Good evening everyone.
I'm Doctor Mary I'm lost Burg and
welcome to this edition of Smiley
shares on breast Cancer Awareness Month.
Our focus today will be on new
treatment advances and innovations.
Please allow me to introduce our speakers.
Come and Mary M Lustberg and
I'm chief of breast oncology.
I'm here at Yale.
Joining me tonight is Doctor Tristan.
Park is an assistant professor of
surgery and in addition we have
vector bookdown pomoc who is a
chief who's a chief of plastic and
reconstructive surgery together,
will present three talks to
you that focus on the most.
Recent advances in multidisciplinary
management of breast cancer.
To start with, in honor of
breast Cancer Awareness Month,
I wanted to just briefly recap
where we are with breast cancer.
As you can see here.
Breast cancer is diagnosed in all ages now.
It tends to peak in in in the 6th decade.
However, younger women and older women
can still be diagnosed with breast cancer.
In addition, men can also be diagnosed
with breast cancer and they comprise
1% approximately of all diagnosis when
their right hand graph you can see
differences and outcomes based on race.
And this is an area of active
advocacy and effort here at Yale
as well as nationally to improve
disparities in breast cancer.
Who's at risk? The biggest risk
factor is is is is is being female.
Advancing age, family history and there are
other risk factors that are listed here,
including exposure to radiation,
abnormal biopsies, post menopausal obesity,
excessive alcohol use as well as
hormonal features including early
age of man are late age of menopause.
Late pregnancy.
We have identified a number of
different genetic factors that are
associated with breast cancers.
Some of them are associated with
higher risk of breast cancer and
these are things that we can test for
in the majority of cases, though,
we do not find an identifiable genetic
factor that tells us why an individual is
diagnosed with breast cancer versus not.
This is also an area of active investigation.
The number one message tonight is that the
diagnosis of breast cancer is no one's fault.
Certainly there are risk
factors that we cannot change.
There are certain modifiable risk
factors that can reduce risk and that
includes weight management exercise.
However, none of these factors
100% takes away the risk.
We strongly recommend following
breast imaging screening guidelines
starting at age 40 and annually.
However,
I just wanted to re emphasize
that we can do all these things
even with regular screening.
Uhm?
Now where women and men can
count about breast cancer,
and again it's nobody's fault,
and the focus of tonight is once a
breast cancer diagnosis happens.
What are the latest ways that we are learning
to manage it better and more successfully?
So the first talk will be the one I
will give focusing on personalizing
and rightsizing rest oncology care.
The outline is to focus on personalized
medicine,
explain what it is,
what does it mean with respect to
breast oncology and review a few
current strategies for personalizing
breast oncology care and wrap up
with future opportunities so the
short version of what personalized
medicine or precision medicine that
you have heard a lot in the news.
The best way that I find to describe
it is the right treatment for the
right patient at the right time
and this is what we focus on.
And Breast Cancer Care as well.
And so how are we personalizing
Breast Cancer Care?
And I think as you can see tonight with
our panel of having a medical oncologist,
a surgeon and a reconstruction
surgeon altogether,
is that ultimately the best
personalization or Breast Cancer
Care is multidisciplinary management.
I'm really working together as
a team to deliver the best care.
So in most recent years we have
seen greater use of neoadjuvant.
Also known as preoperative chemotherapy
or therapy that we get prior to surgery.
You will hear tonight about advances
in surgery and reconstruction.
And then I will cover the therapies
that we give throughout the whole body
or systemic therapy to personalize
treatment and a lot of a lot of
work has gone into better matching
patients to the right treatment.
And throughout this process.
Our goal is to partner with you
as key stakeholders as we help you
make the decisions that are best
for your Breast Cancer Care.
So one of the key points of tonight in
terms of personalized medicine on breast
cancer is that not all breast cancer
is the same and that we actually have
multiple subtypes of breast cancer.
And this is the major advance that
we've had in the last two decades.
Many breast cancers are estrogen
receptor positive, but not all of them,
and not even all estrogen receptor positive
breast cancer is created the same.
We sometimes further classify
them as Lumina lay and aluminum.
We we also have a unique subset
of breast cancers known as her
two overexpressing breast cancers
and these are approximately about
15% of our breast cancers.
And then we have another category of
breast tumors, approximately 15% as well,
which are known as triple negative.
However,
even these can be further subdivided
into multiple sub categories,
sometimes up to eight different categories.
So really this slide is meant
to show you how.
Breast cancer can be quite different
from one patient to another,
and it's so important to understand
the biology of breast cancer
and target other treatments.
Soum further emphasizing this point that
a lot of our treatments are focused
on this subtype of breast cancer.
We also look at the pathology
or tumor characteristics.
Looking at the Histology,
the grade, the stage of the tumors,
and we also really look at molecular
and genomic characteristics,
which I'll cover in the upcoming slides
and all of this information helps us.
Taylor, the best systemic therapy for you.
So more information on this coming up.
So what are our current strategies for
personalizing our breast cancer therapies?
This is a big topic and could be
an hour long lecture in itself.
However, for the purposes of this talk,
I have divided it into three sub categories.
One is targets and targeted therapy.
Less is more, and more is more,
so you'll hear each of these
mini chapters coming up,
so targeted targets and targeted therapy.
So we are understanding more and
more about the various targets that
are present in breast tumor cells.
In this schema you can see a
number of different targets,
including the PDL pathway which we
are targeting with immunotherapy.
The EGFR and her two pathways are
targeted with her two directive.
Therapies and a whole new emerging
area of Turkey targeting DNA DNA
repair pathways through very precise
on targeted therapies that have
been shown to be very effective.
I will show you some saw some data on those.
And so we've begun to test,
uhm, in the last decade,
both the tumor tissue for
genomic targets as well as you.
So your germline DNA, what makes you,
you and eat many of these,
actually have targetable drugs,
for example patients with germline
BRCA one and two or bracket one and
two alterations actually have very
specific drugs known as PARP inhibitors.
These are pills that you can take
in the comfort of your home.
And they've been shown to be
very effective.
We're also beginning to find very specific
markers of immunotherapy response,
including tumor mutation burden.
Breast cancer was one of the
later tumor types to enter what
we call the immunotherapy age.
However, just in the last few years,
we've had several approvals for
different indications for immunotherapy,
particularly in the setting of
triple negative breast cancer.
So back to the burqa or Bronco story
on these drugs were first approved in
patients with metastatic breast cancer
who had a BRCA one or two alteration,
and both these studies showed that if
you took these oral drugs and actually
compare them to traditional chemotherapy,
you can see in the Burgundy line here.
The targeted therapy actually
outperformed chemotherapy,
so this led to the FDA approval
of these agents.
And then most recently,
we actually just just this past summer.
Just a few months ago,
we received news of a major
international collaboration looking
at oral PARP inhibitors and early
stage breast cancer patients who
had a BRCA one or two alteration,
and this included patients both with triple.
Negative as well as.
You're positive, high risk breast cancer,
and again the addition of targeted
therapy led to improvements in outcomes,
so this again highlights the importance of
knowing our targets and going after them.
The next chapter is about less,
is more,
UM,
and we've made a number of advances in
terms of actually testing the tumor
tissue through a number of validated assays,
and these may include Oncotype or
Mammaprint mammaprint and select for
patients who need chemotherapy and avoid
chemotherapy and those that don't need it.
And we this is already in routine
practice and we're we're doing this,
something that's evolving.
And not quite ready outside of
research is actually testing the
tumor tissue for what we call
tumor infiltrating lymphocytes.
And these are cells that actually leave
the bloodstream and enter tumor tissue.
And what we have found is that
tumors that actually have a lot of
these tills or tumor and filtering
left side actually do really well,
and so a number of studies are looking
at well, can we spare chemotherapy?
In patients that have high tails
and so this is a work in progress,
not not in not ready for prime time,
however is being actively researched.
Again,
the FEMA is if we can select the tumors
that are more likely to do better.
We can scare toxic treatments.
Those patients.
And then the last chapter is more,
is more up and the idea is if we
can pluck out the tumor types
that actually need more treatment,
we can improve our outcomes,
and so the best way that we know how
to do this is through preoperative
or pre surgery, chemotherapy.
So by using these treatments upfront
before surgery we can decide if
more therapy is needed after and
it's a type of precision medicine
because we can see in real time.
How you actually responded
to your treatment and
I'll give you just a few examples before
wrapping up in her two positive breast
cancer after using traditional chemotherapy,
there was a groundbreaking study that
if there was any remaining tumor,
using a smart therapy called Tyler or TDM,
one actually dramatically improve outcomes.
So it really allows us to tailor your
treatment in triple negative breast cancer.
We we also have.
Good data that if we use preoperative
chemo and there is remaining risk visual
disease using a pill therapy known as
the Lodha can also improve outcomes,
but it's not perfect so there's a lot
of work being done with immunotherapy
in the setting to see if we can further
improve outcomes in triple negative
breast cancer and in high risk,
ER, positive disease.
We're looking at using oral
targeted therapies these drugs.
We like to describe them as things
that put the brakes on tumor growth
and by slowing down any residual
tumor cells that may be left,
the anti estrogen therapy
can actually work better.
So these three examples are examples
of how by adding more treatments,
that's precise we can actually
improve outcomes and breast cancer.
Lastly, future opportunities.
There are lots of new smarter
drugs that are in the horizon,
and they're actually here.
I think this is the future of
breast cancer chemotherapy.
They're known as antibody drug conjugates,
and essentially what it is is
there is an antibody component.
And then there's a linker.
And then the chemo is actually
very precisely linked,
and so the drug can actually be
very precisely delivered to to the
cells that actually have the target.
And they're actually here today.
I mean that this is something that
we're actually using and in the
clinic now there are a number of
them I've chosen to highlight them
for two drug known as and her two.
This was just presented and
dramatic improvement over some
of our traditional drugs.
So I think what we'll see is
earlier use of these antibody drug
conjugates in breast cancer with
the hope of improving outcomes.
So in summary,
we have lots of biomarkers and
more targeted therapeutics.
We need to address equity
issues and breast cancer.
Lots of multi deep collaborations and whole
system thinking and rightsizing therapy.
Some people will need less therapy
and some people will need more.
And throughout all this we want
to partner with you hear your
thoughts and impressions where
one team together with you and.
Ultimately,
all of these efforts will help
us improve patient experience,
patient outcomes,
and have a more efficient
health delivery system.
Feel free to put your questions in
the chat will have time at the end,
but at this point I will turn
it over to my colleague,
Dr Park who will speak about
the latest advances in surgery.
Hello I am Tristan Park,
I'm a breast surgical oncologist.
I'm I will be sharing with you today.
Advances in the surgical management
of the axilla in breast cancer.
So when a woman comes to me to get
her breast cancer treated, there's
two parts that we have to think about.
One is the cancer that exists in the breast,
and then they're great.
And then we also have to address
the draining lymph nodes.
So there's two things that
are generally done.
If they don't think that they
have any cancer in the left notes,
that's obvious we have to do something
called a staging study or assessing.
If there's cancer there, or if there's
or we have high level of suspicion.
That the lymph nodes are involved.
Then we need to address the lymph
nodes in a therapeutic fashion.
Remove the cancer and and treat it so
it's like a two part surgical treatment.
Historically, many,
many decades ago,
the only way to figure out what was
going on in the axilla was by doing
a complete lymph node dissection.
So that's removing many lymph nodes.
All the lymph nodes in the axilla
at the levels one and two.
So level one is this green area here,
level 2 is this blue area here.
That's all in relation to one of
your chest wall muscles called
the pectoralis minor.
So way back when in the 1970s and 80s,
this was the only way to figure out what
was going on in the axilla everything.
Was taken out each and every left node
was looked at carefully and we could
determine nodes were not involved or
there was some cancer involved in the nodes.
Uhm,
there was.
There is a significant and definite
morbidity and complication rate
with this type of surgery and
there's blood like blood vessels,
nerves,
arteries and veins to be wary
of in this area.
And most people have a drain placed
and they have to stay overnight.
So it later on in the 19 around like
the 70s and 80s people were thinking
maybe there's a way to assess the
lymph nodes in the axilla without
removing all of the lymph nodes,
like not removing like every.
I could, you know, sometimes be up
to 20 to 30 efforts so the this was
the era of the Sentinel node biopsy.
So the way that this was done is
that the breast is injected with a
special material called either a blue
dye or a radioactive tracer or both.
And then it's quite miraculous.
'cause as a surgeon I'm the one that
injects the breast prior to surgery
and it's better like this and every
time within 30 seconds the die has
reached the most important nodes
in the axilla or the Sentinel left
nodes or the first training left.
Uhm, so then these first rating
left nodes is on average,
it's it's two or three is identified
by looking for a blue color or
using a special probe that detects
radioactive dye that's also injected.
And then you know small incision
is made and a couple of lymph
nodes are removed and looked at.
Looked at carefully so this is clearly a big.
Big switch from doing this
actually left no dissection.
Removing all these lymph nodes and all
the complications associated with that,
you could also do some preliminary assessment
of these lymph nodes by the pathologist
by something called a frozen section,
which is kind of a looking at a couple
of slices of the left node to eyeball
if there is any cancer involvement.
So clearly these are two different
types of surgeries,
and there's complications related to
both that are shared lymph edema or
swelling of the arm is the most kind of
dreaded complication and intentional left.
No biopsy,
which is just removal of few nodes
versus axillary left node dissection,
which is removal of all the left nodes.
There's a lot more lymphoedema
in the axillary if you get
the full axillary dissection.
The literature sites about
1 to 3% in center left,
no biopsy and up to 30%.
If you get all of your left notes.
These other complications hematoma injury
to the nerves in the neighborhood Olympo.
See Laura would affection are
all present and as you can see,
although these numbers are very very low,
it's always you know three or
four times more.
In the axillary livnot dissection group.
So when I was doing this presentation,
I was thinking, you know,
maybe some people don't know
exactly what the fadima is.
They probably know that it means swelling,
but you know, there's actually kind of a
definition for it and different grades,
so there's great stage one,
which is up clinical.
So there's no clinical signs of swelling,
but there's a sensation of numbness,
achiness and heaviness there stage two,
which is mild lymphoedema,
which results in a soft pitting edema.
That's basically their arm looks swollen,
and if you press your finger into it,
it leaves an indentation, but.
There's no fibrosis or scarring,
and if you elevate the arm
this the swelling goes away.
Moderate or stage three lymph
edema is more severe.
There's more fibrous findings and scarring,
and the limb elevation
doesn't reverse anything.
And then severe lymphoedema
or stage four is, you know,
severe scarring and you get skin changes.
And it's quite kind of irreversible
and usually moderate to severe.
Lymphoedema is the type that.
Is permanent and is limiting to
your ability to use the heart,
which could be problematic if
you're if that's your dominant arm.
There's varying different definitions
of exactly how to measure this,
but a lot of clinicians have reported.
A circumference difference
of two or more centimeters,
or a volume difference of 200
millimeters or more if you compare
it to your non involved arm.
So uhm,
basically this is the history of the central.
If no biopsy versus actually
left node dissection.
Overall the big picture is as time went
on we replaced this lymph node biopsy.
We've replaced that.
Actually live dissection with
this less invasive lymph node
biopsy for multiple indications.
So way back in the 1960s,
Doctor Gould defined the
term central lymph node,
meaning the first draining
lymph node in 1977.
This procedure of identifying the first
training left node was described by
a doctor at Memorial Sloan Kettering,
who was a fellow and was actually
studying penile cancers and trying
to find the draining lymph nodes
in the treatment of that in 1999.
The use of the radioactive tracer
was reported by Doctor Morton,
a luminary in the field in the in the
setting of Melanoma surgery in 1994.
Doctor giuliano.
Seminole figure in the role of
lymph nodes in breast cancer,
described left no mapping and sent a
love note biopsy for breast cancer.
So all of this stuff from 1960
to 1994 talks more about the
central lymph node biopsy.
Replacing axillary dissection for
staging or just kind of figuring
out figuring out if the lymph nodes
are involved or figure out what's
going on in the in the lymph nodes.
What I'd like to focus on this talk is
the really kind of milestone mental.
Cut a groundbreaking changes in the
past decade regarding the use of
sentimental boxy as potential therapy
to replace actually left no dissection.
If you have known tumor.
Known cancer in cancer burden in your axilla.
So I'll be talking about low
volume of disease in your XL.
A higher volume of disease in the axilla,
and then even more higher volume
of disease in your axilla,
and how we're continuously pushing
the envelope and that you know
things that were done that would
have been considered malpractice.
When I was a medical student is
now considered well studied,
safe and highly recommended in kind
of personalizing and downsizing the
type of actuaries surgery you get
as a breast breast cancer patient.
So milestone one do we have to do
a full access right dissection?
If we find cancer in the lymph nodes
after surgery and this is in the setting
of you have a small tumor burden.
The left nodes.
This is also called clinically no negative.
This patient has a normal feeling axilla,
the axillary left nose look normal on
imaging and we go and do the surgery,
and lo and behold,
on the central lymph nodes there's a.
There's a few lymph nodes at Farber,
some cancer cells.
So with the acceptance of Sentinel lymph
node biopsy as a staging technique,
a lot of clinicians were thinking,
you know, there's very low amount
of cancer in these lymph nodes.
Maybe we don't have to do a full actually
dissection so they were just doing this.
You know, even before the studies came out,
so in the 1990s and early 2000s,
almost 20% of practitioners were doing this,
kind of as a kind of.
But by their own clinical judgment.
So this, uh, this landmark trial Acogs 11,
was the trial that looked at
this in a rigorous fashion.
It was a multicenter,
randomized prospective trial which
is like the gold standard of trials,
and this definitively looked at.
If you had very small amount
of cancer in your lymph nodes,
do you really need a full extra lift?
No dissection?
Or is the lymph node biopsy enough so
these folks had small breast cancers
are clinically negative axilla and
they were to undergo lumpectomy with
whole breast radiation therapy,
which is considered the definition
of breast cancer.
Patient therapy they would get a
Sentinel lymph node biopsy and if
they had one to two lymph nodes
that harbored cancer cells in them,
they either got nothing else or
they got the further surgery.
The complete axillary dissection.
So this study showed that there was no
difference if you got no further surgery
or you got the full axillary dissection.
There was no difference in local recurrence,
meaning recurrence in your armpit,
and there's no difference in how long
you lived or five year overall survival.
It was equivalent, and then they found
this study up in another nine years
and the original findings held true.
Your local recurrence and your
overall survival were similar.
So take on point is if you have a
small breast cancer that's going to be
treated with lumpectomy and radiation.
You could have up to two lymph
nodes that have cancer in them,
and you don't need a full,
actually lift, no dissection,
and you'll still get a great
treatment that will render you
with excellent Disease Control.
That's equivalent to getting
all your left nodes out.
So that's milestone one.
There was a there's.
This was further kind of, UM,
supported by a study that was done
in Europe called the Amero study,
which looked at instead of doing
an axillary left node dissection.
They did actually radiation,
and can we wait for the milestone
was could we radiate the Excel
instead of doing more surgery?
If there's cancer in the left nodes,
the kind of the subtleties,
and this was you were not necessarily
getting lumpectomy and radiation as
part of your breast cancer treatment.
You could also be getting up stuck to me.
So that was also a variation,
and this study also showed basically
that your overall survival and you're
disease free survival with the same
whether or not you've got all the lymph
nodes out or you got actually radiation.
And the nice thing was the rate of
lipedema and the radiation group was about
half of the axillary lymph node biopsy group.
So the most obvious one is at five years.
If you had actually radiation,
you had a 6% risk of lipedema.
And if you had a full actually left
outer section here at 13% of us,
so clearly less that more than half decrease.
So take on point as if you have
breast cancer not treated with
breast conservation i.e mastectomy,
so a more kind of loosening the surgical
criteria and you have positive lymph nodes.
This can be.
This may be treated with radiation to axilla
and you may not need full axillary surgery,
so they were pushing the envelope some more.
And then milestone two was, you know,
let's see if we could push the envelope
some more and go even with a higher
level of disease burden in your axilla.
Could you read this section if you
have known cancer in the left nodes?
AKA clinically node positive
more tumor in the lymph nodes,
hard burden of disease?
So if you have clinically node
positive cancer like you go in
your lymph nodes feel large.
They live large on imaging
biopsied and there's cancer.
There's obvious,
documented cancer in her left nodes
in this day and age we always
treated with chemotherapy first.
It's also called neoadjuvant
chemotherapy for the,
with the hopes that we could shrink
everything up to make the surgery minimized,
and also it gives us great
prognostic information afterwards,
so folks that got chemotherapy
before surgery or new agent.
Chemotherapy,
it was noted that 40% of patients who were
initially tumor bearing in the axilla,
like became no negative after
this new regimen chemotherapy.
So we thought maybe if we
could identify these people,
they don't have to get the the
final axillary surgery or the
full axillary dissection.
So this was the ECOSOC 1071 trial and
basically patients with known cancer
in their lymph nodes were enrolled.
They came with therapy first and then
they got surgery and then basically they
looked at something on a false negative rate.
So basically.
Most negative rate is if you had a central
lymph node biopsy that was negative,
but then when you look further there
is actually more cancer in there.
So our goal false negative rate.
For this to work was it
had to be less than 10%.
So 10% was like the key number and we
were able to get that achieve that number
by having a more stringent central
biopsy criteria using dual tracer.
Meaning you had to use two different
types of lymph node tracing,
blue dye and technetium or
the radioactive material.
We had to remove at least.
Three left nodes,
and optimally we had to remove the
initially diagnosed left node or the AKA.
The clipped lived because we place the clip.
In the lymph node that has the
known biopsy proven cancer.
So a series of studies demonstrated
that we got this good false negative
rate or high sensitivity rate.
Basically is another way to think about it.
If you use the dual agent or got three
more than three central lymph nodes,
the number was always around 10 or less,
10% or less and then further
follow-up studies demonstrated that
if you got the clip note as well,
you could drop that false negative
rate to 6.8%. And even down to 1.4%.
So the take home point for this was.
Pushing the envelope some more.
Now we have bulky disease or
known disease in your axilla.
We could create your treatment so
that you know you have the lymph
nodes shrink up and then we could
minimize your surgery and we could
do it in a safe and accurate manner.
It's a much more stringent criteria,
but the fact that we're able to
identify this and get to this
point is like really remarkable.
So finally that the third milestone,
which is ongoing,
is looking at even more levels of disease.
People that have some response
to the chemotherapy.
They get their central dental
biopsy and there still looks like
there's some cancer there.
Do they really need axillary surgery
or could we replace that with?
Radiation, so those are ongoing studies
by the alliance group as well as the.
Nsap group so I just wanted to
kind of press upon everyone that
significant advances has been
made regarding our understanding
of the treatment of breast cancer
that spread to the left nodes.
Uhm? Actually,
there's no dissection which has removed many,
many lymph nodes and has known
morbidity and complications has
slowly been replaced over the years.
By this much more targeted curated
Sentinel lymph node biopsy.
First for staging purposes in the 60s,
Seventies, 80s nineties,
and then more and more for
therapeutic purposes.
For tumors that were left node bearing
lymph nodes that are known to harbor
or cancer cells in them and we're
continuously pushing the envelope.
So I feel like with the addition
of all of this great data,
we could make personalized
care and decision making.
This data helps us avoid axillary surgery
in patients who may have risk factors
that predispose them to infection,
lymphoedema, and etc.
And this is done as a kind of a collaborative
conversation between the patient and
their their doctors in a in a team setting.
So we we I am.
I'd like to come thank you for
listening and it's great to
be part of this breast cancer
Awareness Month outreach program,
and I hope that all the wonderful
advances and understanding that
we have made in this field,
particularly in surgery,
where we're constantly learning
more about the biology of the
disease and being able to mold
the type of surgery that's needed
and still feel good about it and
know that we're rendering the
patient with a good outcome.
Is ongoing, thank you.
Great, thank you so much.
Doctor Park and I think your talk
really highlights just all the
advances in personalized medicine
that we've been able to achieve
through dedicated clinical trials
which would not have been possible
with all the thousands of individuals
who have participated with that.
We will move on to our third
talk with Doctor Pomahac.
Thank you.
Thank you very much and I
couldn't stop thinking about all
the aspects of Breast Cancer Care and
how it starts with medical oncology.
Goes through radiation oncology,
surgical oncology and then
finally plastic surgery.
But also the communication of the team.
How much it may impact the
choice of reconstruction and
the timing of reconstruction
because the type of chemotherapy,
the timing of chemotherapy as well
as the presence of previous radiation
or plan for future radiation.
Those are all incredibly.
Important factors and beyond
the scope of this presentation,
but certainly document how we all
communicate together as one team.
I wanted to start with.
With sort of the basics back in 1995,
there were only 8% women receiving
breast reconstruction and there was
because largely this was viewed as
esthetic surgery and out of pocket payment.
In 1998,
the Women's Health and Cancer Rights
Act actually allowed women to be
eligible under in medical insurance
to obtain breast reconstruction,
and from then we have had a steady
rise in breast reconstruction
numbers up to the COVID year
where it plateaued and the pig.
Was actually the year before or a couple
years before around 43% of women,
so women with invasive cancer.
Almost half of them at the present
time received breast reconstruction.
Now the trends have also evolved
over the time,
and if you look at the early 1998,
which is when the Women's Care
Act was approved,
we had about the same amount of
autologous meaning using utilizing
patient's own tissue type of
reconstructions and the same amount
of implant based reconstructions.
But over the years this trend has
diverged and with the growing
number of reconstruction,
overall we have seen steady increase
in implant based reconstruction.
Now, why is it so well
from patients perspective,
a implant based reconstruction means
shorter operation and faster recovery.
Everything happens on the chest,
whether it's one or both breasts.
There is no additional donor site,
and the healing is generally limited
to probably two to four weeks
rather than four to six visitor.
Even eight weeks with the autologous
reconstruction techniques.
We have also seen increase in.
The number of bilateral
mastectomy both sides.
Both breasts are removed,
and that's because of the
identification of some of the genes
that predispose women to breast
cancer and and mastectomies that we
call prophylactic or also increased
anxiety among patients to leave
healthy breast in place when they
suffered from cancer on one side.
And although those are not generally
recommended as medically appropriate, there
has been increase of those cases as well.
Additionally, FDA has.
Has triggers her their stance on
moratorium on silicone implants
in 2006 as they were found to be
relatively safe and certainly
not connected to the connective
tissue disorders in large numbers
and studies that were performed.
Another factor is what's called
****** sparing mastectomy,
which is a technique of removing
the breast gland and breast tissue
without removing the ****** which
traditionally is viewed as as
a part of the breast gland and
traditionally was part of the operation.
And then finally the surgical
advance of structural fat grafting,
which is essentially a liposuction
of area where the patients have a
little bit of access and countering
the reconstruction with an implant
has helped immensely to improve
the aesthetic outcomes.
On the other hand,
the autologous breast reconstruction
techniques using the patient's own
body largely evolved into perforate,
are based techniques,
and I'll talk about it a little bit more,
but it is essentially a technique
where we try to spare.
Muscles or deeper structures
and just find vessels that.
By skin and fat there will be ultimately
used to replace the missing breast mound.
These operations are quite sophisticated
but tedious and take long time,
and frankly there is really not enough
surgeons in the country that would
be able to perform these operations.
That sometimes bilateral reconstruction can
take a whole day in the operating room,
and so the Community has also driven
the need or the the rise in implant
based reconstruction as well.
Now when I'm talking about implant
based reconstruction,
would I what I'm talking about is
really these two circumstances
release two options?
In some instances we place at
the time of mastectomy and tissue
expander and then later on come back
to exchange the expander for implant
and that's done for numerous reasons.
Sometimes it's concerned about the
viability of the skin because the
breast cancer surgeon has really
the hard job to remove the breast
gland without injuring the skin,
but the skin can be traumatized.
Putting additional full size
implant may cause additional trauma,
so placing expander allowing the skin
to heal and then gradually expand
the skin is a safer way to perceive.
Sometimes the patients want to be
larger than what they started with,
and that's another reason to put an
expander at the time of the reconstruction,
but ultimately the expander is a
temporary prosthetic prosthesis that's
ultimately exchanged for an implant.
Lately, though, we have been using more and
more immediate implant reconstructions.
Bad for proper patient can eliminate
one of the operations and can lead
to quite nice results in one stage.
Now there are different nuances
where this implant ultimately can
be placed on the upper row you
can see what's called subpectoral,
implant based reconstruction and
different views of this reconstruction.
Fundamentally,
the implant is placed underneath
the large chest muscle that covers
the implant and prevents some of the
problems such as capsular contracture
or tight scar around the implant,
but it also creates natural sloping
of the upper pole of the breast.
On the other hand,
because immediately superficial
to this muscle is a skin,
patients often develop what's
called animation deformity,
which is when you engage the chest muscle,
the skin suddenly moves and
it can look quite abnormal,
especially in dresses or
or swimming swimming suit.
That's one of the reasons why
lately we have reverted,
they were converted back to what's
called prepectoral implant placement,
which is placement of an implant in
front of the pectoralis major muscle.
In this case,
the implant has the disadvantage
of having less protection,
and sometimes the transition to
the upper pole of the chest can
be slightly abnormal,
but that's where the structural fat
grafting or injection of fat at later
date can actually make a difference
and considerable improvement.
So let me show you some of the examples.
This is a patient before and after
bilateral implant reconstruction.
She wanted to be considerably larger,
so this was actually interim
expander placement and then exchange
of implant whenever there is a
****** sparing mastectomy,
meaning the native ******* can be preserved,
and even though the breast
is largely insensate.
As the nerves are removed along
with the breast gland the the
result looks remarkably natural.
Another example of patient who had
the single stage reconstruction
implants placed at the time of
mastectomy with nice aesthetic result.
Patient who had who had tissue
expanders first and then implant
as she wanted to be larger.
One of the things that you can see here
is a little bit of rippling of the skin.
So sometimes the implant in the
prepectoral or in front of the
muscle plane causes rippling or
or visibility through the skin.
A problem that's really very difficult
to correct and can be really not correctable.
Another example is patients that
undergo only what's called skin,
sparing mastectomy,
so the mastectomy skin is spared,
but ****** area is not.
This invariably results in larger
longer scars and then the *******
have to be reconstructed later.
Ultimately the shape can look quite natural,
but it does never quite match the
result of ****** sparing mastectomy.
This is a patient who had skin
sparing mastectomy and then following
reconstruction of ****** areola.
Which can be actually these days
made fairly natural looking.
We use 3D tattooing as well as
reconstruction of the projecting part of
a ****** to complete the reconstruction.
In cases of significant ptosis
or drooping of the breasts,
the ******* are really not wise to
save as there would end up in really
wrong position and in those cases we
have to create a new unit process in
proper relation and the mastectomy
scars end up being low on the breast,
not across the president from
the previous previous image.
So the position of the mastectomy
scar is really related to the
position of the areola complex.
Example of unilateral or one
sided reconstruction with
contralateral symmetry procedures.
So many patients that opt to proceed
with only reconstruction of the
breast which is affected by cancer,
can undergo contralateral lift
or small reduction to match the
volume as as much as possible.
So one of the scary parts lately in the
literature has been anaplastic large
cell lymphoma was also called alcl,
associated with breast implants early on,
the incidence was considered
to be one in 500,000,
but then later was thought that maybe
even as frequent as in one in 1000.
Based on careful statistical analysis,
the truth is probably somewhere around
1 to 30,000 patients and 90 or over 90.
Percent of these are associated
with textured implants.
Textured implants were used
because of their anatomic shape
and ability to hold the position,
but also anatomically shape that we could
create and less complications related to
a capsular scar formation or contracture.
Now in those 10% of cases where
patients did not have textured
implants at the time of diagnosis,
it is unclear whether they may
have had textured expander or
other texture device in the past.
So it appears to be strongly
correlated with textured implants
and even types of texturing.
Certain manufacturers have seen
larger incidents of anaplastic large
cell lymphoma as compared to others.
It is a scary disease that
presents often with Blumberg,
asymptomatic swelling of the breast
and treatment is really removal of an
implant and complete removal of this
scar or capsule around the implant.
In rare cases there is need for
systemic therapy and there have been
unfortunately cases reported of deaths,
but the with transition to smooth
implants and smooth tissue expanders.
This should really be largely
minimized if not. Almost eliminated.
Now let's switch gears to tallages or
patient's own tissue breast reconstruction.
There are studies showing
superior long term outcomes,
so it's I always tell my patients
there's big upfront investment,
but the long term there is a better aging,
less concerns about the exchange of
an implant in case they rupture,
and any complications ready to the
implants are essentially eliminated,
and in studies again,
it's been shown that patients are satisfied
more than with implants overwhelmed.
Period of time now the donor
site that's most commonly used.
The workhorse is the lower abdomen
and traditionally in back.
In the 70s.
Technique that utilized the detachment
of the muscle and using an island
that you see in this ellipse on the
abdomen of skin and subcutaneous fat
to build the breast has sacrificed
one of the straight muscles of
the abdomen rectus muscles.
And that caused there is abdominal
strength problems or even weakness
or bulges or hernias.
This is why this what's called tram
flap or transverse rectus abdominis
muscular cutaneous flap was largely
replaced by perforator flap,
where we no longer sacrifice the
muscle but rather split the muscle
and find individual vessels that
feed the overlying skin and fat in
order to build the breast that way.
Uhm,
theoretically there should be
intact much left behind,
although there's a certain degree
of damage that occurs just by
dissecting the perforating vessels.
Results can be remarkably nice
again in ****** sparing mastectomy,
but more commonly these are
skin sparing mastectomies
that result in replacement of the
****** areola complex with skin coming
from the abdominal flab and this
is the score of the donor site and
islands that come from the abdomen.
These islands can be later changed or
reduced or made circular as as needed
and the revisions are fairly common.
This is one of the such an example where the
initial islands of skin were just too large.
They're important early on for monitoring
of the healthiness of the tissues,
but later can be removed and the shape of
the breast can be remarkably improved.
Now, in patients that don't have
enough subcutaneous fat and often don't
have enough even tissue on the chest
to reconstruct with implant alone,
we still use a combination of
autologous or patients own.
In this case,
latissimus dorsi broad muscle
of the back has brought.
Forward and wrapped around an implant.
So this is this.
Is Miss Dorsey muscular cutaneous weapon
implant and that allows us to reconstruct
president is challenging patients
with inadequate amount of tissues.
Now we have heard a little bit about
breast cancer related lymphoedema we
are now and it's one of the new things
that is very interesting and and the
early results are just trickling in
from all over the United States.
There are new treatments that allow us,
especially early on,
perform various interventions
that bypass the obstructions.
They're typically related to dissection
of the armpit as well as radiation
and treated by either connecting.
Now the lymphatic vessels directly
through the veins.
What's called Lynn for the venous
anastomosis or transfer of lymph
nodes from elsewhere in the body
to provide the breach of drainage.
So if I were to summarize some of
the new techniques,
gradually replacing breast
with structural fat grafting,
removing implant or expander,
deflating it is one of the novel ways
that we're looking at potentially
treating patients in order to
maximize the natural feel of the
breast and minimize the need for
implant and in some cases the implant
can be removed altogether.
In cases where we really need,
we don't have enough abdominal donor site.
There are other potential donor
sites for reconstructing breasts
and outside of the stomach it can
be hipped areas or inner thighs,
and then finally lymphatic surgery
for upper extremity lymphoedema.
Those are just some of these new advances.
But in summary,
I would say almost every patient has
an option of breast reconstruction.
There are very,
very few exceptions where I would
feel it's not recommended there.
They should be tailored.
All of those options should
be tailored to each option,
their overall medical status,
their body,
and their personal preferences.
Not everybody can invest the time
of recovery to use their own
tissues for breast reconstruction,
but it's always an option later.
I would say that more than half
of breast reconstructions require
more than one operations.
And that's important to remember
whether it's ****** reconstruction
or revision revisions of shape
for the two really
enhance the cosmetic appearance are very,
very common. And finally,
it's important to remember that
every reconstructive operation
ends as aesthetic operations,
so the nice result is really
paramount of our efforts.
And with that, thank you very much.
Thank you so much Doctor Pomahac.
We have a few questions in our chat
box and to the audience members.
Feel free to continue to put your
questions in the chat for Doctor Park
and perhaps you also Dr Palmer height.
There is a question about ******
sparing procedures and if one of you or
both of you would like to talk about.
Who is a candidate for a ******
sparing mastectomies?
On what considerations should
be taken for that?
Sure, so I think this is Carol's question.
So what is the recurrence of disease
in those that opt to spare their
******* and are they at higher risk?
So there are indications for
****** sparing mastectomy.
We really consider it like any other
skin margin at this day and age.
We also so as long as the cancer is not
frankly right behind the ****** we think
that you know uncle logically it's safe
to do the ****** sparing mastectomy.
We also also have a fail of a fail safe
step in the operating room where we do
a ****** core biopsy and make sure so
you know we do the ****** sparing mastectomy.
We take any tissue that's right
behind the ****** and we had that
specially tested by the pathologist
with intraoperative frozen section.
They look for any appearance of
any cancer cells, and you know.
So that's another safeguard.
Other than that,
the other kind of very conservative,
but in more and more relaxing criteria
for ****** sparing mastectomy generally,
folks that are smaller breasted,
have less risk of something called
****** necrosis or ****** death.
And folks that have less breast
ptosis or droopiness of the breast
basically also have less complications
with their ******* potentially
having issues post operatively.
But I always tell patients if this
very important to you could always
try it and you know if the ****** ends
up being involved in the interrupter
frozen section then we'll we'll deal
with it at that point and remove it.
But we could at least give it a
good shot from the beginning.
Also, there's great data saying that.
Even in patients that have.
The. BRCA, one or two gene?
So these are very high risk
patients to develop breast cancer.
****** sparing procedure is considered
very safe and that's actually a
preferred method for for preventative
surgery for ****** sparing mastectomy
for these bracket 1/2 patients.
These patients are generally younger
in their 20s and they're doing this for
a preventative reason so we love to
give them ****** sparing mastectomies
so that they could continue on with
their lives with with a good quality.
Life.
Great
thank you Doctor Park Dr.
Going to turn this one to you,
which is one of the
audience members is asking.
I guess the broader issue of how we
present options to our patients.
Obviously, we present reconstruction
options and her point is can come
non-surgical breast replacement
options such as external prostheses
be also discussed prior to surgery,
so essentially kind of presenting
the whole gamut and spectrum of care.
Yeah, no, I I think it's absolutely true.
Breast reconstruction is an option.
It's not a must, and it's always.
An option to do nothing essentially
allow the chest to be flat and
and fit with matching prosthesis
as close as it can go as close
as it can to the natural side.
The other thing that I would say
is often the remaining one side
can be too large or too droopy,
so there are options to treat that
up that one residual healthy breast
with either Lyft or reduction so that
it's easier to match the prosthesis.
So all of those are options that can
be discussed and certainly should
be discussed during the visit.
Whether it's with surgical oncologist
or plastic surgeon.
Great thank you all kind of pose.
Pose a question to our
panel members about age.
We have come a long way to kind of
as we kind of continue the theme
of personalizing our therapies.
Wanted to kind of get your thoughts
on the age of the patient and how
that may impact or decision-making.
I'll start with medical oncology by
saying that we have really kind of kind
of stopped thinking of an age cutoff.
For certain treatments and medical
oncology and really focus on looking
at the whole patient looking at
how functional you are, what what,
what other medical conditions you
have and so typically do not have
an age cutoff for our medical
oncology treatments up.
You know, with the exceptions,
of course,
maybe I'll turn it over to Doctor
Park in terms of age considerations
and axilla management.
And then we'll go to Doctor Palmer,
so
I completely echo Dr Lustberg
statements about. Uhm, about age.
I feel like the life expectancy
is getting more and more longer.
You know, until level,
I think like 70 is the new 50 because
our ability to keep people alive
in a with a good quality of life.
As is. You know it's not unusual to
have people live to their late 90s.
It's not surprising.
So I myself also don't.
I alter and curate the surgical
treatment based on patients medical
problems and they're kind of overall
functional status and sometimes on an
older person has a great functional
status and sometimes the person that's.
Decades younger has a terrible
functional status because they
have lots of comorbidities and
lots of other medical problems.
That kind of make them a
higher surgical risk.
So I think about that versus
actual chronological age.
And I would. I would echo
exactly what it was just said.
It's a it's really tailored to the patient,
not necessarily age of the patient.
And we work with the patient to make
sure that they choose option that they
find most palatable and going forward.
I think there's a huge future in in
even specializing the postoperative
protocols for patients above certain
age so that we can we can minimize
complications related to the smaller
reserve or certain of certain types.
Doctor Park, I'm going to take this
one to you. An audience member is
asking about atypical hyperplasia.
UM and a risk factor for breast cancer.
So atypical ductal hyperplasia,
or atypical or kind of precancerous
or cancerous duct cells that are in
the breast duct, but at a very, very.
Limited fashion, so we actually treat
this in a outside because the best
way would be like a holistic manner.
We look at the patients risk factors.
All of their other breast cancer risk
factors which are many things as well
as their family history and also how it
looks like on mammography, if it looks.
Very concerning on mammography and the
vibes ended up being atypical ductal
hyperplasia that would generally push
us to excising it in case there is
a hidden cancer in there somewhere.
That's called upgrade. So that is.
It's really a multi factorial thing
so if you have a lot of family
history of breast cancer,
other risk factors which include
your reproductive history as well
as estrogen exposure as well as
your mammographic findings is it
kind of a suspicious looking masks?
Or is it just you know some
borderline looking calcifications?
All of that is taken together
as well as you know,
age is also consideration to remove it.
And to see if there's an
underlying cancer in there.
Great, we have one question
is being answered in the chat.
UM so keep an eye on that up and then come.
But this question I'm going to turn
over to you Doctor Park as well.
It's about operating on stage zero and DCIS,
and considerations for that. So
ductal carcinoma, insight,
or DCIS, is a pre invasive cancer.
This is like consider like a step multiple
steps past atypical ductal hyperplasia.
But before invasive breast cancer,
as of now, the textbook treatment is
very similar to treating a cancer.
You remove it where it's treated
with radiation and if it's
estrogen receptor positive.
Also treated with systemic type
therapy like endocrine therapy.
There is some thought that certain low grade.
Types of DCIS that strongly
estrogen receptor positive could
be treated non operatively.
That's an ongoing.
Point of study and trials are
actively the comet trial.
And a central are being actively done
to see if we could identify a subgroup
of patients that have DCIS that may
never really progressed to cancer
and may be a slow growing indolent
static phenomenon for that cohort,
but definitely for other cohorts.
Folks with higher were busy
looking cancer cells or high
grade cancer cells that are DCIS.
We we generally stick with standard of care,
which is excision or radiation,
and and it's some sort of systemic
hormonal anti hormone therapy.
Create an. Where at the top
of the hour I wanted to come,
there's just one more question.
I'm just gonna answer and then
I'll close that so so it's
related to the park inhibitor.
All impares a.
Is it recommended for all BRCA one or
two carriers regardless of cancer type?
So studies are being done for prevention
or risk reduction if there's no cancer,
but in terms of current FDA approval
it's indicated for metastatic,
BRCA one and two tumors.
And then the Advent indication for
high risk here positive as well
as triple negative breast cancer.
Their results have been reported.
We don't have official FDA approval yet,
but were able to get the agents,
so I would say in the metastatic setting,
regardless of the cancer type
in the adjuvant setting,
it would be triple negative and higher risk,
ER, positive disease for now.
Well,
thank you to the audience members
for joining on your evening.
A special thank you to my panelists for
a great discussion and wonderful talks.
There will be a number of other smiles,
shares events with different
topics throughout the month,
so feel free to check out our sites
for those events and thank you again.
Have a good night.