribe
- 49:21anti anxiety meds or antidepressants.
- 49:23And if you could just comment if
- 49:25you have your preferred, if you,
- 49:28if there's certain SSRI's that you prefer,
- 49:30certain ones you want us to avoid,
- 49:32if you could maybe discuss that,
- 49:34that would be great. Sure.
- 49:38So it some of it depends on what
- 49:40the patient is actually taking
- 49:42from a cancer standpoint.
- 49:44Tamoxifen has some theoretical interactions
- 49:47with certain SSRI's such as paroxetine,
- 49:51sertraline, fluoxetine kind of
- 49:54all of the gotos it they can.
- 49:57They are sip 2D6 inhibitors which
- 50:01can inhibit tamoxifen's forming its
- 50:04active metabolite which is called.
- 50:06Oxygen little CME.
- 50:08Not that anyone actually cares
- 50:10but the the so we try not to Co
- 50:14prescribe those however venlafaxine
- 50:16so the SNR I and I use citalopram.
- 50:19Mrs Citalopram if you're really
- 50:21looking looking for an Sr those
- 50:24are good go TOS that don't have
- 50:26the same degree of interaction.
- 50:28There are no interactions for aromatase
- 50:30inhibitors that we worry about.
- 50:33Umm.
- 50:34You know,
- 50:35the the question of benzos is always one
- 50:39that we we try to minimize as much as we can.
- 50:43We can use it as a bridge,
- 50:44especially around diagnosis when we're just
- 50:46kind of in this very high anxiety time,
- 50:49but I generally do not favor.
- 50:52Long term use of benzodiazepines.
- 50:56Agreed.
- 50:56Thank you.
- 50:57Yeah.
- 50:58No,
- 50:58and that's really what I wanted
- 51:00to get to the choir.
- 51:02For sure
- 51:02there is psycho oncologists that
- 51:04are hard to get, but they are
- 51:06available and they are very helpful.
- 51:08And I think it's, again,
- 51:10the best thing is to have the good
- 51:12interaction between the primary
- 51:13care and the oncologist and that is
- 51:15very helpful when you are helping
- 51:17us take care of the anxiety parts.
- 51:19You know, that's very helpful.
- 51:22One of my personal favorite opportunities
- 51:24is when a patient comes to me for a
- 51:27second opinion on whether they should
- 51:29continue an aromatase inhibitor.
- 51:32They hurt all over while actually
- 51:34what I have found is one of my most
- 51:37important tools is chart review.
- 51:39So I simply go back to the note and and
- 51:41very often it's actually outlined like the
- 51:43risk of recurrence with this medicine,
- 51:46the risk of recurrence without this medicine.
- 51:47It's part of the counseling that
- 51:49you do is often documented and and
- 51:51and it's enormously helpful to me.
- 51:54As I explore the patient's thinking,
- 51:56obviously I'm I'm not going to
- 51:58give a clear directive for that,
- 52:00but I don't know if you have hints for
- 52:03us in management of some of the symptoms
- 52:06so that people can continue to take it.
- 52:09Are are there anything that you
- 52:10would like us to know about that?
- 52:13Any question?
- 52:16So exercise is actually one of the things,
- 52:19so musculoskeletal complaints,
- 52:21arthralgias related to aromatase
- 52:23inhibitors is a very common side effect,
- 52:27probably 30 to 50%
- 52:29experience some some degree,
- 52:31not necessarily the severe amount,
- 52:34but but some degree and exercise,
- 52:37weight bearing exercise has so many benefits
- 52:40just from cardiovascular risk and from
- 52:43bone density standpoints that in addition to.
- 52:46Being shown in clinical trials to produce
- 52:50aromatase inhibitor induced musculoskeletal
- 52:53complaints is is incredibly helpful.
- 52:56Other things acupuncture has
- 52:58been shown to be helpful.
- 53:00And duloxetine has been shown to be
- 53:03helpful and that's in phase three
- 53:06clinical trials placebo-controlled.
- 53:09Those are the most kind of.
- 53:15Studied ways, but there are other
- 53:17things that that Waji and I can
- 53:20do from moving from 1 aromatase
- 53:22to another for whatever reason.
- 53:25Sometimes switching helps,
- 53:26sometimes taking a break to figure out
- 53:29is it really the AI that's doing it?
- 53:32Sometimes switching to tamoxifen,
- 53:34which has fewer musculoskeletal
- 53:37complaints and all of that,
- 53:39that conversation really does need to
- 53:41include what's the underlying risk?
- 53:43Is this somebody who's.
- 53:45Incredibly high risk that we want to
- 53:47give the absolute fully loaded endocrine
- 53:48therapy for as long as we possibly can.
- 53:50Or is this somebody with a very low
- 53:52risk cancer where the difference
- 53:54between 2 endocrine therapy strategies
- 53:56is probably minimal and a month off
- 53:58is not going to make a big deal,
- 54:00make a big difference? So.
- 54:02If you elicit that history,
- 54:05it's it's we love getting those kind of,
- 54:08hey heads up.
- 54:09So and so is really having a tough time.
- 54:13And and we can certainly explore
- 54:15options and sometimes people
- 54:16just can't tolerate it.
- 54:18It happens and and you have to do the
- 54:21risks and benefits and and it's our
- 54:23job to make sure that we understand
- 54:25all of the benefits and it's up to
- 54:27the patient to decide whether or
- 54:28not it's something that they can
- 54:30tolerate and and many people can't.
- 54:34Good. I like that permission not
- 54:37to tolerate understanding risks.
- 54:38It's exactly right. It's it's, you know,
- 54:41we just have to explore it and make
- 54:42sure it's an informed decision.
- 54:46So we are drawing to the end of our hour.
- 54:49I'll ask one final question, which is,
- 54:52is there anything you just really
- 54:54wish the primary care clinicians
- 54:57knew in our relationship with you?
- 55:00And then I'm going to ask Jill if
- 55:02there's anything she really wishes that
- 55:04her oncology team knew for referrals?
- 55:12I think an open I'll I'll volunteer again.
- 55:17Um, I I think we've already hit on.
- 55:19Probably my my. Favorite thing,
- 55:23which is pick up the phone,
- 55:25send me a my chart,
- 55:27I'll give you my cell phone number.
- 55:30The we want to be involved,
- 55:33especially when it comes to more
- 55:36advanced stages when people have
- 55:38metastatic disease, goals of care,
- 55:40conversation, prognosis.
- 55:41We really do try very hard to to explore
- 55:45those with our patients and and document it,
- 55:49but we want to be involved with all.
- 55:52Decisions and sometimes it may make
- 55:55sense not to be doing evidence based
- 55:58primary healthcare maintenance in
- 56:00patients who have advanced cancer
- 56:02and we're happy to to talk about it.
- 56:04But then in other cases,
- 56:05it may make sense for somebody to
- 56:08have a colonoscopy even if they
- 56:10have metastatic breast cancer.
- 56:11We love to participate in
- 56:13those conversations.
- 56:15Absolutely. You know, yes,
- 56:17it's good to have a good connection.
- 56:18That's very important.
- 56:19It's very helpful honestly and
- 56:22it's very helpful also for non
- 56:24oncologic care to be good also.
- 56:26So that's why we definitely
- 56:27need you and we need primary
- 56:29care physicians to be deeply
- 56:31involved in the care of patients.
- 56:35All right. And Jill, your
- 56:37perspective and then we will. I
- 56:40think I agree with everything that's
- 56:42been said and I think just knowing
- 56:44that our oncology colleagues are ready
- 56:46and willing to pick up the phone for
- 56:49us and we're willing to pick up the
- 56:51phone for them to allay a patient's
- 56:53fears because there are times when,
- 56:55you know, we get asked what is the unco.
- 57:00My number, what is the number mean?
- 57:02You know those kinds of conversations
- 57:04that are sort of beyond our expertise,
- 57:08but that we can be helpful
- 57:09in other ways. So thank
- 57:11you. All right. So thank you to all
- 57:14of you and to everybody who attended.
- 57:18This has been a very helpful conversation.
- 57:22Please stay tuned for a few final
- 57:25seconds because there is one more
- 57:27slide that is a kind of very quick.
- 57:29Evaluation and completing that
- 57:31is helpful for the series.
- 57:33And do you have any closing comments?
- 57:35No, this is terrific.
- 57:37The contacts are there.
- 57:39And then once this closes,
- 57:41you'll get a survey.
- 57:42If you could, if you could fill that out,
- 57:45that'd be helpful for us.
- 57:46And and tell your friends we we have
- 57:50one for next week or next month and
- 57:53actually we're scheduled throughout June.
- 57:55So if you enjoyed this today,
- 57:56just let us know.
- 57:57That would be helpful.
- 57:57Thanks so much everybody and.
- 58:00Happy Breast Cancer Awareness Month.
- 58:02Thank you.