Diagnosed With Breast Cancer: What's Next?

Jonathan Fialkow, M.D. hosts a panel of breast cancer experts to answer the most common questions women have after receiving a cancer diagnosis. Listen in to their wide-ranging discussion about treatments, genetic testing, fertility issues, support services and the importance of finding an experienced multidisciplinary care team.

Guests:
Louise Morrell, M.D., medical director at Lynn Cancer Institute
Jane Mendez, M.D., chief of breast surgery at Miami Cancer Institute
Ana Botero, M.D., radiation oncologist at Miami Cancer Institute

Transcript

Announcer:

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Dr. Jonathan Fialkow:

Welcome Baptist HealthTalk Podcast listeners, I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Miami Cardiac and Vascular Institute where I'm also Chief of Cardiology at Baptist Hospital and the Chief Population Health Officer at Baptist Health. October is Breast Cancer Awareness Month and we're starting out with one of the biggest and most critical questions after a cancer diagnosis. What happens next? What do the stages of breast cancer mean? What treatments are available? How could treatment affect fertility and many more? It was my pleasure to host a recent episode of Baptist Health's Resource Live program with some of our top breast cancer experts who covered the most frequently asked question with insights gained through the years of battling breast cancer alongside their patients.

Dr. Jonathan Fialkow:

My guests were Dr. Louise Morrell, Medical Director at Lynn Cancer Institute at Baptist Health Boca Raton Regional Hospital, Dr. Jane Mendez, Chief of Breast Surgery at Miami Cancer Institute and Dr. Ana Botero, a Radiation Oncologist at Miami Cancer Institute. Let's hear what they had to say. Let's get started and Louise, I'm going to direct the first question at you. What are the providers within a clinical care team, a cancer care team, if a woman's diagnosed with breast cancer it's not just them and an individual. What's the makeup of the team that manages breast cancer?

Dr. Louise Morrell:

Yeah, I think every woman or nearly every woman I've ever met, who has a new diagnosis with breast cancer, I'm sure my colleagues would say the same thing, the word by itself causes so much terror that it might not even be able to think straight. But at the end of the day, getting information and getting a plan is what gets that under control. In other words, getting really confident that you know everything that you need to know before you start treatment. And that is a team and that's, I think what you're referring to.

Dr. Louise Morrell:

I organize my thinking this way, basically, when you have cancer of the breast you have three goals. One is get it out, don't let it come back and don't let it spread. It's that simple because if that's what happens then you're cured, right? If it never comes back, if it's out, it's gone. So those core things require the specialization of a surgeon who's going to get it out, of the radiation oncologist who's going to assure that it doesn't come back in the same area and of the medical oncologist who is ultimately going to plan how do we prevent it from spreading. But because of all the breakthroughs and advances that have come in this field, there are going to be other people involved in your care. Some of whom a patient might meet and some whom that we consider very, very critical to the team.

Dr. Louise Morrell:

Pathology, molecular testing, the kind of detailed testing that goes on requires a pathology team that has expertise at breast. Radiology, the person who is seeing this imaging doing the multiple tests, really helping us assess what needs to be removed is a critical part of that team. We consider the social worker, the nutritionist, the support services also critical part of the team even they're not making necessarily the treatment decisions. So for me, that's the expanse of the team. And then we've added genetics because genetic information at the beginning of treatment may be important for some patients increasingly so.

Dr. Jonathan Fialkow:

So clearly some of those resources would be very patient-centric, some might be behind the scenes, but it's a multidisciplinary approach to taking the individual with cancer and providing the best resources available, which is done at the Lynn Center at the Miami Cancer Institute so a great kick-off information. Jane, so going back to a woman's diagnosed with breast cancer, mammogram usually the first test, what would a woman's experience be after they have a mammogram and the ordering doctor says, "I'm concerned, this looks like it maybe a malignancy." What additional testing might be done? Give an example of what the patient experience might be.

Dr. Jane Mendez:

When you have a mammogram, just when you're completely symptomatic that it's a screening mammogram and if something is detected on the screening mammogram they might recommend additional views or to complement that mammogram with an ultrasound. And then the state of the art is to do image detected breast biopsies. So do a needle biopsy in the area where's identified let it be by ultrasound or by mammography so we can lead to the diagnosis even before bringing that patient into the operating. That is the state of the art.

Dr. Jane Mendez:

And then once we have the diagnosis, depending on this particular case, sometimes we may need to order any selected patients, breast MRI, or magnetic resonance imaging so that we can get more information to define the extent of disease or to exclude any multicentric breast cancers, better assess the axilla, or sometimes if it is very dense breast issue, even exclude any contralateral breast cancer. But the state of the art, as you already mentioned and the gold standard is mammography complemented by ultrasound.

Dr. Jonathan Fialkow:

So follow up with that if you would, regarding are there different kinds of breast cancers and when we talk about the stages of breast cancer can you speak to what that means a little bit?

Dr. Jane Mendez:

Yeah. First I'll talk about what the different types of breast cancer are. Number one, over the past 20 years we've really learned more about the fact that there's different sub types of breast cancer. The most common is those that respond to the female hormones that respond to the estrogen and the progesterone they call as Luminal A breast cancer, there's others that don't respond to any of the hormones or the receptors that we know about, the estrogen, the progesterone, the HER2. Those are known as the basal or triple-negative breast cancers. And we have those that respond to the HER2 receptor. And those certainly have a specific target that we can aim as part of the treatment.

Dr. Jane Mendez:

When it comes to the staging the way that we stage breast cancer is called the T-N-M. T stands for tumor size and stars whether there's involvement of the lymph nodes or not. And M whether it is spreading then what is called metastasis. So the earliest stages is at zero, obviously the latest stages is at stage four where we've already evidence of distant spread. So the key is early detection.

Dr. Jonathan Fialkow:

So the detection, further imaging, stage it, find out the type and then treatment plans are set based on that discussion?

Dr. Jane Mendez:

Absolutely. And as Dr. Morrell Alluded to, Louise that the base on that type is when this multidisciplinary team that we alluded to earlier will tailor an individualized therapy to the patient's own comorbidities to the patient's type of breast cancer, so we can start to do that planning. So it's the tailoring of the treatment.

Dr. Jonathan Fialkow:

So Ana, if you could pick that thought up, Jane mentioned hormonal therapy, chemotherapies, et cetera. Go through a little bit what are the kind of different treatment options, at least in broad categories for various forms of breast cancer?

Dr. Ana Botero:

Right. In general, the main pillars of the treatment is surgery, chemotherapy, radiation therapy, and what we call hormonal therapy, the pills for five years. All the patients qualify for those, but not every patient needs the three modality of treatment. And some of those patients may need on the surgery and chemo or surgery and radiation, or even chemotherapy and radiation, or even a single modality of treatment. As Jane mentioned it depending on not only of the staging of the patient based on the tumor size, the status of the lymph nodes and evidence of distant metastasis or not.

Dr. Ana Botero:

But also we take in consideration the age of the patient, but more than the age, I would say that is the performance status of the patient, other comorbidities or other disease, and very important what is the patient wishes? What do the patient want? So I think that summarizing basically very important that the patient is aware of early detection, consultation right away, finding the right team, having good communication, having good understanding and not fear about the treatment that is coming. But not to believe that because we are recommending let's say surgery, chemo, and radiation is because she's at the very advanced stage.

Dr. Ana Botero:

Actually many early stages we treat it with a combination of the three modalities of therapy and not always surgery is the first one and then chemo and then radiation. Sometimes chemotherapy goes up front to facilitate or to test the tumor and to prevent the spread of the disease and then the surgery and then the radiation. So it's multiple potential treatments that Jane said we have to tailor specifically for that patient. Not every patient is just because it's the same as stage three has the same type of treatment for stage three. Every single patient is different, not only because as a patient, as the staging, comorbidities, as well as your own wishes, you know.

Dr. Jonathan Fialkow:

How urgent should the diagnosis follow with assessment and subsequently treatment?

Dr. Ana Botero:

Time it is important, definitely is important. And I will say that the sooner the patient has started the treatment the better, but it's not like the tumor is growing in 24 hours. Finding, that's why it's so important to find the team, multi-disciplinary that you don't have to be going from one hospital to the other, or from one decision to the other and waiting for appointment. That everything is coordinated. So as soon as the patient gets some plan of the treatments, some directive of treatments, some recommendations I think that the sooner that the patient is scheduled, for example, for the surgery, after the recovery of the surgery, the sooner that they start the chemotherapy. And after the chemotherapy, specifically for radiation, we let the patient have maybe one or two weeks for recovery and then we start the radiation.

Dr. Ana Botero:

Typically, it could be two, three weeks between the each modality of therapy, but time is very important. And not by saying that, that it's just to panic and say that I have to have the surgery tomorrow.

Dr. Jonathan Fialkow:

So the efficiency of the team, the coordination of your care again, that's what separates the higher programs of which you all participate. So Louise when a woman finds out they have breast cancer, is it hereditary? What would you tell a woman regarding family members in terms of any types of evaluations?

Dr. Louise Morrell:

Yes, Jonathan I think that most women in reaction to learning we have breast cancer the very first thing is going to be, what's going to happen to me? What do I need to do? And then probably not a breath away is what does this mean to my family? And so, as a result of that for a long time now, we've introduced quite early on that sort of family risk assessment and what is the role of genetic testing? And that of course has evolved quite a bit. I mean, most of folks have heard of the BRCA gene or the B-R-C-A gene, and are aware of the Angelina Jolie story and of that testing being available. But again, trying to figure out when and how to incorporate that into treatment planning is an interesting question. And so we want to address it right away.

Dr. Louise Morrell:

In other words, we want to address by take taking a family history and then by speaking to the patient about what can be learned from the genetic testing, sometimes learning of gene is going to influence treatment, surgical choices, especially a younger woman. And so we incorporate that from the very beginning, so that is important. But most of the time, that information is going to be more important for future screening for family members and ultimately actually in the last few months, an important article and bit of research on a targeted drug for specifically BRCA patients was published. And that data is now being incorporated so sometimes we're treating people based on their BRACA, not very often. And so that's becomes another reason to do that genetic testing.

Dr. Jonathan Fialkow:

So Jane, if the genetic testing would be considered indicated for family members of someone with breast cancer, what if a woman has no family history of breast cancer and says, should I get... Are there any genetic test out there? Is there anything for someone without that family history that they should either be, a, concerned with or, b, have done?

Dr. Jane Mendez:

Yeah, Jonathan, this is a really important area because only 5% of breast cancers are explained by genetic predisposition. 10% of women have a family history but with not a genetic mutation that we can identify that leads to action. And ultimately 85% of breast cancers occurs sporadically. So the minority of women who get diagnosed with breast cancer have some, either family history or genetic predispositions, it's a really small number. So I try to clarify that to the patients, right from the get go. Women diagnosed with breast cancer below age 50, all are considered to be candidates for genetic testing. And we have a fabulous group of genetic counselors and geneticists, and will refer the patients for genetic testing.

Dr. Jane Mendez:

And nowadays there's been an explosion of genetic information and we can have genetic panels, and it's not only about surgical implications and treatment implications, but also about prevention for the future. Because somebody's identified with something like the BRCA mutations either one or two, we also have to then refer them for ovarian cancer and do an oncology evaluation. So I think it's a very useful piece of information so that the patient can also prevent other potential cancers that might be associated with the particular gene that is identified and there's many that are associated with breast cancer. And when it comes to other family members being tested, certainly the patient has the right to share that genetic information with their relatives. And then the genetic counselors are really helpful in then contacting those family members with the patient's permission. So that, that way they can get tested if indicated.

Dr. Jonathan Fialkow:

So if a woman has no family history of breast cancer, clearly self-examination and mammography still remains the gold standard. Doing the genetic test and it being normal does not really mean you're not at risk.

Dr. Jane Mendez:

Correct. Nobody... If they're below age 40 and so below age 50, and they get with breast cancer with or without a family we will refer them for genetic testing. Because the younger you are the higher the index of suspicion for a potential genetic mutation.

Dr. Louise Morrell:

In the early days, my early is not that long ago, but initially we could only really test one or two cancer gene at a time, so BRCA1, BRCA2, for example. And the technology that she alluded to is that we can now do panels of tests because you can literally do as many genes as you want to. And so a question that often comes to my attention is if I was already tested in the past, do I need to do a test again with the updated test? And really the answer to that question is generally, probably yes, depending on what the indication was, if you were tested before 2014, that did not include the panel.

Dr. Louise Morrell:

So anybody who did that test before that you were basically, unless you were in a research testing setting had the standard kind of sequence testing and the panel testing became available after 2014. And we do have data that tells us about five to 10% of individuals who tested negative on the initial kind of testing will have some kind of a finding, maybe not BRCA, maybe not as potent, but something that's useful to the family. So depending on the original indication for doing the testing we are offering retesting.

Dr. Jonathan Fialkow:

So it's not that if you had tested a long time ago, it was inaccurate, it's just that the panels and the genetic testing have expanded that there's still benefit. And I do want, hopefully you guys agree caution that if one wants a genetic test it's really important to have genetic counseling with it.

Dr. Jane Mendez:

Absolutely.

Dr. Jonathan Fialkow:

And what the test shows, what it may show, what the implications are, just getting a result in the mail may give wrong information, or at least wrong action.

Dr. Jane Mendez:

That and also the patients need to have an understanding of what the results might represent. Because even if you have a genetic mutation is not 100% guarantee that you're going to develop the cancer associated with it. And sometimes you'll find things about your family that you didn't even know. So you really need to be prepared by the genetic counselors to really be able to understand the information.

Dr. Jonathan Fialkow:

When women are diagnosed with breast cancer at childbearing age, I know it's part of the decision in treatments, as we said everything's individualized. What would be the effects of radiation or chemotherapies on fertility or what is discussed and what outcomes come from those discussions?

Dr. Ana Botero:

Any breast cancer patient that is at the childbearing age should be educated about how the fertility, her fertility could be impacted, just, you know, at the moment of the diagnosis, as well as in the future with the cancer treatment. So we have a really amazing oncofertility department, in which after we discuss with the patient, if they desire to preserve the fertility we refer the patient to this oncofertility program. They evaluate the patient and if the patient wants to proceed, they have to understand that at the minimum probably will be a month before proceed with the treatment, but it would be for the egg retrieval. After that the patient start treatment.

Dr. Ana Botero:

They also have to understand that during the chemotherapy, most likely they will protect also the fertility with some type of hormonal therapy that is some injection with [inaudible 00:19:12]. Chemotherapy could last for three or six months. Typically, without this protection still the young females could get pregnant, probably 20, 30% of them can still have a baby and get pregnant in the future. With this type of treatment we might say that probably you increase your chances of preserved fertility probably 50%, 50/50. And some patients have to really delay the potential or the probability of getting pregnant for the five years of the entire treatment with the hormonal therapy.

Dr. Jonathan Fialkow:

I'm going to ask one last question to Louise, then give everyone an opportunity for a final question. Talk about how important it is to have that strong support system and what's provided by your services in that circumstance. And then Louise, I'll turn it to you first.

Dr. Louise Morrell:

Yeah, I think you're right it does fit the theme, right? We started with what's the importance of the team. And we started with the key sort of physician providers, because that's going to be the part that we always want to start with is how do we cure this? How do we make sure you have every piece of information that you need? But I think everybody here knows and agrees how critical it is to have that sense of a team and the resources. Everybody is coming at this from a different situation in their life and different support people around them. But everybody needs to do this as support. Nobody has faced this before. This is going to be all new in territory and having the psychological support, if it's a social worker support, if it is support groups, if it's nutritional. All of those pieces are absolutely as critical to the success of this as every breast cancer patient will tell you.

Dr. Louise Morrell:

And I think that comes back to the key of getting your care at a cancer center is just not like going to a doctor's office. And going in and getting the treatment and walking out. It's about entire team, including those resources that make this really a journey that includes the patient at the center and the team around them. And that is so critical to getting through this and the survivorship on the other side.

Dr. Jonathan Fialkow:

Thank you. Jane, any final comments? Any thoughts?

Dr. Jane Mendez:

Yeah, I think to follow up on Louise just said, you know, is patient-centered care. You know, we've talked about the importance of the team, about also the importance of the support of the family, where I think it's sometimes that element of care that we don't really consider. But it's so important to get the patient through the breast cancer journey and ultimately how to stress that the individualization of their care is critical in getting to where we are today, where if somebody's diagnosed with stage one breast cancer we have 98.5 survival at 10 years. So it is a real testament to all these specialties coming together to accomplish that over the past four decades.

Dr. Jonathan Fialkow:

Wonderful points. And Ana, final thoughts, comments?

Dr. Ana Botero:

Final point is that just kind of a message of hope for everybody. You know, because breast cancer is kind of so common that it's a matter of when. At some point we are going to be the ones to be affected by that. But I just... A message of hope because patient that are early stage, they are really, really high chance to get cured. And even in the worst situation that patients are diagnosed with a stage four, you know, with more advanced disease or a spread disease, there's a lot of hope nowadays thanks to the new medications that we have available, target therapy, immunotherapy and such.

Dr. Ana Botero:

And from the radiation therapy also treatments used to be to kind of really more side effects than benefit, but nowadays with the technology that is available, it's a very short treatment and pretty much no side effects and really highly effective for local control, even from the distant metastasis. So again, it's an individual basis, but there's a lot of hope, not only for being alive, cured, but in sometimes even for the quality of life for example, quality of life.

Dr. Jonathan Fialkow:

To our listeners, remember that you can send us your comments and suggestions for future topics at baptisthealthtalk@baptisthealth.net. That's baptisthealthtalk@baptisthealth.net. On behalf of everyone at Baptist Health, thanks for listening and stay safe.

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