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 a 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 are very patient oriented as a surgeon I am 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. como doctor thank you 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 them 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 at 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 non invasive breast cancer in united states alone and about 40,000 of those people diagnosed will eventually die of breast cancer well not of those 300,000 40,000 a year will die in us as a result of breast cancer so for perspective three rolls bowls full of women diagnosed with breast cancer annually in the United States 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 all over all cancers diagnosed in women and there are currently about three million u.s. breast cancer survivors of note about fifteen percent of people diagnosed with a breast cancer will have a family history and your risk essentially doubles if you have a family history and a first-degree relative eighty-five percent 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 that's not true and one of the reasons why we screen so aggressively okay 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 a 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 up 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 onto a computer screen the image can be manipulated and we can use computer-aided diagnosis software to help us detect things that you may not have seen on the first go around we call it a r2 or second reader system in my opinion digital outperforms screen film so if you have the option to go to a center with digital it's 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 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 mqs a or the mammography Quality Standards Act was passed and it's 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 with the ACR through the FDA via the MQ SI 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 cancers 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 at 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 and implant with a mammogram I get to ask 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 patients in good health and willing to go under undergo additional testing if we find an abnormality then go ahead and screen as it still can make a significant impact on mortality when as additional screening needed well this is largely dependent on the patient history and one of the things that makes us unique at Pacific Breast Care as we do in 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 when you had children if you had 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 02 11 intermediate 12 to 19 high risk is twenty percent 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 and 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 a 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 a mammogram can see that NMR 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 the mammogram here are two MRI pictures of cancers you can see on the image on the Left ter 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 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 test but it does have its role in screening 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 ultrasound experiences 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 it's 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 comment and then cancers to tend to have very irregular margins this is a benign cyst for for contrast so you can see the nice circumscribed margins of this lesion I picked this slide because sometimes we see interesting shapes on ultrasound and this kind of looks like a lemon or Charlie Brown's head so our approach at Pacific Breast Care and and UCI we think screenings 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 by giving same rate same day with results we reduced their anxiety and I think we need to change the way that we look at at 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 diagnose 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 abnormality we can get you to a surgeon like dr. police and she can fix you up or an oncologist if necessary in summary breast cancers not the disease is it once was and this is primarily due to advances in radiology surgery and oncology it used to be that 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 it's 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 and their patient populations 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. cones 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 Pacific Breast Care and UC Irvine health these two new technologies together are unique to UC Irvine we're the only Breast Center in the state that has these two technologies combine to help you through your breast cancer diagnosis the first is margin probe margin probe i like to call it my magic wand margin probe 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 30 or more than that times to get your radiation therapy so these are the two new technologies I want to focus on today so margin probe 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 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 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 cost the healthcare system a lot of money so after we get clear margins using margin probe we can now do your intra-operative radiation therapy in one session in the operating room while you're still asleep after your lumpectomy so this shows the zeiss interview 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 recurrences happen within one 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 making surgical improvements the first reference to any kind of cancer in history was 3500 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 file ladies watch your black file 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 advance in this disease in dr. William Halsted a British surgeon performed the first formal mastectomy in modern times by removing the breast all of the chest wall muscles all the overlying skin and all of the accelerated 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 to the 1900s in the US which was the first time there was any further advance ninety percent of us surgeries for breast cancer were halsted ian mastectomies some better cure rates were found using chemotherapy which became available in the 1940s but the operation hadn'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 cure rates to mastectomy recent radiation therapy data suggests that lumpectomy radiation has a better long-term cure that mastectomy which is a very important point in the 1990s there was decreased mortality rate due to 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 or almost the same as they did before their surgery so let's talk about margin probe 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 a recurrence is twice as high in the first five years obtaining clear margins is very important it's important oncological e and like i was discussing before it's very important psychologically it's devastating for patients it's one of the worst conversations I have to have in my practice is what 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 region actually is 25 to 40 percent so at Pacific Breast Care and UC Irvine in my practice Mairi excision rate is now down to three percent and that's because of margin probe and I'm going 4-0 we're going to try to make it zero 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 it's 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 have a bigger operation because they just can't get to the radiation therapy center every day Geographic miss radiation oncologists 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 intra-operative radiation therapy we know where the tumor eyes we just took it out we're looking at the tour bed and we put that applicator right in the tumor bed collateral damage heart lungs skin damage is way higher with whole breast radiation and interpretive radiation therapy cosmesis is much better with intraoperative radiation therapy and a delay in starting chemotherapy is it is another issue so the target a trial which looked at dice intervene interpretive radiation therapy was 33 centers in 11 countries two very smart British doctors dr. Michael balm and dr. jebediah 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 in a much lower cost so this shows how the randomization went the target group and the external beam radiation therapy group they 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 margin probe we may or may not do a region of that area I'm inking the specimen myself because I want the pathologist have it perfectly oriented we're putting in the inter operative radiation therapy device and dr. Jeffrey quote 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 a breast cancer so we have surgery we have the physicists we have anesthesia we have radiation oncology and we have the radiation oncology dr. smiling this was his first case it was very happy so and now I'd like to invite dr. combs back up and we'll do some questions and answers okay so our first question is how many radiologists 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 know if if you're a 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 yet and if you're wondering if you need to have genetic testing you can come see us for a risk evaluation will do a complete risk evaluation and will test you right then and there if you meet guidelines okay next question how often should a woman get a mammogram after age 40 annually yes that is currently the recommendation is annually okay 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 at bilateral mastectomies unfortunately all the public heard was the celebrity's name breast cancer and bilateral mastectomy the 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 may 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 a general thing mastectomy as a better operation is no longer true next question these are good how do you know if you were 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 take that one 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's 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 7 and 10 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 fears regarding radiation and I think we need to improve that knowledge and 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 okay next question I was diagnosed at age 30 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 ten years earlier than the age it 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 and for that we would recommend in addition to mammogram and MRI as well can I say something to that patient dr. Conte the other thing to know about genetic mutations in having breast cancer at 30 is we don't just test for Braca jeans now we test for a whole array of jeans there's a test called my risk from marriott which tests for 25 jeans so if you have breast cancer at age 30 you need to be checked for lee from a knee or p53 gene you need to be checked for a check to mutation and there's a whole host of other mutations that need to be looked at now so I would invite that patient to see their physician or come see us and we'll do a full panel of genetic testing okay so we have so far any other questions so thank you all for coming it's been our pleasure to talk to you about the work we're doing at Pacific 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 Pacific breast care calm and dr. combs and I will answer any questions that you have thank you very much you

1 Comment

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