Previously Recorded: Treating the Whole Patient: A Comprehensive Approach to Breast Cancer Care
Tuesday, November, 19th at 7:00 PM ET
In a recent webinar, in sightful panel discussion, led by Jane Mendez, M.D., Chief of Breast Surgery, where we take a deep dive into a real-world breast cancer case and explore how a multidisciplinary approach leads to optimal patient outcomes. Our esteemed panel of experts—including Reshma Mahtani, D.O., Chief of Breast Medical Oncology, Joseph Panoff, M.D., a Breast Radiation Oncologist, and Beatriz Currier, M.D., Medical Director of the Cancer Patient Support Center and Chief of Psychosocial Oncology —will collaborate to discuss the importance of treating the whole patient, beyond the disease itself.
Beatriz Currier, M.D.
Good evening everyone and welcome to Baptist Health Mammy Cancer Institute webinar. Uh, we will be discussing, um, this webinar that will be treating the whole patient, a comprehensive approach to breast cancer. Uh, you will be learning about all our speakers shortly. Uh, we're gonna be taking a deep dive into a real world breast cancer case and explore how a multidisciplinary approach leads to optimal patient outcomes. I would first like to share who I am. I'm Christy Flatus. I am with the physician. Business development team for Miami Cancer Institute and it is my pleasure to introduce our moderator and chief of breast surgery, Doctor Jane Mendez. Uh, Doctor Jane Mendez is a board certified by the American Board of Surgery and had her fellowship trained at New York Memorial Sloan Kettering. She specializes in the treatment of breast cancer and performs all types of breast surgical procedures. Um, her undergraduate was with Harvard University and her medical degree is from Mount Sinai School of Medicine in New York. Uh, prior to joining Miami Cancer Institute, she was at the Boston Medical Center. She served as president of the medical staff, amongst many other, uh, responsibilities. Doctor Mendez having multiple accolades, um, she has contributed notable breast cancer research, um, and her findings have been. Widely published above all, uh, Doctor Mendez is uh renowned for her incredible patient care and advocacy. She is passionate about educating patients and advancing breast cancer awareness. Um, she is a fellow of the American College of Surgeons and an active member of numerous professional societies. So with that, um, I'm happy to share Doctor Mendez and quickly. Uh, Jackie, you will be sharing, um, something about some videos or Doctor Mendez will be going first. Oh, thank you, uh, Christy. um, actually, thank you for the opportunity to be part of this webinar and to be moderating. So now it's my honor to introduce our team, my esteemed colleagues who will be part of this webinar today. Uh, first, we have Doctor Reshma Matani, who's the chief of Breast Medical Oncology at Miami Cancer Institute. Doctor Matani, uh, certainly a medical oncologist and she's a leader in medical oncology. Um, Baptist health wellness as well as um our clinical trials. Doctor Maitanni's practice is limited to the treatment of breast cancer. Prior to joining Baptist Health, uh, which she did in 2022, Doctor Matani actually worked as an associate professor. And she was in my, you know, at the University of Miami, and she was the director of community outreach. Doctor Mike Tan is active in clinical research and she leads our research efforts on multiple clinical trials, some uh with industry and some within the cooperative groups. And she really excels in that regard, and as you can see she is nationally recognized through her leader in breast cancer as presented her cancer research broadly as well. Doctor Tammany served as the national committee to recognize the cancer clinical trials of quality care across the country, and she's involving several initiatives for the um. Enhancing patients access to health care as well as in the community and I can attest to that. She's also very um important public speaker. She presents in many uh national organizations and societies including San Antonio and other very renowned uh meetings and this has got to moderate at the San Antonio meeting uh this coming December. So it's a pleasure to have her. Uh, next, uh, we have Doctor Joseph Panoff, uh, who is one of our breast radiation oncologists. Uh, Doctor Panoff is a board certified radiation oncologist. He specializes in breast cancer, at Miami Cancer Institute, Baptisal South Florida. He serves as a professor of radiation oncology at FIU as well as um. Obviously has research interests as well. He trained at the University of Miami at Miller School of Medicine, a completed radiation oncology residency in Jackson Memorial Hospital, as well as a Sylvester Comprehensive Cancer Center, where he served as assistant as a resident. I'm sorry. Furthermore, he collaborates with the institute in multiplenary setting to coordinate the most effective treatments for radiation oncology patients and beyond. He has great uh clinical knowledge as well as research findings and peer reviewed medical journals and healthcare symposiums. He's a member of the radiation therapy Oncology Group and American Society of Radiation oncologists, physician Patient relations is extremely important to Doctor Panov, and I can attest to that, and he provides patient centered approach in all his patients as you'll get to hear this evening. Um, then, uh, last but not least, we have, uh, Doctor Beatrice Currier, who is the medical director of the Cancer Patient Support Center and Chief of Psycho Oncology here at Miami Cancer Institute. Doctor Currier is the medical director of the Cancer Patient Support Services and Cancer Institute and chief of Psychosocial oncology at the Institute. She's board certified in psychosomatic psychiatric and leads multinational team in comprehensive. you know, including patients and including all sorts of services including psychiatry, integrative medicine, cancer rehab, as well as pain management, in addition to other services that you'll hear about including nutrition, patients well-being, acupuncture, and others that are part of the holistic approach. Doctor Carrier earned her medical degree from the University of South Florida. Um, medicine in Tampa, she completed general psychiatric residency at the University of Miami Jackson Memorial Medical Center program and completed a clinical fellowship in psychosomatic medicine at Harvard Medical School in Massachusetts. So I would love to thank all my colleagues this evening to be part of this webinar and welcome to all of you. Hi everyone, my name is Jackie Mercado. I am the marketing manager for the Cancer Service line. Throughout this webinar, as Christie mentioned, we will be discussing physicians will be discussing the importance of a comprehensive and multidisciplinary approach to breast cancer care, and to bring this to life, we wanted to share some stories uh from patients who have experienced this journey, um, with our institute firsthand. So in the first video, we'll hear from one of our patients, Stephanie Rio Masterson, who shares her personal experience with breast cancer and talks about how early detection and the support of this dedicated care team really made a difference in her journey. And in our second video, we'll be highlighting the story of another breast cancer survivor, Judy Sanchez, who also emphasizes the life saving value of early detection and the role it played in her successful treatment. Um, so we'll see these testimonials are a very powerful reminder of the impact that we can make when we focus on treating not just the disease, but the whole patient. So let's watch. Someone once told me that one day I would tell my story of how I overcame everything that I went through, and it would be someone else's survival guide. I am a pediatric nurse, so I'm always on my feet. I am married. We love to go out on the boat. The ocean is our safe haven. Befy makes me feel like the luckiest man in the world. That's the reality. Probably one of the just happiest people I've ever met in my life, and she just makes people around her happy. So the day that I realized something was wrong, I was experiencing a pain under my armpit where it just wouldn't go away. And so I called my OBGYN. They referred me to Doctor Star Mautner, who diagnosed me with invasive ductal carcinoma. Breast cancer is the most common cancer in women, and the average risk woman will have a 1 in 8 or 13%. Risk of developing breast cancer during her lifetime. So in Stephanie's case when she was discovered to have breast cancer, it was discovered not only in the breast but in her lymph nodes, and then a PET scan confirmed that she had a lesion in her liver. This is known as stage 4 or metastatic disease. Stephanie's cancer was particularly aggressive, and we see this sometimes in young women. Cancer doesn't have any manuals. There's no instructions on how to get through it. Steffi never lost hope. In knowing that she was gonna beat this, she has always been positive from day one. I think the hardest part for me was to see my family in pain. I knew we were going to get through this, and I knew that there was going to be roadblocks that we would have to get through. My desire to be a mother was everything I had ever wished for. What a lot of patients don't realize is that the treatments for cancer in general and specifically breast cancer can Impact fertility and for a young woman that's extremely important. We had to go through fertility preservation with that is just a lot of steps along the way. Stephanie received the full gamut of treatment and as I had mentioned, her cancer was very aggressive and needed to be treated aggressively, not only because of the subtype that it was HER2 positive, but because she was 28 years old. And so even though she was diagnosed with a stage 4 breast cancer, we were going for a cure. I just. Enjoy spending time with the nurses and being able to have my care all in one facility. From every step of the way, I mean, the entire team was incredibly good at communicating with us. We felt very comfortable with them really throughout the process, you know, from start to finish. The best part of my job is to be able to see my patients 6 months, 1 year, 2 years later, and be able to tell them they're doing great, that they have no evidence of recurrent disease. Um, and that they're cancer free and so it's amazing to be able to celebrate with Stephanie. I enjoy seeing her even outside of the office and I see her living life to the fullest. I am cancer free and I'm very grateful for all the physicians on my side. Doctor Mautner, to me it sounds pretty cliche, but she is a star. She's just an amazing physician. She loves her patients. She cares for them deeply, and she was with me every step of the way. I am now a mother of a one month baby and we are very grateful to have her here with us and for the opportunity to be able to go through such a beautiful process it's unbelievable to see Stephanie as a mom to go through everything that she went through over the past few years and now have a little baby of her own. It's extremely rewarding as a mother. There's no other better feeling in the world. Cancer does not discriminate. It doesn't care what age you are. Miami Cancer Institute is the only place here in South Florida where my family and friends should be treated. My name is Judy Sanchez. I'm 41 years old. I was born and raised in Miami. I have 3 daughters, 9, 10, and 11 years old, and I'm a marketing director at a Squierra law firm. I like to spend my free time traveling, going on adventures, reading, exercising, and watching my kids play sports. At 40 I had my first mammogram, um, which was normal, and then 6 months later because of family history I was supposed to do an MRI, just a routine MRI. So on my routine MRI they came back saying I needed to do a biopsy and then in the biopsy it showed I had two small tumors in my left breast. When I first. Got the call that I needed to do the biopsy I cried and I it was hard, very hard for me, um. But then once I think I had time to process, so by the time they told me I had cancer, I didn't cry I was fine. I had already gotten there in my mind but just hearing the first time and with my mom passing from it, it just was very scary. I first met her. Uh, she already knew her breast cancer diagnosis, and she came to see us here at Miami Cancer Institute for a second opinion. When I walked in, I was floored by how clean and how nice everything looked. It just is an uplifting place. It changed my perspective, I think on my cancer journey. And then I met with Doctor Mendez on Monday. I left Doctor Mendez's office on top of the world. I felt great. I was very reassured with everything whenever I have that first visit, I like to explain with that drawing and I actually tell them how we refer to the breast like a clock and furthermore, for me it's also symbolic. Because any cancer news changes a patient's life they feel that that clock is ticking, so the sooner we come with a plan, the sooner they can prepare for what's coming because it's a journey. So when I met with Doctor Mendez, she recommended a lumpectomy which I was very comfortable with. May 30th I had my surgery and it was very easy, simple. And then she saw one of our medical oncologists, one of our radiation oncologists, and the decision was made not to recommend chemotherapy and so when I met with her and she told me, OK, it's looks pretty clear that you're gonna go straight to radiation and skip chemo. Kind of had a tear um dripped down my cheek and she told me it's nice for me to see happy tears and then yes you receive adjuvant radiation treatment which was successfully completed. I am currently on hormone therapy for 5 years. I'm taking tamoxifen. I love it. I love the medicine. I feel like I'm sleeping better on it and I've got plenty of energy, so I've been really happy with all of my treatments so far. And it's so nice now to see her, you know, and there's no evidence of disease, she's gonna follow with routine imaging but she's cancer free and moving on with her life. Ringing that bell I got to get um I got my 3 girls out of school. They wanted to come and so ringing that bell, looking at their smiles, I was just on top of the world. Today is a great opportunity to remind women are some key messaging that we need to have opportunity to breast cancer awareness as well as prevention. #1, that will be know your body. #2, know your family history like in Judy she could take. Additional step because she has a family history and number 3 is take care of yourself and by that I mean living a healthy lifestyle monitoring what you eat, exercise, mammogram once per year starting at age 40 and all those other diseases that we have early detection of a much better prognosis, you know, I feel like cancer is a journey and um right now on this journey I'm at the top. So thank you, Jackie for sharing those videos, and I hope they illustrate a lot of the issues that we're gonna discuss as part of this webinar. So we'd like to share with you this is a real clinical case, and we're gonna do it in a multiplenary format, um, as obviously we do this every Friday and we have our breast tumor board. So this is the case of a 40 year old woman uh who uh was very healthy and presented to our clinic for a second opinion with a newly diagnosed multifocalist sexual um left breast invasive globular carcinoma. Her gynecological history, normal for men at at age 11, gravia 3, part of 3, and pregabida at age 30. Family history is significant for a mother with a history of breast cancer diagnosed at age 65, and she was already diagnosed at a metastatic stage. The patient had genetic testing performed and no actionable breast cancer-related mutations have been identified. Uh, in terms of the social history of region from South Florida, she actually lived in Japan for 3 years. She worked as marketing director for a local law firm, and she enjoyed running, reading, and basically weights, and she denied any alcohol use, tobacco use, or illicit drug use. So she had had a bilateral screening mammogram that dated back to August 25, 2022, and at that time, the mammogram was absolutely normal. It had been categorized as a virus too, which means that it was normal benign findings and given the Tusic calculated score 27.4, they have recommended a MRI for further workup. Uh, the Tussek risk assessment model is a model that we routinely use as part when we do the mammographic screenings, and if it's greater than 20%, then the patient is recommended to have a breast MRI for a further assessment. And as you can see here, her mammogram showed no underlying abnormalities. So she underwent the bilateral breast MRI on March 27, 2023, which showed I pay your attention to the left hand side of the screen on the left breast, you can see there's an area of abnormal enhancement. So the MRI showed that there was this indeterminate left breast, 1 o'clock, 6 centimeter from the nipple irregular mass for which additional recommended work was recommended, including a biopsy. And usually we do a second look ultrasound because it's easier to perform the biopsy through ultrasound rather than MRI and then if there was no sonographic correlated, then MRI get a core biopsy would be performed. And in addition to that, they saw at the 1 o'clock position 6.5 centimeters from the nipple, an oval mass with MRI characteristics consistent with benign finding, and no suspicious findings were seen on the right side, so the virus was classified as a virus uh 1, whereas the left side was classified as a virus uh 4 and the biopsy recommended. So this is the 2nd loop ultrasound that was performed in addition to a diagnostic left mammogram uh for further evaluation of the of the abnormalities that have been seen on the MRI. And as you can see at the left breast at 1 to 2 o'clock position, they at 6 centimeters on the nipple, they see this hypoechoic lesion that corresponded with the. MRI findings and in addition, they could see upon further detail on the diagnostic mammogram this area of shadowing and increased density on the left breast corresponding to the same area. So the patient went on to have a left breast sonographic guided core biopsy performed here on the image that you see on the left, you see the actual procedure where you see the needle coming through. This is done by obviously the radiologist, and here on the right hand side you see the pulse biopsy mammogram illustrating that you have the clip in the good position at the side of the biopsy with, and it was marked with a stoplight clip. Just so you know, we usually put the marker after the biopsy is performed and we perform the mammography just so that we can check proper placement. And if there are any other lesions, then we have other shape uh clips that we can apply to identify the different areas. So the pathology of this first biopsy revealed an invasive lobular carcinoma morally differentiated at least 4 millimeters tumor size, and there was no insight to carcinoma and no lymphovascular invasion. The tumor receptor status was estrogen receptor greater than 80% positive, the progesterone receptor as well, and the HER2 was equivocal, 2+, but the fish was negative. So, given the 2nd lesion that had been identified, uh, the patient also underwent the 2nd biopsy of the 2nd lesion, as you can see here on the sonographic cat core biopsy, and now you can see on the right sided image, now we have two clips and they appear to be pretty close to each other with the left post biopsy mammography. So at this point, uh, the Patient had shown to us, um, we submitted everything for consultation that standard practice when our patients come for a second opinion, we submit both the images as well as the pathologic findings for review. So this was the review of the external consultation and they recommended them to proceed. They didn't see any additional abnormalities except on the right side. They were concerned about an aerial device for which they recommended a biopsy as you can see here, so they con they confirmed the biopsy proven invasive carcinoma in the left breast at 1 o'clock. Appropriate action should be taken and then they saw the second area on the right side at 1 o'clock posterior death, and they recommend the MRI got a core biopsy for the right sided lesion. This is upon the second consultation from the external images. So this is the MRI got a core biopsy that was performed on the right side, which reveal a benign and concordant findings and certainly at this point, there was no evidence of any disease on the right. So it's very important whenever we do these core biopsies, we check the concordance. So our radiology team is critical in making sure that we agree that the pathologic findings really explain the imaging. And therefore, if it's discordant, then certainly the patient will require additional surgery, but in this case, this was benign and concordant. So here is the patient after a very thorough discussion about all these surgical treatment options, especially given her family history and her age, in terms of breast conserving treatment versus mastectomy with or without reconstruction, the patient opted to proceed with breast conservation. uh, and with that certainly sentinel lymph node assessment so that we can have that information for staging purposes. So for illustration purposes, these were her wire localization. Uh, for in preparation for the surgery, for her lumpectomy and cavity reexcision, what we refer to as cavity reexcision is removing all the margins after the lumpectomy, uh, specimen has been removed to assure negative surgical margins and then the axillary sentin only from a biopsy, which in this case was performed with the dual tracer using both the blue dye as well as the sulfur color technician 99. So the lumpectomy was successful and the sentinel lymph node biopsy as well. So then the lumpectomy, the patient had the two separate fossa of invasive lobular carcinoma. It was a grade 2. each of the lesions measured 3 and 2 millimeters, uh, each associated with the biopsy clips. There was no evidence of any lymphovascular invasion. She was also found to have some focal lobular neoplasia and surgical margins were negative for residual carcinoma, and a total of 4 lymph nodes were negative for carcinoma. And I'd like to point out that initially uh this patient had been diagnosed with invasive ductal at the outside institution, but further testing performed at Miami Cancer Institute Baptist Health demonstrated that according to the additional staining that was being formed this was consistent with a lobular and no doctoral histology. So certainly the patient had a lobular cancer and we talk about the subtleties of ductal versus lobular. So this is the histologic assessment, as you can see on the left hand side, that is the negative axillary node, looks beautiful with this uh cortex and no evidence of any invasion, beautiful lymph node. In the center you can see uh the obviously the margin, you can see the lobular histology and obviously that all the margins were free. And in the next slide you can see the uh ecahedron staining that led to the diagnosis of a lobular histology instead of just ductal histology. As you know, doctoral histology is most common, 80% of breast cancers are ductal in etiology, how lobular accounts for about 15% of breast cancers. And with that the different receptor status, which was confirmed to be estrogen and progesterone receptor positive and HER2 negative. So with that, I'd like to open this case for discussion. So, uh first, Doctor Reshma Matani is gonna address some of the medical oncology issues followed by Doctor Panov who will address radiation oncology and Doctor Currier, who will talk about more of the survivorship issues. So Reshma. Questions that I have for you. Uh, number one, you know, in terms of this patient or early stage breast cancer, uh, so I want you to give your impression about that. Then when it comes to the use of genomic profiling in some cases with indicated, what are the tools that we have available to help us in the decision making process about chemotherapy versus no chemotherapy, certainly adjuvant endocrine therapy, what options do we have available? And in a patient like her who's premenopausal at age 40, what other strategies can we use, such as ovarian suppression or other strategies to help avoid a recurrence in the future. So thank you for being here tonight, Rashma. Thank you, Jane. Uh, all great questions. So let's break it down from the medical oncology standpoint. Uh, so first off, this patient has an early stage breast cancer and we know in the next few slides, I'll be sharing some statistics on breast cancer. We know that fortunately, most cases are diagnosed very early and the Take home message here is the importance of screening. We know that when patients are diagnosed with earlier stage disease, their survival rates are significantly higher. This woman presented as a premenopausal woman with breast cancer, and that, of course, brings up other considerations that we'll get into with regards to genetic testing. But in terms of her systemic therapy options, I think that We've come a far away in medical oncology in terms of uh tailoring our treatment approaches for patients who really need the additional therapies as we're trying to balance the efficacy of our treatments with the toxicities in the old days, not too far, not too far long ago, uh, any woman with a tumor that was over 1 centimeter. regardless of lymph node involvement, used to be offered adjuvant chemotherapy. And now we have genomic assays that give us a better understanding of the biology of the disease, the risk of recurrence, and the predicted benefit to chemotherapy. This woman has an ER positive, HER2 negative, small multifocal, less than 1 centimeter tumor. Uh, in fact, she had a few fosa. The importance of getting that pathology clarified is, is really an important one as well. I don't know that I would have sent a genomic assay in this situation, uh, but those assays can be particularly helpful in providing prognostic information about the risk of recurrence and the benefit of chemotherapy. Beyond that, Endocrine therapy would be considered standard. Uh, tamoxifen would be a very reasonable option. We tend to consider ovarian suppression and an aromatase inhibitor or ovarian suppression and tamoxifen in women who have higher risk disease such as larger tumors, lymph node involvement. And as I'll be sharing with you in the next couple slides, we also have additional tools such as adjuvant CDK46 inhibitors. Again, not in this case because this patient wouldn't meet criteria. But here we see the subtypes of breast cancer and we recognize that breast cancer is not just one disease. About 2/3 of all women will develop hormonally driven breast cancers such as this woman, she had an ER positive tumor. Uh, they tend to be more common after menopause, but we're increasingly seeing younger women be diagnosed with breast cancer and maybe during our open discussion, we can talk about uh some of the reasons. That we are are postulating that that is happening. And in terms of HER2 positive disease, this accounts for a much smaller percentage, about 10 to 20% uh and linked to amplification of the HER2 gene overexpression of the HER2 protein. This is a much more aggressive type of breast cancer. We tend to treat these patients with preoperative therapy when they're Tumors are as small as 1.5 centimeters, but definitely when we get to 2 centimeters or any lymph node involvement with HER2 positive disease, we're very often offering preoperative therapy and then triple negative breast cancers that again account for about 10 to 20% of all early stage disease, and it's standard now preoperative treatment for stage 2 or 3 triple negative breast cancer. In the next slide, uh, it, we just highlight the importance of uh understanding an individual's family history. So this woman has a first had a first degree relative, I believe her mom passed of metastatic breast cancer, and of course, even without that history based on her age, she would qualify for genetic testing. We know that germline mutations uh account for a small percentage of uh the reason that Many women, uh, that, that women develop breast cancer. We know the risk is 1 in 8 in the general population, around 12%. If a patient has one of these high-risk germline mutations, most commonly BRCA1 or 2, that risk can be as high as 80%. And of course, just family history alone also can impact risk as shown here. In the next slide. You see a breakdown of uh of all the uh uh uh many of the genes that we're aware of that are associated with hereditary breast cancer. But notice there's a huge part of this pie that is gray, and it simply says other genes, familial risk factors. Of course, we see families that have really strong History and we just have not perhaps identified the gene that is impacted in that individual's family, but most commonly BRCA1 or 2 or uh uh some of the other genes that are shown here like CE2, ATM uh account for hereditary breast cancer syndromes. In the next slide, Uh, it just makes the point, and I think patients become confused about the terminology, uh, genetics versus genomics. So, of course, genetics, as we all know, is the study of individual genes and inheritance, and when we talk about, uh, for example, HER2, the HER2 gene, uh, that's not a, um, a, an inherited genetic mutation or, or Amplification in the tumor that is a property of the tumor itself. That's a genomic change where we see the study of multiple gene functions and how they interact with each other and the environment, so things like ER, PR, HER2, those are genomic changes and of course we can now even utilize next generation sequencing to get a greater detailed understanding of the tumor genomic landscape. So really sophisticated tools we now have and you see how that's changed over time. So broadly speaking, there are 3 treatment decision points in ER positive, HER2, uh negative breast cancer. And so, for example, in this woman's case, she had a hormone receptor positive, HER2 negative breast cancer, and of course the question is, does she need chemotherapy and endocrine therapy or endocrine therapy? Alone, recognizing she has a relatively small low-risk tumor, endocrine therapy alone would be sufficient. Again, in individuals that have larger tumors, lymph node involvement, we now have the opportunity to consider other adjuvant therapies in addition to endocrine therapy, namely CDK46 inhibitors. There are two that are currently available to be taken after um. Uh, uh, local therapy and while an individual is on hormonal therapy. And then, of course, uh, in the longer duration of follow-up, we consider length of time of endocrine therapy, recognizing that there are patients that will have late recurrences, meaning beyond 5 years. And there is an opportunity to individualize treatment decisions for patients that are felt to be higher risk of a late distant recurrence. There are genomic assays that can also give us information on that risk and the benefit of continuing endocrine therapy beyond 5 years. And I think that that was uh probably I hope uh addressed all the questions that you raised. No, thank you. That was extremely helpful and certainly to our audience. If you have questions, please uh jot them down. We're gonna address questions at the end of the presentations. We're gonna allow enough time. So now, um, I would like to hear from Doctor Joseph Panel, what about the radiation oncology piece? You know, this lady had a lumpectomy, so what is the role of radiation? You know, she had negative lymph nodes. Um, are there any alternatives, uh, to the standard radiation? I know you have all the gadgets and all the tools. So if you can then approach this from the radiation oncology standpoint. Thank you, Jane. So in the Before we get to this, so in the, in the early stage breast cancer setting, I think that the way to look at this or approach this is kind of three T's, and those are, those Ts would be target technique. And technology. Um, and so with a case like this, the first thing that the radiation oncology team would want to do is decide what is the target. So there for there's basically there would be three options for something someone like this. Um, one, there's a certain subset of patients now that we don't treat uh after lumpectomy in the adjuvant setting with radiation as long as they do endocrine therapy. um, this patient is too young for that subset. Um, so she would need to be treated, and then the, the next decision that you'd have to make is, do you treat partial breast or whole breast. And so for a patient like this who has multifocal disease, um, she wouldn't be a good candidate for partial breast because you want to treat uni focal unifocality. And so this would be someone who would get whole breast radiation, and once you decide that's the target, then the next step is, well, what is the technique you're gonna use? And in general, at Miami Cancer Institute, Baptist South South Florida, we like for when we treat the whole breast, our go to technique is prone, uh, a pruning technique, and we use a simple but elegant type of planning called 3D conformal and prone, and I have an example of it um in the next slide. This is just an example of the symmetry that you get from a patient who's prone. So this uh uh this is actually this patient. And so she's, um, lying on her belly and the breast hangs away from the heart and lung, and what you're seeing in blue is the tar. dose and it quickly falls off, um, posteriorly where her heart is. And so you're able to very simply lay all the dose on the breast while sparing the heart even in a left sided case. And this is bread, we bread and butter are very simple. If you go back, so then if you go back uh two slides before, um, to the video that I was you first had, uh, one before this one. There we go. OK, so if you click on this, this is a video and I was just uh wanted to show that every morning we meet, oh, is it not playing? We're not able to play. If, if you click in the actual center of it, if you move the cursor to the center, does it not work? OK, it's OK. I was gonna show um a video that we meet as a group, we have a a large team and we decide what technique and what technology we're gonna do for each each patient. And um this was a video of that in fast motion, that's OK. So, um, if you continue on the slides and you go past this slide, So this is a a proton plan for a more locally advanced uh treatment plan for a patient who has would have lymph nodes involved, it's actually a patient we're gonna talk about later. Um, and what this is showing is this is a much more sophisticated technique. But you're basically getting the same cardiac sparing. So in this plan, we're treating the internal memory lymph nodes, we're treating the, the, the reconstructed breast or chest wall, and other lymph node basins, um, to a higher dose than the previous plan, and we're getting great cardiac sparing, including the uh left anterior descending artery, which you can actually see on the left side. We're treating this patient supine, not prone, um, because we, we just wouldn't be able to do this prone. Um, if you go to the next slide. So when you, the next T is technology, and so like uh Jane said, or Doctor Mendez said, we have the the the great benefit to our institution is that we have all the technology under one roof, so we can decide what treatment platform we want to use to treat what patient who has with what targets and what technique. And just, I will be quick, um, the top left are the bread and butter of most modern, um, radiation oncology programs in the country. We have 3 of them. Those are linear accelerators, um, which is what we would do for the prone treatment. Um, the CyberKnife is for more focal tumors that are mostly in lung, and we're actually going to be, um, uh. Putting in a new machine into the CyberKnife fault. Uh, Tomotherapy is a, um, uh, helical. Um, linear accelerator that has very um unique, uh, properties for certain uh targets which include breast, especially bilateral breasts when you have to treat both sides and lymph nodes, uh, and the spine. The gamma knife on the top right is used mainly for brain mets and is is is actually our most uh pinpoint treatment platform. It, it can treat submillimeter. And then bottom right is our 3 gantry proton unit, which is the largest in South Florida, and the first in South Florida. Um, the MR Linac, which is the bottom, second from the bottom on the right, is an MR based linear accelerator, which we have really, um, uh, Doctor Chung here has pioneered and it has allowed us to treat. Um, many different malignancies, but especially gastrointestinal and pancreatic malignancies to much higher doses than we previously could, because we're able to treat in uh image in real time and watch breathing because of the MRI. Um, and then on the left side, we do what's called brachytherapy, which we also do for early stage breast cancer, um, which you can see all the way to the left, which is a savvy, um, technique where you insert catheters into the breast and then deliver uh high dose radioactive seeds into the um into the lumpectomy cavity. And if you go to the next slide, this is my last slide, um, these are just our The you advance to the next one. These are actual uh units. So, um, the last thing I would say is it's just it's having All of the tools allows you to deliver the best patient care for each patient. There's no doubt about that or argument. And if you don't have all those tools in some way or another, you're gonna have to compromise, um, which, which can result in increased toxicity or long term complications to the patient. Thank you, Joe. Obviously, you've demonstrated that no one size fits all, not even from the radiation standpoint. And hm. So now, I'd like to invite Doctor Carrier to talk about the psycho-oncology survivorship component. So certainly this is a young woman, 40 years old, certainly had a family issue, have been very diligent about her screening because of her mother. So, could you comment on what services we have uh from the survivors and psycho oncologists standpoint? Yes, thank you, Doctor Mendez. So, a cancer diagnosis and its treatment may represent one of the most stressful times in an individual's life. And that cancer treatment does take an emotional and physical toll on patients. So, at most major cancer centers, there are cancer support centers that are designed specifically. To to target those physical needs, the psychological needs, the emotional, social, and spiritual needs of patients. And on the next slide, our mission at the cancer support center is Specifically to improve the health outcomes of those patients by targeting these varied needs among all these patients. So, in addition to having healthcare providers such as surgeons, medical oncologists, and radiation oncologists to provide the life-saving cancer treatment, we still need a multi-specialty group of healthcare providers there to provide all the other needs that the patients develop along their cancer journey. And the cancer support center is comprised of 4 different hubs of service, that's all in one footprint. The psycho-oncology group looks at all the emotional psychological needs. Uh we also have cancer rehab, integrative medicine, and then the survivorship clinic. Next slide. And very specifically, to give you an idea, when you're looking at the left upper uh quadrant, the psycho-oncology needs are addressing anxiety and depression, especially in young breast cancer patients who are trying to raise a family and dealing with their careers, starting their careers, or thriving in their careers. We have found that the prevalence rate of newly diagnosed anxiety or depressive disorders is 3 times that of the general population. So we're talking close to 40% of our cancer patients, including our breast cancer patients, develop anxiety or mood disorders. In addition, this young woman was a marketing director. If she had received certain types of chemotherapy, she may have developed chemobrain. Our center looks at that. We're able to diagnose and treat it in-house. Um, In addition, we're also looking at patients who may develop body image issues or sexual dysfunction as a result of their treatment. So there's a whole variety of things we're here to treat, and you need to target and treat that. There's now compelling evidence that untreated major depression can actually increase the risk of cancer, breast cancer recurrence. So very important to be vigilant and to uh screen for it, diagnose it and treat it. In addition, the cancer rehab physicians are here to target the physical symptoms that are side effects of their cancer treatment. And that in our breast cancer patients may include lymphedema. They may develop uh balance issues due to the development of peripheral neuropathy from some of their treatment. They're also here to help with cancer-related fatigue, deconditioning. And it's, it's, uh, all of these issues have to be addressed, um, within either during their treatment or in the survivorship care because otherwise we've really compromised their quality of life and have compromised their health outcome if it's not addressed. Then we have our integrative medicine. Uh, uh, spectrum of care. And for example, in this young woman who um may have gone on to ovarian suppression since she was hormone uh positive and young, still premenopausal, she may develop severe hot flashes or vasomotor symptoms. We now have evidence-based protocols looking at acupuncture to aggressively and effectively treat those hot flashes. In addition, uh, it's, it's also used for um patients who may develop arthrogis or myalgias, secondary to some of the endocrine therapies, specifically the aromatase inhibitors, very effective acupuncture protocols to mitigate those types of side effects that could actually compromise compliance with this life-saving maintenance therapy. So you need to keep that in mind that we need a variety of healthcare providers to target all of this. I've, I have frequently said that it takes a village of healthcare providers to care for our cancer patients. Our nutritionists play a critical role in making sure that one of the most frequent uh risk factors for recurrence in breast cancer patients may include excess weight. Our nutritionists play a critical role in trying to mitigate these modifiable risk factors that can help prevent recurrence. Our exercise physiologists play a pivotal role also in getting the patient engaged into a much more active lifestyle because we know a sedentary lifestyle is also a risk factor for recurrence. So we're looking at all of these issues to try to help the patient, to empower them to take a more active role in prevention, which brings us to the survivorship program. The survivorship program is critical in focusing on healing, re recovery, wellness, and prevention. And very specifically, they are the, the program in which they look at ensuring that the patient is being monitored with certain surveillance guidelines to pick up for any recurrence of their cancer early on. In addition, they're providing screenings for other types of primary cancers because we all know that early detection is critical in terms of having excellent outcomes. And they also play a big role in all the mitigation of those risk factors we just talked about and doing a lot of wellness teaching. But I think most importantly, the final slide shows the customized survivorship care plan that our um survivorship program offers patients. And this goes through the detailed treatment summary of the patient in which we look at their history in terms of their diagnosis, the staging. The, the histology, the specific treatments they received, what type of surgery, if there were any um remarkable findings with their lymph nodes, the type of chemotherapy or targeted therapy they received as well as radiation. And these documents are typically 10 to 15 pages long because it covers everything in their history. And we distribute this to their primary care physicians, as well as the oncology team and the patient. So that they can take this as transportable, and they can take this to whichever physician they're seeing to ensure that all the physicians are on the same page in terms of the treatment they've received. So I hope this gives you an idea of the snapshot of the role that cancer support services plays in cancer centers. Thank you so much, uh, Doctor Carrier, you know, just to illustrate that as you very well said, it takes a village, you know, all the multiple specialties and not only doing the treatment but uh keeping the patient healthy and with quality of life after completion of the treatment. So with that, I hope that this uh cast illustrated the importance of individualized care. It's certainly a multisciplinary approach, no one size fits all. And since we have 8 minutes to the hour at this point, I'd like to open up for questions from our audience. Um, Joe, while we're waiting for questions uh to consult doctor panel from the audience, could you comment, you know, this patient had a left sided, uh, breast cancer, would there have been any role for any proton therapy on this patient? Right. So, um, first of all, there's, there's questions, just to tell you, they're there. Um, uh, no is the answer. I, I, I, this wouldn't be a candidate for protons because we're not treating the regional nodes. And so the main reason is you just don't need them. You're able to get essentially the same, a low enough, a very low heart dose with that pruning, much simpler technique. Um, and I only use protons when I'm treating the left side and I have to treat the regional nodes, including the internal memory nodes, cause they sit on the heart. I mean, they're they're almost inside the heart for some patients. They're just so close and um the the difference in dose to the heart in LAD is is incredible with with protons. Thank you, Doctor Panov. Um, Doctor Matani, it's so important to uh research and clinical trials. I know you are the 4. Front of that uh Miami Cancer Institute so you could comment to our audience what trials we have opened, cooperative groups and other things that we are the forefront when it comes to clinical trials so that our patients can benefit from participation in these trials. Thank you for that opportunity to highlight our clinical trial menu, and I think as we're all aware, breast cancer is not one disease as we've talked about tonight. And with that in mind, we have very intention. opened clinical trials for all subsets of breast cancer patients and for all stages. So our goal is to have a trial to offer an individual who comes in with early stage disease, even before that, a patient who's high risk and has not developed breast cancer. We have trials for those patients. We have early stage uh uh uh breast cancer trials as well as metastatic. Disease and within early stage and metastatic, we have ER positive, HER2 negative studies, HER2 positive, and triple negative trials, again, both in the early stage and metastatic setting. And one really important question that I see that came through the chat is uh asking about how we collaborate with referring physicians to ensure, ensure continuity of care for patients enrolled in clinical trials, and I love this question because It really highlights the importance of the patient physician relationship. And we know when individuals are diagnosed with breast cancer, uh, they put a lot of faith in the person who is their primary oncologist. And with that in mind, we're always mindful of that relationship and making sure that our notes are sent to the referring physician, that the physician understands why the patient may or may not be a candidate for the study, and most importantly, After their participation on the trial is complete, we return them to the care of their referring physician. Thank you very much, Doctor Matai. Um, I guess, um, any, um, last message from the survivor system stand for Doctor Carrier? Um, just the importance of making sure that um our survivors are well taken care of in a very proactive fashion because that can really shape their overall health outcome as they move forward through their journey. And as I, as our CEO Doctor Zinner, you know, has said from the beginning, it's all about how they had touched. I hope that these webinar and short case discussion in this multisciplinary has showcased to all of you the importance of every single discipline and really taking care of the patient as a whole with this specific type of breast cancer would have in an individualized personalized manner. And that is something that we take very seriously. We have our tumor board every Friday where we discuss cases as this one are more difficult ones, so we can ensure as a multiplinary team, what is the optimal care for each and every one of our patients. So, Doctor Panov, any last comment from the radiation oncology standpoint? Um, my only comment is that Uh, When when referring to a radiation oncology center, I said this already, um, I think it's important to uh make sure that they have a lot of experience treating a lot of different, um, complicated types of cases, and, um, you wanna a really a busy, a busy place that has a lot of, you know, the most modern technology, um, to be able to treat your patients with. And Doctor Matani from your standpoint. Well, I think I've spoken to the importance of being treated in an institution that has access to clinical trials. Uh, I'm very glad to say that our, our, um, mortality rates and breast cancer are steadily declining and a lot of that has to with um getting the word out about the importance of screening and diagnosing these cancers early, but a lot of that decrease in mortality is related to improvements in our novel therapies, and so I'm proud to say that we have many Of these cutting edge trials available for our patients in the early stage as well as metastatic disease setting, uh, including patients that are heavily pre-treated and have exhausted all other treatments as well as, uh, those who are newly diagnosed with metastatic disease where it still may be appropriate to offer them trial participation. Thank you and I want to remind all of the, um, all of you listening to this webinar that we have a service line uh for breast services. We have our cancer care clinic. We have our breast cancer prevention clinic where we address patients with high-risk pathologic conditions or genetic mutations that deem them to be a high risk for breast cancer, for breast cancer prevention. And we have benign breast clinic where we focus on benign lesions so that way we can really have excellent access to our patients who really need the access for cancer care versus those that need the specific service lines. So please, we're here, we're here to serve you at the community and you can see, I would like to thank all my colleagues. Uh, for taking the time to be part of this webinar and for all of you for taking time off your busy schedules to listen to us tonight. So thank you all for your participation and thanks to Doctor Matani, Doctor Panov, Doctor Currier, and the whole marketing team who helped us put this together and everybody behind the scenes. So have a wonderful evening, everyone.
