Smilow Shares with Primary Care: Gynecologic Cancers

Transcript

• 00:00Like to welcome you to smile
• 00:03shares with primary care.
• 00:05And we are going to be talking
• 00:07about gynecologic issues tonight.
• 00:11And let's see. Let's
• 00:12advance to the next slide.
• 00:18Great. So this is a program that SMILE
• 00:21has developed with an EMG and in Doctor
• 00:24Karen Brown is is my partner in crime here.
• 00:28It's a monthly lecture series that
• 00:30really focuses on primary care,
• 00:32perspectives on cancer and hematology
• 00:35for primary care clinicians.
• 00:37There are lots of other formats
• 00:39and venues to learn about cancer,
• 00:42but the aim here was really to develop
• 00:45a panel that would address questions.
• 00:48That primary care.
• 00:50Has around cancer on different
• 00:53topics and and also to focus on.
• 00:57Teams working together in a specific region.
• 01:00So we're we're focusing on gynecologic
• 01:02oncology care today and and really in the
• 01:06westerly water filled Waterford region.
• 01:09It's a monthly lecture series,
• 01:13first Tuesdays of the month from 5
• 01:15to 6 and we have programs all the
• 01:19way through until June and I'll
• 01:22show you at the end.
• 01:23I'm gonna hand it over to to Karen
• 01:26any other words and and to get started
• 01:28with the with our first introductions.
• 01:32I would just echo your
• 01:35excitement at this series.
• 01:37Welcome to everybody who's watching
• 01:40and gratitude to everybody who
• 01:43has put together this program.
• 01:46You know, in primary care,
• 01:48we do a lot of work and we also
• 01:51rely on specialists around us.
• 01:54When our patients get very sick,
• 01:56we take pride in recognizing when
• 01:58they get very sick and being able
• 02:00to expedite their care in a way.
• 02:03That meets their needs both medically
• 02:06and also psychologically and and
• 02:09new cancer is a high time of need
• 02:11and and so this series represents
• 02:14not just education around new cancer
• 02:17but it also recognizes that we are
• 02:20actively working to build bridges
• 02:22between primary care both through
• 02:25education through some of our care
• 02:28signature pathways and and and
• 02:30regionally as well because we know.
• 02:33Curious relationship based and
• 02:34we hope that this will be part
• 02:38of building those relationships.
• 02:40So I am pleased to introduce Jeff Joseph.
• 02:44Doctor Joseph is now a gynecologist in
• 02:49in the westerly region. He graduated.
• 02:53From Block Island High School.
• 02:56Fun fact. And it's really true.
• 03:00His graduating class had eight people in it.
• 03:03So talk about practicing medicine in a
• 03:05community and being from the community.
• 03:07His undergrad degree was in
• 03:09chemical Engineering,
• 03:10Masters degree in Georgetown and
• 03:12then New York Medical College.
• 03:14He did a residency at Bay State
• 03:17Medical Center,
• 03:17and then he worked at South
• 03:20County Hospital in Wakefield,
• 03:22RI for many years until he's
• 03:24joined northeast.
• 03:25Medical Group in 2021 and
• 03:29now his practice is GYN only,
• 03:31although he can say he's probably
• 03:35delivered over 3000 babies in
• 03:38his OBGYN years earlier.
• 03:40We are happy to have him present
• 03:42some cases on to kind of kick off
• 03:45discussions and I'll turn it over to
• 03:47you and for additional introductions.
• 03:50Great, thanks and welcome Doctor.
• 03:53Joseph, you're, you're a specialist,
• 03:55but tonight you're also primary care
• 03:57in terms of the gynecologic piece.
• 04:00So I'd like to introduce Johanna D'addario,
• 04:03MHS, PA She's a 2008 graduate of Quinnipiac
• 04:08University Physicians assistant program.
• 04:11She's got clinical experience
• 04:13in hospital medicine,
• 04:14primary care and gynecologic
• 04:16oncology and also experience in
• 04:19patient safety and PA education.
• 04:21Um, she's very interested in genetics,
• 04:23health and Wellness, disease prevention,
• 04:25and she joined us at Yale New Haven Health
• 04:28in 2018 as the coordinator of the Sexuality,
• 04:32Intimacy and Menopause Clinic.
• 04:33She enjoys helping women with cancer
• 04:36maintain healthy relationships and
• 04:38manage treatment side effects.
• 04:40And she's a member of the
• 04:43Society of Gynecologic Oncology,
• 04:45the North American Menopause Society
• 04:47and the Scientific Network on
• 04:49female Sexual health and cancer.
• 04:53Like to then turn to Doctor Mitchell Clark,
• 04:56who is an assistant professor and
• 04:59OBGYN at the division of Kynance
• 05:02at Yale School of Medicine.
• 05:04He did his residency at Yale New Haven
• 05:07Health and completed his fellowship
• 05:10training at the internationally
• 05:12renowned Princess Margaret Cancer
• 05:14Center at the University of Toronto,
• 05:17where he gained clinical and
• 05:18surgical expertise in all
• 05:20aspects of gynecological cancer.
• 05:22Cancer care.
• 05:23He also was very much engaged
• 05:25in a rigorous research program
• 05:28furthering on further understanding
• 05:30the role of surgery and high risk
• 05:32ovarian cancer and also during his
• 05:35fellowship completed a Master of
• 05:36Public Health degree and continues
• 05:38to actively research cervical cancer
• 05:40prevention at a population level
• 05:43using administrative databases.
• 05:45He's received numerous National
• 05:47International awards for his research,
• 05:50teaching and surgical skills.
• 05:52Including this,
• 05:53the Society of Gynecologic Oncology
• 05:55of Canada Research Award Award of
• 05:58Excellence and minimally invasive gynecology,
• 06:00gynecology and Yale School
• 06:02of Medicine Teaching award.
• 06:04Thank you, Mitchell.
• 06:06And then finally, Doctor Christy Kim,
• 06:09MD, FACP,
• 06:10She's an assistant professor in
• 06:12clinical medicine and a General
• 06:14Medical oncologist with special
• 06:16interest and passion in gynecologic
• 06:18and breast cancers and lymphoma.
• 06:20She works at she,
• 06:22she's at the Our Smile Cancer
• 06:24Hospital Care Center in Waterford
• 06:26and has also participated in
• 06:29gynecologic oncology group clinical
• 06:31trials as a primary investigator.
• 06:34And as a member of the Society
• 06:37of Gynecologic Oncology Clinical
• 06:39Practice Committee,
• 06:40she co-authored neuroendocrine tumors
• 06:42of the gynecologic tract update
• 06:45and she's also an active member
• 06:48of the International Gynecologic
• 06:49Cancer Society and European
• 06:51Society of Gynecologic Oncology.
• 06:53She was appointed at as an adjunct
• 06:56assistant professor at Icahn
• 06:58School of Medicine at Mount Sinai.
• 07:00She's committed to improve the lives
• 07:02of those who are impacted by cancer
• 07:04and she feels really passionate about.
• 07:06Providing the best evidence based therapy
• 07:08options personalized to each patient.
• 07:11So great faculty tonight I will ask
• 07:15you to remember that we do have time
• 07:18reserved at the end for questions
• 07:20and that's been some of the the most
• 07:22interactive and really interesting session.
• 07:24So keep your questions.
• 07:25You can put them in the chat later or
• 07:28along the way we'll keep track of them.
• 07:30Umm one more comment,
• 07:32Doctor Brown, before we start,
• 07:35before before we begin, I just need to
• 07:38recognize the fact that the New Haven.
• 07:41Primary care community lost one of its
• 07:44own last month and I want to dedicate
• 07:48this session to Laura Whitman and
• 07:51and also say a few words about her.
• 07:55After spending time at Duke,
• 07:58UNC Upenn and Case Western
• 08:00Reserve School of Medicine,
• 08:02Laura completed her residency in
• 08:04internal medicine here at Yale in
• 08:071996 and it was specifically in
• 08:09what we called an ambulatory care.
• 08:11Back she was also a chief resident
• 08:14in the primary care center,
• 08:16which used to be located on Howard Ave.
• 08:18and it was there that she and I
• 08:22worked together most intensively.
• 08:24She was recruited as a faculty
• 08:27member based on her excellent
• 08:29clinical and also educational skills.
• 08:32She demonstrated patient centeredness,
• 08:35and her kind manner was obvious
• 08:38to all of us who worked with her,
• 08:40whether we worked with her as a patient,
• 08:43in an exam room, in a clinic,
• 08:46conference room or lecture hall.
• 08:48She was a leader in the primary
• 08:52care medical education.
• 08:53And which relocated to the Cornell Scott
• 08:57Hill Health Center several years ago.
• 09:01She also was an author of the Yale
• 09:04Office based Medicine curriculum,
• 09:06which is a case based study that's
• 09:09used in medical residency clinics
• 09:11all over the country.
• 09:13She was a fierce advocate for
• 09:15vulnerable populations as well as a
• 09:17fierce advocate for primary care.
• 09:19Those of us who practice medicine,
• 09:21we we learned very quickly that
• 09:24there's no US versus them.
• 09:26And that we have another expression.
• 09:29I know we use it in this practice.
• 09:31I I suspect it's universal,
• 09:33that there's a clear lack of
• 09:35justice in most cancer diagnosis.
• 09:37Laura's illness and death is is no exception.
• 09:40The primary care community in the
• 09:42Yale Medicine community has lost
• 09:44someone whose impact will be felt
• 09:46for years to come in the lives
• 09:48of those who she trained in our
• 09:50memories and in our hearts.
• 09:54So with that, we will kick off
• 09:57with the first slide Doctor Joseph.
• 10:00Thanks Doctor Brown and welcome everybody.
• 10:03Our first patient is a 56 year old
• 10:06gravida 2 para, 22 vaginal deliveries.
• 10:08She's postmenopausal and she presented
• 10:10to the emergency department with a 2
• 10:13day history of abdominal discomfort.
• 10:15Workup including CAT scan of the abdomen and
• 10:17pelvis was consistent with gastroenteritis.
• 10:20She was treated with Ivy fluids and
• 10:22she was deemed stable for discharge.
• 10:25A6 centimeter left ovarian cyst
• 10:26was seen incidentally on the CAT
• 10:29scan in the emergency room arranged
• 10:31to follow up with gynecology.
• 10:33I think right there is where we see a little
• 10:35bit of the power of epic because I was paged.
• 10:38I think the emergency room physician was a
• 10:40little the patient wouldn't have follow up.
• 10:43She didn't have a GYN.
• 10:45So I was able to review the record and
• 10:47request that they drew tumor markers
• 10:49and asked that she have a pelvic
• 10:52ultrasound before she was discharged.
• 10:54She wasn't able to get the ultrasound.
• 10:55For discharge, but did get back in the
• 10:57morning so by the time I saw her telephone,
• 11:00ultrasound was already completed.
• 11:03So by the time she sees gynecology,
• 11:05the abdominal discomfort had improved.
• 11:08But she did note some abdominal bloating,
• 11:11which she attributed to her new plant
• 11:13based diet. Past medical history?
• 11:15Not too significant. Hyperlipidemia.
• 11:17She'd had an appendectomy.
• 11:20Her family history a little more
• 11:22interesting from maternal cousin
• 11:23with breast cancer at age 45.
• 11:25Maternal uncle with pancreatic
• 11:27cancer at age 60.
• 11:28Her parents,
• 11:29siblings and children are all healthy,
• 11:31and she was not Ashkenazi Jewish ancestry.
• 11:36Pelvic exam was normal.
• 11:38External genitalia, normal speculum exam.
• 11:40The abdomen was certainly not acute,
• 11:42but there was a palpable left adnexal cyst.
• 11:48The transvaginal ultrasound
• 11:49that was ordered did show that
• 11:52it was a complex ovarian cyst,
• 11:54and thankfully the right
• 11:56ovary and uterus are normal.
• 11:57Again, I think that's where the
• 12:00ultrasound is a little bit more
• 12:02accurate test for gynecology.
• 12:04Remember with the CAT scan
• 12:06you need IV or oral contrast,
• 12:08and with uterus tubes and ovaries
• 12:10those those can be sort of.
• 12:12Exaggerated on the CAT scan,
• 12:14so we kind of live and die
• 12:16with the ultrasound.
• 12:17I had asked you tumor markers to be
• 12:19drawn that was the CA 125 and the H4.
• 12:21The CA 125 came back elevated.
• 12:24That's returned in about 24 hours.
• 12:26The H4 unfortunately takes about
• 12:28a week and that was pending
• 12:31at the time of the evaluation.
• 12:33CEA and CA. 19 nine for normal.
• 12:38With the elevated C125I referred
• 12:41the patient to GYN Oncology.
• 12:45Thank you, Doctor Joseph.
• 12:46So I had the pleasure of meeting with
• 12:48this lady and and reviewed the workup
• 12:50that had been completed by Jeff thus far.
• 12:52And I completely agree the the ultrasound
• 12:55is really such a a more sensitive
• 12:57and specific tool for us and given
• 13:00the complex features that we saw.
• 13:02So some solid components,
• 13:04some abnormal vascularity within that cyst,
• 13:07this patient was was counseled that
• 13:09she would she should really undergo
• 13:10a laparoscopic evaluation and at a
• 13:13minimum removal of that tube and ovary.
• 13:15With Frozen section and plans
• 13:17for surgical staging,
• 13:18if that was to reveal a malignancy,
• 13:21most of these cases can be
• 13:22done laparoscopically now.
• 13:23But for this patient,
• 13:24we put the camera inside and what
• 13:27was immediately apparent was
• 13:28that there was already evidence
• 13:30of disease outside of the ovary.
• 13:32This can certainly be missed on CT scan,
• 13:35especially when we see very small
• 13:37peritoneal based disease and
• 13:39fortunately it's not often that those
• 13:41things are overlooked by a CT scan,
• 13:44but we do know that.
• 13:45Most women with an ovarian cancer will
• 13:48present at a more advanced stage just
• 13:50due to really our lack of of good
• 13:53screening and early diagnosis right now.
• 13:56And so because of this,
• 13:57this patient's procedure was
• 13:59converted to an open approach.
• 14:01That's really still the standard of care
• 14:03when we find disease outside of the ovary,
• 14:06but it never hurts to put a camera
• 14:08inside and just sees going on 1st.
• 14:10And so we proceeded with more of
• 14:12a sudden reduction or what we used
• 14:14to call the debulking and now.
• 14:15The goal is really shifted towards
• 14:17removing all of the visible disease
• 14:19that we see at the time of surgery
• 14:21and that confers really the
• 14:23best survival for these women.
• 14:25So we completed that surgery without any
• 14:27complications and she was discharged
• 14:29home three or four days after her
• 14:32laparotomy and we referred her on
• 14:34to meet with our medical oncologist.
• 14:36And they're really an incredible
• 14:37part of what we do for these women
• 14:40because it's a real combination
• 14:42of surgery and chemotherapy.
• 14:44And so she met with their medical oncologist.
• 14:46Discuss chemotherapy as she was found to
• 14:49have a stage 3C ovarian high grade serous,
• 14:52which is the most common type
• 14:54of ovarian cancer we see.
• 14:56And we'll talk a little bit about
• 14:58the importance of genetics and why
• 14:59every woman with serous ovarian
• 15:01cancer is referred to meet with
• 15:02our wonderful genetics team.
• 15:04And this patient was actually found to
• 15:06harbor a mutation in the BRCH 2 gene.
• 15:08Next slide.
• 15:10This is a really great figure to
• 15:12show sort of how exciting things
• 15:14have become over just even the last
• 15:1610 years in this disease.
• 15:18For the last you know if we look
• 15:20back here 2025 years really it was it
• 15:22was toying with which chemotherapy
• 15:24combination is going to give us the
• 15:26best outcomes and those outcomes were
• 15:29still very disappointing for this disease.
• 15:31What we're very excited by are
• 15:33the advances in maintenance
• 15:34therapy and our understanding of
• 15:36the underlying biology of most
• 15:38of these cancers and how that.
• 15:40Would impact what our medical
• 15:42oncologist and author recommending
• 15:44for patients to go on after they've
• 15:47completed their chemotherapy.
• 15:48So next slide.
• 15:52This is probably one of the more
• 15:54important papers and and one of the
• 15:56figures that gets put onto every
• 15:58talk and it really highlights that
• 16:00this is no longer just A1 fit all
• 16:02cancer that we really go ahead and
• 16:05look at the underlying genetics
• 16:06of all of our patients tumors.
• 16:09And why that matters is that it has
• 16:11been found that about 50% of women
• 16:14with serious ovarian cancer, hybrid,
• 16:15serious ovarian cancer will have an
• 16:18underlying deficiency in homologous
• 16:19recombination and that means.
• 16:21That about half of women are eligible
• 16:23for these new types of oral medications
• 16:26that are taken after chemotherapy and
• 16:28have really revolutionized the outcomes
• 16:30and the survival for women for with
• 16:32the disease that many years ago had a
• 16:35survival that was measured in a few years.
• 16:37And we continue to look forward
• 16:40to seeing the excellent outcomes
• 16:41of the data from these trials.
• 16:44So with that,
• 16:44I'm going to hand things over to Doctor
• 16:46Kim to talk a little bit more about
• 16:48some of the nuances in these oral meds.
• 16:52Thank you, Doctor Clark.
• 16:53So this is a part park inhibitor.
• 16:56Park stands for the Poly ADP ribose
• 17:00story polymerase inhibitors enzyme
• 17:03that involves in the DNA repair through
• 17:06the another pathway called place.
• 17:10Or uh. Accessing goals strand DNA
• 17:13breaks and partly vision blocks
• 17:16the ability to park inhibitor to
• 17:19participate in the DNA damage repair.
• 17:23So it's what's called synthetic lethality.
• 17:27So where the.
• 17:30To Mark cannot really repair its own
• 17:32and kind of comes to a cell bed so it's
• 17:35most effective in the BRACA mutations
• 17:38as Doctor Clark had deluded about
• 17:4050% of the serious ovarian cancer
• 17:43harbors so HR along with becoming
• 17:47BRACA mutations and there are four
• 17:50main part manipulator including elaborate.
• 17:55And that was that for the first three years
• 17:57are at the approved for Dorian cancers,
• 18:00the last one is for the breast cancer.
• 18:04Next slide. So this was a big
• 18:07trial that kind of led to the.
• 18:10The 2018. As a maintenance,
• 18:13so currently in the US the apartment numbers
• 18:16are indicated as a maintenance therapy.
• 18:19So this is a breakthrough in you know
• 18:22this kind of demonstrated we are.
• 18:26Curing some of the you know high,
• 18:28high aggressive you know ovarian cancer
• 18:30patients and I draw your attention to
• 18:33the five year mark overall survival.
• 18:36There are 73% of patients that are
• 18:39alive compared to those 63% percent
• 18:43of the patients at 5 year Mark.
• 18:46At 7 year Mark and there are still
• 18:49strong separation of the curve,
• 18:5167% are still alive in about
• 18:5446% are alive and.
• 18:56Just mind you that about 50%
• 18:59of the placebo arm across.
• 19:03Crossed over to the elaborate plan and
• 19:05which can impact the overall survival.
• 19:07So this is really impactful
• 19:09and it's changing. Next slide.
• 19:15But this is just the kind of give you
• 19:17like what's new in ovarian cancer.
• 19:19I think what we call antibody
• 19:22drug conjugate or ADC.
• 19:24This was a just recently
• 19:26approved it's against the fully
• 19:28receptor alpha Mervin tuxmath.
• 19:31So just kind of have a diagram,
• 19:32it's a little bit busy picture
• 19:35but they're so Morehead,
• 19:37it's kind of like a smart bomb as
• 19:40antibody that targets the cell
• 19:43cell surface receptor and then.
• 19:45You linked to the lot of
• 19:47phototoxic drugs what we call
• 19:49payload and the ratio can be high.
• 19:52So the it's the potencies
• 19:54are quite remarkable.
• 19:56If you were to give the
• 19:58patients those same dose,
• 19:59it can be quite lethal to their patients.
• 20:01But the the way that you designed
• 20:03the antibodies or conjugate you can
• 20:05deliver the drug in a safe manner
• 20:07and targets the cancer cell directly.
• 20:10Then the second pictured on the diagram
• 20:13is called the tumor treating field.
• 20:17This is already the technique that
• 20:19was approved for the neoplasma
• 20:21multifamily highly aggressive glioma
• 20:23and also the for mesothelioma.
• 20:26And there are ongoing studies
• 20:28phase three as to electric field
• 20:31that pulses through the skin and
• 20:33interrupts the cancer cell that's
• 20:36impacting the ability to divide.
• 20:39Next. Slides at least two. Join us.
• 20:44Stop. Regarding genetic testing.
• 20:48Yeah. So the question
• 20:49is for this first patient is,
• 20:50was there could, could there have been
• 20:52some kind of early detection or prevention
• 20:55of her cancer based on on her history.
• 20:58And I think in the primary care setting
• 20:59that's really important to think about.
• 21:01She did have a family history,
• 21:04not a first degree relative.
• 21:05She had a cousin with cancer and
• 21:07an I believe an uncle with cancer
• 21:09and we think about genetic testing.
• 21:12There's a couple of things I wanted
• 21:13to point out about some of the recent
• 21:16guideline updates for cancer genetics.
• 21:17Um, the first is really important in
• 21:20the primary Care World is that the
• 21:22preventative Services Task Force does
• 21:24recommend that clinicians at least
• 21:26assess women with a family history of breast,
• 21:29ovarian, tubal or peritoneal cancer,
• 21:32or who have an ancestry associated
• 21:34with the BRACA mutation.
• 21:35So this is specifically for BRCA one
• 21:38and two thinking about family history.
• 21:40Of ovarian cancer, which she did not have.
• 21:43But in the primary care setting,
• 21:45it's important to take a good family
• 21:47history at your annual physicals
• 21:49and identify.
• 21:52Benefit from a genetics consultation.
• 21:55First degree relatives with of
• 21:57a patient with ovarian cancer.
• 21:59First degree relatives of a patient
• 22:01with pancreatic cancer should
• 22:02certainly qualify for genetic testing.
• 22:04Or of course if there are multiple family,
• 22:06multiple family members with various cancers,
• 22:08or somebody, for example,
• 22:09who's had a bilateral breast cancer or
• 22:12multiple cancers in one family member.
• 22:14So in this patient
• 22:15it may have been interesting to ask,
• 22:18you know had had your uncle
• 22:20had any genetic testing,
• 22:21had your cousin had any genetic
• 22:23testing because that may inform
• 22:25this patient's genetic testing.
• 22:26Unfortunately for people who are referred
• 22:29for genetic counseling and testing without
• 22:31a cancer diagnosis but a family history,
• 22:34the wait time is a few months to have genetic
• 22:37consultation and and genetic testing.
• 22:39But in this case because our patient
• 22:42is now diagnosed with ovarian cancer.
• 22:44And it may inform her treatment options,
• 22:47including PARP inhibitor therapy.
• 22:48She is of course, expedited and has
• 22:51an urgent genetics referral for her.
• 22:53Umm, BRC 2 testing, which came back positive.
• 22:57I'm a firm believer in genetic counseling.
• 23:01You know, there are people who
• 23:03feel informed enough to order
• 23:05genetic tests in the community.
• 23:06Gynecologists are well informed
• 23:08to do that based on their level of
• 23:11experience with genetics up at UConn.
• 23:13There are some really nice.
• 23:15Um, educational programs to kind of educate
• 23:17you on how to to do genetic screening.
• 23:21But really the most important thing is
• 23:23that patients need to have pre test
• 23:26counseling and post test counseling.
• 23:27And the pre test counseling really
• 23:29needs to be thorough enough to be
• 23:31able to take a good family history,
• 23:33know which test to order,
• 23:34determine if there should be panel
• 23:37testing which company to order from,
• 23:38and then making sure the patient
• 23:41understands the possible outcomes and
• 23:42possible consequences of their test results.
• 23:44So again.
• 23:45And you know,
• 23:46there is a high demand for our
• 23:48genetic counselor colleagues,
• 23:49but I do rely on them a lot to
• 23:51help me with patients when I'm
• 23:54thinking about genetic testing.
• 23:56And my last few updates before we
• 23:58move on is that there is a very new
• 24:02guideline updates from the National
• 24:04Cancer Comprehensive Network that
• 24:07we no longer formally or the NCCN
• 24:10no longer formally recommends
• 24:12ovarian cancer surveillance even in
• 24:14our very high risk populations,
• 24:17the BRC A1 and B RC2 carriers.
• 24:20You know for many,
• 24:21many years we've done transvaginal
• 24:23ultrasounds routinely, we've done CA 125.
• 24:27Routinely and.
• 24:29This is the first year that the NCCN
• 24:30has removed that from the guidelines.
• 24:34Apologizing.
• 24:37And last but not least,
• 24:39the most important thing I want to
• 24:40share with you as well is knowing the
• 24:43terminology for cancer genetics in
• 24:44regards to mutation no longer being
• 24:46as as often used as a term that we
• 24:48use BRACA mutation we use variant.
• 24:51So there are there's a spectrum now,
• 24:53pathogenic variant meaning cancer
• 24:56causing likely pathogenic benign or
• 24:59likely benign variants meaning the.
• 25:02The gene is altered but not
• 25:05necessarily cancer causing and then
• 25:07this Gray area called a variant of
• 25:09uncertain significance that we do
• 25:11not necessarily clinically act upon.
• 25:13So if you have a patient who has
• 25:15a VUS or a variant of uncertain
• 25:17significance in a gene,
• 25:19it does not necessarily mean that he
• 25:21or she needs to have any prevention
• 25:24surgery or any surveillance for that
• 25:26specific type of cancer related to that gene.
• 25:30So I hope that helps.
• 25:31This is my last slide before we move on.
• 25:34Very important brand new in the
• 25:35New York Times.
• 25:36It was a joint statement from the
• 25:38Society of GYN Oncology and the
• 25:41National Ovarian Cancer Research
• 25:42Alliance just came out earlier
• 25:45this week saying that again,
• 25:46we don't have great surveillance
• 25:49for ovarian cancer.
• 25:50And if there is a genetic risk or
• 25:52even in women without a genetic
• 25:54risk and there's an opportunity
• 25:56to remove the fallopian tubes,
• 25:58that should certainly be considered.
• 26:00With any other surgical procedure
• 26:03under certain circumstances to
• 26:04prevent these high grade serious
• 26:06ovarian cancers that we believe
• 26:08may be starting originating in the
• 26:10fallopian tubes so hot off the press.
• 26:17Let's start our second case.
• 26:19Our second patient is a 65 year old gravity
• 26:22zero gravity 0 should postmenopausal
• 26:24female referred to gynecology by her
• 26:26primary care provider for vaginal spotting.
• 26:29She reports spotting on and
• 26:30off for the past two weeks.
• 26:33This patient came from primary care,
• 26:35but we also see this patient
• 26:37from urgent or walking care.
• 26:38Often seeing if you can't see your primary
• 26:41care or or from the emergency room.
• 26:43Past medical history is significant.
• 26:45She is suffers from obesity,
• 26:48type 2 diabetes and hypertension.
• 26:50She takes 2 medications for her
• 26:52hypertension as well as metformin.
• 26:54Her BMI is 40,
• 26:56so now Class 3 obesity.
• 26:58Her last period was at age 53 and she did
• 27:01not take any hormone therapy after menopause.
• 27:05Family history notable for diabetes
• 27:07and multiple family members,
• 27:08and coronary artery disease and her father.
• 27:11On exam, she is in fact obese.
• 27:13GYN exam is limited by her body.
• 27:15Habitus Speculum exam reveals dark
• 27:17menstrual appearing blood in the
• 27:19vaginal vault and the uterus and
• 27:20adnexa are not able to be palpated.
• 27:26So kind of following the algorithm
• 27:28of postmenopausal bleeding,
• 27:29stop the bleeding, make a diagnosis,
• 27:31and then make treatment
• 27:33options with this patient.
• 27:35I thought the bleeding was a little too
• 27:37brisk to attempt the endometrial biopsy.
• 27:40Danger is put the patient through
• 27:42the biopsy but only receive blood.
• 27:44Umm, and and sometimes a little
• 27:46uncomfortable biopsying the uterus.
• 27:48I can't palpate or see that well,
• 27:51so I elected to start Provera 10 milligrams
• 27:54daily and order transvaginal ultrasound.
• 27:57The ultrasound revealed the 60
• 27:59millimeter heterogeneous endometrium,
• 28:01which is abnormal.
• 28:02Uterine length is 10 centimeters,
• 28:04which is generous and no
• 28:08myometrial abnormality.
• 28:09I then performed an endometrial biopsy
• 28:11in the office and it was returned as
• 28:15endometrial intraepithelial neoplasia.
• 28:16That's somewhat the new technology
• 28:19for complex hyperplasia with atypia.
• 28:23That diagnosis,
• 28:23I thought,
• 28:24should see Joanne Oncology.
• 28:29Thanks Jeff. And yes, we did have the,
• 28:31the chance to see this lady and what
• 28:34we spoke with her about is is sort
• 28:36of left untreated this condition
• 28:38can progress into a cancer in
• 28:40about 40 to 50% of women that some
• 28:43of the data from the older term
• 28:45of complex atypical hyperplasia.
• 28:47And so there are a lot of you know
• 28:49different options for treatment
• 28:50depending on the patient's age,
• 28:52they're surgical risk factors and
• 28:55and what it is that they like to do.
• 28:58Just to sort of trail off from
• 29:00this patient for a second,
• 29:01let's say this woman was young.
• 29:03Maybe she was in her early 30s and
• 29:05she had not had an opportunity to
• 29:07have children and that was part
• 29:08of her family planning long term.
• 29:10We do actually now have some exciting
• 29:12data to show that using things like
• 29:15the progestin releasing IUD's that
• 29:17we know very well from contraception
• 29:19can actually cause this to regress in
• 29:22about 80 to even maybe 90% of women.
• 29:24The downside is there that that's
• 29:26not a definitive approach.
• 29:28Um, and if the underlying risk factor
• 29:30so the diabetes, the hypertension,
• 29:32the morbid obesity haven't been corrected,
• 29:34that patient is likely to.
• 29:37Rebound into a refractory hyperplasia at
• 29:40some point if and when the IUD is removed.
• 29:43The other population that we consider
• 29:45using either the IUD or an oral
• 29:48progestin in a long-term fashion
• 29:49are those women who we meet who have
• 29:52really high surgical risk factors sort
• 29:54of inherent in this population with
• 29:57the the diabetes, the hypertension,
• 29:59the obesity,
• 29:59some of the cardiac disease that really
• 30:02put patients at risk of going to the OR.
• 30:04Sometimes we will choose to do a
• 30:07non-surgical approach in those women.
• 30:09However,
• 30:09in this lady we sat down,
• 30:11she was seen by her primary care provider.
• 30:13Who helped with risk stratification
• 30:16and optimization for her comorbidities
• 30:18before going to the OR and we
• 30:20considered her and butcher for
• 30:22a robotic assisted hysterectomy,
• 30:23removal of both tubes and
• 30:25ovaries and frozen section.
• 30:27You know you might ask,
• 30:28you know Doctor Joseph has taken
• 30:29the time to do an endometrial
• 30:31biopsy and we we have a diagnosis
• 30:33of a precancerous process.
• 30:34But if you look at some of
• 30:36the historical data,
• 30:36the risk of there being a concurrent
• 30:40already invasive endometrial cancer
• 30:41can be as high as about 40 to 45.
• 30:44Percent.
• 30:44And so because of that risk and
• 30:46the potential of a sampling error
• 30:48with an office based biopsy,
• 30:50we do recommend that women have
• 30:52a frozen section of the uterus
• 30:55at the time of the procedure.
• 30:57If that does relevant cancer then
• 30:59we do proceed with the appropriate
• 31:01staging which typically involves some
• 31:03assessment of the pelvic lymph nodes.
• 31:05And so we plan for this patient.
• 31:09The standard of care for these surgeries
• 31:11really is now moving on with an MRI.
• 31:14Approach or laparoscopic,
• 31:15you may have some patients who ask,
• 31:17you know they've read the
• 31:18New York Times that robotic
• 31:19surgery is associated with worse outcomes
• 31:21that's in cervical cancer and we are very
• 31:24interested to see where that that goes.
• 31:26But for endometrial processes really
• 31:28the standard of care has been a
• 31:30MIS and and we continue to see
• 31:32good outcomes with that approach.
• 31:34So this city was found to have an
• 31:37early stage SO1A Grade 2 endometrioid
• 31:40endometrial adenocarcinoma and
• 31:42this is probably one of the more.
• 31:44Common, you know final pathology
• 31:46that we see what we do for all of
• 31:50our endometrial cancer patients is
• 31:51we screen them for mismatch repair
• 31:54deficiency or microsatellite instability
• 31:56through both the combination of the
• 31:59immunohistochemistry and the PCR.
• 32:01And that is both just screened
• 32:03for Lynch syndrome,
• 32:04but also to look for inherent somatic
• 32:06changes in the tumor that may not be related
• 32:09to anything in the family or the DNA.
• 32:11And I have to say this is one of the most
• 32:13common questions I hear from women is they.
• 32:14They get a cancer diagnosis and
• 32:16the first thing they're saying
• 32:17is what do I tell my daughter?
• 32:18If you know, what do I tell my sisters?
• 32:20How can I inform my family
• 32:22on on their risk of cancer.
• 32:24This patients results did show
• 32:26loss of staining in the MLH one.
• 32:29However that reflexes a test to look
• 32:31for an epigenetic phenomenon called
• 32:33hypermethylation in the promoter region
• 32:36and that is not when that is positive.
• 32:39That's not indicative typically
• 32:40of a lynch syndrome and therefore
• 32:42those patients don't often or
• 32:44don't necessarily meet outward.
• 32:45Criteria to go on to meet with
• 32:47genetics just based on that result.
• 32:49However,
• 32:50they would then qualify down the road
• 32:52for any treatments or medications
• 32:54like immunotherapy that have shown
• 32:57promise in in this subgroup of of women
• 33:00because of the final results of her
• 33:02pathology showing some high risk factors.
• 33:04So the Grade 2 disease,
• 33:06the lymphovascular space invasion,
• 33:08we did ask Miss T to meet with
• 33:11our radiation oncology team to
• 33:13discuss vaginal brachytherapy and
• 33:15that is really the most common.
• 33:17Type of radiation women are now
• 33:19receiving for these endometrial cancers,
• 33:20it's typically three sessions,
• 33:22very well tolerated with very minimal
• 33:25long term toxicity and really has
• 33:28shown to decrease the risk of
• 33:30recurrence quite significantly.
• 33:32The next slide.
• 33:35I just wanted to highlight some of the
• 33:38sort of newer exciting technology that we
• 33:40have in the field of endometrial cancer.
• 33:43I'm sure many of you who have been seeing
• 33:45women with breast cancer or are other cancers
• 33:47have have been familiar with Sentinel
• 33:49node technology and those disease sites.
• 33:51But really over the last five to 10 years,
• 33:53we've we've seen a huge influx of
• 33:54data in and around the youth of a
• 33:57Sentinel node technology in almost
• 33:58all of our gynecologic cancers,
• 34:00which is very exciting.
• 34:02Pelvic Notice segment is very
• 34:03important in endometrial cancer.
• 34:05For stratifying risk and assign
• 34:08assigning adjuvant either chemotherapy,
• 34:10radiation therapy or both.
• 34:12And for years that included a pretty
• 34:15extensive pelvic node dissection over a
• 34:18fair bit of of space in the pelvis there.
• 34:20And so this trial or or more of an
• 34:23observational study tried to quantify
• 34:24how many of these women were going on to
• 34:27develop lymphedema of the lower legs.
• 34:29And just like the difficulties in
• 34:30treating that in the upper arms
• 34:32and the breast cancers,
• 34:33we have had a real challenge
• 34:35in managing that.
• 34:36Edema long-term women who develop
• 34:37it in the lower extremities and
• 34:39it's not a negligible number and it
• 34:41depends on which of the gynecologic
• 34:44cancers it is associated with.
• 34:45And so we've got really robust data now
• 34:48showing that across all the different
• 34:51subtypes of endometrial cancer that
• 34:53in women whose disease appears to
• 34:55be fine to their uterus at diagnosis
• 34:58that central no technology is safe,
• 35:00effective and almost eliminates the risk
• 35:03of lower extremity long term symptomatic.
• 35:06Of the team up offline.
• 35:07Next slide.
• 35:10So I'm going to pass it back over to
• 35:12Doctor Kim to talk a little bit about
• 35:13where we're moving and endometrial cancer
• 35:15and excitement coming down the road.
• 35:18Thank you doctor card. So this
• 35:20is a trial. Cancer
• 35:23is the most common gynecologic cancer
• 35:25in United States and incidents
• 35:27are rising as you are aware.
• 35:29So five year over survival for the
• 35:32localized early stage disease is
• 35:34quite good 95% or some for advanced
• 35:36stage that's not the case about
• 35:39higher overall survival is about
• 35:4118% and you know ultimately women
• 35:43die from succumb to their disease.
• 35:46So the our trend is more and more toward.
• 35:48You know successful outcome and trying
• 35:50to kind of figure out what are the you
• 35:53know the you know targeted approach.
• 35:55So based on the TCG a data the
• 35:58individual cancers are classified
• 35:59based on the molecular subtopics.
• 36:02So I draw your attention to the left column.
• 36:04So there are four subtypes one the
• 36:07two on the left is called Poly or
• 36:11polymerase X1 or alternated tumors.
• 36:13These are instance are quite small
• 36:17about 2.6% but their outcomes.
• 36:19They're quite excellent compared to
• 36:21the microsatellite instability or
• 36:23hyper mutated tumors or these are
• 36:26considered hot tumor in the instance
• 36:29about the 30 about close to 40%.
• 36:33I mean these are the type of tumor that
• 36:36respond really well to the immunotherapy,
• 36:38the 1/2 on the right,
• 36:40the copy number level or endometrioid
• 36:43subtype in the one that's the
• 36:46worst prognosis is the one called.
• 36:49Sarah slate.
• 36:50With P53 mutated tumor there
• 36:53outcome is quite poor.
• 36:55So based on the what does the
• 36:59classifications or treatments going
• 37:00to be changing and especially the
• 37:03based on the port tech for studies our
• 37:08pathologist going to classify and mental
• 37:11cancer differently than what we used to.
• 37:14So next slide.
• 37:17These are just to kind of giving
• 37:20you perspective of people.
• 37:21Isn't that was the proof for
• 37:24the as a second line?
• 37:26Melissa that's tumor type for the MSI micros.
• 37:32Stability of the MSI or mismatch
• 37:37repair deficiency tumors but with
• 37:40the junction with the multi oral
• 37:43tyrosine kinase inhibitor then that
• 37:45and this was a this changing that
• 37:49they were seeing patients with
• 37:51advanced cancer settings are living
• 37:54longer regardless of double marker.
• 37:57So next slide, what to expect
• 37:58or for the new direction?
• 38:01Adverse events are basically can
• 38:05affect any organ systems and most
• 38:08common organ that can be affected.
• 38:10So thyroid and people to come on
• 38:12on the hypothyroid and also we
• 38:15need some replacement therapy.
• 38:17But these are early recognition
• 38:19and interventions and you know
• 38:22have your subspecialist,
• 38:24your pulmonologist, gastroenterologist,
• 38:27dermatologist,
• 38:28endocrinologist you know have a referral.
• 38:31You have early interventions because
• 38:33these are quite impactful therapy
• 38:36and you want the patients to be on
• 38:38really effective therapy for long.
• 38:42Next.
• 38:45It's just kind of giving you like a.
• 38:49You got the. And tougher to therapies
• 38:53not just for the breast cancer
• 38:55nowadays at the lab in combination
• 38:58with the chemo and her to express.
• 39:04Advanced urine service.
• 39:05Serious cancer can improve the overall
• 39:09outcome and so overall survival,
• 39:11and this was based on the
• 39:14doctor Elizondo sentence work.
• 39:19Next that. Thanks.
• 39:25So this kind of brings everybody through
• 39:29that kind of over the purple pearls.
• 39:33Alright, so let's review the clinical pearls,
• 39:36a transvaginal ultrasound is
• 39:37often helpful prior to gynecology
• 39:40or GYN oncology consultation.
• 39:42The ultrasound evaluates the ovaries
• 39:44more accurately than a CT scan
• 39:46and can measure the endometrium.
• 39:47And I I think that if there's ever a
• 39:50question and you have to refer the
• 39:52patient on to gynecology or do you
• 39:54in oncology get the pelvic ultrasound
• 39:56ahead of time it it'll it'll make
• 39:59that consultation pump that much more
• 40:02thorough any person with ovarian cancer or.
• 40:04Course to be relative with ovarian cancer
• 40:07would benefit from genetic testing and
• 40:09I think we heard tonight how to do that,
• 40:11how to kind of get in line
• 40:13for genetic counseling.
• 40:14Before the genetic testing,
• 40:16ovarian cancer can be a chronic disease,
• 40:19one of our slides showed.
• 40:22That with the the new treatment,
• 40:23the life expectancy is much
• 40:25longer than we we had years ago.
• 40:27All postmenopausal bleeding
• 40:29must be evaluated.
• 40:30Even spotting and remember the
• 40:32algorithm stopped the bleeding,
• 40:34make a diagnosis and then treatment options.
• 40:38Order an FSH level if there's
• 40:40any question that a patient is
• 40:42is menopausal or not menopausal.
• 40:45Again,
• 40:4652 year old woman has had a
• 40:48few periods in a year.
• 40:50Is that postmenopausal bleeding
• 40:51or or perimenopausal?
• 40:53So an FSH ahead of time is very helpful.
• 40:56And many gynecologic cancer
• 40:58survivors are candidates for hormone
• 41:00replacement therapy if needed.
• 41:02That's an important point as well.
• 41:03If it if it's not an estrogen
• 41:06sensitive cancer,
• 41:08then hormone therapy can
• 41:11certainly be investigated.
• 41:20So and I can guide some
• 41:22questions if you'd like.
• 41:24Yeah, I I just want to remind
• 41:26the folks who are on the line to
• 41:29complete the survey when you're
• 41:30done to get your credit and you can
• 41:33always e-mail us with questions and
• 41:35and these are the upcoming ones.
• 41:37There is one question in the
• 41:40chat from from Beth Allard,
• 41:42maybe we can start there.
• 41:45And and and Beth if you noticed his actually
• 41:47on the panel for next month's session,
• 41:50so she's getting a little warm up here.
• 41:54No, I think Jeff,
• 41:55this is probably for you.
• 41:57Is there a place for endometrial
• 42:00biopsy in a pre menopausal woman
• 42:03versus post menopausal?
• 42:05When would you do that?
• 42:07So I think an endometrial biopsy,
• 42:10it's it's I, I do it more often
• 42:12than not when there's a question.
• 42:14So remember men, Araja has an endometrial
• 42:17biopsy and and perimenopausal bleeding
• 42:20would as well because remember
• 42:23tonight's topic was GYN oncology.
• 42:25But most of the abnormal bleeding
• 42:27I see is not going to be oncology,
• 42:29right, even postmenopausal bleeding,
• 42:31it's probably 8020 benign.
• 42:33So fibroids, polyps, endometritis.
• 42:37There's there's a lot of other reasons,
• 42:39which is why I do the biopsy and it
• 42:42doesn't go right to Doctor Clark.
• 42:47So I have a couple of questions that
• 42:50had come to me through colleagues
• 42:52before the session that I'll ask.
• 42:54And I would also encourage all of anybody
• 42:56who's attending to please send in questions.
• 42:59This is a pretty great opportunity
• 43:01to have a panel of people who can
• 43:04answer them at a intense level.
• 43:07So one question that I have is
• 43:11about this fallopian tube study.
• 43:14So in the past you know,
• 43:17we also recommended prophylactic oophorectomy
• 43:20for many women having hysterectomy.
• 43:23And at this point at least in my practice,
• 43:25there are a lot of women having
• 43:28hysterectomies, hysterectomies
• 43:29as part of pelvic reconstruction.
• 43:31So they're they're not in the
• 43:32cancer world at all and as a primary
• 43:35care clinician I may offer some.
• 43:36Advice and it comes back with
• 43:39mixed perception.
• 43:39Is that outdated?
• 43:40Is it just the fallopian tube?
• 43:42Now tell me the how did this all evolve?
• 43:47That's a great question, Karen.
• 43:48And we're still actually sort of going back
• 43:51and forth that pendulum continues to swing.
• 43:54A few years ago, there was a really
• 43:56nice paper that came out to suggest
• 43:58that there may actually be some
• 43:59underlying estrogen still produced
• 44:01by the ovaries even if it's not high
• 44:03enough to trigger the menstrual cycle.
• 44:06And so the pendulum swing to keeping
• 44:08ovaries in place for women in the the
• 44:10age seemed to be about 65 is what that
• 44:13study showed now since then there's
• 44:15been a few sort of large scale.
• 44:17Paper saying, you know,
• 44:19that benefits gained their weight
• 44:21against the potential of an
• 44:24ovarian cancer left undetected.
• 44:26And so there is a bit of sort of
• 44:28equipoise within the scientific community.
• 44:31I sit down with my patients.
• 44:33We try to do a more individual
• 44:35risk assessment.
• 44:35You know,
• 44:36is there a high risk of osteoporosis,
• 44:37heart disease,
• 44:38dementia,
• 44:38where those ladies might benefit
• 44:40from even if there's still a little
• 44:42estrogen being produced there to
• 44:44maybe prevent some of those conditions
• 44:46that we know are associated with low.
• 44:48Estrogen early in menopause and and
• 44:50the other thing is where women come
• 44:52from in their own life experience.
• 44:54You know if someone they saw
• 44:56go through an ovarian cancer.
• 44:57I have to say those leaders are
• 44:59typically asking us to remove the
• 45:00ovaries at the same time, but we do.
• 45:02We do think the majority of at
• 45:04least the high grade serious does
• 45:05come from the two.
• 45:08And of course, family history
• 45:10public plays into that quite a bit,
• 45:11right? Yeah, OK. Very helpful.
• 45:17Wait, I have a comment about that.
• 45:18So this is something that I learned
• 45:21a long time ago, but which maybe,
• 45:23maybe everybody knows,
• 45:25but it's because the developmentally
• 45:27right that the the tissue that
• 45:30the fallopian tube and peritoneal
• 45:33that lines the peritoneum is,
• 45:35is is originating from the same tissue
• 45:39that that that develops into the ovary,
• 45:42you guys get better.
• 45:43Is that that's why?
• 45:45The sense that it is,
• 45:47when we look at all the sort
• 45:49of epidemiologic data over the last 50 years,
• 45:52essentially any risk,
• 45:53anything that reduces the number of
• 45:55lifetime ovulation, so pregnancy,
• 45:58continuous hormonal contraceptives,
• 46:01breastfeeding, all of those
• 46:03things seem to reduce your risk.
• 46:05And so people thought every time the egg
• 46:07comes out of the ovary, that rupture,
• 46:09that repair of the surface of the ovary,
• 46:12that's eventually going to lead to your
• 46:13first hit and your second hit in that
• 46:15sort of reconstruction of the ovary.
• 46:17But now we've learned that's actually
• 46:19probably the content of the ovum.
• 46:20So the sort of pro inflammatory fluid
• 46:23that's in the egg that's coming out,
• 46:25that's bathing the fallopian tubes on
• 46:27their fimbriated end and they live in
• 46:30very close proximity and that's that
• 46:32repeated pro inflammatory exposure.
• 46:34That's at least the tubal hypothesis
• 46:36that most of us are sort of going with
• 46:39right now and it's that's probably why
• 46:42all those epidemiologic factors hold.
• 46:44But it's less has to do with what's
• 46:46happening on the surface of the ovary.
• 46:47The ovary and what that ovulation is
• 46:49doing to the fimbriated end of the
• 46:51fallopian tube and and the data on
• 46:53this is really quite impressive in in
• 46:55countries and centers that have been
• 46:57doing this for quite a bit longer than
• 46:59we have have seen a nice decline in
• 47:00their population rates of ovarian cancer.
• 47:06So I want to just add that the patients
• 47:08with the BRACA mutations that by
• 47:10the time they undergo prophylactic
• 47:12southernmost reckoning they already
• 47:14find existing tumors that are already
• 47:17formed like we call stick regions.
• 47:19So kind of give you like
• 47:21how the cancers are rising,
• 47:23that's a great point.
• 47:24And and last thing I'll talk about the
• 47:26tubes because I'm obsessed with the tubes.
• 47:28If you can't tell,
• 47:29we actually have now open at Yale we
• 47:32believe so strongly and they said
• 47:34a scientific level that women with.
• 47:36Bracket 2 mutations can enroll in
• 47:39the clinical trial that will remove
• 47:41just the fallopian tube and delay the
• 47:44removal of the ovary until menopause
• 47:46and they'll be followed for quality
• 47:48of life measures as well as of course
• 47:51development of an ovarian cancer.
• 47:53But because ovarian cancers occur a
• 47:55little later in the bracket two women,
• 47:58this trial has been designed to evaluate
• 48:00if removal of just the two would be
• 48:03sufficient risk reduction for that
• 48:04population and we are now enrolling patients.
• 48:07At both the Waterford and
• 48:08our New Haven Care Center.
• 48:11That is fascinating. And honestly,
• 48:13as a primary care physician,
• 48:15I didn't know that.
• 48:16And so I I think it's really helpful
• 48:18to bring out here where people may be,
• 48:20you know, counseling people as to whether
• 48:22to participate in a trial like that,
• 48:24that it's a strong theory, Jeff.
• 48:26It looked like you were
• 48:27about to say something.
• 48:29So, so all, so all female voluntary
• 48:32sterilization now has gone to salpingectomy.
• 48:35So you know back in the day clips, rings,
• 48:38tubal ligation using single port laparoscopy,
• 48:42that's all kind of gone by the wayside.
• 48:44I bet it's been 10 years now that
• 48:47voluntary sterilization is now a
• 48:50laparoscopic bilateral salpingectomy.
• 48:51And we started the fimbriated end because
• 48:53we think it's the most important.
• 48:56They kind of tease the the fallopian
• 48:58tube off the ovary through the broad
• 49:01ligament and and get very close
• 49:03to the uterus so that you know.
• 49:06The whole fallopian tube is
• 49:08is effectively removed.
• 49:10It's kind of changed the surgery
• 49:11just a little bit,
• 49:12but it's still 35 millimeter ports.
• 49:16Still a rather simple surgery.
• 49:20Back at, you know,
• 49:21when I was doing C sections,
• 49:22if we had a tubal at C-section,
• 49:24the same thing,
• 49:25no longer were we just sort
• 49:26of interrupting the tube but
• 49:28removing the whole fallopian tube.
• 49:30And that's been quite a while now.
• 49:33And I I think for
• 49:34any reduction in ovarian cancer with that
• 49:36that or is it hard to tell because of?
• 49:40There are other factors at play.
• 49:42I think that's where the studies
• 49:44are going right now, Doctor Brown.
• 49:46Yeah. OK. Is there risk reduction
• 49:49in the high risk population?
• 49:51It'll take many, many years to
• 49:53know if this brings the risk down
• 49:55of an ovarian cancer subsequently.
• 49:57But you know we've seen patients
• 49:59who do have these stick precursor
• 50:01lesions who then unfortunately have
• 50:03to have full usually hysterectomy
• 50:06and fiereck tomy afterwards if an
• 50:09incidental stick lesion is determined.
• 50:12And then we followed them along to make
• 50:14sure that they're doing well afterwards,
• 50:16but but. A lot of young women, I think,
• 50:19who are interested in permanent
• 50:21sterilization but also feel like
• 50:23this is maybe something that they
• 50:25can really do to reduce their risk.
• 50:27If they have a family history,
• 50:29even if the genetics are negative,
• 50:31they really are inclined to do something
• 50:32that's in their control to reduce their risk,
• 50:34and this is one thing they can do.
• 50:37Great. So I just I'm John I'm glad you
• 50:41were talking because I'll come back
• 50:42to you and then I still don't see any
• 50:45other questions from our audience.
• 50:47I would encourage people to ask but
• 50:51I I loved your wording you you blew
• 50:54over it a little it was actually
• 50:56you know sometimes when you hear
• 50:58things twice in one week it they
• 51:00stick and and so a week ago in.
• 51:02Internal medicine.
• 51:03We had a grand rounds from a faculty
• 51:06member named Anna Deforest who had written
• 51:09a book and her point was words matter.
• 51:12And and she specifically said what you said,
• 51:15which is we don't call things
• 51:18mutants and mutations.
• 51:19They're called variations and
• 51:21that that wording is important.
• 51:23In addition to hearing that
• 51:24from you and her this week,
• 51:26I also got back a lab report
• 51:28on a patient with.
• 51:29I don't know hemochromatosis or something
• 51:31and it said mutant detected and you
• 51:34know I had never been so kind of
• 51:36sensitized to that as I was with that.
• 51:39So I I think it's helpful to
• 51:41remember that that words matter and
• 51:44and and and the other thing that's
• 51:46helpful is this concept of.
• 51:49I guess it's futility,
• 51:50but advice now against surveillance,
• 51:51so in those who are high risk doing
• 51:54these regular ultrasounds and markers
• 51:56has not proven to be effective.
• 51:58And so knowing that that's now also
• 52:01within the gynecologic community
• 52:03in addition to our, you know,
• 52:05kind of preventive health focused
• 52:07on internal medicine communities
• 52:08is very helpful.
• 52:11And I think the background.
• 52:12Oh, go ahead, Doctor Clark.
• 52:14No, no, sorry, go ahead. I was going
• 52:15to say something more of an aside.
• 52:18Real quick, I'll just point out
• 52:20that all the more importance now on
• 52:22family history and identification of
• 52:23genetics is really the key as far
• 52:26as prevention of ovarian cancer.
• 52:28Yeah, and testing the the mutation, OK. What
• 52:33I was gonna say I just about
• 52:34one of the reasons probably
• 52:36that the NCCN has now dropped.
• 52:37This is just the really
• 52:39poor performance of C125.
• 52:41You know we order it but there are so
• 52:45many things that can cause it to be
• 52:48elevated whether that's diverticulitis
• 52:49Crohn's disease you know you see
• 52:52any sort of inflammatory condition.
• 52:54Recent COVID I had a patient who
• 52:56is on surveillance for ovarian
• 52:57cancer who didn't tell me she had
• 52:59had COVID recently chapter 25.
• 53:01It was mildly elevated obviously
• 53:03very anxiety provoking.
• 53:04For that woman.
• 53:05And so you know in ordering that
• 53:08it's always good to just sort of
• 53:09I try to really tell patients,
• 53:11you know,
• 53:12if it's a little elevated and you
• 53:14have one of these other conditions,
• 53:16please don't interpret that
• 53:17as a test for ovarian cancer.
• 53:19And so you have 125 has really
• 53:21helped us with so many ways,
• 53:22but has really caused a lot of
• 53:24anxiety for for healthy women
• 53:26in other ways and so sort of
• 53:29being cognizant of sort of how
• 53:30to interpret those results in
• 53:32the context of of each patient.
• 53:34Um,
• 53:34to try to reduce some of that anxiety
• 53:36until they get a chance to meet
• 53:38with one of us at the Cancer Center.
• 53:42Thank you. This was just wonderful.
• 53:45I am so appreciative and I know my
• 53:48primary care colleagues who are
• 53:50listening and who will listen later.
• 53:52We'll feel the same.
• 53:53And do you want to?
• 53:55Wrap us up, you, you had a question,
• 53:57if you have a question we wrap it up
• 53:59from the New York Times.
• 54:01It seems like there's some some new
• 54:03studies coming out around estrogen
• 54:06replace hormone replacement therapy
• 54:07and I think that always comes up.
• 54:10You've had a you know if you're if you've
• 54:12had cancer or you are at high risk
• 54:15of cancer because of a family member,
• 54:17what's the bottom line about is it safe
• 54:19to take estrogen replacement therapy?
• 54:25In 3 minutes I'll take this
• 54:27one. In 30 seconds.
• 54:29It's it's an individualized decision,
• 54:32depends on the tumor,
• 54:33depends on the patient,
• 54:35depends on her all other risk factors.
• 54:38Smilo does have a sexuality menopause
• 54:40for cancer survivors program.
• 54:41We love to see women and talk about
• 54:43risks and benefits for the most part.
• 54:45Vaginal vulvar, cervical cancer.
• 54:47Yes, it's safe.
• 54:49Endometrial and ovarian depends
• 54:51on the tumor type.
• 54:53Doctor, you agree with that?
• 54:57Absolutely. And Joanna is
• 54:59underselling her role in Sims Clinic.
• 55:01This is an incredible resource at Yale,
• 55:04one of the first in the country to
• 55:07comprehensively evaluate and support
• 55:08women who have been previously
• 55:10told that they are, you know,
• 55:12not eligible or candidates for something
• 55:14that can really improve quality of life,
• 55:17especially in our young women who who
• 55:19go on to develop a gynecologic cancer.
• 55:22And so it's very individual.
• 55:24I have patients who you know.
• 55:27Or on hormone replacement therapy,
• 55:29who came off because of their cancer
• 55:31and their quality of life was so poor
• 55:33and and we really don't actually have
• 55:36prospective randomized data to say that
• 55:37it will cause your cancer to recur.
• 55:39And so it is important that you actually
• 55:41sit down with someone like Joanna or
• 55:43someone who has experience with this
• 55:45and hear the actual data so that you
• 55:47know your patients can make an A truly
• 55:50informed decision and and not just
• 55:52based on you know what their friends
• 55:55have told them or to do or not to do.
• 55:57Because quality of life is just
• 55:59as important as survivorship.
• 56:03I think that's a great place to end.
• 56:05Thanks to all of our faculty for
• 56:08the the great discussion the cases.
• 56:10Thanks to our participants for
• 56:13attending and and please again tell
• 56:15your tell your colleagues to to attend
• 56:18or listen these are recording so
• 56:21they're available and we look forward
• 56:24to seeing you in the future at our
• 56:27next smilo chairs which is Renee
• 56:30can you put that back up for the.
• 56:33For the. For folks.
• 56:41OK. Well, that's all right.
• 56:43We'll, we'll, we'll send it around.
• 56:44It's always the the same Tuesday at
• 56:47the same time, same time, same time,
• 56:49same place, March 7th, GI cancers. Yes.
• 56:53Thank you so much and again please
• 56:55make sure to complete the survey.
• 56:57We really appreciate that and
• 56:58have a good night everyone.
• 57:00Thank you again.
• 57:01Goodnight. Thank you. Thank you
• 57:03guys. Thank you.