Smilow Shares with Primary Care: Gynecologic Cancers

February 08, 2023

Information

February 7, 2023

Hosted by: Dr. Anne Chiang
Presentations from: Johanna D'Addario, MHS, PA-C, Mitchell Clark, MD, Jeff Josephs, MD, and Christi Kim, MD, FACP

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00:00Like to welcome you to smile
00:03shares with primary care.
00:05And we are going to be talking
00:07about gynecologic issues tonight.
00:11And let's see. Let's
00:12advance to the next slide.
00:18Great. So this is a program that SMILE
00:21has developed with an EMG and in Doctor
00:24Karen Brown is is my partner in crime here.
00:28It's a monthly lecture series that
00:30really focuses on primary care,
00:32perspectives on cancer and hematology
00:35for primary care clinicians.
00:37There are lots of other formats
00:39and venues to learn about cancer,
00:42but the aim here was really to develop
00:45a panel that would address questions.
00:48That primary care.
00:50Has around cancer on different
00:53topics and and also to focus on.
00:57Teams working together in a specific region.
01:00So we're we're focusing on gynecologic
01:02oncology care today and and really in the
01:06westerly water filled Waterford region.
01:09It's a monthly lecture series,
01:13first Tuesdays of the month from 5
01:15to 6 and we have programs all the
01:19way through until June and I'll
01:22show you at the end.
01:23I'm gonna hand it over to to Karen
01:26any other words and and to get started
01:28with the with our first introductions.
01:32I would just echo your
01:35excitement at this series.
01:37Welcome to everybody who's watching
01:40and gratitude to everybody who
01:43has put together this program.
01:46You know, in primary care,
01:48we do a lot of work and we also
01:51rely on specialists around us.
01:54When our patients get very sick,
01:56we take pride in recognizing when
01:58they get very sick and being able
02:00to expedite their care in a way.
02:03That meets their needs both medically
02:06and also psychologically and and
02:09new cancer is a high time of need
02:11and and so this series represents
02:14not just education around new cancer
02:17but it also recognizes that we are
02:20actively working to build bridges
02:22between primary care both through
02:25education through some of our care
02:28signature pathways and and and
02:30regionally as well because we know.
02:33Curious relationship based and
02:34we hope that this will be part
02:38of building those relationships.
02:40So I am pleased to introduce Jeff Joseph.
02:44Doctor Joseph is now a gynecologist in
02:49in the westerly region. He graduated.
02:53From Block Island High School.
02:56Fun fact. And it's really true.
03:00His graduating class had eight people in it.
03:03So talk about practicing medicine in a
03:05community and being from the community.
03:07His undergrad degree was in
03:09chemical Engineering,
03:10Masters degree in Georgetown and
03:12then New York Medical College.
03:14He did a residency at Bay State
03:17Medical Center,
03:17and then he worked at South
03:20County Hospital in Wakefield,
03:22RI for many years until he's
03:24joined northeast.
03:25Medical Group in 2021 and
03:29now his practice is GYN only,
03:31although he can say he's probably
03:35delivered over 3000 babies in
03:38his OBGYN years earlier.
03:40We are happy to have him present
03:42some cases on to kind of kick off
03:45discussions and I'll turn it over to
03:47you and for additional introductions.
03:50Great, thanks and welcome Doctor.
03:53Joseph, you're, you're a specialist,
03:55but tonight you're also primary care
03:57in terms of the gynecologic piece.
04:00So I'd like to introduce Johanna D'addario,
04:03MHS, PA She's a 2008 graduate of Quinnipiac
04:08University Physicians assistant program.
04:11She's got clinical experience
04:13in hospital medicine,
04:14primary care and gynecologic
04:16oncology and also experience in
04:19patient safety and PA education.
04:21Um, she's very interested in genetics,
04:23health and Wellness, disease prevention,
04:25and she joined us at Yale New Haven Health
04:28in 2018 as the coordinator of the Sexuality,
04:32Intimacy and Menopause Clinic.
04:33She enjoys helping women with cancer
04:36maintain healthy relationships and
04:38manage treatment side effects.
04:40And she's a member of the
04:43Society of Gynecologic Oncology,
04:45the North American Menopause Society
04:47and the Scientific Network on
04:49female Sexual health and cancer.
04:53Like to then turn to Doctor Mitchell Clark,
04:56who is an assistant professor and
04:59OBGYN at the division of Kynance
05:02at Yale School of Medicine.
05:04He did his residency at Yale New Haven
05:07Health and completed his fellowship
05:10training at the internationally
05:12renowned Princess Margaret Cancer
05:14Center at the University of Toronto,
05:17where he gained clinical and
05:18surgical expertise in all
05:20aspects of gynecological cancer.
05:22Cancer care.
05:23He also was very much engaged
05:25in a rigorous research program
05:28furthering on further understanding
05:30the role of surgery and high risk
05:32ovarian cancer and also during his
05:35fellowship completed a Master of
05:36Public Health degree and continues
05:38to actively research cervical cancer
05:40prevention at a population level
05:43using administrative databases.
05:45He's received numerous National
05:47International awards for his research,
05:50teaching and surgical skills.
05:52Including this,
05:53the Society of Gynecologic Oncology
05:55of Canada Research Award Award of
05:58Excellence and minimally invasive gynecology,
06:00gynecology and Yale School
06:02of Medicine Teaching award.
06:04Thank you, Mitchell.
06:06And then finally, Doctor Christy Kim,
06:09MD, FACP,
06:10She's an assistant professor in
06:12clinical medicine and a General
06:14Medical oncologist with special
06:16interest and passion in gynecologic
06:18and breast cancers and lymphoma.
06:20She works at she,
06:22she's at the Our Smile Cancer
06:24Hospital Care Center in Waterford
06:26and has also participated in
06:29gynecologic oncology group clinical
06:31trials as a primary investigator.
06:34And as a member of the Society
06:37of Gynecologic Oncology Clinical
06:39Practice Committee,
06:40she co-authored neuroendocrine tumors
06:42of the gynecologic tract update
06:45and she's also an active member
06:48of the International Gynecologic
06:49Cancer Society and European
06:51Society of Gynecologic Oncology.
06:53She was appointed at as an adjunct
06:56assistant professor at Icahn
06:58School of Medicine at Mount Sinai.
07:00She's committed to improve the lives
07:02of those who are impacted by cancer
07:04and she feels really passionate about.
07:06Providing the best evidence based therapy
07:08options personalized to each patient.
07:11So great faculty tonight I will ask
07:15you to remember that we do have time
07:18reserved at the end for questions
07:20and that's been some of the the most
07:22interactive and really interesting session.
07:24So keep your questions.
07:25You can put them in the chat later or
07:28along the way we'll keep track of them.
07:30Umm one more comment,
07:32Doctor Brown, before we start,
07:35before before we begin, I just need to
07:38recognize the fact that the New Haven.
07:41Primary care community lost one of its
07:44own last month and I want to dedicate
07:48this session to Laura Whitman and
07:51and also say a few words about her.
07:55After spending time at Duke,
07:58UNC Upenn and Case Western
08:00Reserve School of Medicine,
08:02Laura completed her residency in
08:04internal medicine here at Yale in
08:071996 and it was specifically in
08:09what we called an ambulatory care.
08:11Back she was also a chief resident
08:14in the primary care center,
08:16which used to be located on Howard Ave.
08:18and it was there that she and I
08:22worked together most intensively.
08:24She was recruited as a faculty
08:27member based on her excellent
08:29clinical and also educational skills.
08:32She demonstrated patient centeredness,
08:35and her kind manner was obvious
08:38to all of us who worked with her,
08:40whether we worked with her as a patient,
08:43in an exam room, in a clinic,
08:46conference room or lecture hall.
08:48She was a leader in the primary
08:52care medical education.
08:53And which relocated to the Cornell Scott
08:57Hill Health Center several years ago.
09:01She also was an author of the Yale
09:04Office based Medicine curriculum,
09:06which is a case based study that's
09:09used in medical residency clinics
09:11all over the country.
09:13She was a fierce advocate for
09:15vulnerable populations as well as a
09:17fierce advocate for primary care.
09:19Those of us who practice medicine,
09:21we we learned very quickly that
09:24there's no US versus them.
09:26And that we have another expression.
09:29I know we use it in this practice.
09:31I I suspect it's universal,
09:33that there's a clear lack of
09:35justice in most cancer diagnosis.
09:37Laura's illness and death is is no exception.
09:40The primary care community in the
09:42Yale Medicine community has lost
09:44someone whose impact will be felt
09:46for years to come in the lives
09:48of those who she trained in our
09:50memories and in our hearts.
09:54So with that, we will kick off
09:57with the first slide Doctor Joseph.
10:00Thanks Doctor Brown and welcome everybody.
10:03Our first patient is a 56 year old
10:06gravida 2 para, 22 vaginal deliveries.
10:08She's postmenopausal and she presented
10:10to the emergency department with a 2
10:13day history of abdominal discomfort.
10:15Workup including CAT scan of the abdomen and
10:17pelvis was consistent with gastroenteritis.
10:20She was treated with Ivy fluids and
10:22she was deemed stable for discharge.
10:25A6 centimeter left ovarian cyst
10:26was seen incidentally on the CAT
10:29scan in the emergency room arranged
10:31to follow up with gynecology.
10:33I think right there is where we see a little
10:35bit of the power of epic because I was paged.
10:38I think the emergency room physician was a
10:40little the patient wouldn't have follow up.
10:43She didn't have a GYN.
10:45So I was able to review the record and
10:47request that they drew tumor markers
10:49and asked that she have a pelvic
10:52ultrasound before she was discharged.
10:54She wasn't able to get the ultrasound.
10:55For discharge, but did get back in the
10:57morning so by the time I saw her telephone,
11:00ultrasound was already completed.
11:03So by the time she sees gynecology,
11:05the abdominal discomfort had improved.
11:08But she did note some abdominal bloating,
11:11which she attributed to her new plant
11:13based diet. Past medical history?
11:15Not too significant. Hyperlipidemia.
11:17She'd had an appendectomy.
11:20Her family history a little more
11:22interesting from maternal cousin
11:23with breast cancer at age 45.
11:25Maternal uncle with pancreatic
11:27cancer at age 60.
11:28Her parents,
11:29siblings and children are all healthy,
11:31and she was not Ashkenazi Jewish ancestry.
11:36Pelvic exam was normal.
11:38External genitalia, normal speculum exam.
11:40The abdomen was certainly not acute,
11:42but there was a palpable left adnexal cyst.
11:48The transvaginal ultrasound
11:49that was ordered did show that
11:52it was a complex ovarian cyst,
11:54and thankfully the right
11:56ovary and uterus are normal.
11:57Again, I think that's where the
12:00ultrasound is a little bit more
12:02accurate test for gynecology.
12:04Remember with the CAT scan
12:06you need IV or oral contrast,
12:08and with uterus tubes and ovaries
12:10those those can be sort of.
12:12Exaggerated on the CAT scan,
12:14so we kind of live and die
12:16with the ultrasound.
12:17I had asked you tumor markers to be
12:19drawn that was the CA 125 and the H4.
12:21The CA 125 came back elevated.
12:24That's returned in about 24 hours.
12:26The H4 unfortunately takes about
12:28a week and that was pending
12:31at the time of the evaluation.
12:33CEA and CA. 19 nine for normal.
12:38With the elevated C125I referred
12:41the patient to GYN Oncology.
12:45Thank you, Doctor Joseph.
12:46So I had the pleasure of meeting with
12:48this lady and and reviewed the workup
12:50that had been completed by Jeff thus far.
12:52And I completely agree the the ultrasound
12:55is really such a a more sensitive
12:57and specific tool for us and given
13:00the complex features that we saw.
13:02So some solid components,
13:04some abnormal vascularity within that cyst,
13:07this patient was was counseled that
13:09she would she should really undergo
13:10a laparoscopic evaluation and at a
13:13minimum removal of that tube and ovary.
13:15With Frozen section and plans
13:17for surgical staging,
13:18if that was to reveal a malignancy,
13:21most of these cases can be
13:22done laparoscopically now.
13:23But for this patient,
13:24we put the camera inside and what
13:27was immediately apparent was
13:28that there was already evidence
13:30of disease outside of the ovary.
13:32This can certainly be missed on CT scan,
13:35especially when we see very small
13:37peritoneal based disease and
13:39fortunately it's not often that those
13:41things are overlooked by a CT scan,
13:44but we do know that.
13:45Most women with an ovarian cancer will
13:48present at a more advanced stage just
13:50due to really our lack of of good
13:53screening and early diagnosis right now.
13:56And so because of this,
13:57this patient's procedure was
13:59converted to an open approach.
14:01That's really still the standard of care
14:03when we find disease outside of the ovary,
14:06but it never hurts to put a camera
14:08inside and just sees going on 1st.
14:10And so we proceeded with more of
14:12a sudden reduction or what we used
14:14to call the debulking and now.
14:15The goal is really shifted towards
14:17removing all of the visible disease
14:19that we see at the time of surgery
14:21and that confers really the
14:23best survival for these women.
14:25So we completed that surgery without any
14:27complications and she was discharged
14:29home three or four days after her
14:32laparotomy and we referred her on
14:34to meet with our medical oncologist.
14:36And they're really an incredible
14:37part of what we do for these women
14:40because it's a real combination
14:42of surgery and chemotherapy.
14:44And so she met with their medical oncologist.
14:46Discuss chemotherapy as she was found to
14:49have a stage 3C ovarian high grade serous,
14:52which is the most common type
14:54of ovarian cancer we see.
14:56And we'll talk a little bit about
14:58the importance of genetics and why
14:59every woman with serous ovarian
15:01cancer is referred to meet with
15:02our wonderful genetics team.
15:04And this patient was actually found to
15:06harbor a mutation in the BRCH 2 gene.
15:08Next slide.
15:10This is a really great figure to
15:12show sort of how exciting things
15:14have become over just even the last
15:1610 years in this disease.
15:18For the last you know if we look
15:20back here 2025 years really it was it
15:22was toying with which chemotherapy
15:24combination is going to give us the
15:26best outcomes and those outcomes were
15:29still very disappointing for this disease.
15:31What we're very excited by are
15:33the advances in maintenance
15:34therapy and our understanding of
15:36the underlying biology of most
15:38of these cancers and how that.
15:40Would impact what our medical
15:42oncologist and author recommending
15:44for patients to go on after they've
15:47completed their chemotherapy.
15:48So next slide.
15:52This is probably one of the more
15:54important papers and and one of the
15:56figures that gets put onto every
15:58talk and it really highlights that
16:00this is no longer just A1 fit all
16:02cancer that we really go ahead and
16:05look at the underlying genetics
16:06of all of our patients tumors.
16:09And why that matters is that it has
16:11been found that about 50% of women
16:14with serious ovarian cancer, hybrid,
16:15serious ovarian cancer will have an
16:18underlying deficiency in homologous
16:19recombination and that means.
16:21That about half of women are eligible
16:23for these new types of oral medications
16:26that are taken after chemotherapy and
16:28have really revolutionized the outcomes
16:30and the survival for women for with
16:32the disease that many years ago had a
16:35survival that was measured in a few years.
16:37And we continue to look forward
16:40to seeing the excellent outcomes
16:41of the data from these trials.
16:44So with that,
16:44I'm going to hand things over to Doctor
16:46Kim to talk a little bit more about
16:48some of the nuances in these oral meds.
16:52Thank you, Doctor Clark.
16:53So this is a part park inhibitor.
16:56Park stands for the Poly ADP ribose
17:00story polymerase inhibitors enzyme
17:03that involves in the DNA repair through
17:06the another pathway called place.
17:10Or uh. Accessing goals strand DNA
17:13breaks and partly vision blocks
17:16the ability to park inhibitor to
17:19participate in the DNA damage repair.
17:23So it's what's called synthetic lethality.
17:27So where the.
17:30To Mark cannot really repair its own
17:32and kind of comes to a cell bed so it's
17:35most effective in the BRACA mutations
17:38as Doctor Clark had deluded about
17:4050% of the serious ovarian cancer
17:43harbors so HR along with becoming
17:47BRACA mutations and there are four
17:50main part manipulator including elaborate.
17:55And that was that for the first three years
17:57are at the approved for Dorian cancers,
18:00the last one is for the breast cancer.
18:04Next slide. So this was a big
18:07trial that kind of led to the.
18:10The 2018. As a maintenance,
18:13so currently in the US the apartment numbers
18:16are indicated as a maintenance therapy.
18:19So this is a breakthrough in you know
18:22this kind of demonstrated we are.
18:26Curing some of the you know high,
18:28high aggressive you know ovarian cancer
18:30patients and I draw your attention to
18:33the five year mark overall survival.
18:36There are 73% of patients that are
18:39alive compared to those 63% percent
18:43of the patients at 5 year Mark.
18:46At 7 year Mark and there are still
18:49strong separation of the curve,
18:5167% are still alive in about
18:5446% are alive and.
18:56Just mind you that about 50%
18:59of the placebo arm across.
19:03Crossed over to the elaborate plan and
19:05which can impact the overall survival.
19:07So this is really impactful
19:09and it's changing. Next slide.
19:15But this is just the kind of give you
19:17like what's new in ovarian cancer.
19:19I think what we call antibody
19:22drug conjugate or ADC.
19:24This was a just recently
19:26approved it's against the fully
19:28receptor alpha Mervin tuxmath.
19:31So just kind of have a diagram,
19:32it's a little bit busy picture
19:35but they're so Morehead,
19:37it's kind of like a smart bomb as
19:40antibody that targets the cell
19:43cell surface receptor and then.
19:45You linked to the lot of
19:47phototoxic drugs what we call
19:49payload and the ratio can be high.
19:52So the it's the potencies
19:54are quite remarkable.
19:56If you were to give the
19:58patients those same dose,
19:59it can be quite lethal to their patients.
20:01But the the way that you designed
20:03the antibodies or conjugate you can
20:05deliver the drug in a safe manner
20:07and targets the cancer cell directly.
20:10Then the second pictured on the diagram
20:13is called the tumor treating field.
20:17This is already the technique that
20:19was approved for the neoplasma
20:21multifamily highly aggressive glioma
20:23and also the for mesothelioma.
20:26And there are ongoing studies
20:28phase three as to electric field
20:31that pulses through the skin and
20:33interrupts the cancer cell that's
20:36impacting the ability to divide.
20:39Next. Slides at least two. Join us.
20:44Stop. Regarding genetic testing.
20:48Yeah. So the question
20:49is for this first patient is,
20:50was there could, could there have been
20:52some kind of early detection or prevention
20:55of her cancer based on on her history.
20:58And I think in the primary care setting
20:59that's really important to think about.
21:01She did have a family history,
21:04not a first degree relative.
21:05She had a cousin with cancer and
21:07an I believe an uncle with cancer
21:09and we think about genetic testing.
21:12There's a couple of things I wanted
21:13to point out about some of the recent
21:16guideline updates for cancer genetics.
21:17Um, the first is really important in
21:20the primary Care World is that the
21:22preventative Services Task Force does
21:24recommend that clinicians at least
21:26assess women with a family history of breast,
21:29ovarian, tubal or peritoneal cancer,
21:32or who have an ancestry associated
21:34with the BRACA mutation.
21:35So this is specifically for BRCA one
21:38and two thinking about family history.
21:40Of ovarian cancer, which she did not have.
21:43But in the primary care setting,
21:45it's important to take a good family
21:47history at your annual physicals
21:49and identify.
21:52Benefit from a genetics consultation.
21:55First degree relatives with of
21:57a patient with ovarian cancer.
21:59First degree relatives of a patient
22:01with pancreatic cancer should
22:02certainly qualify for genetic testing.
22:04Or of course if there are multiple family,
22:06multiple family members with various cancers,
22:08or somebody, for example,
22:09who's had a bilateral breast cancer or
22:12multiple cancers in one family member.
22:14So in this patient
22:15it may have been interesting to ask,
22:18you know had had your uncle
22:20had any genetic testing,
22:21had your cousin had any genetic
22:23testing because that may inform
22:25this patient's genetic testing.
22:26Unfortunately for people who are referred
22:29for genetic counseling and testing without
22:31a cancer diagnosis but a family history,
22:34the wait time is a few months to have genetic
22:37consultation and and genetic testing.
22:39But in this case because our patient
22:42is now diagnosed with ovarian cancer.
22:44And it may inform her treatment options,
22:47including PARP inhibitor therapy.
22:48She is of course, expedited and has
22:51an urgent genetics referral for her.
22:53Umm, BRC 2 testing, which came back positive.
22:57I'm a firm believer in genetic counseling.
23:01You know, there are people who
23:03feel informed enough to order
23:05genetic tests in the community.
23:06Gynecologists are well informed
23:08to do that based on their level of
23:11experience with genetics up at UConn.
23:13There are some really nice.
23:15Um, educational programs to kind of educate
23:17you on how to to do genetic screening.
23:21But really the most important thing is
23:23that patients need to have pre test
23:26counseling and post test counseling.
23:27And the pre test counseling really
23:29needs to be thorough enough to be
23:31able to take a good family history,
23:33know which test to order,
23:34determine if there should be panel
23:37testing which company to order from,
23:38and then making sure the patient
23:41understands the possible outcomes and
23:42possible consequences of their test results.
23:44So again.
23:45And you know,
23:46there is a high demand for our
23:48genetic counselor colleagues,
23:49but I do rely on them a lot to
23:51help me with patients when I'm
23:54thinking about genetic testing.
23:56And my last few updates before we
23:58move on is that there is a very new
24:02guideline updates from the National
24:04Cancer Comprehensive Network that
24:07we no longer formally or the NCCN
24:10no longer formally recommends
24:12ovarian cancer surveillance even in
24:14our very high risk populations,
24:17the BRC A1 and B RC2 carriers.
24:20You know for many,
24:21many years we've done transvaginal
24:23ultrasounds routinely, we've done CA 125.
24:27Routinely and.
24:29This is the first year that the NCCN
24:30has removed that from the guidelines.
24:34Apologizing.
24:37And last but not least,
24:39the most important thing I want to
24:40share with you as well is knowing the
24:43terminology for cancer genetics in
24:44regards to mutation no longer being
24:46as as often used as a term that we
24:48use BRACA mutation we use variant.
24:51So there are there's a spectrum now,
24:53pathogenic variant meaning cancer
24:56causing likely pathogenic benign or
24:59likely benign variants meaning the.
25:02The gene is altered but not
25:05necessarily cancer causing and then
25:07this Gray area called a variant of
25:09uncertain significance that we do
25:11not necessarily clinically act upon.
25:13So if you have a patient who has
25:15a VUS or a variant of uncertain
25:17significance in a gene,
25:19it does not necessarily mean that he
25:21or she needs to have any prevention
25:24surgery or any surveillance for that
25:26specific type of cancer related to that gene.
25:30So I hope that helps.
25:31This is my last slide before we move on.
25:34Very important brand new in the
25:35New York Times.
25:36It was a joint statement from the
25:38Society of GYN Oncology and the
25:41National Ovarian Cancer Research
25:42Alliance just came out earlier
25:45this week saying that again,
25:46we don't have great surveillance
25:49for ovarian cancer.
25:50And if there is a genetic risk or
25:52even in women without a genetic
25:54risk and there's an opportunity
25:56to remove the fallopian tubes,
25:58that should certainly be considered.
26:00With any other surgical procedure
26:03under certain circumstances to
26:04prevent these high grade serious
26:06ovarian cancers that we believe
26:08may be starting originating in the
26:10fallopian tubes so hot off the press.
26:17Let's start our second case.
26:19Our second patient is a 65 year old gravity
26:22zero gravity 0 should postmenopausal
26:24female referred to gynecology by her
26:26primary care provider for vaginal spotting.
26:29She reports spotting on and
26:30off for the past two weeks.
26:33This patient came from primary care,
26:35but we also see this patient
26:37from urgent or walking care.
26:38Often seeing if you can't see your primary
26:41care or or from the emergency room.
26:43Past medical history is significant.
26:45She is suffers from obesity,
26:48type 2 diabetes and hypertension.
26:50She takes 2 medications for her
26:52hypertension as well as metformin.
26:54Her BMI is 40,
26:56so now Class 3 obesity.
26:58Her last period was at age 53 and she did
27:01not take any hormone therapy after menopause.
27:05Family history notable for diabetes
27:07and multiple family members,
27:08and coronary artery disease and her father.
27:11On exam, she is in fact obese.
27:13GYN exam is limited by her body.
27:15Habitus Speculum exam reveals dark
27:17menstrual appearing blood in the
27:19vaginal vault and the uterus and
27:20adnexa are not able to be palpated.
27:26So kind of following the algorithm
27:28of postmenopausal bleeding,
27:29stop the bleeding, make a diagnosis,
27:31and then make treatment
27:33options with this patient.
27:35I thought the bleeding was a little too
27:37brisk to attempt the endometrial biopsy.
27:40Danger is put the patient through
27:42the biopsy but only receive blood.
27:44Umm, and and sometimes a little
27:46uncomfortable biopsying the uterus.
27:48I can't palpate or see that well,
27:51so I elected to start Provera 10 milligrams
27:54daily and order transvaginal ultrasound.
27:57The ultrasound revealed the 60
27:59millimeter heterogeneous endometrium,
28:01which is abnormal.
28:02Uterine length is 10 centimeters,
28:04which is generous and no
28:08myometrial abnormality.
28:09I then performed an endometrial biopsy
28:11in the office and it was returned as
28:15endometrial intraepithelial neoplasia.
28:16That's somewhat the new technology
28:19for complex hyperplasia with atypia.
28:23That diagnosis,
28:23I thought,
28:24should see Joanne Oncology.
28:29Thanks Jeff. And yes, we did have the,
28:31the chance to see this lady and what
28:34we spoke with her about is is sort
28:36of left untreated this condition
28:38can progress into a cancer in
28:40about 40 to 50% of women that some
28:43of the data from the older term
28:45of complex atypical hyperplasia.
28:47And so there are a lot of you know
28:49different options for treatment
28:50depending on the patient's age,
28:52they're surgical risk factors and
28:55and what it is that they like to do.
28:58Just to sort of trail off from
29:00this patient for a second,
29:01let's say this woman was young.
29:03Maybe she was in her early 30s and
29:05she had not had an opportunity to
29:07have children and that was part
29:08of her family planning long term.
29:10We do actually now have some exciting
29:12data to show that using things like
29:15the progestin releasing IUD's that
29:17we know very well from contraception
29:19can actually cause this to regress in
29:22about 80 to even maybe 90% of women.
29:24The downside is there that that's
29:26not a definitive approach.
29:28Um, and if the underlying risk factor
29:30so the diabetes, the hypertension,
29:32the morbid obesity haven't been corrected,
29:34that patient is likely to.
29:37Rebound into a refractory hyperplasia at
29:40some point if and when the IUD is removed.
29:43The other population that we consider
29:45using either the IUD or an oral
29:48progestin in a long-term fashion
29:49are those women who we meet who have
29:52really high surgical risk factors sort
29:54of inherent in this population with
29:57the the diabetes, the hypertension,
29:59the obesity,
29:59some of the cardiac disease that really
30:02put patients at risk of going to the OR.
30:04Sometimes we will choose to do a
30:07non-surgical approach in those women.
30:09However,
30:09in this lady we sat down,
30:11she was seen by her primary care provider.
30:13Who helped with risk stratification
30:16and optimization for her comorbidities
30:18before going to the OR and we
30:20considered her and butcher for
30:22a robotic assisted hysterectomy,
30:23removal of both tubes and
30:25ovaries and frozen section.
30:27You know you might ask,
30:28you know Doctor Joseph has taken
30:29the time to do an endometrial
30:31biopsy and we we have a diagnosis
30:33of a precancerous process.
30:34But if you look at some of
30:36the historical data,
30:36the risk of there being a concurrent
30:40already invasive endometrial cancer
30:41can be as high as about 40 to 45.
30:44Percent.
30:44And so because of that risk and
30:46the potential of a sampling error
30:48with an office based biopsy,
30:50we do recommend that women have
30:52a frozen section of the uterus
30:55at the time of the procedure.
30:57If that does relevant cancer then
30:59we do proceed with the appropriate
31:01staging which typically involves some
31:03assessment of the pelvic lymph nodes.
31:05And so we plan for this patient.
31:09The standard of care for these surgeries
31:11really is now moving on with an MRI.
31:14Approach or laparoscopic,
31:15you may have some patients who ask,
31:17you know they've read the
31:18New York Times that robotic
31:19surgery is associated with worse outcomes
31:21that's in cervical cancer and we are very
31:24interested to see where that that goes.
31:26But for endometrial processes really
31:28the standard of care has been a
31:30MIS and and we continue to see
31:32good outcomes with that approach.
31:34So this city was found to have an
31:37early stage SO1A Grade 2 endometrioid
31:40endometrial adenocarcinoma and
31:42this is probably one of the more.
31:44Common, you know final pathology
31:46that we see what we do for all of
31:50our endometrial cancer patients is
31:51we screen them for mismatch repair
31:54deficiency or microsatellite instability
31:56through both the combination of the
31:59immunohistochemistry and the PCR.
32:01And that is both just screened
32:03for Lynch syndrome,
32:04but also to look for inherent somatic
32:06changes in the tumor that may not be related
32:09to anything in the family or the DNA.
32:11And I have to say this is one of the most
32:13common questions I hear from women is they.
32:14They get a cancer diagnosis and
32:16the first thing they're saying
32:17is what do I tell my daughter?
32:18If you know, what do I tell my sisters?
32:20How can I inform my family
32:22on on their risk of cancer.
32:24This patients results did show
32:26loss of staining in the MLH one.
32:29However that reflexes a test to look
32:31for an epigenetic phenomenon called
32:33hypermethylation in the promoter region
32:36and that is not when that is positive.
32:39That's not indicative typically
32:40of a lynch syndrome and therefore
32:42those patients don't often or
32:44don't necessarily meet outward.
32:45Criteria to go on to meet with
32:47genetics just based on that result.
32:49However,
32:50they would then qualify down the road
32:52for any treatments or medications
32:54like immunotherapy that have shown
32:57promise in in this subgroup of of women
33:00because of the final results of her
33:02pathology showing some high risk factors.
33:04So the Grade 2 disease,
33:06the lymphovascular space invasion,
33:08we did ask Miss T to meet with
33:11our radiation oncology team to
33:13discuss vaginal brachytherapy and
33:15that is really the most common.
33:17Type of radiation women are now
33:19receiving for these endometrial cancers,
33:20it's typically three sessions,
33:22very well tolerated with very minimal
33:25long term toxicity and really has
33:28shown to decrease the risk of
33:30recurrence quite significantly.
33:32The next slide.
33:35I just wanted to highlight some of the
33:38sort of newer exciting technology that we
33:40have in the field of endometrial cancer.
33:43I'm sure many of you who have been seeing
33:45women with breast cancer or are other cancers
33:47have have been familiar with Sentinel
33:49node technology and those disease sites.
33:51But really over the last five to 10 years,
33:53we've we've seen a huge influx of
33:54data in and around the youth of a
33:57Sentinel node technology in almost
33:58all of our gynecologic cancers,
34:00which is very exciting.
34:02Pelvic Notice segment is very
34:03important in endometrial cancer.
34:05For stratifying risk and assign
34:08assigning adjuvant either chemotherapy,
34:10radiation therapy or both.
34:12And for years that included a pretty
34:15extensive pelvic node dissection over a
34:18fair bit of of space in the pelvis there.
34:20And so this trial or or more of an
34:23observational study tried to quantify
34:24how many of these women were going on to
34:27develop lymphedema of the lower legs.
34:29And just like the difficulties in
34:30treating that in the upper arms
34:32and the breast cancers,
34:33we have had a real challenge
34:35in managing that.
34:36Edema long-term women who develop
34:37it in the lower extremities and
34:39it's not a negligible number and it
34:41depends on which of the gynecologic
34:44cancers it is associated with.
34:45And so we've got really robust data now
34:48showing that across all the different
34:51subtypes of endometrial cancer that
34:53in women whose disease appears to
34:55be fine to their uterus at diagnosis
34:58that central no technology is safe,
35:00effective and almost eliminates the risk
35:03of lower extremity long term symptomatic.
35:06Of the team up offline.
35:07Next slide.
35:10So I'm going to pass it back over to
35:12Doctor Kim to talk a little bit about
35:13where we're moving and endometrial cancer
35:15and excitement coming down the road.
35:18Thank you doctor card. So this
35:20is a trial. Cancer
35:23is the most common gynecologic cancer
35:25in United States and incidents
35:27are rising as you are aware.
35:29So five year over survival for the
35:32localized early stage disease is
35:34quite good 95% or some for advanced
35:36stage that's not the case about
35:39higher overall survival is about
35:4118% and you know ultimately women
35:43die from succumb to their disease.
35:46So the our trend is more and more toward.
35:48You know successful outcome and trying
35:50to kind of figure out what are the you
35:53know the you know targeted approach.
35:55So based on the TCG a data the
35:58individual cancers are classified
35:59based on the molecular subtopics.
36:02So I draw your attention to the left column.
36:04So there are four subtypes one the
36:07two on the left is called Poly or
36:11polymerase X1 or alternated tumors.
36:13These are instance are quite small
36:17about 2.6% but their outcomes.
36:19They're quite excellent compared to
36:21the microsatellite instability or
36:23hyper mutated tumors or these are
36:26considered hot tumor in the instance
36:29about the 30 about close to 40%.
36:33I mean these are the type of tumor that
36:36respond really well to the immunotherapy,
36:38the 1/2 on the right,
36:40the copy number level or endometrioid
36:43subtype in the one that's the
36:46worst prognosis is the one called.
36:49Sarah slate.
36:50With P53 mutated tumor there
36:53outcome is quite poor.
36:55So based on the what does the
36:59classifications or treatments going
37:00to be changing and especially the
37:03based on the port tech for studies our
37:08pathologist going to classify and mental
37:11cancer differently than what we used to.
37:14So next slide.
37:17These are just to kind of giving
37:20you perspective of people.
37:21Isn't that was the proof for
37:24the as a second line?
37:26Melissa that's tumor type for the MSI micros.
37:32Stability of the MSI or mismatch
37:37repair deficiency tumors but with
37:40the junction with the multi oral
37:43tyrosine kinase inhibitor then that
37:45and this was a this changing that
37:49they were seeing patients with
37:51advanced cancer settings are living
37:54longer regardless of double marker.
37:57So next slide, what to expect
37:58or for the new direction?
38:01Adverse events are basically can
38:05affect any organ systems and most
38:08common organ that can be affected.
38:10So thyroid and people to come on
38:12on the hypothyroid and also we
38:15need some replacement therapy.
38:17But these are early recognition
38:19and interventions and you know
38:22have your subspecialist,
38:24your pulmonologist, gastroenterologist,
38:27dermatologist,
38:28endocrinologist you know have a referral.
38:31You have early interventions because
38:33these are quite impactful therapy
38:36and you want the patients to be on
38:38really effective therapy for long.
38:42Next.
38:45It's just kind of giving you like a.
38:49You got the. And tougher to therapies
38:53not just for the breast cancer
38:55nowadays at the lab in combination
38:58with the chemo and her to express.
39:04Advanced urine service.
39:05Serious cancer can improve the overall
39:09outcome and so overall survival,
39:11and this was based on the
39:14doctor Elizondo sentence work.
39:19Next that. Thanks.
39:25So this kind of brings everybody through
39:29that kind of over the purple pearls.
39:33Alright, so let's review the clinical pearls,
39:36a transvaginal ultrasound is
39:37often helpful prior to gynecology
39:40or GYN oncology consultation.
39:42The ultrasound evaluates the ovaries
39:44more accurately than a CT scan
39:46and can measure the endometrium.
39:47And I I think that if there's ever a
39:50question and you have to refer the
39:52patient on to gynecology or do you
39:54in oncology get the pelvic ultrasound
39:56ahead of time it it'll it'll make
39:59that consultation pump that much more
40:02thorough any person with ovarian cancer or.
40:04Course to be relative with ovarian cancer
40:07would benefit from genetic testing and
40:09I think we heard tonight how to do that,
40:11how to kind of get in line
40:13for genetic counseling.
40:14Before the genetic testing,
40:16ovarian cancer can be a chronic disease,
40:19one of our slides showed.
40:22That with the the new treatment,
40:23the life expectancy is much
40:25longer than we we had years ago.
40:27All postmenopausal bleeding
40:29must be evaluated.
40:30Even spotting and remember the
40:32algorithm stopped the bleeding,
40:34make a diagnosis and then treatment options.
40:38Order an FSH level if there's
40:40any question that a patient is
40:42is menopausal or not menopausal.
40:45Again,
40:4652 year old woman has had a
40:48few periods in a year.
40:50Is that postmenopausal bleeding
40:51or or perimenopausal?
40:53So an FSH ahead of time is very helpful.
40:56And many gynecologic cancer
40:58survivors are candidates for hormone
41:00replacement therapy if needed.
41:02That's an important point as well.
41:03If it if it's not an estrogen
41:06sensitive cancer,
41:08then hormone therapy can
41:11certainly be investigated.
41:20So and I can guide some
41:22questions if you'd like.
41:24Yeah, I I just want to remind
41:26the folks who are on the line to
41:29complete the survey when you're
41:30done to get your credit and you can
41:33always e-mail us with questions and
41:35and these are the upcoming ones.
41:37There is one question in the
41:40chat from from Beth Allard,
41:42maybe we can start there.
41:45And and and Beth if you noticed his actually
41:47on the panel for next month's session,
41:50so she's getting a little warm up here.
41:54No, I think Jeff,
41:55this is probably for you.
41:57Is there a place for endometrial
42:00biopsy in a pre menopausal woman
42:03versus post menopausal?
42:05When would you do that?
42:07So I think an endometrial biopsy,
42:10it's it's I, I do it more often
42:12than not when there's a question.
42:14So remember men, Araja has an endometrial
42:17biopsy and and perimenopausal bleeding
42:20would as well because remember
42:23tonight's topic was GYN oncology.
42:25But most of the abnormal bleeding
42:27I see is not going to be oncology,
42:29right, even postmenopausal bleeding,
42:31it's probably 8020 benign.
42:33So fibroids, polyps, endometritis.
42:37There's there's a lot of other reasons,
42:39which is why I do the biopsy and it
42:42doesn't go right to Doctor Clark.
42:47So I have a couple of questions that
42:50had come to me through colleagues
42:52before the session that I'll ask.
42:54And I would also encourage all of anybody
42:56who's attending to please send in questions.
42:59This is a pretty great opportunity
43:01to have a panel of people who can
43:04answer them at a intense level.
43:07So one question that I have is
43:11about this fallopian tube study.
43:14So in the past you know,
43:17we also recommended prophylactic oophorectomy
43:20for many women having hysterectomy.
43:23And at this point at least in my practice,
43:25there are a lot of women having
43:28hysterectomies, hysterectomies
43:29as part of pelvic reconstruction.
43:31So they're they're not in the
43:32cancer world at all and as a primary
43:35care clinician I may offer some.
43:36Advice and it comes back with
43:39mixed perception.
43:39Is that outdated?
43:40Is it just the fallopian tube?
43:42Now tell me the how did this all evolve?
43:47That's a great question, Karen.
43:48And we're still actually sort of going back
43:51and forth that pendulum continues to swing.
43:54A few years ago, there was a really
43:56nice paper that came out to suggest
43:58that there may actually be some
43:59underlying estrogen still produced
44:01by the ovaries even if it's not high
44:03enough to trigger the menstrual cycle.
44:06And so the pendulum swing to keeping
44:08ovaries in place for women in the the
44:10age seemed to be about 65 is what that
44:13study showed now since then there's
44:15been a few sort of large scale.
44:17Paper saying, you know,
44:19that benefits gained their weight
44:21against the potential of an
44:24ovarian cancer left undetected.
44:26And so there is a bit of sort of
44:28equipoise within the scientific community.
44:31I sit down with my patients.
44:33We try to do a more individual
44:35risk assessment.
44:35You know,
44:36is there a high risk of osteoporosis,
44:37heart disease,
44:38dementia,
44:38where those ladies might benefit
44:40from even if there's still a little
44:42estrogen being produced there to
44:44maybe prevent some of those conditions
44:46that we know are associated with low.
44:48Estrogen early in menopause and and
44:50the other thing is where women come
44:52from in their own life experience.
44:54You know if someone they saw
44:56go through an ovarian cancer.
44:57I have to say those leaders are
44:59typically asking us to remove the
45:00ovaries at the same time, but we do.
45:02We do think the majority of at
45:04least the high grade serious does
45:05come from the two.
45:08And of course, family history
45:10public plays into that quite a bit,
45:11right? Yeah, OK. Very helpful.
45:17Wait, I have a comment about that.
45:18So this is something that I learned
45:21a long time ago, but which maybe,
45:23maybe everybody knows,
45:25but it's because the developmentally
45:27right that the the tissue that
45:30the fallopian tube and peritoneal
45:33that lines the peritoneum is,
45:35is is originating from the same tissue
45:39that that that develops into the ovary,
45:42you guys get better.
45:43Is that that's why?
45:45The sense that it is,
45:47when we look at all the sort
45:49of epidemiologic data over the last 50 years,
45:52essentially any risk,
45:53anything that reduces the number of
45:55lifetime ovulation, so pregnancy,
45:58continuous hormonal contraceptives,
46:01breastfeeding, all of those
46:03things seem to reduce your risk.
46:05And so people thought every time the egg
46:07comes out of the ovary, that rupture,
46:09that repair of the surface of the ovary,
46:12that's eventually going to lead to your
46:13first hit and your second hit in that
46:15sort of reconstruction of the ovary.
46:17But now we've learned that's actually
46:19probably the content of the ovum.
46:20So the sort of pro inflammatory fluid
46:23that's in the egg that's coming out,
46:25that's bathing the fallopian tubes on
46:27their fimbriated end and they live in
46:30very close proximity and that's that
46:32repeated pro inflammatory exposure.
46:34That's at least the tubal hypothesis
46:36that most of us are sort of going with
46:39right now and it's that's probably why
46:42all those epidemiologic factors hold.
46:44But it's less has to do with what's
46:46happening on the surface of the ovary.
46:47The ovary and what that ovulation is
46:49doing to the fimbriated end of the
46:51fallopian tube and and the data on
46:53this is really quite impressive in in
46:55countries and centers that have been
46:57doing this for quite a bit longer than
46:59we have have seen a nice decline in
47:00their population rates of ovarian cancer.
47:06So I want to just add that the patients
47:08with the BRACA mutations that by
47:10the time they undergo prophylactic
47:12southernmost reckoning they already
47:14find existing tumors that are already
47:17formed like we call stick regions.
47:19So kind of give you like
47:21how the cancers are rising,
47:23that's a great point.
47:24And and last thing I'll talk about the
47:26tubes because I'm obsessed with the tubes.
47:28If you can't tell,
47:29we actually have now open at Yale we
47:32believe so strongly and they said
47:34a scientific level that women with.
47:36Bracket 2 mutations can enroll in
47:39the clinical trial that will remove
47:41just the fallopian tube and delay the
47:44removal of the ovary until menopause
47:46and they'll be followed for quality
47:48of life measures as well as of course
47:51development of an ovarian cancer.
47:53But because ovarian cancers occur a
47:55little later in the bracket two women,
47:58this trial has been designed to evaluate
48:00if removal of just the two would be
48:03sufficient risk reduction for that
48:04population and we are now enrolling patients.
48:07At both the Waterford and
48:08our New Haven Care Center.
48:11That is fascinating. And honestly,
48:13as a primary care physician,
48:15I didn't know that.
48:16And so I I think it's really helpful
48:18to bring out here where people may be,
48:20you know, counseling people as to whether
48:22to participate in a trial like that,
48:24that it's a strong theory, Jeff.
48:26It looked like you were
48:27about to say something.
48:29So, so all, so all female voluntary
48:32sterilization now has gone to salpingectomy.
48:35So you know back in the day clips, rings,
48:38tubal ligation using single port laparoscopy,
48:42that's all kind of gone by the wayside.
48:44I bet it's been 10 years now that
48:47voluntary sterilization is now a
48:50laparoscopic bilateral salpingectomy.
48:51And we started the fimbriated end because
48:53we think it's the most important.
48:56They kind of tease the the fallopian
48:58tube off the ovary through the broad
49:01ligament and and get very close
49:03to the uterus so that you know.
49:06The whole fallopian tube is
49:08is effectively removed.
49:10It's kind of changed the surgery
49:11just a little bit,
49:12but it's still 35 millimeter ports.
49:16Still a rather simple surgery.
49:20Back at, you know,
49:21when I was doing C sections,
49:22if we had a tubal at C-section,
49:24the same thing,
49:25no longer were we just sort
49:26of interrupting the tube but
49:28removing the whole fallopian tube.
49:30And that's been quite a while now.
49:33And I I think for
49:34any reduction in ovarian cancer with that
49:36that or is it hard to tell because of?
49:40There are other factors at play.
49:42I think that's where the studies
49:44are going right now, Doctor Brown.
49:46Yeah. OK. Is there risk reduction
49:49in the high risk population?
49:51It'll take many, many years to
49:53know if this brings the risk down
49:55of an ovarian cancer subsequently.
49:57But you know we've seen patients
49:59who do have these stick precursor
50:01lesions who then unfortunately have
50:03to have full usually hysterectomy
50:06and fiereck tomy afterwards if an
50:09incidental stick lesion is determined.
50:12And then we followed them along to make
50:14sure that they're doing well afterwards,
50:16but but. A lot of young women, I think,
50:19who are interested in permanent
50:21sterilization but also feel like
50:23this is maybe something that they
50:25can really do to reduce their risk.
50:27If they have a family history,
50:29even if the genetics are negative,
50:31they really are inclined to do something
50:32that's in their control to reduce their risk,
50:34and this is one thing they can do.
50:37Great. So I just I'm John I'm glad you
50:41were talking because I'll come back
50:42to you and then I still don't see any
50:45other questions from our audience.
50:47I would encourage people to ask but
50:51I I loved your wording you you blew
50:54over it a little it was actually
50:56you know sometimes when you hear
50:58things twice in one week it they
51:00stick and and so a week ago in.
51:02Internal medicine.
51:03We had a grand rounds from a faculty
51:06member named Anna Deforest who had written
51:09a book and her point was words matter.
51:12And and she specifically said what you said,
51:15which is we don't call things
51:18mutants and mutations.
51:19They're called variations and
51:21that that wording is important.
51:23In addition to hearing that
51:24from you and her this week,
51:26I also got back a lab report
51:28on a patient with.
51:29I don't know hemochromatosis or something
51:31and it said mutant detected and you
51:34know I had never been so kind of
51:36sensitized to that as I was with that.
51:39So I I think it's helpful to
51:41remember that that words matter and
51:44and and and the other thing that's
51:46helpful is this concept of.
51:49I guess it's futility,
51:50but advice now against surveillance,
51:51so in those who are high risk doing
51:54these regular ultrasounds and markers
51:56has not proven to be effective.
51:58And so knowing that that's now also
52:01within the gynecologic community
52:03in addition to our, you know,
52:05kind of preventive health focused
52:07on internal medicine communities
52:08is very helpful.
52:11And I think the background.
52:12Oh, go ahead, Doctor Clark.
52:14No, no, sorry, go ahead. I was going
52:15to say something more of an aside.
52:18Real quick, I'll just point out
52:20that all the more importance now on
52:22family history and identification of
52:23genetics is really the key as far
52:26as prevention of ovarian cancer.
52:28Yeah, and testing the the mutation, OK. What
52:33I was gonna say I just about
52:34one of the reasons probably
52:36that the NCCN has now dropped.
52:37This is just the really
52:39poor performance of C125.
52:41You know we order it but there are so
52:45many things that can cause it to be
52:48elevated whether that's diverticulitis
52:49Crohn's disease you know you see
52:52any sort of inflammatory condition.
52:54Recent COVID I had a patient who
52:56is on surveillance for ovarian
52:57cancer who didn't tell me she had
52:59had COVID recently chapter 25.
53:01It was mildly elevated obviously
53:03very anxiety provoking.
53:04For that woman.
53:05And so you know in ordering that
53:08it's always good to just sort of
53:09I try to really tell patients,
53:11you know,
53:12if it's a little elevated and you
53:14have one of these other conditions,
53:16please don't interpret that
53:17as a test for ovarian cancer.
53:19And so you have 125 has really
53:21helped us with so many ways,
53:22but has really caused a lot of
53:24anxiety for for healthy women
53:26in other ways and so sort of
53:29being cognizant of sort of how
53:30to interpret those results in
53:32the context of of each patient.
53:34Um,
53:34to try to reduce some of that anxiety
53:36until they get a chance to meet
53:38with one of us at the Cancer Center.
53:42Thank you. This was just wonderful.
53:45I am so appreciative and I know my
53:48primary care colleagues who are
53:50listening and who will listen later.
53:52We'll feel the same.
53:53And do you want to?
53:55Wrap us up, you, you had a question,
53:57if you have a question we wrap it up
53:59from the New York Times.
54:01It seems like there's some some new
54:03studies coming out around estrogen
54:06replace hormone replacement therapy
54:07and I think that always comes up.
54:10You've had a you know if you're if you've
54:12had cancer or you are at high risk
54:15of cancer because of a family member,
54:17what's the bottom line about is it safe
54:19to take estrogen replacement therapy?
54:25In 3 minutes I'll take this
54:27one. In 30 seconds.
54:29It's it's an individualized decision,
54:32depends on the tumor,
54:33depends on the patient,
54:35depends on her all other risk factors.
54:38Smilo does have a sexuality menopause
54:40for cancer survivors program.
54:41We love to see women and talk about
54:43risks and benefits for the most part.
54:45Vaginal vulvar, cervical cancer.
54:47Yes, it's safe.
54:49Endometrial and ovarian depends
54:51on the tumor type.
54:53Doctor, you agree with that?
54:57Absolutely. And Joanna is
54:59underselling her role in Sims Clinic.
55:01This is an incredible resource at Yale,
55:04one of the first in the country to
55:07comprehensively evaluate and support
55:08women who have been previously
55:10told that they are, you know,
55:12not eligible or candidates for something
55:14that can really improve quality of life,
55:17especially in our young women who who
55:19go on to develop a gynecologic cancer.
55:22And so it's very individual.
55:24I have patients who you know.
55:27Or on hormone replacement therapy,
55:29who came off because of their cancer
55:31and their quality of life was so poor
55:33and and we really don't actually have
55:36prospective randomized data to say that
55:37it will cause your cancer to recur.
55:39And so it is important that you actually
55:41sit down with someone like Joanna or
55:43someone who has experience with this
55:45and hear the actual data so that you
55:47know your patients can make an A truly
55:50informed decision and and not just
55:52based on you know what their friends
55:55have told them or to do or not to do.
55:57Because quality of life is just
55:59as important as survivorship.
56:03I think that's a great place to end.
56:05Thanks to all of our faculty for
56:08the the great discussion the cases.
56:10Thanks to our participants for
56:13attending and and please again tell
56:15your tell your colleagues to to attend
56:18or listen these are recording so
56:21they're available and we look forward
56:24to seeing you in the future at our
56:27next smilo chairs which is Renee
56:30can you put that back up for the.
56:33For the. For folks.
56:41OK. Well, that's all right.
56:43We'll, we'll, we'll send it around.
56:44It's always the the same Tuesday at
56:47the same time, same time, same time,
56:49same place, March 7th, GI cancers. Yes.
56:53Thank you so much and again please
56:55make sure to complete the survey.
56:57We really appreciate that and
56:58have a good night everyone.
57:00Thank you again.
57:01Goodnight. Thank you. Thank you
57:03guys. Thank you.