Breast Cancer Awareness: New Treatment Advances & Innovations

October 07, 2021

Information

Smilow Shares | October 6, 2021

Presentations by:

Maryam Lustberg, MD, MPH, Chief of Breast Surgery, Director of The Breast Center at Smilow Cancer Hospital

Bohdan Pomahac, MD, Chief of Plastic & Reconstructive Surgery

Tristen Park, MD, Assistant Professor of Surgery (Surgical Oncology)

ID6962

To CiteDCA Citation Guide

00:00Good evening everyone.
00:01I'm Doctor Mary I'm lost Burg and
00:04welcome to this edition of Smiley
00:06shares on breast Cancer Awareness Month.
00:09Our focus today will be on new
00:13treatment advances and innovations.
00:16Please allow me to introduce our speakers.
00:19Come and Mary M Lustberg and
00:21I'm chief of breast oncology.
00:23I'm here at Yale.
00:25Joining me tonight is Doctor Tristan.
00:27Park is an assistant professor of
00:30surgery and in addition we have
00:33vector bookdown pomoc who is a
00:36chief who's a chief of plastic and
00:40reconstructive surgery together,
00:41will present three talks to
00:43you that focus on the most.
00:46Recent advances in multidisciplinary
00:49management of breast cancer.
00:54To start with, in honor of
00:56breast Cancer Awareness Month,
00:57I wanted to just briefly recap
01:00where we are with breast cancer.
01:02As you can see here.
01:05Breast cancer is diagnosed in all ages now.
01:08It tends to peak in in in the 6th decade.
01:13However, younger women and older women
01:16can still be diagnosed with breast cancer.
01:20In addition, men can also be diagnosed
01:22with breast cancer and they comprise
01:241% approximately of all diagnosis when
01:28their right hand graph you can see
01:32differences and outcomes based on race.
01:35And this is an area of active
01:38advocacy and effort here at Yale
01:40as well as nationally to improve
01:42disparities in breast cancer.
01:46Who's at risk? The biggest risk
01:48factor is is is is is being female.
01:52Advancing age, family history and there are
01:56other risk factors that are listed here,
01:59including exposure to radiation,
02:03abnormal biopsies, post menopausal obesity,
02:07excessive alcohol use as well as
02:10hormonal features including early
02:12age of man are late age of menopause.
02:16Late pregnancy.
02:19We have identified a number of
02:21different genetic factors that are
02:23associated with breast cancers.
02:24Some of them are associated with
02:26higher risk of breast cancer and
02:28these are things that we can test for
02:30in the majority of cases, though,
02:32we do not find an identifiable genetic
02:36factor that tells us why an individual is
02:38diagnosed with breast cancer versus not.
02:40This is also an area of active investigation.
02:44The number one message tonight is that the
02:47diagnosis of breast cancer is no one's fault.
02:50Certainly there are risk
02:52factors that we cannot change.
02:54There are certain modifiable risk
02:56factors that can reduce risk and that
02:59includes weight management exercise.
03:01However, none of these factors
03:04100% takes away the risk.
03:06We strongly recommend following
03:08breast imaging screening guidelines
03:10starting at age 40 and annually.
03:13However,
03:14I just wanted to re emphasize
03:17that we can do all these things
03:19even with regular screening.
03:22Uhm?
03:22Now where women and men can
03:25count about breast cancer,
03:27and again it's nobody's fault,
03:29and the focus of tonight is once a
03:32breast cancer diagnosis happens.
03:34What are the latest ways that we are learning
03:37to manage it better and more successfully?
03:40So the first talk will be the one I
03:43will give focusing on personalizing
03:46and rightsizing rest oncology care.
03:49The outline is to focus on personalized
03:51medicine,
03:51explain what it is,
03:53what does it mean with respect to
03:55breast oncology and review a few
03:58current strategies for personalizing
04:00breast oncology care and wrap up
04:03with future opportunities so the
04:06short version of what personalized
04:08medicine or precision medicine that
04:10you have heard a lot in the news.
04:13The best way that I find to describe
04:15it is the right treatment for the
04:16right patient at the right time
04:18and this is what we focus on.
04:20And Breast Cancer Care as well.
04:22And so how are we personalizing
04:24Breast Cancer Care?
04:26And I think as you can see tonight with
04:29our panel of having a medical oncologist,
04:32a surgeon and a reconstruction
04:34surgeon altogether,
04:35is that ultimately the best
04:37personalization or Breast Cancer
04:39Care is multidisciplinary management.
04:41I'm really working together as
04:43a team to deliver the best care.
04:47So in most recent years we have
04:50seen greater use of neoadjuvant.
04:53Also known as preoperative chemotherapy
04:56or therapy that we get prior to surgery.
05:00You will hear tonight about advances
05:03in surgery and reconstruction.
05:05And then I will cover the therapies
05:07that we give throughout the whole body
05:11or systemic therapy to personalize
05:13treatment and a lot of a lot of
05:16work has gone into better matching
05:19patients to the right treatment.
05:22And throughout this process.
05:24Our goal is to partner with you
05:27as key stakeholders as we help you
05:29make the decisions that are best
05:31for your Breast Cancer Care.
05:35So one of the key points of tonight in
05:37terms of personalized medicine on breast
05:39cancer is that not all breast cancer
05:41is the same and that we actually have
05:43multiple subtypes of breast cancer.
05:45And this is the major advance that
05:48we've had in the last two decades.
05:50Many breast cancers are estrogen
05:53receptor positive, but not all of them,
05:55and not even all estrogen receptor positive
05:57breast cancer is created the same.
06:00We sometimes further classify
06:01them as Lumina lay and aluminum.
06:04We we also have a unique subset
06:06of breast cancers known as her
06:08two overexpressing breast cancers
06:10and these are approximately about
06:1215% of our breast cancers.
06:15And then we have another category of
06:19breast tumors, approximately 15% as well,
06:22which are known as triple negative.
06:24However,
06:25even these can be further subdivided
06:28into multiple sub categories,
06:31sometimes up to eight different categories.
06:33So really this slide is meant
06:35to show you how.
06:39Breast cancer can be quite different
06:41from one patient to another,
06:43and it's so important to understand
06:45the biology of breast cancer
06:47and target other treatments.
06:50Soum further emphasizing this point that
06:52a lot of our treatments are focused
06:55on this subtype of breast cancer.
06:58We also look at the pathology
07:01or tumor characteristics.
07:02Looking at the Histology,
07:05the grade, the stage of the tumors,
07:09and we also really look at molecular
07:12and genomic characteristics,
07:14which I'll cover in the upcoming slides
07:17and all of this information helps us.
07:20Taylor, the best systemic therapy for you.
07:24So more information on this coming up.
07:28So what are our current strategies for
07:31personalizing our breast cancer therapies?
07:33This is a big topic and could be
07:36an hour long lecture in itself.
07:38However, for the purposes of this talk,
07:41I have divided it into three sub categories.
07:45One is targets and targeted therapy.
07:48Less is more, and more is more,
07:50so you'll hear each of these
07:53mini chapters coming up,
07:55so targeted targets and targeted therapy.
07:58So we are understanding more and
08:00more about the various targets that
08:03are present in breast tumor cells.
08:05In this schema you can see a
08:07number of different targets,
08:09including the PDL pathway which we
08:12are targeting with immunotherapy.
08:14The EGFR and her two pathways are
08:16targeted with her two directive.
08:18Therapies and a whole new emerging
08:22area of Turkey targeting DNA DNA
08:26repair pathways through very precise
08:29on targeted therapies that have
08:32been shown to be very effective.
08:34I will show you some saw some data on those.
08:38And so we've begun to test,
08:40uhm, in the last decade,
08:42both the tumor tissue for
08:44genomic targets as well as you.
08:47So your germline DNA, what makes you,
08:49you and eat many of these,
08:52actually have targetable drugs,
08:54for example patients with germline
08:57BRCA one and two or bracket one and
09:00two alterations actually have very
09:02specific drugs known as PARP inhibitors.
09:05These are pills that you can take
09:07in the comfort of your home.
09:09And they've been shown to be
09:11very effective.
09:12We're also beginning to find very specific
09:16markers of immunotherapy response,
09:18including tumor mutation burden.
09:20Breast cancer was one of the
09:23later tumor types to enter what
09:25we call the immunotherapy age.
09:27However, just in the last few years,
09:30we've had several approvals for
09:33different indications for immunotherapy,
09:35particularly in the setting of
09:38triple negative breast cancer.
09:40So back to the burqa or Bronco story
09:43on these drugs were first approved in
09:47patients with metastatic breast cancer
09:50who had a BRCA one or two alteration,
09:53and both these studies showed that if
09:56you took these oral drugs and actually
09:59compare them to traditional chemotherapy,
10:02you can see in the Burgundy line here.
10:06The targeted therapy actually
10:08outperformed chemotherapy,
10:10so this led to the FDA approval
10:12of these agents.
10:14And then most recently,
10:17we actually just just this past summer.
10:20Just a few months ago,
10:22we received news of a major
10:25international collaboration looking
10:26at oral PARP inhibitors and early
10:29stage breast cancer patients who
10:31had a BRCA one or two alteration,
10:33and this included patients both with triple.
10:36Negative as well as.
10:39You're positive, high risk breast cancer,
10:41and again the addition of targeted
10:44therapy led to improvements in outcomes,
10:47so this again highlights the importance of
10:50knowing our targets and going after them.
10:52The next chapter is about less,
10:54is more,
10:55UM,
10:55and we've made a number of advances in
10:58terms of actually testing the tumor
11:01tissue through a number of validated assays,
11:04and these may include Oncotype or
11:07Mammaprint mammaprint and select for
11:09patients who need chemotherapy and avoid
11:12chemotherapy and those that don't need it.
11:15And we this is already in routine
11:17practice and we're we're doing this,
11:20something that's evolving.
11:22And not quite ready outside of
11:25research is actually testing the
11:28tumor tissue for what we call
11:30tumor infiltrating lymphocytes.
11:33And these are cells that actually leave
11:36the bloodstream and enter tumor tissue.
11:39And what we have found is that
11:41tumors that actually have a lot of
11:43these tills or tumor and filtering
11:45left side actually do really well,
11:47and so a number of studies are looking
11:50at well, can we spare chemotherapy?
11:52In patients that have high tails
11:54and so this is a work in progress,
11:56not not in not ready for prime time,
11:59however is being actively researched.
12:02Again,
12:02the FEMA is if we can select the tumors
12:05that are more likely to do better.
12:07We can scare toxic treatments.
12:11Those patients.
12:13And then the last chapter is more,
12:15is more up and the idea is if we
12:17can pluck out the tumor types
12:19that actually need more treatment,
12:21we can improve our outcomes,
12:24and so the best way that we know how
12:26to do this is through preoperative
12:28or pre surgery, chemotherapy.
12:30So by using these treatments upfront
12:33before surgery we can decide if
12:35more therapy is needed after and
12:38it's a type of precision medicine
12:40because we can see in real time.
12:42How you actually responded
12:44to your treatment and
12:45I'll give you just a few examples before
12:48wrapping up in her two positive breast
12:51cancer after using traditional chemotherapy,
12:54there was a groundbreaking study that
12:56if there was any remaining tumor,
12:58using a smart therapy called Tyler or TDM,
13:03one actually dramatically improve outcomes.
13:06So it really allows us to tailor your
13:09treatment in triple negative breast cancer.
13:11We we also have.
13:13Good data that if we use preoperative
13:16chemo and there is remaining risk visual
13:20disease using a pill therapy known as
13:24the Lodha can also improve outcomes,
13:26but it's not perfect so there's a lot
13:29of work being done with immunotherapy
13:31in the setting to see if we can further
13:34improve outcomes in triple negative
13:36breast cancer and in high risk,
13:37ER, positive disease.
13:39We're looking at using oral
13:42targeted therapies these drugs.
13:44We like to describe them as things
13:46that put the brakes on tumor growth
13:49and by slowing down any residual
13:51tumor cells that may be left,
13:53the anti estrogen therapy
13:54can actually work better.
13:56So these three examples are examples
13:59of how by adding more treatments,
14:02that's precise we can actually
14:05improve outcomes and breast cancer.
14:08Lastly, future opportunities.
14:09There are lots of new smarter
14:11drugs that are in the horizon,
14:13and they're actually here.
14:14I think this is the future of
14:16breast cancer chemotherapy.
14:18They're known as antibody drug conjugates,
14:21and essentially what it is is
14:23there is an antibody component.
14:26And then there's a linker.
14:27And then the chemo is actually
14:30very precisely linked,
14:31and so the drug can actually be
14:34very precisely delivered to to the
14:36cells that actually have the target.
14:39And they're actually here today.
14:41I mean that this is something that
14:44we're actually using and in the
14:46clinic now there are a number of
14:48them I've chosen to highlight them
14:50for two drug known as and her two.
14:52This was just presented and
14:54dramatic improvement over some
14:56of our traditional drugs.
14:58So I think what we'll see is
15:01earlier use of these antibody drug
15:04conjugates in breast cancer with
15:07the hope of improving outcomes.
15:09So in summary,
15:10we have lots of biomarkers and
15:12more targeted therapeutics.
15:14We need to address equity
15:16issues and breast cancer.
15:17Lots of multi deep collaborations and whole
15:21system thinking and rightsizing therapy.
15:23Some people will need less therapy
15:25and some people will need more.
15:27And throughout all this we want
15:29to partner with you hear your
15:32thoughts and impressions where
15:34one team together with you and.
15:36Ultimately,
15:37all of these efforts will help
15:39us improve patient experience,
15:41patient outcomes,
15:42and have a more efficient
15:45health delivery system.
15:47Feel free to put your questions in
15:49the chat will have time at the end,
15:51but at this point I will turn
15:53it over to my colleague,
15:55Dr Park who will speak about
15:57the latest advances in surgery.
16:03Hello I am Tristan Park,
16:06I'm a breast surgical oncologist.
16:08I'm I will be sharing with you today.
16:12Advances in the surgical management
16:14of the axilla in breast cancer.
16:19So when a woman comes to me to get
16:22her breast cancer treated, there's
16:25two parts that we have to think about.
16:27One is the cancer that exists in the breast,
16:30and then they're great.
16:31And then we also have to address
16:33the draining lymph nodes.
16:34So there's two things that
16:37are generally done.
16:38If they don't think that they
16:39have any cancer in the left notes,
16:41that's obvious we have to do something
16:43called a staging study or assessing.
16:45If there's cancer there, or if there's
16:47or we have high level of suspicion.
16:49That the lymph nodes are involved.
16:51Then we need to address the lymph
16:53nodes in a therapeutic fashion.
16:55Remove the cancer and and treat it so
16:59it's like a two part surgical treatment.
17:04Historically, many,
17:06many decades ago,
17:08the only way to figure out what was
17:10going on in the axilla was by doing
17:12a complete lymph node dissection.
17:14So that's removing many lymph nodes.
17:17All the lymph nodes in the axilla
17:19at the levels one and two.
17:20So level one is this green area here,
17:23level 2 is this blue area here.
17:25That's all in relation to one of
17:27your chest wall muscles called
17:28the pectoralis minor.
17:30So way back when in the 1970s and 80s,
17:32this was the only way to figure out what
17:34was going on in the axilla everything.
17:35Was taken out each and every left node
17:38was looked at carefully and we could
17:41determine nodes were not involved or
17:43there was some cancer involved in the nodes.
17:46Uhm,
17:46there was.
17:47There is a significant and definite
17:50morbidity and complication rate
17:52with this type of surgery and
17:55there's blood like blood vessels,
17:57nerves,
17:57arteries and veins to be wary
18:00of in this area.
18:01And most people have a drain placed
18:03and they have to stay overnight.
18:06So it later on in the 19 around like
18:08the 70s and 80s people were thinking
18:11maybe there's a way to assess the
18:14lymph nodes in the axilla without
18:17removing all of the lymph nodes,
18:18like not removing like every.
18:23I could, you know, sometimes be up
18:25to 20 to 30 efforts so the this was
18:27the era of the Sentinel node biopsy.
18:29So the way that this was done is
18:32that the breast is injected with a
18:35special material called either a blue
18:37dye or a radioactive tracer or both.
18:40And then it's quite miraculous.
18:41'cause as a surgeon I'm the one that
18:43injects the breast prior to surgery
18:45and it's better like this and every
18:46time within 30 seconds the die has
18:48reached the most important nodes
18:49in the axilla or the Sentinel left
18:52nodes or the first training left.
18:54Uhm, so then these first rating
18:56left nodes is on average,
18:58it's it's two or three is identified
19:01by looking for a blue color or
19:03using a special probe that detects
19:05radioactive dye that's also injected.
19:07And then you know small incision
19:09is made and a couple of lymph
19:11nodes are removed and looked at.
19:13Looked at carefully so this is clearly a big.
19:16Big switch from doing this
19:19actually left no dissection.
19:20Removing all these lymph nodes and all
19:23the complications associated with that,
19:24you could also do some preliminary assessment
19:26of these lymph nodes by the pathologist
19:29by something called a frozen section,
19:30which is kind of a looking at a couple
19:34of slices of the left node to eyeball
19:37if there is any cancer involvement.
19:39So clearly these are two different
19:42types of surgeries,
19:43and there's complications related to
19:45both that are shared lymph edema or
19:48swelling of the arm is the most kind of
19:51dreaded complication and intentional left.
19:53No biopsy,
19:53which is just removal of few nodes
19:55versus axillary left node dissection,
19:57which is removal of all the left nodes.
19:59There's a lot more lymphoedema
20:00in the axillary if you get
20:02the full axillary dissection.
20:03The literature sites about
20:051 to 3% in center left,
20:07no biopsy and up to 30%.
20:09If you get all of your left notes.
20:11These other complications hematoma injury
20:13to the nerves in the neighborhood Olympo.
20:17See Laura would affection are
20:18all present and as you can see,
20:20although these numbers are very very low,
20:22it's always you know three or
20:24four times more.
20:24In the axillary livnot dissection group.
20:28So when I was doing this presentation,
20:30I was thinking, you know,
20:31maybe some people don't know
20:32exactly what the fadima is.
20:33They probably know that it means swelling,
20:35but you know, there's actually kind of a
20:37definition for it and different grades,
20:39so there's great stage one,
20:41which is up clinical.
20:42So there's no clinical signs of swelling,
20:44but there's a sensation of numbness,
20:46achiness and heaviness there stage two,
20:48which is mild lymphoedema,
20:50which results in a soft pitting edema.
20:52That's basically their arm looks swollen,
20:54and if you press your finger into it,
20:55it leaves an indentation, but.
20:57There's no fibrosis or scarring,
20:59and if you elevate the arm
21:01this the swelling goes away.
21:03Moderate or stage three lymph
21:05edema is more severe.
21:07There's more fibrous findings and scarring,
21:11and the limb elevation
21:12doesn't reverse anything.
21:13And then severe lymphoedema
21:15or stage four is, you know,
21:17severe scarring and you get skin changes.
21:20And it's quite kind of irreversible
21:23and usually moderate to severe.
21:25Lymphoedema is the type that.
21:27Is permanent and is limiting to
21:29your ability to use the heart,
21:31which could be problematic if
21:33you're if that's your dominant arm.
21:35There's varying different definitions
21:37of exactly how to measure this,
21:39but a lot of clinicians have reported.
21:44A circumference difference
21:45of two or more centimeters,
21:47or a volume difference of 200
21:49millimeters or more if you compare
21:52it to your non involved arm.
21:54So uhm,
21:55basically this is the history of the central.
22:00If no biopsy versus actually
22:01left node dissection.
22:02Overall the big picture is as time went
22:05on we replaced this lymph node biopsy.
22:09We've replaced that.
22:10Actually live dissection with
22:11this less invasive lymph node
22:13biopsy for multiple indications.
22:15So way back in the 1960s,
22:17Doctor Gould defined the
22:19term central lymph node,
22:20meaning the first draining
22:21lymph node in 1977.
22:23This procedure of identifying the first
22:25training left node was described by
22:28a doctor at Memorial Sloan Kettering,
22:30who was a fellow and was actually
22:32studying penile cancers and trying
22:34to find the draining lymph nodes
22:36in the treatment of that in 1999.
22:39The use of the radioactive tracer
22:42was reported by Doctor Morton,
22:44a luminary in the field in the in the
22:47setting of Melanoma surgery in 1994.
22:51Doctor giuliano.
22:53Seminole figure in the role of
22:55lymph nodes in breast cancer,
22:58described left no mapping and sent a
22:59love note biopsy for breast cancer.
23:01So all of this stuff from 1960
23:03to 1994 talks more about the
23:05central lymph node biopsy.
23:07Replacing axillary dissection for
23:08staging or just kind of figuring
23:10out figuring out if the lymph nodes
23:12are involved or figure out what's
23:13going on in the in the lymph nodes.
23:15What I'd like to focus on this talk is
23:20the really kind of milestone mental.
23:23Cut a groundbreaking changes in the
23:26past decade regarding the use of
23:28sentimental boxy as potential therapy
23:30to replace actually left no dissection.
23:32If you have known tumor.
23:34Known cancer in cancer burden in your axilla.
23:38So I'll be talking about low
23:40volume of disease in your XL.
23:42A higher volume of disease in the axilla,
23:45and then even more higher volume
23:46of disease in your axilla,
23:48and how we're continuously pushing
23:49the envelope and that you know
23:51things that were done that would
23:53have been considered malpractice.
23:55When I was a medical student is
23:57now considered well studied,
23:58safe and highly recommended in kind
24:01of personalizing and downsizing the
24:03type of actuaries surgery you get
24:05as a breast breast cancer patient.
24:09So milestone one do we have to do
24:11a full access right dissection?
24:12If we find cancer in the lymph nodes
24:14after surgery and this is in the setting
24:16of you have a small tumor burden.
24:18The left nodes.
24:19This is also called clinically no negative.
24:21This patient has a normal feeling axilla,
24:24the axillary left nose look normal on
24:26imaging and we go and do the surgery,
24:28and lo and behold,
24:29on the central lymph nodes there's a.
24:31There's a few lymph nodes at Farber,
24:32some cancer cells.
24:37So with the acceptance of Sentinel lymph
24:38node biopsy as a staging technique,
24:40a lot of clinicians were thinking,
24:43you know, there's very low amount
24:44of cancer in these lymph nodes.
24:46Maybe we don't have to do a full actually
24:48dissection so they were just doing this.
24:50You know, even before the studies came out,
24:52so in the 1990s and early 2000s,
24:54almost 20% of practitioners were doing this,
24:57kind of as a kind of.
25:01But by their own clinical judgment.
25:08So this, uh, this landmark trial Acogs 11,
25:12was the trial that looked at
25:13this in a rigorous fashion.
25:15It was a multicenter,
25:16randomized prospective trial which
25:18is like the gold standard of trials,
25:20and this definitively looked at.
25:21If you had very small amount
25:23of cancer in your lymph nodes,
25:24do you really need a full extra lift?
25:26No dissection?
25:27Or is the lymph node biopsy enough so
25:29these folks had small breast cancers
25:31are clinically negative axilla and
25:33they were to undergo lumpectomy with
25:35whole breast radiation therapy,
25:36which is considered the definition
25:38of breast cancer.
25:38Patient therapy they would get a
25:40Sentinel lymph node biopsy and if
25:42they had one to two lymph nodes
25:43that harbored cancer cells in them,
25:45they either got nothing else or
25:48they got the further surgery.
25:50The complete axillary dissection.
25:54So this study showed that there was no
25:56difference if you got no further surgery
25:58or you got the full axillary dissection.
26:00There was no difference in local recurrence,
26:02meaning recurrence in your armpit,
26:04and there's no difference in how long
26:06you lived or five year overall survival.
26:08It was equivalent, and then they found
26:10this study up in another nine years
26:13and the original findings held true.
26:15Your local recurrence and your
26:17overall survival were similar.
26:22So take on point is if you have a
26:23small breast cancer that's going to be
26:25treated with lumpectomy and radiation.
26:27You could have up to two lymph
26:28nodes that have cancer in them,
26:29and you don't need a full,
26:30actually lift, no dissection,
26:32and you'll still get a great
26:33treatment that will render you
26:35with excellent Disease Control.
26:37That's equivalent to getting
26:38all your left nodes out.
26:42So that's milestone one.
26:43There was a there's.
26:44This was further kind of, UM,
26:46supported by a study that was done
26:48in Europe called the Amero study,
26:50which looked at instead of doing
26:52an axillary left node dissection.
26:53They did actually radiation,
26:56and can we wait for the milestone
26:59was could we radiate the Excel
27:00instead of doing more surgery?
27:01If there's cancer in the left nodes,
27:03the kind of the subtleties,
27:05and this was you were not necessarily
27:08getting lumpectomy and radiation as
27:09part of your breast cancer treatment.
27:11You could also be getting up stuck to me.
27:13So that was also a variation,
27:15and this study also showed basically
27:17that your overall survival and you're
27:20disease free survival with the same
27:22whether or not you've got all the lymph
27:25nodes out or you got actually radiation.
27:27And the nice thing was the rate of
27:30lipedema and the radiation group was about
27:32half of the axillary lymph node biopsy group.
27:35So the most obvious one is at five years.
27:39If you had actually radiation,
27:40you had a 6% risk of lipedema.
27:43And if you had a full actually left
27:45outer section here at 13% of us,
27:46so clearly less that more than half decrease.
27:52So take on point as if you have
27:53breast cancer not treated with
27:55breast conservation i.e mastectomy,
27:57so a more kind of loosening the surgical
28:00criteria and you have positive lymph nodes.
28:03This can be.
28:03This may be treated with radiation to axilla
28:05and you may not need full axillary surgery,
28:08so they were pushing the envelope some more.
28:11And then milestone two was, you know,
28:14let's see if we could push the envelope
28:16some more and go even with a higher
28:19level of disease burden in your axilla.
28:21Could you read this section if you
28:25have known cancer in the left nodes?
28:26AKA clinically node positive
28:28more tumor in the lymph nodes,
28:30hard burden of disease?
28:32So if you have clinically node
28:35positive cancer like you go in
28:37your lymph nodes feel large.
28:39They live large on imaging
28:40biopsied and there's cancer.
28:42There's obvious,
28:43documented cancer in her left nodes
28:45in this day and age we always
28:47treated with chemotherapy first.
28:50It's also called neoadjuvant
28:52chemotherapy for the,
28:53with the hopes that we could shrink
28:55everything up to make the surgery minimized,
28:57and also it gives us great
28:59prognostic information afterwards,
29:00so folks that got chemotherapy
29:02before surgery or new agent.
29:04Chemotherapy,
29:05it was noted that 40% of patients who were
29:09initially tumor bearing in the axilla,
29:11like became no negative after
29:13this new regimen chemotherapy.
29:15So we thought maybe if we
29:17could identify these people,
29:18they don't have to get the the
29:20final axillary surgery or the
29:22full axillary dissection.
29:24So this was the ECOSOC 1071 trial and
29:27basically patients with known cancer
29:29in their lymph nodes were enrolled.
29:31They came with therapy first and then
29:33they got surgery and then basically they
29:35looked at something on a false negative rate.
29:37So basically.
29:40Most negative rate is if you had a central
29:41lymph node biopsy that was negative,
29:43but then when you look further there
29:44is actually more cancer in there.
29:46So our goal false negative rate.
29:47For this to work was it
29:49had to be less than 10%.
29:50So 10% was like the key number and we
29:53were able to get that achieve that number
29:56by having a more stringent central
30:00biopsy criteria using dual tracer.
30:03Meaning you had to use two different
30:04types of lymph node tracing,
30:05blue dye and technetium or
30:07the radioactive material.
30:09We had to remove at least.
30:10Three left nodes,
30:11and optimally we had to remove the
30:14initially diagnosed left node or the AKA.
30:16The clipped lived because we place the clip.
30:20In the lymph node that has the
30:22known biopsy proven cancer.
30:24So a series of studies demonstrated
30:26that we got this good false negative
30:29rate or high sensitivity rate.
30:31Basically is another way to think about it.
30:34If you use the dual agent or got three
30:36more than three central lymph nodes,
30:38the number was always around 10 or less,
30:4110% or less and then further
30:43follow-up studies demonstrated that
30:44if you got the clip note as well,
30:46you could drop that false negative
30:48rate to 6.8%. And even down to 1.4%.
30:56So the take home point for this was.
30:59Pushing the envelope some more.
31:01Now we have bulky disease or
31:03known disease in your axilla.
31:05We could create your treatment so
31:08that you know you have the lymph
31:10nodes shrink up and then we could
31:13minimize your surgery and we could
31:14do it in a safe and accurate manner.
31:18It's a much more stringent criteria,
31:20but the fact that we're able to
31:22identify this and get to this
31:24point is like really remarkable.
31:28So finally that the third milestone,
31:30which is ongoing,
31:32is looking at even more levels of disease.
31:36People that have some response
31:39to the chemotherapy.
31:40They get their central dental
31:42biopsy and there still looks like
31:43there's some cancer there.
31:44Do they really need axillary surgery
31:47or could we replace that with?
31:49Radiation, so those are ongoing studies
31:53by the alliance group as well as the.
31:57Nsap group so I just wanted to
32:01kind of press upon everyone that
32:02significant advances has been
32:04made regarding our understanding
32:05of the treatment of breast cancer
32:07that spread to the left nodes.
32:10Uhm? Actually,
32:12there's no dissection which has removed many,
32:14many lymph nodes and has known
32:16morbidity and complications has
32:17slowly been replaced over the years.
32:20By this much more targeted curated
32:22Sentinel lymph node biopsy.
32:24First for staging purposes in the 60s,
32:26Seventies, 80s nineties,
32:27and then more and more for
32:29therapeutic purposes.
32:30For tumors that were left node bearing
32:32lymph nodes that are known to harbor
32:34or cancer cells in them and we're
32:36continuously pushing the envelope.
32:41So I feel like with the addition
32:43of all of this great data,
32:45we could make personalized
32:46care and decision making.
32:48This data helps us avoid axillary surgery
32:51in patients who may have risk factors
32:54that predispose them to infection,
32:56lymphoedema, and etc.
32:58And this is done as a kind of a collaborative
33:02conversation between the patient and
33:04their their doctors in a in a team setting.
33:07So we we I am.
33:12I'd like to come thank you for
33:14listening and it's great to
33:16be part of this breast cancer
33:18Awareness Month outreach program,
33:20and I hope that all the wonderful
33:23advances and understanding that
33:25we have made in this field,
33:28particularly in surgery,
33:29where we're constantly learning
33:30more about the biology of the
33:33disease and being able to mold
33:34the type of surgery that's needed
33:36and still feel good about it and
33:39know that we're rendering the
33:41patient with a good outcome.
33:43Is ongoing, thank you.
33:45Great, thank you so much.
33:47Doctor Park and I think your talk
33:50really highlights just all the
33:52advances in personalized medicine
33:55that we've been able to achieve
33:57through dedicated clinical trials
33:59which would not have been possible
34:01with all the thousands of individuals
34:03who have participated with that.
34:05We will move on to our third
34:07talk with Doctor Pomahac.
34:09Thank you.
34:13Thank you very much and I
34:15couldn't stop thinking about all
34:16the aspects of Breast Cancer Care and
34:19how it starts with medical oncology.
34:21Goes through radiation oncology,
34:23surgical oncology and then
34:24finally plastic surgery.
34:25But also the communication of the team.
34:28How much it may impact the
34:30choice of reconstruction and
34:31the timing of reconstruction
34:33because the type of chemotherapy,
34:35the timing of chemotherapy as well
34:37as the presence of previous radiation
34:40or plan for future radiation.
34:42Those are all incredibly.
34:43Important factors and beyond
34:45the scope of this presentation,
34:47but certainly document how we all
34:49communicate together as one team.
34:52I wanted to start with.
34:55With sort of the basics back in 1995,
34:59there were only 8% women receiving
35:01breast reconstruction and there was
35:03because largely this was viewed as
35:06esthetic surgery and out of pocket payment.
35:08In 1998,
35:09the Women's Health and Cancer Rights
35:12Act actually allowed women to be
35:14eligible under in medical insurance
35:16to obtain breast reconstruction,
35:18and from then we have had a steady
35:20rise in breast reconstruction
35:21numbers up to the COVID year
35:23where it plateaued and the pig.
35:26Was actually the year before or a couple
35:28years before around 43% of women,
35:31so women with invasive cancer.
35:33Almost half of them at the present
35:36time received breast reconstruction.
35:38Now the trends have also evolved
35:39over the time,
35:40and if you look at the early 1998,
35:44which is when the Women's Care
35:46Act was approved,
35:48we had about the same amount of
35:51autologous meaning using utilizing
35:53patient's own tissue type of
35:56reconstructions and the same amount
35:58of implant based reconstructions.
35:59But over the years this trend has
36:01diverged and with the growing
36:03number of reconstruction,
36:04overall we have seen steady increase
36:07in implant based reconstruction.
36:11Now, why is it so well
36:14from patients perspective,
36:15a implant based reconstruction means
36:18shorter operation and faster recovery.
36:21Everything happens on the chest,
36:23whether it's one or both breasts.
36:25There is no additional donor site,
36:27and the healing is generally limited
36:29to probably two to four weeks
36:31rather than four to six visitor.
36:33Even eight weeks with the autologous
36:37reconstruction techniques.
36:38We have also seen increase in.
36:41The number of bilateral
36:43mastectomy both sides.
36:45Both breasts are removed,
36:46and that's because of the
36:48identification of some of the genes
36:50that predispose women to breast
36:51cancer and and mastectomies that we
36:53call prophylactic or also increased
36:55anxiety among patients to leave
36:57healthy breast in place when they
37:00suffered from cancer on one side.
37:02And although those are not generally
37:04recommended as medically appropriate, there
37:06has been increase of those cases as well.
37:09Additionally, FDA has.
37:11Has triggers her their stance on
37:15moratorium on silicone implants
37:17in 2006 as they were found to be
37:21relatively safe and certainly
37:23not connected to the connective
37:26tissue disorders in large numbers
37:28and studies that were performed.
37:30Another factor is what's called
37:32****** sparing mastectomy,
37:34which is a technique of removing
37:36the breast gland and breast tissue
37:38without removing the ****** which
37:40traditionally is viewed as as
37:42a part of the breast gland and
37:45traditionally was part of the operation.
37:47And then finally the surgical
37:50advance of structural fat grafting,
37:52which is essentially a liposuction
37:53of area where the patients have a
37:56little bit of access and countering
37:58the reconstruction with an implant
38:00has helped immensely to improve
38:01the aesthetic outcomes.
38:03On the other hand,
38:04the autologous breast reconstruction
38:07techniques using the patient's own
38:09body largely evolved into perforate,
38:12are based techniques,
38:12and I'll talk about it a little bit more,
38:14but it is essentially a technique
38:16where we try to spare.
38:18Muscles or deeper structures
38:20and just find vessels that.
38:24By skin and fat there will be ultimately
38:26used to replace the missing breast mound.
38:29These operations are quite sophisticated
38:31but tedious and take long time,
38:33and frankly there is really not enough
38:35surgeons in the country that would
38:38be able to perform these operations.
38:40That sometimes bilateral reconstruction can
38:42take a whole day in the operating room,
38:45and so the Community has also driven
38:48the need or the the rise in implant
38:51based reconstruction as well.
38:53Now when I'm talking about implant
38:55based reconstruction,
38:56would I what I'm talking about is
38:58really these two circumstances
39:00release two options?
39:01In some instances we place at
39:03the time of mastectomy and tissue
39:05expander and then later on come back
39:08to exchange the expander for implant
39:10and that's done for numerous reasons.
39:12Sometimes it's concerned about the
39:13viability of the skin because the
39:16breast cancer surgeon has really
39:17the hard job to remove the breast
39:19gland without injuring the skin,
39:21but the skin can be traumatized.
39:24Putting additional full size
39:25implant may cause additional trauma,
39:28so placing expander allowing the skin
39:30to heal and then gradually expand
39:32the skin is a safer way to perceive.
39:35Sometimes the patients want to be
39:36larger than what they started with,
39:38and that's another reason to put an
39:40expander at the time of the reconstruction,
39:42but ultimately the expander is a
39:45temporary prosthetic prosthesis that's
39:47ultimately exchanged for an implant.
39:50Lately, though, we have been using more and
39:52more immediate implant reconstructions.
39:54Bad for proper patient can eliminate
39:57one of the operations and can lead
40:01to quite nice results in one stage.
40:04Now there are different nuances
40:05where this implant ultimately can
40:07be placed on the upper row you
40:09can see what's called subpectoral,
40:11implant based reconstruction and
40:13different views of this reconstruction.
40:16Fundamentally,
40:17the implant is placed underneath
40:20the large chest muscle that covers
40:23the implant and prevents some of the
40:25problems such as capsular contracture
40:27or tight scar around the implant,
40:30but it also creates natural sloping
40:32of the upper pole of the breast.
40:35On the other hand,
40:37because immediately superficial
40:38to this muscle is a skin,
40:40patients often develop what's
40:42called animation deformity,
40:43which is when you engage the chest muscle,
40:45the skin suddenly moves and
40:47it can look quite abnormal,
40:49especially in dresses or
40:51or swimming swimming suit.
40:54That's one of the reasons why
40:56lately we have reverted,
40:57they were converted back to what's
41:00called prepectoral implant placement,
41:01which is placement of an implant in
41:03front of the pectoralis major muscle.
41:05In this case,
41:07the implant has the disadvantage
41:09of having less protection,
41:11and sometimes the transition to
41:12the upper pole of the chest can
41:15be slightly abnormal,
41:16but that's where the structural fat
41:18grafting or injection of fat at later
41:20date can actually make a difference
41:22and considerable improvement.
41:24So let me show you some of the examples.
41:27This is a patient before and after
41:30bilateral implant reconstruction.
41:31She wanted to be considerably larger,
41:33so this was actually interim
41:34expander placement and then exchange
41:36of implant whenever there is a
41:38****** sparing mastectomy,
41:39meaning the native ******* can be preserved,
41:42and even though the breast
41:44is largely insensate.
41:45As the nerves are removed along
41:47with the breast gland the the
41:50result looks remarkably natural.
41:51Another example of patient who had
41:54the single stage reconstruction
41:55implants placed at the time of
41:58mastectomy with nice aesthetic result.
42:01Patient who had who had tissue
42:03expanders first and then implant
42:05as she wanted to be larger.
42:08One of the things that you can see here
42:10is a little bit of rippling of the skin.
42:12So sometimes the implant in the
42:14prepectoral or in front of the
42:17muscle plane causes rippling or
42:19or visibility through the skin.
42:20A problem that's really very difficult
42:23to correct and can be really not correctable.
42:28Another example is patients that
42:29undergo only what's called skin,
42:31sparing mastectomy,
42:32so the mastectomy skin is spared,
42:35but ****** area is not.
42:36This invariably results in larger
42:38longer scars and then the *******
42:40have to be reconstructed later.
42:43Ultimately the shape can look quite natural,
42:45but it does never quite match the
42:49result of ****** sparing mastectomy.
42:51This is a patient who had skin
42:53sparing mastectomy and then following
42:55reconstruction of ****** areola.
42:57Which can be actually these days
42:59made fairly natural looking.
43:01We use 3D tattooing as well as
43:04reconstruction of the projecting part of
43:06a ****** to complete the reconstruction.
43:09In cases of significant ptosis
43:12or drooping of the breasts,
43:14the ******* are really not wise to
43:16save as there would end up in really
43:18wrong position and in those cases we
43:21have to create a new unit process in
43:23proper relation and the mastectomy
43:25scars end up being low on the breast,
43:27not across the president from
43:29the previous previous image.
43:30So the position of the mastectomy
43:33scar is really related to the
43:36position of the areola complex.
43:38Example of unilateral or one
43:40sided reconstruction with
43:42contralateral symmetry procedures.
43:43So many patients that opt to proceed
43:46with only reconstruction of the
43:48breast which is affected by cancer,
43:51can undergo contralateral lift
43:52or small reduction to match the
43:55volume as as much as possible.
43:59So one of the scary parts lately in the
44:02literature has been anaplastic large
44:04cell lymphoma was also called alcl,
44:06associated with breast implants early on,
44:09the incidence was considered
44:10to be one in 500,000,
44:12but then later was thought that maybe
44:15even as frequent as in one in 1000.
44:18Based on careful statistical analysis,
44:21the truth is probably somewhere around
44:241 to 30,000 patients and 90 or over 90.
44:28Percent of these are associated
44:29with textured implants.
44:31Textured implants were used
44:32because of their anatomic shape
44:34and ability to hold the position,
44:37but also anatomically shape that we could
44:39create and less complications related to
44:42a capsular scar formation or contracture.
44:46Now in those 10% of cases where
44:48patients did not have textured
44:50implants at the time of diagnosis,
44:52it is unclear whether they may
44:54have had textured expander or
44:56other texture device in the past.
44:58So it appears to be strongly
45:00correlated with textured implants
45:01and even types of texturing.
45:03Certain manufacturers have seen
45:05larger incidents of anaplastic large
45:08cell lymphoma as compared to others.
45:12It is a scary disease that
45:14presents often with Blumberg,
45:16asymptomatic swelling of the breast
45:18and treatment is really removal of an
45:21implant and complete removal of this
45:23scar or capsule around the implant.
45:25In rare cases there is need for
45:28systemic therapy and there have been
45:30unfortunately cases reported of deaths,
45:32but the with transition to smooth
45:35implants and smooth tissue expanders.
45:37This should really be largely
45:40minimized if not. Almost eliminated.
45:44Now let's switch gears to tallages or
45:46patient's own tissue breast reconstruction.
45:49There are studies showing
45:51superior long term outcomes,
45:52so it's I always tell my patients
45:55there's big upfront investment,
45:56but the long term there is a better aging,
46:00less concerns about the exchange of
46:01an implant in case they rupture,
46:03and any complications ready to the
46:06implants are essentially eliminated,
46:08and in studies again,
46:09it's been shown that patients are satisfied
46:11more than with implants overwhelmed.
46:14Period of time now the donor
46:16site that's most commonly used.
46:18The workhorse is the lower abdomen
46:21and traditionally in back.
46:22In the 70s.
46:23Technique that utilized the detachment
46:25of the muscle and using an island
46:28that you see in this ellipse on the
46:30abdomen of skin and subcutaneous fat
46:32to build the breast has sacrificed
46:35one of the straight muscles of
46:38the abdomen rectus muscles.
46:40And that caused there is abdominal
46:43strength problems or even weakness
46:45or bulges or hernias.
46:47This is why this what's called tram
46:49flap or transverse rectus abdominis
46:51muscular cutaneous flap was largely
46:54replaced by perforator flap,
46:56where we no longer sacrifice the
46:58muscle but rather split the muscle
47:01and find individual vessels that
47:03feed the overlying skin and fat in
47:05order to build the breast that way.
47:09Uhm,
47:09theoretically there should be
47:11intact much left behind,
47:12although there's a certain degree
47:14of damage that occurs just by
47:17dissecting the perforating vessels.
47:19Results can be remarkably nice
47:21again in ****** sparing mastectomy,
47:23but more commonly these are
47:25skin sparing mastectomies
47:27that result in replacement of the
47:29****** areola complex with skin coming
47:31from the abdominal flab and this
47:34is the score of the donor site and
47:36islands that come from the abdomen.
47:38These islands can be later changed or
47:41reduced or made circular as as needed
47:44and the revisions are fairly common.
47:47This is one of the such an example where the
47:50initial islands of skin were just too large.
47:53They're important early on for monitoring
47:55of the healthiness of the tissues,
47:57but later can be removed and the shape of
48:00the breast can be remarkably improved.
48:03Now, in patients that don't have
48:06enough subcutaneous fat and often don't
48:09have enough even tissue on the chest
48:12to reconstruct with implant alone,
48:15we still use a combination of
48:17autologous or patients own.
48:19In this case,
48:20latissimus dorsi broad muscle
48:21of the back has brought.
48:23Forward and wrapped around an implant.
48:25So this is this.
48:27Is Miss Dorsey muscular cutaneous weapon
48:29implant and that allows us to reconstruct
48:33president is challenging patients
48:35with inadequate amount of tissues.
48:37Now we have heard a little bit about
48:39breast cancer related lymphoedema we
48:41are now and it's one of the new things
48:44that is very interesting and and the
48:47early results are just trickling in
48:49from all over the United States.
48:51There are new treatments that allow us,
48:53especially early on,
48:55perform various interventions
48:57that bypass the obstructions.
49:00They're typically related to dissection
49:02of the armpit as well as radiation
49:06and treated by either connecting.
49:08Now the lymphatic vessels directly
49:10through the veins.
49:11What's called Lynn for the venous
49:13anastomosis or transfer of lymph
49:16nodes from elsewhere in the body
49:18to provide the breach of drainage.
49:20So if I were to summarize some of
49:23the new techniques,
49:24gradually replacing breast
49:26with structural fat grafting,
49:29removing implant or expander,
49:30deflating it is one of the novel ways
49:34that we're looking at potentially
49:36treating patients in order to
49:38maximize the natural feel of the
49:40breast and minimize the need for
49:42implant and in some cases the implant
49:45can be removed altogether.
49:47In cases where we really need,
49:49we don't have enough abdominal donor site.
49:51There are other potential donor
49:53sites for reconstructing breasts
49:55and outside of the stomach it can
49:58be hipped areas or inner thighs,
50:00and then finally lymphatic surgery
50:02for upper extremity lymphoedema.
50:04Those are just some of these new advances.
50:08But in summary,
50:09I would say almost every patient has
50:11an option of breast reconstruction.
50:13There are very,
50:14very few exceptions where I would
50:16feel it's not recommended there.
50:18They should be tailored.
50:19All of those options should
50:20be tailored to each option,
50:22their overall medical status,
50:23their body,
50:24and their personal preferences.
50:25Not everybody can invest the time
50:28of recovery to use their own
50:30tissues for breast reconstruction,
50:31but it's always an option later.
50:34I would say that more than half
50:36of breast reconstructions require
50:37more than one operations.
50:38And that's important to remember
50:40whether it's ****** reconstruction
50:41or revision revisions of shape
50:43for the two really
50:45enhance the cosmetic appearance are very,
50:48very common. And finally,
50:49it's important to remember that
50:51every reconstructive operation
50:53ends as aesthetic operations,
50:55so the nice result is really
50:58paramount of our efforts.
51:00And with that, thank you very much.
51:04Thank you so much Doctor Pomahac.
51:07We have a few questions in our chat
51:10box and to the audience members.
51:12Feel free to continue to put your
51:15questions in the chat for Doctor Park
51:17and perhaps you also Dr Palmer height.
51:20There is a question about ******
51:22sparing procedures and if one of you or
51:25both of you would like to talk about.
51:28Who is a candidate for a ******
51:30sparing mastectomies?
51:31On what considerations should
51:32be taken for that?
51:35Sure, so I think this is Carol's question.
51:39So what is the recurrence of disease
51:41in those that opt to spare their
51:43******* and are they at higher risk?
51:45So there are indications for
51:46****** sparing mastectomy.
51:47We really consider it like any other
51:50skin margin at this day and age.
51:53We also so as long as the cancer is not
51:56frankly right behind the ****** we think
51:59that you know uncle logically it's safe
52:00to do the ****** sparing mastectomy.
52:02We also also have a fail of a fail safe
52:06step in the operating room where we do
52:09a ****** core biopsy and make sure so
52:11you know we do the ****** sparing mastectomy.
52:14We take any tissue that's right
52:16behind the ****** and we had that
52:19specially tested by the pathologist
52:21with intraoperative frozen section.
52:23They look for any appearance of
52:26any cancer cells, and you know.
52:28So that's another safeguard.
52:31Other than that,
52:32the other kind of very conservative,
52:34but in more and more relaxing criteria
52:38for ****** sparing mastectomy generally,
52:40folks that are smaller breasted,
52:42have less risk of something called
52:45****** necrosis or ****** death.
52:47And folks that have less breast
52:50ptosis or droopiness of the breast
52:53basically also have less complications
52:55with their ******* potentially
52:56having issues post operatively.
52:59But I always tell patients if this
53:02very important to you could always
53:04try it and you know if the ****** ends
53:07up being involved in the interrupter
53:09frozen section then we'll we'll deal
53:11with it at that point and remove it.
53:12But we could at least give it a
53:15good shot from the beginning.
53:17Also, there's great data saying that.
53:22Even in patients that have.
53:24The. BRCA, one or two gene?
53:28So these are very high risk
53:30patients to develop breast cancer.
53:32****** sparing procedure is considered
53:34very safe and that's actually a
53:36preferred method for for preventative
53:38surgery for ****** sparing mastectomy
53:40for these bracket 1/2 patients.
53:42These patients are generally younger
53:44in their 20s and they're doing this for
53:47a preventative reason so we love to
53:49give them ****** sparing mastectomies
53:51so that they could continue on with
53:54their lives with with a good quality.
53:56Life.
53:57Great
53:58thank you Doctor Park Dr.
54:01Going to turn this one to you,
54:02which is one of the
54:05audience members is asking.
54:06I guess the broader issue of how we
54:09present options to our patients.
54:11Obviously, we present reconstruction
54:13options and her point is can come
54:17non-surgical breast replacement
54:19options such as external prostheses
54:22be also discussed prior to surgery,
54:25so essentially kind of presenting
54:27the whole gamut and spectrum of care.
54:29Yeah, no, I I think it's absolutely true.
54:32Breast reconstruction is an option.
54:33It's not a must, and it's always.
54:36An option to do nothing essentially
54:39allow the chest to be flat and
54:41and fit with matching prosthesis
54:43as close as it can go as close
54:45as it can to the natural side.
54:48The other thing that I would say
54:50is often the remaining one side
54:51can be too large or too droopy,
54:53so there are options to treat that
54:55up that one residual healthy breast
54:57with either Lyft or reduction so that
55:00it's easier to match the prosthesis.
55:02So all of those are options that can
55:04be discussed and certainly should
55:05be discussed during the visit.
55:07Whether it's with surgical oncologist
55:09or plastic surgeon.
55:11Great thank you all kind of pose.
55:15Pose a question to our
55:17panel members about age.
55:19We have come a long way to kind of
55:22as we kind of continue the theme
55:24of personalizing our therapies.
55:26Wanted to kind of get your thoughts
55:28on the age of the patient and how
55:31that may impact or decision-making.
55:33I'll start with medical oncology by
55:35saying that we have really kind of kind
55:39of stopped thinking of an age cutoff.
55:41For certain treatments and medical
55:44oncology and really focus on looking
55:46at the whole patient looking at
55:48how functional you are, what what,
55:51what other medical conditions you
55:53have and so typically do not have
55:55an age cutoff for our medical
55:58oncology treatments up.
55:59You know, with the exceptions,
56:00of course,
56:01maybe I'll turn it over to Doctor
56:04Park in terms of age considerations
56:06and axilla management.
56:08And then we'll go to Doctor Palmer,
56:09so
56:10I completely echo Dr Lustberg
56:13statements about. Uhm, about age.
56:16I feel like the life expectancy
56:19is getting more and more longer.
56:23You know, until level,
56:24I think like 70 is the new 50 because
56:27our ability to keep people alive
56:28in a with a good quality of life.
56:31As is. You know it's not unusual to
56:33have people live to their late 90s.
56:34It's not surprising.
56:36So I myself also don't.
56:39I alter and curate the surgical
56:42treatment based on patients medical
56:44problems and they're kind of overall
56:47functional status and sometimes on an
56:49older person has a great functional
56:51status and sometimes the person that's.
56:53Decades younger has a terrible
56:55functional status because they
56:56have lots of comorbidities and
56:58lots of other medical problems.
56:59That kind of make them a
57:01higher surgical risk.
57:02So I think about that versus
57:04actual chronological age.
57:07And I would. I would echo
57:08exactly what it was just said.
57:10It's a it's really tailored to the patient,
57:12not necessarily age of the patient.
57:14And we work with the patient to make
57:17sure that they choose option that they
57:19find most palatable and going forward.
57:22I think there's a huge future in in
57:25even specializing the postoperative
57:26protocols for patients above certain
57:29age so that we can we can minimize
57:32complications related to the smaller
57:34reserve or certain of certain types.
57:38Doctor Park, I'm going to take this
57:40one to you. An audience member is
57:43asking about atypical hyperplasia.
57:46UM and a risk factor for breast cancer.
57:50So atypical ductal hyperplasia,
57:52or atypical or kind of precancerous
57:55or cancerous duct cells that are in
57:58the breast duct, but at a very, very.
58:00Limited fashion, so we actually treat
58:03this in a outside because the best
58:07way would be like a holistic manner.
58:10We look at the patients risk factors.
58:12All of their other breast cancer risk
58:15factors which are many things as well
58:17as their family history and also how it
58:20looks like on mammography, if it looks.
58:22Very concerning on mammography and the
58:25vibes ended up being atypical ductal
58:27hyperplasia that would generally push
58:30us to excising it in case there is
58:32a hidden cancer in there somewhere.
58:35That's called upgrade. So that is.
58:40It's really a multi factorial thing
58:42so if you have a lot of family
58:44history of breast cancer,
58:46other risk factors which include
58:48your reproductive history as well
58:51as estrogen exposure as well as
58:54your mammographic findings is it
58:56kind of a suspicious looking masks?
58:58Or is it just you know some
59:01borderline looking calcifications?
59:02All of that is taken together
59:04as well as you know,
59:05age is also consideration to remove it.
59:10And to see if there's an
59:12underlying cancer in there.
59:15Great, we have one question
59:17is being answered in the chat.
59:20UM so keep an eye on that up and then come.
59:25But this question I'm going to turn
59:27over to you Doctor Park as well.
59:29It's about operating on stage zero and DCIS,
59:33and considerations for that. So
59:35ductal carcinoma, insight,
59:37or DCIS, is a pre invasive cancer.
59:39This is like consider like a step multiple
59:42steps past atypical ductal hyperplasia.
59:44But before invasive breast cancer,
59:47as of now, the textbook treatment is
59:49very similar to treating a cancer.
59:51You remove it where it's treated
59:53with radiation and if it's
59:55estrogen receptor positive.
59:56Also treated with systemic type
59:58therapy like endocrine therapy.
01:00:01There is some thought that certain low grade.
01:00:06Types of DCIS that strongly
01:00:07estrogen receptor positive could
01:00:09be treated non operatively.
01:00:11That's an ongoing.
01:00:13Point of study and trials are
01:00:16actively the comet trial.
01:00:18And a central are being actively done
01:00:20to see if we could identify a subgroup
01:00:23of patients that have DCIS that may
01:00:25never really progressed to cancer
01:00:26and may be a slow growing indolent
01:00:30static phenomenon for that cohort,
01:00:33but definitely for other cohorts.
01:00:35Folks with higher were busy
01:00:37looking cancer cells or high
01:00:39grade cancer cells that are DCIS.
01:00:42We we generally stick with standard of care,
01:00:44which is excision or radiation,
01:00:47and and it's some sort of systemic
01:00:50hormonal anti hormone therapy.
01:00:54Create an. Where at the top
01:00:58of the hour I wanted to come,
01:01:01there's just one more question.
01:01:03I'm just gonna answer and then
01:01:05I'll close that so so it's
01:01:07related to the park inhibitor.
01:01:08All impares a.
01:01:09Is it recommended for all BRCA one or
01:01:12two carriers regardless of cancer type?
01:01:15So studies are being done for prevention
01:01:17or risk reduction if there's no cancer,
01:01:20but in terms of current FDA approval
01:01:22it's indicated for metastatic,
01:01:24BRCA one and two tumors.
01:01:27And then the Advent indication for
01:01:30high risk here positive as well
01:01:33as triple negative breast cancer.
01:01:35Their results have been reported.
01:01:37We don't have official FDA approval yet,
01:01:39but were able to get the agents,
01:01:42so I would say in the metastatic setting,
01:01:46regardless of the cancer type
01:01:48in the adjuvant setting,
01:01:50it would be triple negative and higher risk,
01:01:51ER, positive disease for now.
01:01:54Well,
01:01:55thank you to the audience members
01:01:56for joining on your evening.
01:01:58A special thank you to my panelists for
01:02:01a great discussion and wonderful talks.
01:02:04There will be a number of other smiles,
01:02:06shares events with different
01:02:09topics throughout the month,
01:02:11so feel free to check out our sites
01:02:14for those events and thank you again.
01:02:17Have a good night.