Multidisciplinary Breast Cancer Care at the Smilow Cancer Hospital Care Center in Guilford

October 14, 2022

October 13, 2022 | Hosted by Rachel Greenup, MD, MPH and Wajih Kidwai, MD, FACP

Presentations by:

• Sarah Schellhorn, MD - Medical Oncology
• Susan A. Higgins, MD - Radiation Oncology
• Gregory Zanieski, MD, FACS - Surgical Oncology
• Paris Butler, MD, MPH, FACS - Plastic Surgery
• Liane Philpotts, MD, FACR - Breast Imaging

Information

ID: 8166
To Cite: DCA Citation Guide

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00:00So in terms of imaging,
00:02obviously mammography and ultrasound tend
00:05to be our main modalities and that is
00:08what I what we do at the shoreline MRI.
00:11We, you know for good quality MRI
00:14it requires a special breast coil
00:17as well as the higher magnets.
00:19The 3T magnet is what we prefer
00:22to perform our MRI on.
00:24So that's why we only perform those
00:26down in New Haven or at Park Ave.
00:29So we're not currently doing MRI.
00:30At Shoreline,
00:31patients do need to go downtown for that.
00:35You know, I just want to talk a little
00:36bit about the 3D mammography because we,
00:38you know we we've been using this
00:40for more than a decade now and it
00:43has really improved our outcomes.
00:44Yale was one of the five original beta
00:47sites for the development of this technology.
00:49So we're quite proud of it and this
00:52led to the FDA approval in 2011.
00:54So we have a long history of it
00:58at Yale and after FDA approval.
01:01We were the first in Connecticut to
01:04obtain a a commercial unit and the
01:06actual 13th unit in the whole United States.
01:09So we've had it for a long time.
01:11We've always offered it to all patients
01:13at no cost and it's really permitted us
01:15to have a a really invaluable research
01:18database that we have been able to
01:21publish and do a lot of good studies with.
01:24So basically you know a lot
01:26of these studies have shown,
01:28I think you know very well
01:30that the 3D mammography is.
01:32Very.
01:34Advantageous over treating mammography.
01:36Multiple sites now throughout the world,
01:38in North America,
01:40Europe,
01:40Asia have repeatedly shown that
01:42it results in lower recall rates
01:45and increased cancer detection,
01:47particularly for invasive cancers.
01:49And for those of you who might not
01:52have seen how it how it works,
01:54you can see here's the 2D portion
01:57of the screening mammogram.
02:00And in the tomosynthesis,
02:02you can see the images moving here.
02:05We look at these in one millimeter
02:07slices through the breast and the
02:10cancers really can pop out beautifully
02:13that otherwise would have been hiding.
02:16So it's easy to understand how
02:18we can find more cancers,
02:20reduce the recalls for false positives,
02:25prove the outcomes for patients.
02:27All right.
02:29Here's just another example of a patient.
02:31This is,
02:32it's the screening mammogram and
02:35there's a questionable asymmetry
02:37in the breast and that's on the 2D
02:41portion when you look at the 3D.
02:43Not only does it tell us exactly
02:45where it is in the breast,
02:47it's actually down here on the 2D.
02:48We might have thought it was up there,
02:50but it's down there.
02:51So we're able to accurately
02:53localize lesions and we're able
02:55to characterize them better.
02:56You see on the 2D that could
02:58easily have been missed,
02:59whereas here we exquisitely see
03:01the detail of the speculations.
03:03So we're able to localize,
03:04characterize and then honestly patients
03:06go directly to ultrasound from from this,
03:09a lot of the diagnostic
03:12workup additional views.
03:14Are not necessary anymore.
03:15We can find things with ultrasound.
03:17So this is what we do.
03:18We do a lot of this at the shoreline,
03:21lot of ultrasound guided biopsies
03:23because the majority of lesions other
03:26than true calcification lesions
03:28can be biopsied with ultrasound.
03:30Just a note about tissue density
03:34with breast in mammography.
03:36The sensitivity of mammography is
03:38obviously related to tissue density.
03:40It's an important aspect of of
03:44of interpreting a mammogram.
03:46While while the sensitivity is
03:47very very high in fatty breast,
03:49it obviously is reduced even with
03:52the 3D mammography in denser tissue.
03:55So as you're probably well aware,
03:57we were the first state in the
03:59in the nation to.
04:00Uh, it's today density notification law.
04:03So this took effect in October of
04:062009 and women are informed of their
04:08brands breast density and since
04:09that time many women with breasts,
04:11with dense breasts have opted to
04:14undergo supplemental screening
04:15particularly with ultrasound just
04:17something that we developed it at Yale.
04:19So I just thought I would show you
04:20is a density an artificial intention
04:23in intelligence density tool.
04:25This is through our visage,
04:26our pack system and this is now
04:28FDA approved and this just.
04:31Obviously,
04:31breast density is a little bit
04:33of a subjective.
04:35It, you know, like classification,
04:37this makes it a little bit more objective.
04:40We get a density reading which
04:43is just an output on our on our
04:46workstations giving the breast
04:49density with the confidence.
04:51Percentage.
04:52So it's a nice tool that we've developed.
04:54I mentioned the mobile van before
04:55is one of our sites and just to
04:58to mention it again because this
04:59does visit the shoreline,
05:01you know four to five times a month,
05:02you may see it up in the parking lot
05:04taking up valuable parking spaces,
05:06but but nonetheless it is good
05:08for our patients.
05:08We do screening on the van with the
05:11course 3D mammography and breast ultrasound.
05:13So this fan which has been on the
05:15road for about 2 years now has both a
05:18mammography unit and an ultrasound separate.
05:21Sweets and while we've had a van for
05:2535 some years in in New Haven at Yale,
05:28this is the first time we've had
05:30mammography and ultrasound on the van.
05:32So certainly those women with
05:33dense tissue that really need the
05:36screening ultrasound as well can
05:37be well accommodated on the van.
05:39And here's a case that was done on the van.
05:41Patient with dense tissue had her
05:44mammography and her ultrasound and
05:46actually had multiple cancers in her breast.
05:49Interventional procedures.
05:49Like I said,
05:50we perform.
05:51About two to three per day at the
05:54shoreline and patients love it.
05:56I'll just say we just do ultrasound
05:58biopsies currently we do not do stereotactic.
06:00Again,
06:01that is just something that is
06:02an extra piece of equipment.
06:04So we're doing those downtown right now,
06:07but maybe in the future we will when
06:09we have a little bit more resources
06:11at the shoreline ultrasound biopsies
06:13though again the majority of patients
06:15can undergo ultrasound biopsies,
06:17which is preferable modality,
06:19we also can localize.
06:21Patients for surgery using
06:23mammographic or sonographic guidance.
06:25We have dedicated breast imaging nurses
06:27now and this is that they're invaluable
06:30and always one is always at the shoreline.
06:33So these these nurses help us
06:35with our procedures, patient care,
06:38communication, pathology,
06:39follow up and then data entry.
06:42So it's really they're, they're wonderful.
06:45Here's just an example.
06:47Again, Doctor Zaneski is going to talk more
06:49about the surgery side of things, you know.
06:51Diagnosed the patients,
06:52we image them, we work them up,
06:54we do the biopsies and then many of them
06:58are able to have surgery at the shoreline
07:00at which is just wonderful for them.
07:03We can do wire localizations
07:04as we've done for years.
07:06This is done on the day of surgery
07:09and something that we've been
07:11doing for the last few years is a
07:13radio frequency tag localization.
07:15The advantage of this is it could
07:17be inserted a few days or weeks
07:19before surgery and then the patient.
07:22Need to go directly to to surgery on that
07:25day and so that facilitates scheduling.
07:28Here's an example of a shoreline patient.
07:30Here is her screening mammogram.
07:32Obvious lesion in the breast.
07:34She goes directly to ultrasound,
07:36doesn't need any extra views.
07:37Mammographic views.
07:38Ultrasound shows a highly suspicious mask.
07:41We then do a core biopsy and leave a marker.
07:45She comes back for a localization on the
07:48day of surgery and her specimen shows
07:50the lesion and the tag all removed.
07:53Very convenient for patients and
07:55they love it. Just in the next.
07:58The very shortly hopefully few months we
08:01are going to be starting construction
08:03and we will have expansion of our
08:06breast imaging services at Yale,
08:08which at the shoreline which is much needed,
08:12we will have an additional 3D
08:14mammography and ultrasound units.
08:15So this is going to help with patient
08:19scheduling and also in terms of the,
08:22the, the physical layout,
08:23we're going to have a direct connection
08:25with the breast surgery suite.
08:27So that permits patients to go
08:28back and forth.
08:29Because I'm happy to go out in the hallway,
08:32so it's really a very comprehensive.
08:38Services and wonderful for patients,
08:40they love it and I think with this expansion
08:44we'll be able to to offer even more.
08:47More, get more patients in and offer more
08:49patients to be seen at the shoreline.
08:51Just a shout out to the wonderful
08:54technologists at the shoreline who
08:55take really good care of patients.
08:58So thank you very much.
08:59Hopefully that was helpful
09:01brief brief overview. Thank
09:04you so much Leanne and we have
09:06patients who specifically reach
09:08out to have you and doctor Butler?
09:10Do their mammograms and overwhelmingly
09:12their experience in the breast
09:14imaging suite and Guildford?
09:16Is is incredibly positive
09:18and patient centered so.
09:19Thank you for all you do.
09:21Next up, we're going to
09:23introduce doctor Greg Zaneski,
09:24I'm thrilled to call him.
09:25My partner and a member of our team,
09:28doctors and Esky joined Yale
09:30School of Medicine in 2019,
09:32he's an assistant professor.
09:34Surgical oncology and cares for women
09:36with benign and malignant breast disease
09:39and also men with breast related issues.
09:42His clinical practice location
09:43is predominantly at the Shoreline
09:45Medical Center in Guilford,
09:47but he also has a clinic weekly and some IT
09:50operating room time at the New Haven site.
09:54And he received his medical degree
09:56from the State University of New
09:58York at Stony Brook and completed
09:59a fellowship in surgical oncology
10:01at the University of Pittsburgh.
10:03And he's going to be giving us.
10:04And updates and breast cancer surgery.
10:08Thank you,
10:09Greg.
10:17Good. Thank you, Rachel. Look at
10:20the share my screen.
10:25OK.
10:29Thank you very much Rachel and and
10:31thank you everybody for attending
10:34on a on a rainy night.
10:36But my goal is tonight is to talk
10:38about breast surgery you know here
10:40at Guildford and also you know
10:42how we integrate it throughout
10:44the system here at smilow.
10:48So here's our our grant institution here
10:51at Shoreline and as Doctor Philpotts,
10:54you know, describe very well the
10:56amount of breast imaging that's done
10:58here and also the various findings.
11:00You know that we can come
11:02across not all malignant,
11:04sometimes benign or needing close follow
11:06up and surgery is an important component
11:10for helping integrate that at times and
11:13of course our multidisciplinary team
11:16which will be talked about further.
11:19So this is a picture of our surgical
11:22clinic and you know I think a lot of
11:24times with the with surgery we think
11:27about that it's a for malignancy.
11:29But I think a big part of our day
11:32including our nurse practitioners here at
11:34Guildford is things like benign disease.
11:37We can't see your slides.
11:42No, no. Sorry about that.
11:46Sorry, sorry about that.
11:48Can you try again?
11:50Yeah, let me. Escape, yeah.
11:59Yeah, share.
12:08Is that better?
12:13Can you see that?
12:20Do you want to send them to me
12:21and I can share them from my
12:23my computer? Sorry about that.
13:02OK. So I got them. Greg,
13:03why don't you go ahead and keep
13:05talking and I'll pull them up here.
13:08Sorry about that. I don't
13:09know why it's not sharing.
13:23Alright, I think maybe now
13:25we can. Now
13:26we can see it.
13:28Sorry about that everybody.
13:30Right. Yeah. So you know again
13:33this is the clinic and you know
13:34what we see with our our nurse
13:37practitioners or or things,
13:38you know benign disease,
13:40you know palpable masses that patients
13:43may feel or if various imaging findings,
13:47you know things that require a close
13:49interval follow up will work with
13:52radiology to follow those patients
13:54or the wealth of biopsies can often
13:56be benign and how do you interpret
13:59them as your primary care or OBGYN.
14:02Positions you know what is a
14:04papilloma need or what type of
14:07follow up a library card inside you.
14:09We're very happy to see those patients
14:12and you know talk about the different
14:16management surgical options or even
14:18screening strategies and of course
14:21breast malignancy of course which you
14:23know breast surgeons are are both kind
14:26of associated with clinical trials.
14:28We enroll patients in our various
14:31surgical clinical trials and even.
14:33Follow those patients up and
14:35coordinate the necessary imaging
14:37regarding the clinical trial protocol.
14:40And you know with the the cooperation
14:43of radiology,
14:44we're able to offer surveillance,
14:46clinical exams for instance you know women
14:48who have undergone breast cancer surgery,
14:51radiation therapy,
14:52oncology therapy and then it's
14:54time for annual follow-up how much
14:58imaging is needed and we're happy
14:59to see our patients for clinical
15:02exam and coordinate the follow
15:04up mammogram on the same day.
15:06A good portion of my clinic today
15:07was seeing some of our patients who
15:09are one year follow up with same day.
15:11Imaging and patients seem to be very
15:13happy to bundle those visits and
15:16make one trip to see the search and
15:19then the the radiologists on one
15:21day take less time off from work,
15:24family and all the other busy
15:26things and also.
15:30OK. Yeah. Yeah, we can't.
15:32We are stuck on the title slide.
15:36OK. Real connectivity that.
15:43Are they advancing now?
15:49You see surgical clinic slide?
15:52No, no, I'll try and pull them
15:55up here, Greg. Thank you.
16:00I'll stop sharing.
16:12Apologies to the audience. Thank you
16:14for your patience.
16:17Yeah.
16:19And it's not stopping the sharing either.
16:31Well, in the interest of time, why don't
16:33we move forward with medical oncology
16:36and then we'll come back or Doctor
16:38Butler from plastic surgery and we
16:40can come back to your slides when we
16:43get the technical issues worked out.
16:45Doctor Butler, Are you ready and loaded?
16:51So I'm going to share my screen too.
16:53Don't have the same challenge, but I'm ready.
16:55I'm gonna introduce Doctor Butler.
16:57He's an associate professor of surgery
16:59in plastics and reconstructive surgery,
17:02and he's the inaugural Yale Department
17:03of Surgery vice Chair of Diversity,
17:05Equity and Inclusion.
17:07He's board certified both by the
17:09American Board of Surgery and the
17:11American Board of Plastic Surgery and
17:12a Fellow of the American College of
17:15Surgeons and his clinical interests
17:16are in breast reconstruction and body
17:19contouring after bariatric surgery.
17:21Reductions left scars and aesthetic surgery,
17:25and we're thrilled to have him
17:26on our Yale team.
17:27So take it away, Paris,
17:29thank you very much for
17:30the kind introduction.
17:31I'm going to share my screen.
17:32Maybe, Rachel.
17:32Just give me a thumbs up if you can
17:35see my screen when the time comes.
17:41Excellent. Looks great, wonderful.
17:47So thanks for allowing me
17:48to join you this evening.
17:49I have most recently been recruited
17:52to Yale plastic surgery from
17:54the University of Pennsylvania.
17:55I've been on faculty here for
17:56a little over five months,
17:58kind of hard to believe and really
17:59fortunate to join an outstanding group
18:01of plastic surgeons within our division.
18:03We are growing our division
18:05rather significantly.
18:06We have six plastic surgeons
18:08amongst our faculty.
18:09We have a faculty of 12 now,
18:12which is rapidly grown in
18:13the last four or five years.
18:14Our chief is Bo Pomahac,
18:16so all six of these.
18:17Individuals perform plastic and
18:19reconstructive surgery on breast in one way,
18:21shape or form.
18:23The majority of us do reconstructive
18:25surgery as well on breast and I
18:28would say that is all about 50%
18:31of my practice in particular.
18:33So we have Obama hawk who is
18:34our division chief.
18:35We have doctor Hari, Ayala myself here,
18:38Doctor Melissa Mastriani,
18:40Dr Peck and Doctor Vasquez,
18:42myself, doctor Pomahac,
18:44Dr Ayala and Doctor Peck will be at.
18:47Shoreline facilities more times than not.
18:50So we are delighted to care for this,
18:52for this Community and this patient
18:54population over the next I would say.
18:5810 minutes,
18:58I'll try to keep it brief.
19:00It's really difficult to give an
19:01overview of plastic and reconstructive
19:03surgery in in eight to 10 minutes,
19:05but I'm going to do my best
19:06to to kind of keep it there.
19:08So as it pertains to the the
19:10goal of a breast reconstruction,
19:12as many of you all know it's to to
19:15restore breast appearance and clothes.
19:17We say as we're setting expectations
19:19with our patients and we don't try
19:22to oversell what our capacity is,
19:24but we also try to provide a
19:26a nice light at the end of the
19:27tunnel as it pertains to.
19:28The, the,
19:29the duration of the completion
19:31of their their oncologic care.
19:33So in my opinion,
19:35I think we can do honestly,
19:37I think we can do better than just
19:39getting them to appear normal in clothes.
19:41I think we can get them to to restore
19:42their breast appearance in a bathing suit.
19:45However,
19:45we do let them know once that bathing
19:47suit is removed and underwear is
19:49removed that they will see their their
19:51scars and such how often is it performed.
19:54So if you look at the the national
19:57data about 65% of the time.
19:59In the US,
19:59formal breast reconstruction is
20:02performed in post mastectomy patients.
20:04So that equates to about 138,000
20:07breast reconstruction procedures
20:09that are performed annually.
20:11This is data from 2020 and the
20:13numbers continue to just go up,
20:16which I obviously is a plastic surgeon.
20:18I'm biased. I think it's a really good thing.
20:21Unfortunately though,
20:21this varies according to age, race,
20:24ethnicity and insurance status.
20:26While I was at the University
20:27of Pennsylvania,
20:28we actually looked at who was
20:30getting breast reconstruction
20:31to determine what the rates were
20:32and also to determine if there
20:34are any patient populations that
20:35were not getting breast
20:36reconstruction at the same rate as others.
20:38And what we identified when we looked
20:41at national data over A6 year period,
20:4348,000 patients, we identify that
20:45there are two subsets of the Community
20:47that don't get breast reconstruction
20:48at the same rate as others.
20:50Those are more. Seasoned ladies,
20:51no one likes to be called old.
20:53So our ladies over 45 and then unfortunately
20:56our ladies of color and namely our
20:59African American and our Latino women.
21:01And then when we look at insurance status,
21:04probably not a surprise that uninsured
21:06women would not receive breast
21:08reconstruction at the same rate as others.
21:09But we've also identified
21:11the fact that unfortunately,
21:12women who have public insurance don't
21:15receive breast reconstruction at the rate
21:17as those that have private insurance.
21:19This is a soft spot for me because
21:21I do a lot of disparity research
21:24and scholastic effort,
21:25but I I do think that this is
21:27something that has been understated
21:28and something that needs to be
21:30addressed kind of nationwide.
21:31I'm going to do my best here at
21:34Yale University to help push that
21:36envelope and push that needle forward.
21:38So what is the best timing for
21:40reconstruction? Pretty much anytime.
21:41Immediate or delayed,
21:43or typically both an option.
21:44There's been good,
21:45really good literature out there
21:47describing the fact that when a woman
21:48wakes up from a mastectomy and has
21:50the semblance of a breast mount it,
21:51it can be helpful emotionally,
21:54socially, psychologically.
21:55And even functionally.
21:57So I would say it's probably strong
22:00language language to say that it is gold
22:03standard to have it done immediately,
22:05but it is more common occurrence
22:07for us to now do it in an immediate
22:09setting rather than a delayed setting.
22:11That being said,
22:12we can offer and do offer breast
22:14reconstruction in a delayed setting,
22:16so anytime after that initial mastectomy.
22:19Who's the candidate?
22:21Free construction,
22:21I would say the vast majority of patients.
22:24So any woman who has had or
22:25is going to have a mastectomy,
22:27there's really no specific age limit.
22:29Women over 60 are welcome to
22:31inquire and I recommend to my
22:33breast surgeons that any woman,
22:34regardless or agnostic of of age,
22:36race,
22:37ethnicity,
22:37have an appointment or consultation with one
22:39of those plastic and reconstructive surgeons.
22:42Breast reconstruction is
22:43covered by insurance.
22:44I get this question all the time when
22:46I'm out in the community talking about
22:48breast reconstruction and doing my best
22:50to enhance breast health literacy.
22:51Our country did a wonderful thing.
22:53In the late 90s,
22:54our legislators in DC passed the Women's
22:56Health and Cancer Rights Act of 98,
22:58which mandated that insurance companies,
23:01if a woman has medical insurance
23:03that's covering her, her surgical care,
23:06lumpectomy, mastectomy,
23:07radiation medical or medical
23:10oncology chemotherapy,
23:12they are also mandated to
23:13cover breast reconstruction.
23:15For the duration of their life,
23:16and that also includes a
23:18balancing operation on say,
23:19the contralateral side.
23:21Patient suffers from a left sided cancer,
23:23has a left sided mastectomy.
23:25We do reconstruction on the left side.
23:26Their insurance company is mandated
23:28for me to also perform a balance
23:31and procedure on that opposite side.
23:33So as breast reconstruction safe,
23:35this has come under a bit of attack of late,
23:38particularly as it pertains to
23:39implant based reconstruction.
23:41So before I get to that,
23:43I just want to comment that brush
23:44reconstruction does not make the
23:45breast cancer recur at any higher rate.
23:47We've looked at this over and over and
23:49over again and there's no heightened
23:50rates of recurrence in patients who've
23:52had reconstruction versus those that
23:54opted to not have reconstruction or were
23:56not healthy enough for reconstruction.
23:58Higher complication rates are noted
24:00in smokers, obesity and diabetics.
24:02Sometimes we can optimize patients
24:03prior to surgery,
24:05other times we cannot.
24:06We just have to let them know once
24:08again what the expectations are and
24:10it sometimes does limit the options
24:11we have for the reconstruction.
24:13Silicone implants have been proven to
24:15be safe and reconstruction patients,
24:17even if they rupture,
24:18they don't cause additional harm.
24:21So about six years ago,
24:22there was a lot of conversation about
24:25this association of anaplastic large
24:27cell lymphoma with textured implants.
24:30The FDA has identified a risk of
24:34about one in 30,000 women who had
24:36textured implants or risk of suffering
24:39anaplastic large cell lymphoma.
24:41The the rates when you look more broadly,
24:44it's like being less than being
24:46struck by struck by lightning.
24:49That being said,
24:50I do.
24:51Address this with my patients at time
24:53of consultation and we we actually now
24:55give them paperwork and have them sign
24:57an affidavit with an understanding
24:59that this association has been made.
25:01Most recently there's been
25:03conversation about an association
25:05with a rare type of of a skin cancer,
25:08squamous cell skin cancer associated
25:10with the capsule that can develop
25:12around the implant.
25:13There have been 15 reported cases worldwide.
25:16This has been in the news in the last
25:18four to six weeks and the FDA made it.
25:21A statement.
25:22This is a statement from Bonita Ashar,
25:24the director of the Office of Surgical
25:26Infection Control Devices for the FDA,
25:28that right now we do not have
25:30enough information to say whether
25:31breast implants cause these cancers
25:32or if any types of implants pose
25:34higher risks than others.
25:35So the reason for the louder part
25:37of that statement is because the
25:39anaplastic large cell lymphoma
25:40has been associated with textured
25:42implants and not smooth implants.
25:44Thankfully,
25:44I really did not put in many
25:47textured implants,
25:48have only put in smooth implants,
25:49but this this skin cancer.
25:52Association has been identified
25:53both in smooth implants as well as
25:56textured implants and once again
25:58we need to do additional studies
26:00and additional surveillance.
26:02So what are the methods of reconstruction?
26:04Once again,
26:05it would take 2 hours to go over our
26:07our methods of breast reconstruction,
26:09but I kind of separate them.
26:10And then three buckets.
26:12First and foremost,
26:14I'd like to consider what we do as,
26:16as breast reconstructive surgeons,
26:18as, as this continuum of care.
26:20So we offer aesthetic flat closures because
26:23not everyone wants breast reconstruction.
26:26Not everyone is healthy enough
26:27for breast reconstruction.
26:28So we offer these services to our
26:31surgical oncology colleagues.
26:32Breast oncology colleagues,
26:33as it pertains to mastectomy closures,
26:36then there's implant based reconstruction
26:38and then autologous reconstruction.
26:40So aesthetic cloud closures
26:41are also becoming more common.
26:44This is an article from the Annals
26:46of Surgical Oncology in 2020 which
26:48documented the fact that there was
26:50some women that were pretty upset
26:52with the fact that 22 / 22% of the
26:55women that were surveyed did not
26:56have this offer to them as an option.
26:59Additionally,
26:59they went on to identify the fact that
27:0274% of the women that did have a flag.
27:04Sure.
27:04We're very satisfied with their outcome.
27:06So this you know plastic surgeons we like
27:08show and tell this is a a patient that I.
27:11Rather recently operated on who
27:12decided that she did not want
27:14formal breast reconstruction,
27:15she wanted to be closed flat.
27:17Our our incision patterns are
27:19changed over time.
27:20There was more of a oblique
27:22incision initially and then we went
27:24to more of a horizontal.
27:26And now I kind of prefer this incision
27:29that's that mimics the inframammary fold
27:32and we've gotten good results with it.
27:34Women are able to be fitted with
27:36external prosthesis if they want.
27:37It also avoids any of the
27:39extra skin and intertrigo.
27:41That can happen after mastectomy,
27:43particularly in large breasted women.
27:45So when it comes to our methods of
27:48of formal breast reconstruction,
27:49reconstructing a breast mound 75%
27:52of the time in this country it's
27:54performed via the use of a of a of
27:57an implant typically in two stage
27:59fashion with a tissue expander placed
28:01slowly inflated over multiple weeks to
28:03months and then a permanent implant placed.
28:06And then 25% of the time we're
28:09using an autologous technique,
28:11so using tissue from another
28:12part of the body to recreate,
28:14reconstruct and recreated.
28:15West Mound,
28:16I would say at Yale this number
28:18is is not necessarily reflective.
28:20I would say that we do probably
28:22more 40 to 50% autologous and
28:24about 50 to 60% implant based.
28:27This is very,
28:29we're fortunate that the vast
28:30majority of us here have a background
28:32in microsurgical reconstruction
28:33which allows us to carry out this
28:36additional technique and provide this
28:38additional option for these patients.
28:41So the realities of implant based
28:43reconstruction for the most part it's for
28:45small to moderate breast sizes kind of aided,
28:48we're limited in the size of implants.
28:51There is a large implant
28:53trial that is ongoing.
28:55So we may have some additional options
28:57for our larger breasted women or women
28:59that desire to to reach a larger size.
29:01It's a shorter operative
29:02procedure about 2 hours,
29:04shorter hospitalization one to two days
29:06and once again as I said typically
29:09requires 2 procedures that expand or.
29:11Followed by a permanent implant.
29:13Implant replacement is recommended
29:14by all three of the big
29:16implant manufacturers to happen
29:17at the 10 to 15 year Mark.
29:19And then it's not ideal for
29:21patients that need radiation therapy
29:23which which once again could be
29:25another hour long conversation.
29:27And then for the most part
29:29for unilateral operation,
29:30the patient must have an understanding
29:33that they should consider a balancing
29:35procedure on the other side.
29:38Realities of flat based reconstruction.
29:41Once again we love, show and tell.
29:42This is the woman that I did,
29:44as in a delayed fashion,
29:46we usually kind of steer women in
29:49this direction if they are are have a
29:51larger BMI or a larger body habitus.
29:54The operative procedure is longer,
29:56it's longer and it's more difficult on
29:57the on the patient, at least up front.
30:00It also requires a longer hospitalization,
30:02usually three to four days.
30:03There is a risk of hernia or bulge.
30:05I don't oversell this,
30:07I inform patient.
30:08It's about the five to 10% risk
30:09of a hernia and then flat death
30:12is about 2% where that and at
30:15microsurgical anastomosis doesn't
30:16work that's about 2% nationwide.
30:18It's not for smokers,
30:20not for super obese,
30:21not for those that have severe
30:22comorbidities and then they also must
30:24know that this is typically not just a
30:27one and done either more times than option.
30:29If you look at the at the literature
30:31I touch up operation either one
30:33or two maybe sometimes three is
30:35required in order to get them to to.
30:38Do a result that they're pleased with
30:40and and we are also satisfied with.
30:42So what about lumpectomy patients,
30:44I've been really pushing and
30:45doctor Greeno can attest to this.
30:47I think there's an operation out
30:49there called Uncle Plastic breast
30:51reduction surgery where a patient
30:52who has a small cancer and a larger
30:55breast that are very toxic breast
30:57and get the benefits of a breast
30:58reduction or a breast lift at the
31:00time of their cancer resection.
31:01This is the silver lining for
31:03many of our ladies.
31:04I do a lot of breast reduction
31:06surgery and being able to.
31:09To combine oncologic reconstructive
31:12principles along with breast
31:14reduction principles has caused this
31:15operation to be one of my favorites.
31:17I really think it's the both
31:19the best of both worlds.
31:20Patients obviously will still necessitate
31:23radiation therapy more times than
31:24not because this is a component of
31:27their breast conservation therapy.
31:29So this is a patient who had large breast,
31:31she had always wanted a breast reduction.
31:32She had a small cancer on the right side.
31:34We were able to do an uncle
31:37plastic reconstruction.
31:37This is actually after her.
31:39Radiation as well and
31:40she's healed beautifully.
31:41She's got just a still a little
31:42bit of skin darkening but was
31:44ecstatic with her result.
31:45Here's another young lady.
31:46She had a cancer on the left side.
31:48Lots of tosis.
31:49Had always wanted a breast lift,
31:50thought she would be vain by setting it,
31:52setting herself for a breast lift.
31:55So we did a breast lift and and lumpectomy at
31:57the same time.
31:58And she was also quite pleased.
32:01The breasts just keep getting larger.
32:02And my slideshow here's a woman who
32:05was actually turned down for breast
32:07reductions previously developed.
32:09Cancer and we were able
32:11to give her this result.
32:12And then finally a much more seasoned lady,
32:15I had a breast surgeon that that sent
32:18this patient to me said I don't think
32:20there's anything we really can do.
32:21And the radiation oncologist,
32:23we're concerned about radiating
32:25such a large entatic breast causing
32:28lymphedema in the breast and we were
32:31able to to give her this result.
32:33So in short and in summary,
32:36there are many options and I believe
32:37that all patients should be offered a
32:39consultation with a plastic surgeon.
32:40To just discuss those reconstructive options,
32:43I'm a big proponent of shared
32:45decision making.
32:46I don't push patients in any direction.
32:49I kind of provide them the menu and
32:50then we have a good conversation about
32:52what's going to be best for them.
32:53And then as I mentioned before,
32:55the method and timing of the
32:57procedure is one that should fulfill
32:59the patients needs and lifestyle.
33:01So with that I will stop sharing.
33:04Thank you all very much.
33:06Yeah. Thank you so much, Doctor Butler,
33:08and we're so lucky to have you at Yale.
33:10Paris has a national reputation in
33:14oncoplastic reconstruction and many of
33:17our patients have thought about breast
33:18reduction or lift their whole life.
33:20And the ability to have it covered by
33:24insurance or the inability to pay cash
33:28has prohibited them from moving forward.
33:30So when they come to us with a cancer,
33:32it's an opportunity to both improve.
33:36Eristics and also make it easier
33:38for their downstream treatment
33:40with lower risk of lymphedema.
33:42As you mentioned,
33:43we're going to ship back to Doctor Zaneski.
33:46I think we've resolved our technical issues.
33:48So Eliza is going to load up his
33:51slides and we look forward to
33:53hearing about breast cancer surgery.
34:03OK. Alright, great. Thank you.
34:08Yes. And you'll be advancing them.
34:09Uh, thank you so much.
34:11You have advanced to the next slide.
34:15Great. And again, one more.
34:20Perfect. Yeah.
34:20We got stuff at the surgical clinic.
34:22Yep. Next slide. Yeah.
34:26So, so this is, you know,
34:27an operating room here at Shoreline.
34:31Detailed view,
34:31you can see the operating room table and
34:34anesthesia station in the very far back.
34:37In the back right is our intraoperative
34:39facts atron where we take specimen
34:41radiographs and of course of
34:43course the instrument table and
34:45the operations that we do here you
34:48know surgical excision, biopsy,
34:50you know things like atypia,
34:52some women choose to have
34:54fibroadenomas removed.
34:55These are benign tumors and so all
34:57can be done here with with the
34:59localization as doctor Philpotts.
35:01Mentioned or without.
35:03Breast conservation to classical lumpectomy,
35:06the big departure from radical
35:08mastectomy decades ago that we're
35:11performing hopefully over 70% of the
35:13time for early stage breast cancer.
35:16Radiological localization,
35:17Doctor Phil Potsin over that with wire
35:21localization and tag localization.
35:22I'll show some images as well.
35:25Localization can be same day,
35:28you know bundled with you want Academy
35:30or we have the option to localize
35:32the small tumors and radiology.
35:34Sleep on a separate day and then
35:36do the going back to me as a first
35:39case early in the in the morning.
35:41Axillary surgery,
35:42things like Sentinel lymph node
35:45biopsy routinely performed here
35:47actually lymph node dissection
35:49or a lymph node excision biopsy
35:51to help our hematologists and
35:54oncologists with lymphoma diagnosis
35:56were often involved in that.
35:59And as we go forward,
36:01we'll be introducing mastectomy.
36:03Under the directorship of
36:06Doctor Greenup at Shoreline,
36:09Same Day mastectomies,
36:11possibly in the near future,
36:14mastectomies with immediate breast
36:16reconstruction, implant based,
36:18possibly same day discharge.
36:21It was working on that in New Haven.
36:23That's a new addition to
36:25the Department of Surgery.
36:27And maybe even overnight stay
36:29at Shoreline one day.
36:30So all these things are are being
36:33thought about and discussed to
36:35again bring more complex breast and
36:38reconstruction surgery out to the
36:39community and closer to the patient's
36:41home that the next slide please.
36:48Yeah. This is again some of the localization.
36:50I can see the two wires there.
36:52That's a bracketed lumpectomy.
36:54And then the other image is what we
36:57call our tag localization, which can
36:59be placed prior to the day of surgery.
37:02And again, these are utilized to
37:05find small tumors within the breast
37:08that are not palpable. Next slide.
37:12There's a picture of a
37:14Sentinel lymph node biopsy.
37:15I can see the tiny blue dye.
37:18We can do intraoperative injection
37:21of the radioisotope or the blue dye.
37:24These are two markers that are injected
37:27into the breast to help identify
37:29the Sentinel lymph node biopsy.
37:31And that's part of a routine staging process.
37:35And as we are moving forward,
37:38there's a new initiative called
37:40the Choosing wisely initiative.
37:41Businesses from the Society of Surgical
37:43Oncology and the American Board of
37:46Internal Medicine where maybe we
37:47can deescalate and not have to do or
37:50routinely do a Sentinel lymph node
37:52biopsy for our women who are 70 and above.
37:55Early stage breast cancer with
37:58favorable biologic markers,
37:59meaning estrogen receptor positive,
38:01her two negative patients are
38:04taking to this very strongly when we
38:07discuss this because what it's able
38:09to do is reduce the amount of side
38:11effects when the even though it's
38:13low risk with Sentinel and biopsy,
38:16we're able to lower that even
38:17further by not removing lymph nodes
38:19and also a range of motion issues.
38:21So that's been a new,
38:24a new approach in surgical.
38:25College over the last four to five years.
38:29And the next slide please.
38:32And the specimen radiograph again, you know,
38:34focusing on the instrument.
38:35Uh, the machine in the back,
38:37right when we do the lower
38:39back we were able to do.
38:41Immediate specimen radiograph,
38:43this is very good for confirming your
38:46removal of the tumor of the biopsy clip,
38:48but it also helps with with
38:50helps us with margin status.
38:52You know one of the big things with
38:55successful oncologic surgery is negative
38:57margins for invasive cancers 2 Senate,
38:592 millimeters or greater for ductal
39:02carcinoma in situ only lobectomies
39:04and we're able to gain more a lot of
39:07information with the intraoperative
39:09specimen radiograph to look at the margins.
39:12To see as a surgeon,
39:13you know are things looking very good
39:15on that on that radio graph and to
39:18take shave margins at that time of
39:20surgery and thereby reduce the risk of
39:22second operations for margin resection.
39:24You know our goal is to keep that
39:28and never we can never achieve 0,
39:30but we want to find a very nice
39:32range where it's not too high,
39:34not too well,
39:34so we can have good cosmetic outcome,
39:36good oncologic outcomes and that
39:38machine is very important.
39:40Next slide please.
39:46Go back one here,
39:48yeah, back one more. There we are. Yeah.
39:52So again, this is a special radiograph.
39:54The larger one is A tag,
39:57a lumpectomy and to the the
39:59middle slide is a lymph node.
40:02You know the tiny lymph node with the
40:04biopsy clip in it here at at Yale over
40:072 routinely put a biopsy clip after a
40:10lymph node has been radiologically biopsied.
40:13And we can confirm retrieval of
40:15that in the operating room to
40:17help with our accuracy and false
40:19negative rates with Sentinel.
40:21You know biopsy.
40:22Next slide please.
40:26And with regard to clinical trials
40:28at the shoreline and in our clinics,
40:31we're able to offer you know,
40:34two trials, surgical trials.
40:36This the alliance A 011202 was open here
40:39and is now reached the coral and we'll be
40:43awaiting those results in about 5 years.
40:46And we've had patients who've enrolled
40:48and able to do their files with
40:50us at Shoreline and we're actively
40:53recruiting within the comet trial.
40:55You know, we're asking ourselves.
40:57Finally, believe it or not is
41:00aggressive treatment as you know,
41:02are invasive cancer type treatments
41:05necessary for precancerous disease,
41:07ductal carcinoma inside you and this
41:09is a randomized trial looking at,
41:12believe it or not,
41:14possibly omitting surgery,
41:15randomizing women with favorable DCIS,
41:19meaning a low risk to surgery or no
41:22surgery with the options of some
41:25of the other adjuvant therapies.
41:27Um, so we've recruited patients at
41:29Shoreline already in our actively
41:31recruiting in this,
41:33this trial to answer some of these
41:35pending questions of how aggressively do
41:37we need to treat ductal carcinoma in situ.
41:41Next slide please.
41:45And comprehensive care, you know,
41:47a lot of our discussions when
41:49patients come in with newly diagnosed
41:52breast cancer or even high risk
41:54things like genetic counseling,
41:57risk stratifying by the various risk models,
42:00the Gale model, the Tyra Cusick model,
42:03we routinely do that in our
42:05clinics with appropriate referrals
42:06due to our genetic counselors.
42:08They're not on site at Shoreline,
42:10but certainly by zoom can do referrals.
42:13Uh, social work we have on site social
42:16workers who help us uh routinely and
42:19we're very grateful to their help our
42:22outpatient oncology rehabilitation services,
42:25OK, not on site,
42:26but again a quick phone call to
42:29the director Scott Kaposa who is
42:31always willing to see our patients
42:34promptly and streamline them for
42:36various post surgical issues or
42:38even non post surgical issues,
42:40things like lymphedema.
42:42Um or postmastectomy, pain,
42:45all of those different things.
42:47Uh, nutrition consultation,
42:48again um within the system,
42:51we're able to access that at Smilo
42:53as well as smoking cessation.
42:56Patients have been very receptive
42:58to these consultations and part
43:00of our comprehensive care model.
43:03Next slide please.
43:07That concludes my my discussion.
43:09Like to thank everybody for their time.
43:12The Breast Center number is
43:13there and there's my e-mail.
43:15You know, certainly I encourage anybody
43:18to e-mail me directly and certainly
43:20will provide my cell phone number
43:23because a lot of the most difficult
43:26discussions I think in the primary
43:28care may very well be what do you do
43:30with some of the radiologic findings?
43:32We're happy to help integrate
43:34and answer those.
43:35Those questions, uh what types of follow-up
43:38screening strategies for high risk.
43:40Um, you know all of those different things.
43:42So always happy to help problem solve
43:46and would really encourage anyone
43:48to primary care OBGYN setting to
43:51certainly send an e-mail how can
43:53we help you remember sure surgery
43:55at shoreline for breast cancer,
43:58you know from Yale started in 2020 that
44:01was our first breast surgery there.
44:04Breast conservation so alive.
44:06Of changing quickly um.
44:08And we would like to certainly get
44:10your feedback on how we can help you
44:12navigate your patients view benign disease,
44:14high risk as well as malignancy.
44:16And there's a a shout out to Doctor
44:19Horowitz who started the clinic
44:21here several years ago with Doctor
44:24Kiley and it's a torture carrying
44:26and we've since her retirement
44:28we've added breast surgery and even
44:31expanding to reconstruction under
44:33the directorship of of Doctor.
44:36Or Salvador.
44:36Great things there.
44:37And that's Elizabeth,
44:39our nurse practitioner, uh Renee,
44:40one of our assistants, and Sherry,
44:43one of our our nurses and coordinators.
44:45Again,
44:46feel free to always send an e-mail
44:48and happy to help in any way
44:49we can. Thank you.
44:51Thank you so much, Greg.
44:53And I think the community had big
44:56concerns that we would not be able to
44:58fill doctor Horowitz's tremendous role in
45:01caring for our breast cancer patients.
45:04Those are big shoes to fill,
45:05but we're doing our best to keep up.
45:07So we all prioritize access and a
45:10high quality patient centered care
45:12and we're here to help anytime.
45:15So I'm going to turn it over to Doctor Zahir.
45:22It's a pleasure to introduce the
45:25next speaker known her for some time.
45:28Sarah Sarah Mcgillion is an
45:30associate professor of medicine,
45:32medical Oncology and chief chief ambulatory
45:35officer for Smilow Cancer Hospital.
45:37She cares for patients with breast
45:39cancer in New Haven and more recently we
45:42are so happy to have her in Guilford.
45:44She's also involved in education of students,
45:46residents and fellows here
45:48at Yale outside the clinic.
45:50She's involved with cancer outcomes,
45:53public policy and effective veness research,
45:56which is called Copper Center
45:58at Yale Cancer Center,
45:59with a specific interest in
46:01chemotherapy regimens used in the
46:03treatment of breast cancer and how
46:05they are used in clinical practice.
46:08So welcome, Sarah.
46:09Thank you for joining us today.
46:11Thanks, waji.
46:12So welcome everybody like Doctor Butler.
46:15I think that this is clearly a topic
46:18that fits very nicely into 10 minutes.
46:21Describe my job in 10 minutes,
46:23no problem. As what you said,
46:25I do see patients at the Guildford
46:28location one day a week.
46:30I'm also in New Haven one day a week.
46:32But what we're really what what
46:33I really want to get across is
46:35anything we can do in New Haven,
46:37we can also do in Guildford and.
46:38I I love working in Guildford.
46:41I love the parking situation.
46:44Air rights is my worst nightmare.
46:46But I love the the group that we have out
46:50here and I love my colleagues in Guildford.
46:54So with the few small exceptions
46:56of a couple of clinical trials
46:58that really have very high level
47:00needs and and rapid turnaround,
47:03we can do just about anything in
47:05Guildford that we can do in New Haven.
47:07What I really want to get across.
47:10If you have a patient who's been
47:12diagnosed with breast cancer,
47:13she's in for, she's in for a ride,
47:16most could be he,
47:17but she is also in for a ride.
47:19So if a patient has breast cancer,
47:20there's a multidisciplinary team
47:22consisting of a medical oncologist,
47:24a radiation oncologist,
47:25a surgeon and those three different
47:29disciplines work closely with
47:31our diagnostic imagers as doctor
47:33Philpotts has described to get
47:35appropriate imaging right off the bat.
47:37We also have social work, physical therapy.
47:40Nutrition, genetics,
47:42fertility and reproductive endocrinology,
47:44all prior to the patient who might
47:47then have to undergo chemotherapy
47:49prior to surgery.
47:50Each of those little dots is a treatment.
47:53Then the patient might have surgery with
47:56a breast surgeon and a reconstructive
47:58surgeon as as doctor Zaneski and
48:00Doctor Butler have described.
48:01They might continue on getting more
48:03chemotherapy or more anti cancer therapy
48:06prior to then getting radiation,
48:08which could be up to 30 or even more.
48:11Treatments, all of that.
48:13With nutrition,
48:14physical therapy all along the
48:18way and then once the definitive
48:20treatment is finished,
48:21there's continued follow-up visits,
48:23mammograms, bone density studies,
48:24infusions,
48:25physical therapy and the list goes on and on.
48:28So this is not one stop shopping,
48:30this really requires a closely knit
48:33group of of clinicians who are working
48:36together to to provide the best care.
48:38So just a little bit more about
48:41multidisciplinary care in the actual.
48:44Treatment of breast cancer itself.
48:46The goal of breast surgery is
48:48to remove the known cancer,
48:49obtain negative margins,
48:51evaluate the lymph nodes,
48:52removed the involved lymph nodes.
48:54Surgery alone can be curative
48:56radiation on top of that,
48:58and I don't want to steal
49:00Doctor Higgins's Thunder.
49:01However,
49:01the goal of radiation,
49:03as I like to describe it in clinic,
49:04is to mop up any microscopic disease in
49:06the breast and the regional lymph nodes,
49:08and this is generally administered
49:10after lumpectomy and can be recommended
49:12even after a mastectomy and this.
49:14The goal of radiation is to reduce local
49:16recurrence. So then you might say,
49:19well surgery, radiation,
49:20breast is all clean.
49:22Why do you need a medical oncologist?
49:23Well, we have a different goal
49:26in medical oncology and our goal
49:28is to mop up the microscopically
49:31undetectable disease systemically.
49:33And our goal is to reduce the risk
49:35of distant recurrence to reduce
49:36the the likelihood that a patient
49:38dies of metastatic breast cancer.
49:42Umm. Nope. I'm going to do
49:46a little more animation.
49:47This is what happens when you oops,
49:50when you copy forward animated things.
49:53So how do we decide who
49:55gets what medical treatment?
49:56It's a really complicated story.
49:58It takes into account patient
50:00characteristics, their age,
50:01their medical comorbidities,
50:03their own personal preferences.
50:04It takes into account tumor stage,
50:07which is tumor size, nodal status,
50:08and the presence or absence of metastatic
50:11disease and tumor characteristics such
50:12as grade hormone, receptor status.
50:14Her two status.
50:16And I know that these may
50:17not be quite familiar.
50:18Concepts,
50:18but they the goal of this slide is
50:21to just demonstrate that it's not
50:24one-size-fits-all for all patients.
50:27And based on that combination we
50:29then choose a systemic therapy.
50:31I want to review really quickly staging
50:33you know it's it's funny everybody
50:34comes into clinic and they that
50:36this is their number one question,
50:38what's my stage because apparently
50:40that's the most common question
50:42that they are asked upon revealing
50:44a breast cancer diagnosis stage
50:46is more than just the tumor,
50:48the nodal status and the presence
50:51or absence of metastases.
50:52More recently we started in
50:54incorporating some of these other.
50:57Features of of a breast cancer such
50:59as the grade, the estrogen receptor,
51:01the progesterone receptor and her two
51:04to come up with a more prognostic
51:06stage that's really more aligned with
51:09the patient's overall prognosis.
51:11So you might say, OK,
51:12well what does all that mean?
51:13Well grade is a measure of how
51:15aggressive the cancer appears
51:16under the microscope as described
51:18by our pathology colleagues.
51:20And in general, the higher the grade,
51:21the more aggressive the cancer and
51:23the more aggressive we have to be
51:25to prevent a systemic recurrence.
51:27Then we get on to the estrogen
51:29and progesterone receptors.
51:30These are nuclear based hormone receptors.
51:33They and the kind of quick and
51:35dirty way of thinking about these
51:37is if the cancer expressed expresses
51:39estrogen or progesterone receptors,
51:42it's fueled by hormones and so hormone
51:45deprivation or interference with
51:47that receptor and ligand interaction
51:49can be a therapeutic option and we
51:52have medications that do just that.
51:54Her two is a member of the EGFR
51:56family of cell surface receptors,
51:59and it can be overexpressed in some
52:01of the most aggressive breast cancers.
52:06Her two positive or her her
52:08two overexpressing cancers are
52:09often poorly differentiated and
52:10require chemotherapy and really,
52:12really aggressive and intense therapy.
52:16We also have gene expression
52:18profiles at our disposal that
52:21can help determine whether or
52:23not a patient needs chemotherapy.
52:26One such example is the Oncotype DX,
52:28which is a 21 cancer related gene
52:32expression panel that spits out a
52:34number on a scale of zero to 100.
52:37The higher the number,
52:38the higher the risk of the recurrence
52:40and if that number is over 25 in general
52:43chemotherapy is going to be discussed.
52:46It's it's a kind of a a quick and
52:49dirty way of thinking about what's
52:51the underlying biology of the cancer.
52:54In determining who needs chemo,
52:57we take a lot of things into consideration.
53:00We take into account medical history and
53:02the presence or absence of heart disease,
53:04diabetes, osteoporosis,
53:06prior venous thromboembolism,
53:09autoimmune disease and then importantly,
53:13and we haven't mentioned this much,
53:14but we take into account family history,
53:17there are a lot of different
53:19genetic syndromes associated with
53:20breast cancer and the presence or
53:22absence of a genetic predisposition.
53:24May impact not only local therapy,
53:26but it's becoming increasingly
53:28used to determine what systemic
53:30therapies might be used.
53:32So I'll quiz you all on
53:34this a little bit later.
53:35These are all the chemotherapy
53:37regimens actually.
53:37These are not all of them,
53:38these are some of them,
53:40but they're complicated and they
53:41all have different side effects.
53:43They all have different schedules,
53:44they all have different needs,
53:45different central access requirements,
53:49different durations.
53:51It's because of this that doctors
53:52are here and I have a job.
53:54So, so not to not to make light of this,
53:58but it's complicated and different
54:00regimens are used for for different.
54:03Different settings.
54:05We use a lot of different chemotherapy drugs.
54:08Here are some common ones and
54:10some of the more long-term side
54:11effects that can happen.
54:13These are really potent drugs
54:14that that do kill cancer,
54:16and it's great that they kill cancer,
54:17but they can cause other problems as well,
54:20namely cardiomyopathy with
54:21some of the anthracyclines,
54:24neuropathy with some of the taxanes,
54:26and and hypersensitivity
54:27reactions across the board.
54:32Just really quickly, we,
54:33the multidisciplinary treatment of
54:35breast cancer does require conversations
54:37for a number of different clinical
54:39scenarios where we have to decide, well,
54:41who's going first, surgery going first?
54:43Is chemotherapy going first? Are we,
54:45are we thinking about other strategies?
54:48And there are different
54:50rationales for doing either.
54:53It's called adjuvant systemic therapy
54:54when surgery is 1st and it's called
54:57neoadjuvant when chemotherapy is first.
54:59So if you ever see that in a note,
55:00that's kind of all that that's describing.
55:02But this really does require
55:04close communication,
55:05particularly between the surgeon
55:07and the and the medical oncologist,
55:09but often requires the radiation
55:11input as well as the reconstructive
55:14surgery input to to plan down the
55:17line once chemotherapy is complete.
55:20And then moving on into the more chronic
55:23phase of cancer of many cancer treatments,
55:26we use a lot of anti estrogen therapy,
55:29namely tamoxifen or other or aromatase
55:32inhibitors which work by preventing
55:34the peripheral aromatization
55:36of steroids into estrogen.
55:39And they work in different ways.
55:42They have pretty nasty
55:45potential side effects.
55:46Tamoxifen can cause vasomotor
55:48symptoms like hot flashes.
55:50Food changes.
55:51There's a small risk of blood
55:53clots and uterine cancer,
55:55although it may be helpful for osteoporosis.
55:58Aromatase inhibitors,
55:58on the other hand,
56:00can cause more of a second menopause in
56:03postmenopausal women with a persistent
56:05or even more pronounced low estrogen state,
56:08and can cause vasomotor symptoms,
56:10accelerated bone loss,
56:11and and even increased cholesterol.
56:14Once we've completed the definitive treatment
56:17or in and are into the surveillance phase,
56:21we do history and physicals one
56:23to four times per year.
56:24We do periodic screenings for family history.
56:27We manage some of the acute and chronic
56:30toxicities of our cancer treatments.
56:32Patients get annual mammograms.
56:33I think it's important to note that
56:36we're not doing routine surveillance
56:38imaging in the absence of clinical
56:40signs and symptoms that suggest recurrence.
56:43However,
56:43there may be a.
56:44A low threshold to image in the
56:47setting of symptoms that meet
56:48what I like to call the three P's
56:50symptoms that are perplexing,
56:52persistent or progressive.
56:53And that's that's where patients
56:56with a history of cancer may end up
56:59getting more scans as a result of.
57:02What may end up being being just
57:04a common problem then a patient
57:06without that same history?
57:08Unfortunately about 15% of the
57:10time are are curative treatments
57:13aren't effective or patients present
57:16with metastatic breast cancer.
57:19The most common sites of breast
57:21cancer metastases are bone,
57:22liver, lung,
57:23with brain being a distant fourth.
57:26Although on average the life
57:28expectancy after a diagnosis of
57:30breast cancer is about two years,
57:32this is a huge spectrum with
57:35patients that could live for
57:37even decades depending on some
57:39of their their disease burden,
57:41their performance status,
57:42what type of breast cancer they have,
57:44and then then the the response
57:47that their cancer has to treatment.
57:50I wanted just to mention that this
57:52is an area that breast cancer and
57:54breast oncology is an area of
57:56a lot of research with lots of novel
57:58drugs that are all at our beckon
58:01call and all of which can be either
58:06administered IV IM subcutaneously or or
58:09orally with new targeted agents such
58:13as CDK 46 inhibitors, PARP inhibitors,
58:16PI3 kinase inhibitors and antibody drug.
58:20Projects, and I'm not gonna bore you with all
58:22of the mechanisms of all of those things,
58:23but they are new and exciting,
58:26and we're doing an even better job
58:28keeping people with metastatic breast
58:30cancer alive for longer, to enjoy more
58:32quality life with their loved ones.
58:35That is all that I have.
58:38Thank you very much for the opportunity.
58:39I'll turn it back over
58:41to I think Doctor Zahir.
58:44Thank you, Sarah. That was wonderful.
58:45That was an excellent review of what we do in
58:4810 minutes and I completely agree with you.
58:50We try to do what we are doing in New
58:52Haven and and even more because of the very
58:54people that are presenting here tonight.
58:57So before I go on to the last speaker
58:59of the evening, I just want to
59:02mention if you have any questions,
59:03please be prepared to ask.
59:05And don't be afraid to ask
59:07and write them down.
59:08Also, there's a there's a choice to do that.
59:11So the next speaker is really a pleasure
59:14to introduce Doctor Susan Higgins,
59:16who I have known for forever,
59:18I think for many years.
59:19She's a professor of therapeutic
59:21radiology and of obstetrics,
59:23GYN and reproductive services.
59:25She she also serves as a.
59:27Last year of Wellness and engagement
59:30for therapeutic radiology and she is
59:32a medical director for the radiation
59:34Oncology at Shoreline Medical Center.
59:36She completed her residency in
59:38therapeutic radiology at Yale and
59:40Great Great for Yale and all of
59:42us that she decided to stay here.
59:45She for nearly 25 years has
59:47dedicated herself as an educator,
59:49mentor,
59:50researcher and above all a dedicated
59:53clinician at Yale.
59:54It's really a pleasure to work with her.
59:57We all,
59:58the all the patients as well as
01:00:01the staff at at the shoreline are
01:00:04so grateful that she's here with
01:00:06us and takes care of our patients.
01:00:08Thank you.
01:00:13So then you're muted.
01:00:15Yep. Thank you Angie.
01:00:17I'm going to share my screen
01:00:18and hopefully let me get to.
01:00:24Let's see if I can get this
01:00:26to show the slideshow. OK.
01:00:29Hold on one second. OK.
01:00:31Can everybody see that?
01:00:34So one of the things I wanted to
01:00:35do was just a little bit of a,
01:00:37a little bit of a historic overview before
01:00:39I talk about radiation and and basically.
01:00:43It continues on some of the themes
01:00:44that others have talked about here.
01:00:46But in terms of the regional
01:00:48oncology services and the shoreline,
01:00:49you know we started the Shoreline
01:00:52Medical Center actually it's now
01:00:53about 18 years ago and it was one
01:00:55of the first places where we were
01:00:57able to get Yale medical Oncology,
01:01:00radiation oncology and diagnostic
01:01:02imaging under the same roof.
01:01:04And I think we all had you know
01:01:06great hopes for the shoreline that
01:01:08are all now sort of coming true.
01:01:10So it's it's a really exciting
01:01:12time to be here.
01:01:13And Umm, we had served at this phase
01:01:16of the Yale New Haven Hospital,
01:01:18Shoreline Medical Center phase
01:01:19in the early 2000s,
01:01:21but then we in 2019 here,
01:01:24well in the near term we had this
01:01:25smile all of course expansion
01:01:27of our Cancer Center downtown
01:01:28with the Smilow Cancer Center.
01:01:30And then in 2019,
01:01:32the investment in our infrastructure here
01:01:34with the renovation and expansion of
01:01:37all of our oncology and imaging services,
01:01:40including upgrades that gave
01:01:42us a beautiful surgical center.
01:01:45With more accommodations for our
01:01:47breast surgeons including our
01:01:49plastic surgeons and more space for
01:01:51our medical oncology colleagues.
01:01:53And I think that you know we continue
01:01:56to build the team and build the services.
01:01:59And what we're seeing now in 2022
01:02:02as my colleagues have spoken about
01:02:04is that we really have a truly
01:02:08comprehensive multidisciplinary
01:02:09oncology Center for breast care here
01:02:12and we are happy to see you know in our.
01:02:15Our catchment area is expanding.
01:02:17And you know,
01:02:18we're just very happy to serve the
01:02:20community and I think that as you know,
01:02:22we continue to to grow.
01:02:24We're seeing a lot of gratitude from
01:02:26the patients and it's just a great
01:02:27place to work and a great place to Park,
01:02:30right, Sarah?
01:02:33Not only a great place to work
01:02:34but a great place to Park.
01:02:35But anyway, so I just wanted to you know
01:02:37just I think if I get one point across
01:02:39is we're happy to see your patients,
01:02:41we love working here and you know
01:02:43it's one stop shopping for patients
01:02:45with breast cancer and it's sort of
01:02:47a dream come true for a lot of us.
01:02:49So basically with regard to
01:02:52radiation therapy.
01:02:54To do a little bit of an overview,
01:02:56uh, people know a little less about
01:02:58radiation than they do about some
01:02:59of the other oncologic disciplines.
01:03:01So I'll just start with like a
01:03:03little tiny intro of radiation 101,
01:03:05then talk about radiation therapy
01:03:07and the multidisciplinary treatment
01:03:09of breast cancer,
01:03:10both for breast conservation and
01:03:12patients who have had a mastectomy.
01:03:15And one of the technical advances that I
01:03:17wanted to talk about today is one of our,
01:03:20our, our projects that we began a few
01:03:22years ago that's at all of our sites.
01:03:24That has really changed what we do with
01:03:26regard to treatment and that's the deep
01:03:29inspiration breath hold technique.
01:03:30And then finally,
01:03:31I thought it would be helpful to
01:03:33speak about some of the things
01:03:34that we do for our patients with
01:03:36metastatic disease because as our
01:03:37systemic therapies are getting better,
01:03:40we're being called upon.
01:03:42We as radiation oncologists are being
01:03:44called upon now even more to help
01:03:47with the sites of sanctuary sites
01:03:49like the CNS and some extracranial
01:03:51sites have been static disease.
01:03:53So, you know, for five decades now,
01:03:56radiation therapy has been an
01:03:58essential part of the oncologic
01:03:59triad of oncologic treatments and
01:04:01about 50% of people who have cancer
01:04:04receive radiation therapy during
01:04:05their course of their illness.
01:04:09And it's radiation is a key component
01:04:12of curative breast cancer treatment,
01:04:14both in breast conservation therapy
01:04:16where patients who receive lumpectomy
01:04:18in general with a few exceptions,
01:04:20but most patients who get a lumpectomy.
01:04:22It's followed by as as
01:04:24Doctor Mccallion pointed out,
01:04:26we are the cleanup crew radiation
01:04:27therapies used to take care of
01:04:29microscopic cells that might be
01:04:31left in the breast or nodes and
01:04:33following mastectomy select patients,
01:04:34not all, but many patients received
01:04:38postmastectomy radiation therapy.
01:04:39To reduce the risk of local
01:04:42regional recurrence.
01:04:43In either case, radiation has been
01:04:46shown to be really safe and effective,
01:04:47and it can reduce the risk of local
01:04:50and regional recurrences by 50 to 70%.
01:04:52And in certain patient subsets,
01:04:54radiation therapy is associated
01:04:56with an increase in survival.
01:04:59And in general, um, this very,
01:05:01very basic radiobiology.
01:05:03It's ionizing radiation causes damage
01:05:06to cellular DNA and in malignant cells.
01:05:09They are not able to repair this DNA
01:05:12damage and they cannot reproduce
01:05:15in normal cells.
01:05:16There's also damage to the DNA,
01:05:17but it's normal cells are better able
01:05:21to repair this type of DNA damage.
01:05:24And radiation therapy is delivered
01:05:25with the linear accelerator.
01:05:27We have two bays downstairs
01:05:29in our department,
01:05:31we'd say emits high energy photon beams and
01:05:33we target the breast and regional nodes.
01:05:36And what you see here is just a
01:05:37schematic of a patient on the
01:05:39treatment table getting what we
01:05:40would call breast tangents.
01:05:42And in the upper right hand corner,
01:05:43you can see that we're targeting
01:05:45the breast and we basically have a
01:05:48tangential field that comes across
01:05:50the chest wall and you can see that
01:05:52sometimes we have a little bit of underlying.
01:05:54Along in the field and we're going
01:05:56to talk about that in a minute.
01:05:57But basically,
01:05:58as Doctor Magellan referred to,
01:06:00we do daily treatments and it's delivered
01:06:02over the course of three to six weeks,
01:06:04so there is some time involved.
01:06:07Treatment again is directed at
01:06:09the breast or chest wall with
01:06:11or without the regional nodes.
01:06:13And the way it's done is in
01:06:15terms of the just logistics,
01:06:17patients come in for something
01:06:19called the simulation,
01:06:19which is a CAT scan and they're
01:06:21immobilized in the position that
01:06:22we're going to use for treatment.
01:06:24And basically it's shown here
01:06:26they're on a slant board.
01:06:28The arms are over the head because
01:06:29we need to have the arms out of the
01:06:31way when we treat the breast and
01:06:32the nose with with fields that are
01:06:34directed and those at the chest.
01:06:37And what we get is a CT scan that
01:06:39shows us the patient's entire,
01:06:41you know,
01:06:41body and we can do sort of a 3D
01:06:44reconstruction. Of their body.
01:06:46And the doctor then goes to the
01:06:49computer and we use that CT data
01:06:51set to contour.
01:06:52We will contour out the targets
01:06:54which are the breast and the nodes
01:06:57and then the physician prescribes
01:06:58the the dose to those targets.
01:07:00Then then our sophisticated
01:07:03treatment planning system
01:07:04comes up with what we
01:07:06call a 3D conformal plan.
01:07:07It's a basically the optimal beam
01:07:09arrangement and the beam strength
01:07:11and beam shape to maximize the dose
01:07:13to the targets which breast in nodes
01:07:16and minimize the dose to the organs
01:07:18at risk like the lung and heart.
01:07:21So this is sort of a what a
01:07:23this actually comes right off of
01:07:25our treatment planning system.
01:07:26This is what you would see when
01:07:28you do that 3D conformal treatment
01:07:30in the upper left hand corner.
01:07:32I don't know if you could see
01:07:33my can you see my pointer here?
01:07:35Probably not, but in the upper,
01:07:37you can't good in the upper left hand corner.
01:07:39Thank you, Sarah.
01:07:40You can see there are two tangential
01:07:43fields and there's a green that
01:07:45represents the dose to the breast tissue.
01:07:47So this would be a right breast cancer,
01:07:49a beam would be coming this way
01:07:50from the right,
01:07:51a beam from the left and then a
01:07:54single field that's pointed at the
01:07:57patient for the Super cloud fields.
01:07:58But this would be a typical sort of
01:08:01dose distribution and this is the,
01:08:02this is what the physician basically is.
01:08:05Is going to you know devise in order
01:08:08to treat that patients breast cancer.
01:08:10I'm a have one sort of schematic here
01:08:13just to show you again this is a
01:08:16cross section of a patient's heart.
01:08:18In Gray's lungs in black,
01:08:21the actual treatment fields for
01:08:22a right breast cancer,
01:08:24one would be the lateral field,
01:08:25one would be a medial field and the
01:08:28beams basically treat the breast and
01:08:30just some of the underlying lung.
01:08:34For postmastectomy radiation,
01:08:35it's very similar sort of theme.
01:08:39But in this case, we're treating the
01:08:41chest wall or a reconstructed breast,
01:08:44whether that's an implant or a
01:08:47deep flap and the regional notes.
01:08:49So again, you can see on the patient
01:08:51that the regional notes up above in
01:08:53the clavicle area and under the arm are
01:08:55being treated along with the chest wall.
01:08:58And not everyone who has a mastectomy
01:09:01needs postmastectomy radiation.
01:09:02We often have lots of discussions
01:09:04with patients about whether they
01:09:06fall into the category that is high
01:09:08risk and that usually includes.
01:09:10Patients with positive nodes AT3 or
01:09:13larger tumor or a positive margin.
01:09:18So what has happened over the years
01:09:20is that our technical advances have
01:09:23basically been aimed at making this
01:09:26a safer treatment, and that means
01:09:28maximizing the dose of the target,
01:09:30minimizing the dose to the underlying
01:09:32organs and for left press treatment,
01:09:34the underlying organs that we're
01:09:36trying to spare a lung and heart.
01:09:38So one of the new things we've
01:09:40been able to do in the last few
01:09:43years is to address this with the
01:09:45deep inspiration breath hold.
01:09:47Technique.
01:09:47But let me just show you what the
01:09:50challenge is from an anatomic standpoint.
01:09:52I think was just showing you that the
01:09:54tangent fields that we're trying to
01:09:55use are coming across the chest wall
01:09:57and you're trying to treat the green,
01:09:59which is the breast tissue without
01:10:01encountering too much lung,
01:10:03which is black and heart circled here in red.
01:10:07But the problem is, in many ladies,
01:10:09the heart and lung are immediately
01:10:11adjacent to our target.
01:10:12And in the past,
01:10:14we could adjust the beams,
01:10:15we could change the strength of the beam,
01:10:17the angle of the beam,
01:10:18we could shape the beam,
01:10:19but we couldn't change the anatomy.
01:10:22So we do now have a technique to
01:10:24do that and it's called the deep
01:10:27inspiration breath hole technique.
01:10:29And it's there are two things
01:10:31we need to do this we have to
01:10:34use in surface imaging system.
01:10:36Uh,
01:10:36a specific surface imaging system
01:10:37that I'll show you in a minute,
01:10:39and a special gated treatment
01:10:42delivery system.
01:10:44So the surface imaging system is
01:10:46a new technology that allows us to
01:10:50map out and actually in real time
01:10:53put a surface map on a patient.
01:10:55Using a light system,
01:10:57there are three cameras and
01:10:59we're able to check a patient's
01:11:02position prior to treatment.
01:11:04And see if they're in the correct position.
01:11:07By looking at the overlay of a pre
01:11:09sort of pre recorded or pre obtained
01:11:12body contour and basically when
01:11:14blue and green coincide they're in
01:11:16the exact right position position.
01:11:18Every part of their body is within a few
01:11:21millimeters on you know where it should be,
01:11:23but if you see red or yellow that
01:11:26means that body part is in or out of
01:11:28the plane of the field and basically
01:11:30that allows us to maneuver them in the
01:11:33exact position prior to treatment,
01:11:35which is really important again
01:11:37when we're trying to.
01:11:38Deliver with, you know,
01:11:40sub millimeter to millimeter accuracy.
01:11:42The other thing this does is allows
01:11:44us to track in real time this these
01:11:46cameras are on in real time and
01:11:48giving constant feedback so that as a
01:11:50patient's chest wall changes in the
01:11:53motion of the chest as the chest wall moves,
01:11:56we are all we are able
01:11:57to track the chest wall.
01:11:59And that allows us to perform
01:12:01what we call gated treatments.
01:12:03So when the patient is breathing
01:12:05we can choose when to deliver
01:12:07radiation and when to have the
01:12:09radiation beam stopped and we call
01:12:12those gated treatments.
01:12:13So it actually all starts
01:12:14when we simulate the patient.
01:12:16So when they come in for simulation
01:12:18and we used a basically a
01:12:20just a mockup of a torso here.
01:12:22But when they come in,
01:12:23there's a a camera here that
01:12:25actually starts to collect this data
01:12:27on their surface of the patient,
01:12:29collects the surface image and
01:12:31we pick up a spot for tracking
01:12:34their chest wall motion.
01:12:35And who so once we picked that spot?
01:12:40We then have the patient start
01:12:42breathing and where this is what
01:12:43we're seeing in the control room,
01:12:45the patients actually in,
01:12:47let's imagine this patients in the simulator.
01:12:49And we're tracking this position on
01:12:51their chest. They have these goggles on.
01:12:54We asked them to basically,
01:12:58this is their baseline breath
01:12:59and then we ask them to inhale.
01:13:01You'll see they'll hold their
01:13:02breath and then we exhale and
01:13:04the baseline breathing inhale.
01:13:06What we're trying to do is figure
01:13:08out exactly what position can they
01:13:11sort of reproducibly obtain with,
01:13:13you know, expanding their chest.
01:13:15In other words,
01:13:16what's their kind of comfortable
01:13:18breath hold volume?
01:13:20And it's really cool because what was
01:13:21really interesting about this is we thought,
01:13:23oh,
01:13:23this is going to be too much for patients.
01:13:24It's going to make them really nervous.
01:13:26But what was really cool about it
01:13:28was it gave them something to do.
01:13:30And the Goggles Act
01:13:32sort of like A to insulate them from other,
01:13:35like, distractors.
01:13:35And it actually helped a lot of our
01:13:38patients feel more comfortable.
01:13:39And I think people like to
01:13:41participate in their care.
01:13:42You know, people like say, oh,
01:13:43what can I do to help myself?
01:13:44And when we tell them this is something
01:13:46you could do and you can't do it wrong,
01:13:48they like that.
01:13:50So when we do the simulation and you look at.
01:13:53The comparison will do
01:13:55basically a simulation.
01:13:56We'll look at it in free breathing,
01:13:57and we'll look at what their
01:13:58chest looks like in breath.
01:13:59Hold on the left.
01:14:01You can see this patient in free breathing.
01:14:04The chest is right up against,
01:14:06I'm sorry, the the.
01:14:07Heart is right up against the chest wall.
01:14:10You could see the heart sitting on the
01:14:12diaphragm on the right when they expand
01:14:15their chest and the diaphragm moves down.
01:14:17The heart that creates a little space
01:14:19between the heart and the chest wall.
01:14:21So diaphragm drops and the heart moves
01:14:23down and away from the chest wall.
01:14:26So now when we go to do our planning.
01:14:28So Step 2,
01:14:29as you did your simulation,
01:14:31now you want to go back and
01:14:32do your treatment plan.
01:14:33And on the left you could see free breathing.
01:14:36The chest is sort of collapsed.
01:14:38And there's the line.
01:14:39That little green line is where we'd like
01:14:40to put the edge of our tangent field.
01:14:42You could see it's right near,
01:14:43actually right near the left
01:14:45anterior descending artery.
01:14:46But when the patient on the
01:14:47is doing their breath hold,
01:14:49this is the same patient on
01:14:50the right and breath hold.
01:14:51We've moved the chest on the
01:14:53contents of the chest such that
01:14:55the heart is now moved away from
01:14:57the field and a smaller portion of
01:14:59the lung is now being radiated.
01:15:00So actually you know it was really
01:15:02a game changer because now you know
01:15:04your your sort of therapeutic ratio,
01:15:06your risk benefit is really
01:15:09changed because you've been able
01:15:11to change the internal organs.
01:15:13And then finally,
01:15:13when they get on the treatment machine,
01:15:15you have to have what's called
01:15:16a gated delivery system.
01:15:17So now we've set up the plan.
01:15:20They know what to do with the goggles,
01:15:21but when you actually deliver radiation,
01:15:23you have to have a system that
01:15:25basically will only give the
01:15:27radiation when they're in the
01:15:28exact correct breath hold position.
01:15:30And I tell them you can't do it wrong
01:15:33because they all get nervous about that.
01:15:35But basically we have three cameras in
01:15:37the room and the three cameras again
01:15:39are tracking the patient's chest wall motion.
01:15:42And we have,
01:15:43the patient has their goggles in the goggles,
01:15:46they see this little green box
01:15:47and the orange is like sort of a,
01:15:49a vertical line that goes up and down.
01:15:50And this biofeedback allows them
01:15:52to position their chest in exactly
01:15:55the right spot and when they're
01:15:57in that spot
01:15:58and their chest wall is expanded.
01:16:00The beam goes on,
01:16:01treatments delivered in 20 seconds,
01:16:0330 seconds at a time and when
01:16:05they exhale the beam goes off.
01:16:08So this is a way that you know
01:16:10again with this system that we use
01:16:12we can significantly reduce the
01:16:13the dose to the heart and lung.
01:16:15And again it was a real game changer
01:16:17because this is an actually this is
01:16:19being used with lymphomas and other
01:16:21thoracic malignancies because now
01:16:23using breath hold we can actually
01:16:25change their anatomy to suit what
01:16:27we need to do for the malignancy.
01:16:30And then just two final things
01:16:32I wanted to speak about.
01:16:34Now that we have such great
01:16:36systemic therapies,
01:16:37we are seeing that we're using more
01:16:40and more radiation therapy and a
01:16:43stereotactic fashion to deliver radiation.
01:16:47In higher doses to more targeted
01:16:50sites so that we can optimize the
01:16:53control of both intracranial and
01:16:55extracranial metastatic disease.
01:16:57For intracranial metastatic disease,
01:17:00we have the only gamma knife stereotactic
01:17:03radiosurgery unit in the state.
01:17:05We have a huge gamma knife program.
01:17:07It's very active.
01:17:08I don't know how many thousands
01:17:10of patients they see a year,
01:17:11but it's I'd say the gamma knife is
01:17:13pretty much running almost all the time.
01:17:16Now we also have a new program
01:17:18with Doctor Ann,
01:17:19which is the Spine SRS program
01:17:23and that program with Doctor
01:17:25Mandel is getting very active.
01:17:27And I'll just.
01:17:28I'll give the little background in why
01:17:30we do spine radiosurgery in a minute,
01:17:32but we also have the ability to do
01:17:34body radio surgery and that would
01:17:37be for sites that again someone
01:17:39has a long disease free interval,
01:17:41something comes up in a site that
01:17:43we feel might be the only site or a
01:17:45limited site of extracranial metastatic
01:17:47disease. We can also do body SRS.
01:17:51So any type of stereotactic radiosurgery
01:17:53requires a very highly precise,
01:17:56precise treatment and a
01:17:58lot of immobilization.
01:18:00But the advantage there is
01:18:01that you can treat a large,
01:18:02a small target with extremely
01:18:04high doses and very high dose,
01:18:07steep falloff of dose.
01:18:08So very little dose to the
01:18:10surrounding tissue and it's typically
01:18:12done in a single fraction.
01:18:14This is actually being used very,
01:18:16very frequently for lung cancers.
01:18:18Now for early stage lung cancer,
01:18:20the benefit from metastases is,
01:18:22is that you can get more durable local
01:18:24control and again in select patients.
01:18:28As they spoke about with the spine SBRT
01:18:31program, the spine SBRT, here's just a.
01:18:35Schematic that shows how precise it is.
01:18:37You can see that you can take this very
01:18:39high dose curve which is red and wrap
01:18:42a very high dose around the vertebral
01:18:44body while avoiding the spinal canal,
01:18:47canal, spinal cord and that dose can be
01:18:50adjusted within again a few millimeters.
01:18:53It's a very precise treatment.
01:18:54It requires milligrams, etcetera,
01:18:56but very helpful for various
01:18:59patient populations.
01:19:00Spinus PRT is being used for people
01:19:03with oligo metastatic disease,
01:19:04especially if it's a new diagnosis.
01:19:07Some people have a limited metastatic
01:19:09lesion after a long interval
01:19:11from their primary diagnosis.
01:19:13Or for people who have previously
01:19:16radiated spine metastases,
01:19:18we've done maybe external beam,
01:19:20and then they have a recurrence,
01:19:21which is unusual,
01:19:22but maybe a recurrence a few years later.
01:19:24We can give this and spare the spinal
01:19:27cord and treat the vertebral body.
01:19:29And finally,
01:19:30just our gamma knife program and
01:19:33especially in this era of of very,
01:19:35very effective targeted therapies,
01:19:38we still have the,
01:19:41the brain is still a sanctuary site.
01:19:43We are still dealing with people who
01:19:46have uncontrolled or come to us with
01:19:49uncontrolled intracranial disease.
01:19:50And with our gamma knife program,
01:19:52we're able to deliver very high doses of
01:19:54radiation to multiple brain metastases.
01:19:57It's a single treatment session.
01:19:58People go home.
01:19:59I know that Doctor Bindra says his famous,
01:20:02his,
01:20:02his favorite call is like the people who say,
01:20:04Oh yeah,
01:20:04I just went golfing like the guys like
01:20:0624 hours out and he gives him a follow
01:20:08up call and the guy was out golfing.
01:20:10It's a very,
01:20:11very beneficial,
01:20:12very effective treatment and gives more
01:20:15durable local control for brain medicine,
01:20:17significant decrease in morbidity
01:20:19when compared with our standard
01:20:21whole brain radiation therapy.
01:20:23And you know,
01:20:24Doctor Chang and my other colleagues are
01:20:26just always available and a doctor is
01:20:28here and I work really closely with them.
01:20:31And and Doctor Mcgauley and we we can
01:20:33get those patients to the gamma knife
01:20:35people to the spine radio surgeons
01:20:37and anything they need at any time.
01:20:39So we we have a very like hand in
01:20:41glove type of relationship with them.
01:20:43So basically radiation therapy
01:20:45to summarize is an essential
01:20:47part of the multidisciplinary.
01:20:50Treatment for breast cancer,
01:20:51it's very safe and effective and
01:20:53you know I think the DBH is making
01:20:55it even more safe and effective and
01:20:57it reduces the risk of local and
01:21:00regional recurrence by 50 to 70%.
01:21:02And you know what's really I think
01:21:04going to help in the future with
01:21:06quality of life for patients,
01:21:08especially for gamma knife is the
01:21:10use of these stereotactic procedures
01:21:13to to control local regional
01:21:15disease and metastatic disease.
01:21:17Thank you very much.
01:21:22Thank you Susan for a very you
01:21:25know good comprehensive review,
01:21:27comprehensive with short review of radiation
01:21:29oncology and what we provide here.
01:21:32The the biggest thing is availability
01:21:34of all the providers and really the
01:21:36great thing that I can call you and
01:21:38get the person in fairly quickly
01:21:40within the same day or sometimes
01:21:42within 24 hours and that's wonderful.
01:21:45So thank you very much for everybody
01:21:47to to join us today and I just
01:21:49was hoping we would have some
01:21:50questions from the audience.
01:21:54I had. I don't see any.
01:21:56No, there is one question here.
01:21:58I'm going to stop sharing. There we go.
01:22:02I don't know how do they ask
01:22:03questions, I'm not sure.
01:22:06I'm looking at the question
01:22:07answer in the in the chat,
01:22:08but I don't see any so.
01:22:12So I may ask one question of all the,
01:22:14you know, all the speakers
01:22:16tonight and anyone can answer.
01:22:18Umm, it's a very simple question.
01:22:21What do you think is the most
01:22:23important advance in breast cancer
01:22:24over the past year and it can be
01:22:27one or two sentences and we can
01:22:28finish up this meeting this evening.
01:22:30Sarah, you want to start.
01:22:33So in in breast medical oncology,
01:22:35I think the the biggest breakthrough was
01:22:37the use of an antibody drug conjugate,
01:22:40which is kind of like a.
01:22:42Very directed heat seeking missile
01:22:44toward the her two protein which is
01:22:47effective in not just people who have
01:22:49truly hurt to overexpressing cancers,
01:22:51but lots of different other kinds that
01:22:53have very low levels of expression.
01:22:55Kind of revolutionary in the
01:22:57treatment of metastatic disease waji.
01:22:59I would point out that there is a
01:23:01question that asks about the best way to
01:23:03initiate a referral to the breast team.
01:23:06You can answer there,
01:23:07OK. We are happy to take referrals
01:23:12through any referrals to breast
01:23:14surgery can be breast surgery.
01:23:16Guildford can be breast surgery New Haven.
01:23:18And a part of our process is to try
01:23:20to make sure that we're accommodating
01:23:22where the patient's coming from.
01:23:24So that if the patient is
01:23:25located on the shoreline,
01:23:26we really try to get them into
01:23:28the shoreline because there's no
01:23:29reason for them to shut down and
01:23:31tolerate the air rights garage.
01:23:34And you know, if there's ever any question,
01:23:35you're welcome to call us.
01:23:37Any one of us call me especially
01:23:38if you want to. I mean,
01:23:40I will get the person in right away.
01:23:42All of the providers here.
01:23:44I know, I know they can,
01:23:45they can make space.
01:23:49I happen to know that people sit in
01:23:51the queue for our referrals for less
01:23:53than 24 hours, so we usually make those
01:23:55appointments within one business day.
01:24:00So Leanne, what do you want to tell
01:24:02us about the latest development
01:24:04in radiology over the past year,
01:24:07there have been many.
01:24:10In the past year.
01:24:13Not really sure if there's anything
01:24:15really in the in the past year.
01:24:18I mean there are things artificial
01:24:21intelligence is obviously
01:24:22taking off in breast imaging.
01:24:24It's a challenging area though
01:24:25compared to other areas of radiology.
01:24:27Mammography is just really
01:24:29one of the hardest things.
01:24:32But I think we'll see that coming
01:24:34very shortly and that should help
01:24:36us some you know hopefully improve
01:24:38our accuracy and reduce again
01:24:40reduce a lot of false positives.
01:24:42I think that's that's where I see it,
01:24:44it helping a lot.
01:24:46I can't share any more slides
01:24:48on Thomas synthesis,
01:24:48but we're going to be presenting
01:24:50data next month looking,
01:24:51you know,
01:24:52we've been doing it for 10 years
01:24:54and looking at all of our cancers
01:24:56on detected with Thomas synthesis
01:24:58and comparing it with the 2D
01:25:00mammography and we are finding a
01:25:02difference in the advanced cancers,
01:25:04significantly fewer advanced cancers, so.
01:25:09You know,
01:25:10that's it's encouraging you know,
01:25:13because we just don't want
01:25:13to find more cancers,
01:25:14we want to find the bad cancers and we're
01:25:16finding the bad cancers at a a lower stage.
01:25:18So really feel good about that.
01:25:22So, you know,
01:25:23definitely tomosynthesis is is here to stay,
01:25:25there's no doubt about that.
01:25:26But yeah,
01:25:27I think AI is going to
01:25:28be the next big thing.
01:25:31Any of the other speakers,
01:25:33Paris or Greg, Susan,
01:25:36I would say in the in the plastic
01:25:39and reconstructive surgery space.
01:25:41The medical devices, the the prosthesis,
01:25:43the implants they get better and better.
01:25:44We're on our fifth generation of
01:25:46implants at this point in time and
01:25:48they they increasingly get more sturdy.
01:25:50I have been in practice long enough.
01:25:52So president plants of silicone
01:25:54breast implants have been
01:25:55out for well over 50 years.
01:25:56And that first generation and even second
01:25:58generation when they ruptured it was it
01:26:00was a nightmare to to remove them and I
01:26:02I've had to do more than my fair share.
01:26:05This fifth generation they
01:26:08call them cohesive, stable so.
01:26:11The gummy bear implants.
01:26:11So you can imagine a gummy bear,
01:26:13if you cut a gummy bear in half,
01:26:14nothing leaks out.
01:26:15That's what all of these
01:26:16new devices are like,
01:26:17which is which is of of benefit in in many,
01:26:20many ways.
01:26:21One is they tended to have better durability.
01:26:26The second is that they tend to
01:26:27have longer and better projection
01:26:29for a longer period of time.
01:26:31So I would say and over the course
01:26:33of the year this most recent
01:26:35generations kind of come out and
01:26:37really has become very popular.
01:26:39Great.
01:26:41Greg, yeah, absolutely. You know,
01:26:46as we go through training,
01:26:47you know through residency and
01:26:49fellowship I think and also the the
01:26:51menu clinical trials we see at breast.
01:26:53I think I think what I've seen the
01:26:56most is the patients now inactive
01:26:58participant. Yeah, they they now
01:27:01have a big voice in terms of how
01:27:03much imaging they want to do,
01:27:05how much treatment they want to do.
01:27:07With the help of medical oncology
01:27:09we can reduce your tumor burden and
01:27:12give them more surgical options
01:27:13with the help of plastic surgery.
01:27:16You know we're able to give them
01:27:17more options and and I think what
01:27:19we're going to see more and more
01:27:20is more options of de escalation.
01:27:22You know as we're accumulating
01:27:24more trials we're finding that
01:27:26you know maybe less axillary lymph
01:27:28node dissections and surgeries,
01:27:30maybe patients are going to
01:27:31be doing just as well.
01:27:33We have a lot of trials that have met
01:27:36accuro and are going to be releasing their,
01:27:39you know their data in five years
01:27:41and I think it's nice to see
01:27:44you know the patient advocacy.
01:27:46For themselves and and they've really
01:27:48been an active participant and you
01:27:50know it's nice to see physicians
01:27:52who have had an open year and a lot
01:27:54of our conversations are are really
01:27:56you know geared toward them and and
01:27:58we're happy to provide all those
01:28:00different operations different options.
01:28:01So it's really been enlightening.
01:28:04Thank you. That's, that's great.
01:28:06Susan, you want to add something?
01:28:08I I would say that the thing I've
01:28:09seen over the last few years that's
01:28:12been gratifying on a personal level
01:28:13and I think my colleagues are,
01:28:15we're just enjoying working with our
01:28:18plastics colleagues and making sort
01:28:20of this I think multidisciplinary
01:28:24efforts of knowing when and how to
01:28:26kind of coordinate the radiation
01:28:28with regard to all the different
01:28:31reconstruction techniques has been
01:28:32really gratifying and as they check.
01:28:35Says the techniques change.
01:28:36We like to learn how to change with them.
01:28:38So I think that, you know,
01:28:42radiation therapy in the post mastectomy
01:28:44setting has gotten more and more complex,
01:28:46but in a good way because I think that.
01:28:49Our group, you know,
01:28:50we all have very good communication and
01:28:52we're able to sort of preempt a lot of
01:28:55the issues that I think maybe in the
01:28:58beginning of many years ago when we
01:29:01people started doing plastics procedures,
01:29:03we didn't know all the questions
01:29:04to ask up front.
01:29:05But now I think we have a really
01:29:07great workflow for communicating
01:29:09with their colleagues and patients
01:29:11get really good oncologic as well
01:29:14as plastics outcomes because we're
01:29:15all sort of on the same page and
01:29:18speaking the same language.
01:29:19So I think our patients really
01:29:20benefit from that.
01:29:21I think all of us have a lot of
01:29:24sort of satisfaction from that
01:29:25part of our job and it continues
01:29:27to evolve and get better.
01:29:30Thank you. Thank you very much.
01:29:31I think we are just about to overtime
01:29:33and I really greatly appreciate all
01:29:35of you for joining us and really
01:29:38appreciate for what you do every day
01:29:40and thanks everyone for joining in.
01:29:42Have a great night.
01:29:43Thanks very much. Thank you. Take care.