Welcome to Yale Cancer Center Answers with doctors Francine Foss and Anees Chagpar.  Dr. Foss is a Professor of Medical Oncology and Dermatology, specializing in the treatment of lymphomas.  Dr. Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven.  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 1-888-234-4YCC.  This week, Dr. Foss welcomes our new co-host Dr. Chagpar to the program.
Foss              Tell us a little bit about yourself and what your role is here at Smilow?
Chagpar        I am a breast cancer surgeon and that takes up a good amount of my time, as Director of the breast center at Smilow Cancer Hospital and I love that.  I lead an outstanding team of professionals and researchers who are dedicated to really making a difference in breast cancer every day.  I have another hat; I am also the Assistant Director for Yale Cancer Center in charge of the portfolio of diversity and health equity and we can talk a little bit more about that if you would like during the show.  And finally, I am the program director for Yale's Interdisciplinary Breast Cancer Fellowship, so I am involved in education, teaching, and research as well as clinical care, so I wear all of those hats.
Foss              There are lots of things to talk about, but let’s start first by having you tell us a little about the multidisciplinary breast program?
Chagpar        We, as most really fine breast cancer programs, really embrace this multidisciplinary approach to patient management.  So our breast radiologists, our breast pathologists, breast cancer surgeons, and medical oncologists who just do breast cancer, partner together and we are located in the same environment, we meet with each other every week, and we really have a very close relationship and dedicated team of nurses and social workers, dieticians, and physical therapists.  One of the greatest things about breast cancer is that the team is so comprehensive and we really do care for the whole patient and as you say, this is the multidisciplinary aspect to breast cancer care.
Foss              I know that your whole service there is very accessible, because I have called you a couple of times at the last minute and said, I have a patient in my office, can I send them right down? And Anees always says, sure.
Chagpar        Absolutely, I think that one of the things that is really important when you are a patient and you have a breast cancer, or maybe you do not have breast cancer but you feel a lump, your anxiety level is through the roof and one of the things that I have tried to do at the breast center is have that ability where we see patients as soon as possible, certainly within 3 to 5 days, and often times on the same day if we can accommodate it.  We want to do everything we can to enhance the patient experience.
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Foss              How do most patients come to you?  Do they come because they felt a lump or do they come because they had a mammogram that was abnormal, what is the typical presentation?
Chagpar        It really varies across the board, but many of our patients will come with the diagnosis of breast cancer.  They had a mammogram, they had a work up with their family physician or their OB/GYN, they had a biopsy done closer to home and then their family physician or OB/GYN sends them to us for their more definitive comprehensive management.  Other people, however, will come to see us if they feel a lump or if they have had a mammogram at Smilow and need a referral because they have an abnormal mammogram.  All those different aspects are part of the breast center.  The breast imaging team, which is lead by a fantastic breast imager by the name of Liane Philpotts, works very closely with me as part of my leadership team at the breast center.  So when Liane or one of her crew of eight breast imagers see something on a mammogram, the surgeons, and we now have five incredible breast surgeons who are side by side, they call us and say, I have got a patient Anees, can you see them?  And we would do the same thing, when a patient comes to see me and I say, I really need a mammogram or an ultrasound, they are often able to do that for me on the same day.
Foss              That's great, and I am sure that that helps a lot of patients with that anxiety component that you mentioned.
Chagpar        Yes, and the other piece is that we have a really great system of social work in psycho oncology, we partner very closely with physical therapy, with complementary therapy, and with our boutique.
Foss              Anees, you mentioned something that really intrigued me, and that is the concept of the breast cancer fellowship?  Can you talk a little bit about that?
Chagpar        There have been many things that have revolutionized breast cancer care, but one of them is this understanding and realization that breast cancer care is really a speciality.  It is something where you want whoever is doing your breast surgery to be a breast cancer surgeon because then they will understand how surgery integrates with all of those other components.  In order to do that, you want somebody who has trained specifically in breast cancer care and that is what a fellowship is, so after medical school and residency where people train, for example, to become a surgeon, they can then do a fellowship where they sub-specialize in breast cancer surgery, and it is really great that we are able to offer that kind of sub-speciality training to our fellows and the nice thing is that our fellows not only get dedicated training with the surgeons, but they also spend time in breast medical oncology and radiation oncology, pathology, imaging, even out in the community, survivorship, high risk, so that they really understand all of those components that makes them even better breast cancer surgeons when they get out into the community.
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Foss              Do most of your graduates actually go to community jobs or do they go into other academic teaching jobs?
Chagpar        They have done both, we have had fellows that have gone on to university positions.  We have had fellows go on to community jobs as well.  It is tailored to what they want to do in terms of their own individual practice, I am just really glad that we are able to provide them with state-of-the-art training.
Foss              You also mentioned the concept of getting into the community and I know that you have been active in the community, can you tell us a little about what you have been doing?
Chagpar        One of the great things about New Haven and about Connecticut and the Northeast in general, actually the world in general, is that there are so many individuals out there who are passionate about breast cancer awareness and screening and getting the message out. And with October just around the corner, there are so many great events that I have been blessed to be a part of. On September 28 there will be about 160 construction workers and medical people and patients and advocates all lined up in a big pink ribbon in Amistad Park for what's called the pink hard hat event which is to get awareness out there for breast cancer.  There are a number of other events.  There is a pink picnic, I’m part of a movement called fit week, where not only are we encouraging people to raise awareness about physical fitness, but also because this is going to be in October, to raise their awareness about breast cancer.  There is an event called ArtBra.  There is another event where we are partnering with a local pasta maker to make pink pasta.  All of this is really about making sure that people are aware about breast cancer, that it is something that we can do something about, encourage screening and encourage early detection.  It is wonderful to be part of all of those events.
Foss              Anees, can you talk a little bit about what's happening at the state level with respect to breast cancer?  Are there those kinds of activities happening on a state level or are they mostly community based activities?
Chagpar        There are a lot of home grown activities that are really grass root groups and very local, but there are also statewide things, and there are things that, for example, the American Cancer Society does or Komen, or other organizations even on a national level, and there are events all over the world that are focused on raising awareness about breast cancer.
Foss              If a woman out there wants to get involved and become an advocate can you give us some recommendations as to how she would start? Where would she go for instance and how would she initiate that?
Chagpar        One of things to do is you could always talk to your healthcare provider.  You could always 
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contact a cancer center local to you, and certainly at Yale we would be able to provide all of those avenues to you, talking to other community organizations like the American Cancer Society or others and talking to other breast cancer survivors.  Oftentimes people know a lot of the events that are going on and even if they do not, some of the best ideas have come from advocates and survivors who come up with an idea on their own.  Champion a cause and then just go for it and you know we have had so many people come to us and say we want to do xyz and it has been so wonderful to partner with them.
Foss:             There have been a lot of exciting things happening in the whole breast cancer world, obviously what you are doing here in the community, but can you talk a little about Smilow Cancer Hospital and some of the academic programs and some of the exciting research being done?
Chagpar:       There is no end to the fantastic research that is going on both at Smilow and Yale Cancer Center, as well as around the country and around the world, but speaking from a personal standpoint of some of the work that I have been doing we are making huge strikes.  Clinical trials are so pivotal and we have some fantastic trials ongoing, some in surgery like the SHAVE margin trial which is a trial of mine where we are looking at how we can optimize doing surgery for patients with breast cancers.  There are some fascinating trials that Dr. Lajos Pusztai is heading up.  Lajos is actually our new Chief of Breast Medical Oncology.  He is just a dynamo who came from MD Anderson and has some incredible ideas about how we can take genetics and genomics, find out where the mistakes are in a person’s cancer, find out how we can tailor that cancer and really make a difference. 
Foss:             We are going to take a quick break for a medical minute and then come back to talk with Dr. Chagpar about her work in the breast center.
Minute          The American Cancer Society estimates that the lifetime risk of developing colorectal cancer is about 1 in 20 and that risk is slightly lower in women than in men.  Early detection is the key. When detected early colorectal cancers are easily treated and highly curable.  Men and women over the age of 50 should have regular colonoscopies to screen for this disease.  Each day more patients are surviving the disease due to increased access to advanced therapies and specialized care.  New treatment options and surgical techniques are giving colorectal cancer survivors more hope than they ever had before.  Clinical trials are currently underway at federally designated comprehensive cancer centers like the one at Yale to test innovative new treatments for colorectal cancer.  New options include a Chinese herbal medicine being used in combination with chemotherapy to reduce side effects of treatment and help cancer drugs work more effectively.  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.
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Foss              Welcome back to Yale Cancer Center Answers.  This is Dr. Francine Foss and I am joined today by my new co-host, Dr. Anees Chagpar, who is also my guest tonight, and we are talking about breast cancer.  We touched on a lot of the things that you are doing Anees, but I was particularly intrigued about the SHAVE protocol that you mentioned.  Could you talk a little bit more in detail about that, tell us exactly what that trial is and what the impact of that is going to be.
Chagpar        You might have read in the New York Times not too long ago about this whole concept that women who have breast cancer can have breast conservation.  So no longer is it mandated that if you have breast cancer, you have to lose the breast.  But one of the things that is important when we just remove the tumor in women who have breast cancer, while keeping the rest of the breast there, is that we get what is called a margin. This is normal tissue that we take out surrounding the tumor that is kind of like an insurance policy so we can feel very comfortable that we have taken out the whole tumor and not left any cancer cells behind.  So, one of the issues is that when we do that, I often tell my patients that there are only two people who can tell you anything for sure, God and the pathologist.  So, while I try to take out the cancer and a rim of normal tissue all the way around, there is always a possibility that the pathologist afterwards, and it takes them about a week to fully analyze every aspect of that margin, may come back and say to me, there is a little cancer cell at the edge here, and if the pathologist says that, then I have to go back and take out a little bit more.  No patient, and certainly no physician, ever wants to take the patient back to the operating room.  So, it has been a controversy not only here at Yale, but around the country, as to how do we optimize this surgical procedure?  Should we take a little bit more while we are there? Some surgeons will routinely take a little bit extra tissue all the way around in the hopes that they will then reduce the chances that we would need to go back.  Other surgeons say, well why do that?  You could simply just take a larger piece of tissue initially.  Because taking a little bit extra might not guarantee you that you will reduce the chances of going back, and what affect does this have on the cosmetic outcome on the intraoperative time, and so on.  It is a difficult question and we are at what we call equipoise, which is that all of the surgeons are kind of scratching their heads.  Half of them take a little bit extra, half of them do not.  What we want to do is we want to figure out the answer, so that we can provide patients with the very best care.  So the SHAVE protocol is essentially that.  For the patients who have this surgery, we take out what we would normally take out, we x-ray the specimens’ right in the operating room, and I am able to see it right in the operating room.  We have technology that transports it to our radiologists electronically, so they call us in the operating room so that we have a second set of eyes looking at what we took out, and we use every possible aspect that we can to make sure that we got it out, and then once we are happy, the patients are randomized to either take a little bit more, or not.  And we are going to see which way of doing this procedure actually leads to better outcomes.  It is a fantastic protocol and one that a lot of surgeons around the country are really excited about.
Foss              Are you enlisting the help of other facilities and other academic centers to do this trial?
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Chagpar        Many academic centers have actually expressed interest in doing this study, but currently we are only doing this at Yale.  We are accruing very well to this study; we have well over a hundred patients now.  So likely this study will close to accrual within the next year, year and a half at most, and so we will be able to provide those answers very quickly.  Oftentimes for other centers to start up this protocol it will take them some lead time, and so they are all awaiting to see what the answers are that are going to come out of Yale.
Foss              Can you explain the process for women, how would someone actually get involved in this clinical trial?
Chagpar        Well, as with all clinical trials, there are number of ways to do it.  Number one is to be an educated patient.  Patients can find out about clinic trials that are going on anywhere in the country, because all clinical trials need to be registered with a government website, so you can go on the web and you can look up what clinical trials are available close to you.  You can often check out the cancer centers website at whatever cancer center you are going to, to see what clinical trials are available, and then when you see your physician, your surgeon, your medical oncologist, because certainly there are trials not only in surgery, but in every aspect of medicine, talk to your physician, be proactive.  Ask about whether there are any clinical trials that you are eligible for.  Remember that the patients who participate in clinical trials tend to do better than patients who do not.  So, it is in your best interest to participate in clinical trials, plus you really help to advance the standard of care for all the women and men who come after you.  All of the greatest advances that we have had in medicine today have been because of the champions of people who have participated in clinical trials.
Foss              In this trial you mentioned that women are randomized, does the woman actually find out what arm they got randomized to, and is that really something that will make a difference to that woman in terms of thinking about their care?
Chagpar        Because of the design of the study, we could not pick people and say, would you like to be in one group or would you like to be in another, because that would bias the results.  So both the physician and the woman at the time of the surgery do not know what group they are in.  That really makes it such that we do the very best operation we can right at the time.  The beauty of this trial is that the randomization, the magic envelope that is opened is opened after we have done our optimal surgery.  So you are quite right, women do not know what group they are randomized to.  Neither does the surgeon prior to the surgery.  Women do find out which group they were randomized to after the fact, but one of the nice things is that we partner with the women in the study.  The number one thing that we want to find out is whether this makes a difference to the cosmetic outcome, and the person to whom cosmetic outcome makes the biggest difference is the patient.  So, we ask the patient after the surgery, what do you think about your cosmetic outcome, 
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and they rank what they think, fair, good, excellent, outstanding, and then they are told what group they were randomized to so that does not bias their interpretation of their cosmetic results.  I think the patients really enjoy being a part of the trial.
Foss              It sounds like it will be really interesting to see what your results are.
Chagpar        I am really excited about that.
Foss              You also have some other exciting trials that you mentioned to me over the break and one of them was this trial that involved exercise and mindfulness.  Can you tell us a little bit about that?
Chagpar        Another great thing about Yale is the close collaboration with our School of Public Health.  Yale, Harvard, and Dana-Farber are jointly doing this trial, which is looking at the biologic impact of exercise and mindfulness on cancer.  Because we have always thought that exercise is good for you, mindfulness is good for you, we think that this has a positive effect on stress, and stress, we know, may be related to your immune system and your immune system may have something to do with cancer.  So when we connect the dots, we think that maybe exercise and/or mindfulness may really have a positive impact on the fundamental biology of cancer, but we are into robot science here, and so what we are really looking at is not just the psychological aspects of these, but the biological ones.  And so the way that this trial works is the patients who have cancer are randomized again, either you get exercise, a great intervention, or you get mindfulness, another great intervention and we take a biopsy before the intervention, and then at the time of your surgery, we check the biologic markers comparing it to the biopsy that was taken before the intervention.  We are really looking at what impact did that exercise or that mindfulness have on the tumor biology; it’s a really cool study.
Foss              How long does that study go on for?
Chagpar        It does not delay your surgery, because that is another thing that patients often ask.  They say, I do not want to delay my surgery, and it really does not.  The intervention can be as short as 2 to 4 weeks.  And oftentimes, the patients are still in the preoperative planning process, especially if they need to see a plastic surgeon and coordinate reconstruction and so on, so they are doing something positive while they are waiting.  Another similar trial to that one is the study that Erin Hofstatter, our high risk specialist here at Yale is doing, looking at black cohosh, which is a natural substance that may have preventative effects in a precancer that we call DCIS.  Except in that one, we do not even need to get the biopsy at baseline.  She is really looking at the effects at the time of the surgery, so that is another great trial.
Foss              Are all patients with breast cancer eligible for these trials?
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Chagpar        For the most part, each trial will have some inclusion and exclusion criteria.  For example, in the exercise trial, your tumor needs to be at least 1.5 cm, because we need to take a little piece beforehand and we want to make sure that our pathologist has enough tissue to look at in terms of making a diagnosis.  In Erin’s study, the one with the black cohosh, she is really looking not at invasive cancers, the kind that can spread, but precancers or DCIS, because she thinks that this black cohosh may have preventative effects in this early stage, so, again, for every patient there is a clinical trial. Ask your doctor, there are so many fantastic interventions that are available.
Foss              Anees, you have done a lot of work over a number of years now in breast cancer and I am wondering if you could just talk with our audience about what you think the important questions are and what you think we need to be doing next for research.
Chagpar        I mentioned before the break a little bit about Lajos Pusztai and I think that is probably one of the most exciting things that is going on in breast cancer research right now and probably in cancer research in general, is this whole notion of genomics and personalized medicine and figuring out how your cancer is different from my cancer and not only that, but what we can target in your cancer that would be just targeting your cancer cells.  Another cool study that Lajos and I are actually doing right now is looking at tumor heterogeneity and next generation whole genome sequencing, which sounds like a big fancy Star-Treky type term that is really looking at how different cancers are different even within the cancer, really giving us insights into tumor biology.  I think that is probably one of the most exciting things, but again, whenever we talk about breast cancer research I am always like a kid in a candy shop.  There are so many wonderful things going on in every aspect.  It is just phenomenal.
Foss              Do you think we know all the answers yet?
Chagpar        No, not yet, but I think that we are getting there and I think that the more that we have people in the community who are advocating, who are raising funds who are supporting us, we have got administrators who are looking at programs and supporting us that way, we have researchers in the clinic who are spending night and day trying to find these answers and pairing with clinicians who are really focused on how do we translate what they are doing in the lab, we can really make a difference at the bedside.  I think that is the perfect storm, and so we are getting closer and closer everyday.  It is a complicated puzzle and it is one that you know is kind of like you keep peeling back the onion skin and finding another layer and another layer.  It becomes ever more intriguing, but we really are making huge drives and getting really, really close.
Foss              We talked a little about this molecular profiling of tumors and the genomics and all the fancy testing that we can do nowadays, do you think that that kind of approach will raise more questions than answers, and how do we actually sort through all that data that we get?
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Chagpar        It is the boondoggle of genomics, that we are getting so much data and we are trying to figure out all of these complicated pathways and molecules, and so another one of our great partners is bioinformatics and how do we analyze all of this data that is coming out.  These are good problems to have.
Foss              And I think for the individual woman listening, thinking should I get my tumor profiled, should I get genomics done on my tumor, what is your response to that?
Chagpar        I think that you should talk to your doctor.  There are many ways and trials that use that technology that might be really useful.
Dr. Anees Chagpar is Associate Professor of Surgical Oncology and Director of the Breast Center at Smilow Cancer Hospital at Yale-New Haven.  If you have questions or would like to add your comments, visit yalecancercenter.org, where you can also get the podcast and find written transcripts of past programs.  You are listening to the WNPR Health Forum on the Connecticut Public Broadcasting Network.