Breast Cancer: Exploring Treatment Options

October 13, 2021

Information

Smilow Shares Greenwich | October 12, 2021

Presentations by Drs. Allysa Gillego, Beverly Drucker, and Allison Campbell

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00:04This is the outline of my talk tonight.
00:06I'll go over the statistics from there.
00:10Eric Cancer Society.
00:11I'll talk about how often a woman
00:14is diagnosed with breast cancer.
00:16Then I'll move on to screening.
00:18There are three ways to look for
00:20breast cancer in the breast,
00:21and that's mammography.
00:22Breast ultrasound and breast MRI.
00:25And then I'll talk about a very
00:27important part of breast cancer.
00:29And that's the sub for major
00:32subtypes of breast cancer.
00:34How those subtypes are determined
00:36and how this impacts treatment.
00:38And lastly,
00:39I'll go over breast cancer surgery options.
00:43Is that effects are from the
00:45American Cancer Society and you can
00:48see along the top nearly 2 million
00:50people in the United States will
00:52receive a new diagnosis of cancer.
00:54So about a million women will
00:56be diagnosed with breast cancer,
00:58and you can see breast cancer really
01:01remains the most common cancer
01:02diagnosed accounting for about a
01:04third of cancers diagnosed in women.
01:06And this is followed by lung
01:08cancer and colon cancer.
01:13At the bottom is, some are the
01:15statistics for death from cancer.
01:17Breast cancer is the second leading
01:20cause of cancer death and this
01:24year approximately 43,000 women
01:26will die from breast cancer.
01:33We know that incidence of breast
01:35cancer increases with age,
01:37so increasing age increases one's
01:39risk of developing breast cancer.
01:41So a woman in her 70s has the highest
01:44risk of developing breast cancer.
01:46But overall, the lifetime risk of
01:49developing breast cancer is 12%,
01:51with one in eight women in the United
01:53States being diagnosed with breast cancer.
01:58We know that there are also geographic
02:01variabilities for breast cancer.
02:03The states that are colored dark blue,
02:05or the states with the highest
02:07rates of breast cancer,
02:08and you can see New York and
02:10Connecticut have one of the highest
02:11rates of breast cancer in the country.
02:17This graph is showing each line representing
02:20a cancer from a certain part of the body,
02:23and the Red Arrows pointing to the light
02:26Gray line that represents mortality
02:29from breast cancer and you can see from
02:32about 1989 to 2018 there has been a 40%
02:36reduction in breast cancer mortality,
02:40most likely attributed to earlier
02:42detection and better treatment.
02:46In fact, there are over 3.8
02:48million breast cancer survivors
02:49living in the United States.
02:55So screening is important for for
02:57breast cancer, early detection,
02:59typically breast cancer has no symptoms,
03:01and most women diagnosed with breast
03:04cancer are diagnosed on mammography.
03:07Tumors that are detected earlier tend to
03:11be smaller and more easily easily treated.
03:15Three ways that we imaged the
03:17Brester mammography, breast,
03:19ultrasound, and breast MRI.
03:22The technology for mammography has improved.
03:24Initially, mammography used a
03:27technique using film and then digital.
03:30Mammography was developed first 2D
03:32mammography and now we we do mammography
03:36with using 3 dimensional images and
03:39this is known as Tomo synthesis.
03:42Tomosynthesis involves taking
03:43serial images of the breast.
03:48And a woman should begin start should begin
03:52having my map mammograms at the age of 40.
03:57A woman, when she turns 40,
03:59should speak to her primary care doctor.
04:01Her gynecologist about starting
04:04to undergo annual mammograms.
04:07There are some women who need to start
04:09having mammograms at an earlier age.
04:11So if a woman has a first degree relative,
04:14such as a mother or sister
04:16diagnosed with breast cancer,
04:18she should start having mammograms.
04:2010 years before the age of diagnosis.
04:23So the example on the screen
04:24is a woman who has a mother
04:27diagnosed with breast cancer 42.
04:28That person should start having
04:30mammograms at the age of 32.
04:36The addition of breast ultrasound can
04:39improve the sensitivity of mammography
04:41and ultrasound can be added to imaging,
04:44and a woman can undergo annual
04:47ultrasound along with her mammogram.
04:50It was a study
04:51by Doctor Brem that looked at
04:54over 15,000 women who had both
04:57mammography and ultrasound,
04:58and the study showed that the
05:01addition of ultrasound tomography
05:02did detect more cancers in
05:04women undergoing screening.
05:10We use screening. Breast MRI women.
05:13High risk of breast cancer when a woman's
05:16lifetime risk is greater than 20%,
05:19that woman should have an annual mammogram.
05:21In addition to an annual MRI.
05:26When an abnormality is detected on
05:29a mammogram, breast, ultrasound,
05:31or breast MRI and that abnormality appears
05:35suspicious or it's possibly a breast cancer,
05:38that woman typically will will
05:41undergo a needle biopsy performed
05:43by radiologists using that modality.
05:46So along the top row you can see
05:49an abnormality on a mammogram,
05:51and the woman on the top right
05:53picture is undergoing a biopsy.
05:56Using a specialized mammogram
05:59machine to target the area,
06:03that's abnormal.
06:04In the middle of the screen you
06:06can see a typical appearance of a
06:08tumor or breast cancer on breast
06:10ultrasound and to the right of
06:12that picture you can see a woman
06:14undergoing an ultrasound biopsy.
06:17If a woman has an abnormality
06:19seen on her MRI,
06:20she may need to undergo a MRI
06:23guided biopsy so the woman in the
06:25bottom right corner is undergoing
06:27a MRI biopsy of the breast.
06:32In the past, women diagnosed with breast
06:35cancer received similar treatment,
06:37but currently the treatment for
06:40patients diagnosed with breast
06:42cancer is very individualized.
06:44Over the next couple slides,
06:46I hope to show you a little bit of
06:48that evolution because currently
06:49in 2021 we do provide our patients
06:53with personalized targeted therapy.
06:55And this is known as precision
06:59or personalized medicine.
07:00And this is the picture of William Halsted,
07:03who is a surgeon who performed
07:06the first radical mastectomy
07:07in the United States in 1882.
07:11And you'll see that over the next 100 years,
07:15radical mastectomy was the main treatment
07:17for most women diagnosed with breast cancer.
07:21I mammography was invented in the 1930s,
07:24also in the 1930s we started to use
07:28radiation to treat breast cancer,
07:30and there were early developments and
07:32chemotherapy between the 1930s and the 1960s.
07:36Mark Seven is a medication used
07:38not only to treat breast cancer,
07:40but also to prevent breast cancer
07:43and tamoxifen received FDA approval.
07:45In 1977,
07:47surgeons began performing lumpectomy's.
07:50In the 1980s,
07:51a lumpectomy is a surgery which involves
07:54removal of the cancers portion of the breast,
07:57and so you can see from the time
07:59hosted the first mastectomy in 1882
08:01to one surgeons began performing
08:04lumpectomy's in the 1980s,
08:05bisected me really became.
08:07The mainstay firm for the treatment
08:09of breast cancer.
08:12A relationship between a genetic
08:15abnormality and the development of breast
08:18cancer was discovered in the mid 90s.
08:21And throughout the last 50 years
08:24there have been huge advances in
08:27the treatment of breast cancer with
08:29the approval of multiple medications
08:31for the treatment of breast cancer,
08:34such as anastrozole and trastuzumab.
08:39Uhm, before we talk about the different
08:42treatment options for breast cancer,
08:43I think it's really important to go over
08:46the main subtypes of breast cancer.
08:49From tumor receptors are what
08:51determines a breast cancer subtype,
08:53and after a patient undergoes a biopsy,
08:56we can determine which subtype of breast
08:59cancer a woman is diagnosed with.
09:03On the screen you can see the four
09:06main groups of breast cancer subtypes.
09:09The four main groups are luminal,
09:10a luminal B. Her two positive and
09:14triple negative breast cancers.
09:17UM the UM subtypes luminal A and luminal
09:21B tend to have better prognosis,
09:24whereas the her two positive and
09:26the triple negative breast cancers
09:28and the yellow and the orange
09:30tend to have a worse prognosis.
09:34Approximately 75% of breast
09:36cancers diagnosed or on the left.
09:39In this and the luminal being luminal
09:42B alumina and luminal B categories?
09:45And thankfully, most cancers are that are
09:48diagnosed are on this end of the spectrum.
09:53Luminal A luminal B cancerous are typically
09:56treated in addition to surgery with any
09:59estrogen therapy and hormonal therapy,
10:02and the center of the her
10:04two positive cancers and,
10:05in addition to surgery,
10:07most her two breast cancers,
10:09unless they're small,
10:10are treated with a combination
10:13of chemotherapy and targeted
10:15her therapy and more and more.
10:17Often, treatment begins with
10:18the chemotherapy and her two
10:21therapy prior to surgery.
10:23The purple negative subtypes
10:25have the worst prognosis.
10:27There are also sometimes referred
10:29to as basal like breast cancers.
10:32This is a study just showing those
10:35four subtypes again with the
10:37better prognosis and the luminal
10:39A and the luminal B cancers.
10:41This is another study that
10:43looked at the survival of
10:45those four different subtypes.
10:51But how are the subtypes determined?
10:53Uhm, so upon a biopsy.
10:56Upon getting a biopsy of the breast,
10:57the cells are examined,
10:59and the tissue that's retrieved
11:01from the breast is examined
11:03through a process called IHC which
11:05stands for immunohistochemistry.
11:10The slides that are highlighted on the left,
11:13or estrogen and progesterone receptor
11:15negative and then on the right are
11:18the cells that are estrogen and
11:20progesterone receptor positive.
11:21You can see there staining brown.
11:26Immunohistochemistry is also the
11:27process in which we determined
11:29the her two status of the tumor.
11:35And I want to surgery.
11:40Some patients diagnosed with breast
11:42cancer can undergo a lumpectomy,
11:44while other women undergo a mastectomy.
11:48And the decision to undergo a
11:50partial mastectomy or a mastectomy
11:52did it determined by many factors,
11:55and these factors include how
11:57much diseases in the breast,
11:59the size of the cancer relative
12:00to the size of the breast,
12:02the number of the tumors in the
12:04breast and location of the tumors,
12:06as well as other medical conditions.
12:10So on the screen is a mammogram image
12:13of ductal carcinoma insight two DCIS
12:17and ductal carcinoma site inside two
12:19is an early form of breast cancer.
12:22On the left you can see
12:24ductal carcinoma insight.
12:25Two is confined to a small area of the
12:27breast and a woman with this type of
12:30mammogram can undergo a lumpectomy,
12:31which is removal of just part
12:33of the breast on the right,
12:35even though it's an early cancer.
12:37The DCIS is spread out over
12:39a larger area of the breast.
12:41And a woman who's DCIS presents
12:43such as the image on the right
12:46may need to undergo a mastectomy.
12:49Tumor size is also an important
12:52criteria when determining if a patient
12:54can have a lumpectomy or mastectomy.
12:57And sometimes a woman has more than
12:59one area of disease in the breast,
13:02or more than one tumor.
13:05Multifocal disease is two or more
13:09cancers in the same quadrant or
13:12location or area of the breast,
13:14whereas the multicentric involves disease
13:17in another quadrant of the breast.
13:20A woman with multifocal disease
13:23can possibly undergo a lumpectomy,
13:25while a woman with multicentric disease
13:28may need to undergo a mastectomy.
13:31Women who are found to carry a
13:34gene mutation and are diagnosed
13:36with breast cancer are typically
13:38recommended to undergo a mastectomy.
13:41For women who undergo a mastectomy,
13:43some have no reconstruction,
13:45and so that the chest is flat with a
13:49scar going across the chest and some
13:52other women may undergo reconstruction.
13:55There are two main forms of reconstruction.
13:58The first main type of reconstruction
14:00is the use involves the use of
14:03an implant and the second type of
14:06reconstruction is using one body
14:09fat from one part of the body.
14:12To build a new breast and this is called
14:15autologous tissue reconstruction.
14:20So, in summary, breast cancer remains
14:23the most common cancer in women.
14:25You can see there have been promising
14:27developments of both the diagnosis
14:29and treatment of breast cancer.
14:30Women should have yearly
14:32mammograms supplemented with
14:34a yearly ultrasound defence.
14:36Breast cancer subtype is critical in
14:38determining treatment approach and breast
14:39cancer has evolved into individualized,
14:41patient centered treatment that is
14:43unique and specific to each woman.
14:48Uhm, the next part of. Uhm,
14:52the webinar will be Doctor Drucker.
15:00Think you're you're on mute? Thank
15:03you. Hi everyone, I'm going to focus on so.
15:07I'm a medical oncologist here
15:10at Greenwich and give treatments
15:12you know for breast cancer.
15:15And so my talk is going to focus on how
15:17we determine what those treatments are,
15:19again giving attention to what
15:20Doctor Gallego spoke about.
15:22How treatment is individualized?
15:25Uhm, so let me bring up my slides.
15:28Hold it.
15:32Nope, sorry, there we go.
15:39OK, here we go. Are they up?
15:46Hello so so this is going to explore
15:49treatment options for breast cancer. Uhm?
15:56So just took a quick overview
15:57of the statistics, very similar
15:59to what Doctor Gallego said,
16:00that breast cancer is very
16:02common of all cancers.
16:04It's about 25 percent, 30% in women,
16:07and again the statistic we always get
16:09back to is one in eight women will
16:11develop breast cancer in their lifetime,
16:13with that risk increasing
16:15the longer they live.
16:17The majority of breast cancers are actually
16:22not related to inherited mutations.
16:25Even though we we talk a lot
16:27and we screened for those,
16:28so 90% are thought to be either
16:32due to environmental issues.
16:35Most breast cancers because of screening,
16:37are caught at an early stage when
16:39they're curatives and the majority do
16:41fall into the good prognostic range.
16:43A category where they are both
16:46estrogen and progesterone positive,
16:47and her two negative, that being said.
16:52What we consider early stage disease is
16:56anything potentially curable by surgery
16:58and various amounts of additional
17:01therapies and but 30% will recur,
17:04though that's usually more
17:06in the more advanced stage.
17:09And when we talk about
17:10what increases the risk,
17:11there are many things that increase the risk.
17:13But of course,
17:14being a woman is one of them and
17:16and living longer and a lot of times
17:19people talk about how there's more
17:21cancer now than there used to be.
17:23And part of that is because of
17:25the improving prognosis people
17:26cardiologists have done their
17:28jobs and people are living longer
17:30and therefore get at more risk of
17:32developing cancers in general and for
17:34women breast cancer in particular.
17:39So what we always like to stress
17:41just as doctor Gallego mentioned,
17:43is the individualized approach
17:45to breast cancer treatment.
17:47Breast cancer is not one disease,
17:49it's many, and we there are various
17:54different ways you can categorize cancers,
17:57so one of the first things that decides
17:59how we're going to treat breast cancer
18:01either before or after their surgery,
18:03is the stage stages.
18:05One through three are
18:07considered curable stage.
18:08Or is not?
18:10Other factors that go into deciding how
18:13we're going to treat a patient is the age
18:15of the patient and their comorbidities.
18:17Usually, younger,
18:18healthier patients are treated
18:21with more aggressively because
18:23there are more years at stake,
18:25and also we think they can handle
18:27treatments a little bit better.
18:29And then of course some of the
18:31treatment is also determined by the
18:33unique characteristics of the tumor.
18:35There are different options available
18:37if the tumor is, ER, positive.
18:40Such as hormone therapies.
18:42If the tumor is her two positive,
18:45there are therapies specifically
18:47targeted to that and want
18:50to tumors triple negative.
18:53That we tend to focus on chemotherapy
18:56so so our treatment decisions are
18:59based on a combination of the
19:02patient and their characteristics,
19:04what the stage of the tumor is,
19:06and what the characteristics
19:07of the tumor are.
19:11So the most common, uh,
19:14early stage breast cancer or
19:16estrogen receptor positive cancers.
19:21Hormonally targeted agents are actually the
19:24most potent treatments for these cancers,
19:28and there are a variety that we can use,
19:30and again, which we pick
19:32depends on on the patient.
19:35Tamoxifen came out in the 1970s.
19:38It is the oldest of the hormone treatments
19:40and it used to be used for everyone and
19:44now mostly used for pre menopausal women.
19:48If we feel the need to be more aggressive,
19:50we will sometimes give LHRH agonists
19:53those work by lowering estrogen and are
19:56often given to premenopausal women as
19:59an additional sort of more aggressive
20:02way of treating them hormonally.
20:05If the tumor is small,
20:06we might go with tamoxifen only
20:08if we think the tumor.
20:11Or as has higher risk,
20:12will use a continent tamoxifen
20:15and LHRH agonists.
20:16The big difference between tamoxifen
20:18and the drugs we use for post
20:20menopausal women is tamoxifen mostly
20:22works as an estrogen blocker.
20:24Drugs that we use for
20:26menopausal women such as Rome.
20:28Taste inhibitors work by lowering estrogen,
20:31so again looking at the patient.
20:33We have to determine if the
20:35patient pre or post menopausal.
20:37Figure out what their other medical
20:40conditions are and decide which of these
20:43endocrine therapies are best for the patient.
20:46If we think the tumor is higher risk,
20:49then we will not only use endocrine therapy,
20:53but we will use a combination of
20:56chemotherapy and endocrine therapy.
20:58Very often,
20:58when patients have a are newly
21:00diagnosed with breast cancer,
21:02you know their question is will I get
21:05chemotherapy or will I get entrepren therapy?
21:08And again it's for an estrogen
21:11receptor positive cancer.
21:12We will always offer endocrine therapy.
21:16Work in therapy actually is more effective
21:19therapy with less toxicity than chemotherapy.
21:22But if we think we need to use everything
21:24in our war chest to treat the cancer,
21:26we will use both.
21:28Some of the newer advances that have
21:31occurred in making these decisions is.
21:34The use of the Oncotype DX test,
21:37which is a molecular assessment
21:41of how likely the tumor is to
21:44respond well to hormonal therapy.
21:46So when first presented with a with a
21:49patient who has an ER, positive cancer.
21:52Again trying to figure out her risk,
21:55we will look at tumor size.
21:57We will look at lymph node involvement.
22:00The grade of the tumor,
22:01which is an assessment of how abnormal
22:03it looks under the microscope.
22:05Uhm,
22:06we will look at the tumor itself and
22:08see if we see cancer cells within either
22:12lymphatic vessels or or blood vessels.
22:15To see,
22:15does this cancer have a chance
22:17to spread elsewhere?
22:19The larger the tumor,
22:20the greater the odds that the
22:22cancer can have left before surgery.
22:24Kind of left and spread to elsewhere
22:26in the body before surgery was done.
22:28If we see lymph node involvement
22:30that already tells us cancer cells
22:32have left the site of the tumor
22:33and gone elsewhere in the body.
22:35Before surgery was accomplished,
22:39tumor grade,
22:40which again is a sort of value
22:42judgment by the pathologist of
22:44how abnormal it looks often
22:46correlate's with how aggressive the
22:48tumor will behave and how likely
22:50it is to spread and similarly
22:52seeing blood cancer cells within
22:54blood vessels or within lymphatic
22:56vessels does suggest that there's a
22:59possibility that the cancer has spread.
23:03Before surgery happened,
23:04even if when the lymph nodes
23:06are assessed their negative.
23:08That being said,
23:09that sort of those components,
23:12tumor size, lymph node involvement,
23:14lymphovascular involvement will
23:15tell us what is the likelihood
23:18that the cancer could have left
23:20the breast and gonna be hiding
23:22somewhere in the body after surgery.
23:25But it doesn't necessarily tell us
23:27how likely it is that hormone therapy
23:29will kill off any cells that might be.
23:32Working,
23:33and that's what the Oncotype DX says.
23:36And what that does.
23:37That was a test that was generated
23:40by looking at historical controls.
23:43Women who were diagnosed in the
23:4570s and 80s who were treated with
23:48tamoxifen that was awhile ago.
23:50We know what their outcome was.
23:52Their tumors,
23:53if they were involved in clinical trials,
23:55were kept in pathology banks and the
23:59people who devised the Oncotype DX test,
24:02actually.
24:02Wanted to know if the cancer
24:05patients who they knew were cured
24:08with tamoxifen were different
24:10than the patients who weren't,
24:13so they went back to the pathology labs,
24:16looked at the molecular expression
24:18patterns of the cancers of those who
24:21were cured with hormonal therapy and
24:23those who were not and found that
24:26there was a different pattern of
24:28protein expression in the cancers
24:31that responded well to hormonal therapy.
24:33Versus the cancers that did not.
24:36They then sort of made and sort of as
24:39a way to assess a newly diagnosed cancer.
24:42Which was it more like the good
24:44behaviors or the bad behaviors?
24:46And then came up with the tool
24:48that we have before we start
24:50treatment to to get a better sense.
24:52Will this persons tumor respond well
24:55to hormonal therapy and do we need to
24:59give them chemotherapy and and therefore
25:01actually the benefit of this test is that?
25:03We give a lot less chemotherapy
25:06than we used to.
25:07Some of the newer developments
25:09with this test strips.
25:11I went the wrong way.
25:12A is there has been re
25:15assessment of that data.
25:17The test was originally only validated for
25:20people with small tumors and no lymph nodes.
25:23We knew there was a group that.
25:26Based on the test prediction would
25:28do very well with hormonal therapy.
25:30We knew there was a group
25:32that based on the tests.
25:34The score would do very poorly if
25:36all we did was hormone therapy,
25:38so those we gave chemo to and
25:39when the test first came out
25:41there was this intermediate zone
25:43that we really didn't know.
25:45There were some on the edge and we
25:47didn't know if giving chemotherapy to
25:50those patients would prove beneficial.
25:53More actually published,
25:54I think two years ago was the
25:56result of the Taylor RX trial,
25:58which specifically looked at
26:00whether or not giving chemotherapy
26:03to women whose tumors scored in
26:06the intermediate zone had any
26:08added value. And interestingly,
26:11if you were over 50.
26:14There was no value to giving chemotherapy
26:17to people in the intermediate zone,
26:19but if you were under 50,
26:21there was a small benefit,
26:23so that allowed us to give
26:25chemotherapy to even fewer patients.
26:27More recently,
26:28the tests you know the verification
26:33has been expanded to women who have
26:36involved nodes and generally are
26:38thought to have higher risk of disease.
26:42In the past, if we saw lymph nodes involved,
26:45we were much more concerned that they
26:47that the patient would involve lymph
26:49nodes was going to have their cancer
26:51come back and we would almost need
26:53your give those patients chemotherapy.
26:55But further evaluation of patients
26:58using the Oncotype test and going back
27:01and looking at historical control shows
27:03that even women who have anywhere from
27:06one to three involve lymph nodes might
27:09do just fine with hormone therapy.
27:12Provided that their cancer expresses
27:15the protein pattern that suggests that
27:18hormone therapy will work really well.
27:21So whereas in the past any woman
27:23with lymph node involvement would
27:25have been giving chemotherapy.
27:27Now if their recurrence score is low,
27:30if the characteristics of their tumor suggest
27:33an excellent response to hormone therapy,
27:35we won't give them chemotherapy and
27:39and similar to the tailor X trial.
27:42Older women.
27:43Are less likely to get a benefit from
27:46chemotherapy than younger woman,
27:49and in that trial they looked at.
27:50They made the division.
27:52If you were already in menopause,
27:54you actually got less benefit than if
27:57you were pre menopausal and some of that
28:00is thought that the post menopausal
28:03has less estrogen and more likely
28:06to respond to hormone manipulation,
28:10but again the the wonders of the
28:12appetite DX test is it allows us.
28:14Or or helps us prevent us from over
28:17treating patients with chemotherapy.
28:19They don't need so,
28:21so this is sort of when we talk about
28:25personalized care and everyone's
28:27cancer being different.
28:28This is assessing it on a molecular level,
28:31allowing us to correctly treat patients
28:33with hormone therapy who only need
28:36hormone therapy and reserve chemotherapy
28:38to people who are both at higher risk
28:41based on characteristics like tumor size,
28:43lymph node status.
28:45But also the molecular aspect of their tumor.
28:52So, so something that Doctor Gallego had
28:55talked about was the four types of cancer,
28:58a luminal a the luminal B which are.
29:02ER positive her two negative cancers.
29:07Presumably with the archetypes,
29:09sort of compliments in that is that you
29:12know luminal a are more likely to be
29:15patients treated with hormone therapy only,
29:18and that can help is better
29:21determined by the Oncotype test
29:23lumenal be those patients who have
29:25ER positive her two negative cancer,
29:28but are still at high risk. Again,
29:31can be identified by the archetype test,
29:34but she had talked about how the
29:36her two positive cancers.
29:38For poorer prognosis cancers,
29:41which historically was true.
29:44Though that has changed because of new
29:46drugs that have been developed that
29:49specifically target the her two protein,
29:51you can see her two is a protein
29:54that is involved with cell growth.
29:57It is one of a family of of cancers,
30:02not cancers of proteins that
30:04help regulate cell growth and in
30:07about 1/3 of breast cancers it is
30:10overexpressed so you have more of
30:12these pro proteins that help cells.
30:14To grow then should be there,
30:17and these cells grow very quickly
30:19and they spread very quickly the the
30:22because of this aggressive nature.
30:25When we see her two positive breast cancers,
30:29chemotherapy is almost always recommended.
30:32Unless of course,
30:33the patient is extremely elderly
30:35or we don't think they can tolerate
30:39chemotherapy historically.
30:40The reason these were thought
30:41to be such poor prognosis.
30:43High risk cancers is even if
30:45you gave these patients.
30:46Chemotherapy and if they were,
30:48they were positive.
30:49Even if you gave them hormonal therapy,
30:50they would come back.
30:52However,
30:53in 1998 Herceptin was FDA approved
30:57initially for the treatment of
31:00only widespread metastatic cancer,
31:03but in 2006 it was shown that
31:06if you use the Herceptin early,
31:08you could have a significant
31:11impact on these cancers,
31:13so that small cancers that are.
31:16Don't involve lymph nodes.
31:18The If you treat them with a combination
31:21of chemotherapy and Herceptin therapy.
31:23You can get cure rates of up to 9598%.
31:28Drug manufacturers have really
31:30focused on this really very impressive
31:33change in how we view these her two
31:37positive cancers and have developed
31:39additional drugs in the past 20 years.
31:42At least five drugs have come out,
31:45possibly more to treat
31:47her two positive disease.
31:49Many are still only used
31:51in the metastatic setting,
31:52but would have been added to the early
31:54setting where we're looking at cure patients.
31:56There is now another.
31:57Her two targeted drug called.
31:59Perjeta, which came out in 2017,
32:02and then there's a third drug, Kadcyla.
32:07First came out in 2013 for the
32:09treatment of metastatic disease,
32:11but in 2019 was shown to.
32:16Improved cure rates for patients who had,
32:20if they were treated first with Herceptin,
32:22and at the time of surgery,
32:24were found to have persistent disease.
32:27So something that has changed.
32:28Also how we incorporate chemotherapy
32:31and surgery for early stage.
32:33Her two positive disease.
32:35Historically,
32:35we would always give chemotherapy afterwards,
32:38but now because of the studies that have
32:41shown that if you can't make all the
32:44cancer go away with treatment before surgery.
32:47Changing therapy to Kadcyla
32:49also improves cure rates.
32:51This has really changed when we
32:54introduce chemotherapy now sometimes,
32:56specially for her two positive disease will
32:58do it before surgery rather than after.
33:01Uhm,
33:03and then lastly,
33:04we get to triple negative disease,
33:05which is very high risk.
33:09Partially 'cause we don't have targets up.
33:12Hormone therapy with either tamoxifen
33:14or Roman taste inhibitors won't
33:17work because there's no estrogen
33:20receptor controlling cancer growth.
33:22Her two targeting agents won't work
33:24because the her two protein is not
33:26overexpressed and chemotherapy
33:27is the only option.
33:31Things that have a new approaches that
33:34have come in the past few years and
33:37things that are currently under study are
33:40the ideas of adding yet another drug.
33:43Often we will treat triple negative
33:45disease with a combination of three
33:47different chemotherapy agents and what's
33:49being actively looked at now is the
33:52benefit of adding a fourth and perhaps
33:54one of the more exciting changes that
33:56has also occurred with triple negative
33:59disease is the addition of immunotherapy.
34:02Trying to get the immune system involved
34:05in trying to kill cancer cells in addition
34:08to the chemotherapy and just this year,
34:11the FDA approved an immunotherapy drug
34:14for high risk but curable triple negative
34:18disease in combination with chemotherapy,
34:21which is again been shown to
34:23improve cure rates. Uhm?
34:25Here at Greenwich we are continuing
34:28to participate in clinical trials,
34:30hoping again to add more options
34:32to our patients who are diagnosed
34:34with breast cancer.
34:36One trial is the DARE trial,
34:38which is looking at women who are
34:41who have potentially curable disease,
34:43but high risk because the tumors
34:45were either large or involved.
34:47A lot of lymph nodes and looking
34:49for evidence of circulating tumor
34:51cells in the blood.
34:53If those are found, the clinical trial.
34:56Will a rant randomize them to going
35:01to different hormone therapies to
35:03treat their cancer in combination
35:05with some oral drugs that can make
35:08hormone therapies more effective versus
35:10continuing as we normally would with
35:13just continuing on hormone therapy.
35:15And this is a trial to look at one.
35:17Are there better hormone combinations
35:21for women with estrogen receptor
35:24positive disease?
35:25And is this tool looking at?
35:28Circulating cancer cells in the blood.
35:30An effective tool to guide our treatments.
35:33We also have some studies for
35:36triple negative disease.
35:38One referring to regarding adding
35:41a fourth drug, two chemotherapy.
35:44We, our standard of care,
35:45is using three drugs and checking to see
35:48if adding a fourth will have benefit,
35:51and then we have another study here,
35:54again,
35:55looking at for patients who don't get
35:58immunotherapy upfront if they still
36:01have disease at the time of surgery,
36:03will adding immune therapy help so?
36:07Again,
36:08the major things to the major points of
36:12what I'm trying to say here tonight is
36:14that breast cancer is not one disease.
36:17It is many and is very important to
36:20personalize treatment to both the
36:22patient who has the cancer and the
36:25characteristics of their tumor and
36:27then things are improving all the time.
36:30So as I always like to look to the
36:33future and participate in clinical trials,
36:36it's the way we get answers and
36:38better treatments.
36:39And then thank you for your time.
36:43Thank you Doctor Drucker. Uhm?
36:45Now for Doctor Alison Campbell
36:48from radiation oncology. OK. Just
36:53trying to share my screen here.
37:00Can you guys see my slides?
37:03OK great so thank you so much for
37:07inviting me to be part of this panel.
37:10My name is Allison Campbell and
37:12I'm are radiation oncologist here.
37:14So Dr, Gallego and Doctor Drucker have
37:17given a great overview into sort of
37:19the statistics of breast cancer and how
37:22important individualized treatment is.
37:24So I'm going to shift gears a little
37:26bit and talk about radiation because
37:28a lot of times people haven't
37:31really encountered radiation in
37:32sort of their daily life.
37:34So radiation is a part of cancer care in
37:38that it's very good at killing cancer cells,
37:41but not healthy cells.
37:42So what we say is that radiation
37:46selectively kills cancer cells,
37:49so we use beams of high energy particles.
37:51Usually these are photons.
37:53Sometimes these can be electrons
37:56or protons and we target the breast
37:59and these high energy particles
38:02damage the DNA in the cells.
38:04That they fall on,
38:06but normal healthy cells are able to
38:08repair their DNA while cancer cells
38:11are dividing very quickly and cannot
38:13repair their DNA and so when they go
38:16and try to divide, they actually die.
38:18And so that's how radiation
38:21kills cancer cells selectively.
38:24Generally speaking,
38:24when we are using radiation,
38:26it's coming in after surgery.
38:28But as Doctor,
38:29Gallego and Doctor Drucker said,
38:30every patient's journey through
38:32breast cancer is different and
38:34depends on their stage and their
38:37hormone receptor status.
38:38But a lot of times people ask me,
38:40you know if margins are
38:42negative after surgery.
38:43Why come in with radiation and
38:45give that as another treatment
38:47when everything that we can see
38:49has been gotten out.
38:51But we know that occasionally.
38:53Even single cells that are cancerous,
38:56or precancerous that are left behind,
38:58can go on to divide and cause the
39:01tumor to come back so radiation
39:03can kill these cells and reduce
39:06the risk of cancer recurring,
39:08and to put some numbers to this.
39:10So in older clinical trials,
39:13we know from many, many studies that,
39:16generally speaking,
39:17the benefit of radiation is to
39:20reduce the risk of local recurrence
39:23by approximately 50%.
39:24In early stage breast cancer for
39:27patients who've had a lumpectomy
39:29and that this reduction in local
39:32recurrence actually also translates
39:34to a benefit in overall survival.
39:36So the numbers that have come out
39:38of these really big studies are for
39:41every four are occurrences prevented.
39:43We save one life for late stage
39:46breast cancer.
39:47The numbers are a little different.
39:49It's usually a greater than 50% benefit,
39:51but this depends a lot on some of
39:53the characteristics of the tumor.
39:55And whether there are any lymph
39:58nodes involved.
39:58But radiation can also confer
40:01an overall survival benefit.
40:03In advanced stage breast cancer.
40:07So how do we give radiation if it is
40:10part of a patient's treatment strategy?
40:12So we actually take great care
40:15when we plan the radiation,
40:17so I'm going to talk through
40:19exactly what we do.
40:20And and then we use a
40:22machine called a linear
40:23accelerator to actually deliver radiation,
40:26and it's a treatment that you get every
40:28day for a period of weeks depending
40:31again on your own personal stage
40:33and and risk factors that you have.
40:36So we'll talk about all of this in detail.
40:39So the first thing we do when we
40:43plan radiation is we do a simulation
40:46session or a planning session and
40:49we bring the patient in and have
40:51them lie flat on their back and
40:53they go through a cat scanner and
40:56that's what you're looking at here.
40:58This is a picture of a woman who is lying.
41:02Her feet are toward us,
41:03so the right hand side of the screen
41:06is the left hand side of her body.
41:08The two sort of.
41:11Dark ovals in the middle of the lungs and
41:14then in the center of that is the heart
41:16and the breast tissue is over to the side.
41:20So the first thing that I do after we
41:22get this kind of scan is I actually go
41:25through and map out both normal structures
41:27and also the area that we want to target.
41:30So here you can see the
41:31heart is circled in red.
41:33The lungs are circled in green and
41:35then on the left there you might
41:38think that that looks potentially.
41:39Like a tumor,
41:40but actually this is for a patient
41:42who's already had surgery.
41:44So what you can see there outlined
41:46in the pink is a very small fluid
41:48collection where the tumor used
41:50to be so a lot of times we can see
41:52surgical changes that we then go
41:54through and we map and we put a
41:56margin on to make sure that when
41:58we're treating the breast were
42:01covering that surgical area very well.
42:05So then once we have our mapping done,
42:08we design our radiation fields and
42:10this is all done by computer right
42:14here you can see several different
42:16representations of how we arrange our beams,
42:19but generally speaking here,
42:21they're kind of shown as flashlights,
42:24even though in real life the
42:27beams are invisible.
42:28You can see that one beam
42:30comes in on the top left here,
42:32sort of from the middle of the chest.
42:34Pointing toward the armpit on the
42:37other below right below here you can
42:40see we have our other beam coming in
42:42from sort of the back into this side.
42:45So what you get if you look on the top
42:48right here is you get this targeting
42:50of all of the breast tissue with
42:52a tiny little slice of the lung.
42:55Because of the curvature of the chest
42:58wall and what you can see down here in
43:01the bottom right hand corner is an actual.
43:05Representation of those beams so you
43:08can see that the radiation is coming in
43:12from two sides and then we're getting
43:15excellent coverage of our surgical bed.
43:18So a lot of mathematics goes
43:20into the planning of all of this.
43:23But then you know one thing
43:26that we do when we're putting
43:28all of this together is not only are we
43:30making sure that we're targeting the
43:32breast tissue and the surgical bed,
43:34but we want to do.
43:36Everything that we can to protect
43:38and a normal structures from getting
43:40any significant radiation.
43:42So for right sided cases this
43:44is more straightforward,
43:45but on the left side the heart is very
43:47close right underneath the breast,
43:50so we have two different strategies
43:52that we can use to protect the heart.
43:55The first strategy is to have the
43:57patient actually lie on their stomach
43:59and we have a special table with
44:01a cat scanner so the breast can
44:04actually hang down away from the body.
44:06So that's what you're looking at here.
44:08This is a person who's lying on
44:10their stomach.
44:10This is the heart here and then.
44:12In blue is the breast tissue and
44:14yellow is the border of the radiation field.
44:17So you can see that we're able to
44:19treat the breast which is hanging down
44:21in a way without treating the heart.
44:23Sometimes this technique isn't
44:25the right one to choose.
44:27Sometimes people can't lie on their stomach,
44:29and sometimes we really need
44:32to treat this area.
44:33That's that's a lateral to the breast,
44:36sort of in the armpit where
44:37the lymph nodes are,
44:39and this technique doesn't give
44:40us great coverage for that.
44:42So my favorite way to protect
44:44the heart is actually to use a
44:47breath holding technique.
44:48So when you take a deep breath,
44:50your lungs inflate and it
44:52pushes your heart down in a way.
44:54From your chest wall and we're actually
44:56able to come in with radiation beams
44:58between the heart and the chest wall.
45:00So we're blocking the heart from
45:03getting any radiation while still
45:04giving radiation to the breast.
45:06And this also gives us really
45:08good coverage of those lymph node
45:11regions under the arm.
45:12So we have a lot of very special
45:15monitoring systems that allow us
45:16to see how the chest rises and
45:18falls in real time while people
45:20are taking and holding a breath.
45:22So when we ask patients to hold their breath,
45:24they're only holding it for about
45:2720 seconds and we're able to see
45:29that there holding the correct
45:31depth of breath by monitoring
45:33the surface of their body.
45:35If someone were to sneeze
45:37or have the hiccups,
45:38or you know anything that
45:39got in the way of that,
45:41our machines would shut off automatically.
45:43Because we tell them exactly where the
45:46chest wall should be to get the the
45:49beam of radiation to come in safely,
45:51keeping the heart blocked.
45:54Once we've done our planning,
45:56then we bring the patient in for treatment.
46:00This is the treatment machine that we have.
46:02It's called a linear accelerator and X rays
46:05come out of the circular part at the top.
46:08The patient lies on the table and the machine
46:11moves around them to deliver the radiation.
46:15A lot of patients want to know how we
46:17know that we're right on target and we
46:20have multiple mechanisms to do this.
46:22So at our planning session will make markings
46:25on the skin and then when we bring the
46:28patients back for their actual treatment,
46:30we use those markings to set up two to
46:33make sure that we're in the right place.
46:35We have a laser alignment system and
46:38we use those lasers to line up right at
46:40the center of the markings that we make
46:43it our planning scan, but we also do.
46:46Other things too.
46:47We have X ray verification of internal
46:49anatomy so that we know that even even
46:52when we're right on the skin marks,
46:55we also know that the bones are lining
46:57up because we do an X ray before
46:59the start of our first treatment and
47:02then for almost all patients we use
47:04surface monitoring of the skin so we
47:06can see if there's any changes in
47:09how they are setting update today,
47:11how the breast is falling,
47:12if there's any swelling.
47:13All of these things can be
47:15monitored by our systems.
47:17So we know every time we're giving
47:19radiation that we're really right on
47:21target down to the millimeter level.
47:25Come and then. Finally,
47:27in as Doctor Drucker and Doctor
47:31Gallego explained everybody's breast
47:33cancer journey is different depending
47:35on their stage and their hormone,
47:37receptor status,
47:38and their age and their general health.
47:40So we don't give the same radiation
47:42regimen for every woman that we see.
47:45We have three major regiments
47:47that we choose from.
47:48The first is a standard
47:50fractionation regimen,
47:51so this is an older regimen,
47:53but we still use this for
47:55our high risk patients.
47:57Or for patients that have had a
48:00mastectomy or who have cancer in lymph
48:03nodes where we need to set up special
48:05fields specifically targeting those nodes,
48:08so for these patients it's five
48:11weeks of radiation to the whole
48:13breast or to the whole chest wall,
48:15followed by 5 treatments where
48:18we boost the surgical bed.
48:21For most early stage or lower
48:23risk breast cancer patients,
48:25we use what we call a
48:27hypofractionated regimen,
48:28which just means it's a
48:29fewer number of fractions.
48:31So in that case it's treatment
48:33for 15 treatments or three
48:36weeks to the whole breast,
48:38followed by 4 treatments to the surgical bed.
48:41And then there's a special category
48:44of women who have lower risk
48:46cancer and who are over the age
48:48of 70 where we can use a special
48:51regimen called the fast regimen.
48:53And this is 5 treatments total given
48:57one treatment per week without a boost.
49:01So again, this is a special regimen
49:04for very low risk cases,
49:06but those are our general paradigms.
49:10So to kind of tie everything together,
49:13you know.
49:13And as Doctor Gallego and Doctor
49:16Drucker have said,
49:17and as I've tried to emphasize as well,
49:19every patient that comes in gets sort
49:23of a a custom path through their treatment.
49:28Based on everything that we know about
49:31their risk factors that they have.
49:33Generally speaking,
49:35for early stage disease,
49:37patients will get surgery.
49:39Maybe, maybe chemotherapy
49:41if their Oncotype test does.
49:43Doctor Drucker was talking about returns
49:45as high risk followed by radiation,
49:48and then hormonal therapy if they have
49:51hormone positive markers for disease,
49:53that's more advanced when
49:55the tumor is very large.
49:57Initially,
49:57a lot of patients may get chemotherapy first,
50:01followed by surgery,
50:02and then radiation therapy and
50:05additional systemic therapy.
50:06I think ultimately the the.
50:09Message is that all of us work together.
50:15Doctor Gallego and I have local therapies,
50:18so surgery and radiation specifically
50:20target the the tumor where it is
50:23and the surrounding breast tissue,
50:25while Dr Drucker specializes in
50:27systemic therapies that work
50:29throughout the whole body,
50:31and so these kind of all go hand in
50:34hand to give people the best possible care.
50:39That is the end of my talk,
50:41so I think it's time for questions
50:43which I think Dr Gallego is
50:45going to moderate for us.
50:52I'd like to thank the speakers,
50:54but most importantly I'd like to
50:56thank all the people who joined
50:59us tonight for the webinar.
51:01Thank you for taking the
51:03time to watch the talks.
51:06And if you have any questions,
51:08you can type it into the
51:11question and answer section.
51:12I don't see any.
51:16I don't see any questions.
51:21Right now.
51:40I guess I'm not really.
51:41I'll ask a question, OK? Uhm?
51:45Some some women would like to know
51:49what they can do to decrease their
51:51risk of getting breast cancer.
51:53So in a woman who doesn't have breast cancer,
51:57what are some of the things that she can
51:59do to decrease her risk of developing the
52:01disease so so? Some of the
52:07things that I've patient can do.
52:08There have been studies that have shown
52:10that women who exercise regularly
52:12have lower rates of breast cancer.
52:16Which is also just good for your heart
52:18health and general overall health.
52:20UM, you know, a set of a diet low in fats.
52:26Again, all the normal things
52:27we think are healthy.
52:28You know there's a slight
52:30increase risk with smoking.
52:31There is potentially a slight
52:33increase risk with alcohol use,
52:36and so you know lifestyle.
52:38Everything in moderation.
52:40Sort of being health conscious.
52:43UM, I sometimes hate to stress that because I
52:46don't like to blame people for their cancer.
52:48So I have people who are vegans and exercise
52:51all the time and can still get breast cancer,
52:54so I I always hate to like I
52:56don't want to think that you did
52:59something to get breast cancer.
53:01Being a woman puts you at
53:03risk for breast cancer,
53:05but certainly you know to be mindful of,
53:08you know our our weights,
53:10what we eat.
53:11And what sort of I hate to say common sense.
53:15Approach to keeping healthy.
53:17The other thing that I like to stress is,
53:20you know,
53:20sometimes you know bad stuff happens.
53:22People are diagnosed with cancer,
53:25but early detection is really key.
53:27So I spent my whole talk focusing
53:31on early stage breast cancers.
53:34It is so important to go for your
53:37mammograms because when we catch
53:39breast cancer early when we catch it,
53:41when it's small,
53:42that's when we can cure it and
53:44that the earlier we catch it,
53:47the less chance that I have to do
53:49something like give chemotherapy
53:50and something I I didn't stress when
53:52going through the archetype is,
53:54you know,
53:55originally Oncotype this ability to
53:57better define who doesn't need to get
54:00chemotherapy was only for patients
54:01with lymph node negative disease.
54:04It is now been.
54:05Expanded to include more groups,
54:07but for for patients who come.
54:12You know our sort of not mindful
54:14of going from mammograms.
54:16If it the cancer is there
54:19and not detected early,
54:20we feel forced that the risk is
54:22higher and we have to give chemo.
54:24So certainly exercise quote.
54:27Eat right.
54:29Everything in moderation,
54:30you know, try to avoid fats.
54:32Eat more complex carbs and less simple carbs,
54:36but also can't stress enough.
54:38Go for your mammograms.
54:43Thank you and I have a question for
54:47Doctor Campbell if you could go over.
54:52You know women who undergo
54:55a lumpectomy or surgical
54:57removal of the cancers portion
54:58of the breaths, or typically
55:01recommended to undergo radiation.
55:03But what are the indications in
55:06which a woman has a mastectomy,
55:09but then is recommended to have
55:14radiation aftermath mastectomy? Yes,
55:16so that is there's some areas of that
55:19that are very straightforward and
55:21some that are more controversial.
55:23So after mastectomy,
55:26if there is lymph nodes that are involved,
55:30then depending on the number of nodes,
55:33the strength of the recommendation goes up.
55:36So the more lymph nodes that you have
55:38involved, the stronger the recommendation
55:41is for radiation after mastectomy,
55:43and we treat the lymph node
55:45region and the chest. Wall, uhm.
55:47In addition, even if you have
55:50only one to three positive nodes,
55:53there's still been shown to
55:54be a benefit of radiation.
55:56So right now,
55:57the NCCN current guidelines recommend
56:00that even in the setting of just
56:03one to three notes positive with a
56:05dissection that women still consider at
56:08least come see a radiation oncologist
56:10to talk about post mastectomy
56:13radiation and other things that
56:15can can push us in the direction.
56:17Of talking about radiation are large tumors,
56:21so tumors that involve the
56:23chest wall or the skin,
56:26or where there's lymphovascular
56:28invasion and and then always for young
56:32women with triple negative cancer,
56:34most of the time they've
56:36received chemotherapy upfront,
56:38and there are some ongoing clinical
56:40trials looking at whether we could maybe
56:43omit radiation for women who've had a
56:45complete response to that chemotherapy.
56:47Upfront followed by surgery,
56:50but even in those cases currently,
56:54before those clinical trials result
56:57back the standard of care is still
57:00to offer radiation based on that
57:03initial staging of the cancer.
57:07Thank you so a question just
57:10came in Doctor Campbell.
57:12If you can go over the side effects
57:16during radiation for a patient who's had
57:20a lumpectomy has early stage disease.
57:24Are you able to say what kind of
57:26treatment she would get and the most
57:28common side effects she would experience?
57:31Yeah, so uhm. So stage one disease.
57:35Uhm, it's sorry. Did you say a
57:39hormone receptor negative? UM
57:42formal yes hormone receptor
57:44negative her two positive.
57:46OK so I think also we can loop doctor
57:49Drucker in on this question too
57:51because with her two positive ITI,
57:53that's definitely something that needs
57:55to be addressed with systemic therapy.
57:58But to start with,
57:59the radiation side of things.
58:01So if there's no lymph node involvement,
58:03then you would be eligible for this
58:07three weeks course with a boost
58:10to the surgical bed for a total of
58:1419 treatments and the side effects
58:16for this treatment course are,
58:18generally speaking, relatively mild.
58:20So the things that I most of the time,
58:23CR, fatigue and skin irritation and the
58:28skin irritation can range from just a
58:30mild pinkness of the skin with maybe.
58:33Some dry peeling like a mild sunburn,
58:36mild to moderate sunburn.
58:39All the way to an extreme cases
58:41on this I don't expect,
58:42but some blistering of the skin,
58:45especially sort of along the
58:47bra line underneath the breast.
58:49I would say the vast majority of patients,
58:51though, go through with just some,
58:54some pinkness and some dry peeling
58:56like a sunburn,
58:58and that usually within 10 days after
59:00radiation that's really started to heal up,
59:02and by one month the side effects
59:06are are much less.
59:09Other things that are are
59:11rare with radiation,
59:12but that I always talk to patients about our.
59:15There's a very tiny risk,
59:17less than 1% that radiation can
59:21cause inflammation of the lungs.
59:24Something called radiation pneumonitis,
59:26and that's something that we have
59:28to treat with steroids to cool
59:31down inflammation if it happens.
59:33So those are the main side effects.
59:35Usually that three week course is
59:38tolerated very well by patients,
59:40and then I'll let Doctor Drucker
59:41talk a little bit about the her
59:43two positive side of things.
59:45So
59:46so typically with an ER negative
59:48her two positive cancer.
59:50Once you recover from surgery
59:53we would do chemotherapy prior
59:56to receiving radiation therapy.
59:58We keep those separate because chemotherapy
01:00:01can interact with radiation and make
01:00:03it more potent and therefore have
01:00:05more side effects than we anticipate,
01:00:08so we usually do the chemotherapy first,
01:00:10and for a small tumor with no lymph nodes,
01:00:14we've been able to cut.
01:00:16Again, cut back on what we give the
01:00:18most important part of the therapy.
01:00:19There is the her two targeting agents,
01:00:22so very common regimen for a tumor
01:00:25such as yours would be 12 weeks of
01:00:29weekly chemotherapy followed then by
01:00:31a full year of Herceptin therapy.
01:00:34And I always like to distinguish
01:00:36Herceptin based therapy or her two
01:00:39targeted therapies from chemotherapy.
01:00:40People often hear, Oh my God,
01:00:42a year of therapy.
01:00:43Oh my God and the Herceptin.
01:00:46Is not chemotherapy?
01:00:47The only commonality is you have to come
01:00:50into the office and get it intravenously.
01:00:53However, whereas chemo we
01:00:54always worry about hair loss,
01:00:56there is no hair loss with
01:00:58Herceptin minimal fatigue,
01:01:00no nausha.
01:01:01In proof of that,
01:01:03you can start the radiation while
01:01:06you're receiving chemotherapy
01:01:07the the Herceptin because again,
01:01:09it's not going to have the side
01:01:12effects we associate with.
01:01:14With chemotherapy and then this is
01:01:18a commonality throughout all of our
01:01:20treatment plans for breast cancer.
01:01:23I don't know why it often works
01:01:24out like this, but.
01:01:25Surgery aside, 'cause you're asleep for that.
01:01:29When we give our therapies after surgery,
01:01:31we often start with the worst first.
01:01:34So and I have to say,
01:01:35even though it is my job to
01:01:38make the chemotherapy tolerable,
01:01:40the chemotherapy is certainly worse
01:01:42than the radiation without question.
01:01:45So you get your chemo with Herceptin.
01:01:47And then you can take a deep
01:01:49breath when it's done,
01:01:50because the next phase,
01:01:52the radiation is,
01:01:53is nothing for anyone who's had chemotherapy.
01:01:57We actually do give you a break to
01:01:59recover so so usually if you haven't
01:02:03already already met Doctor Campbell,
01:02:05we set you up to meet her like your
01:02:07last week or two of chemotherapy.
01:02:09You then get about three to four
01:02:12weeks to recover from chemotherapy
01:02:13before you go on to the radiation,
01:02:16but again,
01:02:17since the Herceptin is really not
01:02:20like chemotherapy that continues
01:02:23throughout and then you just
01:02:24get very used to our our site.
01:02:28Thank you, but it's past the hour,
01:02:32so I think that's the end of the webinar.
01:02:35Thank you again to the panelists and thank
01:02:38you, especially to all the participants
01:02:40who joined us tonight. Thank you.
01:02:44Thank you goodnight.