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Breast Cancer Surgery

June 15, 2020
  • 00:00Support for Yale Cancer Answers comes
  • 00:03from AstraZeneca providing important
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  • 00:15Welcome to Yale Cancer Answers with your
  • 00:18host doctor Anees Chagpar. Yale Cancer
  • 00:20Answers features the latest information
  • 00:22on cancer care by welcoming oncologists
  • 00:25and specialists who are on the forefront
  • 00:27of the battle to fight cancer. This week
  • 00:30it's a conversation about the role of surgery
  • 00:32and breast cancer with Doctor Tristen Park.
  • 00:35Dr Park is an assistant professor of surgical
  • 00:38oncology at the Yale School of Medicine,
  • 00:41where doctor Chagpar is a
  • 00:43professor of surgical oncology.
  • 00:45Why don't you start by telling
  • 00:48us a little bit about breast cancer?
  • 00:51We know that it's incredibly common,
  • 00:53so tell us a little bit about
  • 00:55how it's found and
  • 00:57how it's treated.
  • 00:58So this is one of the reasons why
  • 01:01I chose to go into breast cancer.
  • 01:04I feel like breast cancer is
  • 01:06one of the fields in oncology,
  • 01:08especially the surgical treatment of it,
  • 01:10that has evolved so drastically
  • 01:12in a positive way that I
  • 01:14really wanted to take part
  • 01:16in its care. So as of 2020
  • 01:21the treatment of breast cancer,
  • 01:23the detection of breast cancer
  • 01:25actually has morphed to the point
  • 01:27where a lot of these cancers are
  • 01:29caught by screening modalities
  • 01:30such as mammogram and ultrasound.
  • 01:33Many, many decades ago,
  • 01:34before this was implemented,
  • 01:36these types of cancers would be
  • 01:38caught in a much later stage where
  • 01:41the patient would be able to feel it.
  • 01:44Fortunately,
  • 01:44in this day and age,
  • 01:46that's a more rare occurrence,
  • 01:48and we capture these cancers through
  • 01:50screening modalities implemented by
  • 01:51general practitioners and obese humans.
  • 01:53And we catch them at very early stage
  • 01:58where the patients
  • 02:00generally can't even feel
  • 02:01it, and people will
  • 02:03go for their regular mammogram.
  • 02:05I suppose one of the other questions
  • 02:08in this field
  • 02:10and is always controversial,
  • 02:12is the question that many people may
  • 02:14be asking themselves, which is when
  • 02:16should I start having a mammogram?
  • 02:19Well, the
  • 02:20guidelines are all over the place
  • 02:27I generally see patients and recommend
  • 02:30patients to start getting their annual
  • 02:32mammograms at the age of 40. There
  • 02:35have been adjustments and different
  • 02:37entities such as the USPSTF
  • 02:43prolonged or delayed the age of
  • 02:46screening up till the age of 50,
  • 02:48but in general I see patients that have
  • 02:52started screening at the age of 40,
  • 02:54and that's the general recommendation.
  • 02:56And so you know
  • 02:58people out there should know
  • 03:00that getting mammograms
  • 03:02are really effective in terms
  • 03:04of finding these cancers early,
  • 03:06which really allows them to be
  • 03:08treated in the most efficacious way
  • 03:11and actually improves survival.
  • 03:13So let's suppose somebody goes for
  • 03:15a mammogram, and they find something
  • 03:17that they didn't otherwise feel.
  • 03:19They felt absolutely fine,
  • 03:20and then they are shocked and
  • 03:22horrified that the radiologist wants
  • 03:24to do a biopsy and does a biopsy,
  • 03:27and lo and behold,
  • 03:28it comes back breast cancer.
  • 03:30What is the conversation that
  • 03:32you have with these
  • 03:33patients at that point?
  • 03:34At this point, I tell the patient that
  • 03:37the current cancer that was
  • 03:41detected is generally very small
  • 03:43and in the average patient this
  • 03:46happens to be a generally favorable
  • 03:49receptor profile or the blueprint
  • 03:52of the cancer is quite favorable.
  • 03:54It's generally estrogen receptor positive,
  • 03:57lower grade, and this is generally
  • 03:59more in the older population,
  • 04:02so I at this point I usually
  • 04:06tell them that this is not a
  • 04:09death sentence by any means,
  • 04:11and that this is treated on a routine basis.
  • 04:16Most commonly and most likely,
  • 04:18the bulk of the patients I see,
  • 04:20particularly as a surgical oncologist,
  • 04:22will not die from their breast cancer,
  • 04:24but will die of other natural
  • 04:26means outside of their cancer.
  • 04:28And you know,
  • 04:29breast cancers are really
  • 04:31well treated these days.
  • 04:32Tell us a little bit about the modalities
  • 04:34by which breast cancer is treated.
  • 04:37I mean, you're a surgeon,
  • 04:38so clearly surgery is one of the
  • 04:40mainstays of treatment of breast cancer.
  • 04:42So what are the surgical options
  • 04:44that patients have these days?
  • 04:46In this day and age we're
  • 04:48very lucky to have several modalities,
  • 04:51surgical modalities available for
  • 04:52the treatment of breast cancer.
  • 04:54Way back in the day,
  • 04:58back well over 50 plus
  • 05:01years ago, there was only one option
  • 05:03which is removing the whole breast,
  • 05:06otherwise known as mastectomy.
  • 05:09But now with
  • 05:10modern surgical and multidisciplinary
  • 05:12management we're able to do something
  • 05:15called Breast Conservation Therapy
  • 05:17where we just remove the tumor
  • 05:19if it's small enough and the ratio of
  • 05:22the breast and the tumor is favorable
  • 05:25and supplement that local resection
  • 05:27of the tumor with something called
  • 05:30whole breast radiation therapy.
  • 05:32Which can give you a cancer free
  • 05:34result that's nearly identical to what
  • 05:37we would traditionally have to do,
  • 05:39which is remove the whole breast.
  • 05:41So how do
  • 05:42you do breast conserving surgery if
  • 05:44you can't see or feel this tumor?
  • 05:47I mean, these women wouldn't have
  • 05:49been able to feel this tumor.
  • 05:51It just got picked up incidentally,
  • 05:53on a mammogram.
  • 05:54So how do you know that you're
  • 05:56getting out the spot that actually
  • 05:59had the cancer?
  • 06:00So this is one of my favorite
  • 06:03elements of my job is we get to use
  • 06:05all this wonderful technology to help
  • 06:08us find this tumor in a situation where
  • 06:11otherwise my naked eyes,
  • 06:13my hands and the patient wouldn't
  • 06:16be able to tell me where it is.
  • 06:19So basically we use a combination
  • 06:21of imaging as well as localizing
  • 06:23technologies to help us pinpoint
  • 06:25exactly where it is.
  • 06:27The most classical one is
  • 06:29something called a wire,
  • 06:31which basically the patient comes in and
  • 06:34my radiology colleagues using either
  • 06:36a mammogram or an ultrasound can
  • 06:39pinpoint exactly where it is and
  • 06:41place this little wire that basically
  • 06:43points to exactly where the tumor is,
  • 06:46and I use this wire to help me
  • 06:48in the operation and find
  • 06:52exactly where to resect.
  • 06:53And then I get to use another
  • 06:56very fun hightech machine,
  • 06:58which I call it a mini mammogram
  • 07:01machine inside the operating room
  • 07:03where I could place the specimen
  • 07:05inside and confirm with all of
  • 07:08that technology that I indeed
  • 07:10took the suspicious area out.
  • 07:13Now that's the wire that kind of
  • 07:16physically points to where the
  • 07:18tumor is is being replaced by these
  • 07:21other non wire localization methods.
  • 07:23This includes little
  • 07:25gadgets that are the size
  • 07:27of like a grain of rice that uses
  • 07:31different either radioactivity or
  • 07:33radio frequency or magnetic
  • 07:35waves to help us detect it.
  • 07:37And I get to use something that's in the
  • 07:41similar vein as like a Geiger counter,
  • 07:43and I get to use that to tell
  • 07:46me exactly where to go.
  • 07:48So as of two 2020 we have all
  • 07:52these wonderful modalities to
  • 07:55find exactly where these tiny
  • 07:58tumors are and bring minimal
  • 08:02harm to the patient
  • 08:03and so for many of these patients
  • 08:06who have very small cancers,
  • 08:08you can use technology to help you to find
  • 08:11exactly where the cancer is and remove it.
  • 08:14Sometimes patients may have, you know,
  • 08:17widespread calcifications or calcium
  • 08:18spots that show up on their mammogram,
  • 08:21that may in fact be pre cancer,
  • 08:24but if that is all over the breast,
  • 08:27is there still a role for mastectomy in these
  • 08:31patients?
  • 08:32Certainly if they have large areas of
  • 08:35calcifications that we generally
  • 08:36confirm with additional biopsies that
  • 08:39these are either
  • 08:41early stage cancer or pre cancer.
  • 08:44I would definitely recommend
  • 08:45the patient to have a mastectomy,
  • 08:48but fortunately in this day and
  • 08:50age we could also have wonderful
  • 08:53reconstructive options
  • 08:54working side by side with our
  • 08:57plastic surgery colleagues and have
  • 08:59results where it looks much better.
  • 09:02Or if not, it looks just as good as
  • 09:05we started.
  • 09:08Tell us a little bit about how that works.
  • 09:10I mean, do you operate with the
  • 09:13plastic surgeons all at the same time?
  • 09:15Do they use implants? Do they
  • 09:18use people's own tissue?
  • 09:19How does that work?
  • 09:23Generally we work at the same time and sometimes start at
  • 09:26the same time and we work as a big team,
  • 09:29so that's actually a lot of fun and
  • 09:32the way that the plastic surgeons
  • 09:34can reconstruct the breast once I've
  • 09:37removed it includes using implants,
  • 09:39and in some cases some patients
  • 09:42could also use their natural tissues
  • 09:45that are found either in the belly area,
  • 09:48the leg area, or the bottom area to
  • 09:51reconstruct a breast that's actually
  • 09:53made from their own tissues.
  • 09:55This is a much longer procedure obviously,
  • 09:58but has a lot of benefits,
  • 10:01including feeling more natural.
  • 10:04Accordingly,
  • 10:04as the patient ages as well,
  • 10:07a lot of times we
  • 10:09partner with the plastic surgeons really
  • 10:12to get an optimal aesthetic result.
  • 10:15There's now a concept that has come about
  • 10:18called oncoplastic surgery where
  • 10:20people are are kind of combining
  • 10:22oncology and plastic surgery.
  • 10:24Even when doing these smaller resections.
  • 10:26Do you do that? Tell us a little
  • 10:29bit about that concept.
  • 10:32I think this is a
  • 10:34developing concept in America.
  • 10:36I think it's done more so in certain
  • 10:39parts of America as well as I
  • 10:41think it's done more so in Europe.
  • 10:44But I'm a big proponent of it
  • 10:47and I try to incorporate
  • 10:50oncoplastic techniques in my surgeries,
  • 10:52particularly since I feel like
  • 10:54as of 2020 and as a surgeon,
  • 10:57I'm able to treat these patients and
  • 11:00resect their cancers and hopefully
  • 11:02they'll be living for another 20 to 50 years.
  • 11:05And I want them to be happy
  • 11:08with how they look.
  • 11:10So this includes more minor things
  • 11:12such as very strategic incision
  • 11:14placement where it's well hidden.
  • 11:16It could be in areas of the breast
  • 11:19where there's like a natural crease,
  • 11:22or there's a natural shadowing
  • 11:24so that the scar is quite hidden.
  • 11:27This also could include once
  • 11:29you remove the actual tumor,
  • 11:31the tissues or the breast tissues
  • 11:34that are surrounding it are
  • 11:36moved around a bit so that the
  • 11:39cavity that's left behind is not as
  • 11:41obvious, not completely filled up,
  • 11:44and there's another wonderful option
  • 11:46called oncoplastic reduction where if
  • 11:49the patient starts off quite large breasted,
  • 11:51we could remove a tumor and then
  • 11:54the plastic surgeon could do a
  • 11:57classical style reduction of that
  • 11:59breast and then also do a reduction
  • 12:02of the other breast so that she
  • 12:05ends up both with the tumor
  • 12:07removed and both breasts that
  • 12:09look quite symmetrical and a lot of
  • 12:12times in these larger breasted women
  • 12:14it also has the added benefit of
  • 12:17the relief of back pain and the other
  • 12:20issues that occurred with that
  • 12:22prior.
  • 12:25As you said,
  • 12:26is not necessarily a death sentence.
  • 12:28There are many surgical options for women,
  • 12:31especially when they present early.
  • 12:32Now, you mentioned some of the adjuvent
  • 12:35therapies that we also use in the
  • 12:37importance of a multidisciplinary
  • 12:39team. One of the things you talked
  • 12:41about was radiation therapy
  • 12:43after breast conserving surgery.
  • 12:45Can you tell us a little bit more
  • 12:47about that and what things people
  • 12:50might have to look forward to
  • 12:52in terms of the side effects of
  • 12:55radiation, how long it is and so on?
  • 12:58Certainly so again, we're very blessed
  • 13:00in this modern times that this radiation
  • 13:03treatment can be very seamless and
  • 13:05incorporated to one schedule in a
  • 13:08way that causes minimal disruption.
  • 13:09I usually tell
  • 13:11patients that it's
  • 13:13around 30 minutes
  • 13:15door to door and that you could
  • 13:17fit it in during your lunch hour.
  • 13:20Or you could go before work,
  • 13:22or you could drop by after work.
  • 13:25It lasts about four to six weeks
  • 13:27depending on the plan that the
  • 13:29radiation oncologist maps out for you,
  • 13:31and they basically radiate the chest
  • 13:34wall of the side of the tumor.
  • 13:36So we call it whole breast
  • 13:38radiation therapy.
  • 13:39Most common side effects include
  • 13:41during the time of the radiation,
  • 13:44patients generally feel some
  • 13:45level of fatigue,
  • 13:47but most patients actually
  • 13:48could work through it.
  • 13:50They work full time and they do note
  • 13:53that fatigue, but it's not limiting.
  • 13:55The fatigue goes away
  • 13:56once the radiation stops.
  • 13:58The other most common side effect
  • 14:00would include changes to
  • 14:02the skin and texture of the breast.
  • 14:05This includes a darkening of
  • 14:07the skin like you had
  • 14:08a deep tan and
  • 14:10also, the breast tissue could get more
  • 14:13firm and slightly more contracted.
  • 14:15Sometimes patients consider that a
  • 14:16positive because it's a more
  • 14:19firm feeling which some people like.
  • 14:21So it sounds like there are
  • 14:24lots of options for breast cancer.
  • 14:26We're going to learn a little
  • 14:28bit more right after we take a
  • 14:30short break for a medical minute.
  • 14:32Please stay tuned.
  • 14:34Support for Yale Cancer Answers comes
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  • 14:38aims to empower metastatic breast cancer
  • 14:41patients and their loved ones to learn more
  • 14:43about their diagnosis and making
  • 14:46decisions. Learn more at lifebeyondpink com.
  • 14:51This is a medical minute about
  • 14:54survivorship. Completing treatment for
  • 14:56cancer is a very exciting milestone,
  • 14:58but cancer and its treatment can be a life
  • 15:01changing experience for cancer survivors.
  • 15:04The return to normal activities and
  • 15:06relationships can be difficult and
  • 15:09some survivors face long term side
  • 15:11effects resulting from their treatment,
  • 15:13including heart problems,
  • 15:14osteoporosis, fertility issues,
  • 15:16an an increased risk of 2nd cancers.
  • 15:19Resources are available to help
  • 15:21keep cancer survivors well
  • 15:22and focused on healthy living.
  • 15:25More information is available
  • 15:27at yalecancercenter.org.
  • 15:28You're listening to Connecticut public radio.
  • 15:32Welcome back to Yale Cancer Answers.
  • 15:34This is doctor Anees Chagpar
  • 15:36and I'm joined tonight by
  • 15:38my guest doctor Tristen Park.
  • 15:39We're talking about the role of
  • 15:41surgery in breast cancer and right
  • 15:43before the break we talked about many
  • 15:45surgical options varying from breast
  • 15:47conserving surgery which we can do
  • 15:49for even non palpable tumors all the
  • 15:51way up to mastectomies that we can
  • 15:53do with immediate reconstruction.
  • 15:55And we talked a little bit about radiation,
  • 15:57which is one of the ancillary
  • 15:59adjuvant therapies that we use
  • 16:01after breast conserving surgery
  • 16:02that allows outcomes to be
  • 16:04equivalent to that of a mastectomy,
  • 16:08but one of the questions that
  • 16:11people often ask is do I need chemo?
  • 16:14Can you talk a little bit about
  • 16:16who needs chemotherapy and
  • 16:18who doesn't in terms of breast cancer?
  • 16:21Certainly.
  • 16:22Chemotherapy is the systemic kind
  • 16:25of treatment for breast cancer,
  • 16:27and generally in patients that have larger,
  • 16:31tumors or tumors
  • 16:33that are higher grade,
  • 16:35meaning at the cellular level that
  • 16:38the cancer cells are more active,
  • 16:41or if they have evidence that the
  • 16:45disease has spread to either the
  • 16:48lymph nodes or to other organs,
  • 16:50chemotherapy is then recommended.
  • 16:52And on this show,
  • 16:56we've talked a lot about different kinds
  • 17:00of chemotherapy, but before we get to that,
  • 17:02you did mention before
  • 17:06the break that many of these cancers
  • 17:09are what you called a favorable subtype,
  • 17:12and you mention things
  • 17:14like estrogen receptor.
  • 17:15Tell us how those things
  • 17:17impact whether a patient
  • 17:19will need chemotherapy or not.
  • 17:23Breast cancer subtypes are
  • 17:25dependent on the expression of three
  • 17:28different receptors that were molecules
  • 17:31that are found on top of the cancer
  • 17:35cell that includes estrogen receptor,
  • 17:38progesterone receptor and a 3rd
  • 17:39receptor called HER-2 Neu.
  • 17:41So depending on your combination of
  • 17:45receptor expression that determines
  • 17:47the blueprint of your
  • 17:49cancer and there are certain
  • 17:51combinations where we have specific or
  • 17:54so-called targeted therapies available.
  • 17:56So if your estrogen receptor positive,
  • 17:59you could have treatment that blocks
  • 18:01estrogen receptor in the form of
  • 18:04systemic undercurrent therapy.
  • 18:06If you're HER 2 Neu positive,
  • 18:08you could have targeted therapy
  • 18:10in the form of Herceptin.
  • 18:13And if you were negative for all three,
  • 18:16generally chemotherapy.
  • 18:18And some evidence that immune
  • 18:20based therapies, or therapies
  • 18:22that target the immune system can
  • 18:24provide benefit.
  • 18:26I want to get to the immune therapy,
  • 18:28because certainly that's a hot topic,
  • 18:30but just before we go there tell us
  • 18:33a little bit about endocrine therapy.
  • 18:35Is this really chemotherapy?
  • 18:37I mean, should people be afraid that
  • 18:39they're going to lose their hair or those
  • 18:42kinds of things?
  • 18:44It's not the same as chemotherapy,
  • 18:45but it is systemic therapy,
  • 18:47meaning that it it will affect
  • 18:49you from head to toe
  • 18:52so any cancer cells that
  • 18:53are floating in your body
  • 18:55could be
  • 18:58sufficiently targeted.
  • 19:00But it definitely will not cause
  • 19:02hair loss. It mainly blocks
  • 19:05the estrogen receptor
  • 19:06through multiple mechanisms.
  • 19:07Then there's different families
  • 19:09of estrogen blocking modalities,
  • 19:10but generally it will not cause hair loss,
  • 19:14and it's a pill that
  • 19:16you take like a vitamin,
  • 19:19for instance,
  • 19:19and generally it's given from 5
  • 19:22to 10 years and it could result
  • 19:25in the risk reduction of cancer
  • 19:27recurrence or the emergence of
  • 19:30new estrogen receptor positive
  • 19:32cancers on either breast.
  • 19:33It sounds like
  • 19:35for many people, especially if they have
  • 19:38an estrogen receptor, positive cancer
  • 19:40endocrine therapy with a little pill that
  • 19:43you take once a day might be sufficient,
  • 19:47but for some patients,
  • 19:49particularly those who have larger
  • 19:51cancers or who are lymph node
  • 19:54positive or who may have a genomic
  • 19:56profile that is a little bit worse,
  • 19:59chemotherapy might be
  • 20:01something that's indicated.
  • 20:03Yes, it will definitely be indicated in
  • 20:05those types of patients and then after
  • 20:08their course of chemotherapy is finished,
  • 20:11they have the added benefit of having
  • 20:13this additional treatment of the endocrine
  • 20:16therapy that could provide further benefit
  • 20:18in the last five to 10 years,
  • 20:21as long as they take the pill.
  • 20:24So something really to think
  • 20:26about now are the side effects
  • 20:28of that endocrine therapy.
  • 20:30You mentioned that it doesn't
  • 20:32make your hair fall out.
  • 20:34Does it have other side effects
  • 20:37that people should be aware of?
  • 20:40Yes, it could cause some symptoms of menopause,
  • 20:44including hot flashes and fatigue.
  • 20:46Other common things include
  • 20:48musculoskeletal pain,
  • 20:49joint pain, and muscle aches,
  • 20:52and then there's very rare side effects
  • 20:55which include clots in your lower
  • 20:58extremities or in your lungs, and
  • 21:01rare cancers, but those are quite
  • 21:03rare and actually the risk benefit
  • 21:06ratio for the average patient is
  • 21:08to the point where we generally,
  • 21:11if they could take
  • 21:13the endocrine therapy,
  • 21:14it's a plus to take it.
  • 21:17OK now getting into the chemotherapy and
  • 21:19you mentioned that in some of these cancers,
  • 21:23particularly those where the
  • 21:24estrogen receptor is negative,
  • 21:26so they can't take endocrine therapy,
  • 21:28they can't take HER 2
  • 21:30directed therapy because,
  • 21:31let's say their HER 2 is negative,
  • 21:34the chemotherapy might be of
  • 21:36benefit because there is no other
  • 21:38targeted therapy for these patients,
  • 21:41and you mentioned specifically
  • 21:42immunotherapy.
  • 21:43Now I know that that's something
  • 21:46that you're working on in your lab.
  • 21:49Can you tell us a little bit
  • 21:51more about these so-called
  • 21:53triple negative breast cancers?
  • 21:55The implications of that subtype,
  • 21:57and how they're managed?
  • 21:59So triple negative breast cancers are
  • 22:01considered the most poor prognosis.
  • 22:04An aggressive subtype of cancer.
  • 22:06It's negative for all three receptors.
  • 22:09There's a possibility of
  • 22:10treatment options for them.
  • 22:12As you know they're not eligible
  • 22:15for the estrogen or the HER 2
  • 22:17based targeted treatments,
  • 22:19since they're not expressing those receptors.
  • 22:22And the interesting thing, though,
  • 22:24is that they happen to in
  • 22:28multiple preclinical studies,
  • 22:29these tumors have shown to
  • 22:31generate more mutations.
  • 22:33They're called somatic
  • 22:34mutations, the mutations are
  • 22:38only found in the actual cancer cells.
  • 22:41So they have a higher level of
  • 22:44what we call mutational load,
  • 22:47an generally that's correlated with
  • 22:50more response to immune therapy.
  • 22:52The more mutations you have
  • 22:54on your non normal cells,
  • 22:56the more likely your immune system
  • 22:59could detect them or kind of seek
  • 23:02them out and kill these cancer
  • 23:04cells that have all these targets
  • 23:07that are not self and
  • 23:10portraying themselves to yourself.
  • 23:11So how come then your normal
  • 23:14immune system given the
  • 23:15mutational load of these cancers,
  • 23:17doesn't
  • 23:20seek them out and get rid of them by
  • 23:23itself?
  • 23:27There are multiple schools of thought for the reasons why
  • 23:31cancer cells evade the immune system.
  • 23:35So this includes the cancer
  • 23:39cells could evolve ways to
  • 23:43hide themselves from the immune system.
  • 23:46Overexpressing kind of inhibitory
  • 23:49markers that blunt the immune
  • 23:53system or makes the immune system
  • 23:57weaker in that particular location.
  • 24:03That's that's the main one.
  • 24:07Are there therapies
  • 24:10that have tried to unhide the cancer
  • 24:13or make the immune system stronger
  • 24:15against these particular cancers?
  • 24:18Tell us more about the
  • 24:20immunotherapy.
  • 24:22The Nobel Prize for
  • 24:25cancer has been awarded recently to this
  • 24:28concept called checkpoint inhibitors,
  • 24:30so the checkpoint,
  • 24:32the immune checkpoints are natural
  • 24:34breaks that people have as well as the
  • 24:38cancer cells have kind of manipulated to
  • 24:41make the immune system blunted,
  • 24:42so normally if one of your
  • 24:45immune cells recognizes let's say
  • 24:46a foreign antigen like the flu or
  • 24:48something and it generates a response
  • 24:51you want it generate enough of a response
  • 24:53that it clears that problem,
  • 24:55but you don't want it to go crazy because
  • 24:58then it could harm your normal tissues.
  • 25:01And that's actually the opposite side of
  • 25:03that spectrum called autoimmune disease,
  • 25:05so these immune checkpoints occur in
  • 25:07nature and are also kind of taken
  • 25:09advantage of by the cancer cells.
  • 25:11So one way to selectively strengthen
  • 25:16the immune system or make
  • 25:19the cancers more visible
  • 25:21to the immune system
  • 25:23include something called
  • 25:24checkpoint inhibitors,
  • 25:25which basically takes the brakes
  • 25:27off these immune cells and makes the
  • 25:29immune cells more prone to detecting
  • 25:32the cancer cell that's
  • 25:34non self.
  • 25:36And have there been studies looking at these immunotherapies
  • 25:38and triple negative breast cancer?
  • 25:40Does this concept really work?
  • 25:42And the second part of that question is
  • 25:45if you take the brakes off the immune
  • 25:48system and the brakes were put there
  • 25:51so that you don't go nuts as you said
  • 25:53and get kind of autoimmune conditions
  • 25:56do we find that in patients who are
  • 25:58taking these immune therapies that they
  • 26:00get these symptoms of autoimmune disease?
  • 26:03Certainly.
  • 26:04In the past one year actually,
  • 26:07the FDA has approved the first immune
  • 26:09based therapy for triple negative breast
  • 26:12cancer in the metastatic setting,
  • 26:15meaning the patient has widespread disease
  • 26:17outside of the breast and lymph nodes.
  • 26:20This drug is called
  • 26:22Atezolizumab, and it targets PDL1,
  • 26:26which is one of these checkpoint markers.
  • 26:29It's shown benefit for overall survival in
  • 26:32a specific cohort of triple
  • 26:34negative breast cancer cells that
  • 26:36express high levels of the PDL1
  • 26:39so that's been an exciting
  • 26:41milestone and also as a surgeon
  • 26:43I've been eagerly following the use of these
  • 26:46checkpoint inhibitors
  • 26:48in the neoadjuvant setting,
  • 26:49meaning we give the therapy
  • 26:51prior to surgery and hopefully
  • 26:53that will make the tumor shrink.
  • 26:56Sometimes it makes it shrink to the
  • 26:58point where it's completely gone,
  • 27:00and by the time we take it out
  • 27:07The tumor has completely disappeared
  • 27:09and that results are something called a
  • 27:12pathological complete response.
  • 27:14So the latest trial
  • 27:17that's coming to my head is the
  • 27:20Keynote-522 trial that was
  • 27:22discuss at ESMO this past year and
  • 27:24that had shown that when you add one
  • 27:27of these checkpoint drugs called
  • 27:29pembrolizumab with the traditional
  • 27:32neoadjuvant chemotherapy setting,
  • 27:34that this could increase or improve
  • 27:36the complete response rate,
  • 27:38meaning the cancer is completely
  • 27:40obliterated and there's no evidence of it.
  • 27:43When we remove it from the patient,
  • 27:46sometimes up to 70% in certain
  • 27:49cohorts of patients that have
  • 27:51expressed high levels of PD L1.
  • 27:53But in general it improves this
  • 27:56surrogate of pathological
  • 27:57complete response by almost 15 points,
  • 27:59which is definitely very encouraging.
  • 28:01So that
  • 28:02sounds really exciting.
  • 28:03But what about the side effects
  • 28:06of this immune therapy?
  • 28:07I mean, do people get
  • 28:09autoimmune conditions?
  • 28:10Are those long lasting?
  • 28:12Is there a way to put on
  • 28:14the brakes after you've
  • 28:16taken the brakes off?
  • 28:18Well, certainly with every new
  • 28:21tool comes the negatives, so there
  • 28:24are autoimmune side effect profiles
  • 28:27seen with the use of these drugs.
  • 28:30But in breast cancer,
  • 28:32I think we're fortunate in this
  • 28:35Keynote-522 trial that the side effect
  • 28:38profile or the autoimmune profiles
  • 28:40was rather mild than in other disease processes.
  • 28:44Other cancers that utilizes
  • 28:46checkpoint inhibitors
  • 28:47there could be more
  • 28:50severe autoimmune effects,
  • 28:51including pneumonitis.
  • 28:52For colitis,
  • 28:53requiring interventions and hospitalizations,
  • 28:55but in the breast cancer setting,
  • 28:59the most common
  • 29:00side affects seen that's autoimmune
  • 29:03related is an affect on your thyroid gland,
  • 29:06which can be alleviated in an outpatient
  • 29:10setting with supplemental thyroid medication.
  • 29:12But the more severe toxicity
  • 29:16profile seen in other cancer types,
  • 29:19including melanoma,
  • 29:21that's the most famous one,
  • 29:23actually are not seen as much.
  • 29:26That being said,
  • 29:28there are the occasional and quite
  • 29:30rare severe side effects that
  • 29:33sometimes could even cause death,
  • 29:36so we have to be careful,
  • 29:39cautiously optimistic with the use
  • 29:41of these these breakthrough drugs.
  • 29:44Doctor Tristen Park is an assistant
  • 29:47professor of surgical oncology
  • 29:49at the Yale School of Medicine.
  • 29:50If you have questions,
  • 29:52the address is canceranswers@yale.edu
  • 29:53and past editions of the program
  • 29:56are available in audio and written
  • 29:57form at Yalecancercenter.org.
  • 29:59We hope you'll join us next week to
  • 30:02learn more about the fight against
  • 30:05cancer here on Connecticut public radio.