Knowledge is Power — MedStar Health Cancer Network Breast Cancer Webcast

Knowledge is Power — MedStar Health Cancer Network Breast Cancer Webcast


>>Costello: And a good
evening everybody and welcome to MedStar Health Cancer
Networks Knowledge is Power Breast Cancer Webcast. You’re watching us on Facebook Live. I’m Jamie Costello from WMAR-2 News
and we are streaming to you live from the MedStar Health
Bel Air Medical Campus. There are more people in this tonight
than the Oriole game last week. This is– now I want everybody
just to turn around and look because we’ve got the back of your heads
right now and so just everybody turn, it’s almost like a selfie, there
you go, look at everybody here. All right. I didn’t say
wave, you did not follow– all right [laughter] Listen, we have
a panel of ten experts right now and we only have a couple up
here but we have several more out in the audience here
but they have developed and they have taken their entire
lives to make our lives better and they are incredible people
that you are going to meet and they have spent their entire
medical careers, their entire residency in making us better for it and
we’re going to meet them right now. But first, I want to tell everybody
to post your comments and questions, click a like to be sure to share the
post so your Facebook friends can join in on the discussion and we want
to hear from you, we want to talk to you about breast cancer. So we want to meet the team right now
and you can remain seated, all right, Doctor, you can– all right, Dr.
Shweta Kurian who has been here, she’s an Oncologist, Hematologist at
MedStar Franklin Square Medical Center and she sees patients right
here in Bel Air, right here. Thank you so much for
joining here, Doctor. Diagnostic Radiologist, Jennifer
Flaim is here affiliated with the. Baltimore MedStar Hospitals in Bel Air. Jennifer, nice to see you as always
and here we have Dr. Atsuko Okabe who is a breast surgeon for
over 20 years, right Doctor, 20 years you’ve been
doing this breast cancer. Certified Genetic Counselor, Emily
Kuchinsky is going to tell us who, why and when we should seek
genetic counseling, she’s always– everybody’s heard from
her before, right? Emily is incredible, she could write
a book and also, Dr. Gabriel Corral from MedStar Plastic and Reconstructive
Surgery, is a very important role in breast reconstruction following
mastectomy, so stay tuned for that, we’re waiting for you,
Doctor and we mentioned at MedStar Georgetown Cancer
Institute, we’re seeing new signs all around this campus and Dr. Aboulafia is
here with us here tonight and Doctor, I think we can go right
to you right now. He’s going to talk about the
MedStar Georgetown Cancer Institute and the new name here in Bel Air. We have a network of experts,
clinical nutritional support and rehab. Doctor, can we go to
the doctor right now, we’ll give him the mic
and start talking. Just tell us about the
Georgetown signs all around us.>>Aboulafia: Yeah, so this
really an exciting time for us at the MedStar Georgetown
Cancer Institute. This is a combination or
a hybrid or a marriage between what has been a community
practice and now combining that with an academic
program at Georgetown. This allows us to have the personal
touch, the personal feel that you get with MedStar as well as
collaboration with the academic setting that allows patients to be enrolled
in pretty advanced clinical trials, take advantage or leverage
the opportunity with various advanced technologies
and really give people the opportunity to have the best of both
worlds from the academic as well as the community setting.>>Costello: Dr. Aboulafia,
you look on TV by the way. You look like you’re
on Dr. Oz right here.>>Aboulafia: It was raining last night.>>Costello: You are a renowned as
far as bone tissue and soft tissue, can you elaborate on that, why you went
down that alley and why we’re so lucky to have you going down that alley?>>Aboulafia: So actually I
wasn’t expecting that question but it is a pretty personal story in the
sense, I was interested in orthopedics, I was interested in sports medicine
and orthopedics and I realized that there were mostly healthy people
and it wasn’t a collaborative thing, you took care of people, you
did your surgery, they went home and everyone did well and
in oncology what appealed to me was there were
patients with real problems where you could really
impact their lives and that it wasn’t an individual
activity or an individual sport, it really was a team
effort that we collaborated with the medical oncologist, the
radiation oncologist, the imaging people from radiology, plastics and
reconstructive surgery, dietary, so it really was what appealed to me.>>Costello: Thank you Doctor. All
right, let’s start with Dr. Kurian. Let me ask you something right out of
the box, you have a lot of women right out here, can breast
cancer be prevented?>>Kurian: Sure. You cannot stress
the importance of certain things that can help prevent breast
cancer, one of course is exercise, daily exercise to keep a healthy
weight, and you’re talking about moderate exercise of one 15
minutes every day or 75 minutes of vigorous exercise every day. Cutting down the amount of alcohol, if you look at guidelines they’ll
say one alcoholic drink per day for a woman is probably the most
you want to take, anything beyond, you’re talking about two to three drinks
a day for a woman increases the risk by 20 percent of developing
breast cancer. So those are probably two
most important things. Diet, making sure you keep a healthy
weight is probably most important, post menopausal weight gain is linked to
with increased risk for breast cancer. Also, understanding what is
your family history, who had it, who didn’t have it can impact your risk
and discussing that with your physician, probably you can talk about some other
things to help prevent breast cancer, you could talk about some
medications that can cut down your risk if you’ve had certain
changes in the breast and we–>>Costello: And, I’m sure
everybody out here, how many of you, I know it’s personal, have known
somebody who has had breast cancer? Look. Does everybody get breast
cancer, is it just a matter of time?>>Kurian: So no, not everybody gets
breast cancer, the risk increases of course, it depends, if you’re a woman
definitely, men tend to get it less but it’s not like they don’t get it. It also is age dependent,
younger women lesser. As you grow older, the risk goes higher. It depends on your, we discussed
about the family history so if there are multiple people in
the family who had different types of cancer especially related to breast
cancer or colon cancer, prostate cancer, they might have a higher risk.>>Costello: Youngest
patient you’ve ever seen.>>Kurian: With breast cancer, in 30s.>>Costello: Oldest, first time?>>Kurian: Ninety-one.>>Costello: Ninety-one?>>Kurian: Yes.>>Costello: Imagine that news.
All right, thank you, Doctor. Let’s bring on Brooke, Brooke Sawicki
is a registered dietician who works with the oncology team at MedStar and
you had mentioned about dietician, you mentioned about your
diet and eating right, can help prevent breast cancer, Brooke?>>Sawicki: So what’s most important
is consuming a diet that’s full of vegetables and fruit. The American Institute for Cancer
Research actually recommends this new American plate which is two-thirds of
fruits, vegetables and whole grains and then one-third of animal
protein, the animal protein, we want to steer closer
towards chicken and fish and limiting our red meat consumption to
about 18 ounces a week and need to keep in mind that a standard serving size
for meat is about three ounces so that’s about the size of a deck of cards, so just keep that in mind
while you’re serving your meat that you are aware of the portion size.>>Costello: There’s only so much stuff
we can do with fish, what are you going to do, what are you going
to pull out of the bay now? What do you find that’s really good,
that really works, I mean salmon?>>Sawicki: I love salmon, I
eat it multiple times a week, I eat chicken all the time, ground
turkey, incorporating that into meals over ground beef, things like that.>>Costello: No red meat?>>Sawicki: Trying to limit it as
much as possible, there still needs to be a lot more research on the topic
but for now I would kind of stick to the guideline of about
18 ounces a week.>>Costello: Do you eat
your Brussels sprouts?>>Sawicki: I do.>>Costello: Carrots?>>Sawicki: Carrots aren’t my favorite.>>Costello: What kind of
vegetables nobody thinks of?>>Sawicki: There really is no
limit, any kind of vegetable you see in the grocery store, I usually
recommend sticking to the outside of the store, focusing mostly on
the produce and the fresh fruits and vegetables but if necessary frozen
are just as good, they are picked at prime season and then frozen so they
do have the same nutrient value as well as canned goods, just want to make sure
that you rinse them first to get rid of some of that extra sodium
that they’re packed in.>>Costello: How many times a
week do you eat Chick-fil-A?>>Sawicki: I don’t. I want to but–>>Costello: Okay, we all do. All
right, let’s bring in Emily now. Emily, prevention is key,
what about the risk factors that you cannot change,
the risk factors?>>Kuchinsky: With genetic mutations for
breast cancer, you can’t change that, you inherit these genetic mutations from
your parents, however, knowing you have that mutation is so powerful because
if you know you’re at higher risk for breast cancer, we can start
screening earlier, we usually start at age 25 rather than the
recommended age 40 when most people in the general population start. We also add in a breast MRI which
increases sensitivity for breast cancer and then women can also think
about preventative options like removing the breasts or
having a bilateral mastectomy which reduces their risk by over
90 percent for breast cancer.>>Costello: How soon can we get
like a family tree of our genetics, how soon can we work that, that
would be great if we get a map right out of the hospital, “Here you go,
here’s the map, here’s the Google.”>>Kuchinsky: Yeah, no, that’s
so true. I always tell patients that the greatest gift that you can
give to your family is to keep– so they have to do an intake when they
come to see genetics and they have to draw out their family tree, so I
said, “Make copies of this and give it to all your family,” because over time
people lose track of who’s had cancer and what types and if we see certain
patterns of cancer in the family like breast along with ovarian
cancer it really raises our suspicion that there could be a genetic
mutation, so it’s important to know your family history.>>Costello: You’re a hit on Facebook
Live because Paula in Aberdeen wants to ask you when is the right time to
bring the family in to come see you?>>Kuchinsky: That’s a good
question, I think it really depends on the individual patient so some
patients when they’re recently diagnosed with breast cancer want to come in
right away to talk about genetic testing because if they have a mutation,
they would be at higher risk to get additional breast
cancer in the future. With the BRCA mutations, BRCA 1 and
BRCA 2, they’re the most common cause of inherited breast cancer, we
see up to a 50 percent change of getting a second breast cancer after
a woman has already had her first. So she may want to have testing even
before her breast cancer surgery because she may elect to
have a bilateral mastectomy or both breasts removed rather than
just the one affected with cancer. But for other families, it’s too much
to know right when they’re diagnosed.>>Costello: All right,
Emily, you’re hot right now, here’s an audience question here, my
mom and aunts all had breast cancer, what is my risk and my daughter’s risk?>>Kuchinsky: So that’s a hard
question to give a number but definitely would be increased
with that family history. It would be important to
know the ages of diagnosis because the younger breast
cancer happens, the more we think about genetic mutations and
also, when we do genetic testing, we actually like to start with
someone who’s already had cancer, it sounds backwards but the reason is
is we need to see can we find a mutation in that person with cancer
that would be helpful and then we can test
the rest of the family.>>Costello: All right. Did she
answer those questions correctly, did everybody know? Yes, yes. All right,
knowledge really is power. Let’s go to Dr. Flaim who is going to explain diagnostic
radiology, take us through it.>>Flaim: All right, so I see lots of
women in our audience that are probably in the screening mammogram age range
which for the general population lots of our listeners hopefully are going
to be in that 40 and above range and the American College
of Radiology and Society of Breast Imaging are recommending
yearly mammography starting at age 40 and a common question I get about screening mammography
is when do you stop? And there is no hard stop, we all
age differently, there are some women at 60 years old that may
have a life expectancy of two more years likewise
I’ve seen some women at 85 that could easily expect to
live another 10 or 15 years. So I try to tell people that there
are two factors they should think about to continue screening
mammography and that’s if they think they have ten
good years of life expectancy, I think that’s reasonable and if it’s
actionable, if someone is not going to do anything about it then that might
be something to consider and talk about. So you come in and you get
your screening mammogram, lots of know what that’s like, I
evaluate those every single day and look for anything that might be a disturbance
or an abnormality that I would need to look at further, those women get a
letter, they get contacted to come back for additional imaging and then we do
what’s called a diagnostic mammogram and a diagnostic mammogram is
we think there may be a problem. Women can get diagnostic mammograms
because we see an abnormality on their initial mammogram or they
can come to us with a problem, they feel something, they’re having
discharge, they’re having redness or pain, something that we need to
evaluate, so we do a different set of imaging to evaluate
those areas more closely. There are other tools that we use in
medical imaging such as ultrasound which is an excellent tool, we use
it very frequently in breast imaging, it’s just another way to look at the
tissue, it uses different physics, we see things very differently and
it can help us to really figure out what’s going on when we
see an area of abnormality.>>Costello: Let me ask you a question,
when somebody comes in to see you and goes into one machine, should
they keep going to that one machine or should they go to the one machine
and then, “Oh, we’re going to go to the next machine over here,”
should they be consistent on the machines that they use?>>Flaim: In terms of the
same mammogram unit? [Yes]>>Flaim: There are very
strict guidelines and we do quality assurance
techniques every day to make sure that our equipment is up to snuff
and that’s pretty universal, everyone has to kind of go through
the same standards when you’re in a screening protocol because
we know that the majority of women that we’re seeing, they don’t have
breast cancer but we have to check a lot of women to find as many
of those cancers early on when they are treatable, when we
can reduce the amount of morbidity and mortality from those cancers and
give those women the best quality of life that we possibly can.>>Costello: Let’s go to Dr.
Okabe, tell me, mammograms, you know how important
they are in detecting this.>>Okabe: Oh absolutely, and
that’s a very good point because by the time you can feel a lump
in the breast, it’s already been there for a number of years and so in
order to catch breast cancer early where you have the most
options of treatment as well as of course the best chance
for cure, it’s so important that you follow breast screening and
I agree with Dr. Flaim, women 40 years and older should get annual mammography.>>Costello: Okay. It’s always in October because
of Breast Cancer Awareness Month that we get different– “Oh my good–
we got to go in when we’re 12,” they change the rules all the time. But you’re saying 40 that’s it, that’s
the key one, right, go in at 40. Let me ask you, here, we got Lisa
Solomon just speaking in here. Can you speak about women with
dense breasts that have to follow up with ultrasounds and are they
more likely to get breast cancer? This is from Lisa.>>Flaim: When I read a mammogram, there
are certain words that I have to use and that’s so that say you move to
god bless, Hawaii, somewhere wonderful so that if you get your
mammogram there it’s consistent, so that we’re all using the same words
so that you get a similar quality of care so that you can follow up
on something that is an annual exam. So when I first look
at someone’s mammogram, the first thing I assess
is how much, quote unquote, “breast tissue” meaning
the glandular tissue and the fibrous components
are there versus fat which is the other normal
thing that occurs in a breast. There are four designations,
heterogeneously dense and extremely dense are what we call
kind of increased breast density, most women will have what we call
scattered breast density meaning there’s not quite as much of that dense pressed
tissue there and what we know is that having dense breasts does incur
a slightly increased risk of cancer, it also makes cancers more difficult
to see because on a mammogram which is an x-ray, it’s shades of grey,
cancer shows up as a whiter looking mass or entity but also that background
glandular tissue is also white so it can sometimes be like looking
for one snowflake in a snowstorm.>>Costello: How many
ladies and gentlemen, we should not exclude the gentlemen
but when you go out and you look for deodorant, do you read the
label and does that worry you about breast cancer using deodorant? Anybody? Yes, yes. Is that a worry we should
have about picking out– somebody even asked online here on
Facebook Live, “Is deodorant a worry?”>>Kurian: No, not that
I have much data, no.>>Flaim: To my knowledge occasionally
in lymph nodes that are sampled, there have been traces of aluminum found
in some lymph nodes but I don’t know of any definitive research
that would say that there’s a direct causative link.>>Costello: Okay. All right.>>Flaim: If you have a non aluminum
option, sure, give it a try.>>Costello: All right.
Theresa Ann Lewis, “I’ve recently been diagnosed
with a cyst in my breast. Does that increase my
risk of breast cancer?>>Flaim: If it is a simple cyst then
no, complicated cysts or anything other than a simple cyst, obviously I
can’t make a definite designation without seeing it but in general a
simple cyst meaning there’s no solid components does not incur an increased
risk of it turning into something else.>>Costello: All right, Dr. Kurian.
Once a patient is diagnosed, what is the first step
to determine what’s best for that patient, first step?>>Kurian: When you’re diagnosed, I
think he first step is pathology, looking at the tumor, what type it is,
what it looks like under the microscope, is it an invasive cancer
or is it ductal carcinoma in situ or what are we looking at. Depending on the pathology, you also look at whether it has the
protein receptors on the surface which decides what treatment
the patient’s going to get, you’re looking at estrogen receptor,
progesterone receptor and HER2 receptor, that actually decides what type
of medication you’re going to use to have an effect on the tumor, you
also look at the size of the tumor, you look at if the lymph
nodes are involved, you look at the patient themselves, what
they can tolerate, what can be done, what treatment is best for them. So you actually have to personalize
treatment for most patients, you have to look at the genetic makeup
of the tumors and that can help guide, determine the risk of this tumor
coming back or the risk for recurrence. So a lot of thought and
a lot of information goes in before we decide what to
do and how to treat a patient when they are first diagnosed
with breast cancer.>>Costello: Out of ten breast cancer
patients, how many are the same?>>Kurian: Well if you put all the
multiples together, I don’t think– every person is unique and that’s
why I said, you have to personalize.>>Costello: All right,
let’s go with the– you want to talk about lymph node
dissections, Doctor, you want to talk about that and also breast
conserving, what is breast conserving?>>Okabe: When a woman gets breast
cancer, if it does spread somewhere, the first place that it
will usually spread to is to the lymph nodes in the underarm area. So we call that the axillary
lymph nodes and this only pertains to invasive breast cancer, so invasive
breast cancer means that instead of just being contained inside
the duct or the lobules, the cancer cells have gone through the
wall of that structure and when it goes through the wall, those cancer cells
can then enter into the bloodstream or into your lymph stream
and more often like I said, it will go into your lymph stream
and then travels to the lymph nodes and since lymph nodes are
part of your immune system, they will try to trap
cancer cells for as long as it can before it lets it spread
and goes deeper into the body. So lymph node evaluation is a very
important part of staging breast cancer and fortunately for us instead of
always going to what we used to do which is an axillary node dissection,
taking out 10 to 20 or more lymph nodes from the underarm, when it is early
stage breast cancer that is diagnosed, we will do sentinel node
biopsy and this is a way of assessing the first few lymph
nodes that that lymph fluid flows to and if those are negative, we know
that they’re not going to skip and go to deeper lymph nodes. So when we talk about
lymph node dissection, in most cases we are performing
what’s called sentinel node biopsy which is done at the time of
either lumpectomy or mastectomy, but if cancer has already spread
to the lymph nodes then sometimes and I would say most of the times, we
will do an axillary node dissection which is removing more lymph nodes.>>Costello: Isn’t it neat to be
smart, I mean wow, thank you, Doctor. What? We’ll bring in
Dr. Del Corral here, thank you for joining us here
tonight, you’re going to tell us about lymph nodes because these
little glands can cause a lot of trouble, can’t they, Doctor?>>Del Corral: They can. Thank
you for your question Jamie. You know, lymph nodes really
are as they mentioned before, they have that autoimmune
effect but they also transfer and helps us transfer
fluid from one compartment of your body to another compartment. So when the lymph nodes are removed
in the case of a lymph node dissection or a sentinel lymph node it can
cause a problem known as lymphedema. Lymphedema is really that
accumulation of fluid that can drain on the extremity, it limits that
drainage from that lack of lymph nodes and that becomes a problem for the
patient after having a diagnosis of breast cancer and there are
certain options that we can talk to the patient depending upon their
degree of lymphedema and their stage to see if we can improve
surgically their lymphedema.>>Costello: All right, Doctor.
We have a question here, this is a tossup question
here from Jackie Anderson. What advice do you have to
offer to those who are afraid of yearly mammograms due to exposure? Due to exposure, who
wants that question?>>Flaim: Yeah, so the
degree of radiation with annual mammography is really
relatively low when you think about background radiation which
occurs all the time, you know, if you take a trans Atlantic flight,
you get a fair amount of radiation and the benefit to that is
obviously hopefully some vacation. If you’re talking about your
mammogram, you’re getting this tiny dose of radiation and the benefit is really
the possibility to save your life.>>Flaim: So to me it’s a risk–
there is some risk, of course, there’s a little bit of
radiation but the risk versus benefit there,
it’s definitely there.>>Costello: I think it’s
something very important, you know, we’re talking about some
real tough situations but we do have some great breakthroughs
going on for those of you watching, breakthrough treatment that’s
really only available in a handful of facilities around the country and
Doctor, you’re going to talk about one of them, it’s VLNT surgery.>>Del Corral: We call it a
vascularized lymph node transfer which is just a fancy name for
just grabbing healthy lymph nodes from one area of the body
and placing them in the area where they were removed
for cancer purposes. There’s also another less invasive
procedure known as a lymphatic bypass and just as you reroute the
traffic jam on a highway, it allows you to reroute the traffic jam
on that lymphatic circulation and help that extremity or that arm or leg
to decompress from the lymphedema. So it real ly depends on
what the patient needs and what stage the patient is.>>Costello: Are second opinions
recommended for a cancer diagnosis? You got it, I want a second
opinion, you okay with that?>>Whole Panel: Yes. absolutely.>>Okabe: I think having cancer treatment
is a huge step in a person’s life so you want to make sure that you. feel comfortable not only with
the physician that you have met but also you want to know that what
was recommended for you is appropriate and by having a second opinion, I think
you are able to get that information.>>Costello: Okay. All right, we’re
going to bring in Dr. Kamila Nowak Choi who is a radiation oncologist
and Doctor, can you tell us about radiation therapy
and how this all works?>>Choi: Sure, absolutely. So I think in
radiation and oncology just like in any of the specialties taking
care of breast cancer, the key is really a personalized
approach where you consider each patient as a unit, as a unique individual. So just like with other specialties
when I see a patient for consultation, there’s not one size
that fits all in terms of the radiotherapy that’s
recommended but you look at all of the patient’s characteristics as well as the tumor characteristics before
talking to them about recommendations of the specific type of radiation
that they’re getting both in terms of the extent of the radiation as
well as the length of the radiation, so that’s one of the keys and I think
something else that’s very important that we’ve been focusing
more and more is also looking at the potential side effects from
radiation not just in the short term but also in the long term and utilizing
techniques that will decrease the risk of damage to normal tissues which is something there’s definitely
been a big push in the field, for example, protecting the heart.>>Costello: All right, Dr. Choi, thank
you, Dr. Del Corral is a plastic surgeon with the Georgetown Cancer
Institute of MedStar. Doctor, can a breast cancer patient get
implants after breast cancer, can they?>>Del Corral: It’s a good
question, yeah, absolutely, they can definitely get an
implant after breast cancer, it’s actually the most common way of performing breast
reconstruction in the United States. The one important thing is to make
sure that that implant gets some kind of surveillance, usually
we recommend an MRI after having an implant
reconstruction and our society of plastic surgeons recommend
that MRI to be performed at least every three years for
the first three years and then after that every two years. So it’s important to remind yourself
that you have an implant in your body that is going to need to be
monitored for the rest of your life.>>Costello: And reconstruction options, there are a number of
them out there, right?>>Del Corral: Absolutely, but
primarily you can divide them in an implant reconstruction
or you can use your own tissues and the tissues can come from
different areas of the body and we’re really trying to find
the best way and the best fit for that patient depending on
their aesthetic goals and really if they have the ability to
take the time off from work and how do they see them self
five ten years from now to decide which option would be
best fit for that patient.>>Costello: Okay, I want to ask you what
is it like to sit across from a patient to tell them that they have breast
cancer and then to tell them that they’re cured, the
two scenarios from start to finish, tell me about that. Or is there one patient out there
that will always stick in your mind on how it looked bleak but man
they see the sun rise tomorrow?>>Kurian: Whenever there is a
diagnosis of cancer it’s unnerving for anybody whether it’s a
small cancer, big cancer, it doesn’t matter whether
younger have different, younger patients have different
things they worry about and older patients have
different things they worry about. For me, what makes it comfortable
telling them this news is I know there are options to treat, there
are very good options, the likelihood of curing somebody with
early breast cancer is very, very high, over 90 percent and so those are
some things I can tell the patient, make them feel comfortable that
if they do the right things, if they follow the guidelines,
if this thing is done, if we provide the treatments
that is appropriate, the likelihood of his thing
getting cured is very, very high and once they are done with treatments,
yes, of course, sitting in front of them and saying that, “I think your cancer
is cured,” is probably the best thing as a physician can feel
because that’s a very– I don’t know if I can explain that
feeling, it is that you were able to do what you worked for all this while
and the patients, the way they feel when they hear that, “Yes, it’s
cured and it’s probably not going to be something hanging
over my head all my life.” There are patients who walk in at age,
as I said, older patients who walk in and if they are 90 some year
old, the discussion is different, the discussion is sometimes,
“I want to cure this for you without making you uncomfortable.” And I know of some of my patients
or one of my patients who had walked in with a lot of problems and in
the end when we were able to do and complete everything, I said,
“It’s all done, and you’re free,” and I’m seeing her three years
out from it, yes, the 91 year old, three years out from it, doing well.>>Kurian: That’s an amazing thing, yes.>>Costello: That is amazing.>>Kurian: Yes.>>Costello: I want to go
back to Dr. Del Corral who, you’re going to describe the DIEP
flap reconstruction, DIEP flap.>>Del Corral: Sure, so it’s
primarily an advanced way of doing a TRAM reconstruction which
is the way we used to take tissue from the abdomen, in the past we used
to take the tissue from the abdomen to reconstruct the breast
primarily taking someone’s muscle and for those patients who had a double
mastectomy, you can imagine the amount of recovery and pain that those patients
can have if both muscles are removed. So the DIEP flap is the modern or
sophisticated way to do the surgery by–>>Costello: How long
has this been going on?>>Del Corral: You know, it’s really
a technique that has been going on since the early ’90s and it’s
changed over the last ten years to really limit the dissection,
to just take the skin and the fat and the little tiny blood vessels and
spare the nerve, the muscle to make sure that that patient doesn’t develop
a problem in their abdomen, make sure that that patient
has an easier recovery. Because we’re really replacing
tissue like with like, you’re removing the breast tissue which
is technically a subcutaneous organ and using your abdominal tissue
to reconstruct that breast.>>Costello: It’s like liposuction
and then instead of discarding it, hey, we’re going to use it.>>Del Corral: Exactly,
it’s a good way to use that abdominal tissue,
put it to good use.>>Costello: Holy cow. All right, Doctor,
you’re in the business to cure us, what’s it like to tell that
patient, “You’re going to make it, you’re going to survive,
you’re going to make this?”>>Flaim: It’s almost indescribable and
I can think of one particular patient and there are so many, you know, there
are so many patients but there are so many individual patients
and I remember all of them. But I remember a patient that I saw
here, my first week and she is just, she knows who she is and when I
tell this story, she’ll really know who she is, but I saw her a year
ago at Disney World and it was like the greatest reunion of all time,
they set off fireworks over the castle, that’s how it feels inside
to see that person out there doing exactly
what she wants to be doing with nothing holding her back, that
cancer diagnosis that’s in the past, she was at Disney World, we
were having a great time. That’s the only way I
can think to explain it. Sorry, I have small children. So it call come down to Disney World.>>Costello: That is great,
that is good and Doctor, you’ve been around the block a
time or two, you started out, tell me what it was like to start out 20
years ago to today and the technologies and the advancements and
the cures that we’re seeing that we may not have seen 20
years ago, tell me about that.>>Okabe: That’s a really good
question and I would say that’s one of the reasons the advances
that occur in breast cancer that keeps me really engaged in this
field because every year when I go to my annual American Society
of Breast Surgeons meeting, there is some new something
being discussed. So when I was in residency, most
women were getting mastectomies and not getting immediate reconstruction
so yes, there was an option for delayed reconstruction but you had
to wake up with that drastic change in your body, very shocking and for
the lymph nodes, we were not doing that lesser surgery that I described
earlier which was sentinel node biopsy, we were automatically doing
axillary node dissection and what studies showed is that
for over 60 percent of women who were getting axillary node
dissection, there was no involvement of the lymph nodes and yet by taking so
many lymph nodes they were going to be at high risk for developing
lymphedema and such. So what I’ve seen over the years
is less invasive treatment, so for the lymph nodes,
sentinel node biopsy and then for the breast surgery itself, most
women are going to be candidates for what you had mentioned earlier
which is breast conservation therapy. So breast conservation is
conserving or saving the breast, so even if you have breast cancer
it does not automatically mean that you have to have
removal of the breast, most times you can have a lumpectomy
which is just removing a part of the breast where the cancer is, lumpectomy however does almost always
go hand-in-hand with radiation therapy and that’s another thing
that I’ve noticed too over the years is radiation therapy
used to be just one way, that’s it, that’s all, taking about
six weeks or seven weeks, now even the daily treatment is
down to about three to four weeks and sometimes we have these other
options like doing a onetime radiation in the operating room which is called
intraoperative radiation therapy before the woman even has woken up from her
lumpectomy and lymph node surgery, we have already done that radiation
treatment, or there is another kind where the treatment can
be performed in five days. So it’s just been a progression
of less traumatic, yes, it’s a difficult diagnosis but I think
with all the advances that we’ve made over the years, we have such a
variety of options that we can discuss with our patients and I think
one of the things that is so key is the early diagnosis. When you have been having screening
mammograms and I would like to throw out there breast self exam because
there’s a lot of controversy, do you do it or not, I am still a very
strong proponent for breast self exam because I still have patients who come in who found something
because they felt it.>>Costello: How often?>>Okabe: It’s not that often, I would say that if they’re
getting their mammograms, to be missed by a mammogram could
be maybe about what, 15 percent?>>Flaim: It’s very low, yeah.>>Okabe: Yeah. Maybe even
lower than 15 percent. But you can also have what’s
called interval breast cancer, so we mean you’ve been having
your regular mammograms but before that year has come around for your next
mammogram, you start to feel something. So if you have a more aggressive
cancer, you may detect it that way.>>Costello: How often, a week, once
a week, every day in the shower?>>Okabe: Oh, for the self exam?>>Costello: Yeah, for the self
exam, what would you advise?>>Okabe: I usually recommend
once a month.>>Costello: Once a month?>>Okabe: Yeah and for women
who are having periods, the best time to check is one
week or so after your period.>>Costello: After, okay.>>Okabe: Because as you’re
approaching or during your periods, your breasts are more swollen,
more tender, more lumpy bumpy so you can get false alarms.>>Costello: Okay. Lumpy bumpy,
there you go, that’s good.>>Okabe: [laughs] Very medical.>>Costello: Emily, I want you to
take me down your career path, why genetic testing, how did
that reach out and grab you, what attracted you to this?>>Kuchinksy: I think what really got me into genetic counseling
is just the ability to dig into people’s family
histories and be able to help them understand maybe why
a disease or condition happened and be able to give them
power to know that information and possibly start earlier screenings
or preventative options or just to get a better understanding of why the
same condition keeps happening and also on a personal level, my father had
a genetic condition in his family and they didn’t really
understand why it was happening but through genetic testing
it really came to light so I think there’s combinations of just
how our DNA, our genes shape so much about us and sometimes it’s really
important to look at them and see if cancer or maybe other conditions
are inherited in the family.>>Costello: Do we skip several– have you seen several generations
skipped or have you seen–>>Kuchinksy: So genetic
mutations don’t skip in a family, you have to inherit them from a parent but let’s say you get the
genetic mutation from your dad for breast cancer, he may not
have developed breast cancer because his risk is pretty low, he
could possibly develop prostate cancer because that is a much higher
risk in our BRCA positive and other breast cancer
mutations families. So it may look like it’s skipping but
the dad had the mutation it’s just that he may not have shown
signs of it but he can pass it on to his daughters and his sons.>>Costello: What do you see in
the future of genetic testing, what do you see down the road,
tell me what you would like to see?>>Kuchinksy: Well we’re already starting
to see more genes than we can test, I’ve been mentioning BRCA 1
and 2 as the most common cause of inherited breast cancer
but now it’s routine to test over a dozen genes related to
inherited breast and ovarian cancer and I’ve had a couple of families that
I saw a few years ago and they came back to do expanded testing which is
looking at a larger panel of genes and we actually got a mutation that
we didn’t pick up before and now that patient’s daughter got
tested and she has it too and now we better understand
her risk and she’s going to pursue preventative options. So it’s so powerful because before
we’re like, “We think it’s genetic but we can’t pinpoint it,” but now with this additional testing we
are picking up more families.>>Costello: All right. Dr. Okabe, somebody wants to know
what a SAVI SCOUT is.>>Okabe: Oh, SAVI SCOUT. Okay. So
that is a device that we can use when you’re doing a lumpectomy so
when we’re doing a lumpectomy we have to know exactly where the cancer is and
there’s different ways to know that, if you can feel it, that’s fine,
we know where to do our surgery but if you can’t feel it then we need to
have some roadmap to show us what part of the breast needs to be removed. The more common way and the
way it’s been done for many, many years is a needle
localized lumpectomy we call it, so on the day of surgery you
go to the radiology department and a skinny wire is placed. So now there are different devices
that have come out so actually on the screen I’m seeing a picture of a
SAVI SCOUT and that is a special marker that is based on radio frequency so
you put that marker into the tumor and instead of having to have
a wire tell us where to go, we use a special probe that
they’re showing here to show us where the tumor is and by doing
that, we know exactly where to cut and where to remove tissue.>>Costello: Hey, just like that, look
at that and how long does that take?>>Okabe: Oh, I think not long, I mean
Dr. Flaim has put those markers in.>>Flaim: Yeah, we put those in,
moments, just a few moments.>>Costello: Just like that.>>Costello: All right, Dr. Del
Corral, it seems a lot of people find out that there is a treatment
for lymphedema are shocked, and explain what the lymph
node transfer is again.>>Del Corral: Sure, so a lymph node
transfer, it’s really taking lymph nodes from one area of the body
and placing them in the area where the lymph nodes were removed and
they work through different mechanisms, the primary mechanism is that they
really work like little sponges where they’re going to absorb that
fluid and they have little veins within that lymph node and
they’re actually able to excrete that extra fluid that they’re absorbing
through their own vein to improve that arm or leg, that’s how
a lymph node transfer works and there’s different ways to do it and
not everybody’s a candidate perhaps, if you have early stages of lymphedema
and you have some improvement with your massage and your therapy
perhaps you may not need surgery and all these surgeries are
really not a cure for lymphedema, they’re primarily an
adjunct to lymphedema therapy so you really need a
patient who continues to see the lymphedema therapist
and it’s really a collaboration of the two specialties to
improve and have a good outcome. If the patient may have an early stage of lymphedema we can do a very
noninvasive technique where we can go into the arm or the leg and we can
make about a one centimeter incision and we can connect maybe
a one millimeter lymphatic into a two millimeter
vein to help drainage and that’s using special
technology as well.>>Costello: How did you get into this?>>Del Corral: So plastic surgery has
always– I love the field because. it’s really, specifically
for breast cancer, you are really creating something
that was removed completely out of almost nothing and after you
create it, you have to make it match on opposite sides perhaps and you have
to make it, it’s very artistic the way to give that outcome to that
patient and I love about that because every day is a new
challenge and I love that, there’s really no monotony in what I do.>>Costello: Wow. Brooke, I want to go back to Brooke. See, I caught you right here, Brooke. Do you go nuts with all these
studies that we see on TV, “Oh, if you drink wine, two glasses of wine
a day, if you eat garlic all the time,” no Italian would have breast cancer if
we– so what are the hot foods right now that everybody’s garbling
down to prevent breast cancer?>>Sawicki: So a lot of the things that you just mentioned are mainly
phytochemicals so there is a lot of research on the phytochemicals
and cancer protection, they are ingredients found in wine
and garlic, and fruits and vegetables, that’s what give fruits and vegetables
their flavor, their color, their odors and they collect free radicals in
the body which reduces carcinogens and cancer forming in your body.>>Costello: All right, good.
Let’s go to Dr. Kurian. Facebook question, after breast
cancer can a woman still have a baby?>>Kurian: Yes, it depends on
how old you are and of course–>>Costello: Well, no I
can go to med school now–>>Kurian: And depending how early,
I mean you sure can have kids after you’ve had breast cancer. So you should have finished your
therapy, if you had cancer that early and you finished your hormone therapy
or whatever therapy you had then yes, you can have kids after that. But for certain types of cancer,
pregnancy can increase the risk of forming, having the
breast cancer again, so you have to be monitored
very closely.>>Costello: How often do
you all talk to one another?>>Panel: All the time. Daily.>>Costello: Every day. Do you really?>>Panel: Yes.
>>Costello: You share?>>Okabe: Yes.>>Costello: You say, “Can
you do it?” Do you all meet at once with a patient sometimes?>>Okabe: Yes, sometimes.>>Costello: Talk about that
because I think that is, instead of making 19 appointments,
let me just come up and sit down in front of everybody now.>>Kurian: We do something called
a multidisciplinary clinic.>>Kurian: So a patient comes in with a
diagnosis, Dr. Okabe will get in touch with us and say, “Hey,
we have a patient we need to discuss, would it be possible?” And we, me as a medical oncologist
and radiation oncology will meet with a patient at different times, one
after the other, give options in terms of treatment, so they
get a composite picture of what their treatment
would look like so when they leave this place
they have a clear understanding of what it would mean going
forward, how to treat this and how we can take care of it.>>Costello: What’s it like to see fear
in the face of a woman who’s just been– they’re thinking of their
kids, they’re thinking of their husband they’re thinking–>>Okabe: So no woman
ever wants to be told that they have breast cancer it
is a very difficult news to take. But what I try to tell the
patient is that because most of these women are diagnosed
with early stage breast cancer and I think it’s very important
for them to know up front, they’re going to survive
this cancer yes, this is a blip in their life
right now, but you’re going to get all the best up-to-date
treatments that you can possibly have and it’s probably never ever
going to be an issue for you. It still doesn’t take away the fear
but I think it helps to let them know, “This is probably not
what’s going to kill you.” And in fact, every time I go on the
American Cancer Society website, the number of breast cancer
survivors in the US continues to climb and right now I think we’re approaching like three million breast
cancer survivors in the US.>>Costello: Also, here, please explain
Padgett disease and how common is this. This is from Patti who’s
watching us on Facebook tonight. Padgett disease.>>Okabe: Padgett disease is a
special type of breast cancer, it’s not very common and this is where
the ducts inside the nipple are affected with cancer, it is a in situ
cancer meaning it’s not invasive, but oftentimes it can present
with some people say like a rash of the nipple area and as time goes on
you will have flattening of the nipple. So when a woman is doing breast self
exam, I think that’s one of the things to look for are changes in
the appearance of the nipple.>>Costello: And Doctor, give me
some hope, give me some hope, what do you see down the line?>>Kurian: Well I see that we are
able to detect things much sooner where we don’t have to go
through aggressive treatments, where screening can detect
cancer much sooner, earlier and/or we can implement things that prevent cancer from
developing at all. I’m not sure how we’re going to
reach there but that’s the aim. Right now I think even if we have
a diagnosis of breast cancer, there are excellent,
excellent treatments. There used to be a time where cancer
treatments were very, very aggressive, people were sick, there were
floors where it used to be cancer, chemotherapy floors where people
would be throwing up all the time and that’s what everybody associates
with cancer care or cancer treatments, not just with breast
cancer any other cancer. That has completely changed,
people tolerate treatments well, the newer treatments are much, much
more tolerable than they have been in the past, the outcomes are
much better and as I said, most people will survive their
breast cancer and have long lives.>>Costello: That’s good,
you’re giving me hope. All right Emily, here we
go, I got the question here. At age 16 I had a benign tumor removed, my mom and aunts have had breast
cancer, what are my risks? I think you hit this one,
that’s a similar question that we had earlier, right?>>Kuchinksy: Yeah, so
definitely we would be concerned about that family history, having two
family members with breast cancer. But breast cancer can also be familial
where they may be common exposures or common lifestyle factors
that’s making that family a little bit higher risk
so there may not be a genetic mutation. So it would be important to gather
information, how old were the women when there were diagnosed
with breast cancer, make sure that there’s no other
types of cancer in their family, we think more about genetic mutations
with ovarian cancer, prostate cancer, pancreatic cancer, so gather all that
information and then ask your physician to see a genetic counselor who can
really sit down with you and go through the family history and give you
a better sense of could it be genetic and then we can also
calculate the lifetime risk that that person would
develop breast cancer based on not only the family history but their
personal risk factors, hormonal factors like when they got their first period,
when they had their first child and really personalize their risk
assessment and they may qualify for increased screening starting
earlier or adding in breast MRIs, so there’s a lot that can be done
with a genetic risk assessment.>>Costello: I want to go
back to Dr. Aboulafia. I’ve known you for a long, long–
I’ve been a big fan of yours forever. Clinical trials, how do you know
you’re prime for a clinical trial?>>Aboulafia: Well, you know, it’s, the
word we like to use is multifactorial, you know, which just means
there are a lot of variables that go into making that decision. When I initiate a conversation with a
patient about clinical trials what I try and do is the first thing I tell them
is, “This is completely voluntary,” and I follow up with the statement,
because patients frequently want to please their doctors, so I tell
them, “I’m not going to like you more if you do it, I’m not going to
like you less if you don’t do it.” So I really want it to be an
independent and informed decision.>>Costello: But not everybody
fits, right?>>Aboulafia: Absolutely.
So if they don’t fit into a clinical trial
then that’s not an option. But then we go through what the clinical
trial involves and we want to make sure that we’re not exposing them
to an inappropriate risk and that they understand it and that
it’s been vetted through a whole group of researchers, ethicists, statisticians
and that it’s something meaningful.>>Costello: Jennifer from Abington is
asking about fibrocystic breast disease, she has it and her mother
has it. Increased risk?>>Okabe: Typically not, no.>>Costello: Jennifer, that’s great news
for you, from Abington, that’s great and also, Pablo from Forest
Hill asks, this is it, when are you considered cancer free?>>Kurian: So some of the
cancers like the ER PR positive which have the estrogen and progesterone
receptor positive cancers they don’t grow as quick, they’re chance of
recurrence are less but they tend to linger around for a long period
of time, so you need to follow, those patients you have to follow
for a longer period of time to say you’re cancer free, but generally
you consider a five year period after which the risk of
recurrence is lesser. For some of the other cancers
which don’t have the receptors which are triple negative, they
don’t have the ER receptor, they are more aggressive up front,
the risk for recurrence is higher in the beginning few years but as
time goes by the risk of recurrence or the tumor coming back goes down. So yes, five years is considered
to be, but because of trials, that’s when you tell the patient,
“You’re likely cured of your cancer.”>>Costello: Let me go back
to Dr. Choi. You’ve seen so many advances like every day. What do you see when you’re
91, what are we going to see, what do you see down the line?>>Choi: I think the big
focus is really focusing on which patients need the radiation
and which patients are such low risk that they may be able to get less
radiation or even no radiation at all and so a lot of the trials are
focused on teasing out these patients and the other thing is what I mentioned
before is really protecting their normal tissues. We know that the radiation
does have a benefit in terms of decreased recurrences
but we also know that some patients may
have some secondary issues because of the radiation and so all
of the techniques and the advances that we focus is trying tying
to minimize those side effects in the long run as much as possible.>>Costello: Tina from
Aberdeen wants to ask you here. What is linear accelerator and is that
the best option for radiation treatment?>>Choi: Okay, that’s a great option, so a linear accelerator is basically
a machine that generates the x-rays or the radiation that
we use to treat patients with external beam radiotherapy. It’s the most common form
of radiation that we use for patients with breast cancer. There are some patients
that are candidates for something else called brachytherapy
which is basically a treatment where the radiation is
actually introduced through a device that’s placed
in the lumpectomy cavity, not all patients are candidates for that so it’s basically a case
by case scenario. But the linear accelerator is the
machine that’s used in most scenarios.>>Costello: All right. Let’s go and this is our final wrap
up, Dr. Del Corral, how proud are you of your profession now,
seeing what you’re seeing, listening to what you’re hearing
tonight from very great experts?>>Del Corral: Very proud, I think
we have made tremendous changes in the field and I think plastic
surgery is going to continue to evolve tremendously so it’s very
gratifying to what we do and I think over the next several years what we’re
going to see is a tremendous change in doing not only less invasive
surgery but we’re also going to have more adjuvant treatments
such as fat grafting for example after you’re having a mastectomy and I
think implants are changing all the time and getting a lot better and we’re
doing more advanced techniques now that are going to have better outcomes
and going to have less recovery time for patients and they can go back to
their normal activities much faster.>>Costello: Okay. Emily,
brag a little bit, tell me about the good things
happening at MedStar, come on.>>Kuchinksy: Okay, I can do
that easily because there’s so many good things happening
at MedStar. Yeah, so I think something that
I’m really proud of in talking to my colleagues in genetic
counseling is just how much respect that the team gives me and refers
patients to me because at some centers, physicians will do their own genetic
testing and not value genetic counseling and that there’s a lot that goes into
the decision to have genetic testing, “Do you want to know, what are you
going to do with the information, does your family want to know?” And I’m just constantly impressed with
how much the team will just look to me and refer patients and I get them in
as soon as I can if needed so I want to give a thank you to the team
for just respecting what we do and our role is becoming more and more
important not just for the families but the patient, I mean sometimes
it determines their treatment, a certain type of chemotherapy
might be offered if we do find a genetic mutation.>>Costello: All right, Doctor, you’ve got the rooftops,
shout up 95 and down 95. What do you want us to know?>>Okabe: I think what
I would like people to know is how closely we work
together not only on a day-to-day basis but also we have a multidisciplinary
conference that we have every Thursday and all the patients that are
either in some cases newly diagnosed or who have had surgery get presented
and we have a group of breast surgeons, medical oncologists, radiation
oncologists, radiologists, pathologists and as a group we discuss every single
patient and follow national guidelines and come up with the best
possible treatment for that person. I think what Dr. Kurian
mentioned earlier is that one person’s breast cancer is
not another person’s breast cancer, we are so personalizing the treatment
these days and what we found is that all these different features of a particular cancer not only may give
us an idea of prognosis but it helps to direct our care to give them
the best possible treatment.>>Costello: Doctor from Disney World,
you’re in another Disney World, we’re on a ride for our
life, aren’t we, what a ride.>>Flaim: Yeah, we sure are. I think
I’d like to speak to how great a job that MedStar has done in making sure that we have the most
up-to-date technologies here from a radiology perspective,
having 3D mammography, having breast MRI available, having
high quality ultrasound available, having the capability to biopsy a
lesion under all those modalities here in Hartford County is fantastic
but even more than that, something that I’m exceptionally
proud of in this group and in this organization is
that it’s incredibly human. I get a chance in my day to talk
to every patient that comes to me for a diagnostic mammogram, and they’re
terrified and we see it all the time and they don’t just talk to
me, they will talk to me, but they talk to my staff, they talk to
my mammographer they go right next door and talk to Dr. Okabe’s staff. We go behind our little secret back
trap door and we talk to each other and I think that that really shows and I
can see from the start of a new patient to the end of our visit when they
go over to Dr. Okabe’s office, there’s a visible difference in
the stress level in these women when you treat them as they are,
they’re individuals with dignity and it can be an embarrassing
and a stressful experience and I’m really proud of the
way that MedStar handles it.>>Costello: Doctor, I take it
you don’t just treat the patient, you treat every person behind that
patient, the family, everybody.>>Kurian: Absolutely. You
know, every patient that walks in is not just a patient, they have a
family, they have work, they have others who are concerned about their health. When they come in, they come in
with a lot of knowledge or not so much knowledge but my job is to tell
them what you have, how to treat it and make them feel comfortable
that it’s okay, it’s okay to have an aggressive
diagnosis like breast cancer, and it’s okay because
we have a great team and excellent treatments
to take care of things. Every day as Dr. Okabe, Dr. Flaim
and everybody here says, we talk, we discuss, we come up with a plan
for that patient and it’s not just about the cancer part of it, we have
a team that involves a social worker who will talk to the family and
say, “Okay, you are having problems, you’re having these issues,
how can we manage this? You’re having transportation
issues, how can we bring you? How can we make sure that you come
for the things that you needed so we take care of this cancer
and take care of your family?” It’s not just the diagnosis, it’s not,
this is the treatment and you’re done, it’s taking the patient in a whole
and making sure they feel fulfilled when they’re done with this treatment
that, “Okay, I not just took care of the cancer, I took care of my family,
I took care of other things that needed to be taken care of while going
through this aggressive treatment.”>>Costello: Well we love
you all but we don’t want to spend the night. But
weren’t they great? I think everybody should
give them a round of applause for [applause] what we’ve been through
and what we’re going to go through and what we’re going to come out on
the other end, it’s going to be great. Thank you so much for
joining us on Facebook Live, thank you for your questions and
again, thank you from Bel Air tonight, beautiful downtown Bel Air. We’ll see you again, thank
you again for watching.

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