Smilow Shares Primary Care: Breast Cancer

October 05, 2022

Information

October 4, 2022

Presenters: Rachel Greenup, MD, MPH, Sarah Mougalian, MD, Wajih Zaheer, MD, Jill Banatoski, MD

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00:00People get started now.
00:02Thanks for joining us for Smile
00:05shares with primary care this month.
00:08We're focused on breast cancer
00:10because it's certainly breast cancer
00:12awareness month and the next slide.
00:15Oh, my name is Anne Chang.
00:16I'm the deputy CMO and Chief
00:19integration officer for SMILO.
00:21I'm a long medical oncologist
00:24and I developed this this,
00:27this series with Karen Brown and EMG
00:31and Smiler working together to really.
00:33Focus on the primary care perspective
00:36on cancer and hematology and the
00:39audience for primary care clinicians
00:42and we have our primary care
00:45panelist and smilo physicians.
00:47This is a monthly series.
00:49So if you like us then come back.
00:52It's always the first Tuesday
00:545:00 to 6:00 PM virtually and
00:56at some point perhaps in person.
00:59We started last month and really
01:01this is an opportunity to.
01:03To focus on questions that primary
01:06care may have about cancer topics
01:08and we really felt that it wasn't
01:11something that where we wanted the
01:12specialist to tell primary care what
01:14they wanted to know but really ask
01:16primary care what what the topics are
01:18that that you you have questions about.
01:20So we're going to go into introductions
01:23and then we'll go into a case
01:26presentation with our experts and
01:27really we'll let would like to
01:30have about 10 minutes available
01:32for questions answers that you.
01:33We put in the chat as we're going
01:36along or or ask at that time.
01:40So I'm going to introduce Karen Brown first.
01:44Karen,
01:44if you can say a few words and
01:47then and and then.
01:49Start with the interests of our faculty.
01:51Sure. No, I I just want to
01:53thank you and and of course,
01:54all of our smilo folks for sharing with us.
01:59You know, we are always stronger
02:02together and new cancer is.
02:04Can be a really tough time for our patients
02:07and for us to support our patients.
02:09So I think the more that we can
02:11do to coordinate both officially
02:13and unofficially and formally and
02:15informally between us that the better
02:18care that our patients will receive.
02:20And I would also like to point
02:22out that this evenings panel is
02:24largely on the the New Haven region.
02:26So we're hoping to kind of
02:29highlight on different regions and
02:31I'll introduce Joe Bennett,
02:33Toski who is one of our star.
02:35EMG primary care clinicians Jill
02:37attended medical school at the
02:39University of Connecticut and completed
02:42residency in primary care general
02:45internal medicine at Mass General.
02:47She returned to Connecticut to
02:49practice general internal medicine,
02:51where I met her.
02:53She was an assistant clinical
02:54professor and working closely to
02:56educate a lot of the residents
02:58who were training with us at Yale.
03:01The ambulatory setting.
03:03She and her practice joined a NE
03:07Medical Group in 2018 and are clearly
03:11provide excellent patient care.
03:13We get constant demands to see how many
03:17more patients they can follow because
03:19people love them and they do such a
03:22good job taking care of patients.
03:24She's additionally now the medical
03:26director for University of New Haven,
03:28so engaging in some student health as well.
03:32I'll pass it back to you to
03:34introduce our specialist.
03:35So Rachel Greenup is an associate professor.
03:40Surgery. She's a breast surgeon.
03:42She's our chief of breast surgery.
03:44And she came from, came from Wisconsin,
03:48where she did her residency and then
03:50went on to do her fellowship at the MGH,
03:53Dana Farber and Brigham and actually
03:57came before joining Yale from Duke,
04:00where she founded that Duke Breast
04:03Cancer Outcomes Research Group and.
04:05And she has been here how long?
04:09Now I think it's Rachel.
04:13Yes, and it has a real focus on
04:15care of women with young women
04:18with breast cancer and early onset
04:20breast cancer and health equities.
04:22Sarah Shellhorn is a colleague of mine,
04:26associate professor of medicine,
04:29chief ambulatory officer for for Smilo,
04:32and she came from.
04:34She did her residency at Beth Israel
04:36Deaconess in Boston and and came
04:38did her fellowship at MD Anderson.
04:40And she is really interested
04:42in in lots of things.
04:43Around patient care,
04:45using technology to help patients optimize
04:49adherence to oral therapies and, you know,
04:53studying patient reported outcomes.
04:55And she's the physician leader of our
04:58faculty academic practice and also very
05:01interested in early onset breast cancer.
05:04Why do you stay here?
05:05And another colleague,
05:06associate Professor,
05:07Professor of medicine,
05:08he is the medical director for our
05:11Smilow Cancer Care Center in Guildford.
05:13And he trained it.
05:16Yellow affiliated hospital for residency.
05:18He was chief resident and then did
05:21his fellowship at Cornell University,
05:23met while Medical College,
05:24and is a Fellow of the American
05:27College of Physicians and also
05:29very interested in long term care
05:31of patients with breast cancer.
05:33So without further ado,
05:35but with our Distinguished faculty panel,
05:37I'll hand it over to Jill.
05:40Good evening, everyone and thank you.
05:42Thank you for the introduction.
05:43Dan and Karen, we and NMG who are seeing
05:48patients see and have conversations
05:50with over 100,000 women regarding
05:52breast cancer screening annually
05:53and we order hundreds of mammograms.
05:56So this topic is very important to us.
05:59We utilize the health maintenance tab
06:00in EPIC as an opportunity to remind
06:02ourselves and our patients of when
06:04their mammograms are due and to make
06:06sure they're done in a timely fashion.
06:08And one of the focuses we wanted
06:10to make sure.
06:11We took on tonight was recognizing
06:13those who are at increased risk of
06:15breast cancer and might need earlier
06:17or more advanced level screening.
06:19So with that,
06:20I'll start our case with a 35 year old
06:23nulliparous female with a history of obesity,
06:25PCOS and Raynauds who presents
06:27for advice regarding breast cancer
06:30screening and prevention as her mother,
06:32maternal aunt and premenopausal older
06:34sister all have a history of breast cancer.
06:38So questions regarding this case are
06:40what screening imaging is recommended
06:42in light of her family history and at
06:45what intervals is genetic testing indicated?
06:47What tests and how is it best
06:50to arrange that?
06:50And what, if any,
06:52preventative strategies are recommended
06:54regarding prophylaxis or surgery?
06:55And so Doctor Greenup is going
06:57to take this on.
06:58Thank you,
06:59Rachel.
07:00Thank you for having me.
07:02So breast cancer screening has been a
07:05topic of great controversy for many years.
07:08And it flares up in the lay
07:10press every three to five years.
07:12Every different society
07:13has specific guidelines,
07:15but the next slide will show you
07:18that the US Preventive Task Force
07:20guideline demonstrates that women
07:22under 50 screening should be made
07:24on an individual basis and take
07:26patient context into account.
07:28So certainly a strong family history.
07:30We recommend women begin screening
07:33with annual mammogram and or
07:36ultrasound based on the youngest.
07:38Age of the individual and
07:40their family at diagnosis.
07:41So for example,
07:42in this 35 year old woman who
07:44had a history of a mother,
07:46maternal aunt,
07:47and premenopausal older sister,
07:49we would think about the ages of
07:52their diagnosis and recommend
07:53screening for her about 10 years
07:56younger than that earliest diagnosis.
07:59the US Preventive Task Force
08:01guidelines were most controversial
08:03because they did recommend that
08:05screening could be considered in
08:07every other year in women 50 to.
08:0974 and they actually said that
08:11there was potentially no benefit
08:13to clinical breast exam patients.
08:16Asked us about this a lot.
08:18I still encourage women who are
08:20comfortable doing a monthly
08:21breast exam to do so.
08:22Regardless of what the data shows,
08:24we still meet many women who
08:26find their own breast cancer.
08:28The next slide shows the American
08:31Cancer Society guidelines,
08:32and again, this is what most of
08:34us in academic programs adhere to,
08:37which includes.
08:38Annual screening for women 40 to 44,
08:41again lifetime risk should be
08:44considered and then switching
08:46to mammograms every two years
08:48as women are 55 and older,
08:50again depending on risk.
08:52The next slide shows the American
08:54Society of Breast surgeons position
08:57statement on screening mammogram and
08:59this came out in 2019 in response to
09:02differing opinions around frequency
09:04and type of imaging for average
09:06risk women and these guidelines.
09:09Really thoughtful in considering
09:11not only family history but also
09:13breast density and the value
09:15of supplemental imaging.
09:16And I recommend if anyone's
09:17interested you can go on the SBS
09:19website and look at these in detail.
09:21But the next slide will outline.
09:25When women, certainly who have breast cancer,
09:28was,
09:28we see a finding on mammogram followed
09:31by ultrasound plus minus biopsy.
09:33Next slide.
09:34If there's any concern about density
09:37or family history being exacerbated,
09:40inclusion of MRI, 3D mammography screening,
09:44ultrasound or supplemental imaging
09:46such as contrast enhanced mammography,
09:49which is a less common currently
09:51across the country,
09:52but we're hoping to launch that in
09:55our smilow network in the near future.
09:58There's opportunities to do so without
10:01pushback from insurance coverage.
10:04In terms of screening or testing
10:07for a hereditary Cancer syndrome,
10:09next slide,
10:10we typically depended on the NCCN
10:13guidelines and these as many of you know,
10:16we're really based on both a personal
10:19history of breast cancer and a
10:21family history of breast cancer.
10:23It looked at potential for
10:25genetic testing for BRCA one and
10:28two mutation carriers,
10:29any woman 45 or younger women younger
10:32than 50 with first, second or third.
10:353 relatives women with family history
10:38of both breast and GYN cancers,
10:41including ovarian or fallopian
10:42tube or primary peritoneal,
10:44it did account for.
10:47Bilateral breast cancer,
10:49triple negative phenotype under age
10:5160 and individuals with strong family
10:54history of Melanoma and pancreas cancer.
10:57Next slide.
10:59Again, the American Society of
11:02Breast Surgeons did update our
11:04genetic testing for hereditary breast
11:06cancer guidelines to say that any
11:09woman with a known breast cancer
11:11should have access to a genetic
11:14counseling and potential testing,
11:16knowing that a broad genetic testing
11:18panels can include variants of
11:21unknown significance that can cause
11:23difficulty in discussions and are
11:26often not clinically actionable.
11:28And I think that brings us to
11:30our screening key points.
11:34And the final is that average
11:37risk women who need screening can.
11:40Be considered for every other
11:42year starting at age 50,
11:43but all current guidelines recommend we
11:46account for patient family history and
11:48personal history including biopsies.
11:50We should consider screening
11:52every year in women 40 or over.
11:56It's important to screen women 25 and
11:58over for higher risk of breast cancer
12:01and include that on their imaging.
12:03That will help our radiology colleagues
12:06think about supplemental ultrasound
12:08and or MRI related to breast density.
12:10And again, we do have a robust program
12:13at the breast center that includes
12:16breast surgery EP's who can help absorb
12:19these patients if they need a medical
12:22home for their Breast Cancer Care.
12:28Thank you. So now we're we're
12:30taking this same patient and moving
12:32her through the process here.
12:34Now she's presenting at age 49
12:37with a palpable breast mass.
12:39And so when we come to this case
12:41the questions that come up are
12:43what are the appropriate imaging
12:45orders and what is the appropriate
12:47method for referring for biopsy.
12:49Should the patient go straight to
12:51surgery should be a radiological biopsy
12:53and if the if the biopsy is positive?
12:56What's the order of referral and
12:58when should she see oncology in
13:01relationship to her definitive surgery?
13:03I believe Rachel is taking this one as well.
13:06Yeah. So it's certainly a 49 year old woman
13:10with a palpable breast mass initially
13:12should undergo diagnostic mammogram,
13:14a diagnostic ultrasound and certainly
13:17consideration of MRI based on
13:19breast density is very reasonable.
13:22I typically have this discussion
13:24with our radiologist.
13:25Sometimes the reports will say
13:27things such as extremely dense
13:29breast MRI is recommended.
13:31Other times it's valuable to think
13:32about the pros and cons of the MRI
13:35in partnership with the patient.
13:36Ourselves at Yale are we do refer
13:40these women for biopsy and or second
13:43opinion if the imaging is done
13:45outside so that women can get both
13:48a face to face consultation with a
13:50provider in our breast center and
13:53also have a formal review of their
13:57screening imaging that led to the.
13:59The work up or the the area of concern
14:03screening imaging being their annual
14:05imaging that caught the abnormality
14:08and diagnostic being the additional
14:10workup that led to diagnosis.
14:13When we think about breast surgery
14:15and typically our breast surgeons
14:17are the first frontline providers
14:19that see these patients,
14:21there are many options.
14:22So women who are eligible with small
14:25breast cancers can undergo lumpectomy
14:27or mastectomy if they are found to
14:30not have a hereditary cancer syndrome.
14:32And we know their risk of local
14:35recurrence remains very low
14:36lumpectomies are shorter surgeries.
14:38We can do that in conjunction
14:41with Aqua plastic surgery either
14:42reduction or a lift we.
14:44Typically recommend that women
14:46less than 70 years old with a
14:49triple negative or her two positive
14:52breast cancers have lumpectomy,
14:54followed by radiation.
14:56There are some exceptions and older
14:58women with favorable hormone receptor
15:00positive breast cancers where
15:01radiation can be safely omitted.
15:03The recovery time is shorter.
15:05I always tell patients they get
15:06back to their lives a little sooner
15:09and the complication rate is low
15:11when we think about mastectomy.
15:12It's a bigger surgery when we add.
15:14Reconstruction.
15:15That's a second really important layer
15:17from a psychosocial perspective,
15:19but does not contribute to
15:22improve cancer outcomes.
15:23Many women with small tumors after
15:27mastectomy won't need radiation.
15:29They can be exposed to several
15:31surgeries and or revisions and there's
15:33a higher rates of complications
15:35especially if patients are smokers
15:38have diabetes or other comorbidities.
15:40Next slide and these are just some pictures
15:43that everyone on the call is aware of.
15:45Lumpectomy means we're removing
15:46the tumor with negative margins
15:48typically following by radiation.
15:50Next slide we used to be very reliant
15:53on radiology putting a wire in next
15:56slide and now we have the improved.
15:59Sophisticated technology like
16:00radioactive seeds or tag localizers
16:03that women can have placed up to
16:06five days prior to their lumpectomy
16:08without needing to have the wire.
16:12Out of their breasted day of surgery,
16:14we also have good data.
16:15It's more comfortable,
16:16patients have better satisfaction
16:18and their margin rates are improved
16:21with smaller resection specimens.
16:23Next slide when we think about mastectomy
16:26obviously that's removing all of the
16:28breast tissue that can happen with or
16:30without reconstruction.
16:31We have a great group of reconstructive
16:34surgeons across the region that
16:37do both implant based and micro
16:39vascular reconstruction and we're
16:41doing an increasing number of.
16:43Media implant reconstruction,
16:44which does consolidate the
16:46recovery time for our patients.
16:48Next, I think one of the things that
16:51comes up a lot when I meet women,
16:53especially our younger
16:54patients like this one.
16:56As the discussion about whether there's
16:58benefit of removing their healthy
17:00opposite breast through prophylactic
17:02mastectomy on the contralateral side
17:04and the rates of this has actually
17:06tripled in the last few decades,
17:08probably related to cultural and
17:11kind of pop culture conversations.
17:15We know that after one breast cancer,
17:17a woman's risk of a contralateral
17:19cancer is low.
17:20It's between .1 and .5% per year,
17:24and that removing a healthy breast
17:26outside of a hereditary cancer
17:28syndrome does not improve survival.
17:30And there is also an associated higher
17:32risk when we do more surgery inherent
17:35to things like bleeding infection.
17:37But ultimately our patients do
17:40report that sometimes cosmetic
17:42outcomes and a Peace of Mind are
17:44reasons that prompt them to.
17:46Pursue a double mastectomy.
17:49Next slide.
17:50When women need radiation,
17:52this is external beam radiation.
17:54It's painless.
17:55They usually get five days
17:57a week for one to 10 weeks.
17:59It's cumulative, so side effects tend
18:01to come later or towards the end.
18:03This is things like sunburning,
18:05fatigue, low risk of secondary cancers.
18:09Next slide.
18:11And there can be swelling,
18:12redness, cough,
18:13shortness of breath.
18:14Some of this related to the site
18:16that receives the radiation.
18:18But our radiation colleagues have
18:20improved techniques to avoid
18:22Android to heart and lungs,
18:23and they continue to work towards shorter,
18:26abbreviated courses.
18:34Rachel, if we could just go back
18:35to the beginning of the case
18:36with the you don't have to go
18:38all the way back in the slides,
18:39but just about how you would advise
18:42this woman with regard to options
18:45prior to her developing her cancer
18:48in terms of surgical prophylactic
18:51surgery or medical therapeutics,
18:54prophylactic medicine medications.
18:56What is the, how do you,
18:59how do you phrase that conversation?
19:00With her given her risk and whether
19:02or not if she hasn't known mutation
19:04or does not have a mutation
19:06but a profound family history.
19:08Yeah, so it's a complicated discussion.
19:11I think ideally women will come in
19:13early in the process before they're
19:15kind of ready to sign up for surgery.
19:18I first start by taking a good family
19:21history and getting a sense of the
19:23level of family member involvement,
19:26at what age family members are diagnosed
19:29and how those family members have survived
19:33or or not survived their breast cancer.
19:36We do see families where there's many,
19:38many women. With breast cancer,
19:39but they're all diagnosed in the
19:42postmenopausal setting with screen
19:44detected very favorable cancers.
19:46And then we see women who have a
19:48myriad of young women and their
19:50family diagnosed with very highly
19:52aggressive breast cancers where the
19:54it's probably more time sensitive.
19:57As certainly a woman with this strong
19:59family history having a mother,
20:00maternal aunt and older sister,
20:02I would refer her for genetic testing.
20:05Ideally,
20:05we refer an effective family member first.
20:09Because if that person's negative,
20:11less likely that the individual in
20:13front of us would be a mutation carrier.
20:17Again,
20:17screening should start about 10
20:19years younger than the earliest
20:21family member was diagnosed.
20:23And my practice for these high risk
20:26patients although it it is candidly
20:29controversial as to to both a 3D
20:31mammogram screening ultrasound
20:33alternating with annual MRI.
20:36So we're staggering imaging that's
20:37being looked at every six months.
20:40We do see that some women get fatigued.
20:42So it's a shared decision.
20:43We work with them together about
20:45what what feels good.
20:47I have patients that feel very
20:49reassured when they're imaging
20:50is normal and I patients that are
20:53probably overestimate their risk of
20:55breast cancer the more imaging we do.
20:57So it's important to be thoughtful
20:59about how it affects their experience.
21:03If she was postmenopausal I,
21:06typically the breast tissue becomes
21:08fatty or replace we all know
21:10that 3D mammography and becomes a
21:13becomes easier to interpret and.
21:15I think especially if postmenopausal
21:17women are nearing end of life or
21:19they have multiple comorbidities,
21:21discussions around reducing the
21:23frequency of imaging is valuable.
21:27And we do talk to women about
21:29chemo prevention if their family
21:31history is very high,
21:33certainly if women have both a known
21:35BRC 1 mutation and strong family
21:38history or bracket 2 mutation.
21:40Similarly,
21:40we we have good discussions about
21:43risk reducing surgery both from
21:45a mastectomy perspective and
21:47also from a GYN perspective.
21:50Thank you. I I think Sarah had her hand
21:52raised and she wanted to comment as well.
21:54Just wanted, yes, thank you.
21:56Jill, I just wanted to add to that,
21:57that sometimes in women who are at
22:00particularly high risk but don't
22:02wish to go the the surgical route,
22:04chemo prevention is a possibility and
22:07chemo prevention sounds much scarier,
22:09scarier than it actually is.
22:11But Chemoprevention just basically
22:13means tamoxifen or sometimes aromatase
22:15inhibitors which reduce the risk of
22:18developing a breast cancer somewhere,
22:19a relative risk. 30 to 50%.
22:24Over whatever time period they're
22:25taking it in, even past that time frame,
22:28the the issue there.
22:33The issue there, excuse me,
22:34what is that that relative risk
22:36reduction may not translate into a
22:39large absolute risk reduction and
22:40that can get a little bit complicated,
22:43but it's certainly something that we we
22:45do on occasion for people who are interested.
22:49Thank you.
22:51So we'll take our patient who unfortunately
22:54has surgery and is found to have a
22:57stage 2A invasive ductal carcinoma.
22:58The tumor is 2.5 centimeters in grade 3,
23:02does not involve any lymph nodes,
23:04and is ER PR positive and her two negative.
23:07And so we are going to now engage
23:10in discussion about treatment.
23:11If she's pre menopausal,
23:13what is her appropriate adjuvant treatment
23:15and what factors are considered?
23:18How is this different if she's
23:20postmenopausal and how long should she
23:22be on adjuvant hormonal therapy and
23:25doctor shellhorn's going to take it away?
23:28Right.
23:28So breast cancer treatment in 10 minutes,
23:31no problem.
23:32The the,
23:33the initial approach and Rachel did a
23:36really lovely job going through the,
23:39the definitive local management
23:41of breast cancer.
23:42When we think about breast cancer,
23:44they're really three different modalities,
23:46each of which has a different concern.
23:48And so very broadly speaking,
23:50and I know I'm jumping into
23:51the next slide a little bit,
23:52but very broadly speaking, surgery,
23:54the purpose of surgery is,
23:55is,
23:56is to take out the cancer and the affected.
23:58Lymph nodes,
23:59the areas that we know contain cancer.
24:01The purpose of radiation is to mop up behind
24:04the surgeon to to get rid of any micro,
24:07micro microscopic disease that
24:08might reside in the breast or the
24:11OR the XL or other lymph nodes.
24:13And then the purpose of medical
24:15oncology or systemic therapy is really
24:17to reduce the risk of developing
24:20metastatic disease in the long run.
24:22So we all have very different concerns.
24:24The sequencing of treatments can
24:26be different depending on the
24:29clinical circumstance.
24:30Sometimes surgery is done 1st,
24:33and this is particularly helpful
24:34to figure out what it is exactly
24:36that we're dealing with.
24:37What's the size of the cancer,
24:38how many lymph nodes are involved.
24:41You really get a full pathologic
24:42picture of the cancer,
24:44and if that is going to be used to
24:46determine systemic therapy or the need
24:47for radiation later on down the road,
24:49that can be helpful.
24:51Sometimes we use a neoadjuvant approach,
24:53meaning before surgery,
24:54to give some sort of systemic therapy
24:57such as chemotherapy, and this is used
24:59in generally and more aggressive.
25:01Cancers or very locally advanced cancers
25:03when we know that chemotherapy is
25:05going to be needed and we don't need
25:08that additional pathology to determine
25:10what chemotherapy regimen to use.
25:12So just wanted to give a quick word on
25:14adjuvant versus neoadjuvant and then
25:16we'll dive into all of that pathologic
25:18gobbledygook that Jill told us about in
25:20terms of this patients biopsy results.
25:27Before we do that, however,
25:28I've already mentioned over on the
25:30right what the roles of surgery,
25:33radiation and medical therapy are.
25:37Patients often want to
25:38know what their stage is.
25:40In fact, almost 100% of the time and stage
25:43can be thought of in one of two ways.
25:46There's the anatomic stage,
25:48which relies on the size of the tumor
25:50and the presence or absence of lymph
25:52nodes and their number to determine.
25:54How locally advanced a cancer is.
25:57More recently we started incorporating
25:59some of those things that were mentioned
26:02in the biopsy report that Jill that
26:04Jill read earlier including the grade
26:06which in this case was Grade 3,
26:08the estrogen receptor and the progesterone
26:11receptor status and the her two status.
26:14And we can incorporate those features of
26:17the cancer into the tumor size in the
26:20lymph node status to come up with what
26:22the final stage is and stage correlates.
26:25Roughly with prognosis.
26:28So it gets us now the patient's
26:30going to have surgery,
26:31the patients,
26:32if the assuming the patient has a lumpectomy,
26:34she'll need radiation.
26:36How do we decide what kind of medical therapy
26:39we're going to recommend for this patient?
26:42So next slide?
26:44We first look at the grade.
26:46Grade is a measure, broadly speaking,
26:49of how aggressive the cancer
26:50cell looks under the microscope.
26:52It's incorporating a couple
26:53of different things,
26:54including the architecture,
26:56nuclear grade and speed of replication.
26:59And it gives us a sense the higher the grade,
27:02the more aggressive we may need to be,
27:04IE the higher grade,
27:05the more likely the chemo is that
27:08chemo is going to be recommended.
27:10Next slide.
27:13We get into the estrogen and
27:15progesterone receptor.
27:15So the vast majority,
27:1675 ish percent of all breast cancers are
27:19fueled at least in part by the female
27:21hormones estrogen and progesterone.
27:23And so the presence of estrogen or
27:28progesterone near the cancer can
27:30lead to more uncontrolled growth.
27:33So estrogen and progesterone
27:35positive cancers,
27:36estrogen and progesterone receptor
27:38positive cancers are fueled by hormones,
27:41which leads us to.
27:43Talk about some sort of anti hormonal
27:46therapy and interfering with that
27:48interaction between the ligand and the
27:51receptor can lead to decreased gene
27:53expression and therefore decreased
27:54cell proliferation in the long run.
27:56So that's the the reason behind
27:59these hormone type therapies or
28:01rather anti hormone type therapies
28:03that we recommend for patients who
28:06have this type of breast cancer.
28:08You've heard of these drugs.
28:10You probably have hundreds
28:11of patients on these drugs.
28:12Tamoxifen works as a competitive
28:15antagonist of estrogen,
28:16and progesterone 6 sits in the
28:18pocket of the receptor and prevents
28:21breast cancers from from growing,
28:23or breast cells in general from
28:25being able to grow.
28:26Aromatase inhibitors, on the other hand.
28:30Prevent the peripheral aromatization
28:33of steroids into testosterone and into
28:37of rather testosterone into estrogen.
28:41And prevent the body from being
28:43able to make estrogen,
28:44and so you remove the leg in
28:47entirely so there's nothing to
28:48bind to the receptor itself.
28:52The final thing that we look
28:54at is the her two status.
28:55Her two is a member of the EGFR
28:58family of surface receptors,
29:00and it can be either normal,
29:02also called negative,
29:04or it can be positive and it can
29:06be positive in one of two ways.
29:09It can be overexpressed on
29:10the surface of the cell,
29:12or it can be amplified in the
29:15nucleus with lots of additional
29:17copies of the her two encoding DNA,
29:19her two positive cancers in general.
29:22Are more aggressive.
29:24They in general require chemotherapy and
29:28oftentimes we use chemotherapy first.
29:31In this setting, you may have heard
29:33of the name triple negative breast cancer.
29:37Triple negative just means estrogen
29:39receptor is negative,
29:40progesterone receptor is negative.
29:41Her two is -, 1, two,
29:44three, triple negative.
29:46Next slide please.
29:49Jill in in our preparation for
29:52this meeting, Jill shared a risk,
29:55shared a story of a patient who came
29:58in wanting to discuss her number
30:00with her primary care doctor and and
30:02number in this case often refers to
30:05something called the Oncotype DX,
30:07which is a recurrence score.
30:09It's a number on a scale of zero to 100
30:12and it is a number that is calculated
30:16by looking at the gene expression of.
30:1921 cancer specific genes.
30:21It goes into a patented algorithm by
30:24this company genomic health and the
30:26number the recurrence scores is spit out.
30:29So if that number could be on a scale
30:32of zero to 100, it's a complicated,
30:35nuanced conversation with patients.
30:37But in general,
30:38if that number is 25 or lower,
30:42patients may not benefit from chemotherapy,
30:45and so chemotherapy is likely not to be
30:48recommended if that number is higher than 20.
30:51UH-5 or 26 and up,
30:53there needs to be a more detailed
30:55conversation about the use of chemotherapy.
30:58So this is a test that that we
31:00send to determine whether or not
31:02a patient needs chemotherapy.
31:04It does correlate a little bit
31:07to to prognosis,
31:08but the real purpose of this test
31:10is to determine whether or not we
31:12need to use chemotherapy to reduce
31:13the risk of micrometastatic disease
31:15and subsequent distant relapse
31:17and at some point in the future.
31:19Next slide.
31:22Umm, I don't expect you to
31:23actually be able to read the slide,
31:25but the there are a lot of different
31:29regimens and your friendly neighborhood rest,
31:31oncologist, oncologist would be more
31:33than happy to discuss any of these
31:35chemotherapy regimens with you.
31:37I I put this up just to show that
31:39there are a lot of different regimens
31:40with a lot of different side effects,
31:43a lot of different schedules and that's
31:46our job to to really talk through risks
31:49and benefits, potential side effects.
31:51Potential toxicities,
31:52mainstays of treatment for breast cancer,
31:55include taxanes, so Taxol,
31:59taxotere, ABRAXANE.
32:00Those are some commonly used drugs,
32:03sometimes adriamycin or doxorubicin
32:07and anthracycline.
32:08Cyclophosphamide, cytoxan and carboplatin.
32:12And then,
32:13if the cancer is her too positive trust,
32:16who's amab?
32:16Also known as Herceptin,
32:18as well as other anti her two
32:19targeting agents.
32:22Next slide. So this particular
32:26patient would have had most likely,
32:29given that it was a high grade cancer,
32:30it was larger. She's premenopausal
32:32likely to have a high risk Oncotype.
32:35So an Oncotype that's higher than 26,
32:37she likely would have been
32:40recommended chemotherapy.
32:41However, she also needs to
32:43go on endocrine therapy.
32:46Tamoxifen or an aromatase
32:49inhibitor would be indicated.
32:50So just to think about
32:52who we can use these in.
32:54Tamoxifen can be used in in
32:56anyone provided they don't have
32:58a risk of or a history of venous
33:02thromboembolism or endometrial cancer.
33:04Aromatase inhibitors can only be used
33:07in post menopausal women and that
33:10is largely related to its mechanism.
33:13It works by blocking the
33:15peripheral aromatization.
33:16In peripheral tissues, not the ovaries.
33:19But what that leads to is
33:21deprivation of estrogen in the body,
33:23leading to negative feedback and the
33:27ovaries ramping up if if used in
33:30the absence of ovarian suppression.
33:32So aromatase inhibitors can only
33:33be used in post menopausal women or
33:36women who do not have ovarian function,
33:38either surgically, chemically or otherwise.
33:41The side effects of the two drugs
33:43or the two classes of drugs are
33:45are a little bit different.
33:46Tamoxifen could cause vasomotor symptoms,
33:49such as hot flashes.
33:50It can cause mood changes.
33:52There is a small risk of venous
33:55thromboembolism very small
33:56risk of uterine cancer.
33:57It can be beneficial in patients
34:00with osteoporosis and can can lead
34:02to an increase in bone density.
34:04Aromatase inhibitors, on the other hand,
34:06lead to this low estrogen state.
34:08So it's kind of menopause, Part 2.
34:10It can cause vasomotor symptoms such as
34:12hot flashes, night sweats, vaginal dryness.
34:16Accelerated bone loss.
34:18And so we monitor bone density
34:19very closely in these patients,
34:21usually every other year.
34:22It can lead to increased cholesterol as well.
34:26In terms of monitor monitoring,
34:28there's really no monitoring
34:29for tamoxifen other than.
34:59To determining whether or not
35:03we should extend endocrine
35:05therapy past five years.
35:07The slides have disappeared.
35:09I'd be happy to take some
35:11questions until the slides return.
35:14Or we could just go straight
35:16into the next phase of the case.
35:21Thank you very much, Sarah.
35:24And we're going to move into
35:26survivorship and new symptoms.
35:27So our patient is now 54 years old.
35:29She's tolerating her
35:31adjuvant hormonal therapy.
35:33And we'd like to have a discussion
35:35about what risk should we as
35:36primary care physicians be
35:37aware of those being endocrine,
35:39cardiac, pulmonary,
35:40psychological and what testing
35:42should the primary care physician be
35:44prepared to order for those patients.
35:49And in addition, after after that
35:52conversation, eight years later,
35:54our patient presents with new onset of
35:56back back pain of four weeks duration,
35:59which she originally attributed to
36:00a strenuous session of gardening.
36:02But rather than improving as would
36:04be expected, the pain is worsening.
36:06So this would lead us into discussion.
36:08Considering her breast cancer history,
36:10what are the appropriate next steps
36:12in diagnosis and management of her new
36:15onset of symptoms given her history?
36:17And Doctor Zahir is kindly going
36:19to take this on. Thank you.
36:21Thank you for including me in
36:22this conversation. So this is,
36:24I'll take your second question first.
36:26You know, this is, you know,
36:27any kind of workup for a patient with
36:30history of breast cancer should be
36:32based on what was their underlying
36:34risk and what are the symptoms
36:36and obviously this lady is having.
36:38Persistent back pain issues.
36:40So we need to have it worked up to make
36:42sure that there's nothing you know,
36:44we that we work it up for,
36:46whether it's related to breast
36:48cancer or related to a treatment
36:51or related to another etiology.
36:53So if she's having persistent back pain,
36:57she will have a workup that
37:00could include X-rays or well,
37:02if there is persistent pain in
37:05a particular location and MRI,
37:06or if there are diffuse symptoms.
37:093D scan or a PET scan?
37:11And if we find some abnormality
37:13that is highly suspicious based
37:16on the radiology data,
37:17then we have to biopsy at the time of
37:21anytime of anytime we feel that there
37:23is a possibility of a recurrence,
37:25we need to biopsy that for
37:27a variety of reasons.
37:29First reason is we want to confirm
37:31that this is indeed metastatic breast
37:33cancer or is this another malignancy.
37:35And also we need to test for all those
37:38markers that doctor Mcgillian has mentioned,
37:40you know the estrogen receptor.
37:41Suggestion receptor,
37:42her two receptors and also additional
37:46molecular biomarkers that we use
37:49these days for metastatic disease.
37:51Another issue with the metastasis is
37:55that bone metastases are usually seen
37:58in estrogen receptor positive patients,
38:01whereas brain metastases are
38:03more common in her two positive
38:05or triple negative patients.
38:07And anytime a patient is diagnosed
38:09with metastatic disease these days,
38:11we have a lot of choices and
38:13we have a lot of treatments,
38:14additional treatments that can be very
38:17helpful and they are still trying to convert.
38:21This into a chronic disease rather than
38:23a death sentence and then we have to
38:25assess the patient for the for distress,
38:27which requires a lot of help
38:30on part of medical providers as
38:33well as home providers.
38:37So we all know and that's why we have
38:40gathered today that best care for any
38:42patient is good collaboration between
38:44a primary care and an oncologist,
38:47which we do this all the time and
38:49I've had the pleasure of doing this
38:51with Jill for a number of years.
38:53So acute toxicity usually is
38:54taken care of by medical oncology,
38:56but chronic toxicities are shared
38:59between primary care and and medical
39:02oncologist and any woman who has been.
39:05Treated with endocrine therapy,
39:06especially the aromatase inhibitors.
39:08We know about bone health,
39:09we discuss those issues and many
39:11of these patients are placed
39:13prophylactically also on bisphosphonates,
39:16which is an agent that also that helps
39:19with bone health but also may decrease
39:23the risk of disease recurrence in the bones.
39:26We all know about the side
39:28effects of adriamycin.
39:29We do not usually reach that dosage
39:32that causes problems with the heart,
39:33but we usually still check it.
39:35In the adjuvant setting,
39:37anti herto therapy has a potential
39:41for cardiac complications also,
39:43but most of those issues are
39:46temporary and they resolved with
39:48discontinuation of therapy.
39:50We have a excellent cardio oncology
39:52program that actually helps us
39:53out in care of these patients
39:55in some decision making process,
39:57whether to treat or not to treat.
39:59Pneumonitis is another risk that
40:02can happen with chemotherapy that
40:04can happen with radiation therapy
40:07that is happening these days with
40:09immune therapy also.
40:11It's relatively uncommon but has but may
40:15require steroid therapy at some point.
40:18Neuropathy is one of the most common
40:21chronic side effects that we hear about
40:24most commonly in breast cancer patients.
40:26Taxol is the is the culprit,
40:29although in other malignancies oxaliplatin
40:32is more notorious for that side effect.
40:35There are certain medications that
40:37actually help with some symptoms.
40:39We actually have a physical therapy
40:41department that actually focuses
40:43on neuropathy and has been really
40:45successful in helping out with this.
40:48Chronic.
40:50Problem.
40:52Psychological health is very important
40:55in any breast cancer or any cancer survivor.
40:59And with time as as as we
41:02have improved on chemotherapy,
41:04we have improved on side effects,
41:06we have tried to cut back on surgeries,
41:10we have tried to cut back on chemo,
41:11certain type of chemotherapy.
41:13The financial toxicity continues to
41:16increase because of the increased
41:18cost of treatment and increased cost
41:20of taking care of these patients.
41:23So coming back to your first question,
41:25how often this person should be followed
41:27if they do not have metastatic disease?
41:29Normally speaking the NCCN guidelines.
41:33Say that we need to see the patients one,
41:36one to four times a year per year
41:38for five years and decreasing
41:41frequency again based on their.
41:43Their risk and again based
41:46on their symptoms also.
41:48We are actually working on a long term
41:51care plan at the at the Hill Spyro Center,
41:54trying to see what is the best way
41:56to transition back to primary care
41:58after five years and what type
42:00of patient should that be.
42:02And based on their original
42:04pathology as well as need
42:06for continuing care, patients also
42:09need periodic screening for family
42:11history genetic testing because the
42:14genetic testing also can change in a
42:16number of years and new additional.
42:18Testing may be required.
42:19We are all familiar with
42:21the lymphedema management,
42:23which is which can be a problem,
42:26but those problems are decreasing,
42:27thankfully, to less invasive surgery,
42:31and we have good physical
42:33therapists that are available for
42:35those management of lymphedema.
42:37Again, the one of the required radiology
42:40is the yearly mammogram unless
42:42patient has had bilateral mastectomy.
42:46There's actually no indication for
42:48any other testing for routine testing
42:50in the absence of clinical signs and
42:53symptoms suggestive of a recurrence.
42:54And again we have good long term
42:57care plans that we are working on
43:00and we have a lot of these support
43:03services that are available at
43:05the SMILO Cancer Center.
43:07I will not go into individual details,
43:09but all of them are providing
43:11additional help.
43:12We have the extended care clinic for
43:14off hours so that the patient cannot.
43:16Should not go to the emergency room and
43:19can go and can bypass the emergency room.
43:22We have the multidisciplinary care
43:24that we are trying to get patient an
43:27appointment together with the surgeon
43:29and medical oncologist and radiation
43:31oncologist and other supportive.
43:36Agencies, we are trying to
43:38also get next day access,
43:39which we have been successful to some extent.
43:41And then I want to mention that the
43:44oncology pharmacy has been one of
43:46the mainstays that are available in
43:47almost all of our offices that are
43:50readily available to discuss interactions
43:52and discuss any changes as needed.
43:55And thank you very much.
43:58With terrific, I'm going to just
44:00leave a question and answer session,
44:03although we don't have anybody
44:05that's offered any question and
44:07answers through our zoom connection.
44:09So if you are thinking of asking the
44:12question by all means put it in the
44:15Q&amp;A and otherwise I I I have a a couple
44:19of kind of logistic questions. So.
44:22The first thing was in a cancer survivor,
44:26a breast cancer survivor who
44:28has some new symptoms,
44:29whether it's back pain or maybe a lump,
44:31they feel subcutaneous lump.
44:34Is, you know,
44:35you said to assess their risk of
44:38recurrence based on their initial
44:40cancer and and that is one thing that
44:44can really stump us in primary care.
44:47So, you know,
44:47what I find is whenever I see the name of
44:50the oncologist who treated the patient,
44:52and I recognized the name,
44:54and I pick up the phone,
44:56they have this encyclopedic knowledge
44:58of exactly what means what as far
45:01as what they were treated with,
45:02and, you know, their markers.
45:04And so I'm, I'm wondering is,
45:06is that something that's going to
45:08be addressed in this care plan or
45:10is that kind of just the right
45:12thing to do is to pick up the
45:13phone and call an oncologist,
45:15how,
45:15how should we proceed when we do
45:19suspect at late recurrence or of cancer?
45:24I Karen, it's a great question.
45:26Why did you go ahead.
45:27Sorry, go ahead. I basically
45:29you know I would say that you know
45:31picking up the phone is always very
45:33helpful that's it's the best care
45:35possible for the patient and again I've
45:38known Jill and her group for a long
45:40time and I I get these calls all the
45:43time and I think that really improves
45:45the care that tells that directs which,
45:48which test needs to be done and
45:50there are and we are actually
45:52in a better position in a sense.
45:54To tell as to what tests should
45:56be done first.
45:57That sometimes saves money and
45:59as well as unnecessary tests
46:00also and unnecessary anxiety.
46:02Also looking at certain person,
46:04certain patient,
46:05we look at a certain abnormality,
46:07we will say you know it's highly unlikely
46:10related to breast cancer and that
46:12may alleviate the anxiety right away.
46:15Yeah and I would echo exactly that,
46:17that same sentiment it's we love
46:20to hear from primary care doctors.
46:23You know we recognize that we're not
46:25up to date on the latest and greatest
46:28antihypertensives antihypertensives
46:30and I can't name anti diabetes
46:33medications except for metformin.
46:35So the Umm it really has to be
46:40a collaboration that we do come
46:43across any number of patients.
46:45Let's say I had cancer.
46:47My shoulder hurts.
46:49I need all the scans and and so
46:52it's a careful balance of what
46:54that patient's underlying risk is,
46:56which really is our job,
46:57and and what's the likelihood
46:59that this represents a metastatic
47:01or neoplastic process.
47:02And the the thing that I find to be
47:04helpful when explaining to patients at least,
47:06is cancer.
47:06Usually if cancer is going to come back,
47:09it's going to meet the three P's,
47:11it's going to be a symptom.
47:12That's perplexing.
47:13You don't know why you have it.
47:15You you didn't just shovel your
47:17driveway for three hours the day before.
47:20It's persistent.
47:20It's there,
47:21it doesn't go away and it's
47:23progressive and it's getting worse.
47:25And so those are the three things
47:27that kind of help us determine what
47:29we need to be more worried about.
47:31We're not going to worry about
47:32something if it's been there
47:33for an hour and a half.
47:34We're going to worry about
47:36something if it's been there for
47:37weeks and it really isn't behaving
47:39like it should if this were some
47:41other non neoplastic process and
47:42then deciding what test is best.
47:45To do really does kind of require
47:47a knowledge about the biology
47:48of the cancer and where is this
47:51most likely to show up.
47:52Some subtypes are more likely to
47:54actually show up in the brain and
47:56and we have to have that's that's
47:57kind of our job to to catch that.
47:59So we we love to hear from
48:01primary care doctors.
48:04And what if I don't know
48:06who the oncologist is?
48:07Or was the patients moved from out of state?
48:10Or perhaps the oncologist has retired?
48:13Is there a Kawaji Kawaji?
48:17Going out to all of our
48:19New Haven clinicians,
48:20you've got it all right.
48:22That is excellent now.
48:24We're always happy to help.
48:26All on in basket we're all on my chart
48:29and happy to to take a look and we may
48:31not be able to give you the right answer,
48:34but we're we're especially if we don't
48:36have all the information but but that's
48:38not a reason we have long-term people
48:41who can who who are happy to see and
48:43kind of assess their underlying risk.
48:45Thank you and that is again it
48:47is so helpful to say to a patient
48:50you know I'm not concerned that
48:52this cancer that this represents
48:54recurrent cancer and I also spoke.
48:56To your oncologist and they share that
48:59it it actually is is incredibly helpful.
49:02So thank you for that collaboration.
49:06Looks like we don't have other questions.
49:08So Jill, maybe you have a
49:09question I was going
49:10to ask just because in talking about
49:13survivorship or even in the process,
49:15it is very anxiety provoking and we
49:18are often called upon to prescribe
49:21anti anxiety meds or antidepressants.
49:23And if you could just comment if
49:25you have your preferred, if you,
49:28if there's certain SSRI's that you prefer,
49:30certain ones you want us to avoid,
49:32if you could maybe discuss that,
49:34that would be great. Sure.
49:38So it some of it depends on what
49:40the patient is actually taking
49:42from a cancer standpoint.
49:44Tamoxifen has some theoretical interactions
49:47with certain SSRI's such as paroxetine,
49:51sertraline, fluoxetine kind of
49:54all of the gotos it they can.
49:57They are sip 2D6 inhibitors which
50:01can inhibit tamoxifen's forming its
50:04active metabolite which is called.
50:06Oxygen little CME.
50:08Not that anyone actually cares
50:10but the the so we try not to Co
50:14prescribe those however venlafaxine
50:16so the SNR I and I use citalopram.
50:19Mrs Citalopram if you're really
50:21looking looking for an Sr those
50:24are good go TOS that don't have
50:26the same degree of interaction.
50:28There are no interactions for aromatase
50:30inhibitors that we worry about.
50:33Umm.
50:34You know,
50:35the the question of benzos is always one
50:39that we we try to minimize as much as we can.
50:43We can use it as a bridge,
50:44especially around diagnosis when we're just
50:46kind of in this very high anxiety time,
50:49but I generally do not favor.
50:52Long term use of benzodiazepines.
50:56Agreed.
50:56Thank you.
50:57Yeah.
50:58No,
50:58and that's really what I wanted
51:00to get to the choir.
51:02For sure
51:02there is psycho oncologists that
51:04are hard to get, but they are
51:06available and they are very helpful.
51:08And I think it's, again,
51:10the best thing is to have the good
51:12interaction between the primary
51:13care and the oncologist and that is
51:15very helpful when you are helping
51:17us take care of the anxiety parts.
51:19You know, that's very helpful.
51:22One of my personal favorite opportunities
51:24is when a patient comes to me for a
51:27second opinion on whether they should
51:29continue an aromatase inhibitor.
51:32They hurt all over while actually
51:34what I have found is one of my most
51:37important tools is chart review.
51:39So I simply go back to the note and and
51:41very often it's actually outlined like the
51:43risk of recurrence with this medicine,
51:46the risk of recurrence without this medicine.
51:47It's part of the counseling that
51:49you do is often documented and and
51:51and it's enormously helpful to me.
51:54As I explore the patient's thinking,
51:56obviously I'm I'm not going to
51:58give a clear directive for that,
52:00but I don't know if you have hints for
52:03us in management of some of the symptoms
52:06so that people can continue to take it.
52:09Are are there anything that you
52:10would like us to know about that?
52:13Any question?
52:16So exercise is actually one of the things,
52:19so musculoskeletal complaints,
52:21arthralgias related to aromatase
52:23inhibitors is a very common side effect,
52:27probably 30 to 50%
52:29experience some some degree,
52:31not necessarily the severe amount,
52:34but but some degree and exercise,
52:37weight bearing exercise has so many benefits
52:40just from cardiovascular risk and from
52:43bone density standpoints that in addition to.
52:46Being shown in clinical trials to produce
52:50aromatase inhibitor induced musculoskeletal
52:53complaints is is incredibly helpful.
52:56Other things acupuncture has
52:58been shown to be helpful.
53:00And duloxetine has been shown to be
53:03helpful and that's in phase three
53:06clinical trials placebo-controlled.
53:09Those are the most kind of.
53:15Studied ways, but there are other
53:17things that that Waji and I can
53:20do from moving from 1 aromatase
53:22to another for whatever reason.
53:25Sometimes switching helps,
53:26sometimes taking a break to figure out
53:29is it really the AI that's doing it?
53:32Sometimes switching to tamoxifen,
53:34which has fewer musculoskeletal
53:37complaints and all of that,
53:39that conversation really does need to
53:41include what's the underlying risk?
53:43Is this somebody who's.
53:45Incredibly high risk that we want to
53:47give the absolute fully loaded endocrine
53:48therapy for as long as we possibly can.
53:50Or is this somebody with a very low
53:52risk cancer where the difference
53:54between 2 endocrine therapy strategies
53:56is probably minimal and a month off
53:58is not going to make a big deal,
54:00make a big difference? So.
54:02If you elicit that history,
54:05it's it's we love getting those kind of,
54:08hey heads up.
54:09So and so is really having a tough time.
54:13And and we can certainly explore
54:15options and sometimes people
54:16just can't tolerate it.
54:18It happens and and you have to do the
54:21risks and benefits and and it's our
54:23job to make sure that we understand
54:25all of the benefits and it's up to
54:27the patient to decide whether or
54:28not it's something that they can
54:30tolerate and and many people can't.
54:34Good. I like that permission not
54:37to tolerate understanding risks.
54:38It's exactly right. It's it's, you know,
54:41we just have to explore it and make
54:42sure it's an informed decision.
54:46So we are drawing to the end of our hour.
54:49I'll ask one final question, which is,
54:52is there anything you just really
54:54wish the primary care clinicians
54:57knew in our relationship with you?
55:00And then I'm going to ask Jill if
55:02there's anything she really wishes that
55:04her oncology team knew for referrals?
55:12I think an open I'll I'll volunteer again.
55:17Um, I I think we've already hit on.
55:19Probably my my. Favorite thing,
55:23which is pick up the phone,
55:25send me a my chart,
55:27I'll give you my cell phone number.
55:30The we want to be involved,
55:33especially when it comes to more
55:36advanced stages when people have
55:38metastatic disease, goals of care,
55:40conversation, prognosis.
55:41We really do try very hard to to explore
55:45those with our patients and and document it,
55:49but we want to be involved with all.
55:52Decisions and sometimes it may make
55:55sense not to be doing evidence based
55:58primary healthcare maintenance in
56:00patients who have advanced cancer
56:02and we're happy to to talk about it.
56:04But then in other cases,
56:05it may make sense for somebody to
56:08have a colonoscopy even if they
56:10have metastatic breast cancer.
56:11We love to participate in
56:13those conversations.
56:15Absolutely. You know, yes,
56:17it's good to have a good connection.
56:18That's very important.
56:19It's very helpful honestly and
56:22it's very helpful also for non
56:24oncologic care to be good also.
56:26So that's why we definitely
56:27need you and we need primary
56:29care physicians to be deeply
56:31involved in the care of patients.
56:35All right. And Jill, your
56:37perspective and then we will. I
56:40think I agree with everything that's
56:42been said and I think just knowing
56:44that our oncology colleagues are ready
56:46and willing to pick up the phone for
56:49us and we're willing to pick up the
56:51phone for them to allay a patient's
56:53fears because there are times when,
56:55you know, we get asked what is the unco.
57:00My number, what is the number mean?
57:02You know those kinds of conversations
57:04that are sort of beyond our expertise,
57:08but that we can be helpful
57:09in other ways. So thank
57:11you. All right. So thank you to all
57:14of you and to everybody who attended.
57:18This has been a very helpful conversation.
57:22Please stay tuned for a few final
57:25seconds because there is one more
57:27slide that is a kind of very quick.
57:29Evaluation and completing that
57:31is helpful for the series.
57:33And do you have any closing comments?
57:35No, this is terrific.
57:37The contacts are there.
57:39And then once this closes,
57:41you'll get a survey.
57:42If you could, if you could fill that out,
57:45that'd be helpful for us.
57:46And and tell your friends we we have
57:50one for next week or next month and
57:53actually we're scheduled throughout June.
57:55So if you enjoyed this today,
57:56just let us know.
57:57That would be helpful.
57:57Thanks so much everybody and.
58:00Happy Breast Cancer Awareness Month.
58:02Thank you.