Smilow Shares Greenwich: Understanding Gynecologic Cancers and Treatment Advances

January 27, 2021

Information

January 26, 2021

With Drs. Elena Ratner, Gloria Huang, and Daniela Addeo

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00:00Here with us today I see a
00:02lot of friends on this call,
00:04so I'm super excited that you
00:05all join us on the Snowy day.
00:07I guess that's the benefit of kovit instead,
00:09so we don't have to worry
00:11about canceling of the snow.
00:12Nothing changes.
00:13Everything is exactly the
00:14same as my kids were.
00:15Disappointed that there's
00:17not gonna be a snow day.
00:19So I'm Elena Ratner.
00:21I wanted the Joanne oncologists
00:23and Gloria Wong is with us.
00:25Who is one of my colleagues and
00:28associate professor of join
00:30ecology at Yale University and
00:32we provide care all through the
00:35state of Connecticut all the
00:37way from New Haven to granich.
00:39And that's wrong.
00:40Actually now provides care in
00:42Greenwich Full Time which were super
00:45super excited about and that could
00:47then yellow addio who's with us was
00:50an amazing radiation oncologists.
00:52In the Greenwich community,
00:53and we're so excited that you're here
00:55with us today to talk about chemical
00:58logic answers and what has changed
01:00in the management of these cancers.
01:01And this is very informal.
01:03So as you ladies have questions
01:05that you would like to ask,
01:07please put them in the chat and
01:09I will be watching the chat and
01:11we can talk about them as we go.
01:14Otherwise will start back along if
01:16you would like to start talking a
01:18little bit about early detection and
01:20the advances that we've made and
01:22then I will add to your presentation.
01:24And then that area.
01:26If that's OK,
01:27we will have actually,
01:28because radiation it's a little bit.
01:31Probably not.
01:32People don't know so much about,
01:34so I have like a PowerPoint
01:36with some slides. OK,
01:38wonderful, that's great.
01:39So will perceive like that.
01:41So that's a long wonderful thank
01:43you so much for the introduction
01:45Doctor Ratner and hello to all of our guests.
01:49And thank you so much for joining us today.
01:52I actually made some up
01:54PowerPoint pictures as well.
01:56So I will try to share
01:58those and get started now.
02:00So let me just go ahead and
02:02just do my screen share.
02:18So I'm happy to talk about recent advances
02:22in gynecological cancer prevention,
02:23early detection and treatment today.
02:30To review what we're talking
02:32about gynecological cancers.
02:33These are cancers that arise from
02:36the female reproductive system,
02:38with the most common being uterine
02:41cancer arising from the womb.
02:43Most often, the lining of the uterus,
02:46called the endometrium ovarian cancer,
02:49which actually encompases,
02:50ovarian, fallopian,
02:51and peritoneal cancer,
02:52and then cervical cancer,
02:54which arises from the neck.
02:57Or opening of the of the womb.
03:00These are the three most
03:02common types of ginj cancer.
03:06See if I can advance here.
03:09Just how common are these cancers?
03:11Uterine cancer is the most common in
03:14about 1 in 35 women in the US will receive
03:19this diagnosis during their lifetime.
03:22Ovarian cancer is the second most
03:24common with about one and 70
03:27women developing ovarian cancer,
03:29and cervical cancer is less common now due
03:33to improvements in prevention and detection.
03:36With about 160 women
03:39developing cervical cancer.
03:41Cervical cancer is a great example
03:43of how far we have advanced in
03:46prevention and early detection,
03:48so we are able to prevent the vast majority
03:51of cervical cancers through HPV vaccination.
03:55And in addition,
03:56we have met modalities of early
03:59detection using cytology,
04:01most commonly known as Pap test
04:04and HPV testing.
04:06So the vast majority of cervical
04:09cancers are caused by HPV,
04:12human papilloma papilloma
04:13virus infection with HPV,
04:15infection rates historically have
04:17been most adults about 85% or more of
04:22adults having been infected by HPV,
04:25and usually our immune system clears the
04:28infection and no further sequelae developed.
04:32However,
04:32in some women and men,
04:35persistent HPV infection can develop.
04:38Which actually can lead to the
04:40virus genes becoming part of the
04:42cell's DNA called integration,
04:44and that is the type of HPV
04:46infection that can lead to pre
04:49cancer and cancer lesions.
04:53As I said, we are lucky enough to have
04:56cancer prevention for cervical cancer
04:58and that consists of the HPV vaccine,
05:02which in this country is the Gardasil 9.
05:05Not only does this prevent
05:07over 90% of cervical cancer,
05:10but five additional cancers are.
05:13Related to HPV infection in
05:15these include oral pharyngeal,
05:17which is throat cancer, **** cancer,
05:20vulva, ***** and vagina cancer.
05:22So these vaccines work the best
05:25when they are given at an early age,
05:28usually around age 11 or 12 is the
05:31ideal time and in younger patients
05:34only two vaccine two shots are
05:37needed in older teens and adults.
05:39Three shots are needed to have good.
05:43A good preventive effect.
05:46Screening is has evolved over the years,
05:50and screening is still done for women who
05:53have and have not received the vaccines.
05:57However, in order to kind of reduce
06:00the invasiveness of screening and
06:02reduce tests and invasive procedures,
06:05we now start screening at an older age.
06:08So 21 and up and also we have longer
06:12screening intervals for low risk patients.
06:15So while previously patients were
06:17going every year for a PAP Now we
06:21still recommends Wellness visits.
06:22However, the actual PAP and HPV tests
06:25can be spaced at an interval of three to
06:28five years and then also discontinuing
06:31screening in patients at very,
06:33very low risks such as those who've
06:36had a hysterectomy with removal of the
06:39cervix not related to pre cancer or
06:42elderly women who've had many negative
06:44paps and no history of pre cancers.
06:47Just a caveat that these are general
06:50guidelines for lowers patients and
06:52don't apply to high risk patients
06:55so high risk patients are patients
06:58who might have immunosuppression
07:00or have had history of persistent
07:03HPV infection or pre cancer.
07:06In terms of future directions,
07:08an alternative has evolved which is
07:11primary HPV screening with types
07:13typing of the HPV and we'll see this
07:16more and more with HPV screening,
07:19typing and then determining what if
07:22anything needs to be done further.
07:25I am so proud to say that Connecticut
07:28is a national leader in HPV vaccination.
07:31So while the United States as a
07:33whole has lagged vaccination rates
07:35compared to other developed countries,
07:38actually Connecticut over 50% of
07:40eligible women have been vaccinated
07:43and this is directly related to
07:45about a 50% decrease in cervical
07:47cancer deaths since the introduction
07:49of HPV vaccines in 2006.
07:51So really it is a success story.
07:55Now we still see about 12,000 patients per
07:58year in the US who develop cervical cancer,
08:02and we have,
08:03in terms of recent treatment advances,
08:06we can now offer individualized
08:08surgical treatment.
08:09So when cervical cancer does develop,
08:11it's often in women in their 30s and 40s,
08:15for some of whom fertility sparing
08:18to have a family is important,
08:20so we do have the ability to offer fertility
08:24sparing surgery to preserve the uterus.
08:27And allow women to have families
08:30in selected patients.
08:31In addition,
08:32another big advance for patients who
08:35have recurrent or metastatic cancer
08:37is being able to offer patients
08:40immunotherapy when appropriate,
08:41which really has improved outcomes as well.
08:48In contrast to cervical cancer,
08:50where we have declining rates,
08:52endometrial cancer rates
08:54are actually increasing,
08:55so there is year over year increases
08:58in the number of cases and deaths
09:01from endometrial cancer every year.
09:04And this is partly related
09:06to the obesity epidemic.
09:08Over 90% of endometrial cancer
09:10is obesity related, so in part,
09:12related to obesity and related
09:15conditions such as diabetes.
09:17An increased insulin levels about
09:205% are genetically related,
09:22such as Lynch syndrome,
09:24and then there can be other factors such
09:29as unopposed estrogen or tamoxifen.
09:33So we have good ways to lower endometrial
09:37CanSAR endometrial cancer risk.
09:39And these include maintaining
09:40a healthy weight.
09:42Exercising five are made more days of year,
09:45and we know that taking oral
09:47contraceptives or using a Marina
09:49progesterone IUD can be helpful
09:51for reducing long-term risks.
09:53Long term avoiding unopposed estrogen.
09:55If you have a uterus and really
09:58to be aware of what?
10:00Warning signs,
10:01so any bleeding or spotting after
10:04menopause is abnormal and should
10:06prompt a gynecological evaluation.
10:11And we know how how Lynch
10:13syndrome can impact cancer risk,
10:15including risk of colon cancer and
10:18a mutual cancer and ovarian cancer.
10:21So patients who women who
10:22have Lynch syndrome should be
10:24followed with enhanced screening,
10:27cancer screening for endometrial
10:28cancer can include exams,
10:30ultrasounds and endometrial biopsies,
10:32and then we can offer women with
10:35Lynch syndrome risk reducing surgery
10:37usually consisting of hysterectomy and
10:40removal of the tubes and ovaries after.
10:42Childbearing is completed.
10:44I also wanted to highlight
10:46recent advances in the surgical
10:48treatment of endometrial cancer.
10:50So over the past decades we have
10:53really moved to to the point where
10:56almost all of our endometrial cancer
10:59patients are being treated in
11:02minimally invasive surgical approaches
11:04laparoscopically and or robotic assisted,
11:06and this offers short recovery times and
11:09quick resumption to usual activities.
11:12And really.
11:13Decreases the morbidity of an
11:16endometrial cancer diagnosis.
11:18An in fact, often less,
11:20is more,
11:21and this is illustrated by selective
11:24lymph node evaluation with procedures
11:27such as Sentinel node evaluation,
11:30which can be very sensitive for
11:33detecting disease outside the uterus
11:36while decreasing potential side effects.
11:39I also wanted to highlight that
11:42endometrial cancer we really have moved
11:45into the area era of precision medicine,
11:48so we currently perform molecular
11:50testing on all endometrial cancers
11:53to detect protein changes in the
11:55tumor cells that can indicate a
11:57potential presence of Lynch syndrome,
12:00an also these protein changes,
12:02called Immunohistochemical Street,
12:04can guide our treatment decisions as well.
12:07In addition,
12:08immunotherapy is available for
12:10most patients with recurrent or
12:12advanced in Dimitriou cancer,
12:13and in fact we have a number of
12:17clinical trials on going now.
12:19Also looking at immunotherapy in
12:21the frontline setting for patients
12:23with higher risk into mutual cancer.
12:25We also are actively investigating the
12:27how we can best deploy endocrine therapies,
12:31hormone therapies Brenda Mitchell Cancer,
12:33which as you know are very much
12:35the mainstay of breast cancer
12:38and prostate cancer treatment.
12:40A man are in our under active investigation.
12:43In fact,
12:44I'm leading set one such
12:46national trial right now,
12:47which hopefully will lead
12:49to some new therapy,
12:50ways to treat endometrial cancer and
12:52more and more you'll see that will be
12:56incorporating targeted therapies in
12:58the frontline and recurrent setting.
13:00In terms of endometrial cancer survivorship,
13:02this is such an important.
13:06Part of endometrial cancer care.
13:08Because we have excellent oncological
13:10outcomes in endometrial cancer.
13:12Very high cure rates,
13:13especially in patients with
13:15early stage disease and in fact,
13:17long-term follow-up shows that most
13:19engine mutual cancer patients are
13:21more likely to die of heart disease
13:24and other chronic conditions rather
13:26than from endometrial cancer,
13:28and this highlights how important it is to.
13:32To come.
13:35To incorporate lifestyle changes
13:37as well as part of endometrial
13:39cancer survivorship.
13:42Moving on to a barren cancer,
13:45our understanding of ovarian cancer
13:47has really greatly advanced over the
13:50past decade and how we conceptualize,
13:52aware in cancer now is based on
13:55the origins of ovarian cancer,
13:57with type one actually often
14:00arising in endometriosis,
14:01which is a very common benign
14:03condition of reproductive age.
14:05Women as well as from borderline
14:08precursor lesions.
14:09In contrast, Type 2 which are the.
14:12I tend to be more aggressive.
14:16It often actually rise in the fallopian
14:18tube lining cells initiated by insights,
14:21you cancer cells cause sticks,
14:23so this is really kind of a paradigm shift
14:27in how we understand ovarian cancer.
14:31And is related to understanding more of the
14:35molecular and genetics of ovarian cancer.
14:38We know that there's several very
14:41well established ways that we
14:44can lower or ovarian cancer risk.
14:46Breastfeeding and pregnancy are associated
14:49with decreased ovarian cancer risks,
14:51and really anything that decreases the
14:54number of lifetime abula Tori cycles,
14:57including oral contraceptive use
14:59during the reproductive years.
15:01In addition, removal of the fallopian tubes,
15:04such as having a self inject a MIS.
15:08For, for,
15:09for Tubal ligation can greatly reduce
15:12the risk of ovarian cancer women,
15:15especially if they have first
15:17degree relatives with breast cancer
15:20and or first degree.
15:22Relatives with ovarian cancer or
15:24personal history of breast cancer,
15:27should consider genetic counseling
15:29and high risk screening.
15:32And just wanted to highlight some of the
15:35warning symptoms and signs of ovarian cancer,
15:38which unfortunately can sometimes be vague,
15:41such as abdominal bloating change,
15:43increased waistline,
15:44pelvic pain,
15:45change in bowel,
15:46bladder habits,
15:47abnormal bleeding,
15:48nausea or feeling of fullness,
15:50and most of concern would be when
15:53these symptoms are persistent
15:55and don't go away on their own,
15:58and that should prompt a
16:00gynecological examination.
16:03We also have learned a lot about hereditary
16:06breast and ovarian cancer syndrome,
16:08which are you've probably all heard
16:11of BRCA one and BRCA two mutations
16:14so we have very good ways to detect
16:17the presence of inherited changes
16:19through blood or saliva tests and
16:22that is to detect whether you've
16:25inherited these one of these genetic
16:28changes from your mother or father.
16:30Women with hereditary breast
16:32and ovarian cancer.
16:33Syndrome benefit from high risk
16:36screening risk reducing surgery and
16:38I just wanted to highlight that the
16:41risk resort reducing surgery is done
16:44in a minimally invasive ambulatory
16:46surgery usually takes less than one
16:49hour with tiny incisions and is
16:52recommended around the ages of 35 to
16:5545 after completion of childbearing.
16:58Of course,
16:59this is individualized based on
17:01the patient and the patients.
17:04Visual considerations.
17:08And Lastly, I would like to highlight some
17:12recent advances honoring cancer treatment.
17:15We know more and more that tumor
17:18debulking remains a cornerstone of
17:20optimal treatment and improve survival.
17:24So seeing a gynecological oncologist
17:26an having surgery either at the
17:30initial diagnosis or at an interval
17:33after chemotherapy is important
17:35for optimal chances of survival.
17:38We performed we recommend genetic
17:40counseling and testing in all women
17:43diagnosed with aware in cancer.
17:45In addition,
17:45for all women with advanced ovarian cancer,
17:48we suggest tumor molecular testing
17:51and this is important because.
17:53They really guide treatment
17:55decisions on how can we most
17:58effectively treat the women's cancer?
18:02I'd like to summarize with some
18:04take home messages about each of
18:07the major types of GYN cancer.
18:10The Great News is that cervical cancer
18:13is preventable through vaccination and
18:15screening for endometrial and ovarian cancer.
18:19Surgery by gynecology,
18:20oncologists remains a cornerstone
18:22of treatment and maximizes survival.
18:24And we can now offer precision
18:27personalized medicine for all patients
18:29with advanced gynecological cancer.
18:32And this,
18:33of course includes multimodal therapies,
18:35where we work closely with our radiation
18:38oncology experts such as Doctor Dale,
18:41who will be speaking as well
18:44today and other experts,
18:45including geneticists,
18:46medical oncologist and the patients
18:49general OB GY Ensan primary care
18:51physicians for survivorship care plans.
18:54So thank you so much for for the
18:57chance to speak to you today.
19:03Alright, thank you so much Gloria.
19:07If there's any questions,
19:09if you guys would like to just put
19:11them in the chat, feel free. We can.
19:14Again, this is very informal and we can
19:17ask answer questions as as as we continue.
19:20I'm gonna take them a few minutes to
19:23continue the conversation that Doctor
19:26Wong just just started and talk a little
19:30bit more about breast cancer and ovarian
19:33cancer and how they relate to each other.
19:37And I'll take a look.
19:39I'll talk a little bit
19:41about really my passion,
19:43which is early detection of these cancers.
19:47So hold on one second, let me just share my.
19:53So like the long spoke so great about kind
19:57of logic answers and how the paradigm.
20:00This cancers is changing,
20:02so I'd like to take the next
20:06minutes to discuss a little bit more
20:10about detection of these cancers.
20:12How much time and effort is being
20:15spent right now and improving early
20:19detection in improving prevention
20:21of these cancers as well as the fact
20:26that the achievement of cancers
20:28nowadays really has become.
20:30Truly, a personalized approach.
20:32You know,
20:33we don't treat cancers the same
20:35way just because cancer said.
20:37If the same,
20:38we truly treat the patient would
20:40truly treat the woman we study
20:43all the cancers we study,
20:45all the tumors and knowing what
20:47mutations that particular tumor has,
20:49we are able to offer targeted
20:51specific therapy to her.
20:53And that's only something different.
20:55That's not anything that we used
20:57to do before, and we are super,
21:00super excited about.
21:01The future and about the present,
21:04but I'd like to talk a little
21:07bit about what comes before.
21:09I'd like to talk about not just
21:12about early detection of cancer,
21:14but about the Holy Grail.
21:16the Holy Grail is cancer prevention.
21:19So so much of what we're trying
21:22to do now is identified.
21:25The women who are at higher risk
21:28for different cancers and a great
21:31amount of that information comes from
21:34family history and from the genetics.
21:37And this is just one of the
21:40examples of one of my patients who,
21:43when we started discussing her
21:45family history,
21:46clearly had genetic predisposition
21:48and through which.
21:50Her genetic mutation was found and
21:53hence cancer in her was prevented.
21:56And the driving hypothesis of so much
21:59of this work is that many patients
22:01might be at risk for several cancers
22:04based on personal or family history,
22:07kinetic status or personal history of a TPA,
22:10hyperplasia.
22:10And it's so so important to know
22:13because that's the first step.
22:15First step is the knowledge of
22:17knowing who is at high risk and
22:20knowing what they are high risk for,
22:22because if we know that then different
22:25modifications Kim can be done.
22:27And we will talk as to what
22:30those modifications are,
22:31and they're always the same.
22:33They always either surveillance or
22:35chemoprevention or surgical intervention.
22:37So for any cancer,
22:38when we worry that the patient
22:41could be at risk,
22:42we talk about what can be
22:44done to decrease that
22:46risk or hopefully eliminate it completely.
22:49Um, we traditionally management of
22:51this patient has not been easy.
22:54You know, there's a lot of
22:56frustration in the medical community,
22:58but they were more so among women
23:01in about an among men and patients
23:04and families that frequently.
23:07Please join the limitations were taken
23:09care of by a very specific provider.
23:11Very specific. You know,
23:13one Doctor Who really did not talk to
23:16other doctors and there was a lot of
23:19disconnect about these mutations and
23:21frequently women did not get the care
23:23that they needed because you know,
23:25if somebody had a specific mutation
23:27that had to do with the breast,
23:30they would just be managed by the breast
23:32position without really understanding
23:34the correlations and breast and ovary.
23:37And making sure that the whole team of
23:40providers is involved in the optimal care.
23:43And that is what we're trying to correct,
23:45and that is what we're trying to improve.
23:47So we know now that approximately 10% of
23:50cancers are something called hereditary,
23:52which means that there's a mutation
23:54in the gene.
23:56However, we know so much more now,
23:58and we now believe that much bigger number,
24:01closer to 30 if not 50% actually carry
24:04some sort of genetic predisposition,
24:06and there's some sort of a gene that could
24:09be responsible for different cancers as
24:12well As for other cancers in the family.
24:16So what are the risk factors you know
24:19so frequently in in in the office?
24:21I talked to to my women and my
24:23patients and we always talk about,
24:25you know,
24:26quit the cancers that they have be
24:28due to mutation and how do we know
24:31those likely to be due to mutation?
24:33And it's super super important
24:35to know because we want to make
24:37sure that if that's the case,
24:39we identify them so that further cancers
24:42can be prevented in her and in her family.
24:44So the risk factors for having some
24:46sort of genetic hereditary cancer.
24:48It is early age of onset,
24:50so when cancers happen younger in life.
24:53Multiple affected family members
24:55and you saw the pedigree I showed
24:57you in the beginning of that.
24:59Some like we always talk about related
25:01cancers in the family and it's very,
25:04very important to remember that
25:06the related cancers in the family
25:08is not just what we think.
25:10You know, for somebody who has breast cancer,
25:12we're not just talking about breast cancer,
25:15we're talking about breast cancer having a
25:17very close relationship to ovarian cancer.
25:19And now we also think this certain
25:22subtypes of uterine cancer.
25:24That are also part part of that
25:26family of cancers.
25:28This includes pancreatic cancer.
25:29This includes prostate cancer in men.
25:31You know,
25:32this is very important and we talk
25:35about these female jeans.
25:36You know,
25:37the Braca genes that this is not only women,
25:41but this effects.
25:42There is certainly males that this
25:44effects as well.
25:45This includes melanomas of the skin.
25:49Multiple primary,
25:50so a patient woman or man who has
25:53more than one cancer male breast cancer is
25:56something that we always very careful with.
25:58Male breast cancer is very frequently
26:01associated with genetic mutation.
26:02In the old days, like five years back,
26:05we used to talk a lot about Jewish ancestry.
26:09Dash cannot see Jewish women,
26:11as I'm sure a lot of us know carry higher
26:14prevalence of this genetic mutations.
26:16However, recently we have found out the
26:19Jewish connected women are not the only
26:22ones who have this high prevalence.
26:24That there's certain population
26:25of women from Italy.
26:27There are certain population of Mexican
26:29women that carries similarly high
26:31prevalence of these genes, so you know,
26:33whereas years back we used to ask the woman,
26:36you know, are you Jewish Knesset
26:38descend and if she said no,
26:40we wouldn't worry as much.
26:41That's no longer the case.
26:43We know, again,
26:44much more about different mutations,
26:46different ethnicities and also we are
26:48much smarter Now we know many more genes
26:51now than we used to do years back and
26:53pathology as to exactly what kind of.
26:56Cells there are.
26:57And the jeans that we worry about,
27:01you know a multiple so Bracco
27:03wanna bracket too?
27:05I'm sure many of you have heard of
27:08so Bracco Roca one stands for all
27:11breast cancer one clone in 90 four
27:14and increases risk of breast cancer,
27:17ovarian cancer and prostate cancer in males.
27:21Rock a tool for breast cancer.
27:23Two clones.
27:24Soon after that the 95 and carries
27:27lower risk but of more cancers.
27:30Breast cancer, brain cancer,
27:31prostate cancer,
27:32pancreatic cancer,
27:33and this is the cancer that's more
27:37associated with male breast cancer.
27:40This is the life cancer risks.
27:42So in the population.
27:43So if you don't have any genetic mutations,
27:47women have approximately 11 to 13% chance of
27:50getting breast cancer during their lifetime.
27:52But if you had,
27:54but if a woman has a bracket,
27:57one bracket, two mutation,
27:58that that risk is significantly
28:00higher simile for the ovarian cancer,
28:03the risk is approximately 1.4%,
28:05but could be as high as 60% for
28:08bracket one and his highest.
28:1040% for bracket two and their risk
28:13similarly is increased with second
28:16breast cancer primary again up
28:18to 65% in bracket one patients.
28:24Um? So in prostate cancer,
28:27again is quite common in male,
28:2916% of general population has a
28:31risk to develop prostate cancer,
28:33and the risk is as high as 30%.
28:37So doubled in Brock Obama bracket two
28:39males as well as male breast cancer,
28:42which is super super uncommon in general.
28:45Population could be as high as 10% with
28:48bracket 2 and you can see similar increase
28:51with rocketu in pancreatic cancer.
28:54So what can we do?
28:57And this is we mentioned this
29:00in the beginning of the talk.
29:02So when we believe that patient,
29:04a woman or male is a higher risk for
29:07specific cancer, what can be done?
29:09You know, I very frequently have
29:11this conversation in my office
29:13with women when they are reluctant
29:15to get genetic testing them,
29:17because very frequently there is fear is to.
29:20What would I do with this information
29:22if I know I have a genetic mutation?
29:25What does that do?
29:26Does it add anything?
29:28You know, does it help me at all?
29:31And it certainly does, you know, I never.
29:35I never advocate free checking genes,
29:37for which we have no no solution but
29:40for a great number of this variance
29:43in generic deleterious mutation,
29:45there's unquestionably
29:46prevention that can be done.
29:48You know, knowledge is power,
29:50so the way that we usually look at this
29:54kind of management is always similar,
29:57no matter what kind of cancer.
30:00We'll talk.
30:00About so the biggest one,
30:02and probably the easiest one,
30:05is the lifestyle modifications.
30:06Now the easiest one,
30:08as we'll talk a little bit,
30:10but but the cheapest usually
30:13chemoprevention surveillance and then
30:15the most aggressive one which is surgery
30:18which is only reserved for truly,
30:20truly high risk population.
30:22So for the breast cancer,
30:25for those women who are
30:27significantly higher risk,
30:28the most definitive but the most aggressive,
30:31of course, is mastectomy,
30:33and this one is reserved
30:35for women at highest risk,
30:37and it's very complex procedure
30:39reduces the risk substantially,
30:41but the psychosocial implications
30:44and that will study.
30:47We know that even for women
30:50with BRCA mutations,
30:51when they undergo mastectomy,
30:53zero percent of women actually
30:56ended up having breast cancer
30:58compared to 7% of those who did not.
31:03Surveillance,
31:04which is just means closer watching
31:06is consists of clinical breast exams
31:08and you know right now there's a lot
31:11of debate in the literature where
31:13breast exams should be done by providers,
31:16so not for this population.
31:18We continue to encourage it.
31:19Self breast exams again very important,
31:22especially for women to know
31:23where their breasts feel like,
31:25so that if anything feels abnormal
31:27they will be aware of it or offer it
31:31breast MRI's as well as mammograms.
31:33And that starts at age 25.
31:35For women who are truly at high
31:38risk because of genetic mutations.
31:40MRI's are very debatable.
31:41For those of you who get him, you know it's.
31:45It's always a battle with insurance
31:47companies to try to prove it.
31:48This is not meant to replace the mammogram.
31:51Mammogram looks at things
31:52differently and there's a lot of
31:55benefit to the mammogram as well.
31:57It's not proven to impact survival,
31:59and that's why it's so hard to
32:01prove my insurance companies,
32:02but nevertheless it adds to the
32:04full picture and we recommend
32:06getting it for this woman.
32:08Chemoprevention is a little bit more complex.
32:11Again, this is for women at higher
32:14risk and the medicines that
32:16are recommended as these risk
32:18reduction agents tamoxifen are
32:20almost in an investor and there's,
32:23you know, there's no free lunch.
32:25So there's some side effects to them.
32:28So this similarly is reserved for women
32:31at significant risk for women who are
32:34significant risk who take this medicine,
32:37they decrease their risk by good.
32:4050% so the benefit is substantial.
32:45Ask you for a little bit.
32:47This is just how these medicines
32:49work and again, some of them,
32:51all of them decrease the
32:52risk of breast cancer,
32:53but some of them are good for the bones.
32:56Some of them are not good for the bones.
32:59Some of them are good for the uterus,
33:01others are not.
33:05And this is to show that in all
33:08these women in women who have
33:11mutations and who have higher risk,
33:14tamoxifen significantly decrease
33:16the risk of breast cancer.
33:19As I mentioned, the free lunch side
33:22effects of tamoxifen are hot flashes,
33:25some leg cramps.
33:26There's a very small risk of blood clots.
33:30Very small risk of individual cancer,
33:33and cataracts.
33:36The the easiest as I mentioned.
33:38Well not the easiest,
33:40but the most straightforward one,
33:42of course, is lifestyle modifications,
33:44and we do a lot of those conversations.
33:46The biggest one is alcohol.
33:48I'm sure you guys have seen the
33:51literature that there is definitely
33:52correlation of of high alcohol use.
33:55Higher alcohol use to increase
33:56risk of breast cancer.
33:58Women who drink one to two drinks
34:00a day is associated with 30 to
34:0350% increase in breast cancer.
34:05So usually the recommendation is
34:08to have less than one drink a day,
34:11so it's manageable.
34:12So less than 7 drinks a week and it
34:16actually doesn't matter if you do all 7 one.
34:19So if you do once every day,
34:22the total should be less than
34:24that and then wait.
34:26There's a very specific correlation
34:28of weight to risk of breast cancer.
34:31So especially after menopause,
34:33women with a BMI of more than 33.
34:36Had 27% increase risk versus women
34:39would be in my of 21 or less and
34:42we know from the North Nurses
34:45Health Study is study from which we
34:48learned a lot about these cancers.
34:51Then 10 kilogram weight gain since
34:53menopause had almost 20% higher risk of
34:56breast cancer compared to waive maintenance.
34:59So as lifestyle modifications go,
35:01alcohol and then achieving and
35:04maintaining a healthy weight of
35:07the two most important aspect.
35:09I won't spend too long.
35:13But there's of course pluses and
35:15minuses of hormone replacement therapy.
35:17As you know,
35:18we used a hormone replacement therapy
35:21used to be something that women used to
35:24get routinely until the study was published.
35:26The Women's Health Initiative,
35:28the nurses study that showed
35:30that there was a substantial 26%
35:32increase in breast cancer,
35:33and that's when all the hormones stopped,
35:36even though we don't think
35:38that's really the case.
35:40You know some subsequent studies
35:42that were done show that.
35:43When used with estrogen alone,
35:46there really was no increase
35:48in breast cancer,
35:49so nowadays we truly believe that this
35:51is a shared kind of very personalized
35:54decision between a woman and a provider.
35:57Understanding risks and benefits.
36:01And after the women will be RC
36:04mutation undergo definitive surgery.
36:05So if the women and we'll
36:08talk about that in a bit.
36:10If the women, if they are always in
36:12tubes are removed at a younger age,
36:15there's a lot of literature that supports
36:17the use of hormone replacement therapy.
36:20In this women it is completely safe
36:22and it still decreases the risk of
36:25breast cancer by his highest 50%.
36:28And that's all been very well studied.
36:31I'm going to jump briefly for the
36:33next few minutes to now the risk
36:37management ovarian cancer Doctor Wong
36:39mentioned this already, but you know,
36:42we do very similar approach,
36:44surveillance,
36:45chemoprevention or prophylactic surgery,
36:47which again is the most aggressive.
36:51Ovarian cancer remains unfortunately deadly.
36:5422,000 cases year, 15,000 deaths.
36:58Unfortunately,
36:58in comparison to the breast cancer,
37:02which is the most common?
37:07But much,
37:08much more curable and the trouble with
37:10that is that as as again many of you know,
37:13there will be any cancer.
37:15Fortunately, it's the cancer that whispers,
37:17even though we actually don't
37:18think it's the case anymore.
37:20We now do not think there
37:22are varying cancers.
37:23With spring,
37:24we really just think that nobody is
37:26listening over the past couple years.
37:28There's been a lot of studies that
37:30showed that even though great majority
37:32of women with advanced cancer,
37:33stage three and stage four had symptoms,
37:36women with stage one and two.
37:38Great majority of them also had
37:40symptoms issues that the symptoms were
37:43so vague that they were perceived by
37:46the woman and also by her providers
37:49to be normal to be menopausal,
37:51to be hormonal,
37:52you know,
37:53to be just the normal thing that
37:56women in the goal,
37:57which is of course not the case so
38:00so much of what we do with these
38:03symptoms is educating women and and
38:06advocating and teaching them to.
38:09Listen to your body that as that the
38:11Wong said that if you have these symptoms,
38:13the bowel symptoms,
38:14the bladder symptoms then just
38:16not feeling great and having some
38:18some bloating and distention and
38:19your clothes are not feeling well.
38:21And of course we all have those symptoms.
38:24All of us feel that the difference
38:26between what we all feel and the
38:28symptoms that are actually abnormal is
38:30a women who ended up having cancer.
38:32Had these symptoms every single
38:34day for two weeks.
38:35So we do a lot of advocacy work
38:37and a lot of empowering of women
38:39to listen to your bodies.
38:41And when you feel that something is wrong,
38:43you you present to to the provider and
38:46you demand the care that you deserve.
38:48You know you don't take no for an answer.
38:50You don't let the provider tell you
38:52that you know these symptoms are
38:54normal and just it's menopause that
38:56if you continue having these symptoms
38:58that you need to be evaluated.
39:01I'm.
39:03And this is like I mentioned,
39:05those those are the symptoms that we
39:06met the woman feel, and that it's so,
39:09so important to be aware of
39:10it.
39:14The trouble with with varying cancer
39:16in the symptoms is that there's a lot
39:19that mimics a lot of other things.
39:21You know, it makes endometriosis
39:23the most common mimic it,
39:25mimics irritable bowel syndrome,
39:26inflammatory disease and
39:27interstitial cystitis,
39:28and that's why at times it's a
39:30little bit difficult to distinguish.
39:32But the most important thing, again,
39:34is just to know that this is something
39:37that's not that's not same for you as usual.
39:40So when women have these symptoms,
39:42it's very important to be seen.
39:45Many women with this kind of symptoms
39:48actually not seen by gynecologist
39:50they seen by GI personal Gu person,
39:52you know actually the most common doctors
39:55who see women at this stage are guessing
39:59TRA la just urologists chiropractor.
40:01And psychologists, that's what that was.
40:04Number 4.
40:04And then these women always.
40:06It's very important for them to have
40:09a sonogram and some blood work,
40:12and sometimes that CAT scan and
40:14then referral to gynecologist,
40:16which is very important.
40:19Um?
40:22Sorry bout that you guys needed
40:24beauty of of zoom so we don't do
40:27screening for varying cancer.
40:28It doesn't really work.
40:30See what 25 is a tumor marker?
40:32That's just not a great tumor
40:35marker for this scene with 25 is a
40:37very good to market and something
40:39that we use very carefully very
40:42closely for surveillance of cancer.
40:44But we do not.
40:46It does not work great by itself,
40:48so we used it together with an ultrasound.
40:52Before hand.
40:53And this is just studies that show
40:56that together with it with an
40:59ultrasound for women at high risk.
41:02Using imaging,
41:03which is ultrasound together with
41:05the blood test, is the best modality.
41:07Best way to try to find this cancer early?
41:13And then of course, the most.
41:17The most aggressive one which is
41:19surgery and surgery for prophylaxis
41:21for varying cancer is really only
41:24reserved for women at higher risk.
41:26So who are the women who?
41:28What are the factors that are associated
41:31with high risk of ovarian cancer and
41:34those are women who had early minarchy.
41:37Late menopause never had children,
41:39infertility and Dimitriou Sis,
41:40and then the most serious ones,
41:43which are the genetic factors
41:45bracket one bracket two and Lynch.
41:48There's also environmental factors.
41:50You guys all know.
41:51I'm sure about talc use.
41:53There's a lot of debate on that,
41:55but there's cigarette smoking
41:57as well as asbestos.
41:58That's considered risk as well.
42:02And the thinking for that we don't
42:04have time to talk about this now,
42:06but there's two different
42:07thoughts of ovarian cancer.
42:09One thought as I could want mentioned that
42:11some of these cancers actually arise in
42:13the fallopian tubes and ovarian cancers.
42:15Actually, not only in Kansas at all,
42:17their fallopian tube cancers that
42:19have spread to the ovaries and the
42:21other thing is that every time a
42:22woman ovulates that there's some
42:24sort of tumorigenesis that happen.
42:26So the less time shahbulat the lesser risk,
42:28the more times the Morris for risk.
42:31That's why having a lot of
42:34children having five children.
42:35It reduces your risk of basket
42:38of ovarian cancer by 50%.
42:39I got very close.
42:41I got to four very close to that
42:43reduction breast feeding every child for
42:46one year also gives you 50% the other
42:49the other way to decrease your risk,
42:51which is much more sane than
42:54having so many children.
42:55It's birth control pills.
42:57So any woman who uses birth control
42:59pills for five years during her
43:01lifetime decreases her risk by 50%.
43:04Anybody who uses birth control?
43:06Pills for 10 years decreases her
43:08risk by 80% and 15 years decrease
43:10for risk by 15 by by 90%.
43:13So so huge differences and this is
43:15something that I always talk about.
43:18Doesn't matter what talk I ever give,
43:20I always talk about that.
43:22You know,
43:23taking birth control pills is really
43:25the biggest thing that we as women can
43:28do for risk reduction of this cancers.
43:34And then tubal ligations,
43:35like the one mentioned,
43:37because we think that some of these cancers
43:39actually originated fallopian tube,
43:41so removing the fallopian tube is
43:43actually a huge thing that we can do.
43:46It decreases your risk by 70% when you do it.
43:51So I'm going to bring us to the end just
43:54so that we have time for questions.
43:56And you know, I just wanted to to make a
43:59few points about gynecological cancer.
44:01Before that the audio will take it over with.
44:05Talking about radiation oncology so
44:07so much has changed in the field
44:09were going to logic ecology.
44:11So much research is being done.
44:13A lot of you on this call I actually
44:16touched first hand by this and know
44:18the advances that we have made.
44:21You know we no longer treat everybody
44:23the same, you know, not it.
44:25You know you know,
44:26longer just come and get the same
44:29chemotherapy no matter what things
44:30are now truly different,
44:32truly personalized and individualized.
44:33And we understand what mutations the cancer.
44:36Has we studied this in in mice and
44:38we really understand what treatment
44:40is best for you?
44:42This is what allows women the best outcome.
44:45The longest survival cure,
44:46but also quality of life you know,
44:49allowed to live your life how you are
44:51and not allowing cancer to really change.
44:54Change your quality of life but so
44:57much more should be done and so much
45:00more has to be done and so much that
45:03should be done in early detection
45:05and prevention.
45:06But the biggest part of it is really
45:09more than anything else that we've
45:11done in the lab more than more than
45:14testing more than different tumor
45:16markers or biomarkers that we're looking at.
45:18The blood is really kind of awareness
45:21and an advocacy,
45:22and know your body and talking
45:24to your friends.
45:25And you know,
45:26we as women and men on this call,
45:29you guys had the biggest advocates
45:31you know when somebody I cannot tell
45:34you how many women I have talked
45:36to subsequently or diagnose after
45:38one of these conversations.
45:39Because when we stop to think
45:41and remember the date,
45:43these things kind of stick with
45:44us and kind of influence what we
45:47remember going forward.
45:49So thank you so much for the time and
45:51we're so thrilled that you're with us today.
45:54I'll let Doctor Ariel do her part and
45:56then we will have time for questions.
46:13Thank you. Um, let's see.
46:19So I put together a few slides
46:23about radiotherapy applications
46:25for gynecological cancers.
46:28And for the people in audience who are
46:32not quite familiar with radiation therapy,
46:36what is radiation?
46:37It's a treatment modality that uses
46:41high energy particles and hard energy
46:45electromagnetic waves to destroy cancer
46:48cells and the target for radiation
46:51treatment for radiation waves is
46:54basically the DNA molecule of the cell.
46:58The radiation damages the DNA,
47:02breaks the DNA and produces.
47:05In the end cancer cell death.
47:09Um? According to sorry.
47:12So basically radiation happy help
47:15clinically has been a therapeutic
47:18component for gynecological
47:20malignancies for many many years
47:23according to evidence based treatment
47:26guidelines has been published.
47:28An article they looked into estimated
47:32frequency of use of radiation for
47:35gynecological malignancies and can
47:37see that most commonly we apply.
47:41Radiation for cervical cancer is up to
47:4560% of patients then endometrial cancer.
47:4845% volver cased cancer 40%.
47:51Actually vaginal cancer is very rare,
47:55but it's almost 100% of the
47:58cases require radiation and 10%
48:01of patients with ovarian cancer.
48:04So the least.
48:07So there are two approaches.
48:10When we administer radiation
48:12for gynecological cancers,
48:13one is external radiation and the 2nd
48:16is internal radiation or brachytherapy.
48:19So this,
48:20this slide illustrates the external
48:22radiation is administered with.
48:24With this big machine called
48:27linear accelerator,
48:28the patient is positioned on the
48:31treatment table and radiation
48:33treatment is given from is produced
48:36here in the head of the machine and.
48:39He's aimed to the area that we want to treat.
48:44Um,
48:44for gynecological cancers we use a lot
48:47bracket therapy or internal radiation.
48:50What does it mean that applicators are
48:53placed inside the body of the patient
48:57and then they are connected to this machine,
49:01that is housing the radiation source
49:03most frequently is iradium 192 is
49:06high dose rate brachytherapy device,
49:09so when we turn on this machine
49:11the source of radiation travels.
49:14Through this connection to the patient's
49:17body to the applicator delivers the
49:20radiation and after the dose is delivered,
49:23it returns back to the housing.
49:27Machine those are some examples
49:29of applicators that we use for
49:32brachytherapy for inside radiation,
49:35so they are actually placed in close
49:38proximity to the tumor or targeted
49:42area and sometimes right in the tumor itself.
49:46So for example,
49:48those are vaginal cylinders.
49:50Those are thin hollow tubes that are
49:54actually introduced in the uterine cavity.
49:57And placed in proximity to the.
50:00Cervix for basically for cervical
50:03cancer and those are needles that
50:05actually are used for brachytherapy.
50:08When we want to treat gross tumor so
50:11they are placed inside the tumor itself.
50:15So there are basically three main
50:18clinical indications for radiation.
50:20In practice,
50:21one is related to the surgery
50:24that removes the cancer.
50:26So we know surgery we want to the
50:29cancer to be removed by surgery.
50:33But sometimes radiation helps
50:35before surgery to shrink the
50:37tumor and make the surgery.
50:40Maybe a little bit less extensive.
50:43And sometimes we give radiation
50:45based on the stage and
50:48risk factors after the surgery.
50:51In this situation,
50:52is given to prevent tomorrow or to
50:55decrease the risk of tumor recurrence.
50:58So we these. In this third radiation,
51:03when radiation is given related to
51:05surgery can be administered either
51:07external or internal, and usually
51:09the duration is 3 to 5 weeks course.
51:13Another application is definitive treatment
51:16when tumors cannot be removed by surgery,
51:20so we rely on radiation
51:22to control those tumors.
51:25Usually chemotherapy is given together
51:27most frequently in the cervical,
51:30vulvar, and vaginal cancer,
51:33and again when we treat definitively,
51:36it's sometimes it's a combination
51:39of external and internal radiation,
51:42and sometimes it's.
51:43Only external radiation,
51:45but the course is long because
51:47we need to give higher dose.
51:51So 67 even more weeks of treatment.
51:54And of course for palliation,
51:56when kind of Khalaj,
51:58ikle tumors themselves or
52:00metastasis cause symptoms,
52:02then we give short course of radiation,
52:05external radiation treatment
52:06one to two weeks and example of
52:10symptoms are like bleeding pain,
52:12pressure, obstruction.
52:13That reduction has been
52:16proven quite successful.
52:17Successful in palliate.
52:21So it always has been a concern for
52:24treatment related side effects,
52:26radiation related side effects.
52:29So basically technical advancements
52:31that have been achieved in the last
52:34years allow us to get a better cancer
52:38control and decreased side effects
52:40and for gynecological cancers we
52:42are looking at side effects related
52:45to rectum urinary bladder bowel
52:47because those are organs close.
52:50In the area where we administer
52:53radiation for these diagnosis,
52:56so for example,
52:58technical advancements are software
53:00algorithms that have been created
53:04and allow us to incorporate the
53:07PET CT scan images,
53:09MRI images in our treatment planning.
53:13Another advance that now it's
53:16advancement that is now part of our
53:20daily treatments is and standard is
53:23intensity modulated radiation therapy.
53:26This is a way to administer
53:29radiation in a very conform way,
53:32conform to the shape of the tumor.
53:35So in this way we could increase the
53:39dose that we administer to the tumor,
53:43sparing healthy tissues around it.
53:45Another good advancement that we
53:48also apply on a daily basis is
53:51incorporation of high quality images
53:54taking just before each treatment session.
53:57To make sure that patient is
54:00positioned correctly and radiation
54:02is administered with high accuracy.
54:04So this is image guided radiation
54:07therapy and our linear accelerators.
54:10So our machine,
54:11external radiation machines are
54:13very capable and we can obtain
54:16this images before each treatment.
54:21The least promising research
54:25that probably will increase the.
54:29Good results and for example,
54:32new combinations of radiation
54:34therapy with systemic treatments
54:36like immunotherapy or inhibitors
54:39of DNA repair mechanisms in cancer
54:41cells like PARP inhibitors,
54:43and even for the radiation.
54:47Modalities there is a new radiation
54:50treatment devices that are being tested.
54:53For example, this is a miniature
54:55X Ray source exhaust system or
54:58that gives a precise concentrated
55:00dose directly to the tumor size,
55:03so site so this can be applied to breast
55:06cancer but also to gynecological cancers.
55:10So it's always knew research and
55:13new results that we're looking for.
55:16Thank you.
55:19I think.
55:22Wonderful thank you so much.
55:26So we would love to open
55:27it to questions if if you
55:29guys have any you can do it.
55:31Probably live if you want
55:32to raise hands on Q&A,
55:34we happy to talk about anything
55:35you guys would like to talk about.
55:37We're here to disposal.
55:43And if not, then we finished
55:46three minutes earlier. Thank you,
55:48thank you so much everybody will
55:50love being with you. I think your
55:52couple questions on the chat actually.
55:57One is for you, I think.
56:02So the first question that's right now,
56:04can you just repeat what they're
56:06using birth control pills?
56:07Reduce the chance of a very unimpressed
56:10had breast cancer and it's cut off.
56:12Let's see if there's a way I can get.
56:14So today I'll talk a little bit it,
56:17cut off a look at the end
56:19if you would like to just.
56:22If you like to type more so.
56:27Birth control pills unquestionably
56:29reduce the risk within cancer,
56:31and as I mentioned in the numbers,
56:35very much very much so very significantly so.
56:39If you had breast cancer,
56:41is really the only time where
56:43you gotta talk to your provider
56:45to talk about pluses, minuses,
56:46because a lot of breast cancers are
56:49hormone sensitive and we would not
56:51want to do that if you had breast
56:53cancer because even though it would
56:55decrease your risk within cancer,
56:57it would potentially increase
56:58your risk of breast cancer.
57:00So if if you don't have if you
57:02never had breast cancer then we
57:04very much feel that the benefits
57:07that you get from the reduction in
57:09ovarian cancer and uterine cancer.
57:12Outweigh all the risks and and very
57:14much feel that it's worthwhile.
57:16But if you had breast cancer,
57:18that would be the only time where you would.
57:20You would be careful and you would
57:22need to speak with you with your
57:24doctor to make sure that the breast
57:26cancer wasn't hormone sensitive.
57:30The second question is what are the
57:32latest findings for treatment for
57:34varying cancer with immunotherapy,
57:36which one specifically so
57:38I can start them glory.
57:40I'm sure you will like
57:42to get so immunotherapy.
57:43Is this wonderful new treatment
57:45modality that we have started using.
57:48Unfortunately,
57:48it does not seem to be for everybody,
57:51and that's especially the
57:53case in ovarian cancer.
57:55You know, being cancer by itself,
57:57only 7% of women respond to immunotherapy,
58:00so not a great number.
58:02But it is just like everything that
58:05we talked in in the talk today.
58:08It is truly personalized and individualized.
58:11So when the when the cancer cells
58:14studied specifically for the patient,
58:16some of these cancer cells have
58:19specific mutations and for some
58:21of these specific mutations,
58:23immunotherapy is very effective.
58:25So KEYTRUDA is the one that we would use.
58:29But again, it's not for everybody,
58:31it's specifically for those
58:33who have mutations.
58:35And there's a question about poverty matters,
58:37and that's very similar.
58:40Um, that's for proper hitters.
58:42There's nowadays a lot of
58:44literature and pop inhibitors.
58:46In 2014 was the first time where
58:49Papa inhibitors became part of the
58:52treatment regimen for Varian Cancer.
58:54At that time, it was only for women,
58:57with varying cancer,
58:59with Brad commutations.
59:00Subsequently we have found that
59:02property hitters helpful for women
59:04merges with with broccoli mutations,
59:06but with other mutations as well.
59:09Something called homologous
59:11recombination deficiency.
59:11And we now use pop inhibitors in
59:14treatment and also maintenance,
59:16which means that some women take property
59:19matters when they're cancer free to prevent
59:22or delay cancer cells from coming back.
59:25But similarly to what I
59:27mentioned about immunotherapy.
59:29Similarly,
59:29it's not for everybody.
59:31It truly needs to be smart and and directed,
59:35and cells should be studied.
59:37These specific mutations
59:38assessed and decision made,
59:40who really would benefit from these.
59:43Versus others glory.
59:44If you would like to add
59:46I think then Cynthia is
59:49able to speak. Sure, yes,
59:51I agree in terms of immunotherapy,
59:53that what we have available right now
59:57and the data that we have is that immuno.
01:00:00Therapy has a highest likelihood of success.
01:00:04If the tumor has certain characteristics
01:00:08such as mismatch repair deficiency,
01:00:11you might hear that term or
01:00:14or microsatellite instability.
01:00:16So those type of changes
01:00:19happen a bit more frequently,
01:00:21and cancer such as endometrial
01:00:24cancers and colorectal cancers
01:00:27compared to ovarian cancer.
01:00:29But somewhere in cancers can have that.
01:00:33For ovarian cancers that
01:00:36don't have that feature,
01:00:38what we're looking to is probably going
01:00:42to be combination therapies where
01:00:45immunotherapy is combined with other agents.
01:00:49Those that target the abnormal
01:00:51blood vessels of tumors,
01:00:53those that target DNA damage,
01:00:55repair sometimes are drugs that target
01:00:58DNA damage repair like PARP inhibitors
01:01:01can actually lead to DNA changes.
01:01:04That makes the body's immune cells
01:01:07more able to potentially identify
01:01:09those cells as cells that need to
01:01:13be illuminated by the immune cells.
01:01:15Um, so I do think there's promise.
01:01:18Other areas, of course.
01:01:20Um, that are of interest are even,
01:01:24you know, Speaking of HPV vaccines,
01:01:27other cancer vaccines.
01:01:29So potentially.
01:01:30I mean,
01:01:31I think right now everyone has is
01:01:34more educated than we could ever
01:01:37imagine about M RNA vaccines which
01:01:41are being deployed to combat covid.
01:01:44So it's a new technology of vaccination
01:01:48which definitely has promise.
01:01:50For cancer and personalized cancer
01:01:53vaccines as well, so you know,
01:01:56basically stimulating the the natural
01:01:58immune response to recognize abnormal
01:02:01proteins expressed by cancer cells.
01:02:04So other areas of immunotherapy to
01:02:07include things like car T cells.
01:02:11So basically expanding a person's
01:02:13own T cells that can recognize.
01:02:17Tumor antigens or tumor neoantigens.
01:02:19So I do believe there's a lot on the horizon,
01:02:23and these advances are being
01:02:25made possible by.
01:02:29Much increased understanding
01:02:30of how these cancers develop,
01:02:32as well as new technologies
01:02:35that make it more efficient to
01:02:38to consider these modalities.
01:02:40So yes, I'll pause there for a second and
01:02:43we I see there's a few other questions.
01:02:45And then I think Cynthia
01:02:47had a question as well.
01:02:51It's in did you want to go ahead
01:02:53with your question?
01:02:54Can you hear me?
01:02:55We can oh wonderful.
01:02:56Thank you so much doctors.
01:02:58This has been so very informative.
01:03:00I was asking the question about using
01:03:02birth control pills and not for myself.
01:03:04I'm 67. That ship has sailed but as
01:03:07I say I had breast cancer in both
01:03:09breasts at age 52 an my I'm concerned
01:03:11about my 32 year old daughter Ann.
01:03:14My 35 year old daughter in law
01:03:16who's also her mother had breast
01:03:18cancer so when I heard about
01:03:20the birth control pills helping.
01:03:21The health of those two women.
01:03:24That's where my ears turned on.
01:03:26So is that the kind of information
01:03:28they should be talking to
01:03:30their gynecologists about?
01:03:32Yeah, yeah, you know,
01:03:33sending that alone is worth while.
01:03:34This one hour if you if this is what
01:03:37you heard and you're going to tell you,
01:03:39tell your daughter it's
01:03:40absolutely so thrilled.
01:03:41Thank you so so much. You know,
01:03:44so I think important thing not that of
01:03:46course to go into into your history,
01:03:49but very important thing is really
01:03:51just to to like know your risk,
01:03:53you know, like understand your risks.
01:03:55So for a family history like
01:03:57yours or history like yours would
01:03:59be very important to understand.
01:04:01Again like genetic mutations,
01:04:03is there anything that predisposes
01:04:05you or your daughter to increase risk?
01:04:07And even if there was, you know like love,
01:04:10my women allowed my young patients
01:04:12whose mom said take care of.
01:04:14Always ask me while my
01:04:16mom had ovarian cancer,
01:04:17my mom had breast cancer or you
01:04:20know I have a BRACHA gene mutation.
01:04:22Does that mean that I shouldn't
01:04:25be taking birth control pills,
01:04:26but it's the opposite.
01:04:28It's On the contrary.
01:04:29If the only time not to take it is if
01:04:32the woman herself has breast cancer,
01:04:35but the mom having breast cancer
01:04:37or even having Braca mutation
01:04:39herself is the reason to take it,
01:04:42not not to take it because.
01:04:44Even for those women who have broken
01:04:46mutation and they have a significantly
01:04:48higher risk of being cancer,
01:04:50their risk also would decrease by 50%.
01:04:52So if somebody had a risk of 20% and they
01:04:56take birth control pills for five years,
01:04:58the risk will go down to 10%.
01:05:01You know, it's it's it's.
01:05:04Its respective respective decrease so
01:05:06thank you for your question but yes,
01:05:08you know the important thing is to
01:05:11know genetics to make sure that
01:05:13they're not at risk for something else,
01:05:15but that is not a contraindication on
01:05:18country that's even stronger indication.
01:05:20Thank you Lori.
01:05:22Can you see the
01:05:24question over there? Yes, yes.
01:05:27I I see question uh regarding HPV
01:05:30vaccination and yes one of the
01:05:34advances has been the expanded
01:05:36eligibility for getting HPV vaccine.
01:05:39So currently HPV vaccine Gardasil 9 is FDA
01:05:44indicated for ages 9 through 45 for boys,
01:05:48girls, men and women.
01:05:51And so most efficacious considered
01:05:55on time for four.
01:06:00Children to be vaccinated by age 11 to 12
01:06:03and there will be a very robust immune
01:06:06response and as a preventive vaccine.
01:06:09It prevents infection but has minimal
01:06:11effect on established infections.
01:06:13So that's why there's lesser benefit.
01:06:15As one gets older and there's a
01:06:17higher likelihood of having been
01:06:19exposed to common HPV types,
01:06:22given that there's nine different
01:06:24types in the current vaccine,
01:06:25you know there is still probably
01:06:28some benefit in many adults who have
01:06:31not had a chance to be vaccinated.
01:06:34So it's an individualized thing I would.
01:06:36I would suggest speaking with ones
01:06:39physician about the pros and cons,
01:06:41but definitely is a consideration
01:06:43for both men and women.
01:06:44Since you know many people.
01:06:48Of of the older age may want to have
01:06:51catchup vaccination because there was
01:06:53less availability or no availability
01:06:56at at during their their childhood
01:06:59and childhood vaccine schedule.
01:07:01So that's a great question.
01:07:05And and I think another question
01:07:08which Renee has addressed is
01:07:11eligibility for clinical trials.
01:07:13So Renee Place the Renee Goddard place the.
01:07:20Good websites to look for trials.
01:07:24Clinicaltrials.gov, for example,
01:07:26you can search by geographic location,
01:07:30cancer tie.
01:07:31You know what, what phase of clinical trial.
01:07:38And so,
01:07:39and then in terms of local clinical trials,
01:07:42Britney put the website up for the
01:07:46Yale Cancer Center website as well.
01:07:52Um?
01:07:55Let's see. I think there was a question from
01:08:01Audrey about genetic mutations in 2017.
01:08:06So you know it's a good question.
01:08:08We always, you know,
01:08:10I'm a huge proponent of saying yes,
01:08:12you know, retest.
01:08:13If it was longer than 2017,
01:08:15I would definitely retest.
01:08:172017 was already the time where we did.
01:08:19We did this expanded to extend the panels.
01:08:22So you probably OK from 2017.
01:08:24But anytime you you're
01:08:25even thinking about it,
01:08:27I always just urge just reach out to them.
01:08:30Genetics counselor where you got
01:08:32it done and then just ask them
01:08:34you know they they routinely get
01:08:36these phone calls and they can just
01:08:38glance at yours and make sure that
01:08:40everything that everything was done
01:08:41and there's nothing additional.
01:08:43If you had it done before 2014,
01:08:45I always hate to redo it, but we don't.
01:08:47We have so much more now that
01:08:50than we did before,
01:08:51but to only 17.
01:08:52Most likely you are you up to date.
01:08:59Well, thank you so much everybody.
01:09:01We had such a wonderful time with you
01:09:03today and we hoped to do this again
01:09:06and please reach out to all all of us.
01:09:08I actually disposal in you so
01:09:10we always available to you.
01:09:12Thank you, thank you for having
01:09:14a good day and thank you so
01:09:16much for organizing. Thank
01:09:18you Daniela, Gloria. Nice meeting you nice
01:09:20to meet you too.
01:09:22Thank you so much ladies.
01:09:23Bye have a great day.
01:09:25Alright take care everyone.
01:09:27Thank you
01:09:27for joining us.