Game changers in breast cancer treatment

Game changers in breast cancer treatment


-Hello I’m Dr. Alice Police and I am the
Medical Director of Pacific Breast Care. We are a unique breast care and we’re part of UC Irvine health and I’m here today along with my colleague Dr. Freddie
Combs to tell you not only about how we are unique Breast Center but to tell you
about recent advances in screening risk assessment and the overall treatment of
breast cancer. Breast cancer diagnosis and treatment today takes an entire
village. We have a team at pacific breast care to
take care of our patients in the most up-to-date way possible. The patient is in the center of our team
and we’re very patient oriented. As a surgeon I’m often the first person that
the patient sees but I’m by no means the most important person that the patient
sees. We have radiation oncology, medical oncology, plastic surgery for
reconstruction, we have a great collaboration with our
pathology department, and we have a great Imaging Center which is led by Dr.
Freddie Combs So I can’t do anything about the breast
cancer until it’s found, so let’s have Dr. Combs come on and tell
us about advances in imaging. Hello Dr. Combs. -Hi I’m Dr. Combs, Freddie Combs, I am the
director of breast imaging at Pacific Breast Care. We’re going to talk to you a little bit
about how we find cancers and why we look for him the way that we do.
Screening for breast cancer has been controversial since it was invented; its controversial in the medical
community, there’s debate in society. Why all the fuss? Well as one of my
radiology residency professors said, “because it’s out there man, it’s out there.” And to demonstrate that
we’re going to talk a little bit about statistics that I think are handy to
keep in perspective when you’re – when you’re thinking about breast cancer. About one in eight women or twelve
percent of the population will get breast cancer about one in a thousand men during their
lifetime. In 2014, it’s estimated that there will be about 300,000 new cases of
invasive and noninvasive breast cancer in the United States alone and about 40,000 of those people diagnosed will eventually die of breast cancer. Well not of those 300,000, but 40,000/year will die in the US as a result of breast cancer. So for a perspective three Rose Bowls full of women diagnosed
with breast cancer annually in the united states. That’s a lot of people. Additionally, angel
stadium which holds about 45,000, this would be about the number of us women that died as a result of breast cancer. So what do we do about that? Well, we
start screening. Why do we screen? Well it’s the second
most common cancer in US women. It’s about thirty percent of overall cancers diagnosed in women and there are currently about 3 million US
breast cancer survivors. Of note, about fifteen percent of people diagnosed with
breast cancer will have a family history and your risk essentially doubles if you
have a family history and a first degree relative. 85% of people diagnosed with breast cancer have no family history. Most breast cancers are not
genetically linked. Some people believe that if they don’t have a family history
that they’re not at risk and that’s not true and its one of the reasons why we screen to aggressively. Ok so is there any good news? Yes there
is. Since widespread screening with
mammography began in the 1990s, we’ve noticed a significant decline in breast cancer mortality. This is taken from CDC data and it shows
the overall trend. In general, the quoted rate is about thirty percent mortality
since we started screening which makes us very happy. Factors include early
detection, improved screening, advances in treatment, increased awareness, and that’s
in general what leads to the overall reduction in mortality. In general if the
cancer is detected under one centimeter in size the five-year survival is a set
is essentially the same as a normal person in the general population. No matter how we screen it all starts
with the mammogram that is the gold standard study this is a standard
upright unit like we use at pacific breast care. Why do we use mammography? Well it’s been studied extensively and
it is the only modality that’s been proven to reduce mortality.
Many other modalities exist such as MRI, ultrasound, and we’ll talk a little bit
about those, but mammography is the only one that’s been shown to significantly
reduce mortality. It’s not perfect, doesn’t find all cancers, but until we have a better modality or cure, it’s the best tool that we have. In
general when you do a mammogram there’s two types of mammography. There’s screen film which is kind of the old school way of doing it. So old school, he’s working a little
harder, he’s got his magnifying glass out there, he’s trying to find cancers on that
on that film image or a new school which is digital and digital actually projects
the mammogram on to a computer screen the image can be manipulated and we can
use a computer-aided diagnosis software to help us detect things that you may
not have seen on the first go round, we call it an R2 or second reader
system. In my opinion digital outperforms screen films so if
you have the option to go to a center with digital its preferred, as the
radiologist it’s it’s definitely much less labor-intensive as you can see she
looks much happier than he does. So this is a standard mammogram CC view
or cranial coddle which we compress from above and below or mlo which is a medial
lateral oblique which we can compress side to side at an oblique angle. The reason for doing these two views is it it shows the most breast tissue possible.
Mammogram is special because of quality control. In 1992 the MQSA or the
mammography Quality Standards Act was passed and is overseen by the FDA via
the ACR or the American College of Radiology. Basically what it says is all
facilities, technologists, and radiologists that are involved in
mammography must maintain credentials and certification so if you’re looking
for a mammography center to go to, look for one that’s accredited with them – with the ACR through the FDA via the MQSA. So what are the recommendations? This is
a question I get asked very frequently and the answer is not always clear if
you look to the media. The American College of Radiology has
pretty standardized guidelines and that as a radiologist are the guidelines that
I follow. The reason being is in looking at the other guidelines that exist out
there i think these are the most comprehensive and give us the best
chance of finding cancer. So who gets a mammogram? Everybody with average risk
starting at age 40. There are also people that we might
screen before the age of 40 and those are generally women that are of high
risk including women with known BRCA or breast cancer gene mutation or certain
genetic syndromes. Women that have a history of breast cancer or ovarian
cancer or have had an abnormal biopsy they should begin routine screening
regardless of the age which that diagnosis was made. And then last but not
least women who received chest radiation between the ages of 10 and 30 we start
their screening a little earlier as well. So for women with breast implants,
screening guidelines are exactly the same, it doesn’t change. Its still
annually started at 40 – starting at 40. Doing a mammogram on an
implant requires an extra level of skill so you want to make sure that you go to
a place that does a lot of them if they don’t ask you whether or not you have
implants you should tell them and if they don’t offer those services they
should refer you to a place that does the actual risk of rupturing an implant
with a mammogram I get the asked that a lot is is close
to zero in the hands of an experienced technologist. So when do we get to stop screening? I get this question a lot too. There is
no upper age limit. Most of the studies quote between about
ages 40 to 70 for but in general the recommendation is as long as the
patient is in good health and willing to undergo additional testing if we find an abnormality, then go ahead and screen it. It still can make a significant impact
on mortality. When is additional screening needed? Well
this is largely dependent on patient history and one of the things that makes
us unique at pacific breast care is we do an intensive patient history and we do a
risk assessment on every patient and we do that with a tool called IBIS. And IBIS
is a computer model which generates a risk number and it’s based on multiple factors, things like when you had children if you have them, if you have a family history, menstrual
history, etc. All those factors come into play to give you a risk number. Low risk
is considered 0-11, intermediate 12-19, high risk is 20% and above. We then determine the breast density and put you into a screening category so we
tailor the screening to the individual based on their risk. Low-risk patients,
mammogram is generally adequate; intermediate-risk, mammogram and screening ultrasound if they have dense breasts; and then high
risk for patients twenty percent above we recommend mammogram with screening MRI and we add screening ultrasound if for whatever reason they can’t have
an MRI. Doing all three studies mammogram
ultrasound and MRI doesn’t necessarily increase the detection rate over mammogram and MRI alone. so breast MRI, quick word – it’s got a high
sensitivity for detecting cancers, it’s very good at finding them but it doesn’t
replace the mammogram. There are things that mammogram can see that mr I can’t and they should be done together we
recommend it in high-risk women and one of the benefits of MRI is in this day
and age people are concerned with radiation risk there is no radiation
with with an MRI and very little risk with mammogram. Here are two MRI pictures
of cancers you can see on the image on the left here there is a small cancer in
the front of the breast and then a much larger cancer here but I put these
slides in just to show the detail that we get from an MRI and it really is a an
an amazing technology that that I think will eventually become a lot more
prevalent within screen. So ultrasound it’s most effective as a diagnostic tool it’s not a primary screening tests but
it does have its role in screen it’s a preferred imaging modality for
women under 30 we typically don’t do mammograms on
women under 30 unless they’re high risk we use it in addition to a mammogram if the patient has dense breasts or for
whatever reason as i mentioned they can’t have an MRI and if we need to do a
biopsy ultrasound is the easiest so we always try to to do an ultrasound
biopsy first if we can if we can see it on the ultrasound. Experience is the key
with ultrasound places that don’t do a lot of breast ultrasound typically do
not perform as well as finding cancers and abnormalities as centers that do, we do a
lot of them at our center. so here are some ultrasound pictures
just to give you an idea of some of the things that we we look for the top two
images or cancers we can show blood flow within a tumor and you can see this
looks very angry kind of looks like a commet and then
cancers to tend to have very irregular margins this is a benign cyst for for contrast
so you can see the the nice circumscribed margins of this lesion i
picked this slide because sometimes we see interesting shapes on ultrasound
this kind of looks like a lemon or Charlie Brown’s head. So our approach at pacific breast care
and UCI we think screening should be done on an individual basis one size doesn’t fit all for breast
cancer screening and everybody has a different risk which i think should be
taken into consideration so we do that for every patient and we
we screen them accordingly we try to give same day results one of the biggest
barriers for people not to get a mammogram is that they’re worried about
either the mammogram itself or what the results will be by doing it by giving
same very same day with results we reduce their anxiety and I think we need
to change the way that we look at that mammography we want to have informed
consumers we want to have people that are involved in the decision making and
understand what their risk is we also offer same-day diagnostic evaluation biopsy for abnormal screenings again with the intention of
reducing risk and wait time for getting a diagnosis. we utilize a team approach so that we if you do have an abnormally we can get
you to a surgeon like Dr. Police and she can fix you up or an oncologist if
necessary in summary breast cancer is not the
disease at once was and this is primarily due to advances in radiology
surgery and oncology it used to be the breast cancer was a
disfiguring disease now not so much and dr. police will talk
to you a little bit about her surgical techniques that are that are changing
that still screening is all about the mammogram it’s the gold standard is
where we start it’s safe and effective should be done yearly starting at 40 and
I encourage patients and physicians to know what their their level of risks are
within themselves in their patient population so that they can be screened
accordingly and if you have questions you can always
contact us at pacific breaths I’ll turn it over to Dr. Police who will tell you
how she’s going to fix you once we find it. -Thank you very much Dr. Combs. So now
that Dr. Combs has found the breast cancer let’s talk about some new ways of making
it go away so I want to talk to you about to new
technologies today that we now have a specific breast care and UC Irvine
health these two new technologies together are
unique to UC Irvine where the only breast center in the state that has
these two technologies combine to help you through your breast cancer diagnosis the first is marginprobe. Marginprobe – I
like to call my magic wand marginprobe is a device that allows us to test the
tumor intraoperatively at the time of surgery and make sure we have clear
margins in other words to make sure we got it all out at the time of surgery
and once we know that we now have a way to give you your radiation therapy in
one dose in the operating room instead of making you go to a radiation oncology
department thirty or more than that times to get your radiation therapy so these are the two new technologies i
want to focus on today. so marginprobe like I say it’s my magic wand so pretend
like this is the tumor that I just took out the body but it’s only this big it’s
not as big as it is in this picture so margin probe sends a signal into the
tissue and gets a reading and then the signal goes back into the magic wand and
I get a clear or malignant reading on the console this allows us to take more tissue at
the time of surgery if we see malignancy as shown here so i
would be able to take more tissue in this area so that you the patient do not
have to come back for a second surgery and this is a huge innovation the rate
of second surgeries after lumpectomy for breast cancer and nationally is up to
forty percent in some centers this is a huge issue psychologically I hear the patients on
their cell phones telling their families it’s bad they didn’t get it all even
though it may not be a bad thing prognostically for the patient it’s horrible psychologically and cause
the health care system a lot of money so after we get clear margins using
margin probe we can now do your interoperate of radiation therapy in one
session in the operating room while you’re still asleep after your
lumpectomy so this shows these ice center beam
system with the applicator going into the lumpectomy and most patients only
need radiation one centimeter around the area of the cancer and the reason for
that is that ninety percent of our occurrences happen within 1 centimeter
of the cancer so we know that if we radiate this rim of tissue around the
cancer for most patients this is going to take care of the problem and they do
not need six weeks of radiation therapy. So this is a huge advance so let’s talk
about the way it used to be, let’s talk about why we want to keep
advancing and keep me making surgical improvements. the first reference to any kind of
cancer in history was 3,500 years ago. Hippocrates coined the term karkinos
which is Greek for crab to describe a tumor of the female breast. It was the only
cancers people knew about because they were out there and very visible. He postulated that the cause was too much black bile so ladies watch your black bile. There
are records of the world’s first mastectomy in this era and it was postulated that the disease had no cure and never would. so then flash forward to 1882 which is
the next time there was an advanced in this disease and Dr. William Halsted, a
British surgeon performed the first formal mastecomy in modern times by removing the breast, all of the chest wall muscles, all the
overlying skin, and all of the excellent contents. He found that about half of the patients
were alive in three years which was a huge advance at that time remember everybody died. So flash forward to the 1900s in the US which was the first time there was any
further advance. 90% of US surgeries for breast cancer were Halstedian mastectomies, some better cure rates were found using chemotherapy which became available in the 1940s but the operation haven’t changed it was a huge disfiguring operation so in 1973 another British surgeon dr.
Crile figured out that you didn’t have to take off the whole breast for every
single breast cancer you could do a partial mastectomy get
clear margins and you could add radiation therapy and you could get
equal curates to mastectomy recent radiation therapy data suggests that
lumpectomy radiation has a better long-term cure than mastectomy which is
a very important point. In the 1990s, there was decreased mortality rate
do the screening like dr. combs told us about we started catching the cancers early
and in 1998-2000 we really got better with our surgical techniques and now you
can have bilateral mastectomies and you can look like this patients who have lumpectomy radiation
can also look very good are almost the same as they did before their surgery so let’s talk about marginprobe. Why do we
care about clear margins? Clear margins matter if we don’t get clear margins at
the time of surgery your chance of recurrence is twice as high in the first
five years obtaining clear margins is very
important it’s important oncological II and like I was discussing before is very
important psychologically it’s devastating for patients it’s one of the
worst conversations I have to have in my practice is when I have to tell a
patient who’s just had breast cancer surgery that they have to have another
operation. Economically it’s very important to the
health care system that we show that we are doing everything we can to save
money clear margins will probably soon be a
quality measure so the national average for clear
margins having to do a re-excision actually is 25 to 40 percent so at
pacific breast care and UC Irvine in my practice, my re-excision rate is now down to
three percent and that’s because of margin probe and I’m going for 0%. we’re going to try to make it 0. So why
do we need a new type of radiation therapy? We know that traditional
radiation therapy works we cure a lot of cancers using it the problems with traditional radiation
therapy are that its three to seven weeks, it’s one third of the radiation workload
of a radiation oncology department and very expensive, women from remote areas
may choose to have a mastectomy that’s lowering their overall survival rate and
causing them to have a bigger operation because they just can’t get to the
radiation therapy center every day geographic miss. Radiation oncologist
like to give a boost or an extra dose to where the tumor is and when when we have problems knowing exactly where that tumor was that can be an issue for them
if we have an intraoperative radiation therapy we know where the tumor was we
just took it out we’re looking at the tumor bed and we put
that applicator right in the tumor bed. collateral damage heart-lung skin damage
is way higher with whole breast radiation an intraoperative radiation
therapy cause mises is much better with intraoperative radiation therapy and a
delay in starting chemotherapy is another issue. So the TARGIT – A trial which looked at
ZEISS INTRABEAM intraoperative radiation therapy was 33 centers in 11 countries.
Two very smart British doctors, Dr. Michael Baum and Dr. David Daya decided to do a formal trial. it took 12 years, it was early, smaller,
postmenopausal breast cancers for the most part and we looked at local
recurrence as an endpoint. So secondary endpoints were safety patient
satisfaction cosmesis and saving money which in this day and age we all have to
think about whether we want to or not so the two groups were randomized, there
were 2,500 patients, half of them got one dose and half of
them got whole breast radiation and guess what the groups were equivalent as far as
local recurrence, long-term survival, and the target single fraction group had
much better cosmesis and much better patient satisfaction and a much lower
cost. So this shows how the randomization went. The TARGIT group and the external beam radiation therapy group actually open an
envelope in the operating room to decide which group the patient went into. So
let’s talk about what is the perfect breast cancer operation today? The
average breast cancer patient in the u.s. today is 61 years old she has a
stage 1 or 2 cancer so she has a small cancer and she’s postmenopausal that’s
the average breast cancer patient in America so there is me getting the radiation
therapy device ready which first you have to buy it and doing
the lumpectomy here and then we’re testing for clear margins with marginprobe and we may or may not do a re-excision of that area. I’m inking the specimen myself because I
want the pathologist have it perfectly oriented. We’re putting in the intraoperative
radiation therapy device and Dr. Jeffrey Quo our radiation oncologist who’s in
the operating room with us is turning on the machine. This is the perfect breast cancer operation. here’s the team it takes a village to
cure breast cancer so we have surgery we have the physicists we have anesthesia we have radiation oncology and we have a
the radiation oncology doctor smiling, this was his first case was very happy
so now i’d like to invite Dr. Combs back up and we’ll do some questions and
answers. -Ok so our first question is how many
radiologist does it take to change a light bulb? and the answer is zero
because radiologists are not afraid of the dark. That’s why they keep us in dark rooms. Let’s see first question – should i get a
mammogram if I’m only 29 years old? Well the answer to that is in general no. If you’re of average risk then mammography starts at 40, if you’re high
risk or have any of the genetic syndromes that we talked about or have
been radiated in childhood that may change you can talk to your doctor about that
to see if you fit into one of those categories but in general starting at 40.
Who should genetic testing for – who should have genetic testing for
breast cancer? -The National Comprehensive Cancer
Network or NCCN has a set of guidelines for genetic testing and most
insurance companies follow these guidelines but basically if you have
anybody in your family who had breast cancer under 50, if you have any family
history of ovarian cancer, if you’re of ashkenazi jewish origin and
have breast cancer or if you have three or more relatives on one side of the
family with breast cancer or if there’s male breast cancer in your family or if
you yourself have breast cancer in the premenopausal age group those are the main risk factors there
are some other combinations that work but that’s mostly it and if you’re
wondering if you need to have genetic testing you can come see us for a risk
evaluation, we’ll do a complete risk evaluation and we’ll test you right then
and there if you meet guidelines. -Ok next question how often should a
woman get a mammogram after age 40? Annually, yes. That is currently the recommendation is annually ok next question is a mastectomy a
better breast cancer treatment than a lumpectomy? -You know that’s a that’s a great
question and as we all know a recent celebrity had
bilateral mastectomies. Unfortunately all the public heard was the celebrity’s name, breast cancer, and bilateral mastectomy. That particular celebrity along with several others didn’t even have breast cancer so for breast cancer treatment as I was
describing to you before, the average breast cancer in the United States does not
need mastectomy, and in fact makes mastectomy may be depriving the patient of some
other important therapies like radiation therapy which are going to improve their
overall survival rate so every patient is different but in general saying mastectomy is a better operation is no longer true. -Next question, these are good. How do you know if you are at high risk
for breast cancer? one of the ways that we determine that
is with our IBIS risk assessment tool at pacific breast and UCI and basically it’s a computer based model that when you enter in different aspects of your your history it will
give you a risk number and there’s a lot of factors that go into that. That
information is available online so if you have questions as to whether or not
you’re high risk you can actually go and check out the risk assessment tools
online and enter your information and it will tell you if you’re high risk. Can I inherit breast cancer from someone
in my family? -Another important question. Breast cancer is not an inherited disease per se however you can inherit a deleterious
mutation of a gene that might give you breast cancer and so when we talk about
family history we really want to see if the patient is
eligible for genetic testing or has other risk factors but you can’t directly
inherit the disease. -Should I be concerned about radiation
exposure for mammograms? the short answer is no. In general
mammography has been around for a long time it’s a very low dose exposure it’s very safe and for comparison sake, a plane flight from LA to New York and back is about the same exposure as
you would get from a mammogram. The background radiation that we get just
from being on planet earth is somewhere between seven and eight and ten
mammograms worth of exposure a year so it’s not a high dose and it’s not
something that you should be afraid of it shouldn’t prevent you from from
getting a mammogram, regarding radiation and I think we need to improve
that knowledge within the community and let people know that this test has
been around for a long time, there’s never actually been to my knowledge of
proven breast cancer caused from a mammogram it’s very safe and the trade-off is we
find cancers and and reduce mortality What steps can I take to lower my risk
of breast cancer? What factors increase risk? -There are things you can do to lower
your risk of breast cancer one of the main things people can do is
is not something all of us do which is to have children before we’re 25 so that
that’s a big one that does lower the risk of breast cancer but a lot of
people just aren’t doing that anymore so I’m not saying go have children if
that’s not your plan anyway but other things you can do is maintain
a healthy weight and exercise. We can all do that we can maintain a healthy weight we
can exercise limit alcohol don’t smoke a lot of these
are just common sense basic things that we can all do and make
sure that if you’re going to get breast cancer that you get screened early and
you catch it early and so go for your screening when it’s appropriate. -Ok next question. I was diagnosed at age
30 , I have no BRCA mutation, no family
history, what age should my daughter start
mammography? That’s a really good question. There are specific guidelines that we
follow and in general we start 10 years earlier than the age at was which the
family member the first degree family member was
diagnosed but not earlier than 25 and so that would be my – that would be my answer for that, start at 25 and for that we would recommend in addition to
mammogram and MRI as well. -Can I say something to that patient
Dr. Combs? The other thing to know about genetic mutations and having
breast cancer at 30 is we don’t just test for bracket genes, now we test for a whole array of genes. There’s a test called my risk from myriad, which tests for 25 genes, so if you have breast cancer at age
thirty you need to be checked for Li–Fraumeni, or p53 gene, need to be
checked for a CHEK2 mutation and there’s a whole host of other mutations
that need to be looked at now so i would invite that patients to see
their physician or come see us and we’ll do a full panel of genetic testing -Ok, that’s all we have so far. Any other question? -So thank you all for coming. it’s been our pleasure to talk to you
about the work we’re doing epistemic breast care and we hope you got some
good information from our webinar and thank you very much if you want to ask other questions go to pacificbreastcare.com, and Dr. Combs and I will answer any questions that you have Thank you very much.

One comment

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