 So today I'm going to talk a little bit about what the role of a medical oncologist is a lot of people when they're going through this process. I have a lot of questions in terms of where the various people fit on their team and what their various options for treatment are. So I'm going to try and mimic a little bit one of my initial discussions with patients when they first come to meet me. And so who is on a breast cancer oncology team. There are multiple people that are on a breast cancer team. As you'll see from the moment that you get that initial abnormal mammogram to the moment that you come into a medical oncologist's office. So we have our radiologist our breast imager. They're the ones who review our mammograms and MRIs perform the biopsies and to help dictate what additional imaging someone might need to best evaluate their breast cancer. And then we have our breast surgeon, who's in charge of coming up with the surgical plan, whether it's a lumpectomy, where you're removing just the tumor and some surrounding tissue, whether it's a mastectomy, and whether they need to take some lymph nodes. And they're one of the first people that you meet after the radio after the radiologist, then as a medical oncologist and medical oncologist like myself is in charge of determining what systemic therapy therapy that goes in your body that can go anywhere that a tumor can to both treat any cancer that you have but also to reduce future risk of recurrence. And so over time, your medical oncologist becomes a little bit kind of like your breast cancer primary helps to make sure that you're up to date with all of your homework, such as mammograms, GYN visits and helps to come up with ensuring that you have the best treatment plan. And then we have our radiation oncologist who's in charge of doing radiation, Dr. Patel will get in touch in a little bit, and we'll go from there. So what is an amount medical oncologist so we deal with the prevention diagnosis and treatment of cancer, and we evaluate and manage the systemic therapy to treat and prevent cancer. So many women come to me after having a lung factory mastectomy, and say well my breast surgeon took out all the cancer I don't have any cancer why do I need to see you. So one part of our goal is to make sure that we don't hear from your cancer again that we reduce your risk of ending any future disease. So what happens when you come to your initial consultation with a medical oncologist to review both your personal and family history to make sure that if there's any genetic testing that's required that's carried out. We review all of the pathology that's a result of any breast biopsy and any imaging that you may have had. We may decide that some future imaging is ordered such as cat skins or pet skins that may not be necessary and we discussed that as well. So we review what's been done so far in terms of surgery or any other interventions and if anything else is required, and we come up with a plan to treat and to prevent future breast cancer recurrent risk and we work closely, typically with the breast surgeons, the radiologists and the radiation oncologist to determine not only what plan makes the most sense but also in what order that plan will be carried out. So what is breast cancer, and it's staging. So at the end of the day, all cancer cells are basically cells that have started from a normal breast cell, and somewhere along the way, while they were growing and dividing and copying their genetic material cells made a mistake, and they created cells that had kind of more focused on growing and dividing than really on being breast cells and so those cells that initially were, you know, more also to speak than become these immortal cells that are just bent on dividing and not really functioning properly. The staging systems are for breast cancer is based on the location within the breast, the size of the tumor and also the involvement of lymph nodes. All staging systems are different for different tumor types that's something to keep into consideration. A staging system for breast cancer is completely different than say long colon or other things. The distinction that we make is what's called stage zero breast cancer, which is called ductal carcinoma in situ. Very frequently ductal carcinoma in situ is confused with invasive breast cancer. And so what Dr. Carcinoma in situ is is where you have these atypical cells that are stuck completely within the duct. They're stuck there. They haven't gone into the breast cancer into the breast cells and haven't ever come in contact with any highway such as blood vessels or lymph nodes. So they don't typically have the ability after being surgically removed to come back elsewhere in the body. And so that's what ductal carcinoma in situ is. Anything beyond the stage one is invasive breast cancer, meaning that those cells have gone into the breast itself and each of them have an inherent risk of kind of going on to other places in the body, which is our main job to prevent. Many women asked me why did this happen to me? What did I do wrong? What could I do different? At the end of the day, the biggest risk factor for breast cancer is just the fact that one has breasts. And so being a woman, having breasts and age with time increases our risk of breast cancer. Only about five to 10% of our breast cancers are hereditary in nature. In terms of who do we decide we're going to send to a genetic counselor and do genetic testing, that's largely based again on someone's family history, the type of breast cancer they have, and also the age at which they have that breast cancer. The other things that can increase risk are people that we know to have dense breast tissue, history of benign breast disease such as fibroadenomas or other recurrent cystic disease, and things of that nature. In terms of lifestyle factors, there are several lifestyle factors that have been evaluated increasing risk of breast cancer and those are things such as having early onset of periods, in terms of having obesity, decreased activity, having absence of children or children after 30. We know that breastfeeding can decrease the risk of breast cancer. Alcohol use can increase risk of breast cancer. Interestingly, particularly greater than two drinks of dye can increase someone's risk as much as 20% compared to someone who doesn't drink alcohol. Things in terms of myths for breast cancer risk, there's myths out there that antiperspirants can increase risk of breast cancer, that is not the case. In terms of estrogen supplementation such as oral contraceptives or estrogen supplementation postmenopausal, we have shown a concern that these could potentially increase risk of breast cancer, but those risks are very low and actually only occur while someone's on the estrogen supplementation. What are the different systemic therapy options to treat breast cancer? We have many of them. One of the things I always tell people when they come to see me for initial consultation is to be very careful in terms of their googling and as well as when they compare their story to someone else. There are so many women who have been affected by breast cancer with whom one can kind of talk and kind of compare stories. But in terms of our treatment plan, there's so many different things that come into it based on a multitude of factors. We determine someone's treatment plan so that can account for why they very much can look different from each other. So we have neo-adjuvant therapy, neo-adjuvant therapy means any therapy that's given before surgery. For certain tumor types, sizes, other indications, we might try and give people therapy prior to their surgery with the goal of reducing the size of the tumor to make surgical outcomes better. Adjuvant therapy is any therapy that's given after surgery and the vast majority of our therapies are given in the adjuvant setting, meaning you do surgery first and then have your therapy. We have hormone therapy, which can be pills or shots designed to decrease the amount of estrogen we have in our body, which we'll get into. We have chemotherapy and we have targeted therapy, such as HER2 directed therapy. We have immune therapy and sometimes we just observe people. What are the types of breast cancer that are out there? And so one of the initial questions that we ask ourselves when coming up with a treatment plan is what are the things that are making someone's tumor grow, divide, and survive? And so here's where we come down to what is driving someone's particular tumor. So the vast majority of breast cancer is 80% will show estrogen and progesterone positivity, meaning that when they look under the microscope with the pathologist, the certain percentage of someone's tumor cells take up estrogen and progesterone. They're relying on the natural estrogen and progesterone we have in our body, and even postmenopausal women, even men all have some estrogen that's there, and these tumor cells rely on those to help them grow, divide, and survive. So we have HER2 positive disease, which we'll get into, and about 20% of tumors can have HER2 positive. And we have, and then you can have a combination of HER2 with estrogen, progesterone, positive tumors, or it can be HER2 without the presence of estrogen and progesterone. About 10 to 20% of tumors are triple negative, meaning they don't express estrogen, progesterone, or HER2 positivity, and those are treated quite differently than the above. So what is hormone therapy? The most common one that people have heard of is tamoxifen, and so we have what are also called the aromates inhibitors, which are letrasol and astrodol and epsomastane. When we determine what hormone therapy we're using, it's largely based on a couple of factors, the biggest one being whether or not someone is premenopausal or post. The difference between a premenopausal and a postmenopausal woman is a premenopausal woman is still making estrogen from her ovaries. The aromates inhibitors, which are the bottom three, are not capable of reducing the estrogen that comes from the ovaries. So if we give those to premenopausal women, they'll just make estrogen around them. Tamoxifen can be given to pre or postmenopausal women, but it's typically given to premenopausal women. They're blocking the ability of estrogen to bind onto those abnormal cells, and therefore kind of starts of cells of what they need. The letrasol and astrodol and epsomastane grants the conversion of hormones to estrogen in the body. What is chemotherapy and who needs it? So 70% of women with ERPR positive disease will not require chemotherapy. Therapy is almost universally given to our triple negative breast cancers and our HER2 positive breast cancers. As long as they're above a certain size, which is typically generally speaking around five millimeters, they can be different for different people. And so when we make a decision in terms of chemotherapy for hormone positive breast cancer, the vast majority of women won't need it. Because those tumors that express estrogen and progesterone care so much about that hormone, that as long as we deprive them of the estrogen and progesterone, we significantly reduce risk of recurrence by 50% or greater without the use of chemotherapy. It's not that chemotherapy is not beneficial in those patients. It's just not necessary. So how do we figure out who needs chemo and who doesn't? That's where the oncotype DX score comes in. So the oncotype DX score is a score used only in estrogen, progesterone positive, HER2 negative women with breast cancer is above five millimeters and up to three lymph nodes positive. What it does is it's a genetic test of about 21 different genes done on the tumor itself that's removed surgically to give us a numerical score, whether or not someone needs chemotherapy. The score for which we determine that someone needs chemotherapy can be different based on whether someone's pre or post menopausal, and also whether or not they have lymph nodes positive. Generally speaking, if the score is less than 25, the additional benefit of chemotherapy tends to be less than 1% or not at all. In our pre menopausal women, sometimes regardless of the score, we still make a decision to do chemotherapy, because in our pre menopausal women, there are other factors that can contribute to their breast cancer that are benefited by chemotherapy. That is HER2 targeted therapy. And so HER2 receptors are receptors that can be present on a fast sale and when they're multiplied in their function, they can increase the growth of tumors. We have HER2 targeted therapy, which are a variety of either intravenous or oral therapies that can go directly against these HER2 cells and prevent them from growing and dividing. They can be given to women with HER2 positive disease. Typically HER2 therapy in the setting of early stage breast cancer is added to a chemotherapy backbone, which can be different based on different factors. And the HER2 therapy can typically be continued after chemotherapy is done, surgery is given, someone's received radiation, that therapy can continue up to a year and usually longer. People ask, how will my treatment affect everything life? Many women are very concerned about this. I think in the setting of chemotherapy, most women accept the fact that you'll be given something for a period of four to six months. It can make you feel tired. You most chemotherapies, you do result in hair loss. People can have some mild nausea or vomiting, though typically now we've done a significant improvement in terms of managing these adverse effects. I think most women accept that chemotherapy might make them feel yucky for a short period of time and then they can move on. That's a harder thing to accept sometimes is hormone therapy. Adjuvant hormone therapy can hormone therapy given after surgery is typically continued for about five to 10 years. So to ask someone to take a daily medication that can affect their quality of life for five to 10 years is something that most people aren't too excited about. The good news is the vast majority of my women really do tolerate their hormone therapy very well and notice little to no disruption of their quality of life. Most of our hormone therapies have side effects associated with menopausal symptoms because we're reducing that estrogen. So it can be some fatigue, mood changes, hot flashes, achiness in the joints. The good news is even when people do have adverse effects, typically most oncologists are very good at dealing with the side effects. And also sometimes by switching one's medication, we can find one that people can tolerate. You know, we accept as oncologists that we're asking people for a very significant chunk of their life and really focus on ensuring that the quality of people's lives is not adversely affected. Overall, survivorship is a really big component of breast cancer care because so many women continue to follow with their oncologist for significant periods of time, a decade or more. We really do recognize all the ways that having breast cancer, even once it's gone can continue to impact people in terms of, you know, their anxiety around mammogram imaging in terms of their effects. A fax of hormone therapy. But the good news is that breast cancer, you're not alone, 7.8 million women in the past five years have been diagnosed about 280,000 invasive breast cancer in the last year and 50,000 cases of DCIS. Breast cancer has a 13% percent lifetime risk in one in eight women. So the community is big. Our research is strong. And the good news is with every year are outcomes of breast cancer, which are already fantastic. For 90% of stage one in two women will never see their breast cancer return, but those outcomes get better every year. And our risk of death from breast cancer goes down by about 1% to 2% per year. Thank you. Thank you, Dr. Salowicz. And yeah, we're just going to transition. We're going to have here from Dr. Priti Patel, Medical Director of Radiation Oncology at Riverview. So thank you and take it away. Just loading my screen. Okay. So thank you for inviting me to speak with Dr. Salowicz about breast cancer. My name is Priti Patel. I'm the Director of Radiation Oncology at Riverview Medical Center. I'm going to explain a little bit about the role of radiation for breast cancer. So radiation basically how I explain it to patients, it's an x-ray similar to like a chest x-ray, except it's much higher energy. And what these x-rays do is we target it to a tumor or microscopic cancer cells and the x-rays go right through them and they break them and they break their DNA. Cancer cells have a weaker DNA. And so they're vulnerable to damage and they don't have the proteins to repair themselves, whereas normal tissues, they do. So when we use radiation for the breast, for example, if there's microscopic cancer cells there, the cancer cells will die, whereas your normal tissue, even if they get some side effect, they can repair themselves because they have the proteins to do so. So that's the biology behind how radiation works. So external beam radiation therapy can be given either with a low dose per day or high dose per day, and I'll get into that in a little bit. And our field is pretty exciting in that there's been a lot of technology, it's constantly evolving, and the technology has really helped us protect the surrounding critical structures that surround the tumor that we may be treating. And it also allows us to deliver radiation more efficiently so that patients are not on the treatment table for that long. And radiation can be used to help prevent a recurrence in the breast. For example, if there's just microscopic cells that we're not seeing within the breast ducts, or it can help treat tumors that maybe are inoperable. Like in a metastatic setting or, and it also provides local control and survival benefit in breast cancer. So I'm going to briefly discuss the case and we can go from there. So if a patient comes to me in the consultation room. She's a 55 year old female and she had abnormal screening mammogram Dr. Salwitz went into how one of the first physicians that a patient sees would be the breast radiologist and so the breast radiologist saw an abnormal mammogram she suggested a biopsy of a one centimeter mass and the biopsies show that she had an invasive ductal carcinoma. So at that time she's referred to a surgeon and the surgeon discusses two treatment options for the patient. One would be mastectomy where you remove the breast. And the other would be a lumpectomy with radiation. And this is based on phase three studies that showed with 20 year results that removing a breast versus removing just the tumor and giving radiation to the breast afterwards which is called breast conservation that the results are equal that the survival is equal. And so patients that study helped us realize that patients don't need to remove their breast if they have a breast cancer that by removing just the lump and doing radiation afterwards their survival is the same. And in that same study they looked at, well what about the radiation do we really need it. And so when women where they did the lumpectomy, and then in women where they did the lumpectomy and added the radiation. The radiation showed a significant prevention of recurrence. So at 20 years. So the women that did not do the radiation 40% of those women had an in breast recurrence versus 14%. That did have the radiation so that study showed that not only does radiation help prevent the recurrence in the breast but actually it decreases a woman dying from breast cancer so it does help with the breast cancer mortality. So radiation is a very important tool in the treatment of breast cancer. And so the breast surgeon discussed these treatment options with this patient and she decided to proceed with breast conservation. And so she underwent a lumpectomy. And she is meeting with me to discuss her radiation therapy options. Usually, if a patient has a lumpectomy they will meet with myself and they will meet with a medical oncologist like Dr. That is where they would recommend if a patient needs chemotherapy or not if a patient does need chemotherapy they usually have chemotherapy first in this particular instance. She did not need chemotherapy she was recommended to have endocrine therapy alone which is a pill that a patient would take every day. And so that was the first couple of years which Dr. Selvitz alluded to. And so then we decided to, she came to see me about approximately four weeks after her surgery to discuss radiation. This is the case that we just presented about this stage one breast cancer patient she underwent surgery with breast conservation and is coming to see me for the first time for radiation. And so after the surgery for consultation, we review the history that I just did with this prior patient reviewing their imaging reviewing their surgical management, reviewing what the medical oncologist may have recommended. And then we discussed the different treatment options for radiation. And we talk about the number of days that they would need and the different techniques we can use to treat that patient. And then we also discuss the side effects and discuss our next steps. So I'm going to go into that. So, typically, when someone comes for radiation for a stage one breast cancer like this case that I just described, radiation can is typically every day Monday through Friday for about four weeks. We treat the whole breast for three weeks and then give a boost that last week of radiation to the lumpectomy cavity of where the surgery used to be. And women that have multiple lymph nodes that are positive, we end up treating a larger field and radiation can be up to six weeks in those patients. The nice thing about radiation that it is all outpatient, it is painless. Typically no restrictions during radiation therapy, a lot of the women will come to our department before work or after work and they can drive themselves. Side effects of radiation are typically gradual. That is why we give a low dose per day to allow the side effects to gradually accumulate. So basically acute side effects would be an erythema or a redness on the breast. Again, that's pretty gradual technologies come a long way where it is rare to get a very bad sunburn type of look on the breast fatigue. Some women get a rash someone feel itchy someone women can feel some nipple soreness or sensitivity. Some term side effects, the breast can feel more firm or it's what's called fibrosis their breasts can have some tanning and a rear side effect is edema or lymphedema. You know, sometimes that can depend on the field that was radiated the number of lymph nodes that were removed. It can also depend on the size of the woman's breast. And so the technology has come a long way and to cardiac side effects are very rare. There have been studies showing that there actually is no increased cardiac deaths with patient that underwent breast radiation with the present technology. The risk of cardiac injury or secondary cancers or lung complications is almost less than 1% with the technology that we have now. So when a patient decides to have radiation for example this patient with the stage one breast cancer had a lumpectomy. She went met with medical oncology and was decided to undergo endocrine therapy, and then came here with radiation and I recommended four weeks. And so what we do in radiation is we basically do a planning session that's called a simulation. And what we do during that simulation is that we we figure out how to position the patient so that they're in the same position each day for treatment. It's how we map out the beam angles based on their anatomy. So in this particular instance this patient, we make this mold for the patient to lie in in the blue here. The patient is lying down with her arms up. They have a tattoo mark in the middle of their breasts. That is to align them with lasers in the room so that we can make sure that they are not rotated. And so that is the first step in planning for radiation. And then when the patient comes for treatment. As you can see this is the head of the machine where my arrow is. The x-rays are exiting the head of the machine in pink, and we deliver the radiation beams and what's called a tangential field. Basically we treat the breast with this tangential field on this angle to avoid the x-rays going inwards to the heart and lung. So one way we target the breast but avoid the heart and lung is by giving these tangential radiation fields. So as a patient's lying there, there's usually music playing in the room, and it typically takes about five minutes of radiation. They won't feel any pain. They get up and they will leave. So there's a few different techniques that we can use to deliver the radiation. Right here is what's called a Varian Trubium Linear Accelerator. This is the machine that we have in our department and in a lot of HMH hospitals. Basically a patient would lie down on a table and this machine can go around multiple different angles of the patient to deliver a focus targeted radiation. So radiation can be delivered with the patient on their back, which is supine. It also can be delivered with the patient prone or on their stomach, and I will show you a picture of that. There's various phrases that you may hear when researching about radiation, such as IMRT, IGRT, or VMAT, and I will get into that also in the next slide. There's a different way to do radiation also, and that's more of an internal radiation through a radioactive source, and I will go into that in another slide. We also can treat superficial tumors with something called electrons, which are superficial x-rays. And we can also, with these machines, deliver stereotactic radio surgery. Basically, that is a pinpoint very high dose of radiation to a very small spot. So sometimes in terms of breast cancer, we can do stereotactic radio surgery to target an area of metastatic disease, and sometimes we can even use it to target a small area in the breast. So just in further detail with all this technology that has really helped advance our field. The first one is called IMRT, and basically what that is is that at the head of the machine, we have these metallic leaves that modulate or move in and out as the X-ray beam is exiting the machine. And this really allows us to shape at a particular point in time the way the beam is coming out. And so for instance, this middle black picture is a picture of a patient, and the yellow is the area of the breast that we want to include. The red is her heart, the black is the lungs, and this green and yellow shading represents the amount of dose or energy that is being deposited from the radiation beams. And as you can see in the green shading that there is some lung tissue that's involved in this tangential field. But with the advent of IMRT, we're able to really shape the way that the radiation comes out of the machine. And now this is a much more conformal dose distribution. You can see that the green line goes from being here in this previous picture to now more closer to the breast and it spares a lot of radiation going into the lung. So this is another way that we can really treat the breast but minimize the dose to the heart and lung. IGRT is the concept in that we can really, when the patient's laying on a table, we can take images to really confirm that their positioning is exactly how it needs to be. And sometimes there's day to day variation. So that allows us to be confident that we know exactly the position that they need to be in. And VMAT stands for Volumetric Modulated Arc Therapy. The advent of VMAT allows us to really quickly treat patients. Patients are on the table and sometimes within just a few minutes, areas that traditionally would take 15, 25 minutes can be treated within just a few minutes. So this technology with multiple arcs or beam angles with IMRT really allows us to treat anywhere in the body, not just the breast but in the head, neck, brain, lung, pelvis, abdomen, etc. So in this patient with the case that I described she had her consultation, her simulation with the planning. This is the plan that we created and then she went ahead and had her treatment. So some women with very large breasts, we can also treat them on their stomach, it's called a prone breast treatment. In this position, the breastboard is placed on the machine and they put their breasts through this hole here and the radiation beams will go, you know, inferior to this board. So it is an option for women with larger breasts. The special breast irradiation is the ability to deliver radiation to a smaller area, maybe just the tumor where the tumor used to be. For a select group of patients. So myself, the medical oncologist and the surgeon will discuss ahead of time if there's an appropriate candidate. So it needs to be a small tumor, not that aggressive without lymph nodes estrogen positive. And in those women, you're, you know, the risk of recurrence tends to be higher near the tumor bed of where the tumor used to be. And so we can focus the radiation just to that area. And that is a concept of partial breast irradiation. So partial breast irradiation can be done with a catheter this this is called a brachytherapy catheter where a catheter is inserted into the breast, and it's connected to a machine and the radiation delivers the radiation to the tumor bed, and it's typically done twice a day for five days. Alternatively, we can give partial breast irradiation with external beam radiation where we deliver beams targeted to the breast either with an IMRT technique which I just described, or, you know, five different angles that all converge to that spot. And so that is an option of getting radiation done within one week if they are an appropriate candidate. So case number two is this. So sometimes I get asked if we really need radiation in older women. So in this case we have a 75 year old woman with a one centimeter breast cancer that is estrogen receptor positive. She had a lumpectomy and she really does not want to undergo radiation and what is the discussion I have or what are her treatment options. There was a trial that specifically looked at this there was a trial that looked at women over 70 with one centimeter tumors. And these patients received a lumpectomy and either they had tamoxifen, which is an estrogen blocker with radiation or tamoxifen alone. As Dr. Salwood previously described, tamoxifen helps the body lower their estrogen so it prevents feeding the tumor if there are any microscopic cells left after surgery. So after 10 years, the patients that had the radiation and tamoxifen 2% developed the recurrence versus 10% that developed tamoxifen alone. So there is no difference in survival. So the conversation I tend to have with the women that are 70 or possibly even 65 and older is, I look at several factors. I look at their comorbid health conditions. If it is someone that is relatively healthy that can easily come for radiation then I do recommend radiation because it does help prevent overcurrents. So some women have a hard time tolerating these estrogen blocking medications and so if they do the radiation and they try the medication if they do not tolerate it for the full five years at least they've maximized their reduction in recurrence. However, if I have a woman that has multiple comorbid conditions, or it's difficult for her to be transported to radiation back and forth, then that may be a better candidate for endocrine therapy alone. So in summary, radiation therapy or technology, it continues to evolve to decrease side effects and allow us to give a very precise form of radiation while sparing surrounding critical structures. Radiation decreases recurrence is safe and it helps decrease death from breast cancer, and a multidisciplinary approach is crucial to cancer care. And in addition to the surgeon, the medical oncologist, the radiologist and myself, there are nurse navigators that are involved, there are social workers involved nutritionists involved genetic counselors involved. So it truly pathologists it truly does take a whole team to properly treat that patient. Thank you for allowing me to speak today.