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- [00:05]
A
This is Leslie, and you're listening to the interview with Leslie Heaney. So in addition to preparing for Halloween, just again, right around the corner, October is also Breast Cancer Awareness Month. So before this month ends, I just wanted to squeeze in a really important conversation around breast cancer. And I was fortunate enough to ask a new friend here in Nashville who also happens to be an absolute superstar in the field, Dr. Vandana Abramson. Dr. Abramson is a medical oncologist who specializes in the treatment of breast cancer. She's a professor of medicine and holds the Donna S. Hall Dowd Chair and co leads the breast cancer research program here at the Vanderbilt Ingraham Cancer center when she's not incredibly busy maintaining her clinical practice. Dr. Abramson has extensive experience leading clinical trials for breast cancer. She's also co authored hundreds of papers, sits on every incredible committee known to man in this space. We are really, truly so lucky to have a specialist of this caliber sharing the latest information on breast cancer prevention, screenings, treatment, and all the exciting research that she's working on at the Vanderbilt Ingraham Cancer center, one in eight women will be diagnosed with breast cancer in their lifetime. So for all of my women listeners, this really is a very important episode for you to listen to. And for all of my male listeners, it's important for you too, because it will affect, unfortunately, some woman that you care about in your lifetime. So without further ado, here is Dr. Vandana Abramson. Vandana, it is so nice to see you. Thank you so much for taking the time. I mean, we have such a superstar here, superstar doctor. And I'm just so honored that you are here having this conversation with us in October, Breast Cancer Awareness Month, which is such an important issue and topic for us women and for all of the men who love us. But I think it's. I wanted to sort of start by having you give like a little bit of a level set or information about breast cancer rates in America today because I think it's important to kind of set the table before we get into our discussion around risk factors and what we can do and all that good stuff.
- [02:23]
B
So first of all, thank you so much, Leslie, for having me here. Breast cancer, as we all know, is common, and it's very common. There are about two and a half million cases of breast cancer worldwide each year. And in the United States alone, There are about 300,000 new cases each year. So we see a lot of breast cancer. There are about 40,000 deaths from breast cancer each year. And I think, you know that the often cited Statistic is that one in eight women will develop breast cancer or one in seven will develop breast cancer. And that is true over a lifetime. So a woman in the United States has about a 13, 14% risk of developing breast cancer at some point, or 13 to 14% of women will develop breast cancer at some point.
- [03:08]
A
Most men will end up developing prostate cancer if they live that long. Is it similar with breast in that regard that, you know your higher rates the older that you get?
- [03:17]
B
Certainly higher rates the older you get. It's not quite like prostate cancer in that most women still will never develop breast cancer. But cancer in general is a disease of age. Certainly there are pediatric cancers, there are a lot of other types of cancers that develop younger. But in general, we see cancer as we age. And so most cancers in breast cancers in the United States are still in women over the age of 50, with.
- [03:42]
A
That number being the predominant number of cases being over 50. The age for your first mammogram is.
- [03:50]
B
Recommended at age 40 at this point. Yes, yearly at age 40. And there's been a lot of controversy about this back and forth and different groups saying that we should start at age 50 versus 40. Really between 40 and 50, we're not picking up that many cases, but we are picking up numerous cases in there. And it also becomes a cost effectiveness issue when you're talking about a population and an exam that's done every year. So at age 50, it certainly becomes cost effective. At age 40 to 50 there have been arguments, but I still firmly, as a medical oncologist think that, that, that women should start with mammograms at the age of 40.
- [04:28]
A
It's so interesting. I never realized the, the relationship between you mentioned cost effective of kind of insurance companies with our medical care, because that is part, I mean, you could get a mammogram if you wanted to at 30, right. If you felt that there was a family history and I guess you would talk to your doctor about that. But there is so much of that that built into some of those decisions, right?
- [04:51]
B
Yes, there is some of that built in and some of it is also. How many cases are you going to pick up? So at age 30, you're likely to, you may have more dense breasts, you may not be able to see as well on a mammogram. So that may be a little bit more difficult. It may be just a general. The risk of getting a mammogram. It's very low dose radiation, but there is some radiation involved. So at what point does the risk outweigh the bias as well.
- [05:19]
A
That makes sense. All right, so you brought up risks. Let's talk, let's talk. What are the high risk factors for developing breast cancer?
- [05:28]
B
Absolutely. So age is really the first one. The older you are, the more likely you are to develop breast cancer. Family history is another one. Genetics, genetic mutations like BRCA1 and 2 can, can play a role for sure. There are other things like reproductive factors, age of menarche or your first period, how much estrogen you have over a lifetime. Childbirth, are you having children, at what point, breastfeeding, other factors like dietary factors, alcohol, breast density.
- [06:03]
A
You know, the alcohol thing is a, is a bummer. We have to talk through that a little bit.
- [06:06]
B
That's right. So several other other risk factors as well.
- [06:11]
A
So when you say the age of your, of your first period, what, what is the research showing there? That the earlier that you started getting your period you have a higher risk or the later. What, what is the.
- [06:21]
B
Yes. So it's the number of years that you have estrogen being produced. So if we look back into the 60s, 1969, the average age of menarche or your first period was, was 12.5.
- [06:34]
A
By the way, I like menarche. It sounds very regal and important, the menarche, you know, your menarche. So, okay, so the first, I never heard that term. I'm, I'm learning as we go along.
- [06:43]
B
So around 12 and a half years.
- [06:44]
A
Okay.
- [06:45]
B
And now it's closer to 12 or maybe even 11.9, 11.8 depending on the study that you read. And so you know, when we talk about a population and seeing a change like that from 12 and a half years to closer to 12, that's actually a really big deal. Even though it only sounds like six months to see a shift like that, that means that we are there certainly people having children having their first period possibly at the age of 10, 10 and a half, 11. This was really uncommon 50 years ago. So a shift from an average or median down makes, is really relevant. And.
- [07:29]
A
But would you not then go into menopause soon? Is there any sort of lifespan of your reproductive. Reproductive lifespan? I guess what I'm thinking about is if you started at 10, would you then go through perimenopause or menopause earlier? Or you're saying you have more estrogen for longer.
- [07:48]
B
Yes, more estrogen for longer. But it's also, and this is complicated because there's a lot of if this, then that and years of follow up. But certainly if you're starting earlier, you are getting estrogen starting to get estrogen in your body at an earlier age when your breasts are still developing. So when we're talking about, and we may be talking about this in a bit, but just an uptick in the people who get breast cancer at a younger age or younger patients with breast cancer, that's where one of, one of the issues is. Is it because of the early menarche? Is that the reason that we're seeing.
- [08:24]
A
This, the early menarche? I love that we talked a little bit before we started about processed foods or diet or environment being a factor there. And I, I have heard, and I don't know if this is correct, that the hormones in our foods, for example, in dairy products, is that contributing to people beginning their monarchy sooner? And is that part of the larger picture of environment having an impact on, on cancer rates?
- [08:51]
B
And that is a very complicated situation and question because first of all, why are, why are girls starting their periods earlier? That's its own research.
- [09:03]
A
Right.
- [09:03]
B
First of all, we have increasing rates of obesity and we do know that there's some link there between obesity and childhood obesity and earlier menarche. So is that what's contributing? That's probably playing some role. More sedentary lifestyle, that's certainly playing some role. And then is it some other in utero exposure? Is it some other, is it antibiotics? A lot of kids are getting more and more antibiotics for ear infections and other, you know, other legitimate reasons. But is that changing their microbiome, their gut, and is that leading to obesity or just earlier rates of breast cancer? Unclear.
- [09:49]
A
But you mentioned also breastfeeding as a high risk factor or as something that could contribute.
- [09:55]
B
It's protective.
- [09:56]
A
So that's what I wanted to ask. So when you said that, did you mean women who do breastfeed versus those who don't? Can you talk about that?
- [10:02]
B
Correct.
- [10:02]
A
Okay.
- [10:02]
B
Yes. Yes. Breastfeeding is protective only slightly. And all of these factors that I'm mentioning are just adding to that 13%, just a little bit.
- [10:12]
A
Does the research show for how long you need to have breastfed for it to be.
- [10:17]
B
Some of the earlier research was looking at one year, but I think it's safe to say we don't really know.
- [10:23]
A
Okay. Okay. And then the third one, so we knew about genetics. We're going to do a deeper dive into that in a minute. And you said something about the age of which you had your children.
- [10:35]
B
Yes.
- [10:36]
A
What is the research showing there? Younger or older is a positive effect.
- [10:41]
B
Or a, It's a positive effect if you're younger when you have children.
- [10:45]
A
Oh, interesting.
- [10:46]
B
And so we have more and more women choosing to have children later or not having children at all.
- [10:52]
A
Okay.
- [10:52]
B
And that is a negative effect. So that may be contributing again, slightly.
- [10:58]
A
Okay.
- [10:59]
B
That may have some impact as well, because there's more unopposed estrogen in those who are not having children at all. And then when they're having children later, there seems to be a little bit of an uptick as well.
- [11:10]
A
Interesting. Okay. So for people we talked about, there is a slight trend of younger women contracting breast cancer.
- [11:19]
B
That's right.
- [11:19]
A
I mean, we talked a little, little bit about the earlier onset of our menarche. But. But are there other things too, that.
- [11:27]
B
So. And first, to kind of just step back and say, what. How do we define young? So women under the age of 45 developing breast cancer would be considered young.
- [11:37]
A
Okay.
- [11:38]
B
And currently about 10% of breast cancers are in women under the age of 45. So still the other 90% are in women over the age of 45. And then when we talk about very young, it's under the age of 35. And that would be less than 5% of cases. But we are certainly seeing an increase in those numbers. It's probably all the factors we've talked about. There's also increased oral contraceptive use, which we know has an impact on breast cancer. And so this is very hard to study because in oncology, you sort of think about randomized control trials where you have patients who get one treatment or another treatment and you compare them and you follow them. But, you know, doing a randomized controlled trial for oral contraceptives is hard. People aren't going to be okay with either getting it or not. They either want the oral contraceptives or they don't want.
- [12:35]
A
Right.
- [12:36]
B
And you have to follow them for years and years and years. So there was actually a Danish study that was published in 2017 that looked at almost 2 million Danish women. It was an observational study. So again, not randomized control. Looked at 2 million Danish women over almost 10 years and looked at those who were receiving oral contraceptives and those who were not. And they found that there was probably about a 20% increase risk of developing breast cancer with the use of oral contraceptives. And it went up with the longer the person used oral contraceptives. So, you know, certainly over the last 50 years, we've seen an enormous uptick in women choosing to use oral contraceptives. So that may be. And everything I say here is a maybe, because it is so hard to define what exactly is doing any One thing, but that may be contributing. And I also just want to sort of say statistics. And when we talk about statistics, 20% sounds like a lot. But when we're saying 13% of women may develop breast cancer, 20% increase is only a couple percentage points there. So it's not we have to talk about.
- [13:57]
A
That's what I wanted to ask you. When we were saying that there's an increase in younger women developing breast cancer that I mean, I guess compared to 20 years ago, how much of an increase is it? Is it 2%, 3%? You know, how significant is the, is the increase?
- [14:13]
B
It's significant enough to notice, right? It's a few percentage points. But I think we'll know more in the next five years because we'll actually have better data.
- [14:23]
A
More data. Okay, so you mentioned girls and young women taking, you know, oral contraceptives more frequently and estrogen being playing a role here. What about. So hot topics and you know, being a 50 year old woman, HRT or hormone replacement therapy is a very hot topic. Does that increase your risk taking hormone replacement therapy?
- [14:49]
B
Yes, definitely hot topic and something that my friends discuss quite frequently. So the answer is yes, it does to some degree. But we really have to look individually at a person's risk versus benefit profile.
- [15:07]
A
Okay.
- [15:08]
B
That's the way I would advise my friends to think about it as well. Let's talk about risk benefit for one individual person because we know that combined estrogen progestin hormone replacement therapy has an impact on breast cancer. We saw that in the Women's Health Initiative, women who were taking hormone replacement therapy had a higher risk of breast cancer. And after stopping it, we saw certain breast cancers fall in terms of incidence. But also important to point out that most of the breast cancers that are attributed to hormone replacement therapy are the more indolent breast cancers, the less aggressive ones. So that's a good thing.
- [15:49]
A
Okay.
- [15:50]
B
It also, one of the other things I can say is that they appear to be happening from hormone replacement therapy in more lean women. Lower body mass index, interestingly. Okay, why that is is unclear.
- [16:06]
A
So for this lady here who could be a size 8 or a size 10 across from you, so that would be. I'm teasing, but those are the kind of conversations that you would have with your doctor. Right. To really weigh, as you said, sort of the risk, the risk benefit of taking hrt. But so that's women that are, are thinner and are, and are taking it, the research is showing that they have a slight, a slight or higher risk.
- [16:31]
B
Of developing it slightly lower than those who are. Have a higher BMI or more. Even obese women are less likely to develop breast cancer from. From hormone replacement therapy. Now, as a whole, obesity is a risk factor for breast cancer. Okay, so it's. It's sort of. It is.
- [16:51]
A
Well, that's what I was going to ask you. It's probably hard to attribute, you know, which factor the person might be on hrt, but they might also, you know, be a big drinker or they might also be obese or these other risk factors. Right, so exactly how do the studies really parse that out?
- [17:08]
B
That's the problem with that. That is really the reason that it's. It's so hard for any one person to say it's this or it's that.
- [17:15]
A
Right.
- [17:15]
B
Because we just don't know. The Women's Health Initiative was a great study because it really did follow women over a period of time to see what was happening in them. And we saw that once they stopped taking hormone replacement therapy, certain cancers, estrogen receptor positive breast cancers, the incidence went down, not to nothing, but dropped a little bit. And so I think in one individual woman, I would say we really have to think about how much is this affecting your quality of life. So, so is menopause causing hot flashes to the point that you can't sleep? Are you having other issues? Do you need to do this for a couple of years? I would say, you know, one to three years is probably just fine and maybe even longer for an individual person as long as they understand the risks. So, you know, you mentioned alcohol, moderate alcohol use. I'm always surprised at what people think is moderate versus what it is. Moderate is three to five drinks per week.
- [18:13]
A
Right.
- [18:14]
B
And you know, I've had people say, oh, I would think moderate would be like two drinks every other night and.
- [18:21]
A
Or a night. I mean.
- [18:23]
B
Yeah, yeah.
- [18:24]
A
And so one person's, you know, moderate is another drink.
- [18:27]
B
Moderate is another.
- [18:29]
A
That's so interesting.
- [18:30]
B
And when you. When we say moderate, moderate alcohol use can once again increase the risk of breast cancer by about 20%, which again, sounds like a big number. But when we look at absolute numbers, that's not very large at all. But it is there. There's that link. So when you start adding up all these different factors, you can actually have a significant increase in the risk of breast cancer.
- [18:53]
A
Interesting. So it's really important to look at how all of the factors combined would play a role for you, particularly.
- [19:02]
B
Yes. And then there's also the whole epigenetics, which is controversial. How much does one exposure affect you versus another person based on your own genes. So you and I could both have the same exact exposure and one of us could develop some issue from it, whether it be cancer or some other disease, and the other could keep on doing it for forever. Smoking is a great one.
- [19:29]
A
So we had this neighbor, actually, he was a very well known interior designer. His name was Albert Hadley and it was our first apartment building and he was our neighbor and we adored him. And he. I don't know how many scotches he had a night, but more than one. And he was a big smoker. This is 24 years ago. And I smoked at that time and my husband kept saying to me, you've got to quit smoking. I'm like, look at Albert, he's in his 80s. He actually lived into his 90s, you know, smoking and drinking brown water, you know, regularly. But to your point, it really just depends on you, right? Your other risk factors, your genetics, all of those things are, you know, very particular to the particular person, right?
- [20:15]
B
That's right. All we can take is the information we get from large populations and say there's a risk to some degree. But how does that translate to you? Directly? Unclear.
- [20:28]
A
So I had read an article because it is Breast Cancer awareness month. There's a lot of stuff coming across my newsfeed on my Apple newsfeed and it talked about sort of uncommon symptoms of breast cancer beyond you finding a mass through a self exam. And would you want to discuss some of those sort of what other symptoms you could have that could be breast cancer that you wouldn't necessarily think could be breast cancer?
- [20:56]
B
Yes. The first thing I'll say is if there's any question in your mind, go see your doctor, right? Go see some healthcare professional if there's anything that's going on, any change, but masses. There was this idea that breast cancer is not painful and in the vast majority of people it's not. It's usually a painless mass, but depending on where it's sitting, it could be painful as well. So if you notice something and you see someone who says, well, it's hurting, that that's, that's probably just hormonal or cystic or something like that. Well, that's likely the case, but it could also still be breast cancer. Nipple discharge is another one. Most nipple discharge is harmless, but not necessarily. And you should see someone and get imaging if there's new nipple discharge, especially just on one side. Sometimes breast cancers can appear inflammatory where the skin turns red or there's a rash, anything like that, that should Be evaluated. So I would say pretty much any change you might notice, do something about it.
- [22:04]
A
Okay. That's really important to know because you are right. I think that people do think of it as being just sort of the painless. A painless experience that you would just say, oh, you know, I have this thing on my breast, but it hurts. It must be a cyst, or it must. Must be something that's. That's not breast cancer, but it could actually be. So you should definitely have it checked out. Something I wanted to ask you, when we're talking about hormone replacement therapy that I forgot to ask. Are there any other medications that increase your risk of developing breast cancer?
- [22:34]
B
Hormones are the. Are the main ones.
- [22:36]
A
Okay.
- [22:37]
B
And other drugs that may increase hormones in your body. So we were talking about alcohol, right? And the way alcohol works is it actually increases estrogen in your body and it's actually metabolized to see the aldehyde, which can actually. It's a carcinogen that can actually be stored in breast tissue. So. So it's.
- [22:54]
A
It's. I didn't realize that alcohol affected your heart, your hormones.
- [22:58]
B
Yes, it does. It does. And that's probably the main way that it's increasing the rates of breast cancer or one of the ways. But other than that, in terms of other drugs, sometimes immunosuppression can increase the rates of breast cancer, but that would be something that. If you are immunocompromised or you're getting an immunosuppressive drug, your doctor would be talking with you about that. There are a whole variety of immunosuppressive drugs that could play a role potentially.
- [23:27]
A
When would you be taking it? Like, for what type of condition would you be taking an immunosuppressant drug?
- [23:33]
B
Any autoimmune disease, multiple sclerosis, inflammatory bowel disease, any. Any of those drugs.
- [23:41]
A
So in those cases, you're obviously talking to your doctor. But would you want to get screened, have mammograms earlier? Would you want to be having them more frequently? If you were on those medications at.
- [23:50]
B
The point, what we would say is just make sure you do it okay? Yearly, don't skip. And often when you're dealing with another disease, those are the exact people who do end up skipping because they're already dealing with the health care system enough.
- [24:05]
A
Right.
- [24:05]
B
And so, you know, just make sure you keep doing it. And if you notice a change, immediately seek medical care.
- [24:12]
A
You know, one, this tip a friend of mine gave me, which I think is really smart, is that she has her Mammograms, you know, at one time of the year, and then six months later has her appointment with her general practitioner and her gut. And she kind of staggers it because then she's getting a breast exam from her gp, from her gynecologist, and then from you getting her mammogram and sonogram. So you're having coverage, you know, two or three times a year. You're having someone who professionally knows what they're looking for, giving you. Giving you a breast exam.
- [24:44]
B
I think that makes a lot of sense. Absolutely. And we actually do that in our patients who have breast cancer. We'll have the medical oncologist see them at one point and then the surgical oncologist six months later. So we go back and forth. So they're being seen every six months if they're already past the five years when they would be seen once a year.
- [25:01]
A
Because I have a close friend, roommate for one of my years in college, and she developed breast cancer in her early 30s, had just gotten engaged, and she's gone on to have two boys. She had IVF immediately. She's very healthy. But she had gone to have see her doctor and had a breast exam. And then three months later, she found a mass in the shower. So it can. This is why self exam is so important. It can develop quickly.
- [25:25]
B
Absolutely. Interval breast cancers between mammograms are more and more common, especially in younger women, because they often have the more aggressive cancers as well that pop up in between exams. And she probably wasn't getting mammograms at that young age either. But we have lots and lots of patients who have a clean mammogram, a great exam, and then three months later, they're in our office.
- [25:48]
A
So, you know, we hear, you know, as, you know, friends who've developed or family members, the different stages of cancer and of breast cancer. Would you just mind giving a quick overview? So people hear that someone has stage two or stage three, Kind of what that means, or what the recommended course of treatment is for each of those stages.
- [26:07]
B
Absolutely. So the first thing I actually want to say about the staging system is that it's fraught with issues.
- [26:12]
A
Okay.
- [26:13]
B
It was originally designed in order for us to be able to say how high risk is somebody for having the cancer come back.
- [26:19]
A
Okay.
- [26:20]
B
After it's removed. So stage one is.
- [26:23]
A
I'm sorry to interrupt you. So it's not. The stages are not then related to survivability. It's related to reoccurrence, reoccurrence.
- [26:30]
B
Which is then related to survivability.
- [26:33]
A
Okay.
- [26:33]
B
Yes.
- [26:33]
A
Okay.
- [26:34]
B
So. And I can go through that a little bit as well. So stage one is really no lymph nodes involved, under 2cm in size. So a smaller tumor without lymph nodes under the arm on the same side as the breast, involved with cancer. And then stage two is some lymph nodes up to three or a very. A larger tumor, but no lymph nodes. Stage three, greater four lymph nodes or more under the arm or a larger tumor that may be in the skin of the breast. And then stage four is metastatic, or it has spread to other parts of the body outside of the breast, and the lymph nodes under the arm, as in into the liver, lungs, bones, et cetera. Stage four, at this point, is not curable. The good news is most women are diagnosed stage one to three, as in over 90%, which means they're potentially curable. And about 80% or more of breast cancers are actually cured, which is also amazing. It's not. It's not 100%. So we're not satisfied, but, you know, we're getting there.
- [27:43]
A
And how does that compare Rhonda to 20 years ago, for example?
- [27:46]
B
Survivability, it's increasing significantly. Yes. As in 10, 20% more with the new drugs that we have and more screening.
- [27:55]
A
Right.
- [27:55]
B
So it's really. We're coming. We're getting a long way from where we were. Yes. And so when we think about the treatment of breast cancer. So if the cancer is found early, just in the breast, we remove it surgically. Sometimes you get treatment before called neoadjuvant treatment with chemotherapy or hormones, but hormone blockers, and then it's removed. And once the cancer is removed from the breast and the lymph nodes under the arm, we basically say the patient has what we call no evidence of disease. Ned, that doesn't mean that they're cured. We don't know that. But as far as we can tell, there's no evidence of disease. The issue is that a single cancer cell could have left the breast and gotten into the bloodstream before surgery, if it's.
- [28:43]
A
Sorry to interrupt you. Is that why now? It seems as if sometimes you mentioned that you would have chemotherapy before you'd have the mass removed. Is that why is the idea to stop the spread before you would have it surgically removed?
- [28:56]
B
The reason for chemotherapy before surgery is actually to downstage the tumor to make it smaller. Also, we have certain treatments that are only approved before surgery. And then once we shrink it, when the patient goes to surgery. If they still have some cancer left in the breast, we may do something different after surgery.
- [29:17]
A
I see. Okay.
- [29:17]
B
So it's a way to kind of hone in on what we should be doing for them.
- [29:21]
A
Okay.
- [29:22]
B
But really, when we think about breast cancer, I always say it's a systemic disease. It's a disease that's in the bloodstream. It starts out in the breasts, and the lymph nodes take it out. But if a cancer cell has gotten into the bloodstream, first of all, we don't even know. There isn't a test. There isn't any imaging or lab work that shows us rogue cancer cells, few of them floating around in the bloodstream. If they're out there, we want to wipe them out before they have a chance to multiply in the bloodstream and then metastasize or go to another organ like the liver, lungs, or bones.
- [30:00]
A
Okay.
- [30:00]
B
And so when we talk about cancer recurring, we're talking generally about it coming back somewhere else in the body.
- [30:06]
A
I see. So it's that rogue cancer cell that did.
- [30:09]
B
Okay, yes. And so it can recur in the breast, but that's not as common. That's still curable. You could still take it out, do another surgery. But our concern really is the cancer coming back somewhere else in the body. So when we give chemotherapy, or if you have friends who are taking tamoxifen hormone blockers for five or 10 years after they've had their surgery, the reason they're doing that is to kill cancer cells that might be in the bloodstream still before they have a chance to pop up somewhere else.
- [30:42]
A
This is for stage one through three or just stage one?
- [30:45]
B
Stage one through three. But for stage one, we may not give as aggressive of a treatment. So when I start out with saying that the staging system is fraught with issues, it's because it's basically looking at size and number of lymph nodes. And now we know that's not the issue. It's the biology of the disease. So a certain subtype of breast cancer, let's say triple negative breast cancer, stage one, triple negative, may in certain cases, or a lot of cases, be more aggressive than a stage 2, low grade estrogen receptor positive breast cancer. So the staging system isn't giving us what we need anymore. So I have friends who've come to me and said, oh, my gosh, this person was diagnosed with a stage two breast cancer. Or, well, it's okay, it's just a stage one. Well, it all depends.
- [31:36]
A
It depends on what type of cancer. It is.
- [31:38]
B
Exactly.
- [31:38]
A
I see.
- [31:39]
B
Exactly.
- [31:40]
A
Okay. So you mentioned the lymph nodes. How many lymph nodes? And that's a factor. Should we be examining under our armpits, our lymph nodes, in addition to our breasts?
- [31:50]
B
I think as if you're doing a breast exam, going up high to under the arm is important.
- [31:57]
A
Okay. Okay. I never thought of that. Not that. I mean, I. Not that we should be doing an exam here on our thing, but I wish that I, you know, doing them as frequently as I probably should be doing. But that's important to know that you want to sort of go up into your armpit and feel around and see if you feel any masses.
- [32:16]
B
Absolutely.
- [32:16]
A
Okay. There also, I think, has been some different advice or practice recently with either the question of whether to get a mastectomy or not. I have friends who've had their. The mass removed from their breast, and then their doctor sort of gives them the decision of whether or not they want to have a mastectomy. I'm sure it's obviously probably a tough question to answer because it's so particular to the person, but do you have any thoughts about that, or what do you recommend? Or.
- [32:43]
B
So in general, if you're offered a lumpectomy or a partial mastectomy, basically just taking out the lump, the outcome with lumpectomy plus radiation is the same as the outcome with a full mastectomy.
- [33:00]
A
Okay.
- [33:01]
B
So it really is a choice. And in certain people, it's not a choice because the tumor's too large to just do a partial mastectomy or lumpectomy, or the person has a BRCA mutation. So the risk of developing another breast cancer is so high that you would want to go ahead with the mastectomy. But if you're offered both, it's really a personal choice. And I think the choice comes down to also anxiety. A lot of people choose to undergo a lumpectomy with radiation, and then they're really worried after that.
- [33:34]
A
Right.
- [33:34]
B
And for some people, you know, it's. One right choice is another person's wrong choice. So I think if you're offered it, the outcomes are not going to be any different.
- [33:43]
A
I see. Okay, that's interesting. But if the idea, though, is that the concern is in the rogue cell, the rogue cell would have already gone rogue. Right around.
- [33:54]
B
Exactly.
- [33:55]
A
So removing the breast tissue may not.
- [33:59]
B
Right, right, exactly. And I've had so many people in my own clinic come and say, well, I want to do everything, so I want to remove both breasts.
- [34:08]
A
Right.
- [34:08]
B
And I say that's Fine, that is your choice. But let's understand why you're choosing to do that. If you're choosing to do that to prevent this particular cancer from coming back, you're not actually helping this particular cancer by removing the other breast. You're preventing a new breast cancer from forming in the other breast. But the issue with this particular cancer is the rogue cancer cell and it coming back somewhere else in the body.
- [34:35]
A
Will you talk a little bit about the. What are the genes that indicate a higher risk of developing breast cancer and who should be getting that testing? When should they be getting that testing?
- [34:45]
B
Yep, absolutely. So the most common genes associated with breast cancer are BRCA 1 and 2, BRCA 1 and 2 in general, these are not commonly found in the general population. About one in 400 women carry a BRCA mutation or people carry a BRCA mutation. So that's less than half a percent of the general population. Amongst Ashkenazi Jews, that goes up to 2.5%. So significantly higher there. If a person has a BRCA mutation, their chances of developing breast cancer by the age of 70 are somewhere between 50 to 70%.
- [35:24]
A
Oh wow.
- [35:24]
B
Okay. So high. And so in these, in that particular group of people, we recommend yearly MRIs or potentially prophylactic mastectomies going to that extreme because of the risk of developing.
- [35:42]
A
Breast cancer, how would one know whether or not they're at risk of having that gene? Based on family history.
- [35:47]
B
Family history would be the main.
- [35:50]
A
Or if you're of Ashkenazi Jewish descent, then you would probably want to have that test done.
- [35:56]
B
Exactly. Family history of ovarian cancer, lots of other random cancers in the family, younger members in your family developing breast cancer, all or ovarian cancer. Those could all point to you're having a BRCA1 or 2 mutation. You should get tested. And testing is actually pretty widely available now.
- [36:18]
A
One of my questions I made a note was talking is where do you go to get those tests and at what age should you be getting them? If you're a young woman whose, let's say mother died of breast cancer or women in your family have had it, when do you go to get that test and where should you go?
- [36:34]
B
So you would talk with your primary care physician or primary care provider. But there are high risk clinics, especially if you're found to have a BRCA mutation. But really these genetic tests are being are available more widely now. We generally say you should see a genetic counselor or see somebody in the high risk clinic to get this test so that you can really understand what it Means, okay, you know, I think one thing to sort of say is people used to be afraid to get these tests because of some of the consequences. And there are still some consequences of randomly getting the test. As in what if you decide to get the test for no particular reason, you're found to have a mutation. Maybe that doesn't mean anything in your family. Maybe what we call the penetrance of the gene isn't there. So, you know, you could have a BRCA mutation. Well, does that mean I'm at a higher risk? Maybe, probably. But no one else in my family has ever had breast cancer. You know, then, then you start thinking about, is this what's going on? Do we need to have other family members tested? Or maybe that gene just isn't causing issues in your family. So there's that part of it, but the other part that people often talk about is preexisting conditions. So that was one thing that I've had a lot of people say is, well, if I'm found to have a BRCA mutation, that could prevent me from getting health care. That I do want to clarify because with.
- [38:02]
A
Oh, tell me about that. They're concerned about with insurance.
- [38:06]
B
Yes, because actually prior to the Affordable Care act, which now prohibits taking preexisting conditions into account when getting health care, insurance companies could actually charge a higher premium or choose not to cover you if you had a pre existing condition. And one of those could have been a BRCA mutation.
- [38:27]
A
Stop it. Oh my gosh.
- [38:29]
B
So that is no longer a concern or shouldn't be a.
- [38:33]
A
Yes.
- [38:34]
B
The second is just the cost and availability.
- [38:37]
A
I was going to ask, are they, is this testing covered generally? I mean, obviously every insurance plan is.
- [38:42]
B
Different, but it should be covered for a certain group of people. Okay, but you know, up until 2013 there was only one company, Myriad Diagnostics, that tested for BRCA. So interestingly, the gene was actually isolated in the 90s, so not very long ago.
- [39:02]
A
Okay.
- [39:02]
B
And then Myriad Diagnostics developed a test to look for BRCA 1 and 2 mutations and they put a patent on it. And so they were the only people allowed to.
- [39:12]
A
So there's someone sitting on an island somewhere.
- [39:15]
B
That's right. He's back with you. And the test was thousands upon thousands of dollars. And at one point, the American Molecular Pathologists association decided to sue Myriad. And there was a landmark case that was decided by the Supreme Court in 2013, AMP versus Myriad. And the Supreme Court agreed that you cannot patent a gene. That legal precedent would allow us to say that, that a gene is Actually, a natural product. You can't patent natural products. So that kind of went back and forth, but they sided with amp saying you cannot patent.
- [39:56]
A
And because of that, it allowed it to become more accessible.
- [39:59]
B
Now it's $200 or less, and everyone, all health care insurance companies cover it.
- [40:06]
A
And is it a blood test or.
- [40:07]
B
Is it a blood test? And it can be a swab tube.
- [40:10]
A
Okay.
- [40:10]
B
Yes. But there was a time, I remember not that long ago, about 10 years ago, where we would have a long discussion about whether we want to do the test. And it was often denied. But now today, we actually. We actually test almost everybody who's diagnosed.
- [40:25]
A
With breast cancer just because then you kind of have a better understanding of what kind of what their profile might look like or how you could best treat it. Right?
- [40:34]
B
That's right. Exactly.
- [40:35]
A
So now that we've walked through all some of the scary stuff, I want to talk about what we can do to sort of empower us, to sort of help us consider lifestyle choices or things that we can do to help reduce our risk. One of them might be getting, as we just talked about, getting screened for having those genes. But talk about sort of the things we can do, what choices we can make to help reduce our risk.
- [41:02]
B
Exercise, That's. We know that's linked. And obesity. We know that's linked to breast cancer. So just getting out and exercising, 30 minutes a day of walking. Okay, that. That's huge. Low alcohol intake. We. We defined modern earlier.
- [41:18]
A
No, I know, I know. And I. There was an article in the New York Times last week saying, look, no alcohol. Just like alcohol. It's just. They talk about moderation, but that, you know, it's so hard because one person's moderation is not another. It's almost like they. When you're pregnant, they say you no drinking at all. And I didn't ever have a sip when I was pregnant. And the reason why that is the standard, from what I understand, is that you could probably have one or two glasses a week, but they just didn't want to even open the door. The recommendation was just nothing because it was easier for people to adhere to that.
- [41:50]
B
So true. So true.
- [41:51]
A
So, okay, so 30 minutes a day. Is strength training also involved in that? Or it's mostly cardio.
- [41:56]
B
Is that mostly cardio for this risk? But strength training is really, really important. It maintains your bones, and as you age, so important to do that.
- [42:04]
A
Okay, and then healthy diet.
- [42:06]
B
Healthy dieting.
- [42:07]
A
That quotes. Because that might mean. Are we talking more Mediterranean? Are there foods you want to avoid?
- [42:12]
B
That's for a general, general health. That's really important. How much of one little thing versus another impacts breast cancer is unclear. We know that red meat is. It's actually listed as a carcinogen. So, you know, that's, that's probably problematic. Can you have some, some steak every so often? Yes, I'm sure you can. But again, it kind of becomes one of those. How often? Unclear.
- [42:35]
A
What about barbecue? I've heard, like, you know, if you have any black residue from char on your, your meats, it's, it's a, it's a carcinogen and it's increasing your risk to some degree.
- [42:46]
B
Yes. And then again, it comes down to how often are you doing this?
- [42:50]
A
Okay.
- [42:50]
B
Is it here and there versus, you know, once a week, twice a week, all the time.
- [42:55]
A
Let's talk about screening. Yes, we've talked about that a little bit. We know that obviously it's probably in addition to diet. Right. And exercise, the number one thing that you can do to help reduce your risk is to be diligent about your screenings. You mentioned earlier, 40 is the age that you recommend. How often? And then can you talk a little bit about mammogram and sonogram?
- [43:17]
B
Sure. Yes. So 40 yearly, starting at the age of 40. We at this point just recommend mammograms for most people unless they're told that they need more than that. So breast density is something that people talk about quite a bit. And having higher or more dense breasts leads to increased rates of breast cancer. And it's also harder to diagnose a breast cancer when you have dense breasts because it's harder to read the mammogram and what, you know, people sometimes ask, what exactly is breast density? So when you're looking at a mammogram or if you look at your own mammogram, you're going to see areas that are dark and light. So the dark areas are fat. That's fatty breasts.
- [43:55]
A
Okay.
- [43:55]
B
And that's great for mammograms because you can see right through them. And so if there's a mass forming, it's pretty clear. Dense areas look sort of more white on a mammogram. And what density is, is basically more tissue that has glands in it, glandular tissue, the ducts where milk is produced and distributed. That's. And some of the more connective tissue.
- [44:20]
A
Okay.
- [44:20]
B
And the reason that you might have increased rates of breast cancer if you have more dense breasts is because there's more of that.
- [44:26]
A
It's harder to see.
- [44:28]
B
It's Harder to see.
- [44:29]
A
I see.
- [44:29]
B
But it's also, you may have an increased risk of developing breast cancer because you have more of that tissue that breast cancer arises from. So there's that. And then it can obscure a mammogram.
- [44:38]
A
Because cancer doesn't develop out of fat, you're saying. Right, I see. Okay, so.
- [44:42]
B
And then it can obscure the mass. So we have these 3D mammograms, which in certain centers, that's sort of the standard of care, but in others it's not. There are digital mammograms, digital tomosynthesis, and what they do is take low grade X rays from different angles and then they combine them all to basically form a 3D image of the breast. And so you have a better way of looking at the breast. So anybody with dense breast tissue should be getting a 3D mammogram for sure. And like I said, in a lot of centers, that's all they do. Adding the ultrasound to it. So ultrasounds have issues on their own. They're operator dependent. It's a lot of area to cover. But if you have very, very dense tissue, that might be something that needs to be discussed. Should you add on an ultrasound?
- [45:32]
A
Yeah, because I have, I have heard of people who have gotten the mammogram and the cancer was not picked up, but it was picked up on the sonogram. So my question was, why would the sonogram not just be the standard of care, but maybe it's dependent on what kind of breasts you have and they can see what kind of breast you have in the mammogram.
- [45:50]
B
That's right. That. Exactly, exactly.
- [45:52]
A
Would that. Because most people, you have to get the prescription from your doctor of what you're going to get, the mammogram or the sonogram. If you're there and it turns out you do have dense breasts, the technician can't make that call there on the fly. Right. Would they then say, I guess, if they say to you or you hear the word dense breasts, that you may want to go back to your provider?
- [46:15]
B
Yes. And depending on the center, the radiologist who's reading your mammogram may actually say, recommend an ultrasound, but that's only for extremely dense breasts. For heterogeneously dense breasts, they're not going to say that. And why not get an ultrasound, everybody? So issues that may come up is a lot of false positives. You end up with a lot of biopsies. And then we're also getting down to an ultrasound is a longer test, and you Know, cost benefit again.
- [46:42]
A
Okay.
- [46:43]
B
You can't do that over an entire population.
- [46:45]
A
Okay.
- [46:45]
B
That's also the issue with breast MRIs. So breast MRIs are really recommended for a certain subset of patients, like people who have BRCA mutations but who still have their breasts, or somebody who's had radiation to the breast area for another cancer as a child or an adolescent. Okay, those again. And MRI is very, very expensive and it's a big test, so. And it's going to lead to a lot of false positives, so.
- [47:14]
A
Well, there are such disparities, right? Just in my own anecdotally, my own life experience, hearing people going to different doctors and things. You know, you mentioned the 3D mammogram. Should people be asking their gynecologist or their general practitioner or over there getting their health care, what center or what place offers that type of mammogram versus just the kind of old school, you know, put your breast in a vice mammogram, I don't know what happens to you. You probably have to put it in a vice, too, for the 3D one. But to empower people that are listening, what. What should they be asking for or looking for?
- [47:51]
B
People should be asking, what kind of mammogram is this? Okay, that I think is really, really important. And I think it's also important to ask who's reading it? Is it a dedicated mammographer? Okay, there is a difference.
- [48:03]
A
Okay.
- [48:04]
B
So not always. I mean, and for the, for the most part, it should be fine, but I think that that's something that people should know at least.
- [48:13]
A
So if you are in the position where you go, you get a mammogram and you get the phone call from your doctor that they've seen a mass and they want you to have it biopsied, and then you have your biopsy, it turns out that it is diagnosed as cancer. I have had this conversation with friends, not knowing who to go to, where should they go? And I also know sometimes it matters where you start your treatment. If you start your treatment at one hospital or one with one doctor, you can't switch in the middle of your course of treatment. You have to wait till that course of treatment is finished before you could go to another provider. Maybe I'm wrong about that, but that's been my experience in New York. Like, if you go to a hospital and you just, like, you're not quite sure you've already started your treatment, you can't then shift gears and go to morals on Kettering, they won't take you until You've finished your course of treatment. So it's important, I guess, to start out on the right foot. So, yes. What should people be looking for when they're trying to find someone to treat them now that they've been diagnosed with cancer?
- [49:16]
B
Absolutely. So when they get that call, and that is scary, most places will, at this point, say, and we are going to set you up with a breast surgeon and a medical oncologist. Most people will. Will. Most centers will say that. They won't just say, okay, good luck.
- [49:34]
A
Right.
- [49:35]
B
And, you know, you can always, of course, call your primary care once you see. So there's three people who are going to be involved with your care. The surgical oncology team, the medical oncology team, and the radiation oncology team. Radiation oncology team may or may not be involved, depending on what kind of surgery you get and what's happening when you were set up with these people. I think the biggest questions really are, is this a breast specialist?
- [50:02]
A
Right. Okay.
- [50:03]
B
And if not, I think breast cancer is common enough, and general oncologists do an excellent, excellent job of treating breast cancer. That being said, it might be worth going ahead and getting a second opinion with a specialist. That doesn't mean you have to switch to them. But just making a care plan and then going back to your local person to be treated, that's absolutely done all the time.
- [50:28]
A
I think that's a real. I don't interrupt you, but I think that's a very important point that you just made, because a lot of people, I think, think about when they get that diagnosis, what is this gonna look like with my life now? Meaning how sick am I gonna feel? You know, just the logistics of having the disease picking up. Kidding. And they think, gosh, I need to be going to someone that's close to home. But you can go to a top person, you can go to a doctor to get a second opinion. That's you here in Nashville or someone to MD Anderson in Houston or Morrilson Kettle, wherever. Dana Farber, you can go to these places, get your protocol, and be treated in concert with your. With your doctor in your area.
- [51:11]
B
Absolutely. That is a huge percentage of my patients. And now with telehealth, and since COVID we get a lot of people who live five hours away. As long as. For me, because I'm licensed only in Tennessee.
- [51:24]
A
Right.
- [51:24]
B
As long as there's. Within the state of Tennessee, they can be in Knoxville or further four hours away, and we can set up a call and at least make sure that. That the plan is. Is what, what we would do. The other reason to actually speak with a center that, that specializes in breast cancer is clinical trials. So people think clinical trials are for end stage patients. They sort of have this idea that you don't need a clinical trial unless you absolutely do.
- [51:50]
A
You want to explain to what a clinical trial is for the people.
- [51:52]
B
Exactly.
- [51:52]
A
Familiar.
- [51:53]
B
A clinical trial, basically, when you sum it up, it gives you access, potentially gives you access to a treatment you might not have had access to. So in the early stage, if you're just diagnosed, you have a stage one or two cancer even, we may have clinical trials where you get the standard of care because no one would not give somebody who's curable at least the standard of care, but potentially gives you something more, another drug. So that may be maybe exactly what you need. I think a great way to look at it is when we are looking at new drugs that are coming to the market. Their first clinical trials are in metastatic patients, patients in whom the cancer has already spread generally. And then they generally get approval in the metastatic setting for patients with stage four disease. But if they're working really well there, our question always is, well, if they're working well in the person with metastatic disease, why not bring them early, right. To stage one, two or three patients and prevent those patients from ever developing metastatic disease? And that's exactly the type of clinical trial that I'm talking about. So we have all of these. Let's just say somebody is diagnosed with triple negative breast cancer which is not fed by estrogen or progesterone or HER2. The standard of care right now is chemotherapy plus immunotherapy before surgery for most of them. For the larger ones, five years ago, we were not using immunotherapy, but we at Vanderbilt were involved in a clinical trial that took patients exactly like that. They all got chemotherapy, the standard of care.
- [53:31]
A
Right.
- [53:31]
B
Half also got the immunotherapy. And a few years later we found out that the immunotherapy group did better.
- [53:37]
A
Right.
- [53:37]
B
So these are people who had access to a drug well before it became the standard of care. There are lots of clinical trials going on like that and, and always know that there may be something and explore.
- [53:52]
A
Well, I always say to friends that are going through this who. And I've had those conversations with them, they're going to go to the local hospital near them and I'll say, you know, you wouldn't towel your bathroom without getting two quotes from a contractor and you'd want to hire the person that knows that just child's bathrooms. So going to a cancer center or a center that specializes in breast cancer, as you said, has access to these clinical trials is really important. It's really worth the investment and the time to do that because your outcome could be so much greater and you could still have your treat. You'd have to go check in occasionally, but you'd still be able to have your protocol administered to you where you live.
- [54:34]
B
Yeah. You have all your options laid out before you. That, that's the key. That's exactly right. And same with the surgeon. You want somebody who operates right, who does breast surgeries a lot. That does not necessarily mean coming to an academic center or just a dedicated breast center, but it does mean asking your breast surgeon, you know, what are you doing throughout the day? How many breast surgeries?
- [54:56]
A
How many are you doing? Right. Because, you know, I, you know, I'm not a doctor. Just play one on tv. But, but I know the margins, right. Making sure that you're cutting the margins around the tumor where there could be cancer cells is so critical. The surgeons have, you know, not all surgeons are created equal. As, as you mentioned. I mean, you finding the right person who does a lot of them and is skilled in doing them is really important. So you are at Vanderbilt Ingram's cancer center in the breast cancer research program, and you mentioned clinical trials briefly. But what kind of exciting research or exciting treatments have you seen in your time there that you just are so excited about and are seeing such great results from?
- [55:39]
B
There's so, so, so much there. We could actually go on for hours. But I won't do that. The first thing I really want to just say is as a whole, how far we've come.
- [55:48]
A
Right.
- [55:48]
B
Over the last decade, there have been at least 15 new drugs approved for breast cancer and over 30 new indications. So one drug could have two different indications. But I mean, that's remarkable. The decade before only had a few. So I mean, this is the pace of discovery. It's mind boggling.
- [56:07]
A
Is that because there was some key that was unlocked? Is this, is this immunotherapy I know.
- [56:12]
B
Is one of them? Yes, it's one of them. There's so many different pathways that are being under that we understand now. So that's. In fact, two weeks ago today, a new drug was approved in a volisib for a PIK3CA mutation. So it's a gene mutation that your tumor's DNA may have that was just approved two weeks ago, which is again, amazing, but interesting.
- [56:36]
A
So you would do genetic testing. Do you often start when you mentioned that people get genetic testing to start to sort of see what kind of tumor they might have beyond the BRCA gene, or is it.
- [56:47]
B
Yes. So there's two types of genetic testing. There's the genetic testing that's done from your blood for what we call germline mutations, mutations that you can pass on to your children. Okay, there's that. But then there are what we call somatic mutations that develop in you later or your tumor's DNA. So we actually will biopsy. This is pretty standard now to take a biopsy of the tumor and look for genetic alterations that are just in the tumor that you wouldn't pass down. And you can do that through the blood as well because your tumor is always shedding DNA. So you can pick that up in the blood. And people will have lots of different mutations in their tumor's DNA. PIK3CA mutations are pretty much the most common ones in breast cancer. About 40% of breast cancers will have these mutations. So we have drugs that are approved to target that specific mutation. So, you know, there's a lot of. Yeah, it's, it's. It's really, it's. It's amazing just what we know about these tumors and also what we don't know about them. But you asked in terms of Vanderbilt and what we're doing. So we have so many clinical trials going on right now in all stages, stage one through four for breast cancer and all different cancers. Of course, right now, I actually, the ones that I'm the most excited about are the ones that I have going on. I have two big newer studies that I'm just starting up, national studies. One is for androgen receptor positive breast cancer. So when you hear the word androgen, you probably think male. Yes, androgen receptors or androgen treatment is used for prostate cancer.
- [58:28]
A
Okay.
- [58:29]
B
So I mentioned triple negative breast cancer earlier. About 20% of breast cancers are triple negative, meaning they're negative for these three big estrogen, progesterone and HER2. But what are they positive for? As in what can we target? We don't really know. We think that triple negative breast cancer is a bunch of different diseases. And so at Vanderbilt, Dr. Jennifer Petenpol and Dr. Brian Lehman, their lab actually subtyped triple negative breast cancer. And they are my longtime collaborators in the laboratory, and they found that there is a group in there of the triple negatives that actually express the androgen receptor, and that's probably the pathway that is leading to their cancer growth.
- [59:16]
A
Wow.
- [59:16]
B
And so we are using darolutamide, which is actually a drug that's FDA approved for prostate cancer in androgen receptor positive breast cancer. This is going to be a small percentage of breast cancers. And I always think about any cancer is up high and you're always trying to slice it thinner and thinner. Thinner. Right. In the 70s, the big discovery was estrogen receptors. So that was right there, 50% of breast cancers. Well, now within that, we have to slice estrogen receptor thinner and thinner. So we have pi3 kinase mutated estrogen receptors, and, you know, various different ones for triple negative. We actually know that there is this luminal androgen receptor subtype, and we need to find a treatment for it. So that's one of the big studies that I'm working on. Another one is looking at circulating tumor DNA. That's in collaboration with Dr. Ben park, who's our current cancer center director. And we're looking at circulating tumor DNA and looking at whether you can predict in the metastatic setting whether a treatment is going to work based on how quickly circulating tumor DNA in the bloodstream drops after starting a treatment. So you don't have to wait months to get a scan.
- [60:33]
A
So explain this to me again. So when you see the tumor circulating DNA, that it's circulating it out into the bloodstream.
- [60:42]
B
That's right. So when a person has metastatic breast cancer, their tumor is shedding DNA and.
- [60:50]
A
You can pick that up, replicating everywhere.
- [60:52]
B
Yes.
- [60:53]
A
Okay.
- [60:53]
B
It's just, it's out there. You can pick it up and you can look at it. And in the metastatic setting right now, which is, and I say right now, it's. That it's. It's considered not curable. But I have high hopes that that is not going to be the case very soon. For metastatic breast cancer, the way people are treated is they start a treatment and then they have scans every two to three months.
- [61:16]
A
Okay.
- [61:17]
B
And as long as the tumor's shrinking or stable, you keep going with the treatment, but you're waiting two to three months.
- [61:23]
A
Right.
- [61:24]
B
What if you could start a treatment and two weeks later, get a blood drawn to see if you're circulating tumor markers. That's DNA has really dropped. And change treatment based on that.
- [61:36]
A
Wow. Because then to your point, then if it's not working and you have to switch gears, you don't want to wait the two months because it's just spreading more in the two months.
- [61:45]
B
Yes. And you're getting toxicity from the treatment.
- [61:47]
A
Right.
- [61:48]
B
It's often IV chemotherapy.
- [61:50]
A
Wow. Oh, that is so exciting. Gosh, it's so exciting. I mean, I just, in my own lifetime, with being involved a bit with Sloan Kettering and seeing just the advances that they've made with it with immunotherapy. It's just so exciting to think about where we are today and where we're headed. And hopefully, as you said. Did you say that 80% are curable? We want to keep going till it's 100%, but it's just so comforting to know that we have people like you wanting to front lines, seriously continuing that fight and being so passionate about your research and helping to find a cure at the same time that you're treating patients.
- [62:30]
B
And we're also so fortunate to have so many advocates for breast cancer.
- [62:34]
A
Right.
- [62:35]
B
So many people raising money, being parts of clinical trials that sometimes may not even really benefit them, but helps us understand these drugs. So we're really fortunate to be in this place right now.
- [62:48]
A
Well, I'm so fortunate to have you here talking with us about it, and I'm so grateful to you for taking the time. It's a really important conversation. And, you know, I think we've got a day or two left of Breast Cancer Awareness Month. But it's just important, you know, for women to remember, get your scans, do yourself exams, and be mindful about your health and what you're putting into your body.
- [63:09]
B
Absolutely. And so wonderful you're doing this.
- [63:12]
A
Thank you, Vandana, thank you so much for being here.
- [63:14]
B
Thank you so much, Leslie.
- [63:17]
A
That brings us to the end of this episode of the interview. A huge thank you to Dr. Vandana Abramson for joining, and as always, thank you all again for listening. If you enjoyed this episode, please rate or review us on Apple Podcasts and Spotify or wherever you get your podcasts. And a new episode is released every Wednesday, so we hope you'll tune in again next week. And until then, this is Leslie, and thank you for joining the interview.