Coping with a Breast Cancer Diagnosis

Dr. Michael DiGiovanna, Coping with a Breast Cancer
Diagnosis
May 30, 2010Welcome to Yale Cancer Center Answers with Dr. Ed Chu and
Dr. Francine Foss, I am Bruce Barber.  Dr. Chu is Deputy
Director and Chief of Medical Oncology at Yale Cancer Center and
Dr. Foss is a Professor of Medical Oncology and Dermatology
specializing in the treatment of lymphomas.  If you would like
to join the conversation, you can contact the doctors
directly.  The address is canceranswers@yale.edu and
the phone number is 1888-234-4YCC.  This evening Ed and
Francine welcome Dr. Michael DiGiovanna.  Dr. DiGiovanna is an
Associate Professor of Medical Oncology at Yale School of Medicine
and Yale Cancer Center, specializing in the treatment of breast
cancer.  Here is Ed Chu.Chu
Why don't we start off by first defining what breast cancer is and
then maybe you can share with us how common and how significant a
problem breast cancer is?DiGiovanna
The breast is basically an organ that is designed to produce milk
for a baby, and coming from the nipples are a series of ducts
called the milk ducts and at the end of the milk ducts are little
grape like structures that are called lobules.  When a woman
is breastfeeding, the milk is made in the lobules and flows out to
the baby through the ducts, as if the ducts are straws.  And
so what breast cancer is, is cancer that arises in those cells that
are lining the ducts or the lobules and that's why anyone familiar
with breast cancer might know that the two main types of breast
cancer are ductal cancer or lobular cancer.  About 85% of
cancer is ductal cancer and the other 15% is lobular cancer. 
And in terms of how frequent breast cancer is, it's an extremely
common disease.  The number one risk factor is considered just
being female because there are no women who are not at risk of
breast cancer.  It's a very common disease and in the United
States at this time almost one out of eight women will be diagnosed
with breast cancer statistically sometime in their lifetime.Foss
Mike, we used to say one in nine and now you are saying one in
eight, so that suggests to me that the incidence overall is
increasing.DiGiovanna
The incidence has actually been slowly and steadily increasing now
for actually most of the last century, and there are some clues as
to why those reasons might be, but despite the fact that the
incidence has been increasing, the death rate for most of the last
century has remained flat and finally since about the 1990s, the
death rate has actually been going down.Foss
That's one good thing about our War on Cancer, we are actually
winning in one arena.DiGiovanna
We are winning in breast cancer for sure.Chu
And maybe we can get to why we are winning in a little bit, but
just to go back to some of the basics, other than being a woman,
what are some of the other key risk factors?2:55 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3DiGiovanna
One of the most important risk factors is if there is a family
history of breast cancer, because the tendency to develop breast
cancer can be genetically inherited and run in families.  But
what is important to point out and what a lot of people don't
realize is that most of the time that's not the case, only about 5%
or 10% of the time does it run in families and the other 90% is
random or sporadic.Foss
Is there a racial predilection for breast cancer?DiGiovanna
There is.  In the United States, the highest prevalence is in
Caucasian woman with a little less so in African-Americans, and
interestingly, Asians have among the lowest rates of breast
cancer.  However, Asians who migrate and live in the United
States have a higher rate than Asians who remain in their native
countries, but not as high as the Caucasian and African-Americans
in our country.Chu
When does breast cancer typically present in terms of age?DiGiovanna
The average age is about 60 in the United States, and that raises
the question, since we were talking about the genetic background,
that one of the clues that a family might have a genetically
inherited type of breast cancer is when it strikes at an usually
young age, for example in the 30s or the 40s.Foss
Does breast cancer ever occur in very young women in their teens or
twenties?DiGiovanna
It can very occasionally occur in the 20s.  At Yale, the
youngest patient that we have had has been 18 years old.  I
have not seen or heard of any younger than that, it's even
exceptionally rare in the 20s, but we do have some patients in
their 20s as well.Chu
When we talk about family history, which presumably could increase
the risk for developing breast cancer, do you only look at the
mom's side or do you also have to look at the dad's side?DiGiovanna
It's important to look at both the mother's side and the father's
side because the tendency of genetics is that it can come from
either side of the family. Those 5% or 10% of families in which
breast cancer seems to be genetic, we have identified two genes
that account for about half of those families and those genes are
called BRCA1 and BRCA2.  It stands for breast cancer gene 1
and breast cancer gene 2.  But it's interesting that you
brought up the males and the paternal half of the family because
these genes can also cause breast cancer in men and seem to be
associated with prostate cancer in men as well.  Men of course
can pass on these genes to their offspring and make the offspring
at risk for breast or ovarian cancer.5:37 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3Foss
When you see a new patient with breast cancer how important is it
for you to obtain these genes and do essential genetic testing on
these women?DiGiovanna
We take a very careful family history and the odds of carrying a
gene, BRCA1 or BRCA2, factor into whether we will recommend
referral for genetic testing for these genes. The likelihood of
carrying one of these two genes rises the more cases of
breast cancer in the family, in what we call
first-degree-relatives, a person's mother, sister or
daughter.  It rises also if there is both breast cancer and
ovarian cancer in the family because these genes cause both of
those types of cancer.  The risk rises also, as I have said,
if there are unusually early ages of diagnosis in the family and we
actually consider 45 or younger an unusually early age, such that
even without any family history at all someone diagnosed 45 or
younger, we will refer for genetic testing.  The other risk
factor for carrying one of these genes is being of Ashkenazi Jewish
ancestry.  In the United States, approximately one out of 41
or 42 Ashkenazi Jewish people carry a mutation in one of these
genes.Foss
Is the frequency of mutations in these genes the same for
Caucasians as well as other ethnic groups, or are there specific
groups that have a higher risk other than the Ashkenazi's?DiGiovanna
The Ashkenazi's have by far the highest risk, but there are some
other pockets as well including a group in Iceland that has a
particularly high frequency of one of these mutations.Chu
But again, if one has a mutation in say the BRCA1 and BRCA2, what
would be the potential risk for that individual developing breast
cancer?DiGiovanna
The risk of developing breast cancer is as high as about 50% to 85%
sometime in their life, so much higher than 1 out of 8 for the
average women and the risk of developing ovarian cancer is on the
order of about 35% to 50%, and that's in a sense the more worrisome
cancer because we do have effective screening for breast cancer to
catch it early, but we don't have effective screening for ovarian
cancer.Foss
For those particular families who undergo genetic testing, would
all of the screening procedures start at a very young age?DiGiovanna
Yes, in fact, if we know somebody is a carrier we will recommend
those women begin having mammograms and even potentially MRIs of
the breast in addition to mammograms starting at age 25 as opposed
to the general population where we recommend starting at age
40.Chu
You have hit on the topic of screening and early detection. 
So for average risk individuals who don't have a strong family
history, who don't have these underlying genetic abnormalities,
when would the screening usually begin?8:29 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3
 DiGiovanna   We would recommend having annual mammograms
beginning at age 40 and we recommend that all adult women do
monthly self-breast examinations looking for lumps or any other
changes in the breasts. For young women we recommend that that be
performed once a month after the menstrual period has been
completed because in the premenstrual time the breasts tend to be
lumpier and tender. We also recommend that all adult women when
they have general physical examinations from their physicians that
they have the physician conduct a breast exam as well.Chu
There has been a lot in the news and literature about the potential
role of MRIs as opposed to screening mammograms, what are your
thoughts on that subject?DiGiovanna
MRIs actually seem to be even more sensitive than mammograms. 
The biggest downside of MRIs is that they are too sensitive. 
They have what we call a lot of false positives, meaning a lot of
things show up on them that we are not sure what they are and
usually turn out not to be cancer. We don't routinely recommend
that all women have screening with MRIs because if we did recommend
that to all women it would probably be a line going down the
sidewalk for biopsies.  However, we do recommend it for the
women at the highest risk of breast cancer and the most
well-defined group in that sense is those who do carry mutation in
BRCA1 or BRCA2.  So for those women, the recommendation is an
annual mammogram and MRI.Foss
Mike, can you take us down the road say of a woman who goes in and
has a screening mammogram and something is seen that's abnormal,
what happens next?DiGiovanna
The important thing for most women to realize is that most abnormal
mammograms turn out to be not cancer, but we want to err on the
side of being overcautious and act on any finding.  And so if
there is an abnormality on the mammogram, there are different
degrees of how suspicious it might look to the radiologist reading
the mammogram, and if it looks probably benign, the mammographer
might simply recommend an earlier than usual mammogram.  So,
perhaps return in six months rather than waiting a year, so that it
can be monitored a little more closely.  The mammographer also
might simply recommend coming in for additional views, additional
pictures to make sure the abnormality was really there or perhaps
just a shadow, and then if it looks suspicious enough, the
mammographer would then of course recommend a biopsy.Chu
Mike, what would be the findings on the screening mammogram that
would increase, or elevate, the level of suspicion for something
untoward?DiGiovanna
Probably the most common finding on a mammogram is what's called
calcifications, small little tiny deposits of calcium, kind of like
chalk, but even with calcifications there are suspicious looking
calcifications versus benign looking calcifications.  Large
scattered calcifications tend to be benign and the kind that are
called clusters of microcalcifications, so a little spot where
there is 11:35 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3
 one cluster of calcifications and they are very tiny with all
different shapes, what we call pleomorphic, are the more suspicious
calcifications.  The other thing that a mammographer can see
on a mammogram is a density, shadow, or marble and again they can
have different degrees of how suspicious that is.  If it looks
like it has a nice round circle around the edges of it, it's likely
to be a benign growth or fibroadenoma or a benign lymph node, but
on the other hand if it's hard to see the edges and it's a very
irregular shape, that's more consistent with possibly being a
cancer.Foss
If a woman has to undergo a biopsy, what is that procedure
like?DiGiovanna
Now-a-days, the most common way that we do a biopsy is simply with
a needle initially so that we can establish the diagnosis and then
once we have the diagnosis of cancer or not cancer, then we make
plans for the treatment that will come after that.  Most
commonly it's what's called a core needle biopsy.  If it's a
lump that somebody can feel, then a doctor can simply stick the
needle into the lump, but if it's something that you can't feel by
exam, but it's found on a mammogram, then we use a
mammographically-guided needle biopsy.Chu
Who would typically do that biopsy? Would it be the mammographer,
radiologist, or the breast surgeon?DiGiovanna
If it's a lump that you can feel on exam, it would typically be a
surgeon, and if it's something that can only be seen on a
mammogram, then its actually the mammographer who will bring the
patient back to the mammography suite and using a mammogram guide
where to poke the needle in.Foss
At what point does a women need to see a breast surgeon?DiGiovanna
Typically a women needs to see a breast surgeon, obviously if a
biopsy comes back as cancer or if it comes back inconclusive that
area has to be removed surgically to be sure of what the diagnosis
is.Foss
When we come back from the break, we are going to talk a little bit
more about the treatment of breast cancer.  You are here
listening to Dr. Michael DiGiovanna talking to us today about
breast cancer.14:06 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3using two simple tests; a physical exam and a blood
test.  Clinical trials are currently underway at federally
designated comprehensive cancer centers like the one at Yale to
test innovative new treatments for prostate cancer.  The da
Vinci Surgical System is an option available for patients at Yale
that uses three-dimensional imaging to enable the surgeon to
perform a prostatectomy without the need for a large
incision.  This has been a medical minute and more information
is available at yalecancercenter.org.  You are listening to
the WNPR Health Forum on the Connecticut Public Broadcasting
Network.Foss
Welcome back to Yale Cancer Center Answers.  This is Dr.
Francine Foss and I am here with my co-host Dr. Ed Chu. Today our
guest is Dr. Michael DiGiovanna who joins us to discuss the
treatment of breast cancer.  We talked a lot about screening
and identification of breast cancer at the beginning of the show
Mike, could you launch us into a discussion now of what happens
next, once cancer is diagnosed in a woman?DiGiovanna
Once the cancer is diagnosed there is typically a team of doctors
to treat breast cancer, and the three most prominent, front line
members of that team are the surgeon, the medical oncologist and
the radiation doctor.  Breast cancer is often treated with
some combination of those three modalities; surgery, radiation
treatment, and medical therapy.  Surgery in the old days was
typically a mastectomy; now-a-days many women can have the option
of having a lumpectomy rather than a mastectomy.  When a
lumpectomy is performed, it's standard to always give radiation to
the breast and even sometimes when a mastectomy is performed we do
radiation as well, although most of the time not, and then after
the surgery and with the planning of the radiation we also decide
if a patient needs what's called adjuvant systemic therapy, which
means some kind of medicine administered by the medical oncologist
with the goal of preventing a relapse in the future.  As part
of this multidisciplinary team there are also the doctors that are
more 'behind the scenes' such as the pathologist and the
mammographer or the radiologist who might read the mammograms,
MRIs, or any other type of scans as well as other members of our
team including social workers, nurses, and if they are going to be
treated as a part of research, a research team as well.  So
it's very important for all of these doctors to sit down together
and review the entire case to plan the strategy of the
treatment.Chu
Can you expand a little bit on the critical role of the
pathologist? As we now know breast cancer has many different types
and for that the pathologist plays the key role.DiGiovanna
Right, and some ways in which the pathologist plays a role is in
helping us to decide particularly what types of medical treatment
or adjuvant treatment that the medical oncologist gives. Some of
the ways in which we even decide in the first place whether a
patient needs any adjuvant therapy comes from the pathologists
report and that might include things like the size of the tumor,
how many lymph nodes have had tumor spread into them, and what is
the grade of the tumor, meaning17:26 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3
 how abnormal does it look under the microscope.  We also now
know that there are different types of breast cancer; it's not all
the same and they are treated quite differently.  The
pathologist does a series of tests on the tumor to look for
different proteins that we call receptors, and for over100 years
now, we have known that the estrogen receptor is important in
breast cancer.  Estrogen is the female sex hormone and there
is a relationship between estrogen and breast cancer and about 60%
of breast cancers are driven by estrogen and require estrogen to
grow.  We call those the estrogen receptor positive types of
breast cancer, or ER positive to abbreviate it, and those women
will be treated with anti-estrogen pills of some sort, and for
about the last 15 years we have identified another type of breast
cancer that overproduces another type of receptor called HER2, and
that we call the HER2 positive type of breast cancer. There is now
a very effective therapy that is specifically targeted towards the
HER2 protein and we do use it for the HER2 positive breast
tumors.  These are critical results from the pathologist, is
this an estrogen receptor positive tumor or a progesterone
receptive positive tumor, which is another hormone receptor
indicating that they can be treated with anti-estrogen pills, or is
this a HER2 type of cancer which is treated with the medications
directed towards HER2, or is the type of cancer that does not have
any of those in which chemotherapy is the conventional treatment if
any is needed?Foss
There are also cancers called intraductal cancers that may or may
not require additional treatment, can you talk about those?DiGiovanna
That's right.  When breast cancer is caught at the very-very
earliest stages, I talked about how breast cancer is really a
cancer of the milk ducts or the lobules, and when you catch it very
early its possible that those cancerous cells are totally confined
to the inside of the milk ducts or the inside of the lobule, and
that can be treated with nearly 100% cure rate because by
definition there is no chance that the cancer could have spread,
and it's actually the spread of cancer that makes it life
threatening and so we called those the intraductal types of cancer
and/or the intralobular types of cancer.Chu
Do all breast cancers express this HER2 new growth factor
receptor?DiGiovanna
No, it's about 20% to 25% of cancers that are the HER2 positive
type and about 60% are the estrogen receptor or ER positive type
and some might have both ER and HER2 and some might have neither of
those.Foss
Back when Ed and I trained at the National Cancer Institute, we
actually didn't know about HER2 and that's come along recently, now
that we have got the antibody that's directed against that
protein.  To what degree do you think that's actually changed
the treatment of breast cancer?Chu
Well one of the most important breakthroughs in the treatment of
breast cancer is the type of drugs20:29 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3
 that can be used to treat HER2 positive breast cancer.  We
learned in the late 1980s that those HER2 positive cancers are
actually more aggressive cancers, stage for stage those women were
more likely to relapse and more likely to die of their
cancers.  The first medication to come along that could
essentially inactivate the HER2, and be used to treat HER2 positive
cancer, was called Herceptin, and it's the one you just alluded to,
it's an antibody against the HER2 protein, and what we found in the
initial results that were available around 1995, was that for the
patients diagnosed with early stage HER2 positive breast cancer, if
you add Herceptin into their treatment you reduce their risk of
relapsing by an additional 50% above and beyond the benefit they
would have already received from conventional chemotherapy or
anti-estrogen pills, and that kind of breakthrough in one new
medication is as big a step as we often see in the treatment of any
type of cancer.Chu
The treatment of breast cancer really has evolved over the past few
years as Francine has said and in many ways I think it may
represent kind of the model for this so called individualized,
personalized therapy.  Are there other types of targeted
therapies that are now being used to treat women with breast
cancer?DiGiovanna
Experimentally there are.  You used the word targeted, and the
kind of catch phrase that we use now for some of the new types of
treatments that we are having for cancers in general are what's
called 'targeted therapies', meaning new types of medicine that
aren't the conventional type of chemotherapy that we have used for
the last 50 years and they tend to not have the kind of side
effects that conventional chemotherapy can as well.  And
breast cancer has really led in this field as you alluded to for
many years, for decades we have been treating that estrogen
receptor type of breast cancer with anti-estrogens and that's
really the first example of a successful non-chemotherapy treatment
for any type of cancer, targeted therapy as we are calling
it.  And then the second most prominent example, and breast
cancer led the way again, in the modern era was Herceptin for
treating HER2 positive type of breast cancer.  And now in a
number of other types of breast cancers some of these targeted
therapies have been extremely effective as well and experimentally
now we are also using other targets in breast cancer to see if they
are suitable either as individual therapies or in conjunction with
the anti-estrogens or the Herceptin types of therapies.Foss
Mike, you are doing some specific research in this area looking at
signal transduction pathways in breast cancer, can you tell us a
little bit about that?DiGiovanna
Yes, so one of the things that I was very interested in was
combining targeted therapies and so early on my lab studied in the
laboratory and in mice with breast cancers the
promise of combining HER2 directed therapy like Herceptin with
anti-estrogens, and in the laboratory it was quite a significant
and dramatic effect and it's being used in patients now, although
without as dramatic results as we saw in the laboratory.  In
my laboratory we began to wonder why it's not as dramatic in
patients as it is in the lab and that led us to explore another
receptor to potentially target for24:01 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3
 therapy called the insulin-like growth factor receptor, or the
IGF-1 receptor.  And the reason why we became interested in
that is it turns out that this IGF-1 receptor can work in
conjunction with the estrogen receptor or in conjunction with HER2,
and it turns out that this IGF-1 receptor can become over-activated
to cause resistance to the anti-estrogens or resistance to the HER2
directed therapies such as Herceptin.  And so a number of
pharmaceutical companies have been interested in this and now are
developing drugs to target this IGF-1 receptor and we have been
working with one such of those compounds in the laboratory and
found that in breast cancer cells growing in Petri dish,
or in mice with breast cancer tumors growing, that
combining these IGF-1 receptor inhibitors with either
anti-estrogens or Herceptin seems to give a dramatic beneficial
effect as well and so actually the very earliest trials are just
beginning to be conducted in women with breast cancer of these
experimental types of therapies.Chu
Are there any other types of new targeted therapies that look
particularly promising?DiGiovanna
Yes, in another experimental area there is a class of drugs that
are called the PARP inhibitors and the PARP stands for
poly(ADP-ribose) phosphorylase and this is an enzyme that is very
important in the repair of DNA.  Many of our chemotherapy
drugs kill cancer by damaging the cancerous DNA and it turns out,
especially for the women who have mutations in the BRCA1 and BRCA2,
that the important role of BRCA1 and BRCA2 is in repairing
DNA.  And there are basically two pathways that a cancer cell
can use to repair its DNA, and that is either the BRCA1 and BRCA2
pathway or the other pathway that uses PARP.  So if a woman
has a cancer with BRCA1 or BRCA2 mutation that means that pathway
is shutdown and defective.  So, if we treatment them with a
PARP inhibitor that can shutdown the other path that they have to
repair their DNA, they are left with no way possible left to repair
their DNA.  Just in the past year, we have had two studies
using PARP inhibitors that have shown great promise in treating
woman with BRCA1 or BRCA2 mutations and in treating women with the
breast cancer that we call triple negative, because those are the
cancers that don't have estrogen receptors or progesterone
receptors or HER2 and these triple negative tumors, although they
don't have mutations in BRCA1 and BRCA2, they seem to have defects
in that same pathway, so they are also highly susceptible to these
PARP inhibitors.  After we have had, in the past year, these
very exciting results in several small trials, there are now larger
trials going on and we expect this may be a rapidly developing area
where this type of medication may be available in the near
future.Foss
Are these PARP inhibitors oral or intravenous? And are there major
side effects associated with them?DiGiovanna
There are several PARP inhibitors being developed by several
different pharmaceutical companies and one of them is intravenous
and another one is oral, so there are both types. The side
effects27:27 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3
 seem to be quite minimal and that's probably because normal cells
in the rest of the body have very little PARP and don't rely on
PARP very much, it's cancer cells that have high levels of
PARP.  So the side effects, even when added to conventional
chemotherapy, don't seem to add any significant amount of
additional side effects compared to conventional chemotherapy.Chu
Mike, I understand that your group here at Yale Cancer Center has
also been studying one of these PARP inhibitors.DiGiovanna
Yes, we have a clinical trial that's going on right now combining
one of these PARP inhibitors, it happens to be the intravenous one,
in combination with a conventional chemotherapy drug.Chu
And do you have any sense of the results thus far?DiGiovanna
This is a phase 2 trial and so we don't have a large number of
patients enrolled at this time and it's also a national trial, so
there are just a few patients at each center, at a number of
different centers across the country, but I can simply say
anecdotically that patients I have had on it are having very nice
responses to it at this time.Foss
When you think about the treatment of breast cancer, this is a
chronic disease for a lot of women, how tolerable are all these
therapies over periods of time?DiGiovanna
Fortunately the PARP inhibitors, as I said, have almost no side
effects. When you add it to chemotherapy you can't see any
additional side effects and when it's being used as a single agent
without chemotherapy, there is very little in the way of side
effects.  Anti-estrogens are used typically even in women with
curable phases of the disease.  We treat women for at least
five years and we are experimenting with ten years now of
anti-estrogen therapy, they can have their own peculiar side
effects, but they are quite tolerable and even the HER2 directed
therapies are quite tolerable especially when the chemotherapy
portion is finished and the women are simply taking the Herceptin
or the other types of therapies that target HER2.Chu
Many women complain about the development of hot flashes when they
are treated with anti-hormonal therapy, what are your suggestions,
recommendations for trying to treat that side effect?DiGiovanna
So for women who are treated with anti-estrogen pills of any type
that is the most common side effect, hot flashes as if a women is
going through menopause. The explanation being that when women get
hot flashes when they go through menopause, their estrogen levels
are dropping as they go from premenopausal to postmenopausal and so
anti-estrogen pills can mimic that side effect, and for most women
its mild, for some women its more severe and difficult, and there
is no absolute therapy that can make them disappear but there are a
number of different things that can30:08 into mp3 file 
http://yalecancercenter.org/podcast/may3110-cancer-answers-DiGiovanna.mp3
 help and the thing that we use commonly that seems to help the
best is a very low dose of certain types of antidepressants, lower
than the dose you would even use to treat depression, but even baby
doses can be quite effective at relieving those.  Other things
can be simply environmental maneuvers such as having a fan on ones
desk or a fan above ones bed blowing some cool air on a
person.  And other women have experimented with other things
including acupuncture or meditation to help to relieve hot
flashes.  They tend to subside on their own overtime even
without any intervention.Chu
And what about the potential role of soy, soy products, to help
relieve symptoms?DiGiovanna
Some women do find that soy can help and it's probably because
there are weak plant estrogens in soy and so for some types of
anti-estrogen therapies we feel that, that's acceptable to use soy,
with other types of anti-estrogen therapies particularly the type
called aromatase inhibitors, we worry a little bit that we might be
giving back some estrogen in soy all be it a very weak plant type
of estrogen.Chu
Mike, as always it's been great having you on the show to discuss
the latest in terms of the evaluation and treatment of breast
cancer and we look forward to having you on a future show.DiGiovanna
Thank you.Chu
Until next week, this is Dr. Ed Chu from Yale Cancer Center wishing
you a safe and healthy week.If you have questions or would like to share your comments,
visit yalecancercenter.org, where you can also subscribe to our
podcast and find written transcripts of past programs.  I am
Bruce Barber and you are listening to the WNPR Health Forum on the
Connecticut Public Broadcasting Network.