Smilow Shares: Breast Cancer Awareness Month: Screening, Genetics, and Prevention

Transcript

• 00:06Alright. Welcome, everyone.
• 00:08This is Milo Shares Breast
• 00:10Cancer Awareness Month. This is
• 00:11the first of three presentations,
• 00:14and this one is called
• 00:15understanding breast health, screening genetics
• 00:18and prevention.
• 00:20And I'm John Lewin. I'm
• 00:21the moderator for this session,
• 00:24and we have
• 00:26three
• 00:31experts.
• 00:40So we have doctor Pris
• 00:42Salafi,
• 00:42who's my colleague in the
• 00:44department of radiology and biomedical
• 00:45imaging,
• 00:47and she will be talking
• 00:48about
• 00:49screening,
• 00:50and Tracy Battaglia,
• 00:52who is professor of medicine
• 00:54and associate director community outreach
• 00:56and engagement for the Yale
• 00:57Cancer Center,
• 00:59and Linda Erwin,
• 01:01who's associate dean of research,
• 01:03and Susan Dwight Bliss professor
• 01:05of epidemiology,
• 01:07deputy director of the Yale
• 01:09Cancer Center, who will be
• 01:10talking about
• 01:11risk modification.
• 01:14And so without any further
• 01:16ado, I will stop sharing
• 01:17my screen, and doctor Lottie
• 01:19can start her presentation.
• 01:25Okay.
• 01:31I hope everyone is having
• 01:32a good evening.
• 01:34I'm gonna briefly talk about
• 01:35breast cancer, current screening recommendations.
• 01:43We all are aware or
• 01:44have heard of the US
• 01:46Preventative
• 01:47Services
• 01:48Task Force.
• 01:50This is a task force
• 01:51that is,
• 01:53assigned by the government
• 01:55to look at medical data
• 01:58and make recommendations
• 02:00for screening
• 02:01different,
• 02:02types of
• 02:04diseases.
• 02:05But specific to breast cancer
• 02:07screening, they just modified their
• 02:10recommendation,
• 02:11recently last year,
• 02:13and they lowered the start
• 02:16age for screening.
• 02:17Now they recommend women aged
• 02:19forty to seventy four get
• 02:21screened. However, their recommendation says,
• 02:24every two years.
• 02:26And, women seventy five years
• 02:28or older,
• 02:29they said that there isn't
• 02:31sufficient,
• 02:32evidence to assess the balance
• 02:34of benefits and harms of
• 02:36screening mammography in this population.
• 02:38They also recommended that women
• 02:40with dense breast,
• 02:42that there isn't enough evidence
• 02:44to assess the balance of
• 02:45benefits and harms.
• 02:47Now
• 02:48we can talk about an
• 02:50hour about the data they
• 02:51looked at and
• 02:54what they considered harms and
• 02:56benefits. But one thing they
• 02:58considered a harm of screening
• 03:00was anxiety of women and,
• 03:02potential callback rates.
• 03:05Briefly, I just wanna say
• 03:06that when
• 03:08screening mammography is the standard
• 03:10of care, and this is
• 03:11going back decades, and we
• 03:13have,
• 03:15extensive research proving that screening
• 03:17mammography
• 03:18saves lives.
• 03:20Women who had a screening
• 03:21mammogram compared to women who
• 03:23didn't definitely live longer, and,
• 03:26that's how we know.
• 03:29Everything else, ultrasound
• 03:31and MRI
• 03:32and other modalities that I
• 03:34will talk about, like contrast
• 03:36enhanced mammography,
• 03:37we don't have enough data
• 03:38to know decades worth of
• 03:40data to know if these
• 03:42are actually
• 03:43making women die less of
• 03:46a breast cancer.
• 03:49So current
• 03:51guidelines,
• 03:52this is a table that
• 03:54is talking about the different
• 03:55societies, medical societies talking about
• 03:58screening guidelines.
• 04:00I talked about the,
• 04:02task force. It says start
• 04:03at forty every two years.
• 04:05And then different societies like
• 04:07ACOG is the OB GYN,
• 04:09society, American Cancer Society, American
• 04:12Medical Association,
• 04:14they all pretty much are
• 04:15recommending
• 04:16starting at forty. And for
• 04:17the most part, annual screening
• 04:19is recommended.
• 04:21For women older than seventy
• 04:22five, it's based on shared
• 04:24decision making. If people are
• 04:26in good health, if women
• 04:28are in good health and
• 04:29they have at least ten
• 04:30more life, years ahead of
• 04:32them,
• 04:33it's a good idea to
• 04:34continue with mammography. But that's
• 04:36a personal choice, and it
• 04:37can be discussed with,
• 04:40their primary care physicians
• 04:42and, come to a decision
• 04:44that's appropriate for that individual.
• 04:47I am a radiologist, so
• 04:48I'm gonna talk about American
• 04:50College of Radiology and Society
• 04:52of Breast Imaging recommendations,
• 04:55which basically says start at
• 04:57forty.
• 04:57Every year, get a mammogram,
• 04:59and there is no age
• 05:00limit.
• 05:01But, obviously, we do consider
• 05:03individual health status.
• 05:06So,
• 05:07American College of Radiology
• 05:09recently,
• 05:10in the last few years,
• 05:12changed their recommendations
• 05:13in terms of,
• 05:15breast
• 05:16care. And,
• 05:18they brought to light the
• 05:20importance of having a risk
• 05:21assessment
• 05:22for women,
• 05:23and they're recommending that women
• 05:25get a risk assessment
• 05:27by age twenty five. Every
• 05:28woman should know if they're
• 05:30high risk, low risk, if
• 05:31they're average risk, discuss as
• 05:34far as they know,
• 05:36discuss that with their primary
• 05:37care or, their gynecologist
• 05:40so that they can
• 05:41appropriately
• 05:42be screened starting at that
• 05:44age.
• 05:46So
• 05:47high risk women, as determined
• 05:49by the risk
• 05:51assessment models, are deemed high
• 05:53risk.
• 05:55If they desire anything more
• 05:56than a mammogram,
• 05:58because they're high risk, they
• 06:00should get some other supplemental
• 06:02screening.
• 06:03So MRI has been our
• 06:05traditional screening tool for those
• 06:07women. If for some reason
• 06:08they can't undergo MRI screening,
• 06:11and there could be the
• 06:13different reasons for that,
• 06:15definitely ultrasound and,
• 06:17institutions that have contrast enhanced
• 06:19mammography,
• 06:21they should undergo that,
• 06:23procedure.
• 06:24I will talk a little
• 06:25bit more about that, in
• 06:27a bit.
• 06:28Women who have dense breasts
• 06:30and are not necessarily
• 06:32high risk, but they want
• 06:34supplemental
• 06:35screening,
• 06:36they can get a breast
• 06:38MRI. However, sometimes insurances don't
• 06:40cover that. Most insurances don't
• 06:43or the they're cost prohibitive
• 06:45or there's a contraindication
• 06:47for getting an MRI.
• 06:49It's important that these women
• 06:50know they have options. Ultrasound
• 06:52or contrast enhanced mammography
• 06:54should be considered.
• 06:56If someone is intermediate risk,
• 06:58and, again, these are calculated
• 07:00lifetime risks with which my
• 07:02colleagues will talk about,
• 07:04in a minute.
• 07:07The and and have dense
• 07:09breasts.
• 07:09Of course, they should continue
• 07:11with mammography but also get
• 07:13MRI or, ultrasound.
• 07:17So just to talk about
• 07:18mammographic density,
• 07:20mammograms are black and white
• 07:22and gray. And, basically,
• 07:24anything that's gray or black
• 07:26is good.
• 07:28This is the opposite of
• 07:29real life,
• 07:30and white is glandular breast
• 07:32tissue. However,
• 07:33cancer,
• 07:35cysts,
• 07:36benign masses, anything else that
• 07:38is not tracked will also
• 07:39be white.
• 07:41So when we are going
• 07:42from left to right, we
• 07:44are seeing an increase in
• 07:45the breast tissue density.
• 07:47This, the right side is
• 07:49considered an extremely dense mammogram,
• 07:52and you can see that
• 07:53the majority of this breast
• 07:55is white. And if
• 07:57this breast had a small
• 07:59cancer in it, it would
• 08:00be very difficult to see
• 08:02it because it's gonna blend
• 08:03in with the adjacent breast
• 08:05tissue. And this is why
• 08:07it's important that women who
• 08:09have extremely dense breasts
• 08:11should consider additional supplemental
• 08:14screening. This is a fatty
• 08:16breast,
• 08:17and,
• 08:18you can see that if
• 08:19there was a mass this
• 08:21is a normal structure here.
• 08:22But let's say there was
• 08:23a mass, it would be
• 08:24white, and it would be
• 08:25extremely
• 08:27easy to appreciate it.
• 08:30About
• 08:31of the four categories, half
• 08:33are dense and half are
• 08:35not dense. And about half
• 08:37the population
• 08:38has dense breasts and half
• 08:39the population doesn't.
• 08:42The last one, the extremely
• 08:43dense,
• 08:45category is about ten percent
• 08:47of women. So not very
• 08:48common, but extremely important.
• 08:51Density by itself is also
• 08:53a risk factor.
• 08:55So women who have denser
• 08:56breasts have a higher risk
• 08:59for developing breast cancer compared
• 09:01to women who have a
• 09:02fatty breast. For example, one
• 09:04and four,
• 09:06the four, which is extremely
• 09:07dense breast, has a four
• 09:09times
• 09:10more risk of developing breast
• 09:12cancer compared to a fatty
• 09:13breast and about two times
• 09:15higher than an average breast.
• 09:18So when we have, increased
• 09:21density
• 09:22from, again, left to right,
• 09:24we can see the density
• 09:25of the breast or the
• 09:26whiteness is increasing.
• 09:29That lowers our sensitivity
• 09:31of mammography and increases the
• 09:33risk of cancer not being
• 09:35detected.
• 09:36I don't like using the
• 09:38word missing cancer. We're not
• 09:40missing it. We're just not
• 09:41seeing it. We're not detecting
• 09:43it. So as we go
• 09:44from left to right, you
• 09:46can see that,
• 09:48the risk increases for nondetection
• 09:51of breast cancer, and the
• 09:53extremely dense breast has a
• 09:54more than sixty percent risk
• 09:56of, nondetection.
• 10:00So in order to look
• 10:01at,
• 10:03dense breast and utility
• 10:05of, additional supplemental
• 10:08screening,
• 10:09there were several trials that
• 10:10were recently published.
• 10:12One was the DENSE trial,
• 10:14which is the
• 10:16the dense tissue and early
• 10:17breast neoplasm screening. This was
• 10:19a very good trial. It
• 10:20was randomized controlled trial. It
• 10:22was in the Netherlands.
• 10:24And they added MRI in
• 10:26a population of fifty to
• 10:28seventy five year olds,
• 10:30women, who had extremely dense
• 10:31breast tissue and had a
• 10:33normal mammogram.
• 10:35And they wanted to see,
• 10:37different things, but one was
• 10:39they wanted to see patients
• 10:41who had that added MRI.
• 10:43Do they have
• 10:44a lower rate of interval
• 10:46cancer?
• 10:47Interval cancers are cancers that
• 10:49develop in between screening,
• 10:53timelines.
• 10:54And for them, it was
• 10:55every two years. They also
• 10:57looked at other things. For
• 10:59example, they wanted to see
• 11:00what is the detection rate
• 11:01of MRI.
• 11:03Are there false positives?
• 11:05What kind of tumors are
• 11:06detected by MR and some
• 11:08other characteristics?
• 11:10They were lucky. They looked
• 11:12at forty thousand women, and
• 11:13about eight thousand of them
• 11:15had the supplemental MRI.
• 11:17And what they saw that
• 11:18the rates of interval cancer
• 11:21was about half in women
• 11:23who had MRI compared to
• 11:25mammogram only.
• 11:26So it was two point
• 11:27five per thousand compared to
• 11:29five.
• 11:30And,
• 11:31basically, this was great news.
• 11:33I should also make a
• 11:35note that these are average
• 11:36risk patients, not high risk
• 11:38patients.
• 11:39And the women who had
• 11:40the MRI, they had about
• 11:42over sixteen
• 11:44per thousand
• 11:46rate of cancer detection, which
• 11:48is great. Again, mammography
• 11:50alone finds if you have
• 11:51tomosynthesis,
• 11:53on average, four or five
• 11:54cancers per thousand.
• 11:57Another trial called BRAID breast
• 12:00Screening Risk Adaptive Imaging for
• 12:02Density
• 12:03wanted to see, in addition
• 12:05to mammography,
• 12:06other supplemental
• 12:07screening imaging,
• 12:10tools
• 12:11effect.
• 12:12For example,
• 12:13ultrasound, contrast enhanced mammography,
• 12:16and MRI
• 12:17in detection of breast cancer.
• 12:19They had about nine thousand
• 12:21patients. Six thousand completed those
• 12:24extra
• 12:25modalities.
• 12:27And,
• 12:27the cancer detection rates were
• 12:29really great,
• 12:31for
• 12:32and more abbreviated MRI is
• 12:34just the shorter version shorter
• 12:36time version of contrast enhanced
• 12:38MRI.
• 12:39And in that population, they
• 12:41had about seventeen per thousand,
• 12:43detected cancers.
• 12:45Contrast enhanced mammography
• 12:47was even higher, nineteen ish,
• 12:49and,
• 12:50ultrasound was only about four
• 12:52point two per thousand.
• 12:54You can see
• 12:55that. And in that population,
• 12:57the, cancer detection rate was
• 13:00eight point four per thousand.
• 13:01So you can actually look
• 13:02at the numbers and appreciate
• 13:04that ultrasound was just slightly
• 13:06better, but MRI and contrast
• 13:08enhanced mammogram more than doubled
• 13:10it.
• 13:12Tumor size was also much
• 13:14smaller. On the average, it
• 13:15was about a centimeter in
• 13:17women who had the MRI
• 13:19and contrast enhanced mammogram.
• 13:21And,
• 13:22ultrasound detected tumors were slightly
• 13:24larger, about double the size,
• 13:26twenty two millimeters.
• 13:27These are averages.
• 13:29So you can see that
• 13:30earlier detection
• 13:32is,
• 13:33key
• 13:34with
• 13:35contrast enhanced modalities.
• 13:38Now just to say a
• 13:39little bit about contrast enhanced
• 13:40mammography,
• 13:42the premise is that tiny
• 13:44little tumors, anything more than
• 13:46two millimeter, will demonstrate
• 13:48angiogenesis,
• 13:49and that means that they're
• 13:51gonna grow new blood vessels.
• 13:53These blood vessels are leaky.
• 13:55And when we inject a
• 13:56contrast material through an intravenous,
• 14:00access,
• 14:01they go to the breast,
• 14:02and they accumulate
• 14:04in these tumors.
• 14:06We can detect them with
• 14:07two two ways. One is
• 14:09contrast enhanced mammography, and one
• 14:11is MR.
• 14:13A lot of people, patients,
• 14:15physicians know about, MRI. I
• 14:17won't go into into detail
• 14:18about that. But contrast enhanced
• 14:20mammogram is essentially a mammogram
• 14:23that is obtained before and
• 14:24after administration of contrast, and
• 14:26this is an example
• 14:28of that.
• 14:30When patients undergo contrast
• 14:32enhanced mammography, they get a
• 14:33normal mammogram, which is,
• 14:36this image here, and this
• 14:38is another view of the
• 14:39same. It's labeled left CC
• 14:40and left MLL.
• 14:42And then
• 14:43another image,
• 14:45mammogram image is obtained. Those
• 14:47images are subtracted,
• 14:49and what remains
• 14:50is anything that picks up
• 14:52the dye. So in these
• 14:54two images, you can see
• 14:55that there's a tiny little
• 14:57mass that shows up in
• 14:58the left breast,
• 15:00and it's completely obscured. You
• 15:02don't see anything like that
• 15:04because this is an extremely
• 15:05dense mammogram.
• 15:07And,
• 15:09so contrast enhanced mammography
• 15:11is a mammogram that is
• 15:13really not affected by breast
• 15:14density.
• 15:18So
• 15:19let me just oops.
• 15:21I lost my
• 15:24chair.
• 15:33Alright.
• 15:34What we don't have answer,
• 15:35there are several questions with,
• 15:38in general and what these
• 15:40trials that I mentioned have
• 15:41not answered.
• 15:43We know that mammography
• 15:44saves lives by lowering by
• 15:47decreasing mortality from breast cancer.
• 15:50We don't know that about
• 15:51MRI or contrast enhanced mammography.
• 15:54So,
• 15:56there's a lot of research
• 15:57being done about that. Hopefully,
• 15:59we'll have that answer at
• 16:00some point. We also don't
• 16:01know how feasible it is
• 16:03to have these,
• 16:05other supplemental
• 16:06tests,
• 16:08in terms of logistics,
• 16:10cost, capacity
• 16:12for women who are not
• 16:14at high risk.
• 16:15As you know, demand for
• 16:17imaging is very high. We
• 16:19have very low, MRI capacities,
• 16:21and contrast enhanced mammography
• 16:23is not available at every
• 16:25institution.
• 16:27At Yale, we are
• 16:31increasing our MRI capacity at
• 16:33different sites.
• 16:35However, we are sharing with
• 16:36other body parts. You know,
• 16:38everybody wants to have an
• 16:39MR. It's a highly utilized,
• 16:42test.
• 16:43And we don't have enough
• 16:44slots to do diagnostic MRs,
• 16:46to do high risk screening,
• 16:47and also average screening of
• 16:49the women who have dense
• 16:51breasts.
• 16:52We will be starting a
• 16:53contrast enhanced mammography program in
• 16:56the next six months or
• 16:57so. We'll be doing it
• 16:58on both, two campuses at,
• 17:01Smilo
• 17:02and at our North Haven
• 17:04campus. And, that'll be great.
• 17:06It'll be,
• 17:08very, very exciting for us
• 17:10to start that program
• 17:12and offer women,
• 17:14additional supplemental screening.
• 17:21Alright.
• 17:26Alright. Very nice.
• 17:28Doctor Battaglia?
• 17:31I'll pull up my slides.
• 17:32Good evening, everyone. I see
• 17:34there's a couple of questions
• 17:35in the chat, John. I
• 17:35don't know if you wanna
• 17:36take one or two while
• 17:37I'm
• 17:39If you would like, we
• 17:40definitely will have time at
• 17:41the very end for everybody's
• 17:43question. Well, pretty much. So
• 17:45one of our attendees
• 17:46asked, doctor Lottie,
• 17:48about invasive lobular cancer.
• 17:51How would that show up
• 17:52on a contrast enhanced mammogram?
• 17:54So similar to MRI,
• 17:56it will show up,
• 17:58because lobular cancer
• 18:01also has, neovascularity.
• 18:05As you know, lobular cancer
• 18:07is not a very common
• 18:08cancer. It's about ten percent
• 18:09of our cancers. And, occasionally,
• 18:12it may not enhance. It
• 18:14may not take up the
• 18:15dive similar to MRI.
• 18:17And that's why
• 18:21screening mammography, the two the
• 18:22actual mammogram portion of it
• 18:23is super helpful. We read
• 18:23those
• 18:35based on a
• 18:37previous biopsy or diagnosis
• 18:39or whatever,
• 18:41we can either do contrast
• 18:43enhanced mammography
• 18:44or MRI for extent of
• 18:46disease and,
• 18:48other diagnostic workup.
• 18:51Alright. Very good. Let's move
• 18:53on to the next talk,
• 18:54and I will promise we'll
• 18:56get to everybody's questions at
• 18:57the end. Okay. Great. Thank
• 18:59you so much. Good evening,
• 19:01everyone. It's great to be
• 19:01here with you all to
• 19:02kick off breast cancer awareness
• 19:04month. I see,
• 19:05only one of
• 19:06our panelists has pink on
• 19:08today. So, Melinda, you you
• 19:10have it on. You have
• 19:11it on. So I'm here
• 19:12to, take you, through an
• 19:14overview of high risk breast
• 19:16health care. I'm gonna talk
• 19:18a little bit about risk
• 19:19assessments,
• 19:20risk assessment that was alluded
• 19:22to in the
• 19:23the first presentation on breast
• 19:25imaging
• 19:26and, our approach to risk
• 19:28reduction strategies for those who
• 19:29do have high risk.
• 19:31My background is I'm a
• 19:33general internist, women's health provider,
• 19:35and preventive medicine,
• 19:36physician. And so I'm a
• 19:38practicing clinician in our high
• 19:40risk breast practice.
• 19:45So, you know, what we've,
• 19:47historically
• 19:48approached breast cancer screening is
• 19:50using age based screening.
• 19:54And so
• 19:56many of us are familiar
• 19:57with recommendations for screening based
• 19:59on age alone.
• 20:00And we know now that
• 20:02age based screening really ignores
• 20:04the range, the very sort
• 20:05of broad range of risk
• 20:07factors that,
• 20:09influence our individual risks for
• 20:11future cancer.
• 20:12And as we sort of
• 20:14have advances
• 20:15in cancer diagnosis
• 20:17and treatment,
• 20:18we are,
• 20:20increasingly providing personalized care to
• 20:22patients based on their individual
• 20:24presentation. And so the age
• 20:26based sort of screening ignores
• 20:28sort of where we are
• 20:29in our understanding of cancer.
• 20:33Twenty twenty two was the
• 20:35first year that one of
• 20:36the,
• 20:37professional organizations called the National
• 20:39Comprehensive Cancer,
• 20:42Cancer Center recommendation
• 20:44made the recommendations for the
• 20:45first time
• 20:46for individual risk assessment by
• 20:48age twenty five, and then
• 20:50the American College of Radiology,
• 20:51as we heard, followed suit,
• 20:53I think, the following year
• 20:54in twenty twenty three.
• 20:56So high risk guidelines
• 20:58now exist from several professional
• 21:01organizations,
• 21:02and they promote the use
• 21:03of risk prediction models to
• 21:05estimate an individual's
• 21:06patient's risk. So we're gonna
• 21:08talk a little bit about
• 21:09that.
• 21:10When we think about
• 21:12high risk breast health care
• 21:14in general, I think about
• 21:15sort of four general areas.
• 21:17The first is
• 21:19identifying whether or not a
• 21:21patient is at high risk.
• 21:25High risk
• 21:26assessment
• 21:27can be made through the
• 21:28identification of pathogenic variants through
• 21:31genetic testing. So, we need
• 21:32to,
• 21:33in the process of identifying
• 21:35risk, ask ourselves if patients
• 21:38are eligible
• 21:39for genetic testing based on
• 21:41a threshold of potential risk
• 21:44based on family history.
• 21:47We also utilize, in the
• 21:49absence of a pathogenic variant,
• 21:51these risk prediction models, which
• 21:53really give a calculated estimate
• 21:55based on a comprehensive
• 21:57list of risk factors for
• 21:58an individual patient.
• 22:00But there's many nuances to
• 22:02this model, so I'm gonna
• 22:03introduce you to a few
• 22:04of them.
• 22:05And then based on this
• 22:06information, we can provide risk
• 22:08reduction strategies to a patient
• 22:10based on what thresholds that
• 22:12they have in their personal
• 22:14risk.
• 22:16So we already heard in
• 22:17the previous presentation
• 22:19the definition of what is
• 22:20considered high risk.
• 22:22So a lifetime breast cancer
• 22:24risk greater than twenty percent
• 22:25is considered to be in
• 22:27the high risk range. So
• 22:29we're gonna hear more about
• 22:30that.
• 22:32So how do we determine
• 22:34who is at high risk?
• 22:36In order to do that,
• 22:37we need to take a
• 22:38comprehensive
• 22:39review of an individual patient's
• 22:41risk factors,
• 22:43including
• 22:44inherited gene mutations. And so
• 22:46we're gonna walk through that
• 22:47in a moment.
• 22:48But I just wanna point
• 22:49out that while we place
• 22:52a large emphasis
• 22:53around genetic pathogenic variants or
• 22:56carrying the gene that puts
• 22:57you at risk for breast
• 22:58cancer,
• 23:00these pathogenic
• 23:01variants
• 23:03are responsible for a very
• 23:05small percentage of breast cancer
• 23:07cases. So the estimates are
• 23:08somewhere between five and ten
• 23:10percent
• 23:11of these harmful variants. And
• 23:13many of us are familiar
• 23:15with
• 23:16the high risk penetrance genes
• 23:18of the BRCA1 and the
• 23:19BRCA2 mutations,
• 23:21but the field of genetics
• 23:23is rapidly expanding and evolving
• 23:25and we now know about
• 23:26many other pathologic variants. And
• 23:29so
• 23:30when we, pursue genetic testing,
• 23:32we often do a sort
• 23:33of expanded panel looking at
• 23:36a number of different variants.
• 23:38The high risk penetrance genes
• 23:40listed here,
• 23:42confer a risk of,
• 23:44a high risk a risk
• 23:45of lifetime risk as high
• 23:47as sixty to eighty percent.
• 23:50Whereas these moderate risk penetrance
• 23:52genes listed on this slide
• 23:54confer risk more in the
• 23:55twenty to thirty percent range.
• 23:57So it helps us sort
• 23:58of categorize a patient's future
• 24:00risk.
• 24:03So as a clinician, one
• 24:04of the first things we
• 24:05do when we're caring for
• 24:07patients, whether this is in
• 24:08primary care or in a
• 24:10specialty practice, is we ask
• 24:12ourselves, is my patient eligible
• 24:14for genetic testing?
• 24:16And because this field is
• 24:17so rapidly evolving and
• 24:20the professional guidelines
• 24:22change rapidly
• 24:24in response to what we
• 24:25understand about genetics,
• 24:27we have tools in our
• 24:29electronic health record that support
• 24:30our providers in making decisions
• 24:33about who might be eligible.
• 24:35And I share this because,
• 24:38I think it's important to
• 24:40know,
• 24:41as a patient that this
• 24:42is a really complex field
• 24:44that not all providers are,
• 24:48skilled at, and there are
• 24:49tools like this that support
• 24:50our providers. And you can
• 24:51see here that we have
• 24:53tools that have a have
• 24:55a a tab for each
• 24:56disease because the indications for
• 24:58testing
• 25:00differ based on the cancer
• 25:01disease.
• 25:02So, from a breast cancer
• 25:04perspective, if you have a
• 25:06known mutation, there's no need
• 25:07to refer you to a
• 25:09genetic,
• 25:10counseling or testing.
• 25:13But if you've had genetic
• 25:14testing, for example, greater than
• 25:16ten years ago, you may
• 25:17benefit from repeat testing because
• 25:20of the advances in the
• 25:21extended panels.
• 25:24So, this slide,
• 25:25lists for you,
• 25:28the professional
• 25:29organization
• 25:30recommendations
• 25:31around who should be tested
• 25:33or considered for testing for
• 25:34a pathogenic variant.
• 25:36And so I draw your
• 25:37attention to,
• 25:39the underlying text that says
• 25:40personal history and of breast
• 25:42cancer and.
• 25:44So if you have a
• 25:46diagnosis of breast cancer and
• 25:48meet any of the criteria
• 25:49on this list, you should
• 25:50receive genetic testing, ideally, before
• 25:53you initiate any treatment to
• 25:55inform
• 25:56your treatment decisions.
• 25:58So,
• 26:00having breast cancer at a
• 26:01young age under the age
• 26:03of fifty is a red
• 26:04flag for a potential
• 26:06pathogenic variant. So every woman
• 26:08under the age of fifty
• 26:10diagnosed with breast cancer should
• 26:11get tested.
• 26:14There are other indications
• 26:15of genetic,
• 26:17variants, and that also includes
• 26:19the type of cancer that
• 26:20you have. So if you're
• 26:21diagnosed with a breast cancer
• 26:23that is what we call
• 26:24triple negative
• 26:26or hormone negative,
• 26:29then that that is also
• 26:30an indication for testing.
• 26:32If you have a family
• 26:33history
• 26:34of a male breast cancer
• 26:36in your family, that's an
• 26:37another indication.
• 26:40But even patients who have
• 26:42not been affected by cancer
• 26:43are eligible for for testing
• 26:45if any of their family
• 26:47members who had breast cancer
• 26:50meet those criteria.
• 26:53So if a patient meets
• 26:54those criteria,
• 26:56their options in our health
• 26:58system are to go on
• 27:00and see a genetics counselor
• 27:03in our Smilogentics,
• 27:06clinic clinic,
• 27:08or we have tools now
• 27:10for our primary care physicians
• 27:11to do what we call
• 27:12point of care genetic testing
• 27:14in their practices,
• 27:16understanding that while we have,
• 27:18over
• 27:20a dozen counselors, we can't
• 27:22always meet the demand of
• 27:24all the patients that get
• 27:25referred to us. So we
• 27:26have new tools to support
• 27:27our
• 27:28primary care providers to do
• 27:30point of care genetic testing,
• 27:32which is often a blood
• 27:33test.
• 27:35In the absence of a
• 27:36pathogenic mutation
• 27:38or if a patient is
• 27:39not deemed eligible for genetic
• 27:41testing,
• 27:43Clinicians rely upon these risk
• 27:45prediction models, and there are
• 27:47many of them out there.
• 27:49This slide
• 27:51provides a table of the
• 27:53probably the top five,
• 27:55most commonly utilized or most
• 27:57validated and and,
• 28:01usable,
• 28:02tools that are out there.
• 28:05And so when we do
• 28:06these risk assessment models, they
• 28:08provide us with two numbers
• 28:10of of interest that guide
• 28:11through the professional organizations'
• 28:15recommendations for risk reduction strategies.
• 28:17We look at a lifetime
• 28:18risk and we look at
• 28:20a five year risk. And
• 28:22those thresholds,
• 28:23if you reach a lifetime
• 28:24risk greater than twenty,
• 28:26you may be eligible for
• 28:27supplemental breast cancer screening with
• 28:29MRI or other modalities as
• 28:31we just talked about.
• 28:34If you
• 28:36reach a risk threshold of
• 28:38greater than one point six
• 28:39seven, you may also be
• 28:41eligible for risk reduction strategies
• 28:43using medications, what we call
• 28:45chemoprevention.
• 28:47There are several drugs that
• 28:48are available that can
• 28:51act as,
• 28:53that can reduce your future
• 28:55risk of a hormone positive
• 28:56breast cancer.
• 28:59So here's a snapshot of
• 29:01one of the most commonly
• 29:02used tools that you too
• 29:04can can go and calculate
• 29:06on your own.
• 29:07There is the sort of
• 29:08website where you can download
• 29:10this,
• 29:11this,
• 29:12risk prediction model,
• 29:14and this is the kind
• 29:15of output that you will
• 29:16get. What I'm trying to
• 29:18show you on the slide
• 29:18is several things. One is
• 29:20the type of information you
• 29:22need to be able to
• 29:23answer
• 29:24the questions to get an
• 29:25answer
• 29:27and also showing you the
• 29:28results
• 29:29when you change
• 29:30the race of the patient
• 29:32from white to black. And
• 29:34you can see
• 29:35in the same patient who's
• 29:37forty two, had their first
• 29:38menstrual period at ten,
• 29:40had their first baby at
• 29:42thirty five years old, had
• 29:43two prior breast biopsies that
• 29:45were not cancer,
• 29:48had no atypia on those
• 29:49biopsy results,
• 29:51had one first degree relative,
• 29:53so that's mother, daughter, or
• 29:55sister, in this case, one
• 29:57mom with breast cancer,
• 30:00and and we calculate that
• 30:01risk for a black woman.
• 30:03The results are on the
• 30:04left of this screen. So
• 30:06you could see they don't
• 30:07this particular patient who's black
• 30:09with those characteristics
• 30:10does not reach the five
• 30:11year risk threshold
• 30:14for chemo prevention
• 30:15based on this model, nor
• 30:17do they risk reach the
• 30:18high risk threshold for a
• 30:20lifetime risk greater than twenty
• 30:22for MRI.
• 30:24But if you change nothing
• 30:25but the race,
• 30:27this model actually
• 30:28suggests that this patient is
• 30:30eligible for both of those
• 30:31things.
• 30:32And some of this reflects
• 30:34the incidence rates of breast
• 30:35cancer between races, but it
• 30:37also demonstrates
• 30:39how imperfect
• 30:41the models are that we
• 30:42have that sometime contribute
• 30:45to inequities
• 30:46in our ability to care
• 30:48for patients. And so I
• 30:49I I share this
• 30:51to also give sort of
• 30:53an abundance of caution that
• 30:54there are other models that
• 30:55don't take race into consideration
• 30:57that may be more appropriate.
• 31:01So the other model that
• 31:02is widely used and,
• 31:05and recommended by many professional
• 31:06organizations is something called the
• 31:08Tyra Cusick model.
• 31:10In parentheses, I have the
• 31:12word IBIS there because that
• 31:13in my that is the
• 31:15way that you can find
• 31:16it if you Google it
• 31:17on
• 31:18if you go and Google
• 31:19Tyra Cusick, you're gonna get
• 31:20a bunch of different options
• 31:22with web based version that
• 31:24that are really easy to
• 31:26use because they're pretty
• 31:28and they seem really easy
• 31:29to answer.
• 31:30But those are not validated.
• 31:32The only validated one is
• 31:34on this, website that I
• 31:35list for you here. You
• 31:36actually have to download the
• 31:38software, and it's a little
• 31:39cumbersome to use. And it's
• 31:41kind of easy to make
• 31:43mistakes and get the wrong
• 31:45answer. So,
• 31:48when I talk about these
• 31:49risk models, I like to
• 31:50say it's sort of like
• 31:51garbage in, garbage out. If
• 31:53you don't put the right
• 31:54information in, you're gonna get
• 31:55an answer that's not really
• 31:57reflective of your risk.
• 31:59So in this case, this
• 32:01model takes into consideration
• 32:03many more risk factors than
• 32:05the the breast cancer prevention
• 32:07tool that I showed you
• 32:08first.
• 32:08It takes into account your
• 32:10height and your weight,
• 32:12whether you're not you have
• 32:13an Ashkenazi Jewish ancestral background,
• 32:16what your breast density is.
• 32:18We just heard about the
• 32:19the
• 32:20how breast density is another
• 32:22additional risk factor that we
• 32:23need to take into consideration.
• 32:26It also takes into account
• 32:28family members outside your first
• 32:29degree relatives and family members
• 32:31with ovarian cancer.
• 32:33It also allows you to
• 32:35say whether or not you
• 32:36or any of your family
• 32:37members who've been affected have
• 32:38had
• 32:39genetic testing.
• 32:42But you can make mistakes.
• 32:44If you don't,
• 32:48use the right age of
• 32:50die
• 32:51of the family members when
• 32:52you enter the information and
• 32:54asks you for an age,
• 32:55if you give their current
• 32:56age
• 32:57and not the age of
• 32:58the diagnosis
• 32:59at the time of their
• 33:00diagnosis of cancer
• 33:03or you don't include unaffected
• 33:05family members,
• 33:07you can overestimate
• 33:09risk
• 33:10or underestimate risk. And so
• 33:11it's really hard to use
• 33:13these models if you don't
• 33:14have experience,
• 33:16utilizing them.
• 33:19So I'll share here with
• 33:20you the results of this
• 33:21model with that same patient
• 33:24putting in some,
• 33:25you know, average sort of,
• 33:27age of first,
• 33:29average,
• 33:30examples of, like, height and
• 33:31weight.
• 33:32And this gives this is
• 33:34a example of what the
• 33:35printout might look like. And
• 33:36so you might remember the
• 33:38last slide, we had a
• 33:40range of lifetime risk between
• 33:42sixteen and twenty something percent.
• 33:44This one suggests the lifetime
• 33:46risk, if you look up
• 33:47in that right upper corner,
• 33:48is twenty six point five
• 33:50percent.
• 33:51And the five year risk
• 33:52on the other was between
• 33:54one point five and three,
• 33:56and this five year risk
• 33:57is two point one. So
• 33:58it just demonstrates
• 33:59sort of, you know, how
• 34:01imprecise these models are even
• 34:03though they are the best
• 34:04that we have to give
• 34:05us guidance.
• 34:08I wanna make a comment
• 34:09about polygenic
• 34:10risk scores, which are risk
• 34:12scores that you may get
• 34:14if you get genetic testing
• 34:15and provide,
• 34:19if you have genetic testing,
• 34:20they're looking at multiple
• 34:22of your genetic variants
• 34:24to try to estimate a
• 34:26score for you. And these
• 34:27often
• 34:28overestimate
• 34:29risk and make people really
• 34:31anxious that they get back
• 34:32during their genetic testing. If
• 34:34they have no pathogenic variant
• 34:36and then they get this,
• 34:37I think we have to
• 34:38be really cautious that these
• 34:41scores actually are overestimate risk
• 34:44and are not really ready
• 34:45for prime time.
• 34:48So I just wanna make
• 34:49one point about atypia. Atypia
• 34:52is a finding on breast
• 34:53biopsy that is another risk
• 34:56factor for future cancer that
• 34:57needs to be taken into
• 34:59consideration.
• 35:00So if you had a
• 35:01biopsy, you wanna know whether
• 35:02or not there was any
• 35:04atypia present.
• 35:07This is an additional risk
• 35:08factor that confers an intermediate
• 35:10risk.
• 35:11This is another tool that
• 35:13we utilize with our providers
• 35:15to help guide them on
• 35:16who should go on for
• 35:17surgery with atypia and or
• 35:20who might be eligible
• 35:21for risk reduction strategies.
• 35:25I wanna highlight that because
• 35:27this is such a complicated
• 35:29area, we get referrals from
• 35:31primary care physicians and OB
• 35:32GYNs and self referrals from
• 35:34patients
• 35:35to support them in helping
• 35:37them estimate their own risk
• 35:38and determine their eligibility for
• 35:40genetic testing. And if you
• 35:42were to come to see
• 35:43any of our providers across
• 35:44our network,
• 35:45this is the type of
• 35:46clinical care and counseling that
• 35:48we would provide.
• 35:49We don't have time to
• 35:50go into to these,
• 35:53all these different strategies, but
• 35:55we talk about prevention strategies
• 35:57and early detection strategies. And
• 35:59based on the individual
• 36:00risk
• 36:02and the patient preferences,
• 36:04we can talk and counsel
• 36:05about lifestyle and behavior that
• 36:07we're gonna hear about from
• 36:08doctor Erwin,
• 36:09chemoprevention
• 36:10or medications to reduce your
• 36:12risk,
• 36:13risk reduction mastectomy
• 36:15for those with lifetime risk
• 36:16greater than forty percent,
• 36:19and then their early detection
• 36:20options are not preventing cancer,
• 36:22but finding it early. And
• 36:23that includes self exam, clinical
• 36:26exam, and the breast imaging
• 36:27that we just heard about
• 36:28from doctor Laffey.
• 36:31So I'm gonna stop there
• 36:32because I know I took
• 36:33more time than I should
• 36:34have, and I'm gonna pass
• 36:35it to my colleague, doctor
• 36:36Erwin.
• 36:45Okay.
• 36:46Thank you.
• 36:47And I'm gonna try to
• 36:52get it into the right
• 36:54mode.
• 37:03You could maybe answer a
• 37:04question while I'm doing this.
• 37:09Did I freeze?
• 37:15You're good. You're I think
• 37:17we see the center mode,
• 37:18though. Are you you're not
• 37:20full screen yet?
• 37:23Okay. Good. Switch your screen.
• 37:24I was scared. I thought
• 37:25I froze.
• 37:28I thought I froze, but
• 37:29I'm good. I'm not frozen.
• 37:32Alright.
• 37:33I was thinking maybe we
• 37:34can answer some of the
• 37:35questions in the chat while
• 37:37I'm presenting just in case
• 37:38we don't get to all
• 37:39of the, questions.
• 37:41Good evening, everyone.
• 37:43My name is Melinda Erwin.
• 37:44I'm a professor in the
• 37:45Yale School of Public Health
• 37:46and deputy director in the
• 37:48Yale Cancer Center. And I'm,
• 37:50going to share with you
• 37:52breast cancer prevention.
• 37:54And I'm gonna really focus
• 37:55on beyond individual risk factors
• 37:57and more how the environment
• 37:59and systems shape our risk
• 38:00for breast cancer.
• 38:03Also, I wanna first start
• 38:05with acknowledging that breast cancer
• 38:07mortality rates have decreased by
• 38:08forty four percent since the
• 38:10peak in nineteen ninety. And
• 38:12much of this success in
• 38:14reduced mortality rates is because
• 38:16of what, doctor Laffey said
• 38:18in our early detection and
• 38:20our our ability to screen
• 38:22breast cancer, which results in
• 38:23an earlier stage at diagnosis,
• 38:26and then also,
• 38:27amazing
• 38:28advancements
• 38:29in treating breast cancer. And
• 38:31so those together have really
• 38:32helped,
• 38:34reduce breast cancer mortality rates.
• 38:36But what about preventing breast
• 38:38cancer
• 38:39outright so that,
• 38:41we don't have to deal
• 38:42with treatment?
• 38:43So I know this is
• 38:44a busy slide, but it
• 38:45highlights many of the risk
• 38:47factors for breast cancer. And
• 38:49if you look sort of
• 38:50at the top going to
• 38:51the
• 38:52clockwise,
• 38:54in purple
• 38:56are, the non modifiable
• 38:58risk factors.
• 38:59And,
• 39:00Doctor Battaglia mentioned,
• 39:03germline
• 39:04mutations.
• 39:05And while those aren't sort
• 39:07of modifiable, there are ways
• 39:08that we can,
• 39:10be aware from them and
• 39:11change our screening guidelines. And
• 39:13then the other non modifiable
• 39:15are female sex, older age,
• 39:18certain race and ethnic groups
• 39:19have a higher risk of
• 39:20breast cancer,
• 39:22family history,
• 39:23breast density, previous history of
• 39:25breast cancer and age at
• 39:26menarche,
• 39:27or a first period, and
• 39:29then age at menopause.
• 39:31The green factors on sort
• 39:33of from the six P
• 39:35at the bottom to the
• 39:36top of the circle are
• 39:37what we call modifiable factors.
• 39:39And these are primarily related
• 39:41to lifestyle behaviors.
• 39:44So our body composition
• 39:46or, whether we're overweight or
• 39:48obese,
• 39:49physical activity,
• 39:50diet and alcohol,
• 39:52as well as oral contraceptive,
• 39:54contraceptives and hormone replacement therapy
• 39:56in the postmenopausal
• 39:57years. So I'm gonna focus
• 39:59on those for the remainder
• 40:01of the talk.
• 40:04Unfortunately, over the past three
• 40:06decades, we've seen a significant
• 40:08increase in the prevalence of
• 40:10obesity, not only in the
• 40:12US but globally. In fact,
• 40:14every country
• 40:15across the globe has seen
• 40:17increased rates of obesity.
• 40:19Obesity is defined as a
• 40:21body mass index of thirty
• 40:23or greater and body mass
• 40:24index is basically our weight
• 40:26adjusted for height. It's an
• 40:28imperfect measure because it does
• 40:30not take into consideration the
• 40:31amount of muscle you have
• 40:33versus adiposity. And we know
• 40:34muscle weighs
• 40:35more than body fat, but
• 40:37on a population level, it's
• 40:39a pretty good indicator.
• 40:40And what's concerning is seeing
• 40:42that,
• 40:43back in the seventies rates
• 40:44of obesity
• 40:46were, in women's seventeen percent
• 40:48and now they're up to
• 40:49forty two percent.
• 40:51And during this same time
• 40:53period over the last thirty
• 40:54or forty years, we've seen
• 40:55a significant reduction
• 40:57in physical activity levels.
• 40:58And much of this is
• 41:00because of technological advances. We
• 41:02can do our work from
• 41:03home, from a laptop,
• 41:05even from an iPhone. So
• 41:06this has created a society
• 41:08that is very
• 41:09sedentary.
• 41:10So it's not so much
• 41:11about doing exercise,
• 41:13but are we sitting too
• 41:14much and how to reduce
• 41:16our sitting time?
• 41:17I present these two slides
• 41:19to make the point that
• 41:20this is not something that's
• 41:21happening on an individual
• 41:23level, but on a societal
• 41:25and global level.
• 41:27And therefore, the interventions
• 41:29needed
• 41:30to reverse these trends in
• 41:31obesity and inactivity
• 41:33have to be at the
• 41:35environmental,
• 41:36societal, and policy level.
• 41:40And so
• 41:41discussing that, you you may
• 41:43have heard the term obesogenic
• 41:44environment, and this is the
• 41:46fact that we have widespread
• 41:47availability and marketing of high
• 41:49calorie and processed foods.
• 41:51There is recent research showing
• 41:53that more than fifty percent
• 41:54of the foods people
• 41:56consume per day are highly
• 41:58ultra processed foods.
• 42:00This is partly because that's
• 42:01what available everywhere. It's ubiquitous.
• 42:05It's cheaper and it's easier
• 42:06and access is everywhere. So
• 42:08we have limited access to
• 42:10affordable,
• 42:11healthy foods. We also have
• 42:12an urban design that favors
• 42:14cars over walking and biking
• 42:16and work environments with long
• 42:18sedentary or sitting hours. And
• 42:21then lastly,
• 42:22in our free time, we're
• 42:23consumed with social media, which
• 42:25is leading to more sedentary
• 42:28behaviors.
• 42:30So what are the mechanisms
• 42:32of how, some of these
• 42:33modifiable
• 42:34lifestyle factors related to body
• 42:36weight, physical inactivity,
• 42:38poor diet, and alcohol might
• 42:40increase risk for breast cancer.
• 42:42Well, we know that they're
• 42:43primarily through estrogen,
• 42:45inflammation, and metabolic markers such
• 42:47as insulin.
• 42:49Delving down a little bit
• 42:50deeper, we know in our
• 42:51postmenopausal
• 42:52years when women stop producing
• 42:54estrogen via their ovaries,
• 42:56they continued
• 42:57to produce it in their,
• 42:59adipocytes and their body fat.
• 43:02And this is from the
• 43:03conversion of androgens
• 43:04to estrogens via the enzyme
• 43:07aromatase.
• 43:08We know that this is
• 43:09really important because in women
• 43:11who have estrogen receptor positive
• 43:14breast cancers,
• 43:15they're prescribed a standard of
• 43:16care and aromatase
• 43:18inhibitor,
• 43:19which inhibits the conversion of
• 43:21androgens
• 43:22to estrogens.
• 43:23So this is really showing
• 43:24that estrogen is a primary,
• 43:27mechanism
• 43:28that mediates certain
• 43:29modifiable
• 43:30and other factors related to
• 43:32breast cancer.
• 43:33So research on trying to
• 43:35reduce estrogen levels systemically,
• 43:38as well as reducing
• 43:39inflammation,
• 43:41and insulin and other metabolic
• 43:42markers
• 43:43is really,
• 43:45important to better understand the
• 43:46right type of intervention
• 43:48for certain types of of
• 43:50people.
• 43:52You've heard a lot recently
• 43:54about alcohol and how alcohol
• 43:56increases breast cancer risk. And
• 43:58the way this works is
• 43:59alcohol or ethanol
• 44:01can, when we drink it,
• 44:03it's more of a focus
• 44:04on there's a dose response
• 44:06effect here. So one drink
• 44:07might be okay and not
• 44:09much of a risk, maybe
• 44:10a a lifetime five percent
• 44:12higher risk, but it's if
• 44:14you have two or three
• 44:15or four in a day.
• 44:16That's where your risk of
• 44:18breast cancer really increases.
• 44:20And that's through,
• 44:21how alcohol or ethanol is,
• 44:24converted in the enzyme,
• 44:26that of ADH that then
• 44:28leads to,
• 44:29a chemical that can cause
• 44:31chromosome rearrangement
• 44:33and mistakes in our DNA.
• 44:35So,
• 44:36prudent, you know, wanna be
• 44:38modest with our alcohol intake.
• 44:41So I wanna go back
• 44:42to talking about the lifestyle,
• 44:45these factors in the environment.
• 44:46We know that lifestyle risk
• 44:48factors are shaped by the
• 44:49environments we live in and
• 44:51that our lifestyle choices are
• 44:52strongly influenced by the environments,
• 44:54the policies and systems,
• 44:56and that our environments often
• 44:58promote unhealthy eating and sedentary
• 45:00behavior, and that access to
• 45:02places to exercise affordable, healthy
• 45:03food and supportive policies are
• 45:03key to
• 45:04food and supportive policies are
• 45:06key to prevention.
• 45:08And I wanna dig deeper
• 45:09on the the sort of
• 45:11reducing
• 45:11sedentary behavior
• 45:13and making sure you understand
• 45:15the importance of this. This
• 45:17figure here is based on
• 45:18hundreds
• 45:20of prospective
• 45:21cohort studies
• 45:22that have enrolled individuals, let's
• 45:24say at around age forty
• 45:26or thirty or twenty and
• 45:28followed them to fifty, sixty,
• 45:30seventy, eighty years of age
• 45:31one and looked at mortality
• 45:33as the outcome.
• 45:34Cancer,
• 45:35mortality, as well as cardiovascular
• 45:37mortality.
• 45:38And what's really important to
• 45:39recognize in this figure is
• 45:41this drop that going from
• 45:43nothing, being very sedentary to
• 45:45just doing something
• 45:47is where you see
• 45:49the most bang for your
• 45:50buck, the biggest,
• 45:52reduction
• 45:53in breast cancer risk or
• 45:55mortality,
• 45:56implying that just doing something
• 45:58is better than nothing. It
• 46:00doesn't have to be training
• 46:01for a marathon.
• 46:03The goal, the recommended amount
• 46:05is two and a half
• 46:05hours per week of of
• 46:07moderate intensity, such as brisk
• 46:09walking, but it's really important
• 46:10that the research has shown
• 46:12that really just doing something
• 46:13can be beneficial.
• 46:15This same figure comes up
• 46:17time and again
• 46:18in studies looking at walking.
• 46:21And these are from pedometers
• 46:22from iPhones. When you look
• 46:24at how much steps you've
• 46:25taken or Fitbits
• 46:26showing once again a similar
• 46:28curve that going from very
• 46:29little walking less than a
• 46:31thousand steps per day, which
• 46:32is only a half a
• 46:33mile in all of our
• 46:35steps per day, not in
• 46:36kind of going for a
• 46:38walk, but from when you
• 46:39wait till you go to
• 46:40bed at night. So going
• 46:42from a thousand
• 46:43and trying to increase it
• 46:44a thousand steps per day
• 46:46or more,
• 46:47has a significant
• 46:48reduction in risk for
• 46:50all cause mortality, as well
• 46:51as breast cancer mortality.
• 46:54Two thousand steps per day
• 46:55is equivalent to a mile.
• 46:57So if you can kinda
• 46:58think about increasing five hundred
• 47:00or a thousand steps per
• 47:01day throughout your day, then
• 47:03that's gonna really help lower
• 47:04your risk.
• 47:06What about the dietary guidelines?
• 47:08There are a number of
• 47:09guidelines that are listed on
• 47:11the left here, but overall,
• 47:13what's recommended is a,
• 47:15a plant,
• 47:17based diet
• 47:18where,
• 47:20animal products are are maybe
• 47:22one third of what we
• 47:23eat in a a day.
• 47:25We really wanna focus on
• 47:26increasing our fruits and vegetables
• 47:28in our fiber, which is
• 47:29in our fruits and vegetables.
• 47:32So we now have a
• 47:33really good food label, as
• 47:35you can see on the
• 47:35right, that tells you how
• 47:37much grams of fiber you
• 47:38get in various foods, as
• 47:40well as how much added
• 47:41sugar, that's new to the
• 47:42food labels. And that was
• 47:43a significant
• 47:45FDA policy change that came
• 47:47out just a couple of
• 47:47years ago, requiring that added
• 47:50sugars be pulled out on
• 47:52the full food label, because
• 47:53it was very confusing to
• 47:55consumers.
• 47:56For example, if you're drinking
• 47:57orange juice and it shows
• 47:58a lot of sugars,
• 48:00but, it might be that
• 48:01that's not added sugars to
• 48:03the orange juice. So more
• 48:05important to look at the
• 48:06amount of added sugars on
• 48:07the food label than than
• 48:09the overall sugars.
• 48:11We wanna, maintain or increase
• 48:13our protein per day to
• 48:14about one point two grams
• 48:15per kilograms.
• 48:17Generally, most people eat plenty
• 48:19of protein in their diet,
• 48:21even though there seems to
• 48:22be a lot of advertising
• 48:24out there to get more
• 48:25protein, but most people eat
• 48:27plenty of protein.
• 48:28And in thinking about the
• 48:29type of protein you get,
• 48:30having it from fish,
• 48:32and and maybe poultry and
• 48:34reducing it from processed meat,
• 48:37which in turn will also
• 48:38reduce your amount of sodium
• 48:39and low saturated
• 48:41fat.
• 48:44What about supplements? So the
• 48:46American Institute for Cancer Research
• 48:48as well as the American
• 48:49Cancer Society,
• 48:51and NCI
• 48:52do recommend that you do
• 48:54not rely on supplements for
• 48:55cancer prevention
• 48:57and, to reduce your risk
• 48:59of cancer, to choose a
• 49:00balanced diet with a variety
• 49:01of foods.
• 49:02And those diagnosed with breast
• 49:04cancer or any cancer, it
• 49:06is critically important
• 49:08to share the supplements that
• 49:09you're taking with your provider
• 49:11because they could interact with
• 49:13the treatments you're receiving
• 49:15and reduce the efficacy of
• 49:16the treatments.
• 49:17But guidelines are that you
• 49:19should not rely on supplements
• 49:20for cancer prevention. In fact,
• 49:22it's important to recognize the
• 49:23word supplement.
• 49:24If you are low in
• 49:26that level, it helps to
• 49:27supplement. But if many people
• 49:29are already,
• 49:31getting enough vitamins and minerals
• 49:33from their diet and having
• 49:34additional
• 49:35supplements on top of that
• 49:36is not any added benefit,
• 49:38and in fact, it could
• 49:39be harm.
• 49:41So I just wanted to
• 49:42quickly highlight,
• 49:43where the research some of
• 49:45the studies that we've done
• 49:46of,
• 49:48diet and exercise
• 49:50and weight management interventions
• 49:52and the effect on breast
• 49:54cancer risk and outcomes. This
• 49:56was a trial we completed
• 49:58about,
• 49:58ten years ago now, and
• 50:00it was in postmenopausal
• 50:01women without breast cancer.
• 50:03But it was a forearm
• 50:05randomized trial of diet alone,
• 50:07of all the recommendations I
• 50:08just mentioned,
• 50:09exercise, which was basically
• 50:12brisk walking for two hours
• 50:14per week, and then the
• 50:15combination of diet and exercise.
• 50:17And really the takeaway here
• 50:18is all the negative signs
• 50:20you see in all of
• 50:21these markers,
• 50:23biomarkers related to breast cancer.
• 50:25So higher levels of these
• 50:26increase your risk of breast
• 50:27cancer,
• 50:28except for SHBG.
• 50:31And so,
• 50:32these inter the diet and
• 50:33exercise interventions, significant reductions in
• 50:36insulin,
• 50:38in
• 50:39CRP, a marker of chronic
• 50:40inflammation, and in our estrogens.
• 50:42And then the figure on
• 50:43the right shows estrogen levels,
• 50:45which is the most,
• 50:47common,
• 50:49estrogen in postmenopausal
• 50:50women, and you can see,
• 50:53just the significant reduction in
• 50:54estrogen levels with diet, exercise,
• 50:57and the combination
• 50:58of about ten to fifteen
• 51:00percent. And this was within
• 51:02three months of a healthy
• 51:03eating and exercise program.
• 51:07We just completed a trial
• 51:08in women who were receiving
• 51:10chemotherapy
• 51:11for breast cancer,
• 51:12and what we were able
• 51:13to show in working with
• 51:14the registered dietitian,
• 51:16on our team, those who
• 51:17were randomized to receiving
• 51:19receiving counseling of healthy eating
• 51:22and exercise over the year
• 51:24from their diagnosis through chemotherapy.
• 51:26And at one year, we,
• 51:28working with our dietitian, they
• 51:30were able to increase their
• 51:31physical activity levels
• 51:32and the,
• 51:34the diet quality, the quality
• 51:35of the foods they were
• 51:36eating during chemotherapy.
• 51:39And what is,
• 51:40quite remarkable is that this
• 51:42intervention
• 51:43led to a fifty three
• 51:45percent,
• 51:46pathologic complete response rate compared
• 51:49to twenty eight percent in
• 51:50the usual care group. Both
• 51:52groups were receiving chemotherapy, but
• 51:54those that had were randomized
• 51:56to the,
• 51:57exercise and nutrition intervention
• 52:00had less breast cancer
• 52:02at surgery. So this was
• 52:03a group of women receiving
• 52:05new adjuvant
• 52:06chemotherapy
• 52:07and then had surgery. And
• 52:09at the time of surgery,
• 52:10those in the intervention group,
• 52:11there was less evidence of
• 52:13breast cancer.
• 52:15What is the mechanism of
• 52:17that? Well, in this trial
• 52:19also, with women with breast
• 52:21cancer,
• 52:22we showed that really that
• 52:24this intervention led to favorable
• 52:25changes in body composition, but
• 52:27also
• 52:28reduction in c reactive protein,
• 52:30which is inflammation,
• 52:32insulin, and leptin.
• 52:35So I just wanna, touch
• 52:36upon anti obesity medications because,
• 52:40I know that this is,
• 52:42a lot of patients and
• 52:43people, people with and without
• 52:45cancer are very interested in
• 52:47the role of these medications,
• 52:48which are remarkable,
• 52:51really profound in the amount
• 52:52of weight loss and adiposity,
• 52:55loss that occurs with these
• 52:57medications, which are,
• 52:59now sort of called GLP
• 53:01one,
• 53:02glucagon like protein one receptor
• 53:04agonists.
• 53:06There's really limited research
• 53:09on these anti BC medications
• 53:11and breast cancer risk or
• 53:12outcomes among those with breast
• 53:14cancer.
• 53:15It is being conducted now.
• 53:16It's evolving. So in one
• 53:18year and in two, three
• 53:20years, there'll be more research
• 53:21out there. But right now
• 53:22there's very limited
• 53:24information about these medications in
• 53:26regards to breast cancer.
• 53:28We do know that the,
• 53:30the mechanism is they cause
• 53:31significant weight loss up to
• 53:33about twenty, twenty five percent
• 53:35loss,
• 53:36and metabolic changes such as
• 53:38the ones I just mentioned,
• 53:39all these metabolic
• 53:40markers.
• 53:43Most of the studies that
• 53:44are done are observational,
• 53:47looking at outcomes except for
• 53:48the trials of testing the
• 53:49medication on weight loss. But
• 53:51in regards to cancer, they're
• 53:53observational and so there isn't
• 53:54a cause and effect,
• 53:57relationship yet established.
• 53:59Most important, if you are
• 54:01considering
• 54:02one of these medications,
• 54:04discuss it with your provider,
• 54:06especially if you've been diagnosed
• 54:08with cancer.
• 54:12I always get this question.
• 54:13I think it's really important.
• 54:15Many people follow the diet
• 54:17and physical activity guidelines, and
• 54:18they can still develop breast
• 54:20cancer, and it's very frustrating.
• 54:22So it's important to note
• 54:23that a healthy lifestyle lowers
• 54:25risk but does not eliminate
• 54:27it.
• 54:28Whether you like this analogy
• 54:29or not, I think it's
• 54:30simple and can be,
• 54:32helpful.
• 54:33It's like wearing a seat
• 54:34belt, which, lowers your chance
• 54:36of severe injury in a
• 54:38car crash, but it does
• 54:39not guarantee
• 54:40safety, but it lowers your
• 54:42risk.
• 54:43Much like
• 54:44screening and,
• 54:45leads to earlier detection and
• 54:47practicing,
• 54:49you know, changing some of
• 54:50the modifiable risk factors, it
• 54:52lowers your risk.
• 54:54But most importantly, breast cancer
• 54:56is influenced by a mix
• 54:57of factors that are genetic,
• 54:59reproductive
• 55:00history, hormones, environment,
• 55:02and chance.
• 55:03And that for women already
• 55:05diagnosed,
• 55:06these modifiable factors might also
• 55:09improve treatment tolerance, reduce recurrence
• 55:11risk, and improve outcomes. So
• 55:13even if you've been practicing
• 55:14these healthy behaviors and you're
• 55:15still diagnosed with breast cancer,
• 55:18maintaining
• 55:19a healthy diet and exercise
• 55:21can help with your prognosis.
• 55:25Okay. I think my last
• 55:26slide here, I just wanna
• 55:28touch upon postmenopausal
• 55:29hormone replacement therapy because there's
• 55:31been a lot
• 55:33of information on this, especially
• 55:35on social media, and it
• 55:37can get very confusing
• 55:39to individuals.
• 55:41HRT, as you might know,
• 55:42replaces estrogen and progesterone hormones
• 55:45that decline during menopause.
• 55:47And HRT
• 55:49reduces menopausal symptoms and also
• 55:51protects against osteoporosis.
• 55:54Breast cancer risk increases with
• 55:56longer use of HRT.
• 55:59Recent
• 56:00research that came out in
• 56:01the last couple years showed
• 56:02that the risk was less
• 56:04in women from age fifty
• 56:06to fifty nine than in
• 56:07women sixty or older. So
• 56:09many women might take HRT
• 56:11in their 50s and then
• 56:12stop it when the menopausal
• 56:14symptoms subside.
• 56:15And research recently has shown
• 56:17that that's a lower risk.
• 56:20It's also really important to
• 56:21note that hormone therapy, which
• 56:23is also called endocrine therapy
• 56:25for breast cancer,
• 56:26should not be confused with
• 56:28HRT.
• 56:29HRT and endocrine therapy produce
• 56:31opposite effects.
• 56:33Endocrine therapy for breast cancer
• 56:35is a medication to lower
• 56:36hormone levels
• 56:37systemically like aromatase inhibitors
• 56:40or block the action of
• 56:41the hormone at the receptor,
• 56:43such as tamoxifen,
• 56:45which in turn lowers risk
• 56:46of breast cancer recurrence
• 56:48and also can be used
• 56:49in women at high risk
• 56:51for for breast cancer.
• 56:54Most important is to discuss
• 56:56the potential benefits and risk
• 56:57of HRT with a health
• 56:59care provider before starting treatment.
• 57:02So in closing, I just
• 57:04want to,
• 57:06kinda remind again that thirty
• 57:07percent of breast cancers could
• 57:08be prevented through lifestyle changes,
• 57:11yet lifestyle is driven by
• 57:12the world around us, the
• 57:14food industry, urban design, and
• 57:16social norms.
• 57:17We know that changing habits,
• 57:19especially in a world full
• 57:21of stress, limited access to
• 57:23healthy foods and environments that
• 57:24don't encourage physical activity is
• 57:26not easy.
• 57:27So, you know, hoping that
• 57:29there'll be policies and systems
• 57:30changes
• 57:31that can make the healthy
• 57:33choice
• 57:33the easy choice.
• 57:36And important to note that
• 57:38progress is uneven across populations
• 57:41and that access to care,
• 57:43socioeconomic status and environmental exposures
• 57:46contribute to disparities. And unfortunately,
• 57:48there are disparities in breast
• 57:50cancer incidence and mortality.
• 57:52And so lastly, every step
• 57:54we take toward healthier habits
• 57:55matters,
• 57:56Small changes add up such
• 57:58as just focusing on reducing
• 58:00sedentary behavior, and that combined
• 58:02with community level efforts
• 58:04will reduce breast cancer risk
• 58:06and improve overall health.
• 58:09So with that, I will
• 58:10stop sharing.
• 58:16That is great.
• 58:17Thank you, doctor Arun.
• 58:19We do have a few
• 58:20questions
• 58:21that have been submitted and
• 58:25couple of the two that,
• 58:26we've answered a few of
• 58:27them directly, but, couple that
• 58:30are out there radiology questions.
• 58:32So doctor Latvie can take
• 58:34the first one and maybe
• 58:35I'll take the second one.
• 58:37So a questioner asks and
• 58:38she's a breast cancer survivor
• 58:40more than two decades ago.
• 58:42And she says, yes. If
• 58:43mammogram and ultrasound are done
• 58:45and compared to past results
• 58:47and found to be a
• 58:47change, what is the next
• 58:49step? So if there's a
• 58:50change on your mammogram and
• 58:51your ultrasound, what do you
• 58:52do next?
• 58:56And you're muted, Brisa.
• 58:59There we go. Sorry about
• 59:00that. If a patient
• 59:02is found to have a
• 59:04mammographic or sonographic abnormality without
• 59:06any other symptoms, that is
• 59:08called a callback from screening.
• 59:11Generally, women are asked to
• 59:12return for additional specific dedicated
• 59:15diagnostic imaging,
• 59:17which means additional mammographic views,
• 59:20targeted ultrasound
• 59:22with, generally presence of the
• 59:24radiologist
• 59:25who can assess.
• 59:26And,
• 59:27then the radiologist
• 59:29can,
• 59:30determine
• 59:31if there is a need
• 59:32to perform a neal biopsy,
• 59:34follow-up, or do nothing.
• 59:39Yep. So that yeah. So
• 59:41that's a great answer. I
• 59:42hope that answers your question.
• 59:44You'll get called back, and
• 59:45we'll do additional workup with
• 59:46other images. So the other
• 59:47radiology question is what is
• 59:50molecular breast imaging?
• 59:52And so, molecular breast imaging
• 59:55is a nuclear medicine study.
• 59:57So there's a radioactive
• 59:59substance called technetium
• 01:00:01and
• 01:00:02and it's and a form
• 01:00:04of it is used very
• 01:00:05commonly in different medical tests,
• 01:00:07especially a test of the
• 01:00:08heart. And what they found
• 01:00:10when they were testing people's
• 01:00:11hearts is that breast cancers
• 01:00:13would light up
• 01:00:14in this test. So the
• 01:00:16the substance that they were
• 01:00:17giving
• 01:00:18to look at the heart
• 01:00:19would go to breast cancers.
• 01:00:20So they realized they could
• 01:00:21turn this into an imaging
• 01:00:22test, and it's a it's
• 01:00:24an imaging test that has
• 01:00:25good sensitivity.
• 01:00:27It finds cancers at a
• 01:00:28similar level
• 01:00:30to MRI and contrast mammography.
• 01:00:32It hasn't been studied as
• 01:00:33much. It has some downsides,
• 01:00:35though, as opposed to a
• 01:00:36contrast mammogram, which takes about
• 01:00:38five minutes or an MRI
• 01:00:39which takes about
• 01:00:41ten to twenty minutes,
• 01:00:42every image
• 01:00:44on molecular breast imaging is
• 01:00:45about fifteen minutes, five zero.
• 01:00:47It has gone down with,
• 01:00:50better equipment,
• 01:00:51but it's a longer scan,
• 01:00:53and it doesn't quite give
• 01:00:55the anatomy.
• 01:00:56It doesn't give it doesn't
• 01:00:57show us the anatomy
• 01:00:59like MRI or contrast mammography
• 01:01:01does. So it hasn't,
• 01:01:03been as widely accepted.
• 01:01:05But, it's a test. Basically,
• 01:01:07you get injected with a
• 01:01:08radioactive substance, and then you
• 01:01:09get damaged.
• 01:01:13So we
• 01:01:15are,
• 01:01:18there's no more questions on
• 01:01:19the chat. We can
• 01:01:21stay for
• 01:01:23another five minutes or
• 01:01:25if one of our panelists
• 01:01:26would like to
• 01:01:28add something, I'd be happy
• 01:01:30to listen or I can
• 01:01:31ask questions.
• 01:01:37Actually, one of our listeners
• 01:01:38had a question about
• 01:01:40the risk models.
• 01:01:42And,
• 01:01:42so, Tracy,
• 01:01:44yes.
• 01:01:45So,
• 01:01:46and don't forget to unmute.
• 01:01:49You mentioned two websites,
• 01:01:51one of which,
• 01:01:55you know, that one of
• 01:01:56which is web based, and
• 01:01:56the other one you had
• 01:01:57to download software. Can anybody
• 01:01:59download that software, or do
• 01:02:00you have to get permission?
• 01:02:01It's free.
• 01:02:03It's free. It's just the
• 01:02:04interface is not very intuitive.
• 01:02:06It's kinda complicated.
• 01:02:08It's not clear
• 01:02:09exactly what they're asking.
• 01:02:11So I I think it's
• 01:02:12easy to make mistakes using
• 01:02:14that model.
• 01:02:16There are
• 01:02:17other,
• 01:02:18versions of it on the
• 01:02:19web that are, like, pretty
• 01:02:21interface and clear questions,
• 01:02:23but I don't think that
• 01:02:24they're validated, and so I
• 01:02:26wouldn't necessarily
• 01:02:27encourage using them. So, I
• 01:02:29mean, I think you could
• 01:02:30go ahead and assess assess
• 01:02:31your own risk and print
• 01:02:32out your results and bring
• 01:02:33it to your provider.
• 01:02:35Anytime I see a patient
• 01:02:37and they bring me a
• 01:02:37risk model
• 01:02:39result
• 01:02:40without the information of what
• 01:02:41went into it, I just
• 01:02:43repeat it because I don't
• 01:02:44know what went into that
• 01:02:45calculation to give the result.
• 01:02:49So I I think the
• 01:02:50the message I would give
• 01:02:51is
• 01:02:53these are not easy to
• 01:02:54interpret
• 01:02:55and don't panic. If you
• 01:02:56get a very high
• 01:02:58risk, you should review it
• 01:02:59with a a a provider
• 01:03:01who has experience using the
• 01:03:02models.
• 01:03:04Yeah. So someone who's used
• 01:03:06the models, I would definitely
• 01:03:07concur. There are little things
• 01:03:08that can make a big
• 01:03:09difference.
• 01:03:11Height and weight are one.
• 01:03:12You have to put those
• 01:03:13in to be accurate.
• 01:03:15And if you're so if
• 01:03:16you're tall, it increases your
• 01:03:17risk of breast cancer, which
• 01:03:19is not intuitive, but it's
• 01:03:20in the model. One thing
• 01:03:21that seems to drive it
• 01:03:22for
• 01:03:23a lot of our patients
• 01:03:24is having a first child
• 01:03:26after thirty, which has become
• 01:03:27extremely common.
• 01:03:29And so, yeah, then would
• 01:03:31you like to comment on
• 01:03:31that, doctor Taglia?
• 01:03:34Yeah. I mean, I think,
• 01:03:36you know, we take a
• 01:03:36lot of,
• 01:03:39of the reproductive
• 01:03:42history into account for,
• 01:03:45breast cancer risk. And the
• 01:03:46way that I like to
• 01:03:47think about it is it's
• 01:03:48really just to sort of,
• 01:03:50the
• 01:03:51the amount of time an
• 01:03:52individual
• 01:03:53has
• 01:03:55exposure to estrogen unopposed.
• 01:03:58And so when you have
• 01:04:00your period very early
• 01:04:02and you don't go through
• 01:04:03menopause until very late
• 01:04:06and you don't have a
• 01:04:07child
• 01:04:08at all or have a
• 01:04:09child at an older age,
• 01:04:11you're not opposing any of
• 01:04:13the natural hormones of sort
• 01:04:15of your normal cycles
• 01:04:17that interfere sort of that
• 01:04:18may sort of be,
• 01:04:20contributing to breast cancer risk.
• 01:04:23So having children younger for
• 01:04:24whatever
• 01:04:26reason, having any children is
• 01:04:28protective. Having children at a
• 01:04:30younger age probably has something
• 01:04:31to do with the breast
• 01:04:33development
• 01:04:33and the opposition of the
• 01:04:35hormones.
• 01:04:38Great. And,
• 01:04:44that's I've yeah. I have
• 01:04:46no other questions to ask.
• 01:04:51Oh, and doctor Laffey is
• 01:04:52typing an answer,
• 01:04:54looks like, to one last
• 01:04:55question.
• 01:04:56Anything else anybody would like
• 01:04:58to add? Oh, I see.
• 01:04:59If any if anyone's still
• 01:05:00on,
• 01:05:01and does have questions, feel
• 01:05:03free to email me directly
• 01:05:04at melinda dot erwin at
• 01:05:05yale dot edu. I'm happy
• 01:05:07to answer questions later on
• 01:05:09as well.
• 01:05:10And I I have one
• 01:05:11question, doctor Erwin.
• 01:05:15So exercise we know
• 01:05:17and
• 01:05:19being thinner reduces your risk
• 01:05:20of postmenopausal breast cancer. Does
• 01:05:22the same thing apply to
• 01:05:23premenopausal
• 01:05:24breast cancer?
• 01:05:26So for exercise, yes. It
• 01:05:28lowers your risk from you
• 01:05:30know, if you exercise childhood,
• 01:05:32premenopausal
• 01:05:33years, later on is
• 01:05:35a significant lower risk for
• 01:05:36developing
• 01:05:37breast cancer.
• 01:05:39The research with obesity is
• 01:05:40a little confusing because it's
• 01:05:42related to estrogen and and,
• 01:05:45whether you have a twenty
• 01:05:46eight day cycle. And so
• 01:05:48sometimes if you have high
• 01:05:50amounts of body fat, you
• 01:05:51might not have a a
• 01:05:53menstrual cycle that's,
• 01:05:54every twenty eight days. And
• 01:05:56so it kinda confounds the
• 01:05:57relationship with breast cancer risk.
• 01:06:00However, with that said, we
• 01:06:01know that weight gain
• 01:06:03from adolescence through adulthood,
• 01:06:06independent
• 01:06:07of your BMI,
• 01:06:08is associated with increased breast
• 01:06:10cancer risk.
• 01:06:11So I think two messages
• 01:06:12I always like to to
• 01:06:14tell people is to try
• 01:06:15to prevent weight gain
• 01:06:17and to try to reduce
• 01:06:18sedentary
• 01:06:19behaviors.
• 01:06:23Alright. Well, I'd like to
• 01:06:25thank
• 01:06:26our panelists again
• 01:06:28and,
• 01:06:30let everyone know that we
• 01:06:32have two more
• 01:06:34of these webinars. The next
• 01:06:35one is October ninth, and
• 01:06:37it's
• 01:06:38entitled early stage breast cancer,
• 01:06:40what patients and families should
• 01:06:41know.
• 01:06:42And the one after that
• 01:06:44is October sixteenth, so these
• 01:06:45are all on Thursday nights.
• 01:06:48And October sixteenth is progress
• 01:06:49in metastatic breast cancer research
• 01:06:51and treatment. Talk about the
• 01:06:53ways we are,
• 01:06:55have improved the treatment of
• 01:06:56metastatic breast cancer. It's,
• 01:06:59it's been quite astonishing over
• 01:07:00the past decade
• 01:07:01what has the advances we've
• 01:07:03had. So,
• 01:07:08that is all. Looks like
• 01:07:09we're good. Okay.
• 01:07:12Thanks, everyone.
• 01:07:14And, Eliza, unless you have
• 01:07:16any other things, we will
• 01:07:17say goodbye.