July 16, 2024 • 50 mins
Did you know 1 in 8 women will get breast cancer in their lifetime? Join Lauren Bright Pacheco for a special episode from the 2024 ASCO Annual Meeting in Chicago, where she dives into the best collaborative approach to breast cancer diagnoses and care. Medical oncologist, Dr. Nan Chen, and breast cancer surgeon, Dr. Sarah Shubeck share how their teamwork benefits breast cancer treatment.
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Speaker 1 (00:34):
Welcome to Symptomatic.
Speaker 2 (00:35):
Today, we're recording from the twenty twenty four Asco American
Society of Clinical Oncology Annual Meeting, talking about breast cancer.
One in eight women will navigate a diagnosis of breast
cancer during their lifetime, and it accounts for nearly one
third of all cancer cases and women. I am joined
by two esteemed warriors in the battle against breast cancer.
(00:58):
Doctor Nan Chen Breast, a medical oncologist at University of
Chicago Medicine, where she is also an Assistant Professor of Medicine,
and doctor Sarah Shuback, a surgeon who specializes in breast cancer,
also at the University of Chicago Medicine, where she is
an Assistant Professor of Surgery. Welcome doctors, Thank you so
(01:18):
much for joining me.
Speaker 3 (01:20):
Thank you, thank you so much for having us.
Speaker 2 (01:22):
Before we even dive in, I would love to ask
both of you what drew you to breast cancer as
a specialty in Doctor Chin, why don't you start sure?
Speaker 4 (01:33):
I initially became really interested in oncology because I really
liked the idea that we were taking care of the
whole patient. I just thought that it was really mentally
fascinating and then there really was no relationship that I
enjoyed seeing more as a medical student than the relationship
between a patient oncologist. They just felt really important in
their lives, and I really felt like I wanted to
(01:53):
be that person. I think the simplest way to describe
why I like breast cancers, I just really enjoy taking
care of women. I just think it's such a special
group of people. I can get along with them really well.
I also like the fact that, compared to some other cancers,
there are a lot of things that I can do.
There are a lot of options that I have, and
I feel like I can be more helpful.
Speaker 3 (02:12):
I really love it.
Speaker 1 (02:13):
Excellent doctor Shueback.
Speaker 5 (02:15):
Yeah, so I was first really drawn to surgery as
a job because I like to have a one day
event where I fix something, and that felt really satisfying
to me. Cancer, though, is this long term relationship that
also really grabbed my attention and restargible. Oncology was the
last thing I thought I would actually end up doing
until I similarly fell in love with the idea of
taking care of women. And I think mostly because what
(02:37):
we do is pull people back from feeling like a
puddle when They're usually the pillar in their family, and
so I think we often meet people on their worst
day and get to watch women rise from whatever their
ashes may be and become again that force, that strength,
that pillar of their family. And that was ultimately what
I fell in love with. And I think, like so
many of us, they have a lot of breast cancer
(02:58):
in my family, and I always wanted the opportunity, need
to be the one to do it right for people,
because I saw it be so hard for the people
I loved.
Speaker 3 (03:04):
What do you.
Speaker 2 (03:05):
Both find remain the most prevalent misconceptions or myths about
breast cancer in general?
Speaker 4 (03:14):
I think that one of the most common scenarios that
we encounter is women when we first meet them, think
that they did something to cause this breast cancer, that
some decisions that they made in their life have led
them to hear and in the vast majority of cases,
that's really not true. And so one of the things
I think we do when we first meet patients is
to almost unpack that guilt and make sure that we
(03:34):
understand that this unfortunately just happens. As you mentioned before,
and one in eight women, that's probably one of the
most common misconceptions.
Speaker 3 (03:41):
I see.
Speaker 5 (03:42):
I also think that we think of breast cancer as
one disease entity, but it really is a whole collection
of diseases that interact with people's lives at different times
of their life, of different scenarios. And just because your
neighbor had one experience doesn't mean you will. So I
think a lot of what we spend time with saying,
you know in twenty twenty four this is each person
(04:03):
has a different story, each person needs different interventions, and
trying to kind of separate what one woman is facing
based on what maybe she's read or heard about is
really important to give her clarity, to put her as
kind of the captain of the ship, and to allow
her to make good decisions for her health.
Speaker 2 (04:19):
Also, I should think that there is a misconception that
we're just talking about lumps. Yeah, you know, less than
five percent of cases, pain is actually an indicator.
Speaker 5 (04:31):
Yeah. I think when we consider how different women present,
it's a whole host of things. You know, it's new
nipple discharge that they hadn't noticed before. It's a size change,
it's nipple retraction or dimpling of the skin. Things that
just don't sit right with someone. Usually warrant evaluation. You know,
we know our body's best and so I think that
a lot of the women that doctor Tenn and I
(04:52):
take care of are often too young for mammograms right
or are diagnosed before they would have started routine screening.
So we're really relying on them or their doctors to
just notice something is different and to feel that that
difference might be a real health concern and to get
it evaluated.
Speaker 2 (05:08):
In what sense does timing still remain one of the
most important weapons in your arsenal against breast cancer?
Speaker 4 (05:17):
We know in breast cancer, the earlier we find the cancer,
the better it is, and I say better in many
different ways. First and foremost, we know that your prognosis
is better, the chances of you surviving this cancer are better.
It also means in many cases we can de escalate
your therapy. If you have an earlier stage cancer, we
can give you less treatment for it, which I would love.
And so to doctor Schubek's point, it's so important for
(05:39):
women to know their bodies and to make sure that
doctors and other providers are listening to these women when
they mention things going on, and.
Speaker 3 (05:47):
Also the timing in one's life.
Speaker 5 (05:49):
You know, we take care of young women who go
on to live full lives, have healthy pregnancies, fulfill whatever
it is that's in their goals and desires. We also
take care of women later decades of life who have
you know, even shorter intervention periods for care, and that's
because we're learning more that these diseases vary across a
lifetime and very based on the person. And then really,
(06:09):
as dutch Chun mentioned, the earlier we can find a problem,
the less likely it is to threaten someone's safety. And
that is why early intervention, early identification is just critical
and why you know, screening has made so many improvements
for women who are eligible for screening because we're finding
breast cancers at earlier and earlier stages.
Speaker 2 (06:28):
And I believe that in stages one and two, eighty
five percent of the cases you diagnose are treatable.
Speaker 4 (06:36):
I would actually say that one hundred percent are potentially curable.
And really, our therapies are getting better and better every year.
And I think doing this at ASCO twenty twenty four
is just such a stark reminder of the progress we
have made in breast cancer even the last decade, and
the progress we're continuing to make that when I meet
a woman, I say, we can cure you right now.
Speaker 3 (06:57):
We can get rid of this cancer.
Speaker 4 (06:58):
The bigger problem and the bigger goal I have is
to make sure this cancer doesn't come back. And we
are getting better and better every day with our therapies
to make sure that that doesn't happen.
Speaker 2 (07:07):
And the whole concept that don't worry about breast cancer
till you're forty is dated.
Speaker 4 (07:11):
That is quite dated, and I would argue that's a
really dangerous message because we aren't screening women.
Speaker 3 (07:17):
Usually before the age of forty.
Speaker 4 (07:18):
We can actually miss early cancers in younger women because
we're not looking, and those women are also not necessarily
educated to know to look for these things in their body. Unfortunately,
the rate of young breast cancer is actually rising since
like the early two thousands, and so another reason that
we really need to be careful in the younger population.
Speaker 1 (07:38):
What do you attribute that to.
Speaker 4 (07:40):
I think the short answer is, really I don't know,
And the longer answer is, I think there are a
lot of things happening. Girls are getting their periods earlier,
and so you just have a longer time in your
life that you're getting hormonal exposure and that can increase
your risk of developing breast cancer. This is actually, unfortunately
a trend we're seeing in other cancers as well, like
cooling cancer. So there's probably lots of reasons that are
(08:01):
environmental and societal that are leading this, but it's a
concerning trend that we should all very much be aware of.
Speaker 2 (08:07):
I want to jump into the topic of collaboration. But
before we even get their doctor chin. Despite breast cancer
being fairly common, unfortunately and straightforward in terms of the diagnosis,
is there an individual aspect to each case you diagnose.
Speaker 4 (08:27):
So the road to individualizing cancer medicine is a long
road that we are on and will be on for
a long time. We know in twenty twenty four we
are still over treating some women, and we know in
twenty twenty four we are also under treating some women.
We are starting to become smarter using biomarkers and genomic
(08:48):
tools to better thread that needle and make sure that
patients are getting the appropriate amount of therapy, but it
can be difficult sometimes to figure out whether we're being
too aggressive or not aggressive enough, whether patient's cancer and
everything really should be tailored to each individual cancer.
Speaker 3 (09:03):
Two women sitting next to each other.
Speaker 4 (09:05):
Even if they have on the surface very similar cancer features,
stage all a subtype, all of that may still have
very different tumors. We now can do genomic testing and
molecular testing to really be able to dive deeper into
how the cancer actually functions, the biological way that it works.
Speaker 2 (09:22):
And doctor Schuebeck, how do you emphasize the importance of teamwork.
You know, a multidisciplinary team of doctors when treating breast
cancer patients, and why is it crucial for all members
of that medical team to work towards moving in the
same direction.
Speaker 5 (09:42):
Yeah. The reason why I think it's particularly timely now
is because the game is changing for the better. In
the origin story is of breast cancer, we thought it
was a surgery disease, just cut it out. And most
patients are still kind of referred from their primary physician
or provider to a surgeon when they have a new diagnosis.
But very often I'm not the first person at that,
(10:03):
so it's really figuring out for each person who their
starting quarterback should be. And so I think that's not
really something that happens in isolation. Right, Some patients need
medical therapy first to make their surgery smaller. Some patients
need surgery first to help understand how much medicine they need,
and that's not one size fits all.
Speaker 3 (10:21):
That depends on.
Speaker 5 (10:21):
Who the patient is, what cancer they have, how much
cancer they have, what can they tolerate? And so if
I were to decide just all of those things, that's
kind of like an electrician telling you what a plumber
should do. And I think there's a lot of value
in constantly learning from one another and most importantly holding
the patient's values and what they can endure or want
to endure, or just how they're facing their journey as
(10:43):
the centerpiece of our discussions.
Speaker 3 (10:45):
And during a patient's treatment journey, there are many touch
points in which decisions that I make will very much
influence what doctor Schubeck does, and things that she is
thinking of will very much influence what I do.
Speaker 4 (10:57):
Just last week, I called you on my way home
because we just had a stuff patients where I was like,
I want to give you some updates as to kind
of what's going on, to make sure that you're in
the loop and that you can make decisions.
Speaker 3 (11:06):
With the most update information that you have.
Speaker 5 (11:08):
And I think it's important to say too that the
surgeries are getting smaller, right, So breast cancer surgery is
a story of de escalation almost uniformly, which I'm thrilled for.
Speaker 3 (11:17):
I can't wait to be put out of a job.
Speaker 5 (11:18):
And I think that's because the medicines are not necessarily
getting bigger, but getting more tailored. Right, So the medicines
are getting more effective in the upfront setting, which allows
me to do really small surgeries that lead to less
disfigurement for people, leads to better function after surgery. We
need to be supportive of our patients in getting the
right intervention. And so if that means in twenty years
(11:41):
there's no role for surgery and breast cancer, I'll retool.
Speaker 3 (11:43):
I'll be just fine.
Speaker 5 (11:45):
But how amazing would that be if that story and
that trend continues.
Speaker 2 (11:49):
You mentioned team, and you mentioned the different roles plumber, electrician,
you know, but ideally, who would you guys like to
see on your ideal breast cancer management team?
Speaker 4 (12:05):
You know, honestly, that team is as big as a
football team, really is.
Speaker 3 (12:09):
It's huge.
Speaker 4 (12:09):
It is both a surgical oncologist, a medical oncologist, a
radiation oncologist, a reconstructive surgeon. Potentially it is a nurse navigator.
It may be a genetic counselor a therapist.
Speaker 3 (12:21):
Who can help with a lot of the you.
Speaker 4 (12:24):
Know, mental health struggles that women go through throughout this diagnosis.
It is a physical therapist who can help maintain motion
after surgery.
Speaker 3 (12:31):
It really is such a large.
Speaker 4 (12:33):
Team of people that we work with that would make
up the ideal team.
Speaker 5 (12:36):
And often it's things like genetic counselors, right, it's risk
producing for the patient and also thinking about their whole families.
It's fertility doctors for patients who are getting fertility preservation
before surgery. It's primary care doctors, right. It's the person
who knows that patient before their diagnosis and is going
to continue to care for them long after. So it's
all of those people and more. And then if I
(12:58):
had everything I ever wanted, it'd be the PA's family,
it'd be the patient's employers, it'd be all the patients
surrounding ecosystems so that we together can support that person
in their journey. I think that we also all have
to work for the same person, and that's the patient.
Speaker 2 (13:13):
So let's just talk about the importance of collaboration between
specialists like oncologist surgeons to enhance patient outcomes.
Speaker 4 (13:23):
I think one of my favorite parts of our relationship
is how open we are with each other and how
even if something maybe didn't go as well as I
wanted it to, I'm like, hey, this is what happened,
this is where we are, this is how we go forward.
Or it's like, oh, hey, I had this conversation with
a patient. It kind of went off in a left
direction and I didn't really like it, but just so
(13:43):
you know, so when she brings it up, this is
kind of what we discussed, and I think there's no
judgment on that part that you know, this is life
and we do the best we can.
Speaker 5 (13:51):
I think also one of the really breakthrough moments for
me with Nan and our practice that we share is
I was sitting at my kids gymnastics class on a
Friday night and she calls me, and you know, usually
there's a warm up text message to say, you know,
we need to discuss some patients. But I just got
this call and I had like two minutes where I
was able to answer.
Speaker 3 (14:10):
I was otherwise, you know, wrapping up some work for.
Speaker 5 (14:12):
The week, and she called me and told me about
one of our mutually loved kind young patients who was
experiencing a devastating outcome from her breast cancer journey, and
we just kind of sat there together in shock. One
thing that deut Or Chunnan and I both do is
we really emotionally invest our patients, maybe to a point
where it's a bit much, and sometimes we lean on
(14:34):
each other to pull us back. And so in that moment,
the exact person I needed to talk to was somebody
else who was present with that patient, was connected to
that person. You know, cancer is unfortunately still really unfair
in so many ways to such beautiful lives, and so
when things go really south, I know that I can
call her and have that life raft.
Speaker 2 (14:55):
I was going to next venture into the emotional component
of you do, But before I even get there, how
did your paths initially cross?
Speaker 4 (15:05):
I consider myself so lucky that Sarah and I happened
to start our jobs respectively at the University of Chicago
at the same month, literally, and as we got talking,
it was like our philosophies of how we care for
patients and how we practice medicine.
Speaker 3 (15:22):
Are really really similar.
Speaker 5 (15:24):
You know, there's a lot of times we call patients
together on the phone I've gotten really good at connecting
people in through phone calls, and patients really are blown
away when we're both on the phone. But I think
one of the hardest things about patient care is that
often they're retelling their story to every single person on
their team. And if we can sit there together and
I can hear how they're interacting with what doctor Chen
(15:44):
is telling them, you know, and she can hear about
my surgical take, it really helps a lot. It's kind
of forced us to melt together, and it's only making
it feel more seamless, I hope for our patients, and
it feels more seamless for me.
Speaker 4 (15:57):
We're starting to sound like each other. It's a little
creepy time I'm.
Speaker 5 (16:00):
Say things that she does when she's not in the room. Yeah,
because it's fun. Like when we see patients together. If
I'm just sitting and I have a few minutes, I'll
just barge right in and I'll sit on the you know,
on the bed, and I'll listen because I want to
know how she's explaining the same thing I'm trying to.
Speaker 2 (16:16):
That is such honestly an intelligent approach, though, because you
are saving time, but you were also protecting the patient
from having to go through their entire case history.
Speaker 5 (16:31):
Again, Yeah, I think that is a huge, huge advantage
because it's like a shared flock, right, Like, it really
has made it so that we're all getting the same
information and we're really making decisions as a team with
a patient in charge.
Speaker 2 (16:46):
We touched upon the emotional aspect of what you do
in terms of the heavy lifting of that personally, But
what would you say remains the most difficult aspect of
both of your work to navigate.
Speaker 4 (17:04):
I see advanced breast cancer, which is not curable, and
that means that despite for the vast majority of these women,
despite what I do with the best treatments available, they
are unfortunately going to pass from their disease. To be
perfectly honest, I am always very very scared of that happening,
because I know it will happen and it's just part
(17:25):
of my job. But it remains such a constant fear
that I'm going to have to emotionally deal with that
and have to kind of deal with what happens after,
which is that I have to think about, you know,
all the time we spent together and continue doing what
I do.
Speaker 5 (17:40):
On the other side, I think almost similarly, but I'm
even less helpless than doctor chen Is. When patients cross
over the line as being local, locally advanced to being metastatic.
My entire job is to basically sit it out. I
think that's really incredibly humbling. Has I then call on
(18:01):
my teammate, who I already burden with my emotional needs
and my you know, collaborative needs, and say, I've got
nothing as a surgeon to help this patient. Cancer has
this knack of being unexpectedly terrible when things are going okay.
Oh absolutely, you know, it has felt so often like
these humans you see, so full of life and so
(18:22):
full potential that's stolen by cancer. And I think that's motivating,
but it's it's a really hard thing to carry.
Speaker 3 (18:31):
You know.
Speaker 2 (18:31):
There's so much to process in terms of receiving a diagnosis.
How do you help patients navigate that emotionally but also
in terms of information overload?
Speaker 4 (18:43):
I think for that, Sarah and I have wonderful teams
of people that help us. And so, for example, if
someone needs to undergo chemo therapy, I have a wonderful
nurse who goes in there and spends another twenty minutes
just discussing the.
Speaker 3 (18:56):
Logistics of chemo therapy.
Speaker 4 (18:57):
I have a breast cancer pharmacist who goes in there
for twenty additional minutes and talks about these chemos.
Speaker 3 (19:03):
To the last detail.
Speaker 4 (19:04):
There are also some visits where you know, for example,
on a first visit, there's certain pieces of information I
want to impart, but sometimes I don't get to most
of them because we're just really upset and we're just
trying to process and this just isn't a good day
for me to talk about exactly what chemo you need.
And that happens, and if it does, then we'll see
you in two weeks and we'll.
Speaker 3 (19:22):
Kind of have that discussion again.
Speaker 5 (19:23):
I've also adopted that if I get a bunch of
messages about a person, I pick up the phone and
I just introduce.
Speaker 3 (19:29):
Myself on the phone to people.
Speaker 5 (19:31):
It's amazing how different the first visit goes when they
just know that I'm going to show up and that
I'm going to be a person too. And I feel
like in so much in healthcare now, when you try
to schedule a doctor's appointment, you talk to forty two people,
but you don't know what you're going to get, and
so often I just call them and I'm like, Hey,
I'm Sarah Shueck, I'm a breast cancer doctor.
Speaker 3 (19:51):
How are you.
Speaker 5 (19:52):
Being a humans really valuable for people? And so I
do it for myself too, because I want to know
who I'm walking into. I want to ask them who
they're going to bring with because then I know who's
important to them. One of the hardest things is covering
the stress of a cancer diagnosis, the next steps of it,
and still getting to know a person as a person
and being able to understand in that forty minute conversation
(20:14):
what matters most to them, what are they most afraid of,
and how do they feel about this, because usually that
forty minute sounds like doctor Trennon and I rattling off
medical facts to them. And I always tease that my
first favorite visit is the six month post surgery visit
because they usually are themselves and we've never met themselves,
you know, we've never met them like they would be
at the grocery store. They're scared, they're stress, they're families
(20:37):
on edge.
Speaker 4 (20:38):
And then it's so much fun to really get to
know them as we get them through their vivorship.
Speaker 3 (20:42):
That's so much fun.
Speaker 2 (20:43):
One hundred percent you mentioned having that support system present
for some patients who have that go to person with them.
Speaker 1 (20:53):
In what way.
Speaker 2 (20:55):
Does that help in terms of talking through risk assessment
with patients and how do you ensure that there is
actual clarity in these conversations.
Speaker 4 (21:07):
Having a support system is so so huge. Sarah and
I share a patient who when she was diagnosed, she
called on her gang of girlfriends, like a dozen of
these women, and literally every time she came there was
a different girlfriend that came with her that was like
diligently taking notes and asking us questions, and it was
just the most beautiful thing to see. But if a
(21:28):
patient comes alone, I specifically ask like, can we call someone,
because they're going to remember two percent of what I say.
Maybe if there's someone on the phone, they're going to
remember ten percent of what I say. But having support,
I think is just so crucial.
Speaker 5 (21:41):
And I think too, whatever that means to the person
is fine with us. Yes, you know, I've walked into
rooms where somebody has their neighbor, the ophthalmologists, their sister,
the nurse, and their spouse with them. Whoever is your
army who's going to help you make a decision is great,
But Ultimately, especially as a breast surgeon, what physically happens
to your body, right, the changes that are going to
(22:02):
happen to your breast, the way your breats are going
to look and feel afterward. The only opinion I care
about is the patience. But I want everybody else in
the room, you know, it's amazing. Sometimes I tell my
patients that I'm going to be the first one to
make their dad blush if he comes in, and I'm
fine with that. You know, I'm a breast surgeon. We
have to talk about what your body does. We have
to talk about how your body's going to change. We
have to talk about your feelings of whole self, your embodiment,
(22:24):
your sexuality.
Speaker 3 (22:25):
All that has to happen.
Speaker 5 (22:26):
So as long as you're comfortable with the people you
bring hearing all that, I'm comfortable too. It can be
your mailman, you're an uber driver, your whatever, just whoever's
going to show up for you in a time when
you need them. I also to always ask if they
are the person who usually is the one keeping it
together in their life, because if they're the matriarch, right,
if they're the pillar, this is not going to be
(22:48):
a season of life where they get to do that,
and so it's also a really nice opportunity to kind
of say to everyone in the room, Mom, sister neighbor
is not going to be the quarterback for a little while,
to be again because women are strong, but during that season,
somebody else has to take control.
Speaker 2 (23:06):
Going back to an earlier conversation, just in terms of
confusion and misconception, there remains a lot of confusion surrounding
genomic risk. Yeah, how would you break it down and
how does it ultimately influence the treatment decision, particularly for
early stage breast cancer.
Speaker 4 (23:26):
So I think that there are multiple genomic tests now
that are available. I think the most important thing when
we have a test is we need to use it appropriately, right,
because if we're not using it appropriately, then it's really
hard to interpret what those results are. But genomic testing,
especially in ER positive her too negative breast cancer, has
been so instrumental to helping us understand what are the
(23:47):
actual treatments that are going to benefit patients and that
they can spare patients toxic chemotherapy and other drugs. It's
also a great time to have a conversation with a
patient because they always want to know what are the
chances my cancer is going to come back. And I'm
never able to say that with like one hundred percent certainty,
but I can say like, oh, I have these tests
that can help me do a better job of estimating
that for you, so we can better tailor treatment.
Speaker 5 (24:10):
It's often something patients ask me as a surgeon about,
But I think what's so important about genomic testing is
it's not necessarily what's happening right where we're cutting it out.
There's this notion that like where it is where we're
cutting it out from is the only problem. But so
much of this testing and so much of the therapy
we give is for all of that possible confetti that's
trying to make its way elsewhere. So it's a hard
(24:32):
thing for me, and I'm as confused often as our
patients are about the newest genomic tests that we're doing,
the newest indication for it. And so that's where it's
incredibly critical for me as a surgeon to say to patients, Hey,
I get your surgery pathology back. I'm calling you first,
and I'm calling doctor Chen's second, because I want her
to decide if we need specialty testing, if we need
to do anything more so that she can set the
(24:53):
dial right for the medical therapy, just as we worked
hard beforehand to set the dial right for the surgical therapy.
Speaker 2 (25:00):
In terms of the different types of prognostic testing available,
how do they ultimately influence the treatment plan for breast
cancer patients?
Speaker 4 (25:11):
Generally speaking, if you have a higher risk cancer, we
want to do things to try to mitigate that risk,
and more often than not, that means more medical therapy
or stronger medical therapy. This is something that allows us
to say we think that you have a higher recurrence risk.
That means that we need to give you, you know, intensive chemotherapy,
or we can say, oh, you have a low recurrence risk.
Speaker 3 (25:31):
We can just give you let resolve for a few
years and we think you'll be fine.
Speaker 2 (25:35):
This might seem a little bit redundant, but how do
you go about identifying other risk factors for patients, such
as through bio marker.
Speaker 1 (25:44):
Tests, and how do they shape treatment plans.
Speaker 4 (25:48):
So there are genomic tests such as oncotype that are
run on pre treated surgical samples, whether it's at the
time of surgery if doctor Trubek goes first, or.
Speaker 3 (25:59):
On the biopsy sample.
Speaker 4 (26:00):
These tests can give us a recurrence score, and this
is a test that is both predictive and prognostic, predictive
to the benefit of chemotherapy and prognostic to their recurrence risk.
So these tests have been really helpful in the last
decade in helping us better tailor therapies to women and
helping us make sure that we are treating women appropriately
to match their cancer risk.
Speaker 2 (26:21):
When it comes to recurrence. There remains significant unmet need
in the treatment of stage two and three hormone receptive
positive early breast cancer. Despite best efforts and the range
of available treatment options, a concerning number of patients persistently
face the risk of both long term and short term recurrence.
According to a study published in the Journal of Clinical Oncology,
(26:44):
approximately one third of individuals diagnosed with stage two hormone
receptive positive her too negative breast cancer are at risk
of recurrence. The Mayo Clinic further states that women who
have had breast cancer are more likely to experience a
second occurrence. Regrettably, most recurrences progress to metastatic disease for
(27:04):
which there is currently no cure. It is essential for
patients to have access to treatments that allow them to
live their lives to the fullest. Adherence to therapy is
crucial in effectively reducing the risk of occurrence. However, considering
that many patients will need to undergo therapy for years,
their ability to tolerate the treatment becomes vitally important. After
(27:25):
the break, we'll resume our conversation with doctor Chen and
doctor Shuebeck, delving deeper into the harsh reality of breast
cancer recurrence and its unfortunate potential to evolve into metastatic
breast cancer.
Speaker 1 (27:38):
We'll be right.
Speaker 2 (27:38):
Back now back to our conversation with doctor Nanchen and
doctor Sarah Schuebeck.
Speaker 3 (27:58):
Now, you just.
Speaker 2 (27:59):
Mentioned recurrence, but if you could, doctor Scheeback, delve into
the reality of breast cancer recurrence and how unfortunately it
can transform into metastatic breast cancer.
Speaker 5 (28:15):
Sure, so, I think when we think about the first
journey through breast cancer, right when we close that first chapter.
My other favorite kind of analogy is to think of
these as choose your own adventure books. Right, so at
the end of each chapter we have to kind of
push the reset button. And after the initial phase of treatment,
whether that's surgery, medicines, and or radiation, we have to
start over and that means screening, being vigilant, listening to
(28:39):
our bodies, you know, routinely seeing patients taking whatever adjuvant
medical therapies are required for risk reduction and to kind
of have ongoing treatment for their breast cancer, but then
very importantly be vigilant when something changes. So a lot
of times recurrence events are basically found in breast imaging,
so patients get their next mammogram or another MRI, for example,
(29:00):
where they present with a palpable finding something they can
feel that's different along a scar line or something. When
it's that kind of local event, often your breast surgeons
back involved straight away. We do biopsies, we facilitate additional imaging,
and then very importantly, we often make sure it hasn't
gone elsewhere, because if patients have metastatic breast cancer, meaning
it's spread outside of the local area, then they're not
(29:20):
really a candidate for kind of curative intent therapy in
the traditional sense of surgery and medicines as a joint venture,
but rather we lean on medicines as their solution and
at least their treatment modality.
Speaker 4 (29:32):
Breast cancer is unique in that this is one of
the only cancers in which we do not do routine
body imaging after they complete their curative therapy, and so
a lot of us trying to surveil for recurrence is
dependent on the patient knowing their own body. When I
talk to patients, I give them incredibly vague instructions for
(29:53):
the kind of things to let us know about.
Speaker 3 (29:54):
I truly say, if you have.
Speaker 4 (29:55):
Any new symptom that lasts more than a few days
and you're not sure what it's caused by, me, let
me know.
Speaker 2 (30:01):
Circling back for a second, because you touched upon it,
but breaking down what it actually means. So hormone receptor positive,
human epidermal growth factor to negative.
Speaker 3 (30:13):
A mouthful, it is?
Speaker 1 (30:14):
It is.
Speaker 2 (30:15):
I can see why it's abbreviated, but you know it's
the most common subtype of breast cancer, accounting for over
two thirds of all cases. Can you break down what
it actually means and unmet needs in treating it?
Speaker 4 (30:28):
Early breast cancer cells, just like our normal cells, have
hundreds to thousands of flags on the outside. Estrogen receptor
and HER two are two examples of said flags. When
someone is ER positive her too negative. I think of
it as estrogen is one source of food or fuel
to help the cancer grow. The foundational way that we
treat these cancers is with the anti estrogen therapies. There
(30:51):
are a portion of patients that may be, for example,
are less dependent on estrogen signaling or of other high
risk features in which anti estrogen therapy alone is very
much not enough to prevent recurrence. There are newer drugs
now that previously we're used in the metastatic setting, but
are now being brought into early stage breast cancer, which
have shown successfully to be able to mitigate that risk
(31:12):
for certain groups of high risk patients.
Speaker 5 (31:14):
So it's tricky and surgery because a lot of the
role that I'm having to play is really in gathering
information about hormone receptor positive or too negative cancer in
the sense that we often do surgery as a bit
of a diagnostic test. Right for a lot of patients,
the surgery is really a fancier MRI. We go in,
we remove the tumor, we understand the size of it,
(31:34):
We check their lymph nodes. That tells us how big
it is and how extensive it is, and then that
information gets fed back in to make treatment decisions. And
so I think of surgery as really gathering more information
instead of being a definitive treatment, so that Dector Chen
can tailor therapies, especially in this hormone receptor positive group,
because that surgery information sometimes can change the game so substantially.
Speaker 4 (31:57):
And there are some types of breast cancer, such as
popular carcinomas, which are most commonly HR positive hurto negative,
where it can be really hard to tell in mammograms
and MRIs exactly how big things are, how much for
our things have spread, and it may only be at
the time of surgery that we truly discovered the extent
of disease and thus how risky the cancer actually is.
Speaker 2 (32:17):
We've talked about navigating the information overload that comes with
the diagnosis, and you know that educational hurdles that exist
for every single patient, But we haven't really touched upon
racial disparity gap.
Speaker 1 (32:32):
You know, in.
Speaker 2 (32:33):
Terms of Black women are forty percent more likely to
die from breast cancer than white women. How do you
wrestle with that statistic.
Speaker 4 (32:46):
One of the reasons that I came to the University
of Chicago is actually to take care of black women.
In all of my training, I have always taken care
of underserved populations. I find it incredibly gratifying. There are
so many facts about black women in breast cancer that
are uncomfortable.
Speaker 3 (33:05):
You are correct that they are more likely to die
of their disease.
Speaker 4 (33:08):
They are more likely to be diagnosed later, they are
more likely to have triple negative breast cancer, which is
the most aggressive subtype.
Speaker 3 (33:13):
They are more likely to have delays.
Speaker 4 (33:14):
In treatment once they get started, they are more likely
to not complete their treatment, and so there are many,
many factors, both biological as well as socioeconomic, that contribute
to that terrible statistic. Sarah and I think about this
every day to not even be hyperbolic about it because.
Speaker 3 (33:35):
Of the patients that we see. A few months ago.
Speaker 4 (33:38):
We had a couple really terrible outcomes, and Sarah Astuteley
was like, I feel like, we're just seeing what young
black breast cancer looks like. And that was just the
simplest way to kind of describe what was happening. It's
really really terrible, and I think that as a community
and as a cancer community, we really really should be
(34:01):
doing better.
Speaker 5 (34:02):
We also traditionally have not done a good enough job
of recruiting women of color to clinical trials, to providing
everyone with the same opportunities for intervention, genetic testing, different
surgical options, different reconstructive options, and so it's so many
things that we have not done well enough to serve
the whole breast cancer community. And like doctor Chen, I
(34:24):
think that really being able to take care of everyone
and look at them and say, hey, this data, this
brilliant science, this is exactly for you. We don't have
that right now for every patient. So some of our
trials are north of ninety five percent white women, and
then we're extrapolating to all people. That's something that we
(34:44):
really feel, especially at the University of Chicago, is a
priority for us to offer every single patient to be
on a cancer registry, every single patient to be in
a clinical trial. That's appropriate, and that's because we need
to get those numbers to be reflective of the population
we actually serve. Serving people who are different from me
for whatever reason, is the greatest joy of my life.
I didn't necessarily know that would be such a passion
(35:06):
or such an important part of my practice, but it
has been the greatest learning opportunity of working at the
University of Chicago on the South Side of Chicago. There
are patients who teach me every day about what they've
been told to fear about doctors, what they've been told
is not important enough to bring to your doctor. And
I think that if we can break down those barriers
and really empower people to look out for their own
health across everything, we'll get there.
Speaker 2 (35:27):
It's interesting because you would use the word unfair to
describe cancer, and that said, then it's compounded on what
makes the outcome even more unfair for some of your patients?
Speaker 5 (35:41):
Absolutely, and I think patients who have social challenges, right,
women who are the one keeping it together for their family,
the earner, the head of household, maybe somebody who's relying
on social resources to support their children or their family members,
and then we take.
Speaker 3 (35:55):
Her out of the fight. Man, that's really unfair.
Speaker 5 (35:58):
So we'll have young women clinic who are just starting
their careers, are just building their family, are just you know,
just really starting life, and they come in and they're
these incredible humans now with this really terrible problem. That's
when we call each other and we talk about exactly
how unfair this business feels. You know, Like I have
these really incredible women come to my clinic and I'm
(36:20):
just sitting there, like I just want to hang out
with this person. I want to be best friends with
this person. I just want to learn from her. I
want to see what she's going to do in thirty
years with her passions.
Speaker 3 (36:29):
Well, that's here we are.
Speaker 2 (36:30):
That's the other side of the same coin, because today
breast cancer survival rates are much higher.
Speaker 3 (36:37):
Absolutely, how do you factor.
Speaker 2 (36:40):
Planning for life after cancer into the treatment journey?
Speaker 4 (36:45):
I think it is so hard for patients to even
visualize the after cancer when they're in the thick of it,
because it just feels so rotten to be going through treatment,
to be thinking about surgery, to be planning for post
surgical recovery periods. Really, like what Sarah said earlier about
kind of six months afterwards, you really get to see
them come out. It is the favorite part of my
(37:07):
job to see them getting back into their thing. I
have patients who previously golfed and now like during treatment
that you did in golf, And I saw her a
few weeks ago, She's like, Yeah, I kind of went
out a couple of weeks ago, and I was like,
this is amazing.
Speaker 3 (37:19):
This is exactly what I'm hoping for.
Speaker 4 (37:22):
Our hope for everyone is that this is a speed bump,
like it's a big speed bump, and it's a horrible
speed bump, but that it is a speed bump, and
when we get through the other side, you are as
close to the person that you were before as you
can be, recognizing that you've now gone through this transformative,
life changing experience.
Speaker 5 (37:37):
In the middle, I'm in a shamelessly stale phrase from
one of my patients who told me that she's decided
her breast cancer is a rude bump in the road.
It's not going to derail her, it's not going to
change her course. But it's a rude bump in the road.
And I've ever since she told me that, and I
hope someday she hears us to know how wise I
think she is. I tell patients that because often patients
will say to me, I don't care what happens to
(37:58):
my body. I just want to live. And then to that,
I say, hold on, I care what happens to your body,
because in six months you're going to be really mad
at me when you start to be a person again,
your whole self. If you have an ugly scar, if
the first thing you think of when you walk out
of the shower is your breast cancer, if your sexuality
is impacted by what we put you through. I have
(38:18):
to think and hold space for you to be a
person again after breast cancer, and whether that's preserving your
fertility so that you could have a pregnancy in a
few years, if that's putting your breasts back together in
a way that you've always wanted, giving you a breast reduction,
doing all those things that seem really trivial when you're
facing cancer but are really vitally important when you're facing
life again. And that transition for some people is really rocky,
(38:41):
but for others is really natural.
Speaker 2 (38:45):
When you are in a situation where someone isn't handling
it well, how do you integrate the psychological impact of treatment.
Speaker 4 (38:56):
I tell every single one of my patients that this
is an extraordinary experience and that I personally feel that
everyone should be getting psychological support because this is just
so incredibly hard. Sometimes I feel like the best thing
I can do for a patient during a clinical visit
(39:17):
is just hear them out, hear what they're going through,
and just commiserate and validate that, like, Yeah, this sucks.
The emotional component of this, I think is just as
relevant as the physical part.
Speaker 3 (39:27):
It's just so overwhelming.
Speaker 5 (39:29):
I think also patients have perceived support from their family
in a lot of ways, but their family their friends
are also going through something. The biggest kind of disconnect
I see in my practice is when your family and
friends have decided the fight is over right, treven is done.
That's a really lonely time for a survivor, and so
I think people kind of unexpectedly fall off their cliff
(39:52):
at very different times. Some people it's right away, they
can say that they need support, and we are like, yes,
we have mental health resources available for you. The harder
thing is figuring out somebody who's maybe in survivorship or
maybe just finished therapy, and that their struggle is actually
becoming a person again, as opposed to a patient with cancer.
And so the notion that support is really only during
(40:13):
that active journey, I think is a really misguided one,
and that we have to make sure patients understand that
survivorship also is loaded, because it's really full of trauma
and history and physical scars and obviously psychological ones too.
Speaker 1 (40:26):
And it is such a loaded.
Speaker 2 (40:31):
Breasts in general, really what they represent to women, what
they represent to society, so many things, but also to
base one's femininity.
Speaker 5 (40:41):
Our gender expression, our sexuality, our embodiment, everything.
Speaker 4 (40:45):
Our maternal it's such a personal part of our body.
Speaker 5 (40:48):
I often tease that it's amazing that everybody's going to
have an opinion about your breasts, but we're not actually
supposed to talk about them any other time. Right, your
neighbor will tell you to have a bilateral mistake to me,
But man, have you ever talked to your name or
about your breast before? Right, It's meant to be private,
you know. It's a space where we judge one another
about you know, augmentation or how much we're exposing or
you know. And I think it's really funny how then
(41:10):
during a cancer journey, women are supposed to surrender that
notion of modesty and allow us to kind of strip
them of their femininity and in the name of heroism.
Speaker 4 (41:19):
But also all the other things surrounding breast cancer care,
meaning fertility. We have so many fertility conversations, talking about
vaginal health.
Speaker 3 (41:27):
It's just a lot of personal things.
Speaker 2 (41:30):
How do you navigate that fertility conversation, particularly with young patients.
Speaker 4 (41:39):
One of the things I hate the most about this
conversation is that, on top of all the cancer stuff,
you now have to think about this that you shouldn't
have had to make a decision about this for years,
And now you're sitting here in my page box clinic,
and I'm asking you these horrible questions and you have
to sit here and figure out way too early whether
or not you want to have kids, and whether how
(42:00):
much you want to have kids is how that's going
to impact your breast cancer care.
Speaker 3 (42:03):
And that's terrible.
Speaker 5 (42:04):
I agree with doctor Tennant. It's breast cancer so often
robs people of their potential that they haven't even decided yet.
Speaker 6 (42:12):
You know.
Speaker 5 (42:12):
Often we'll see twenty five year old women and we're like, so,
you know, on top of all this trauma.
Speaker 3 (42:16):
Have you thought about having kids? And tell me now?
Speaker 5 (42:18):
Yeah, and tell me now in front of these seven
people you've brought with you.
Speaker 1 (42:22):
Somebody who may or may not be in a relation.
Speaker 5 (42:24):
Sure, yeah, correct, right, And I think, and it's so
amazing to think about how, you know, we put people
through this intense stress test of making all those decisions
in quick succession because they feel that they're delaying their
chemote therapy if they choose fertility, So then it.
Speaker 3 (42:37):
Feels selfish, but it's actually essential.
Speaker 5 (42:40):
You know, I always kind of think of it as like,
we have to do the one on one level course first, right,
we have to do breast cancer one on one, and
then the graduate level course is all of this other stuff,
and we have to build capacity in the patient to
go to the next phase. So we have to have
a shared foundational understanding of what she's up against, of
what decisions she has to make, and then on top
of that, we put all of those things afterward that
(43:02):
will make her whole again after cancer.
Speaker 2 (43:05):
But at the same time, you guys are constantly reevaluating
your role in the journey of treatment. You know, we've
spoken about current patients journey and how it varies and
differs in how your help in supporting them throughout that
has to vary along with it.
Speaker 1 (43:27):
But taking a step back for a.
Speaker 2 (43:28):
Moment in terms of doing what you do right now
in this moment in time, what is the best thing
in terms of the advancements that you've seen.
Speaker 3 (43:41):
I think that we've come so far.
Speaker 5 (43:43):
So I alluded to some family history earlier, and I
have my grandmother's medical records from her breast cancer journey.
Speaker 3 (43:50):
It's wild to read what this woman went through.
Speaker 5 (43:53):
I look forward a generation, and I saw what my
own mother went through, and nowadays, she would have benefit
from these genomic advances, she would have benefited from surgical
de escalation, She wouldn't have had to go through a
lot of what she had to go through. My mom
will say to me, do you do this because of
what I went through? And I, you know, some of
it is, yes, and she's going to listen to this
and get mad at me, But some of it is
(44:15):
because I get to do better. I get to let
people live more often. And while you know, we perseverate
on the people who haven't done well because it takes
a piece of our heart with them. So many of
our patients are living full lives after this, And so
I think, how lucky are we that I, with all
my breast cancer risk, that I'm up against my sisters,
all the women I love in my family. I believe
(44:37):
in my heart we're going to be okay. And I
don't mean to make light of the devastating journeys that
some people are facing, But in twenty twenty four, most
of the time I can say, with a straight face
and with honest intention that you're probably going to be okay,
And we get to think.
Speaker 3 (44:52):
About life after this. That rude bump in the road
is going to go away.
Speaker 5 (44:57):
That's a purely surgical perspective, because I don't take care
of patients in the metasthetic setting, which that is the
weight of a medical and collegist journey. And I sit
in awe of how doctritenn does that with such grace?
But I think most of the patients who sit in
front of me are going to be okay. And what
a gift is that from medical innovations, from screening innovation,
from empowerment of people, right from saying that it's good
(45:19):
to speak up about your health. And so I think
that's my take on the landscape is like, how amazing
is it that?
Speaker 3 (45:24):
How far have we come?
Speaker 5 (45:25):
All we can do is continue to amplify that messaging
to say that the vast majority of people are going
to be okay, So so come forward and let.
Speaker 3 (45:32):
Us help you.
Speaker 4 (45:34):
I started my oncology fellowship in twenty eighteen. There have
probably been at least a dozen if not more, drug
approvals and breast cancer since then. Wow, it is so
much fun to be in this field and see how
(45:55):
things are moving ahead. I tell patients, I hope by
the time I retire, chemo is obsolete, that we have
better targeted therapies to be doing this. I hope to
be doing so much better in forty years, and I
very very much share your optimism that I think we
can do it.
Speaker 1 (46:09):
All right now. In terms of that.
Speaker 2 (46:11):
In terms of the future, what developments and advancements do
you guys see on the horizon for breast cancer treatment
and how are new medicines and therapeutics shaping the future
of patient care.
Speaker 4 (46:27):
There is so much coming down the pipeline. There are
new antibody drug conjug It's coming down the line, both
with different antibodies as well as with different payloads. We
are trying to better understand how immunotherapy fits into breast
cancer and whether it can work in more patients than
it currently works in. We are currently developing many novel
(46:49):
endegrine therapies to disrupt the estrogen receptor in ways that
just weren't really thinkable a decade ago. There is so
much happening in breast cancer. There's a lot of information
being presented literally in two hours at this conference to
really showcase all that we've done in the last year
and kind of where we're going from here.
Speaker 5 (47:09):
From a surgery perspective, I see a world with much
less breast cancer surgery because the medicines are getting better,
and I think that that is such a great thing.
So I would love a world without breast cancer surgery
because people are doing too well or we've learned who
it's essential and who it isn't. Breast surgery is really
the backup move nowadays, and I think that that's really
(47:30):
exciting because we're doing it better. Cancer is not a
local problem. Cancer is a whole body problem, and so
if the medicines can do the heavy lift, it's going
to be better for everybody.
Speaker 3 (47:40):
I'm really excited.
Speaker 5 (47:41):
I'm optimistic, and I think that optimism is what carries
us into each room, so we can tell people with
a straight face, this is what we're up against. These
are the tools we have. We're going to throw everything
we have at this and keep you whole.
Speaker 1 (47:54):
Excellent answer, both of you.
Speaker 2 (47:56):
And lastly, if there is one one thing that you
hope people listening take away from this conversation, what would
it be and why?
Speaker 5 (48:08):
The most important thing in breast cancer is early detection.
So I'm going to be pretty expected and say that
take care of yourself, get your mammogram, take somebody with
you to get your mammogram, Go to your primary care
physician or provider and get a breast exam.
Speaker 3 (48:23):
Pay attention to your body.
Speaker 5 (48:25):
And I think, don't be so scared of this possibility
that you're not empowered enough to figure it out.
Speaker 3 (48:31):
And so that really for me is just take care
of yourself.
Speaker 4 (48:35):
I'm going to say on the flip side that providers
really need to listen to women.
Speaker 3 (48:39):
Women know their bodies really well.
Speaker 4 (48:41):
If someone is telling you that something not right, then
we should figure out why that is. That's really important
for the breast cancer journey.
Speaker 2 (48:49):
Doctor Chen, doctor Schuebeck, thank you so much for joining
me today and thank you so much for this conversation.
Speaker 3 (48:55):
Thank you, thanks.
Speaker 2 (49:00):
Thanks for listening to this bonus episode of Symptomatic. Be
on the lookout in the coming weeks for another special
episode from the twenty twenty four as CO annual meeting.
We'll be speaking with doctor Muhammad a Tique about the
patient struggle against prostate cancer and the current state of treatment.
Speaker 6 (49:17):
What we're having to learn and discover in the current
field is the sequencing of these treatments. Which one should
go first right, we know based on some data, you know, Okay, well, yeah,
and we might start with X treatment and go to
the next one. But then there's just kind of a
mix of options which can all be appropriate, Which one
(49:37):
is the best to continue and LinkedIn the survival is
kind of a big poin discussion.
Speaker 2 (49:42):
And we'll be back next week with another all new
episode of Symptomatic. Until then, we would love to hear
from you. Send us your thoughts on this episode, or
you can share a medical mystery of your own at
Symptomatic at iHeartMedia dot com. And please feel free to
rate and review Symptomatic wherever you get your podcasts.
Speaker 1 (50:01):
We'll see you next time. Until then, be well,
Welcome to Symptomatic.
Speaker 2 (00:35):
Today, we're recording from the twenty twenty four Asco American
Society of Clinical Oncology Annual Meeting, talking about breast cancer.
One in eight women will navigate a diagnosis of breast
cancer during their lifetime, and it accounts for nearly one
third of all cancer cases and women. I am joined
by two esteemed warriors in the battle against breast cancer.
(00:58):
Doctor Nan Chen Breast, a medical oncologist at University of
Chicago Medicine, where she is also an Assistant Professor of Medicine,
and doctor Sarah Shuback, a surgeon who specializes in breast cancer,
also at the University of Chicago Medicine, where she is
an Assistant Professor of Surgery. Welcome doctors, Thank you so
(01:18):
much for joining me.
Speaker 3 (01:20):
Thank you, thank you so much for having us.
Speaker 2 (01:22):
Before we even dive in, I would love to ask
both of you what drew you to breast cancer as
a specialty in Doctor Chin, why don't you start sure?
Speaker 4 (01:33):
I initially became really interested in oncology because I really
liked the idea that we were taking care of the
whole patient. I just thought that it was really mentally
fascinating and then there really was no relationship that I
enjoyed seeing more as a medical student than the relationship
between a patient oncologist. They just felt really important in
their lives, and I really felt like I wanted to
(01:53):
be that person. I think the simplest way to describe
why I like breast cancers, I just really enjoy taking
care of women. I just think it's such a special
group of people. I can get along with them really well.
I also like the fact that, compared to some other cancers,
there are a lot of things that I can do.
There are a lot of options that I have, and
I feel like I can be more helpful.
Speaker 3 (02:12):
I really love it.
Speaker 1 (02:13):
Excellent doctor Shueback.
Speaker 5 (02:15):
Yeah, so I was first really drawn to surgery as
a job because I like to have a one day
event where I fix something, and that felt really satisfying
to me. Cancer, though, is this long term relationship that
also really grabbed my attention and restargible. Oncology was the
last thing I thought I would actually end up doing
until I similarly fell in love with the idea of
taking care of women. And I think mostly because what
(02:37):
we do is pull people back from feeling like a
puddle when They're usually the pillar in their family, and
so I think we often meet people on their worst
day and get to watch women rise from whatever their
ashes may be and become again that force, that strength,
that pillar of their family. And that was ultimately what
I fell in love with. And I think, like so
many of us, they have a lot of breast cancer
(02:58):
in my family, and I always wanted the opportunity, need
to be the one to do it right for people,
because I saw it be so hard for the people
I loved.
Speaker 3 (03:04):
What do you.
Speaker 2 (03:05):
Both find remain the most prevalent misconceptions or myths about
breast cancer in general?
Speaker 4 (03:14):
I think that one of the most common scenarios that
we encounter is women when we first meet them, think
that they did something to cause this breast cancer, that
some decisions that they made in their life have led
them to hear and in the vast majority of cases,
that's really not true. And so one of the things
I think we do when we first meet patients is
to almost unpack that guilt and make sure that we
(03:34):
understand that this unfortunately just happens. As you mentioned before,
and one in eight women, that's probably one of the
most common misconceptions.
Speaker 3 (03:41):
I see.
Speaker 5 (03:42):
I also think that we think of breast cancer as
one disease entity, but it really is a whole collection
of diseases that interact with people's lives at different times
of their life, of different scenarios. And just because your
neighbor had one experience doesn't mean you will. So I
think a lot of what we spend time with saying,
you know in twenty twenty four this is each person
(04:03):
has a different story, each person needs different interventions, and
trying to kind of separate what one woman is facing
based on what maybe she's read or heard about is
really important to give her clarity, to put her as
kind of the captain of the ship, and to allow
her to make good decisions for her health.
Speaker 2 (04:19):
Also, I should think that there is a misconception that
we're just talking about lumps. Yeah, you know, less than
five percent of cases, pain is actually an indicator.
Speaker 5 (04:31):
Yeah. I think when we consider how different women present,
it's a whole host of things. You know, it's new
nipple discharge that they hadn't noticed before. It's a size change,
it's nipple retraction or dimpling of the skin. Things that
just don't sit right with someone. Usually warrant evaluation. You know,
we know our body's best and so I think that
a lot of the women that doctor Tenn and I
(04:52):
take care of are often too young for mammograms right
or are diagnosed before they would have started routine screening.
So we're really relying on them or their doctors to
just notice something is different and to feel that that
difference might be a real health concern and to get
it evaluated.
Speaker 2 (05:08):
In what sense does timing still remain one of the
most important weapons in your arsenal against breast cancer?
Speaker 4 (05:17):
We know in breast cancer, the earlier we find the cancer,
the better it is, and I say better in many
different ways. First and foremost, we know that your prognosis
is better, the chances of you surviving this cancer are better.
It also means in many cases we can de escalate
your therapy. If you have an earlier stage cancer, we
can give you less treatment for it, which I would love.
And so to doctor Schubek's point, it's so important for
(05:39):
women to know their bodies and to make sure that
doctors and other providers are listening to these women when
they mention things going on, and.
Speaker 3 (05:47):
Also the timing in one's life.
Speaker 5 (05:49):
You know, we take care of young women who go
on to live full lives, have healthy pregnancies, fulfill whatever
it is that's in their goals and desires. We also
take care of women later decades of life who have
you know, even shorter intervention periods for care, and that's
because we're learning more that these diseases vary across a
lifetime and very based on the person. And then really,
(06:09):
as dutch Chun mentioned, the earlier we can find a problem,
the less likely it is to threaten someone's safety. And
that is why early intervention, early identification is just critical
and why you know, screening has made so many improvements
for women who are eligible for screening because we're finding
breast cancers at earlier and earlier stages.
Speaker 2 (06:28):
And I believe that in stages one and two, eighty
five percent of the cases you diagnose are treatable.
Speaker 4 (06:36):
I would actually say that one hundred percent are potentially curable.
And really, our therapies are getting better and better every year.
And I think doing this at ASCO twenty twenty four
is just such a stark reminder of the progress we
have made in breast cancer even the last decade, and
the progress we're continuing to make that when I meet
a woman, I say, we can cure you right now.
Speaker 3 (06:57):
We can get rid of this cancer.
Speaker 4 (06:58):
The bigger problem and the bigger goal I have is
to make sure this cancer doesn't come back. And we
are getting better and better every day with our therapies
to make sure that that doesn't happen.
Speaker 2 (07:07):
And the whole concept that don't worry about breast cancer
till you're forty is dated.
Speaker 4 (07:11):
That is quite dated, and I would argue that's a
really dangerous message because we aren't screening women.
Speaker 3 (07:17):
Usually before the age of forty.
Speaker 4 (07:18):
We can actually miss early cancers in younger women because
we're not looking, and those women are also not necessarily
educated to know to look for these things in their body. Unfortunately,
the rate of young breast cancer is actually rising since
like the early two thousands, and so another reason that
we really need to be careful in the younger population.
Speaker 1 (07:38):
What do you attribute that to.
Speaker 4 (07:40):
I think the short answer is, really I don't know,
And the longer answer is, I think there are a
lot of things happening. Girls are getting their periods earlier,
and so you just have a longer time in your
life that you're getting hormonal exposure and that can increase
your risk of developing breast cancer. This is actually, unfortunately
a trend we're seeing in other cancers as well, like
cooling cancer. So there's probably lots of reasons that are
(08:01):
environmental and societal that are leading this, but it's a
concerning trend that we should all very much be aware of.
Speaker 2 (08:07):
I want to jump into the topic of collaboration. But
before we even get their doctor chin. Despite breast cancer
being fairly common, unfortunately and straightforward in terms of the diagnosis,
is there an individual aspect to each case you diagnose.
Speaker 4 (08:27):
So the road to individualizing cancer medicine is a long
road that we are on and will be on for
a long time. We know in twenty twenty four we
are still over treating some women, and we know in
twenty twenty four we are also under treating some women.
We are starting to become smarter using biomarkers and genomic
(08:48):
tools to better thread that needle and make sure that
patients are getting the appropriate amount of therapy, but it
can be difficult sometimes to figure out whether we're being
too aggressive or not aggressive enough, whether patient's cancer and
everything really should be tailored to each individual cancer.
Speaker 3 (09:03):
Two women sitting next to each other.
Speaker 4 (09:05):
Even if they have on the surface very similar cancer features,
stage all a subtype, all of that may still have
very different tumors. We now can do genomic testing and
molecular testing to really be able to dive deeper into
how the cancer actually functions, the biological way that it works.
Speaker 2 (09:22):
And doctor Schuebeck, how do you emphasize the importance of teamwork.
You know, a multidisciplinary team of doctors when treating breast
cancer patients, and why is it crucial for all members
of that medical team to work towards moving in the
same direction.
Speaker 5 (09:42):
Yeah. The reason why I think it's particularly timely now
is because the game is changing for the better. In
the origin story is of breast cancer, we thought it
was a surgery disease, just cut it out. And most
patients are still kind of referred from their primary physician
or provider to a surgeon when they have a new diagnosis.
But very often I'm not the first person at that,
(10:03):
so it's really figuring out for each person who their
starting quarterback should be. And so I think that's not
really something that happens in isolation. Right, Some patients need
medical therapy first to make their surgery smaller. Some patients
need surgery first to help understand how much medicine they need,
and that's not one size fits all.
Speaker 3 (10:21):
That depends on.
Speaker 5 (10:21):
Who the patient is, what cancer they have, how much
cancer they have, what can they tolerate? And so if
I were to decide just all of those things, that's
kind of like an electrician telling you what a plumber
should do. And I think there's a lot of value
in constantly learning from one another and most importantly holding
the patient's values and what they can endure or want
to endure, or just how they're facing their journey as
(10:43):
the centerpiece of our discussions.
Speaker 3 (10:45):
And during a patient's treatment journey, there are many touch
points in which decisions that I make will very much
influence what doctor Schubeck does, and things that she is
thinking of will very much influence what I do.
Speaker 4 (10:57):
Just last week, I called you on my way home
because we just had a stuff patients where I was like,
I want to give you some updates as to kind
of what's going on, to make sure that you're in
the loop and that you can make decisions.
Speaker 3 (11:06):
With the most update information that you have.
Speaker 5 (11:08):
And I think it's important to say too that the
surgeries are getting smaller, right, So breast cancer surgery is
a story of de escalation almost uniformly, which I'm thrilled for.
Speaker 3 (11:17):
I can't wait to be put out of a job.
Speaker 5 (11:18):
And I think that's because the medicines are not necessarily
getting bigger, but getting more tailored. Right, So the medicines
are getting more effective in the upfront setting, which allows
me to do really small surgeries that lead to less
disfigurement for people, leads to better function after surgery. We
need to be supportive of our patients in getting the
right intervention. And so if that means in twenty years
(11:41):
there's no role for surgery and breast cancer, I'll retool.
Speaker 3 (11:43):
I'll be just fine.
Speaker 5 (11:45):
But how amazing would that be if that story and
that trend continues.
Speaker 2 (11:49):
You mentioned team, and you mentioned the different roles plumber, electrician,
you know, but ideally, who would you guys like to
see on your ideal breast cancer management team?
Speaker 4 (12:05):
You know, honestly, that team is as big as a
football team, really is.
Speaker 3 (12:09):
It's huge.
Speaker 4 (12:09):
It is both a surgical oncologist, a medical oncologist, a
radiation oncologist, a reconstructive surgeon. Potentially it is a nurse navigator.
It may be a genetic counselor a therapist.
Speaker 3 (12:21):
Who can help with a lot of the you.
Speaker 4 (12:24):
Know, mental health struggles that women go through throughout this diagnosis.
It is a physical therapist who can help maintain motion
after surgery.
Speaker 3 (12:31):
It really is such a large.
Speaker 4 (12:33):
Team of people that we work with that would make
up the ideal team.
Speaker 5 (12:36):
And often it's things like genetic counselors, right, it's risk
producing for the patient and also thinking about their whole families.
It's fertility doctors for patients who are getting fertility preservation
before surgery. It's primary care doctors, right. It's the person
who knows that patient before their diagnosis and is going
to continue to care for them long after. So it's
all of those people and more. And then if I
(12:58):
had everything I ever wanted, it'd be the PA's family,
it'd be the patient's employers, it'd be all the patients
surrounding ecosystems so that we together can support that person
in their journey. I think that we also all have
to work for the same person, and that's the patient.
Speaker 2 (13:13):
So let's just talk about the importance of collaboration between
specialists like oncologist surgeons to enhance patient outcomes.
Speaker 4 (13:23):
I think one of my favorite parts of our relationship
is how open we are with each other and how
even if something maybe didn't go as well as I
wanted it to, I'm like, hey, this is what happened,
this is where we are, this is how we go forward.
Or it's like, oh, hey, I had this conversation with
a patient. It kind of went off in a left
direction and I didn't really like it, but just so
(13:43):
you know, so when she brings it up, this is
kind of what we discussed, and I think there's no
judgment on that part that you know, this is life
and we do the best we can.
Speaker 5 (13:51):
I think also one of the really breakthrough moments for
me with Nan and our practice that we share is
I was sitting at my kids gymnastics class on a
Friday night and she calls me, and you know, usually
there's a warm up text message to say, you know,
we need to discuss some patients. But I just got
this call and I had like two minutes where I
was able to answer.
Speaker 3 (14:10):
I was otherwise, you know, wrapping up some work for.
Speaker 5 (14:12):
The week, and she called me and told me about
one of our mutually loved kind young patients who was
experiencing a devastating outcome from her breast cancer journey, and
we just kind of sat there together in shock. One
thing that deut Or Chunnan and I both do is
we really emotionally invest our patients, maybe to a point
where it's a bit much, and sometimes we lean on
(14:34):
each other to pull us back. And so in that moment,
the exact person I needed to talk to was somebody
else who was present with that patient, was connected to
that person. You know, cancer is unfortunately still really unfair
in so many ways to such beautiful lives, and so
when things go really south, I know that I can
call her and have that life raft.
Speaker 2 (14:55):
I was going to next venture into the emotional component
of you do, But before I even get there, how
did your paths initially cross?
Speaker 4 (15:05):
I consider myself so lucky that Sarah and I happened
to start our jobs respectively at the University of Chicago
at the same month, literally, and as we got talking,
it was like our philosophies of how we care for
patients and how we practice medicine.
Speaker 3 (15:22):
Are really really similar.
Speaker 5 (15:24):
You know, there's a lot of times we call patients
together on the phone I've gotten really good at connecting
people in through phone calls, and patients really are blown
away when we're both on the phone. But I think
one of the hardest things about patient care is that
often they're retelling their story to every single person on
their team. And if we can sit there together and
I can hear how they're interacting with what doctor Chen
(15:44):
is telling them, you know, and she can hear about
my surgical take, it really helps a lot. It's kind
of forced us to melt together, and it's only making
it feel more seamless, I hope for our patients, and
it feels more seamless for me.
Speaker 4 (15:57):
We're starting to sound like each other. It's a little
creepy time I'm.
Speaker 5 (16:00):
Say things that she does when she's not in the room. Yeah,
because it's fun. Like when we see patients together. If
I'm just sitting and I have a few minutes, I'll
just barge right in and I'll sit on the you know,
on the bed, and I'll listen because I want to
know how she's explaining the same thing I'm trying to.
Speaker 2 (16:16):
That is such honestly an intelligent approach, though, because you
are saving time, but you were also protecting the patient
from having to go through their entire case history.
Speaker 5 (16:31):
Again, Yeah, I think that is a huge, huge advantage
because it's like a shared flock, right, Like, it really
has made it so that we're all getting the same
information and we're really making decisions as a team with
a patient in charge.
Speaker 2 (16:46):
We touched upon the emotional aspect of what you do
in terms of the heavy lifting of that personally, But
what would you say remains the most difficult aspect of
both of your work to navigate.
Speaker 4 (17:04):
I see advanced breast cancer, which is not curable, and
that means that despite for the vast majority of these women,
despite what I do with the best treatments available, they
are unfortunately going to pass from their disease. To be
perfectly honest, I am always very very scared of that happening,
because I know it will happen and it's just part
(17:25):
of my job. But it remains such a constant fear
that I'm going to have to emotionally deal with that
and have to kind of deal with what happens after,
which is that I have to think about, you know,
all the time we spent together and continue doing what
I do.
Speaker 5 (17:40):
On the other side, I think almost similarly, but I'm
even less helpless than doctor chen Is. When patients cross
over the line as being local, locally advanced to being metastatic.
My entire job is to basically sit it out. I
think that's really incredibly humbling. Has I then call on
(18:01):
my teammate, who I already burden with my emotional needs
and my you know, collaborative needs, and say, I've got
nothing as a surgeon to help this patient. Cancer has
this knack of being unexpectedly terrible when things are going okay.
Oh absolutely, you know, it has felt so often like
these humans you see, so full of life and so
(18:22):
full potential that's stolen by cancer. And I think that's motivating,
but it's it's a really hard thing to carry.
Speaker 3 (18:31):
You know.
Speaker 2 (18:31):
There's so much to process in terms of receiving a diagnosis.
How do you help patients navigate that emotionally but also
in terms of information overload?
Speaker 4 (18:43):
I think for that, Sarah and I have wonderful teams
of people that help us. And so, for example, if
someone needs to undergo chemo therapy, I have a wonderful
nurse who goes in there and spends another twenty minutes
just discussing the.
Speaker 3 (18:56):
Logistics of chemo therapy.
Speaker 4 (18:57):
I have a breast cancer pharmacist who goes in there
for twenty additional minutes and talks about these chemos.
Speaker 3 (19:03):
To the last detail.
Speaker 4 (19:04):
There are also some visits where you know, for example,
on a first visit, there's certain pieces of information I
want to impart, but sometimes I don't get to most
of them because we're just really upset and we're just
trying to process and this just isn't a good day
for me to talk about exactly what chemo you need.
And that happens, and if it does, then we'll see
you in two weeks and we'll.
Speaker 3 (19:22):
Kind of have that discussion again.
Speaker 5 (19:23):
I've also adopted that if I get a bunch of
messages about a person, I pick up the phone and
I just introduce.
Speaker 3 (19:29):
Myself on the phone to people.
Speaker 5 (19:31):
It's amazing how different the first visit goes when they
just know that I'm going to show up and that
I'm going to be a person too. And I feel
like in so much in healthcare now, when you try
to schedule a doctor's appointment, you talk to forty two people,
but you don't know what you're going to get, and
so often I just call them and I'm like, Hey,
I'm Sarah Shueck, I'm a breast cancer doctor.
Speaker 3 (19:51):
How are you.
Speaker 5 (19:52):
Being a humans really valuable for people? And so I
do it for myself too, because I want to know
who I'm walking into. I want to ask them who
they're going to bring with because then I know who's
important to them. One of the hardest things is covering
the stress of a cancer diagnosis, the next steps of it,
and still getting to know a person as a person
and being able to understand in that forty minute conversation
(20:14):
what matters most to them, what are they most afraid of,
and how do they feel about this, because usually that
forty minute sounds like doctor Trennon and I rattling off
medical facts to them. And I always tease that my
first favorite visit is the six month post surgery visit
because they usually are themselves and we've never met themselves,
you know, we've never met them like they would be
at the grocery store. They're scared, they're stress, they're families
(20:37):
on edge.
Speaker 4 (20:38):
And then it's so much fun to really get to
know them as we get them through their vivorship.
Speaker 3 (20:42):
That's so much fun.
Speaker 2 (20:43):
One hundred percent you mentioned having that support system present
for some patients who have that go to person with them.
Speaker 1 (20:53):
In what way.
Speaker 2 (20:55):
Does that help in terms of talking through risk assessment
with patients and how do you ensure that there is
actual clarity in these conversations.
Speaker 4 (21:07):
Having a support system is so so huge. Sarah and
I share a patient who when she was diagnosed, she
called on her gang of girlfriends, like a dozen of
these women, and literally every time she came there was
a different girlfriend that came with her that was like
diligently taking notes and asking us questions, and it was
just the most beautiful thing to see. But if a
(21:28):
patient comes alone, I specifically ask like, can we call someone,
because they're going to remember two percent of what I say.
Maybe if there's someone on the phone, they're going to
remember ten percent of what I say. But having support,
I think is just so crucial.
Speaker 5 (21:41):
And I think too, whatever that means to the person
is fine with us. Yes, you know, I've walked into
rooms where somebody has their neighbor, the ophthalmologists, their sister,
the nurse, and their spouse with them. Whoever is your
army who's going to help you make a decision is great,
But Ultimately, especially as a breast surgeon, what physically happens
to your body, right, the changes that are going to
(22:02):
happen to your breast, the way your breats are going
to look and feel afterward. The only opinion I care
about is the patience. But I want everybody else in
the room, you know, it's amazing. Sometimes I tell my
patients that I'm going to be the first one to
make their dad blush if he comes in, and I'm
fine with that. You know, I'm a breast surgeon. We
have to talk about what your body does. We have
to talk about how your body's going to change. We
have to talk about your feelings of whole self, your embodiment,
(22:24):
your sexuality.
Speaker 3 (22:25):
All that has to happen.
Speaker 5 (22:26):
So as long as you're comfortable with the people you
bring hearing all that, I'm comfortable too. It can be
your mailman, you're an uber driver, your whatever, just whoever's
going to show up for you in a time when
you need them. I also to always ask if they
are the person who usually is the one keeping it
together in their life, because if they're the matriarch, right,
if they're the pillar, this is not going to be
(22:48):
a season of life where they get to do that,
and so it's also a really nice opportunity to kind
of say to everyone in the room, Mom, sister neighbor
is not going to be the quarterback for a little while,
to be again because women are strong, but during that season,
somebody else has to take control.
Speaker 2 (23:06):
Going back to an earlier conversation, just in terms of
confusion and misconception, there remains a lot of confusion surrounding
genomic risk. Yeah, how would you break it down and
how does it ultimately influence the treatment decision, particularly for
early stage breast cancer.
Speaker 4 (23:26):
So I think that there are multiple genomic tests now
that are available. I think the most important thing when
we have a test is we need to use it appropriately, right,
because if we're not using it appropriately, then it's really
hard to interpret what those results are. But genomic testing,
especially in ER positive her too negative breast cancer, has
been so instrumental to helping us understand what are the
(23:47):
actual treatments that are going to benefit patients and that
they can spare patients toxic chemotherapy and other drugs. It's
also a great time to have a conversation with a
patient because they always want to know what are the
chances my cancer is going to come back. And I'm
never able to say that with like one hundred percent certainty,
but I can say like, oh, I have these tests
that can help me do a better job of estimating
that for you, so we can better tailor treatment.
Speaker 5 (24:10):
It's often something patients ask me as a surgeon about,
But I think what's so important about genomic testing is
it's not necessarily what's happening right where we're cutting it out.
There's this notion that like where it is where we're
cutting it out from is the only problem. But so
much of this testing and so much of the therapy
we give is for all of that possible confetti that's
trying to make its way elsewhere. So it's a hard
(24:32):
thing for me, and I'm as confused often as our
patients are about the newest genomic tests that we're doing,
the newest indication for it. And so that's where it's
incredibly critical for me as a surgeon to say to patients, Hey,
I get your surgery pathology back. I'm calling you first,
and I'm calling doctor Chen's second, because I want her
to decide if we need specialty testing, if we need
to do anything more so that she can set the
(24:53):
dial right for the medical therapy, just as we worked
hard beforehand to set the dial right for the surgical therapy.
Speaker 2 (25:00):
In terms of the different types of prognostic testing available,
how do they ultimately influence the treatment plan for breast
cancer patients?
Speaker 4 (25:11):
Generally speaking, if you have a higher risk cancer, we
want to do things to try to mitigate that risk,
and more often than not, that means more medical therapy
or stronger medical therapy. This is something that allows us
to say we think that you have a higher recurrence risk.
That means that we need to give you, you know, intensive chemotherapy,
or we can say, oh, you have a low recurrence risk.
Speaker 3 (25:31):
We can just give you let resolve for a few
years and we think you'll be fine.
Speaker 2 (25:35):
This might seem a little bit redundant, but how do
you go about identifying other risk factors for patients, such
as through bio marker.
Speaker 1 (25:44):
Tests, and how do they shape treatment plans.
Speaker 4 (25:48):
So there are genomic tests such as oncotype that are
run on pre treated surgical samples, whether it's at the
time of surgery if doctor Trubek goes first, or.
Speaker 3 (25:59):
On the biopsy sample.
Speaker 4 (26:00):
These tests can give us a recurrence score, and this
is a test that is both predictive and prognostic, predictive
to the benefit of chemotherapy and prognostic to their recurrence risk.
So these tests have been really helpful in the last
decade in helping us better tailor therapies to women and
helping us make sure that we are treating women appropriately
to match their cancer risk.
Speaker 2 (26:21):
When it comes to recurrence. There remains significant unmet need
in the treatment of stage two and three hormone receptive
positive early breast cancer. Despite best efforts and the range
of available treatment options, a concerning number of patients persistently
face the risk of both long term and short term recurrence.
According to a study published in the Journal of Clinical Oncology,
(26:44):
approximately one third of individuals diagnosed with stage two hormone
receptive positive her too negative breast cancer are at risk
of recurrence. The Mayo Clinic further states that women who
have had breast cancer are more likely to experience a
second occurrence. Regrettably, most recurrences progress to metastatic disease for
(27:04):
which there is currently no cure. It is essential for
patients to have access to treatments that allow them to
live their lives to the fullest. Adherence to therapy is
crucial in effectively reducing the risk of occurrence. However, considering
that many patients will need to undergo therapy for years,
their ability to tolerate the treatment becomes vitally important. After
(27:25):
the break, we'll resume our conversation with doctor Chen and
doctor Shuebeck, delving deeper into the harsh reality of breast
cancer recurrence and its unfortunate potential to evolve into metastatic
breast cancer.
Speaker 1 (27:38):
We'll be right.
Speaker 2 (27:38):
Back now back to our conversation with doctor Nanchen and
doctor Sarah Schuebeck.
Speaker 3 (27:58):
Now, you just.
Speaker 2 (27:59):
Mentioned recurrence, but if you could, doctor Scheeback, delve into
the reality of breast cancer recurrence and how unfortunately it
can transform into metastatic breast cancer.
Speaker 5 (28:15):
Sure, so, I think when we think about the first
journey through breast cancer, right when we close that first chapter.
My other favorite kind of analogy is to think of
these as choose your own adventure books. Right, so at
the end of each chapter we have to kind of
push the reset button. And after the initial phase of treatment,
whether that's surgery, medicines, and or radiation, we have to
start over and that means screening, being vigilant, listening to
(28:39):
our bodies, you know, routinely seeing patients taking whatever adjuvant
medical therapies are required for risk reduction and to kind
of have ongoing treatment for their breast cancer, but then
very importantly be vigilant when something changes. So a lot
of times recurrence events are basically found in breast imaging,
so patients get their next mammogram or another MRI, for example,
(29:00):
where they present with a palpable finding something they can
feel that's different along a scar line or something. When
it's that kind of local event, often your breast surgeons
back involved straight away. We do biopsies, we facilitate additional imaging,
and then very importantly, we often make sure it hasn't
gone elsewhere, because if patients have metastatic breast cancer, meaning
it's spread outside of the local area, then they're not
(29:20):
really a candidate for kind of curative intent therapy in
the traditional sense of surgery and medicines as a joint venture,
but rather we lean on medicines as their solution and
at least their treatment modality.
Speaker 4 (29:32):
Breast cancer is unique in that this is one of
the only cancers in which we do not do routine
body imaging after they complete their curative therapy, and so
a lot of us trying to surveil for recurrence is
dependent on the patient knowing their own body. When I
talk to patients, I give them incredibly vague instructions for
(29:53):
the kind of things to let us know about.
Speaker 3 (29:54):
I truly say, if you have.
Speaker 4 (29:55):
Any new symptom that lasts more than a few days
and you're not sure what it's caused by, me, let
me know.
Speaker 2 (30:01):
Circling back for a second, because you touched upon it,
but breaking down what it actually means. So hormone receptor positive,
human epidermal growth factor to negative.
Speaker 3 (30:13):
A mouthful, it is?
Speaker 1 (30:14):
It is.
Speaker 2 (30:15):
I can see why it's abbreviated, but you know it's
the most common subtype of breast cancer, accounting for over
two thirds of all cases. Can you break down what
it actually means and unmet needs in treating it?
Speaker 4 (30:28):
Early breast cancer cells, just like our normal cells, have
hundreds to thousands of flags on the outside. Estrogen receptor
and HER two are two examples of said flags. When
someone is ER positive her too negative. I think of
it as estrogen is one source of food or fuel
to help the cancer grow. The foundational way that we
treat these cancers is with the anti estrogen therapies. There
(30:51):
are a portion of patients that may be, for example,
are less dependent on estrogen signaling or of other high
risk features in which anti estrogen therapy alone is very
much not enough to prevent recurrence. There are newer drugs
now that previously we're used in the metastatic setting, but
are now being brought into early stage breast cancer, which
have shown successfully to be able to mitigate that risk
(31:12):
for certain groups of high risk patients.
Speaker 5 (31:14):
So it's tricky and surgery because a lot of the
role that I'm having to play is really in gathering
information about hormone receptor positive or too negative cancer in
the sense that we often do surgery as a bit
of a diagnostic test. Right for a lot of patients,
the surgery is really a fancier MRI. We go in,
we remove the tumor, we understand the size of it,
(31:34):
We check their lymph nodes. That tells us how big
it is and how extensive it is, and then that
information gets fed back in to make treatment decisions. And
so I think of surgery as really gathering more information
instead of being a definitive treatment, so that Dector Chen
can tailor therapies, especially in this hormone receptor positive group,
because that surgery information sometimes can change the game so substantially.
Speaker 4 (31:57):
And there are some types of breast cancer, such as
popular carcinomas, which are most commonly HR positive hurto negative,
where it can be really hard to tell in mammograms
and MRIs exactly how big things are, how much for
our things have spread, and it may only be at
the time of surgery that we truly discovered the extent
of disease and thus how risky the cancer actually is.
Speaker 2 (32:17):
We've talked about navigating the information overload that comes with
the diagnosis, and you know that educational hurdles that exist
for every single patient, But we haven't really touched upon
racial disparity gap.
Speaker 1 (32:32):
You know, in.
Speaker 2 (32:33):
Terms of Black women are forty percent more likely to
die from breast cancer than white women. How do you
wrestle with that statistic.
Speaker 4 (32:46):
One of the reasons that I came to the University
of Chicago is actually to take care of black women.
In all of my training, I have always taken care
of underserved populations. I find it incredibly gratifying. There are
so many facts about black women in breast cancer that
are uncomfortable.
Speaker 3 (33:05):
You are correct that they are more likely to die
of their disease.
Speaker 4 (33:08):
They are more likely to be diagnosed later, they are
more likely to have triple negative breast cancer, which is
the most aggressive subtype.
Speaker 3 (33:13):
They are more likely to have delays.
Speaker 4 (33:14):
In treatment once they get started, they are more likely
to not complete their treatment, and so there are many,
many factors, both biological as well as socioeconomic, that contribute
to that terrible statistic. Sarah and I think about this
every day to not even be hyperbolic about it because.
Speaker 3 (33:35):
Of the patients that we see. A few months ago.
Speaker 4 (33:38):
We had a couple really terrible outcomes, and Sarah Astuteley
was like, I feel like, we're just seeing what young
black breast cancer looks like. And that was just the
simplest way to kind of describe what was happening. It's
really really terrible, and I think that as a community
and as a cancer community, we really really should be
(34:01):
doing better.
Speaker 5 (34:02):
We also traditionally have not done a good enough job
of recruiting women of color to clinical trials, to providing
everyone with the same opportunities for intervention, genetic testing, different
surgical options, different reconstructive options, and so it's so many
things that we have not done well enough to serve
the whole breast cancer community. And like doctor Chen, I
(34:24):
think that really being able to take care of everyone
and look at them and say, hey, this data, this
brilliant science, this is exactly for you. We don't have
that right now for every patient. So some of our
trials are north of ninety five percent white women, and
then we're extrapolating to all people. That's something that we
(34:44):
really feel, especially at the University of Chicago, is a
priority for us to offer every single patient to be
on a cancer registry, every single patient to be in
a clinical trial. That's appropriate, and that's because we need
to get those numbers to be reflective of the population
we actually serve. Serving people who are different from me
for whatever reason, is the greatest joy of my life.
I didn't necessarily know that would be such a passion
(35:06):
or such an important part of my practice, but it
has been the greatest learning opportunity of working at the
University of Chicago on the South Side of Chicago. There
are patients who teach me every day about what they've
been told to fear about doctors, what they've been told
is not important enough to bring to your doctor. And
I think that if we can break down those barriers
and really empower people to look out for their own
health across everything, we'll get there.
Speaker 2 (35:27):
It's interesting because you would use the word unfair to
describe cancer, and that said, then it's compounded on what
makes the outcome even more unfair for some of your patients?
Speaker 5 (35:41):
Absolutely, and I think patients who have social challenges, right,
women who are the one keeping it together for their family,
the earner, the head of household, maybe somebody who's relying
on social resources to support their children or their family members,
and then we take.
Speaker 3 (35:55):
Her out of the fight. Man, that's really unfair.
Speaker 5 (35:58):
So we'll have young women clinic who are just starting
their careers, are just building their family, are just you know,
just really starting life, and they come in and they're
these incredible humans now with this really terrible problem. That's
when we call each other and we talk about exactly
how unfair this business feels. You know, Like I have
these really incredible women come to my clinic and I'm
(36:20):
just sitting there, like I just want to hang out
with this person. I want to be best friends with
this person. I just want to learn from her. I
want to see what she's going to do in thirty
years with her passions.
Speaker 3 (36:29):
Well, that's here we are.
Speaker 2 (36:30):
That's the other side of the same coin, because today
breast cancer survival rates are much higher.
Speaker 3 (36:37):
Absolutely, how do you factor.
Speaker 2 (36:40):
Planning for life after cancer into the treatment journey?
Speaker 4 (36:45):
I think it is so hard for patients to even
visualize the after cancer when they're in the thick of it,
because it just feels so rotten to be going through treatment,
to be thinking about surgery, to be planning for post
surgical recovery periods. Really, like what Sarah said earlier about
kind of six months afterwards, you really get to see
them come out. It is the favorite part of my
(37:07):
job to see them getting back into their thing. I
have patients who previously golfed and now like during treatment
that you did in golf, And I saw her a
few weeks ago, She's like, Yeah, I kind of went
out a couple of weeks ago, and I was like,
this is amazing.
Speaker 3 (37:19):
This is exactly what I'm hoping for.
Speaker 4 (37:22):
Our hope for everyone is that this is a speed bump,
like it's a big speed bump, and it's a horrible
speed bump, but that it is a speed bump, and
when we get through the other side, you are as
close to the person that you were before as you
can be, recognizing that you've now gone through this transformative,
life changing experience.
Speaker 5 (37:37):
In the middle, I'm in a shamelessly stale phrase from
one of my patients who told me that she's decided
her breast cancer is a rude bump in the road.
It's not going to derail her, it's not going to
change her course. But it's a rude bump in the road.
And I've ever since she told me that, and I
hope someday she hears us to know how wise I
think she is. I tell patients that because often patients
will say to me, I don't care what happens to
(37:58):
my body. I just want to live. And then to that,
I say, hold on, I care what happens to your body,
because in six months you're going to be really mad
at me when you start to be a person again,
your whole self. If you have an ugly scar, if
the first thing you think of when you walk out
of the shower is your breast cancer, if your sexuality
is impacted by what we put you through. I have
(38:18):
to think and hold space for you to be a
person again after breast cancer, and whether that's preserving your
fertility so that you could have a pregnancy in a
few years, if that's putting your breasts back together in
a way that you've always wanted, giving you a breast reduction,
doing all those things that seem really trivial when you're
facing cancer but are really vitally important when you're facing
life again. And that transition for some people is really rocky,
(38:41):
but for others is really natural.
Speaker 2 (38:45):
When you are in a situation where someone isn't handling
it well, how do you integrate the psychological impact of treatment.
Speaker 4 (38:56):
I tell every single one of my patients that this
is an extraordinary experience and that I personally feel that
everyone should be getting psychological support because this is just
so incredibly hard. Sometimes I feel like the best thing
I can do for a patient during a clinical visit
(39:17):
is just hear them out, hear what they're going through,
and just commiserate and validate that, like, Yeah, this sucks.
The emotional component of this, I think is just as
relevant as the physical part.
Speaker 3 (39:27):
It's just so overwhelming.
Speaker 5 (39:29):
I think also patients have perceived support from their family
in a lot of ways, but their family their friends
are also going through something. The biggest kind of disconnect
I see in my practice is when your family and
friends have decided the fight is over right, treven is done.
That's a really lonely time for a survivor, and so
I think people kind of unexpectedly fall off their cliff
(39:52):
at very different times. Some people it's right away, they
can say that they need support, and we are like, yes,
we have mental health resources available for you. The harder
thing is figuring out somebody who's maybe in survivorship or
maybe just finished therapy, and that their struggle is actually
becoming a person again, as opposed to a patient with cancer.
And so the notion that support is really only during
(40:13):
that active journey, I think is a really misguided one,
and that we have to make sure patients understand that
survivorship also is loaded, because it's really full of trauma
and history and physical scars and obviously psychological ones too.
Speaker 1 (40:26):
And it is such a loaded.
Speaker 2 (40:31):
Breasts in general, really what they represent to women, what
they represent to society, so many things, but also to
base one's femininity.
Speaker 5 (40:41):
Our gender expression, our sexuality, our embodiment, everything.
Speaker 4 (40:45):
Our maternal it's such a personal part of our body.
Speaker 5 (40:48):
I often tease that it's amazing that everybody's going to
have an opinion about your breasts, but we're not actually
supposed to talk about them any other time. Right, your
neighbor will tell you to have a bilateral mistake to me,
But man, have you ever talked to your name or
about your breast before? Right, It's meant to be private,
you know. It's a space where we judge one another
about you know, augmentation or how much we're exposing or
you know. And I think it's really funny how then
(41:10):
during a cancer journey, women are supposed to surrender that
notion of modesty and allow us to kind of strip
them of their femininity and in the name of heroism.
Speaker 4 (41:19):
But also all the other things surrounding breast cancer care,
meaning fertility. We have so many fertility conversations, talking about
vaginal health.
Speaker 3 (41:27):
It's just a lot of personal things.
Speaker 2 (41:30):
How do you navigate that fertility conversation, particularly with young patients.
Speaker 4 (41:39):
One of the things I hate the most about this
conversation is that, on top of all the cancer stuff,
you now have to think about this that you shouldn't
have had to make a decision about this for years,
And now you're sitting here in my page box clinic,
and I'm asking you these horrible questions and you have
to sit here and figure out way too early whether
or not you want to have kids, and whether how
(42:00):
much you want to have kids is how that's going
to impact your breast cancer care.
Speaker 3 (42:03):
And that's terrible.
Speaker 5 (42:04):
I agree with doctor Tennant. It's breast cancer so often
robs people of their potential that they haven't even decided yet.
Speaker 6 (42:12):
You know.
Speaker 5 (42:12):
Often we'll see twenty five year old women and we're like, so,
you know, on top of all this trauma.
Speaker 3 (42:16):
Have you thought about having kids? And tell me now?
Speaker 5 (42:18):
Yeah, and tell me now in front of these seven
people you've brought with you.
Speaker 1 (42:22):
Somebody who may or may not be in a relation.
Speaker 5 (42:24):
Sure, yeah, correct, right, And I think, and it's so
amazing to think about how, you know, we put people
through this intense stress test of making all those decisions
in quick succession because they feel that they're delaying their
chemote therapy if they choose fertility, So then it.
Speaker 3 (42:37):
Feels selfish, but it's actually essential.
Speaker 5 (42:40):
You know, I always kind of think of it as like,
we have to do the one on one level course first, right,
we have to do breast cancer one on one, and
then the graduate level course is all of this other stuff,
and we have to build capacity in the patient to
go to the next phase. So we have to have
a shared foundational understanding of what she's up against, of
what decisions she has to make, and then on top
of that, we put all of those things afterward that
(43:02):
will make her whole again after cancer.
Speaker 2 (43:05):
But at the same time, you guys are constantly reevaluating
your role in the journey of treatment. You know, we've
spoken about current patients journey and how it varies and
differs in how your help in supporting them throughout that
has to vary along with it.
Speaker 1 (43:27):
But taking a step back for a.
Speaker 2 (43:28):
Moment in terms of doing what you do right now
in this moment in time, what is the best thing
in terms of the advancements that you've seen.
Speaker 3 (43:41):
I think that we've come so far.
Speaker 5 (43:43):
So I alluded to some family history earlier, and I
have my grandmother's medical records from her breast cancer journey.
Speaker 3 (43:50):
It's wild to read what this woman went through.
Speaker 5 (43:53):
I look forward a generation, and I saw what my
own mother went through, and nowadays, she would have benefit
from these genomic advances, she would have benefited from surgical
de escalation, She wouldn't have had to go through a
lot of what she had to go through. My mom
will say to me, do you do this because of
what I went through? And I, you know, some of
it is, yes, and she's going to listen to this
and get mad at me, But some of it is
(44:15):
because I get to do better. I get to let
people live more often. And while you know, we perseverate
on the people who haven't done well because it takes
a piece of our heart with them. So many of
our patients are living full lives after this, And so
I think, how lucky are we that I, with all
my breast cancer risk, that I'm up against my sisters,
all the women I love in my family. I believe
(44:37):
in my heart we're going to be okay. And I
don't mean to make light of the devastating journeys that
some people are facing, But in twenty twenty four, most
of the time I can say, with a straight face
and with honest intention that you're probably going to be okay,
And we get to think.
Speaker 3 (44:52):
About life after this. That rude bump in the road
is going to go away.
Speaker 5 (44:57):
That's a purely surgical perspective, because I don't take care
of patients in the metasthetic setting, which that is the
weight of a medical and collegist journey. And I sit
in awe of how doctritenn does that with such grace?
But I think most of the patients who sit in
front of me are going to be okay. And what
a gift is that from medical innovations, from screening innovation,
from empowerment of people, right from saying that it's good
(45:19):
to speak up about your health. And so I think
that's my take on the landscape is like, how amazing
is it that?
Speaker 3 (45:24):
How far have we come?
Speaker 5 (45:25):
All we can do is continue to amplify that messaging
to say that the vast majority of people are going
to be okay, So so come forward and let.
Speaker 3 (45:32):
Us help you.
Speaker 4 (45:34):
I started my oncology fellowship in twenty eighteen. There have
probably been at least a dozen if not more, drug
approvals and breast cancer since then. Wow, it is so
much fun to be in this field and see how
(45:55):
things are moving ahead. I tell patients, I hope by
the time I retire, chemo is obsolete, that we have
better targeted therapies to be doing this. I hope to
be doing so much better in forty years, and I
very very much share your optimism that I think we
can do it.
Speaker 1 (46:09):
All right now. In terms of that.
Speaker 2 (46:11):
In terms of the future, what developments and advancements do
you guys see on the horizon for breast cancer treatment
and how are new medicines and therapeutics shaping the future
of patient care.
Speaker 4 (46:27):
There is so much coming down the pipeline. There are
new antibody drug conjug It's coming down the line, both
with different antibodies as well as with different payloads. We
are trying to better understand how immunotherapy fits into breast
cancer and whether it can work in more patients than
it currently works in. We are currently developing many novel
(46:49):
endegrine therapies to disrupt the estrogen receptor in ways that
just weren't really thinkable a decade ago. There is so
much happening in breast cancer. There's a lot of information
being presented literally in two hours at this conference to
really showcase all that we've done in the last year
and kind of where we're going from here.
Speaker 5 (47:09):
From a surgery perspective, I see a world with much
less breast cancer surgery because the medicines are getting better,
and I think that that is such a great thing.
So I would love a world without breast cancer surgery
because people are doing too well or we've learned who
it's essential and who it isn't. Breast surgery is really
the backup move nowadays, and I think that that's really
(47:30):
exciting because we're doing it better. Cancer is not a
local problem. Cancer is a whole body problem, and so
if the medicines can do the heavy lift, it's going
to be better for everybody.
Speaker 3 (47:40):
I'm really excited.
Speaker 5 (47:41):
I'm optimistic, and I think that optimism is what carries
us into each room, so we can tell people with
a straight face, this is what we're up against. These
are the tools we have. We're going to throw everything
we have at this and keep you whole.
Speaker 1 (47:54):
Excellent answer, both of you.
Speaker 2 (47:56):
And lastly, if there is one one thing that you
hope people listening take away from this conversation, what would
it be and why?
Speaker 5 (48:08):
The most important thing in breast cancer is early detection.
So I'm going to be pretty expected and say that
take care of yourself, get your mammogram, take somebody with
you to get your mammogram, Go to your primary care
physician or provider and get a breast exam.
Speaker 3 (48:23):
Pay attention to your body.
Speaker 5 (48:25):
And I think, don't be so scared of this possibility
that you're not empowered enough to figure it out.
Speaker 3 (48:31):
And so that really for me is just take care
of yourself.
Speaker 4 (48:35):
I'm going to say on the flip side that providers
really need to listen to women.
Speaker 3 (48:39):
Women know their bodies really well.
Speaker 4 (48:41):
If someone is telling you that something not right, then
we should figure out why that is. That's really important
for the breast cancer journey.
Speaker 2 (48:49):
Doctor Chen, doctor Schuebeck, thank you so much for joining
me today and thank you so much for this conversation.
Speaker 3 (48:55):
Thank you, thanks.
Speaker 2 (49:00):
Thanks for listening to this bonus episode of Symptomatic. Be
on the lookout in the coming weeks for another special
episode from the twenty twenty four as CO annual meeting.
We'll be speaking with doctor Muhammad a Tique about the
patient struggle against prostate cancer and the current state of treatment.
Speaker 6 (49:17):
What we're having to learn and discover in the current
field is the sequencing of these treatments. Which one should
go first right, we know based on some data, you know, Okay, well, yeah,
and we might start with X treatment and go to
the next one. But then there's just kind of a
mix of options which can all be appropriate, Which one
(49:37):
is the best to continue and LinkedIn the survival is
kind of a big poin discussion.
Speaker 2 (49:42):
And we'll be back next week with another all new
episode of Symptomatic. Until then, we would love to hear
from you. Send us your thoughts on this episode, or
you can share a medical mystery of your own at
Symptomatic at iHeartMedia dot com. And please feel free to
rate and review Symptomatic wherever you get your podcasts.
Speaker 1 (50:01):
We'll see you next time. Until then, be well,
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