Breast Cancer Surgery
June 15, 2020Information
June 14, 2020
Yale Cancer Center
visit: http://www.yalecancercenter.org
email: canceranswers@yale.edu
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- 00:00Support for Yale Cancer Answers comes
- 00:03from AstraZeneca providing important
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- 00:10ovarian, breast and blood cancers.
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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.
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- 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.