Improving Long-term Outcomes for Patients with Breast Cancer

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
00:10 --> 00:11Winer.
00:11 --> 00:13Yale Cancer Answers features conversations
00:14 --> 00:14with oncologists
00:15 --> 00:15and specialists.
00:19 --> 00:21Our guest host is doctor Tracy Battaglia
00:21 --> 00:23who is joined for a conversation about
00:23 --> 00:25breast cancer with doctor
00:25 --> 00:26Maryam Lustberg.
00:26 --> 00:28Doctor Lustberg is a professor
00:28 --> 00:29of internal medicine and medical
00:29 --> 00:31oncology at the Yale School
00:31 --> 00:31of Medicine.
00:32 --> 00:33Here's doctor Battaglia.
00:34 --> 00:36Well, let's dive right in.
00:36 --> 00:37I think we'd like to
00:37 --> 00:39start our session by just
00:39 --> 00:40learning a little bit about
00:40 --> 00:42who you are, doctor Lustberg.
00:42 --> 00:43What brought you to the
00:43 --> 00:44field of breast oncology?
00:46 --> 00:47Yes. Happy to talk
00:47 --> 00:49about this. So I've been
00:50 --> 00:51a medical oncologist
00:52 --> 00:54focused exclusively on breast cancer
00:54 --> 00:55for the last two decades.
00:56 --> 00:59I became interested in working
00:59 --> 01:00with patients and families
01:01 --> 01:03dealing with breast cancer early
01:03 --> 01:04on in my medical training.
01:04 --> 01:06I really enjoyed the close
01:07 --> 01:08bonds that
01:08 --> 01:10physicians and patients were developing
01:11 --> 01:12as they tackled
01:13 --> 01:15this scary diagnosis.
01:15 --> 01:16And it was
01:16 --> 01:17a population that I really
01:17 --> 01:19enjoyed working with. And at
01:19 --> 01:20the same time, I was
01:20 --> 01:21also
01:21 --> 01:22very much drawn
01:23 --> 01:25to the active scientific
01:25 --> 01:27inquiry as well as clinical
01:27 --> 01:28trials that were being devoted
01:28 --> 01:29to breast cancer
01:30 --> 01:32and thought that
01:32 --> 01:33this was a good way
01:33 --> 01:34for me to get involved
01:34 --> 01:36both as a scientist and
01:36 --> 01:36a physician,
01:38 --> 01:39to try to make an
01:39 --> 01:39impact
01:40 --> 01:42in this very common disease.
01:42 --> 01:43So I wonder if we
01:43 --> 01:44could just start by having
01:44 --> 01:46you break down for
01:46 --> 01:46our listeners
01:47 --> 01:48what are the most common
01:48 --> 01:49kinds of breast cancers
01:50 --> 01:51and the treatments that
01:51 --> 01:52are available?
01:53 --> 01:54I often hear
01:55 --> 01:57oncologists say that there's
01:57 --> 01:58not just one kind of
01:58 --> 01:59cancer. There's hundreds kinds of
01:59 --> 02:00cancers. Maybe you can break
02:00 --> 02:02that down for us.
02:02 --> 02:05Exactly. And similarly, we
02:05 --> 02:06also like to say that
02:06 --> 02:08breast cancer is not one
02:08 --> 02:10type, but multiple different types,
02:10 --> 02:11and each of them is
02:11 --> 02:12very unique.
02:12 --> 02:14I think a good way
02:14 --> 02:15to start breaking down breast
02:15 --> 02:17cancer is into the category
02:18 --> 02:19of is it hormonally driven
02:19 --> 02:22or not hormonally driven? And
02:22 --> 02:23hormonally driven
02:24 --> 02:26breast cancers comprise
02:26 --> 02:28approximately two thirds of all
02:28 --> 02:29our breast cancer types,
02:30 --> 02:31and these are characterized by
02:33 --> 02:34rich
02:34 --> 02:36expression within the tumor
02:37 --> 02:39of receptors for estrogen and
02:39 --> 02:41progesterone, which are the main
02:41 --> 02:42female hormones.
02:45 --> 02:47These hormonally driven breast cancers
02:47 --> 02:48are most common, and we
02:48 --> 02:49can certainly talk
02:50 --> 02:51in subsequent questions about
02:52 --> 02:53we have a lot of
02:53 --> 02:55great treatments for hormonally driven
02:55 --> 02:55breast cancer.
02:56 --> 02:57And then the second categorization,
02:59 --> 03:00is the breast
03:00 --> 03:01cancer driven
03:02 --> 03:03by what I call a
03:03 --> 03:04growth antenna
03:05 --> 03:06or growth signal
03:06 --> 03:07called HER2 NEU.
03:11 --> 03:13And being HER2 NEU
03:13 --> 03:15the tumor HER2NEU positive
03:15 --> 03:16or HER2 negative
03:17 --> 03:17is the second
03:18 --> 03:19big categorization.
03:20 --> 03:22And so some
03:22 --> 03:24tumors rely both on estrogen
03:24 --> 03:26receptor pathways as well as
03:26 --> 03:27HER2neu pathways.
03:28 --> 03:29And to make it a
03:29 --> 03:31little bit extra confusing, in
03:31 --> 03:32most recent years,
03:33 --> 03:34the categorization
03:34 --> 03:36of HER-two neu has gone through
03:36 --> 03:37many changes,
03:37 --> 03:38including now we have a
03:38 --> 03:40category of HER-two low. So
03:40 --> 03:42it's not clearly positive
03:43 --> 03:44as we have been used
03:44 --> 03:46to categorizing it in
03:46 --> 03:47distant years.
03:49 --> 03:50It has a little bit
03:50 --> 03:51of that signal.
03:52 --> 03:53And with advances in our
03:53 --> 03:54systemic therapies,
03:55 --> 03:57it's an important category to
03:57 --> 03:58take into account
03:59 --> 04:00for some patients as we
04:00 --> 04:02describe their breast cancer.
04:02 --> 04:03Thank you for breaking that down
04:03 --> 04:04for us.
04:04 --> 04:06It feels a little bit overwhelming
04:06 --> 04:07to sort of hear you
04:07 --> 04:08explain it. And so I
04:08 --> 04:09wonder if you can explain
04:09 --> 04:10to our listeners,
04:10 --> 04:11how do you know what
04:11 --> 04:12kind of tumor you
04:12 --> 04:13have?
04:13 --> 04:14So one of
04:14 --> 04:16the important aspects to keep
04:16 --> 04:18in mind is that breast
04:18 --> 04:20cancer care is very much
04:20 --> 04:21a multi specialty
04:22 --> 04:23type of practice.
04:24 --> 04:25So all of us come
04:25 --> 04:25together
04:25 --> 04:27as a team in this
04:27 --> 04:27multidisciplinary
04:28 --> 04:28way,
04:29 --> 04:31to deliver the best,
04:31 --> 04:33most personalized type of breast
04:33 --> 04:33cancer
04:34 --> 04:35care to our patients.
04:35 --> 04:37So one of our key
04:37 --> 04:38team members is actually the
04:38 --> 04:39pathologist.
04:40 --> 04:42So after a biopsy is
04:42 --> 04:43taken or
04:43 --> 04:45after a patient may undergo
04:45 --> 04:46breast surgery,
04:46 --> 04:48that tumor tissue is actually
04:48 --> 04:50very carefully inspected
04:51 --> 04:53for size and lymph node status.
04:54 --> 04:55But, additionally,
04:56 --> 04:57the tumor tissue is also
04:57 --> 05:00looked at for different driver.
05:01 --> 05:03And so there's very specific
05:03 --> 05:05staining protocols and testing protocols
05:05 --> 05:07where the pathologist is actually
05:07 --> 05:08looking to see
05:10 --> 05:10what are some of the
05:10 --> 05:13categories that I previously mentioned?
05:13 --> 05:14Is there evidence
05:14 --> 05:17that there's hormone receptor expression?
05:17 --> 05:19Is there evidence of HER2
05:19 --> 05:21expression? So I think
05:21 --> 05:22a correct
05:22 --> 05:23tissue diagnosis
05:24 --> 05:25is so central to what
05:25 --> 05:26we do.
05:30 --> 05:31And one of the first steps
05:31 --> 05:32for us to be able
05:32 --> 05:33to devise the
05:33 --> 05:35most accurate and personalized treatment
05:35 --> 05:37plan for you. That's really
05:37 --> 05:38helpful.
05:40 --> 05:40The multidisciplinary
05:41 --> 05:42team will look at your
05:42 --> 05:43tumor and tell you which
05:43 --> 05:44type of tumor that you
05:44 --> 05:46have. And that will, in
05:46 --> 05:46turn,
05:47 --> 05:48determine the types of treatment
05:48 --> 05:50you have available to you.
05:50 --> 05:52Exactly. And typically it starts
05:52 --> 05:53with a biopsy. I think
05:53 --> 05:54that biopsy
05:55 --> 05:56gives us
05:56 --> 05:58that initial clue
05:58 --> 05:59in terms of,
06:01 --> 06:02again, what type of breast
06:02 --> 06:04cancer this is,
06:04 --> 06:06depending on the type, as
06:06 --> 06:07well as,
06:08 --> 06:09some of the imaging
06:09 --> 06:10information.
06:11 --> 06:12Breast radiology
06:12 --> 06:13is also a key
06:13 --> 06:15component of that multi d
06:15 --> 06:17team. So in addition
06:17 --> 06:17to the biopsy,
06:19 --> 06:21understanding based on imaging, and
06:21 --> 06:22that could be mammogram,
06:23 --> 06:24ultrasound, and in some cases,
06:25 --> 06:25breast MRI.
06:29 --> 06:32What is the approximate extent of disease based
06:32 --> 06:33on size and lymph node
06:33 --> 06:34status?
06:34 --> 06:36And all of these pieces
06:36 --> 06:38of information are brought together.
06:38 --> 06:39And typically, there is a
06:39 --> 06:41discussion in a multidisciplinary
06:41 --> 06:43tumor board or sometimes an
06:43 --> 06:45informal discussion among all the
06:45 --> 06:46different specialties
06:46 --> 06:47to kind of decide,
06:48 --> 06:50what are the next steps,
06:50 --> 06:52in terms of that personalized
06:52 --> 06:53care for the patient diagnosed.
06:54 --> 06:55I think it's really
06:55 --> 06:57helpful for our listeners to
06:57 --> 06:58understand what happens behind the
06:58 --> 07:00scenes after a biopsy is
07:00 --> 07:01taken. So thank you for
07:01 --> 07:02breaking that down.
07:04 --> 07:05I'm going to have you
07:05 --> 07:06hold your thoughts about treatment.
07:06 --> 07:07Because I wanted to
07:08 --> 07:09change our conversation to talk
07:09 --> 07:10a little bit about early
07:10 --> 07:12detection.
07:13 --> 07:14Specifically,
07:15 --> 07:17it's hard to not listen
07:18 --> 07:19to the news and hear
07:19 --> 07:20a lot about the rising
07:20 --> 07:21incidence
07:22 --> 07:23of cancer in young people,
07:23 --> 07:24and specifically
07:24 --> 07:26breast cancer in young people.
07:27 --> 07:28So can you tell us
07:28 --> 07:29a little bit about what's
07:29 --> 07:29behind
07:30 --> 07:31this rising incidence of breast
07:31 --> 07:33cancer in young women?
07:34 --> 07:35I think it's a really
07:35 --> 07:37wonderful, important question,
07:38 --> 07:41and we're still actively learning
07:42 --> 07:42exactly
07:43 --> 07:44what is driving
07:45 --> 07:47this rising trend
07:47 --> 07:48in diagnosis of
07:49 --> 07:51breast cancer in younger women,
07:52 --> 07:53those under age fifty or
07:53 --> 07:55under age forty five.
07:57 --> 07:59What we know is that
07:59 --> 08:01it's probably not one factor
08:01 --> 08:02that's driving this increase,
08:02 --> 08:03it's
08:03 --> 08:04multiple factors
08:05 --> 08:06including
08:09 --> 08:11lifestyle factors have changed quite
08:11 --> 08:12a bit in the last
08:12 --> 08:13several decades with
08:15 --> 08:16more sedentary
08:18 --> 08:19culture kind as
08:19 --> 08:22we've become more technology dependent.
08:25 --> 08:26We know that
08:26 --> 08:28there's been changes in
08:28 --> 08:30dietary patterns, including increased
08:31 --> 08:34processed food comes consumption, increased
08:34 --> 08:34fat intake.
08:36 --> 08:37We also know that there
08:37 --> 08:38have been changes in
08:39 --> 08:41reproductive patterns with some delayed
08:42 --> 08:42childbearing,
08:43 --> 08:44that we have noted
08:45 --> 08:46in the last several
08:46 --> 08:48decades, as well as delayed
08:48 --> 08:48breastfeeding.
08:49 --> 08:50Now all of these factors
08:50 --> 08:52are not in any way
08:52 --> 08:54blaming the patients for developing
08:54 --> 08:56breast cancer. That is not
08:56 --> 08:57what I'm saying.
08:58 --> 09:00In many patients,
09:00 --> 09:02we actually don't have a
09:02 --> 09:03clear cause of why
09:03 --> 09:04they develop breast cancer. They
09:04 --> 09:05could have done all the
09:05 --> 09:07right things and been the
09:07 --> 09:08healthiest that they could have
09:08 --> 09:09been. So I think
09:09 --> 09:10there's a lot of unknown
09:11 --> 09:11factors
09:12 --> 09:14in terms of why any
09:14 --> 09:16individual develops breast cancer, and
09:16 --> 09:17that also goes
09:18 --> 09:19for younger women with
09:19 --> 09:20breast cancer.
09:21 --> 09:22But I think there are
09:22 --> 09:23theories that in
09:23 --> 09:24many ways,
09:25 --> 09:26kind of our exposure to
09:26 --> 09:29hormones have changed, our exposure
09:31 --> 09:33to environmental factors may have changed
09:33 --> 09:34in recent years. We're still
09:34 --> 09:36trying to understand exactly
09:36 --> 09:37what's
09:37 --> 09:39driving this increase in rates.
09:40 --> 09:42Yeah. It sounds really complex.
09:42 --> 09:44And there certainly are things
09:44 --> 09:45in our history
09:46 --> 09:48that we can't really change.
09:48 --> 09:49Right? Like our family history,
09:49 --> 09:51for example. But then there
09:51 --> 09:52are things that are potentially
09:53 --> 09:53modifiable.
09:54 --> 09:56Correct. Like our lifestyle choices.
09:56 --> 09:56Maybe you can talk a
09:56 --> 09:57little bit about the difference
09:57 --> 09:58between the things that you
09:58 --> 09:59can change and the things
09:59 --> 10:00you can't.
10:01 --> 10:02Absolutely. As you
10:02 --> 10:03mentioned,
10:04 --> 10:06our family history, having
10:06 --> 10:07a primary
10:09 --> 10:11direct relative with breast cancer
10:12 --> 10:13is one of the central risk factors for
10:13 --> 10:15breast cancer or
10:15 --> 10:16having
10:16 --> 10:18a genetic predisposition,
10:18 --> 10:20a set of genes that
10:20 --> 10:21can increase
10:21 --> 10:22the probability,
10:22 --> 10:24the lifetime probability of developing
10:24 --> 10:26breast cancer. Obviously, we can't
10:26 --> 10:27change our family history. We
10:27 --> 10:29can't change our genetic makeup,
10:30 --> 10:32for certain patients who've had
10:32 --> 10:34other types of exposures for
10:34 --> 10:36other cancers, such as radiation
10:36 --> 10:37treatment for other cancers. Those
10:37 --> 10:38are things we can't change.
10:39 --> 10:40But in terms of modifiable
10:41 --> 10:43risk factors, these are our
10:43 --> 10:43health habits.
10:44 --> 10:45And that includes
10:46 --> 10:48things like exercise. It includes
10:49 --> 10:51our body mass index and
10:53 --> 10:54whether we're falling in that
10:54 --> 10:56overweight or obese category.
10:57 --> 10:59It relates to alcohol use.
10:59 --> 11:00We have more and more
11:00 --> 11:01data about
11:02 --> 11:03stronger associations
11:04 --> 11:04with
11:05 --> 11:07moderate to heavy alcohol use
11:08 --> 11:09being associated with
11:10 --> 11:11a higher chance of developing
11:11 --> 11:12breast cancer. So these are
11:13 --> 11:14factors that
11:14 --> 11:16we have some control over,
11:18 --> 11:19and the these are things that can
11:21 --> 11:22absolutely lower the lifetime risk
11:22 --> 11:24of breast cancer.
11:24 --> 11:26So healthy lifestyle,
11:26 --> 11:27behavior, everything we've been taught
11:27 --> 11:28since we were younger
11:28 --> 11:30also will reduce our breast
11:30 --> 11:31cancer risk. Is that right?
11:31 --> 11:32Yes. And
11:33 --> 11:35what's interesting is that
11:36 --> 11:36cardiovascular
11:37 --> 11:38disease, which is actually the
11:38 --> 11:40most common cause of death
11:40 --> 11:41in the US in both
11:42 --> 11:44men and women, cardiovascular
11:44 --> 11:45disease factors
11:46 --> 11:47actually have shared risk factors
11:47 --> 11:48with breast cancer.
11:49 --> 11:51So you get a two for one
11:51 --> 11:52as you kind of address
11:52 --> 11:53your breast cancer risk factors.
11:53 --> 11:55You're also addressing
11:55 --> 11:57heart disease risk factors.
11:58 --> 11:59Maintaining that healthy
11:59 --> 12:00weight,
12:01 --> 12:02being physically active,
12:03 --> 12:05you know, at least one
12:05 --> 12:07hundred fifty minutes a week,
12:07 --> 12:08if not more,
12:08 --> 12:10and then limiting alcohol,
12:11 --> 12:12focusing on a
12:14 --> 12:15plant forward diet,
12:16 --> 12:17with more plants,
12:18 --> 12:19less animal fat, less processed
12:19 --> 12:22foods and sugars, all these
12:22 --> 12:23are all things that can
12:23 --> 12:24help both your heart as
12:24 --> 12:25well as your breast health.
12:26 --> 12:28That's great. Thank you for
12:28 --> 12:29that advice Doctor. Lustberg.
12:30 --> 12:31In the last minute we
12:31 --> 12:32have before we break,
12:33 --> 12:34I wanna ask you,
12:34 --> 12:35you've talked about lifestyle and
12:35 --> 12:37behavior. What about screening and
12:37 --> 12:39early detection for our listeners?
12:40 --> 12:42Yeah. So it's really important
12:42 --> 12:43to know your risk
12:43 --> 12:44of breast cancer.
12:45 --> 12:46There's gonna be a national
12:46 --> 12:48movement to really focus on
12:48 --> 12:50each individual woman really understanding
12:50 --> 12:52her risk factors for breast
12:52 --> 12:53cancer and for women
12:55 --> 12:57at average risk for developing
12:57 --> 12:58breast cancer,
12:59 --> 13:01typically, we do recommend screening
13:01 --> 13:02starting at age, forty.
13:03 --> 13:04But depending on if you
13:04 --> 13:06have other risk factors, screening
13:06 --> 13:07should really be individualized
13:08 --> 13:09to your risk.
13:09 --> 13:11But starting with a average
13:11 --> 13:11risk woman,
13:12 --> 13:14then mammography starting at age
13:14 --> 13:16forty. And then depending on
13:16 --> 13:17what your breast tissue
13:17 --> 13:19looks like on a mammogram,
13:20 --> 13:22how much glandular tissue there
13:22 --> 13:25is relative to fatty tissue,
13:25 --> 13:26that actually determines
13:28 --> 13:29a factor called your breast
13:29 --> 13:30density.
13:30 --> 13:31And knowing your breast
13:31 --> 13:33density is now the law.
13:33 --> 13:34It should be in your
13:34 --> 13:35mammogram report. And if you
13:35 --> 13:37scroll down, you should be
13:37 --> 13:37able to see
13:38 --> 13:39what type of density you
13:39 --> 13:40have.
13:40 --> 13:42Fifty percent of women in
13:42 --> 13:43the US actually fall in
13:43 --> 13:44that higher breast density,
13:45 --> 13:46category.
13:46 --> 13:47And what that means is
13:47 --> 13:48that it may be more
13:48 --> 13:50difficult for a radiologist
13:50 --> 13:51to see
13:51 --> 13:53solely relying on the mammogram,
13:54 --> 13:55the extent of how your
13:55 --> 13:57breast tissue is. So, typically,
13:57 --> 13:58a supplemental
13:58 --> 13:59imaging,
13:59 --> 14:00whether it be
14:00 --> 14:02an ultrasound or in some
14:02 --> 14:03cases, an MRI is needed
14:03 --> 14:04to be able to see
14:04 --> 14:05more clearly.
14:06 --> 14:08In addition, breast density is
14:08 --> 14:09actually an independent risk factor
14:09 --> 14:11for developing breast cancer.
14:13 --> 14:15That higher glandular tissue
14:15 --> 14:17is more susceptible to changes
14:17 --> 14:18that may predispose it to
14:18 --> 14:19to cancer. So knowing
14:19 --> 14:21your breast density is another
14:21 --> 14:21important
14:23 --> 14:24facet of knowing your risk.
14:25 --> 14:26So many aspects
14:27 --> 14:28of your background influence your
14:28 --> 14:30own personal breast cancer risk.
14:31 --> 14:31Correct.
14:31 --> 14:32Well, we have covered a
14:32 --> 14:33lot of ground in this
14:33 --> 14:34first half. But we're going
14:34 --> 14:35to break now to take
14:35 --> 14:36a one minute break.
14:37 --> 14:38We're going to come back
14:38 --> 14:39and we're going to pick
14:39 --> 14:40up on all of the
14:40 --> 14:41details you gave us about
14:41 --> 14:43tumor and different types of
14:43 --> 14:45cancers and personal risk to
14:45 --> 14:46talk about personalized
14:46 --> 14:48and precision medicine and treatment.
14:48 --> 14:50So stay tuned to learn
14:50 --> 14:52more about improving your outcomes
14:52 --> 14:53for breast cancer care with
14:53 --> 14:54my guest, doctor Maryam Lustberg.
14:54 --> 14:56We'll be right back.
14:56 --> 14:58Support for Yale Cancer Answers comes
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15:00 --> 15:01where all patients have access
15:01 --> 15:03to cutting edge clinical trials
15:03 --> 15:05at several convenient locations throughout
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15:06 --> 15:08To learn more, visit smilowcancerhospital
15:09 --> 15:09dot org.
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15:22 --> 15:24One in eight American men
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15:35 --> 15:36Screening can be performed quickly
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15:42 --> 15:44Clinical trials are currently underway
15:44 --> 15:47at federally designated comprehensive cancer
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15:55 --> 15:57targeted biopsies to be performed.
15:58 --> 15:59More information is available at
15:59 --> 16:01yale cancer center dot org.
16:01 --> 16:03You're listening to Connecticut Public
16:03 --> 16:03Radio.
16:04 --> 16:06Weelcome back to Yale
16:06 --> 16:08Cancer Answers. This is doctor
16:08 --> 16:09Tracy Battaglia.
16:09 --> 16:11I am joined tonight by my
16:11 --> 16:13colleague and guest, doctor Maryam NOTE Confidence: 0.9339017
16:13 --> 16:13Lustberg.
16:14 --> 16:15We're discussing
16:15 --> 16:16breast cancer diagnosis.
16:17 --> 16:19And we've had a riveting
16:19 --> 16:19conversation
16:19 --> 16:21for the first half of
16:21 --> 16:22our time, really breaking down
16:22 --> 16:24the types of different breast
16:24 --> 16:24cancers,
16:25 --> 16:26types of risk factors that
16:26 --> 16:28go into developing breast cancer,
16:28 --> 16:29and even things you can
16:29 --> 16:31do to prevent or find
16:31 --> 16:32cancer early. But we're gonna
16:32 --> 16:35transition our conversation now to
16:35 --> 16:36treatment. We heard a lot
16:36 --> 16:37about the different types of
16:37 --> 16:39tumors that dictate the types
16:39 --> 16:41of treatment that you get.
16:41 --> 16:43So I'm gonna ask our
16:43 --> 16:45guest, doctor Lustberg, to talk
16:45 --> 16:47with us about the different
16:47 --> 16:48types of treatment that are
16:48 --> 16:49available to breast cancer and
16:49 --> 16:50how they relate to the
16:50 --> 16:51type of tumor that you
16:51 --> 16:52have.
16:53 --> 16:55Thanks, Tracy, for that question.
16:55 --> 16:58So multiple
16:58 --> 17:00factors go into us advising
17:00 --> 17:02our patients in terms of
17:03 --> 17:04the type of multi d
17:04 --> 17:06treatment that they might need.
17:07 --> 17:08So we've talked about the
17:08 --> 17:10subtypes of breast cancer. That's
17:10 --> 17:11an important factor.
17:12 --> 17:14Additional factors include
17:14 --> 17:16the stage of the breast
17:16 --> 17:17cancer.
17:18 --> 17:19We have four
17:19 --> 17:19stages.
17:22 --> 17:22And for
17:23 --> 17:24kind of the earliest stage of
17:24 --> 17:25breast cancer,
17:26 --> 17:28generally, we focus on starting
17:28 --> 17:29with local regional treatment,
17:30 --> 17:32which generally consists of surgery
17:33 --> 17:33first
17:34 --> 17:35and really truly understanding as
17:35 --> 17:37a consequence of surgery
17:37 --> 17:39exactly how much tumor and
17:39 --> 17:41disease involvement there was. And
17:41 --> 17:42then after after that,
17:43 --> 17:44kind of depending on the
17:44 --> 17:45type of surgery that was
17:45 --> 17:47had, the amount of disease,
17:48 --> 17:49and the type of breast
17:49 --> 17:51cancer, deciding on,
17:51 --> 17:53whether radiation is needed, which
17:53 --> 17:55is another local regional treatment,
17:56 --> 17:57and then,
17:57 --> 17:58additional
17:59 --> 18:00therapy in the form
18:00 --> 18:02of systemic therapies.
18:02 --> 18:04These are therapies that treat
18:04 --> 18:05the whole body
18:06 --> 18:08and may consist of
18:09 --> 18:10the category of
18:10 --> 18:12endocrine therapy, also known as
18:12 --> 18:15hormonal therapy or anti estrogen
18:15 --> 18:15therapy.
18:16 --> 18:17They may consist of chemotherapy.
18:19 --> 18:20They may consist of
18:20 --> 18:22HER2 monoclonal
18:22 --> 18:24antibodies or HER2 treatments,
18:25 --> 18:25immunotherapy
18:25 --> 18:27in certain cases.
18:27 --> 18:28So these are all different
18:28 --> 18:29categories
18:30 --> 18:31of systemic therapy
18:32 --> 18:33that may be given in
18:33 --> 18:35sequence or combined with each
18:35 --> 18:36other depending on the situation.
18:38 --> 18:39There are
18:40 --> 18:41situations such as in stage
18:41 --> 18:42four
18:43 --> 18:44breast cancer
18:44 --> 18:44where
18:45 --> 18:46focusing
18:46 --> 18:48on the best and the
18:48 --> 18:49most targeted
18:49 --> 18:50systemic therapy
18:51 --> 18:52is the best place to
18:52 --> 18:53start and
18:55 --> 18:56not taking time for local
18:56 --> 18:58regional treatment because that takes
18:58 --> 18:59away from time
19:00 --> 19:01to really treat the whole
19:01 --> 19:03disease process in the body.
19:03 --> 19:05So all of these factors
19:05 --> 19:06come together for us to
19:06 --> 19:07kind of decide,
19:07 --> 19:09what are the right combinations
19:09 --> 19:10of treatments. And all of
19:10 --> 19:12this is often discussed kind
19:12 --> 19:14of, as I mentioned before,
19:14 --> 19:16as part of that multi
19:16 --> 19:16d discussion
19:17 --> 19:18with with all the specialties
19:18 --> 19:19involved.
19:20 --> 19:21You started out
19:22 --> 19:23describing the importance of the
19:23 --> 19:24multidisciplinary
19:24 --> 19:26approach to cancer. And
19:26 --> 19:28as you describe the treatments,
19:28 --> 19:29it becomes more apparent how
19:29 --> 19:30important that is.
19:31 --> 19:32I wonder if you
19:32 --> 19:33could talk about
19:35 --> 19:37there's so many choices
19:37 --> 19:38for cancer
19:38 --> 19:39treatment,
19:39 --> 19:41both the modality and the
19:41 --> 19:42order as you point out.
19:42 --> 19:43We used to always
19:43 --> 19:44start with surgery, for example,
19:44 --> 19:45and now we're sort of
19:45 --> 19:47rethinking the order. So there's
19:47 --> 19:48the types of therapy and
19:48 --> 19:49the order of therapy.
19:50 --> 19:51And how does that decision
19:51 --> 19:53making process happen for a
19:53 --> 19:54patient? Can you walk us
19:54 --> 19:54through that?
19:55 --> 19:56Yes. So
19:57 --> 19:58it goes without saying that
19:58 --> 20:00the patient
20:01 --> 20:02has a key
20:02 --> 20:03central role
20:03 --> 20:05here in terms of many
20:05 --> 20:06of these decision makings, if
20:06 --> 20:07not all of it.
20:08 --> 20:09This is her body, and she
20:09 --> 20:11gets to decide what is
20:11 --> 20:11done.
20:11 --> 20:13We are guides to
20:13 --> 20:15kind of share the evidence
20:15 --> 20:16of what we know so
20:16 --> 20:17far
20:17 --> 20:19about different biological
20:20 --> 20:22characteristics of the tumor and
20:22 --> 20:23what are the pros and
20:23 --> 20:24cons of each approach.
20:26 --> 20:27To give you a more
20:27 --> 20:29tangible example, the
20:29 --> 20:30order of therapy
20:31 --> 20:31for our
20:32 --> 20:32non-hormonally
20:33 --> 20:34driven,
20:34 --> 20:36non HER2 driven tumors,
20:36 --> 20:37which are known also as
20:37 --> 20:39our triple negative tumors,
20:42 --> 20:44in stage two and stage
20:44 --> 20:46three breast cancer, giving upfront
20:46 --> 20:48chemotherapy plus immunotherapy
20:49 --> 20:50has so many advantages,
20:51 --> 20:51including
20:52 --> 20:54having a real time response
20:54 --> 20:55measure of
20:56 --> 20:57is the combination actually
20:57 --> 20:59working for the biology of
20:59 --> 21:01this breast cancer? So o
21:01 --> 21:03by giving that upfront
21:03 --> 21:04treatment and not rushing to
21:04 --> 21:05surgery,
21:06 --> 21:08we we're truly interrogating
21:08 --> 21:10the biology of the breast
21:10 --> 21:10cancer
21:11 --> 21:12and making sure that we're
21:12 --> 21:13on the right track. And
21:13 --> 21:14then when the patient does
21:14 --> 21:16ultimately go to surgery,
21:16 --> 21:17then we have an additional
21:17 --> 21:18measure of
21:19 --> 21:21how good were we
21:21 --> 21:23in terms of targeting this
21:23 --> 21:24tumor. Was there any tumor
21:24 --> 21:25left?
21:25 --> 21:27Was it a partial response
21:27 --> 21:28or no response? And that
21:28 --> 21:31can determine then additional systemic
21:31 --> 21:32therapies that are given subsequently.
21:33 --> 21:35So I would say it's
21:36 --> 21:38all those factors. The patient
21:38 --> 21:40plays that central role.
21:41 --> 21:42And then in addition,
21:43 --> 21:45that shared decision
21:45 --> 21:47making model is
21:47 --> 21:48the scientific evidence of
21:48 --> 21:50the biology of the cancer.
21:51 --> 21:53What can be realistically surgically
21:53 --> 21:54achieved. Like, is a
21:54 --> 21:55tumor
21:56 --> 21:57small enough for it
21:57 --> 21:59to, for example, undergo
21:59 --> 22:00surgery first?
22:00 --> 22:02But patient preference on the
22:02 --> 22:03type of surgery she wants
22:04 --> 22:05is also a key factor.
22:06 --> 22:07So there's a lot of
22:07 --> 22:08discussion, and I would like
22:08 --> 22:09to say that
22:10 --> 22:12there's no reason to make
22:12 --> 22:13a rushed decision on many
22:13 --> 22:15of these factors. Typically, it
22:15 --> 22:16can take several weeks, if
22:16 --> 22:18not longer, for us to
22:18 --> 22:19kinda bring all these pieces
22:19 --> 22:20together
22:20 --> 22:22and also kind of have
22:22 --> 22:23multiple conversations
22:23 --> 22:24with patients,
22:25 --> 22:27so that they're fully informed
22:27 --> 22:28and are truly making a
22:28 --> 22:30decision that's right for them.
22:31 --> 22:32I think that's such a
22:32 --> 22:33critical piece of
22:33 --> 22:35advice that you're giving there,
22:35 --> 22:35which is really
22:36 --> 22:37the urgency
22:38 --> 22:39of decision making.
22:39 --> 22:40I mean, I think any
22:40 --> 22:42of us who have had
22:42 --> 22:44the experience of cancer or
22:44 --> 22:45a loved one who has had
22:45 --> 22:45cancer,
22:46 --> 22:47there's such a sense of
22:47 --> 22:49urgency to do something immediately.
22:49 --> 22:50Because you wanna get rid
22:50 --> 22:51of this toxin
22:52 --> 22:53that's in your body.
22:54 --> 22:55And yet I'm hearing you
22:55 --> 22:57say that it takes time
22:57 --> 22:58and thoughtfulness
22:59 --> 23:00to put together the appropriate
23:00 --> 23:01treatment plan that makes the
23:01 --> 23:03most sense for women. So
23:03 --> 23:04maybe you can just speak
23:04 --> 23:05to that a little bit
23:05 --> 23:06more.
23:08 --> 23:08First I would like to
23:08 --> 23:11acknowledge that the experience
23:11 --> 23:12of going through this as
23:12 --> 23:14a patient and a family
23:14 --> 23:15member,
23:15 --> 23:16that's something that I can't
23:16 --> 23:18fully imagine.
23:18 --> 23:19I want to acknowledge that,
23:21 --> 23:23from meeting thousands of
23:23 --> 23:24patients and families over the
23:24 --> 23:26years, I do want to
23:26 --> 23:28validate and acknowledge that it
23:28 --> 23:29can feel very scary from
23:29 --> 23:31having these conversations with them.
23:31 --> 23:32And that sense of
23:32 --> 23:34urgency that you're talking about
23:34 --> 23:35is absolutely
23:36 --> 23:37a real feeling. I don't
23:37 --> 23:39wanna dismiss it. But then
23:39 --> 23:41the scientific counter to that
23:41 --> 23:43is that we actually have
23:43 --> 23:44really strong data
23:45 --> 23:46that taking our time is
23:46 --> 23:48okay, and it can actually
23:48 --> 23:49help you
23:50 --> 23:52find that right treatment plan.
23:52 --> 23:53Many of these breast cancers
23:53 --> 23:54have actually been in the
23:54 --> 23:56body for quite some time.
23:56 --> 23:57And so taking
23:57 --> 23:59those next few weeks
24:00 --> 24:01to really decide on the
24:01 --> 24:03right treatment plan has not
24:03 --> 24:04in any way been shown
24:04 --> 24:05to be detrimental.
24:06 --> 24:07It can also open up
24:07 --> 24:09doors for more novel therapies
24:09 --> 24:11such as being screened for
24:11 --> 24:12clinical trials, which we think
24:12 --> 24:13are super important.
24:16 --> 24:18I both hear and validate those
24:18 --> 24:19feelings, and at the same
24:19 --> 24:21time, I think I
24:21 --> 24:22can assure my patients that
24:22 --> 24:24it's okay to
24:24 --> 24:26take our time.
24:26 --> 24:27That's great.
24:28 --> 24:29I wanna get back to
24:29 --> 24:31the clinical trials question in
24:31 --> 24:32a moment, but I wanna
24:32 --> 24:33focus a little more on
24:33 --> 24:35the shared decision making piece
24:35 --> 24:35and
24:36 --> 24:38what goes into making a
24:38 --> 24:38decision.
24:39 --> 24:40And there are so many
24:40 --> 24:42things to consider, obviously, but
24:42 --> 24:44side effects are one. And
24:44 --> 24:45side effects that affect
24:46 --> 24:48people differently based on their
24:48 --> 24:50age. So one, I think,
24:50 --> 24:51very prominent example
24:51 --> 24:52of that is
24:53 --> 24:53fertility
24:54 --> 24:54issues
24:55 --> 24:57and impact on fertility for
24:57 --> 24:58younger women with breast cancer.
24:58 --> 24:59So I wonder if you
24:59 --> 25:00can take a few minutes
25:00 --> 25:01to talk about that.
25:02 --> 25:03Yes. Absolutely.
25:04 --> 25:05So I think,
25:06 --> 25:08younger women it's one
25:08 --> 25:09of the central questions that
25:09 --> 25:11we always ask when when
25:11 --> 25:12we see patients under the
25:12 --> 25:14age of forty five is,
25:14 --> 25:15you know, no matter how
25:15 --> 25:17many children they've had, fertility
25:17 --> 25:19is a personal decision and
25:19 --> 25:21what completes your family or
25:21 --> 25:22what that looks like to
25:22 --> 25:24you is a very individual
25:24 --> 25:24decision.
25:25 --> 25:27And so in
25:27 --> 25:29those initial consultations
25:29 --> 25:30it's very important for
25:30 --> 25:32your oncology team
25:32 --> 25:33to be checking in with
25:33 --> 25:34you
25:34 --> 25:36about your fertility goals, what's
25:36 --> 25:37important to you, whether you
25:37 --> 25:39desire to have more children
25:39 --> 25:41or any children. And it is part of the
25:43 --> 25:45decision making and
25:45 --> 25:46taking that time is that
25:46 --> 25:48there for those who do
25:48 --> 25:50want to have more children
25:50 --> 25:51in the future,
25:52 --> 25:53depending on the type of
25:53 --> 25:53treatment,
25:55 --> 25:56I think, taking the time
25:56 --> 25:58to meet with a fertility
25:58 --> 26:00special specialist so that
26:01 --> 26:03certain measures including egg
26:03 --> 26:05harvest or fertilization are taken.
26:05 --> 26:07I think that's important.
26:07 --> 26:08The most toxic of our
26:08 --> 26:11therapies to fertility is chemotherapy.
26:12 --> 26:13And,
26:14 --> 26:15I would say
26:15 --> 26:16that,
26:17 --> 26:18there may be some gray
26:18 --> 26:19zones in terms of when
26:19 --> 26:21chemotherapy is needed or not.
26:21 --> 26:22And so that may
26:22 --> 26:23or may not play a
26:23 --> 26:25play a factor in
26:25 --> 26:26that shared decision making
26:26 --> 26:28that some younger younger women
26:29 --> 26:29make.
26:31 --> 26:32But then there are cases
26:32 --> 26:34where the benefits of chemotherapy
26:34 --> 26:35are very clearly
26:36 --> 26:36evident.
26:37 --> 26:38And,
26:38 --> 26:40I think patients
26:40 --> 26:41have some hard decisions to
26:41 --> 26:42make because
26:42 --> 26:44there are some competing
26:44 --> 26:45factors and competing
26:46 --> 26:46goals.
26:47 --> 26:48But I think
26:49 --> 26:50it doesn't have to be
26:50 --> 26:51an opposition is what I'm
26:51 --> 26:52trying to say is that
26:52 --> 26:54we have wonderful fertility preservation
26:55 --> 26:56techniques and technologies
26:58 --> 26:59and we know that pregnancy after
26:59 --> 27:01breast cancer is safe,
27:02 --> 27:04based on multiple retrospective studies
27:04 --> 27:05as well as the recently
27:06 --> 27:08reported prospective positive study.
27:10 --> 27:11I think we can we can take
27:11 --> 27:13the time to
27:13 --> 27:14really work on both
27:16 --> 27:17treating the breast cancer in
27:17 --> 27:19the most comprehensive way,
27:19 --> 27:20but also kind of
27:20 --> 27:21looking at some
27:21 --> 27:23of those long term goals,
27:23 --> 27:24such as fertility and
27:25 --> 27:26family creation.
27:26 --> 27:27That's wonderful.
27:27 --> 27:29I'm sure we can talk
27:29 --> 27:30a whole segment about this
27:30 --> 27:32topic of fertility and cancer
27:32 --> 27:34treatments. But, maybe a
27:34 --> 27:36takeaway point for our
27:36 --> 27:38listeners is ask the question.
27:38 --> 27:39What is the impact of
27:39 --> 27:41the different treatments on fertility?
27:41 --> 27:43What are my options to
27:43 --> 27:45address those
27:45 --> 27:46side effects? So thank you
27:46 --> 27:48for that. Before we close,
27:48 --> 27:49I just wanna give you
27:49 --> 27:50the opportunity to talk again
27:50 --> 27:52about the importance of having
27:52 --> 27:54access to clinical trials and
27:54 --> 27:55what that means in terms
27:55 --> 27:56of treatment.
27:57 --> 27:58Absolutely.
27:59 --> 28:00It's a good reminder to
28:00 --> 28:02all of us that every
28:02 --> 28:04treatment that's currently known as
28:04 --> 28:06the standard of care or
28:06 --> 28:07current practice
28:07 --> 28:09actually came from a prior
28:09 --> 28:11clinical trial from years ago
28:11 --> 28:12from patients
28:12 --> 28:13and researchers
28:14 --> 28:16really working together in partnership
28:16 --> 28:18to advance the science of
28:18 --> 28:19breast cancer care.
28:20 --> 28:22Asking the question in your
28:22 --> 28:23visits,
28:23 --> 28:24do I have any clinical
28:24 --> 28:26trial options available to me,
28:26 --> 28:28will be a further prompt
28:28 --> 28:30to your clinical oncology team
28:30 --> 28:31to make sure that we're
28:31 --> 28:33not missing any potential opportunities.
28:33 --> 28:35Doctor Maryam Lustberg
28:35 --> 28:37is a professor of internal
28:37 --> 28:39medicine and medical oncology at
28:39 --> 28:40the Yale School of Medicine.
28:41 --> 28:42If you have questions, the
28:42 --> 28:44address is cancer answers at
28:44 --> 28:45yale dot e d u,
28:45 --> 28:46and past editions of the
28:46 --> 28:48program are available in audio
28:48 --> 28:49and written form at yale
28:49 --> 28:51cancer center dot org.
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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Improving Long-term Outcomes for Patients with Breast Cancer with guest Dr. Maryam Lustberg February 23, 2025

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095

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Guests

Dr. Maryam Lustberg

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