Cancer Risks and The Role of Patient Decision Making

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:04Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:09with the director of the
00:09 --> 00:10Yale Cancer Center, Doctor Eric Winer.
00:11 --> 00:14Yale Cancer Answers features conversations
00:14 --> 00:16with oncologists and specialists who
00:16 --> 00:17are on the forefront of
00:17 --> 00:18the battle to fight cancer.
00:19 --> 00:20This week, it's a conversation
00:20 --> 00:21about some of the decisions
00:21 --> 00:22patients are faced with in
00:22 --> 00:24the treatment of breast cancer
00:24 --> 00:25with doctor Sarah Schellhorn.
00:26 --> 00:27Doctor Schellhorn is an associate
00:27 --> 00:29professor of medicine and medical
00:29 --> 00:30oncology at the Yale School
00:30 --> 00:31of Medicine.
00:31 --> 00:33Here's doctor Winer.
00:33 --> 00:35I know that
00:36 --> 00:37over the course of the
00:37 --> 00:39past decade plus, you have
00:39 --> 00:40taken care of
00:41 --> 00:41countless
00:42 --> 00:44women with breast cancer.
00:46 --> 00:48And some of those are
00:48 --> 00:48young women.
00:49 --> 00:51As people know, breast cancer
00:51 --> 00:53affects women of all ages.
00:53 --> 00:55It becomes more common
00:55 --> 00:56as women grow older, but
00:56 --> 00:57it
00:57 --> 01:00is a cancer that's pretty
01:00 --> 01:02common in younger women too.
01:02 --> 01:04And so issues about fertility
01:05 --> 01:06come up.
01:06 --> 01:07They sure do.
01:07 --> 01:08And,
01:08 --> 01:10maybe you could just, you
01:10 --> 01:11know, start with a few
01:11 --> 01:12thoughts
01:12 --> 01:13about
01:13 --> 01:15how you approach those conversations
01:16 --> 01:16with patients.
01:18 --> 01:19It's always a challenge
01:19 --> 01:21when you're meeting a patient
01:21 --> 01:22for the first time and
01:24 --> 01:25they've been given this
01:26 --> 01:27new diagnosis of breast cancer,
01:27 --> 01:28and there are lots of
01:28 --> 01:30things that have to be
01:30 --> 01:32talked about regarding the new
01:32 --> 01:34cancer, regarding the treatment, regarding
01:34 --> 01:35all the options. You've got
01:35 --> 01:38surgical options and medication options
01:38 --> 01:40radiation options, and it
01:40 --> 01:42can all be overwhelming.
01:44 --> 01:45But it's really important to
01:45 --> 01:46remember
01:47 --> 01:49that young women in particular,
01:50 --> 01:51may not have completed their
01:51 --> 01:53families. They may not have
01:56 --> 01:57had children or as many
01:57 --> 01:58children as they would want.
01:59 --> 02:00They may have
02:00 --> 02:01plans, and they may have
02:01 --> 02:03been putting things off for
02:03 --> 02:05career or other reasons.
02:05 --> 02:06And those are NOTE Confidence: 0.9790995
02:06 --> 02:07critical lifestyle
02:08 --> 02:08pieces
02:09 --> 02:10that we have to consider
02:10 --> 02:12in the treatment of
02:12 --> 02:13breast cancer. So
02:13 --> 02:14when I see a new
02:14 --> 02:15patient
02:15 --> 02:16that I have a little
02:16 --> 02:18bit of a mental checklist,
02:19 --> 02:20that I go through
02:20 --> 02:21that's
02:21 --> 02:23certainly talk about the cancer,
02:23 --> 02:25talk about the reasons for
02:25 --> 02:26various treatments, and the reasons
02:26 --> 02:27why things are being recommended.
02:28 --> 02:29But we also wanna make
02:29 --> 02:31sure that we're taking into
02:31 --> 02:31account,
02:32 --> 02:33is your family complete? Have
02:33 --> 02:35you ever thought about having
02:35 --> 02:36children? Because a lot of
02:36 --> 02:37the treatments that we use
02:37 --> 02:38in the treatment of breast
02:38 --> 02:38cancer
02:39 --> 02:40can affect
02:40 --> 02:42someone's future fertility.
02:43 --> 02:45They may prevent someone from
02:45 --> 02:46being able to carry a
02:46 --> 02:47healthy pregnancy
02:47 --> 02:48if they were to become
02:48 --> 02:50pregnant while on these medications.
02:50 --> 02:52So these are critical conversations
02:52 --> 02:53that have to happen.
02:58 --> 03:00And they can effect fertility in different ways.
03:00 --> 03:02Chemotherapy, for example.
03:03 --> 03:03Chemotherapy,
03:04 --> 03:05as I think many of
03:05 --> 03:07our listeners know,
03:07 --> 03:08can
03:08 --> 03:10put a woman into menopause.
03:11 --> 03:11Yes.
03:12 --> 03:12But
03:13 --> 03:14that's not always the case,
03:14 --> 03:16and it's very much age
03:16 --> 03:16related.
03:17 --> 03:17Yes.
03:19 --> 03:20Talk about that a little
03:20 --> 03:21bit. I mean, if
03:21 --> 03:22you're a twenty five
03:22 --> 03:23year old, are you gonna
03:23 --> 03:25go into menopause with chemotherapy?
03:25 --> 03:26You may go into
03:26 --> 03:28a temporary menopause, and you
03:28 --> 03:29may have hot flashes and
03:29 --> 03:30be kind of uncomfortable from
03:30 --> 03:32a menopausal standpoint
03:32 --> 03:33for a short period of
03:33 --> 03:35time. But in all likelihood,
03:36 --> 03:37a twenty five year old
03:37 --> 03:39has very robust ovaries that
03:39 --> 03:40are gonna kick it back
03:40 --> 03:41into gear
03:42 --> 03:43within a few months from
03:43 --> 03:44completing chemotherapy.
03:45 --> 03:47The older a woman is
03:47 --> 03:48and the closer to natural
03:49 --> 03:49menopause,
03:49 --> 03:51the less likely
03:51 --> 03:53that they will regain fertility.
03:54 --> 03:55But a twenty five year
03:55 --> 03:56old, a thirty year old,
03:56 --> 03:58very likely to be
03:58 --> 03:59able to
04:01 --> 04:03have menstrual
04:03 --> 04:05cycles again, may be able
04:05 --> 04:07to become pregnant. And there
04:07 --> 04:07are even things that we
04:07 --> 04:09can do during chemotherapy
04:09 --> 04:11that can help preserve fertility.
04:11 --> 04:13And what are those things?
04:16 --> 04:17I feel like you might
04:17 --> 04:18know the answer to this
04:18 --> 04:19question, but
04:20 --> 04:21you can actually
04:21 --> 04:22use medications
04:23 --> 04:26called GnRH agonists. They're
04:26 --> 04:28shots, injections that
04:28 --> 04:30effectively put the ovaries to
04:30 --> 04:32sleep, kind of put them
04:32 --> 04:33into a dormant
04:33 --> 04:35status so that the chemotherapy
04:35 --> 04:37doesn't affect them as much.
04:38 --> 04:38And
04:39 --> 04:41studies have shown that women
04:41 --> 04:42who receive
04:43 --> 04:45these additional treatments during chemotherapy
04:46 --> 04:47are more likely to go
04:47 --> 04:49on and carry healthy pregnancies
04:50 --> 04:51in the future.
04:51 --> 04:52So we use those a lot
04:52 --> 04:54in people who desire future
04:54 --> 04:54fertility.
04:55 --> 04:56So that's one option
04:56 --> 04:58during chemotherapy itself.
05:01 --> 05:02But you also have to remember
05:03 --> 05:03when someone is
05:05 --> 05:07undergoing chemotherapy and their
05:07 --> 05:08ovaries are a certain age,
05:08 --> 05:10whatever that age is,
05:12 --> 05:13those ovaries are not getting
05:13 --> 05:15any younger, and any eggs
05:15 --> 05:16that are contained in those
05:16 --> 05:17ovaries aren't getting any younger.
05:18 --> 05:19And so even when we
05:19 --> 05:20try to
05:20 --> 05:23preserve someone's fertility by using
05:23 --> 05:23these injections,
05:24 --> 05:26we still may advise
05:26 --> 05:28them to preserve eggs or
05:28 --> 05:29embryos if they're in a
05:29 --> 05:30committed relationship
05:33 --> 05:35to enhance the options of
05:35 --> 05:37having a healthy baby, healthy
05:37 --> 05:38pregnancy
05:38 --> 05:40down the line. Because
05:40 --> 05:41the older an ovary gets,
05:41 --> 05:42the older the egg gets,
05:43 --> 05:45the more chances that
05:46 --> 05:48genetically, a baby may have
05:48 --> 05:48more problems.
05:50 --> 05:51Well in
05:52 --> 05:54my former institution before I
05:54 --> 05:55came to Yale a few
05:55 --> 05:56years ago,
05:57 --> 05:59we had started a program for
06:00 --> 06:02young women with breast cancer,
06:03 --> 06:05something that we're actually starting
06:05 --> 06:06at Smilow,
06:07 --> 06:08for not just young women
06:08 --> 06:09with breast cancer, but young
06:09 --> 06:11people with cancer in general.
06:12 --> 06:13But the reason I bring
06:13 --> 06:14this up is that
06:15 --> 06:15initially,
06:16 --> 06:17we set
06:17 --> 06:19the cut point for age
06:19 --> 06:20at forty two.
06:21 --> 06:23It eventually snuck up a
06:23 --> 06:24little bit as the person
06:24 --> 06:26who was directing that program
06:26 --> 06:28also got a little older.
06:28 --> 06:30But the reason we picked
06:30 --> 06:32forty two is that
06:33 --> 06:35that was probably an
06:35 --> 06:36age where there aren't a
06:36 --> 06:37lot of people who are
06:37 --> 06:38still
06:38 --> 06:40thinking about becoming pregnant after
06:40 --> 06:41that age.
06:41 --> 06:43And while there may be
06:43 --> 06:44a few,
06:45 --> 06:46our options
06:46 --> 06:47are much more limited.
06:48 --> 06:48But,
06:49 --> 06:51the other complicating
06:51 --> 06:53feature is that we also
06:53 --> 06:54sometimes
06:54 --> 06:55suppress
06:56 --> 06:57the function of ovaries
06:58 --> 06:59as part of treatment for
06:59 --> 07:00breast cancer.
07:00 --> 07:02Or we use medications
07:03 --> 07:04that are
07:05 --> 07:05contraindicated.
07:06 --> 07:07They can't be given during
07:07 --> 07:08pregnancy because they cause fetal
07:08 --> 07:09abnormalities.
07:10 --> 07:11And these are
07:11 --> 07:14the hormone based treatments or
07:14 --> 07:16probably more appropriately anti hormone,
07:16 --> 07:17antiestrogens.
07:21 --> 07:23So depending on whatever clinical circumstance,
07:23 --> 07:24we might put someone into
07:24 --> 07:25menopause,
07:26 --> 07:27in which case they can't
07:27 --> 07:28become pregnant naturally,
07:29 --> 07:30if they're in menopause. Their
07:30 --> 07:32ovaries are not functioning.
07:33 --> 07:33Or we use a drug
07:33 --> 07:34called tamoxifen,
07:36 --> 07:37which cannot be given during
07:37 --> 07:38pregnancy.
07:39 --> 07:39And these are given for
07:39 --> 07:41a long time. They're given
07:41 --> 07:43for at least five years
07:43 --> 07:44in many cases,
07:45 --> 07:46assuming they're well tolerated.
07:48 --> 07:50And that's five years of
07:50 --> 07:50time
07:51 --> 07:53where ovaries are also getting
07:53 --> 07:54older and eggs that are
07:54 --> 07:55in the ovaries are getting
07:55 --> 07:56older. So it may become
07:57 --> 07:58just because of
07:58 --> 08:00normal, natural
08:00 --> 08:01history of a woman's fertility,
08:01 --> 08:02it may be harder to
08:02 --> 08:04become pregnant after five years
08:04 --> 08:05of endocrine therapy.
08:06 --> 08:07So I'm not
08:07 --> 08:08sure if this is where
08:08 --> 08:09you were pointing
08:09 --> 08:11our conversation, but
08:11 --> 08:13there's a
08:13 --> 08:15study called the positive study,
08:16 --> 08:18designed, I think, primarily by
08:18 --> 08:19people at your former institution,
08:22 --> 08:24that looked at discontinuing
08:25 --> 08:26endocrine therapy, tamoxifen
08:27 --> 08:27or others,
08:28 --> 08:30earlier than the five years.
08:30 --> 08:31So women had to be
08:31 --> 08:34on that medication for
08:34 --> 08:35at least eighteen months, but
08:35 --> 08:36could be longer.
08:37 --> 08:39And the medication was
08:39 --> 08:41discontinued in an effort to
08:41 --> 08:42have them achieve
08:42 --> 08:44a normal pregnancy, either
08:45 --> 08:45through natural
08:47 --> 08:48means or through
08:49 --> 08:50additional fertility treatments.
08:51 --> 08:52And so far, the results
08:52 --> 08:54from that study have been
08:54 --> 08:54incredibly
08:56 --> 08:57positive, incredibly
08:58 --> 08:58optimistic
08:59 --> 09:00that women can
09:01 --> 09:02stop endocrine therapy,
09:02 --> 09:04have a pregnancy, deliver a
09:04 --> 09:06baby, even breastfeed for a
09:06 --> 09:07little bit, and then go
09:07 --> 09:09back on endocrine therapy with
09:09 --> 09:11no detrimental effects to their
09:11 --> 09:13ultimate outcome, although we're still
09:13 --> 09:14waiting for long term
09:14 --> 09:16follow-up of this study.
09:17 --> 09:18And and, of course, we
09:18 --> 09:20couldn't do the ultimate study,
09:20 --> 09:21which would be to randomize
09:22 --> 09:23patients because it's pretty hard
09:23 --> 09:24to
09:24 --> 09:27randomize someone to get pregnant
09:27 --> 09:28or you don't get pregnant.
09:28 --> 09:29That's a tough thing to do.
09:30 --> 09:31That's not one
09:31 --> 09:33that can be done.
09:34 --> 09:35What was interesting about the
09:35 --> 09:36results from the study too
09:36 --> 09:37is that,
09:39 --> 09:40about three quarters of the
09:40 --> 09:42women, if I remember correctly,
09:42 --> 09:43actually
09:43 --> 09:45were able to become pregnant
09:46 --> 09:48and deliver a child,
09:48 --> 09:50which is a remarkably
09:50 --> 09:51high percentage.
09:51 --> 09:53It is, especially given that
09:53 --> 09:54a fair number of those
09:54 --> 09:55women got chemotherapy,
09:57 --> 09:58so really reassuring,
09:59 --> 10:00and I think opens a
10:00 --> 10:01lot of doors
10:02 --> 10:03that we previously would have
10:03 --> 10:04considered closed
10:05 --> 10:07for younger women with breast
10:07 --> 10:08cancer.
10:09 --> 10:11It does seem that
10:11 --> 10:13as complicated as this dance is around
10:16 --> 10:18breast cancer treatment and pregnancy,
10:18 --> 10:19that there's often a way
10:19 --> 10:20to navigate
10:22 --> 10:24a result that is gonna
10:24 --> 10:25both be optimal
10:25 --> 10:27in terms of treating the
10:27 --> 10:28cancer and will also give
10:28 --> 10:30somebody the chance to have
10:30 --> 10:31a child if that's what
10:31 --> 10:33they really wanna do.
10:33 --> 10:35It's a careful conversation.
10:35 --> 10:37It's a long conversation.
10:38 --> 10:39It can be a really
10:39 --> 10:41emotional and intense conversation,
10:42 --> 10:43because
10:44 --> 10:44pretty
10:45 --> 10:46far reaching ramifications for a
10:46 --> 10:48woman's future. But
10:50 --> 10:51we are often able to
10:51 --> 10:52navigate
10:53 --> 10:54chemotherapy,
10:55 --> 10:57fertility treatments prior to chemotherapy.
10:57 --> 10:59And even when someone needs
10:59 --> 11:00to be on endocrine therapy
11:00 --> 11:01long term,
11:03 --> 11:04getting a woman to a
11:04 --> 11:05point where she can try
11:05 --> 11:06to naturally
11:07 --> 11:08have a child or
11:08 --> 11:10with some medical help have
11:10 --> 11:12a child.
11:12 --> 11:13And for our listeners,
11:14 --> 11:16it is worth pointing out
11:16 --> 11:18that years ago, meaning twenty,
11:18 --> 11:19thirty years ago,
11:19 --> 11:20it was
11:21 --> 11:23widely assumed that getting pregnant
11:23 --> 11:24after breast cancer
11:25 --> 11:26was something that you always
11:26 --> 11:28wanted to avoid because the
11:28 --> 11:30pregnancy could stimulate a recurrence.
11:31 --> 11:33And that really doesn't seem
11:33 --> 11:34to be the case.
11:34 --> 11:35In the data we have
11:38 --> 11:39it has never really been shown. In fact, it
11:39 --> 11:40hasn't been shown.
11:41 --> 11:43That's right. So I think
11:43 --> 11:44we're in a
11:44 --> 11:45much better place. We
11:45 --> 11:46also now
11:47 --> 11:49can not only preserve embryos,
11:49 --> 11:51but if someone doesn't have
11:51 --> 11:51a partner,
11:52 --> 11:53we can save
11:53 --> 11:56eggs, eggs or pieces
11:56 --> 11:57of ovarian tissue, all kinds
11:57 --> 11:59of different things,
12:00 --> 12:01that fertility specialists have at
12:01 --> 12:03their fingertips to be able to help.
12:05 --> 12:07Again, nothing's a
12:07 --> 12:09hundred percent, but lots of
12:09 --> 12:10options that can be explored.
12:11 --> 12:11And I think this
12:11 --> 12:13is another example of the
12:13 --> 12:14fact that
12:14 --> 12:15you often need
12:16 --> 12:16doctors
12:17 --> 12:19and nurses and others from
12:19 --> 12:21many different fields to provide
12:21 --> 12:22optimal care.
12:23 --> 12:25And as medical oncologists,
12:25 --> 12:27we're not the ones prescribing
12:28 --> 12:29fertility treatments
12:29 --> 12:31and we need to work
12:31 --> 12:32with our our colleagues in
12:33 --> 12:34OB GYN.
12:36 --> 12:37The treatment of breast cancer,
12:37 --> 12:39the treatment of any cancer,
12:39 --> 12:40requires a lot of
12:40 --> 12:41hands on deck,
12:42 --> 12:43and close connections with
12:43 --> 12:45lots of different disciplines and
12:45 --> 12:45fields,
12:46 --> 12:47to be able to provide
12:47 --> 12:48truly comprehensive
12:49 --> 12:50whole patient care.
12:52 --> 12:53I just wanna come
12:53 --> 12:54back in our
12:55 --> 12:55last
12:55 --> 12:57few seconds before the break
12:57 --> 12:58and
12:59 --> 13:00just touch very briefly on
13:00 --> 13:01the fact that
13:02 --> 13:04we all recognize this is
13:04 --> 13:05an emotionally charged
13:06 --> 13:08experience. I mean, having cancer
13:08 --> 13:10is hard enough. Having cancer
13:10 --> 13:12and worrying about wanting to
13:12 --> 13:13become pregnant or maybe even
13:13 --> 13:15being pregnant at the time
13:15 --> 13:16just makes it that much
13:16 --> 13:17harder.
13:20 --> 13:21It's hard enough,
13:22 --> 13:23to have to have these
13:23 --> 13:25conversations about treatment. And you
13:25 --> 13:25throw
13:26 --> 13:28fertility and families
13:28 --> 13:29into it,
13:29 --> 13:30it is that much harder.
13:31 --> 13:32Well, we're gonna take just a
13:33 --> 13:35very brief break, and I'll
13:35 --> 13:37return in
13:37 --> 13:39just a minute with doctor
13:39 --> 13:40Sarah Schellhorn,
13:40 --> 13:43associate professor at Yale School
13:43 --> 13:45of Medicine, and we'll continue
13:45 --> 13:46our conversation about
13:47 --> 13:49other issues related to breast
13:49 --> 13:49cancer.
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14:08 --> 14:10The American Cancer Society estimates
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14:15 --> 14:16this year, with over a
14:16 --> 14:18thousand patients in Connecticut alone.
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14:20 --> 14:21accounts for only about one
14:21 --> 14:23percent of skin cancer cases,
14:24 --> 14:25it causes the most skin
14:25 --> 14:27cancer deaths, but when detected
14:27 --> 14:29early it is easily treated
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14:31 --> 14:32Clinical trials are currently underway
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14:59 --> 15:01You're listening to Connecticut Public
15:01 --> 15:02Radio.
15:04 --> 15:05Hello again. This is Eric
15:05 --> 15:07Winer from the Yale Cancer
15:07 --> 15:08Center here with Yale Cancer Answers.
15:10 --> 15:12And I'm joined tonight by
15:12 --> 15:14doctor Sarah Schellhorn, associate professor
15:14 --> 15:15of medicine
15:16 --> 15:18and a breast cancer expert.
15:18 --> 15:20We spent the last
15:20 --> 15:22fifteen minutes or so talking
15:22 --> 15:24about pregnancy and breast cancer.
15:24 --> 15:25We're gonna move on and
15:25 --> 15:27talk about other hormonal aspects
15:27 --> 15:29of breast cancer or in
15:29 --> 15:30particular,
15:30 --> 15:33hormonal or anti hormonal treatments.
15:35 --> 15:36These are given to
15:37 --> 15:38a large number of women
15:38 --> 15:39with breast cancer
15:39 --> 15:40because
15:41 --> 15:42somewhere in the range of
15:43 --> 15:45in excess of seventy
15:45 --> 15:46five percent of all breast
15:46 --> 15:47cancers
15:48 --> 15:50are sensitive to female reproductive
15:50 --> 15:51hormones.
15:53 --> 15:53Sarah,
15:54 --> 15:55maybe you could
15:56 --> 15:57just talk about
15:58 --> 15:59generally the benefits
16:00 --> 16:00of
16:01 --> 16:04these anti hormonal treatments and
16:04 --> 16:06perhaps describe the two most
16:06 --> 16:08common ones that we use
16:08 --> 16:10to help prevent recurrences.
16:10 --> 16:10Sure.
16:11 --> 16:12So it's really interesting.
16:12 --> 16:13I think there's a kind
16:13 --> 16:15of an interesting historical piece to
16:18 --> 16:20the treatment of breast cancer.
16:20 --> 16:21If you think back, and
16:21 --> 16:22I can't give you
16:22 --> 16:24an exact date, but many
16:24 --> 16:24decades
16:25 --> 16:25ago,
16:26 --> 16:28the treatment of breast cancer
16:28 --> 16:30was pretty morbid, lots of
16:30 --> 16:32big surgeries. There were some
16:32 --> 16:33studies of chemotherapy. But what
16:33 --> 16:36was discovered was some
16:36 --> 16:38in many women with breast
16:38 --> 16:38cancer,
16:39 --> 16:40taking out their ovaries and
16:40 --> 16:42putting them into menopause seemed
16:42 --> 16:43to be a pretty good
16:43 --> 16:44treatment for breast cancer. And
16:44 --> 16:45it was on that
16:47 --> 16:50further studies showed that
16:50 --> 16:51many breast cancers, as you
16:51 --> 16:52said,
16:52 --> 16:54probably more than three
16:54 --> 16:55quarters of all breast cancers,
16:55 --> 16:56express
16:57 --> 16:58the estrogen receptor or the
16:58 --> 17:00progesterone receptor.
17:00 --> 17:02And these are
17:02 --> 17:02hormone
17:03 --> 17:05receptors that require
17:05 --> 17:07kind of seeing the hormone,
17:07 --> 17:08estrogen or progesterone,
17:09 --> 17:10that leads to cells,
17:10 --> 17:12cancer cells in particular,
17:13 --> 17:14getting the signals they need
17:14 --> 17:15to grow and divide.
17:16 --> 17:17And so these cancers are,
17:17 --> 17:20in essence, fueled by hormones.
17:21 --> 17:21And
17:22 --> 17:24a number of different types
17:24 --> 17:25of drugs have been developed
17:26 --> 17:28that work on that interaction
17:30 --> 17:32between the hormone and its
17:32 --> 17:32receptor.
17:33 --> 17:34The oldest is a drug
17:34 --> 17:35called tamoxifen,
17:36 --> 17:36which
17:37 --> 17:39is a competitive
17:39 --> 17:41antagonist in the breast
17:41 --> 17:43of estrogen. All that means
17:43 --> 17:44is if we think about
17:44 --> 17:45a receptor kind of like
17:45 --> 17:46a baseball glove
17:46 --> 17:47and we think about the
17:47 --> 17:49hormone like a baseball and
17:49 --> 17:50the glove catches the
17:50 --> 17:51baseball,
17:51 --> 17:52tamoxifen
17:52 --> 17:53is kind of like a
17:53 --> 17:54grapefruit.
17:54 --> 17:56And if you're holding it running
17:56 --> 17:57around in the outfield of
17:57 --> 17:59a baseball field, holding a
17:59 --> 18:00grapefruit in your baseball glove,
18:00 --> 18:01you're never gonna be able
18:01 --> 18:02to catch a baseball. It's
18:02 --> 18:03kind of how I describe
18:03 --> 18:04it to patients.
18:05 --> 18:06But
18:06 --> 18:08Tamoxifen blocks that as the result.
18:08 --> 18:09Great way of describing
18:09 --> 18:11it and for listeners it actually even
18:11 --> 18:13works without seeing your hands.
18:14 --> 18:15I've got some
18:15 --> 18:17really great hand gestures going
18:17 --> 18:18on right now.
18:18 --> 18:20It then leads into a big conversations about
18:20 --> 18:21baseball teams
18:21 --> 18:23and Yankees and
18:23 --> 18:24Red Sox, but I won't
18:24 --> 18:26go there. But,
18:26 --> 18:27tamoxifen,
18:28 --> 18:29when it's given for
18:30 --> 18:31five years, maybe longer,
18:32 --> 18:34has been shown to reduce
18:34 --> 18:35the chances of a breast
18:35 --> 18:37cancer coming back by about
18:38 --> 18:39half, by a
18:39 --> 18:40relative
18:40 --> 18:42risk reduction of fifty percent.
18:44 --> 18:45And if we can just
18:45 --> 18:46say for a minute what
18:46 --> 18:48that means in people's
18:48 --> 18:48terms.
18:49 --> 18:51So if you have a
18:51 --> 18:53ten percent chance of having
18:53 --> 18:54a recurrence, it goes down
18:54 --> 18:56to about five. If
18:56 --> 18:58you have a twenty five
18:58 --> 18:59percent chance of having a
18:59 --> 19:01recurrence of your cancer, because
19:01 --> 19:02it's a higher risk cancer,
19:02 --> 19:04it would go down to
19:04 --> 19:05twelve and a half percent.
19:05 --> 19:06Right.
19:06 --> 19:08It's pretty powerful treatments.
19:11 --> 19:11Arguably it is the first
19:12 --> 19:13real personalized
19:13 --> 19:15targeted therapy in cancer.
19:17 --> 19:19So tamoxifen's been around for
19:19 --> 19:21years and years and years.
19:23 --> 19:24And it's got sort of
19:24 --> 19:26a bad rap.
19:26 --> 19:27Why is that?
19:27 --> 19:28I think
19:29 --> 19:30with the advent of social
19:30 --> 19:32media and online
19:32 --> 19:33web based
19:34 --> 19:35chat groups, there's a lot
19:35 --> 19:37of information sharing.
19:37 --> 19:38And
19:39 --> 19:40tamoxifen does have some potential
19:40 --> 19:42side effects. It can cause
19:42 --> 19:44hot flashes. It can cause
19:44 --> 19:45mood changes. It can cause
19:45 --> 19:47fluid retention and weight gain
19:47 --> 19:49and cause people to not
19:49 --> 19:49feel
19:49 --> 19:51terribly normal, causes headaches.
19:52 --> 19:54Lots of things that
19:54 --> 19:57are maybe not horrible from
19:57 --> 19:58a medical standpoint, but from
19:58 --> 19:59a lifestyle
20:00 --> 20:01quality of life standpoint can
20:01 --> 20:02be really
20:03 --> 20:03problematic.
20:04 --> 20:05But many women
20:06 --> 20:08tolerate the pill just fine.
20:08 --> 20:09And
20:09 --> 20:10when we think about who
20:11 --> 20:12are the
20:13 --> 20:14loudest people on these web
20:14 --> 20:16based chat groups, often it's
20:16 --> 20:18the people who are having
20:18 --> 20:18the problems,
20:20 --> 20:21that
20:21 --> 20:22appropriately,
20:22 --> 20:24are asking for help and
20:24 --> 20:26asking for advice.
20:26 --> 20:27And the people who are
20:27 --> 20:28doing just fine
20:28 --> 20:29are living their lives and it
20:32 --> 20:34tends to be a little
20:34 --> 20:36bit more problematic in younger
20:36 --> 20:38women than older women. So
20:38 --> 20:39you put
20:40 --> 20:41a thirty five year old
20:41 --> 20:42woman on Tamoxifen,
20:42 --> 20:43and at least in
20:43 --> 20:44my practice,
20:45 --> 20:47I tend to expect a
20:47 --> 20:48few more symptoms than I
20:48 --> 20:50would in somebody twenty years
20:50 --> 20:50older.
20:51 --> 20:52And I think it's
20:52 --> 20:53important to remember
20:54 --> 20:56that estrogen and progesterone
20:56 --> 20:58really do serve a purpose
20:58 --> 20:59in women.
21:00 --> 21:00And
21:01 --> 21:02messing around,
21:02 --> 21:03manipulating
21:03 --> 21:04hormones,
21:05 --> 21:07can cause problems and
21:07 --> 21:09and big ones that really
21:09 --> 21:11impact somebody's
21:12 --> 21:13day to day.
21:14 --> 21:15Hot flashes, if they happen
21:15 --> 21:17only once every few days,
21:17 --> 21:18probably not that big a
21:18 --> 21:19deal. But hot flashes that
21:19 --> 21:20are happening ten times a
21:20 --> 21:22night and preventing somebody from
21:22 --> 21:22sleeping and
21:23 --> 21:25leads to chronic fatigue and
21:25 --> 21:27mental fogginess, that's
21:27 --> 21:29really a big deal.
21:29 --> 21:30And so a lot of
21:30 --> 21:32the conversations that we have
21:32 --> 21:32in clinic
21:33 --> 21:35relate to that absolute
21:35 --> 21:36benefit
21:36 --> 21:37conversation
21:37 --> 21:38and the relative
21:38 --> 21:40benefit. So, yes, while tamoxifen
21:40 --> 21:42reduces the chances of a
21:42 --> 21:42cancer
21:43 --> 21:45recurring by fifty percent,
21:45 --> 21:47if someone's risk of a
21:47 --> 21:49cancer recurring is really small,
21:49 --> 21:51the benefit of tamoxifen is
21:51 --> 21:52also really small.
21:53 --> 21:55And for many women,
21:55 --> 21:56it may not be enough to
21:59 --> 22:01warrant staying on a medication
22:01 --> 22:02that makes them miserable.
22:02 --> 22:04Absolutely, and
22:05 --> 22:07there are alternatives to
22:07 --> 22:09tamoxifen as well.
22:10 --> 22:12So there's another class of
22:12 --> 22:14medicines called aromatase inhibitors.
22:15 --> 22:16Going back to my baseball
22:16 --> 22:17analogy,
22:18 --> 22:20aromatase inhibitors basically remove all
22:20 --> 22:21the baseballs. So you can't
22:21 --> 22:22catch a baseball
22:22 --> 22:23if there are no baseballs
22:23 --> 22:24to be caught. It
22:25 --> 22:26basically prevents
22:28 --> 22:29a woman from being able
22:29 --> 22:31to make estrogen.
22:32 --> 22:33It has to be given
22:33 --> 22:35in conjunction with other medicines
22:35 --> 22:37in very young women who
22:37 --> 22:38have ovarian function.
22:40 --> 22:41So that gets a little
22:41 --> 22:42bit more complicated.
22:44 --> 22:44But
22:45 --> 22:47these medicines reduce estrogen levels
22:47 --> 22:48from
22:48 --> 22:49a low level
22:49 --> 22:52to a very low level,
22:52 --> 22:52almost
22:53 --> 22:54undetectable level.
22:56 --> 22:56I was just gonna jump
22:56 --> 22:58in and say, you use
22:58 --> 22:58the baseball,
22:59 --> 23:02metaphor. I typically
23:02 --> 23:02describe
23:03 --> 23:05giving one of these
23:05 --> 23:05medicines
23:06 --> 23:08along with suppressing ovarian function,
23:08 --> 23:09which is what we have
23:09 --> 23:10to do when we do
23:10 --> 23:12it in a young woman,
23:12 --> 23:13as
23:14 --> 23:16entering menopause by jumping off
23:16 --> 23:17the high dive
23:17 --> 23:19instead of instead of wading
23:19 --> 23:20into the water.
23:20 --> 23:22It's not
23:22 --> 23:23a slow process. It's not
23:23 --> 23:24a natural process.
23:25 --> 23:26That's not what normally happens.
23:28 --> 23:30So the side effects of
23:30 --> 23:31those aromatase inhibitors
23:31 --> 23:33is just kind of like
23:33 --> 23:35menopause only more so.
23:35 --> 23:38And you think about
23:38 --> 23:39putting somebody
23:40 --> 23:41who has normal
23:42 --> 23:43ovaries, whose
23:44 --> 23:46normal ovarian function has
23:46 --> 23:48fluctuating levels of hormones
23:48 --> 23:50and has normal menstrual cycles
23:51 --> 23:52into menopause
23:52 --> 23:53is like
23:53 --> 23:54jumping in from the high
23:54 --> 23:56dive or going from sixty
23:56 --> 23:57miles an hour down to
23:57 --> 23:58zero,
23:58 --> 23:59it can be very jarring.
23:59 --> 24:01And what's funny is for
24:01 --> 24:01some people,
24:02 --> 24:04it's associated with almost no
24:04 --> 24:04symptoms.
24:05 --> 24:06And for other people
24:07 --> 24:08and I don't know
24:08 --> 24:09how to predict this, it's
24:09 --> 24:10just miserable.
24:11 --> 24:14I hope someday we
24:14 --> 24:15get to a point where
24:15 --> 24:16we're able to
24:17 --> 24:18predict how someone is going
24:18 --> 24:20to feel. And I don't
24:20 --> 24:21know what we'll use to
24:21 --> 24:22predict that. Maybe
24:23 --> 24:24there will be some
24:24 --> 24:25smart
24:25 --> 24:27genome technology. Maybe there will
24:27 --> 24:29be some prior menstrual history
24:30 --> 24:31piece to all of this,
24:31 --> 24:33but that's a
24:33 --> 24:34hard conversation to have. The
24:34 --> 24:35only way to know if
24:35 --> 24:36someone's gonna have side effects
24:36 --> 24:37is for them to try
24:37 --> 24:39it and see what happens.
24:40 --> 24:40And I think the
24:40 --> 24:42point you made that, you
24:42 --> 24:43know, we give these medicines
24:43 --> 24:44for a long time. So
24:45 --> 24:46these are symptoms that may
24:46 --> 24:48not be life threatening, but
24:48 --> 24:50they're pretty annoying. And so
24:50 --> 24:52putting up with them for
24:52 --> 24:54a number of years for
24:54 --> 24:55many women is often
24:56 --> 24:56challenging
24:57 --> 24:58to say the least.
24:58 --> 24:58Now,
24:59 --> 25:01on the other hand, these
25:02 --> 25:02hormonal,
25:03 --> 25:03antihormonal,
25:04 --> 25:05endocrine therapies, they're called all
25:05 --> 25:07of these different things,
25:07 --> 25:08sometimes,
25:09 --> 25:11are far more beneficial than
25:11 --> 25:12treatments like chemotherapy,
25:13 --> 25:14and it all depends on
25:14 --> 25:16the tumor.
25:16 --> 25:17That's exactly right.
25:18 --> 25:20Breast cancer isn't one disease.
25:21 --> 25:23And it's this big spectrum
25:24 --> 25:25of diseases,
25:26 --> 25:27each of which is treated
25:27 --> 25:28a little bit differently
25:28 --> 25:29or even a lot bit
25:29 --> 25:30differently.
25:31 --> 25:33We make decisions based on
25:33 --> 25:34a few things that the
25:34 --> 25:35pathologist tells us when they
25:35 --> 25:36look at the cancer under
25:36 --> 25:38the microscope. We look at
25:38 --> 25:39the grade of the cancer.
25:39 --> 25:40That's a measure of how
25:40 --> 25:41aggressive the cells look under
25:41 --> 25:42the microscope.
25:43 --> 25:44We look at the
25:44 --> 25:46percent of cells that have
25:46 --> 25:47the estrogen receptor or the
25:47 --> 25:48progesterone receptor.
25:48 --> 25:50And then there's this may
25:50 --> 25:51be where you were going
25:51 --> 25:52with this question, but
25:52 --> 25:54there's this test called the
25:54 --> 25:55Oncotype test,
25:57 --> 25:58which is
25:58 --> 26:00a test of a patient's
26:00 --> 26:02individual cancer.
26:02 --> 26:04It looks at twenty one
26:04 --> 26:05cancer
26:05 --> 26:06related genes,
26:07 --> 26:08and it looks at the
26:08 --> 26:09levels of those genes and
26:09 --> 26:11what levels they're expressed at.
26:11 --> 26:13And based on the
26:13 --> 26:14levels of those genes, it
26:14 --> 26:16goes into this very complicated
26:16 --> 26:17algorithm,
26:18 --> 26:19that some very smart people
26:19 --> 26:21developed many years ago. And
26:21 --> 26:23then it spits
26:23 --> 26:23out
26:23 --> 26:25a number. And so you
26:25 --> 26:26often,
26:27 --> 26:28in breast cancer circles, you
26:28 --> 26:29may have people saying, well,
26:29 --> 26:30what was your number? What
26:30 --> 26:31was your number?
26:31 --> 26:33The recurrent score is a
26:33 --> 26:34number, and it's on a
26:34 --> 26:35scale of zero to a
26:35 --> 26:36hundred.
26:36 --> 26:38Most breast cancers
26:38 --> 26:40have low numbers under fifty.
26:42 --> 26:43And then depending on that
26:43 --> 26:44recurrent score,
26:45 --> 26:46we can help
26:46 --> 26:48decide whether somebody
26:48 --> 26:50needs chemotherapy or benefits from
26:50 --> 26:52chemotherapy or really doesn't benefit
26:52 --> 26:53from chemotherapy.
26:54 --> 26:55And a
26:55 --> 26:57couple of major studies
26:57 --> 26:58that have been published in
26:58 --> 26:58the last
26:59 --> 27:00five, seven years,
27:01 --> 27:03have shown that
27:03 --> 27:05oncotype recurrence scores of
27:05 --> 27:07twenty five or lower
27:08 --> 27:09are not associated
27:09 --> 27:11with much benefit to
27:11 --> 27:13chemotherapy. There are some caveats
27:13 --> 27:14to that. There are
27:14 --> 27:15some questions
27:15 --> 27:17in young women in particular.
27:17 --> 27:19But in most women,
27:19 --> 27:20low oncotypes,
27:22 --> 27:23then don't benefit
27:24 --> 27:26much from chemotherapy, if at
27:26 --> 27:26all.
27:27 --> 27:28And it's so different from
27:28 --> 27:30the way it was thirty
27:30 --> 27:31years ago where, in fact,
27:32 --> 27:33it was one size fits all.
27:33 --> 27:35Right. And, you know,
27:35 --> 27:37we didn't differentiate between different
27:37 --> 27:39cancers. We gave everybody
27:39 --> 27:41essentially the same treatment,
27:42 --> 27:42and
27:43 --> 27:43it's
27:44 --> 27:44come
27:45 --> 27:47so very far. And at
27:47 --> 27:48the same time,
27:49 --> 27:50not only are we able
27:50 --> 27:51to
27:52 --> 27:54allow people to live with
27:54 --> 27:55fewer side effects,
27:55 --> 27:56but
27:56 --> 27:58we're certainly doing no worse
27:58 --> 28:00in terms of overall outcomes.
28:00 --> 28:00And
28:01 --> 28:02I think just as a
28:02 --> 28:03sort of
28:03 --> 28:05give people a general sense,
28:06 --> 28:07what proportion of women who
28:07 --> 28:09have breast cancer go on
28:09 --> 28:11and live a normal
28:11 --> 28:12life afterwards?
28:13 --> 28:14A large proportion,
28:15 --> 28:17eighty, eighty five percent go
28:17 --> 28:18on and never
28:18 --> 28:19hear back from this cancer,
28:19 --> 28:21from their original cancer.
28:21 --> 28:22And even women
28:22 --> 28:23who do hear back from
28:23 --> 28:24the cancer,
28:25 --> 28:27whose cancer comes back
28:27 --> 28:28whether in the breast or
28:28 --> 28:29somewhere else, go on to
28:29 --> 28:30live
28:30 --> 28:32many, many years because of
28:32 --> 28:33the advances in treatment.
28:34 --> 28:36Doctor Sarah Schellhorn is an
28:36 --> 28:37associate professor of medicine and
28:37 --> 28:39medical oncology at the Yale
28:39 --> 28:40School of Medicine.
28:40 --> 28:42If you have questions, the
28:42 --> 28:43address is canceranswersyale
28:44 --> 28:46dot edu, and past editions
28:46 --> 28:47of the program are available
28:47 --> 28:49in audio and written form
28:49 --> 28:50at yale cancer center dot
28:50 --> 28:51org.
28:51 --> 28:52We hope you'll join us
28:52 --> 28:53next time to learn more
28:53 --> 28:54about the fight against cancer.
28:55 --> 28:56Funding for Yale Cancer Answers
28:56 --> 28:58is provided by Smilow Cancer
28:58 --> 28:59Hospital.

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Cancer Risks and The Role of Patient Decision Making with guest Dr. Sarah Schellhorn January 5, 2025

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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Dr. Sarah Schellhorn

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