Breast Cancer in Young Women: Optimizing Knowledge and Care to Improve Outcomes

Transcript

00:00 --> 00:01Funding for Yale Cancer Answers
00:01 --> 00:03is provided by Smilow Cancer
00:03 --> 00:04Hospital.
00:05 --> 00:07Welcome to Yale Cancer Answers
00:07 --> 00:08with the director of the
00:08 --> 00:10Yale Cancer Center, doctor Eric
00:10 --> 00:11Winer.
00:11 --> 00:13Yale Cancer Answers features conversations
00:14 --> 00:14with oncologists
00:15 --> 00:16and specialists who are
00:16 --> 00:17on the forefront of the
00:17 --> 00:18battle to fight cancer.
00:18 --> 00:20This week, it's a conversation
00:20 --> 00:21about breast cancer in young
00:21 --> 00:23women with doctor Ann Partridge.
00:23 --> 00:25Doctor Partridge is a professor
00:25 --> 00:27of medicine at Harvard Medical
00:27 --> 00:27School.
00:27 --> 00:29Here's doctor Winer.
00:30 --> 00:32So we're gonna talk about
00:32 --> 00:33breast cancer tonight.
00:34 --> 00:35We're gonna talk about breast
00:35 --> 00:36cancer specifically in
00:37 --> 00:38young women,
00:39 --> 00:40and we may stray off
00:40 --> 00:42into some other areas as
00:42 --> 00:43well, but that's gonna be
00:43 --> 00:45the main topic. But before
00:45 --> 00:46we get there,
00:47 --> 00:47Ann, if you could just
00:47 --> 00:48tell us a little bit
00:48 --> 00:50about how it is you
00:50 --> 00:51became a doctor
00:51 --> 00:53and how you wound up
00:53 --> 00:55doing oncology and breast cancer.
00:55 --> 00:57My mission to become a
00:57 --> 00:59doctor started when I was
00:59 --> 00:59literally
01:00 --> 01:02in, I think, maybe preschool
01:02 --> 01:04and then germinated
01:04 --> 01:05further in
01:05 --> 01:08elementary school and beyond. I
01:08 --> 01:09grew up in a family,
01:09 --> 01:11where my father was the
01:11 --> 01:13primary parent and he was
01:13 --> 01:14a surgeon.
01:14 --> 01:15And he took my siblings
01:15 --> 01:16and I on rounds with
01:16 --> 01:17him not infrequently,
01:18 --> 01:20when this was still allowed.
01:20 --> 01:20And we spent a lot
01:20 --> 01:21of time in the nursing
01:21 --> 01:23stations and eating all the
01:23 --> 01:24snacks, but we were also
01:24 --> 01:26very, very engaged
01:26 --> 01:27by the work he was
01:27 --> 01:29doing and the meaning of
01:29 --> 01:30that work for the people
01:30 --> 01:32he was caring for and
01:32 --> 01:33to him.
01:33 --> 01:34And that was,
01:34 --> 01:36you know, needless to say,
01:36 --> 01:37life altering in many, many
01:37 --> 01:39ways for me as a
01:39 --> 01:40a young impressionable
01:40 --> 01:41kid. And as I became
01:41 --> 01:42an adult,
01:43 --> 01:44I realized that I too
01:44 --> 01:46wanted to follow that pathway
01:46 --> 01:47into medicine.
01:47 --> 01:48And did you occasionally
01:48 --> 01:50get dragged into rooms with
01:50 --> 01:50patients,
01:51 --> 01:53standing next to your father?
01:53 --> 01:54Oh, yeah. All the time.
01:55 --> 01:55All the time. And my
01:55 --> 01:57father, he not
01:57 --> 01:58only dragged you
01:58 --> 02:00into rooms with patients, but
02:00 --> 02:01we could be out in
02:01 --> 02:02the store. And my father
02:02 --> 02:03who was a general surgeon,
02:03 --> 02:06he's retired now, would find
02:06 --> 02:08a spot on somebody's neck
02:08 --> 02:09in the line next to
02:09 --> 02:10him and say, you really
02:10 --> 02:12should get that checked out.
02:12 --> 02:13So it was also real
02:13 --> 02:15world medicine too, and he
02:15 --> 02:16was often right. There was
02:16 --> 02:17something not good going on.
02:17 --> 02:18So we kind of lived
02:18 --> 02:19it because he was also,
02:19 --> 02:20you know, helping to take
02:20 --> 02:21care of the neighbors and
02:21 --> 02:22the neighbors' kids and things
02:22 --> 02:23like that.
02:23 --> 02:24So we lived
02:24 --> 02:26it as kids.
02:26 --> 02:27And as I
02:27 --> 02:29moved into making my
02:29 --> 02:29own decisions,
02:30 --> 02:32with that impression, what led
02:32 --> 02:33me to oncology was
02:34 --> 02:36both the science and the
02:36 --> 02:37exciting
02:37 --> 02:38things that were taking off
02:38 --> 02:40in terms of understanding
02:40 --> 02:42of why cancers form and
02:42 --> 02:43how we could better
02:44 --> 02:45manage and get rid of
02:45 --> 02:46them for patients,
02:46 --> 02:48as well as the people
02:48 --> 02:49who were doing oncology.
02:50 --> 02:51And finally, the
02:51 --> 02:53experience with patients
02:53 --> 02:55over time, helping them to
02:55 --> 02:56deal with a very, very
02:56 --> 02:58serious illness at times and
02:58 --> 02:59to manage that and the
02:59 --> 03:00privilege of kind of being
03:00 --> 03:01a part of their journey
03:01 --> 03:03and helping to navigate them
03:03 --> 03:03through that.
03:04 --> 03:05Wow. Well,
03:07 --> 03:08you've certainly had a great
03:08 --> 03:09career,
03:10 --> 03:11so far, not that it's
03:11 --> 03:13close to being over,
03:14 --> 03:15in oncology and specifically in
03:15 --> 03:16breast cancer.
03:17 --> 03:19So let's talk about young
03:19 --> 03:21women with breast cancer. And
03:21 --> 03:22first, maybe you could tell us
03:23 --> 03:24how common a problem is
03:24 --> 03:25this. If we take
03:26 --> 03:28women under the age of
03:28 --> 03:30forty five or fifty, how
03:30 --> 03:32often is breast cancer diagnosed?
03:33 --> 03:34So it's not a common
03:34 --> 03:36problem. We don't want anybody
03:36 --> 03:36leaving this
03:39 --> 03:41podcast and thinking that this
03:41 --> 03:41is somehow an epidemic
03:44 --> 03:46of breast cancer in young
03:46 --> 03:46adults.
03:47 --> 03:48But yet it is the
03:48 --> 03:49most common
03:49 --> 03:50cancer diagnosed
03:51 --> 03:51in people
03:52 --> 03:54who are between twenty and
03:54 --> 03:55forty five, kind of
03:57 --> 03:57the conventional
03:58 --> 03:59adolescent young adult
03:59 --> 04:00age groups,
04:01 --> 04:02and is certainly the most
04:02 --> 04:03common in women
04:04 --> 04:06in terms of young adults.
04:06 --> 04:08And so it occurs in
04:08 --> 04:09about depending on where you
04:09 --> 04:10put the age cutoff, somewhere
04:10 --> 04:12between ten to sixteen thousand
04:12 --> 04:13patients a year
04:14 --> 04:16annually in the US alone,
04:16 --> 04:17and, of course, many thousands
04:17 --> 04:18more women worldwide.
04:19 --> 04:20And would that ten thousand
04:20 --> 04:22figure be women under the
04:22 --> 04:23age of forty?
04:23 --> 04:25Yeah. Ten thousand is about,
04:25 --> 04:26the numbers for under the
04:26 --> 04:27age of forty. And one
04:27 --> 04:29of the latest things is
04:29 --> 04:30that those numbers appear
04:30 --> 04:31to be going up, not
04:31 --> 04:33just the absolute number because
04:33 --> 04:35our population is growing in
04:35 --> 04:36the United States, but the
04:36 --> 04:37frequency
04:37 --> 04:38with which a person
04:39 --> 04:40is diagnosed.
04:40 --> 04:42The likelihood of being diagnosed
04:42 --> 04:43is actually going up in
04:43 --> 04:44the young adults.
04:45 --> 04:46So trying to figure that
04:46 --> 04:47out is really important because
04:47 --> 04:48we obviously don't want that
04:48 --> 04:50to happen more. And that's
04:50 --> 04:51a change because for years
04:51 --> 04:53and years, patients would say
04:53 --> 04:54to us, there seems to
04:54 --> 04:55be more breast cancer in
04:55 --> 04:56young women.
04:56 --> 04:58And we would typically say,
04:58 --> 05:00no. It's not changing that
05:00 --> 05:00much. But it's been the
05:00 --> 05:02past several years that that
05:02 --> 05:02trend
05:03 --> 05:04has seemed to emerge.
05:05 --> 05:06That's exactly right. The latest
05:06 --> 05:08data suggests
05:08 --> 05:09the prevalence is growing,
05:10 --> 05:12per, you know, the population.
05:12 --> 05:14But, originally, when we first
05:14 --> 05:15looked into this, as you
05:15 --> 05:15and I know and as
05:15 --> 05:16you alluded to, we've been
05:16 --> 05:18looking at this for two
05:18 --> 05:19and a half decades.
05:20 --> 05:21When we first started looking
05:21 --> 05:22into it, it appeared that
05:22 --> 05:23it was just the absolute
05:23 --> 05:25numbers and that the population
05:25 --> 05:26itself was growing, but that
05:26 --> 05:28the frequency within the population
05:28 --> 05:30wasn't growing or the prevalence.
05:30 --> 05:31But now it does appear
05:31 --> 05:33that it is
05:33 --> 05:34growing even within the population,
05:35 --> 05:36you know, per hundred thousand
05:36 --> 05:37people.
05:40 --> 05:42So, breast cancer in young women
05:42 --> 05:44is in some ways the
05:44 --> 05:45same and in some ways
05:45 --> 05:47quite different than breast cancer
05:47 --> 05:48in older women.
05:48 --> 05:49And maybe we could start
05:49 --> 05:50off talking about some of
05:50 --> 05:53the unique challenges that a
05:53 --> 05:54young woman faces. And let's
05:55 --> 05:56sort of think about
05:57 --> 05:59the age cutoff is
05:59 --> 06:00somewhere in the mid forties.
06:01 --> 06:03Yeah. So, you know, the
06:03 --> 06:04way I think about it is
06:05 --> 06:07that many things are the
06:07 --> 06:08same, and
06:08 --> 06:10young women, just like old
06:10 --> 06:10women,
06:11 --> 06:12care about both
06:13 --> 06:14how they feel and what
06:14 --> 06:15they look like and whether
06:15 --> 06:16they have good sex or
06:16 --> 06:18not and things like that.
06:18 --> 06:20But many things are accentuated
06:21 --> 06:22by being young,
06:22 --> 06:23and that includes
06:24 --> 06:26things like where
06:26 --> 06:27they are in their lives,
06:27 --> 06:28their role functioning as a
06:28 --> 06:30young woman
06:30 --> 06:31is way more likely to
06:31 --> 06:32be starting a family,
06:33 --> 06:35starting a new job, trying
06:35 --> 06:36to finish education,
06:37 --> 06:38in a newer
06:38 --> 06:39relationship
06:39 --> 06:41and trying to work through
06:41 --> 06:42those kinds of things compared
06:42 --> 06:44to an older woman. She's
06:44 --> 06:45also more likely
06:45 --> 06:46to have a
06:46 --> 06:48little less resilience.
06:48 --> 06:49She hasn't seen
06:49 --> 06:51this
06:51 --> 06:52in her friends before, most
06:52 --> 06:53likely.
06:53 --> 06:55She probably cares a little
06:55 --> 06:56bit more than some older
06:56 --> 06:57women about
06:57 --> 06:59her physical health in terms
06:59 --> 07:01of her sexual health and
07:01 --> 07:02her body image.
07:02 --> 07:04Not that older women don't
07:04 --> 07:05care.
07:05 --> 07:07It's really just a kind
07:07 --> 07:09of highlighting
07:09 --> 07:10it more, feeling it more
07:10 --> 07:12as a younger woman on
07:12 --> 07:13average. Not all women,
07:13 --> 07:15of course. And then there
07:15 --> 07:16are things that are unique
07:16 --> 07:17to being young,
07:18 --> 07:19or way more common when
07:19 --> 07:20you're young, like, you know,
07:20 --> 07:21fertility.
07:21 --> 07:22A young person, if you
07:22 --> 07:24cut it off at forty,
07:24 --> 07:25your average forty five year
07:25 --> 07:26old, if they're gonna have
07:26 --> 07:27kids, is done with having
07:27 --> 07:29kids, whereas your average thirty,
07:29 --> 07:30thirty five year old, probably is
07:30 --> 07:32not. The importance there
07:32 --> 07:34is that if someone gets
07:34 --> 07:34chemotherapy,
07:35 --> 07:36they're at risk
07:37 --> 07:37to potentially
07:38 --> 07:39lose that fertility.
07:39 --> 07:41Exactly. The treatments kind of
07:41 --> 07:43impact fertility directly. And then
07:43 --> 07:44the majority of young women
07:44 --> 07:46will have hormone sensitive breast
07:46 --> 07:48cancer, breast cancer that expresses
07:48 --> 07:50estrogen or progesterone receptor.
07:50 --> 07:51And as you know, we
07:51 --> 07:52use
07:52 --> 07:54that to treat them, and
07:54 --> 07:55we use antiestrogens
07:55 --> 07:57or lower their estrogen
07:57 --> 07:58to try and treat them
07:58 --> 07:59to help make their breast
07:59 --> 08:00cancer not come back or
08:00 --> 08:01keep it under control. And
08:01 --> 08:03during that time,
08:04 --> 08:05you should not get
08:05 --> 08:07pregnant because those treatments can
08:07 --> 08:08cause birth defects and or
08:08 --> 08:10you can't become pregnant because
08:10 --> 08:11your ovaries are suppressed.
08:12 --> 08:13And so there's a time
08:13 --> 08:14issue there where the ovaries
08:14 --> 08:15are aging, and that's a
08:15 --> 08:16hard one for our young
08:16 --> 08:17patients who haven't completed their
08:17 --> 08:19families or even started them.
08:19 --> 08:22And oftentimes, those hormonal treatments
08:22 --> 08:23are particularly difficult for younger
08:23 --> 08:24women.
08:24 --> 08:26Very much so. You know,
08:26 --> 08:27again, not to say that
08:27 --> 08:28these treatments are a cakewalk
08:29 --> 08:30for our older women, but
08:30 --> 08:32for our younger women who,
08:32 --> 08:34you know, they're not
08:34 --> 08:36starting to have hot flashes.
08:36 --> 08:37They,
08:38 --> 08:39are often kind
08:39 --> 08:41of not even close to
08:41 --> 08:43menopause by their age
08:43 --> 08:44or their physiology.
08:44 --> 08:46And then when we give
08:46 --> 08:47them things that lower their
08:47 --> 08:49estrogen or block it completely,
08:50 --> 08:51they can become very, very
08:51 --> 08:52symptomatic,
08:53 --> 08:54and often also are
08:54 --> 08:56not as equipped because, again,
08:56 --> 08:57their friends aren't dealing with
08:57 --> 08:59this. Their friends instead are
08:59 --> 09:00having babies or going to
09:00 --> 09:01a club or, you know,
09:01 --> 09:03finishing school. They don't have
09:03 --> 09:04all the help to support
09:04 --> 09:06them on managing of the
09:06 --> 09:08various symptoms that are typical
09:08 --> 09:09for women who are in
09:09 --> 09:10middle age.
09:11 --> 09:12And there's some
09:12 --> 09:14popular folklore out there
09:14 --> 09:16that somehow breast cancer in
09:16 --> 09:17young women is
09:18 --> 09:20much worse and that young
09:20 --> 09:22women are far more likely
09:23 --> 09:24to lose their lives from
09:24 --> 09:26breast cancer than older women.
09:26 --> 09:27Can you comment on that
09:27 --> 09:29and to what extent
09:29 --> 09:30that is true or not true?
09:33 --> 09:35From a disease standpoint
09:35 --> 09:37and a psychosocial standpoint, an
09:37 --> 09:38emotional standpoint, if you look
09:38 --> 09:40at a big picture,
09:40 --> 09:42that folklore is actually true.
09:42 --> 09:44On average, if you're diagnosed
09:44 --> 09:45with breast cancer,
09:45 --> 09:46you are
09:47 --> 09:47less likely
09:48 --> 09:50than an older woman to
09:52 --> 09:53make it through and not
09:53 --> 09:54die of breast cancer. Meaning
09:54 --> 09:55you're more likely to die
09:55 --> 09:57of breast cancer on average.
09:57 --> 09:59And you are also more
09:59 --> 10:01likely to suffer emotionally in
10:01 --> 10:03follow-up, including long term follow-up.
10:03 --> 10:04That's part of the reason
10:04 --> 10:05I started focusing on this
10:05 --> 10:06because I said, how can
10:06 --> 10:08we fix that disparity? Young
10:08 --> 10:10women are a more disparate
10:10 --> 10:12group from a medical and
10:12 --> 10:13an emotional standpoint.
10:14 --> 10:15But that's the big picture.
10:16 --> 10:17The important
10:17 --> 10:19message inside that big picture is
10:20 --> 10:22most young women will be
10:22 --> 10:23long term survivors and will
10:23 --> 10:25not only survive, but hopefully
10:25 --> 10:27thrive through their breast cancer.
10:27 --> 10:29And that's getting better and
10:29 --> 10:30better with our medical advancements.
10:31 --> 10:32And then
10:32 --> 10:34young women don't develop just
10:34 --> 10:36one breast cancer just like
10:36 --> 10:37older women don't develop like
10:37 --> 10:39some, you know, monolith of
10:39 --> 10:41the same exact breast cancer.
10:41 --> 10:42There's a spectrum.
10:43 --> 10:44And young women are more
10:44 --> 10:45likely to be diagnosed
10:45 --> 10:47with more aggressive breast cancer,
10:48 --> 10:49but they can also be
10:49 --> 10:51diagnosed with not so aggressive
10:51 --> 10:51breast cancers.
10:52 --> 10:54And that don't warrant, you
10:54 --> 10:56know, major aggressive therapies
10:56 --> 10:57as in, you know, chemotherapy
10:58 --> 11:00or mega treatments.
11:00 --> 11:01And so
11:02 --> 11:03just like with older women,
11:03 --> 11:04but perhaps even more so
11:04 --> 11:06with younger women where everybody's
11:06 --> 11:08worried and wants to, you
11:08 --> 11:09know, make sure they get
11:09 --> 11:10rid of the cancer, they
11:10 --> 11:11have to be careful
11:11 --> 11:13that they're tailor the treatment.
11:13 --> 11:14We have to be careful
11:14 --> 11:15to tailor the treatment to
11:15 --> 11:16the disease
11:16 --> 11:18in the context of the
11:18 --> 11:19human being who's, you know,
11:19 --> 11:21unfortunately been diagnosed with it.
11:21 --> 11:23So it's a nuanced answer
11:23 --> 11:24that is yes on average,
11:25 --> 11:27but the message is most
11:27 --> 11:28women will be okay,
11:28 --> 11:30and we have to be
11:30 --> 11:31careful not to overtreat
11:31 --> 11:33our young women because we're
11:33 --> 11:34worried about them.
11:34 --> 11:36And that yes on average
11:36 --> 11:38applies mostly to women under
11:38 --> 11:39the age of forty,
11:39 --> 11:41maybe less so in women
11:41 --> 11:42who are in their
11:42 --> 11:44fifth decade or between
11:45 --> 11:47forty and forty nine.
11:47 --> 11:48And, absolutely, young age is
11:48 --> 11:50a moving moving target for as you know.
11:55 --> 11:56When I'm
11:56 --> 11:58thinking about the age disparity,
11:58 --> 12:00it really is the under
12:00 --> 12:01forty and particularly the under
12:01 --> 12:03thirty five on average when
12:03 --> 12:04we've looked at this on
12:04 --> 12:06a population basis. Actually, women
12:06 --> 12:08in their forties, which is
12:08 --> 12:09still young, but not our
12:09 --> 12:10conventional
12:10 --> 12:12very young, women in their
12:12 --> 12:13forties actually do the best
12:13 --> 12:15in terms of their overall
12:16 --> 12:16survival.
12:17 --> 12:18They do have issues, and
12:18 --> 12:19it depends on where they
12:19 --> 12:21are in their lives with
12:21 --> 12:22regard to the emotional things.
12:22 --> 12:23And, of course, some of
12:23 --> 12:25them still wanna have babies
12:25 --> 12:26and are, you know, younger
12:26 --> 12:28in terms of their goals
12:28 --> 12:29in life. And so that's
12:29 --> 12:30why we think about them
12:30 --> 12:31when we think about supporting
12:31 --> 12:32them more,
12:33 --> 12:34and tend to target women
12:34 --> 12:36into their mid forties to
12:36 --> 12:37allow them to define their
12:37 --> 12:38own young.
12:40 --> 12:42And this idea of age being
12:42 --> 12:43a moving target,
12:44 --> 12:46at the risk of
12:46 --> 12:47teasing you a bit, I
12:47 --> 12:50do remember when the program
12:50 --> 12:51that you started at Dana
12:51 --> 12:53Farber focused on breast cancer
12:53 --> 12:55in young women when initially
12:55 --> 12:57the age cutoff was forty-two, and
13:00 --> 13:02as you advanced in age, that
13:02 --> 13:03cutoff went up
13:03 --> 13:04a few years.
13:04 --> 13:05That went up for other
13:05 --> 13:07reasons, but it was coincident
13:07 --> 13:08with my aging out of it.
13:09 --> 13:11I was happy to
13:11 --> 13:13not to have fortunately, have
13:13 --> 13:14become a member. But that
13:14 --> 13:16being said, yeah, age
13:17 --> 13:19is a state of mind. But that being said,
13:21 --> 13:23I think we target and
13:23 --> 13:24think about women who are
13:24 --> 13:26in their thirties and early
13:26 --> 13:27forties for
13:27 --> 13:28the structure and the programmatic
13:28 --> 13:29approaches. But when we think
13:29 --> 13:31about, you know, where the
13:31 --> 13:31disparate
13:32 --> 13:33outcomes are, it's really from
13:33 --> 13:34a disease standpoint, it is
13:34 --> 13:36the younger women,
13:36 --> 13:37the very young women. The
13:37 --> 13:38one thing I wanted to
13:38 --> 13:39add is there's also the
13:39 --> 13:40genetic component.
13:41 --> 13:42And we talked
13:42 --> 13:43a little bit about the
13:43 --> 13:44disease itself,
13:44 --> 13:45but one of the things
13:45 --> 13:47that's kind of a hallmark
13:47 --> 13:48of young onset breast cancer
13:48 --> 13:50is there's a much higher
13:50 --> 13:52likelihood of having a genetic
13:52 --> 13:54predisposition to the disease when
13:54 --> 13:55you're diagnosed as a young
13:55 --> 13:56woman.
13:57 --> 13:58If you include some of
13:58 --> 14:00the newer genetic changes,
14:01 --> 14:02that you can find in
14:02 --> 14:03genes that we now know
14:03 --> 14:05increase risk of breast breast
14:05 --> 14:06cancer, if you look at
14:06 --> 14:08women under forty and certainly
14:08 --> 14:09under thirty five, it's almost
14:09 --> 14:11a twenty five percent chance
14:12 --> 14:13of finding if they're diagnosed
14:13 --> 14:15with breast cancer that young,
14:15 --> 14:16there's about a one in
14:16 --> 14:17four chance of finding one
14:17 --> 14:19of these hereditary predisposition. And
14:19 --> 14:20that's in contrast
14:20 --> 14:22to older women where that's
14:22 --> 14:23more like a
14:23 --> 14:25ten percent chance, which has
14:25 --> 14:27both ramifications for their treatment,
14:28 --> 14:29both what they choose
14:29 --> 14:30to do from their breast
14:30 --> 14:32cancer, the breast
14:32 --> 14:34surgeries and treatment locally, as
14:34 --> 14:35well as now what kinds
14:35 --> 14:36of treatments
14:36 --> 14:37systemically,
14:37 --> 14:38you know, the medicines they
14:38 --> 14:40can take to treat their
14:40 --> 14:42cancer. And it also obviously
14:42 --> 14:43has implications for their loved
14:43 --> 14:45ones and their blood relatives
14:45 --> 14:47who may also be at
14:47 --> 14:48risk
14:48 --> 14:50by virtue of having a
14:50 --> 14:51genetic predisposition.
14:52 --> 14:53And knowledge is
14:53 --> 14:55power, but that can also
14:55 --> 14:56make people quite distressed because,
14:57 --> 14:57of course, you don't want
14:57 --> 14:59your own self to have
14:59 --> 15:00cancer, but god knows you
15:00 --> 15:01don't want your children
15:01 --> 15:02or your loved ones to
15:02 --> 15:04be diagnosed potentially with
15:04 --> 15:05a cancer. So it adds to the
15:06 --> 15:09psychosocial distress these patients face.
15:09 --> 15:10We're gonna take just
15:10 --> 15:12a very brief break. And
15:12 --> 15:13when we come back, we'll
15:13 --> 15:15pick up with some questions
15:15 --> 15:16about
15:16 --> 15:18genetics and breast cancer.
15:18 --> 15:20So we'll be back in
15:20 --> 15:21just a minute.
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15:38 --> 15:40Over two hundred and thirty
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15:48 --> 15:49More than eighty five percent
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16:09 --> 16:10survivors more hope than they
16:10 --> 16:12have ever had before.
16:12 --> 16:14Clinical trials are currently underway
16:14 --> 16:17at federally designated comprehensive cancer
16:17 --> 16:17centers,
16:18 --> 16:19such as the battle two
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16:25 --> 16:27on personal biomarkers
16:27 --> 16:29can help to control non
16:29 --> 16:30small cell lung cancer.
16:31 --> 16:32More information is available at
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16:34 --> 16:36You're listening to Connecticut Public
16:36 --> 16:36Radio.
16:38 --> 16:39Hello again. This is Eric
16:39 --> 16:41Winer with Yale Cancer Answers,
16:41 --> 16:42and I'm joined
16:44 --> 16:45by our guest, doctor Ann
16:45 --> 16:47Partridge, professor of medicine at
16:47 --> 16:48Harvard Medical School and
16:52 --> 16:54a breast cancer physician and
16:54 --> 16:55interim chair of medical oncology
16:55 --> 16:57at Dana Farber Cancer Institute.
16:58 --> 16:59So we were just talking
16:59 --> 17:01about genetics in breast cancer
17:01 --> 17:02and
17:02 --> 17:04the more frequent finding of
17:04 --> 17:05a gene
17:06 --> 17:07change or gene mutation
17:08 --> 17:10that is inherited from one's
17:10 --> 17:12mother or father that increases
17:12 --> 17:13the risk of breast cancer.
17:14 --> 17:15How does having
17:16 --> 17:17such a change,
17:17 --> 17:19such a mutation, like a
17:19 --> 17:21BRCA one or BRCA
17:21 --> 17:23two mutation, which many people
17:23 --> 17:24are familiar with, how does
17:24 --> 17:26that affect decision making
17:26 --> 17:27regarding treatment?
17:28 --> 17:29Having a gene mutation
17:30 --> 17:32or pathogenic variant, as we
17:32 --> 17:33call them these days,
17:34 --> 17:35can have a major impact
17:36 --> 17:37on especially what a young
17:37 --> 17:38woman considers
17:39 --> 17:40in terms of her local
17:40 --> 17:41therapy,
17:42 --> 17:44local therapy meaning surgery with
17:44 --> 17:45or without radiation.
17:47 --> 17:48Generally, a person needs to
17:48 --> 17:50treat the breast where they
17:50 --> 17:51have the cancer from a
17:51 --> 17:53local standpoint in order to
17:53 --> 17:53get rid of it,
17:54 --> 17:56along with often medicines or
17:56 --> 17:57systemic therapy
17:57 --> 17:58to kill off cells that
17:58 --> 18:00might have been left behind.
18:00 --> 18:02When a young woman or
18:02 --> 18:03any woman has one of
18:03 --> 18:05these known hereditary predisposing
18:06 --> 18:08genes or a pathogenic variant,
18:09 --> 18:10her risk of having a
18:10 --> 18:12new primary cancer in the
18:12 --> 18:13breast tissue
18:14 --> 18:15goes up pretty dramatically.
18:16 --> 18:18Often something on the order
18:18 --> 18:19of five to tenfold depending
18:20 --> 18:22on the level of the type of
18:23 --> 18:24gene they have.
18:24 --> 18:26And so, you know, our
18:26 --> 18:27job as
18:28 --> 18:29medical oncologists working with our
18:29 --> 18:32genetic counselors and geneticists is
18:32 --> 18:33if a person tests
18:33 --> 18:34positive for one of these
18:34 --> 18:35genes,
18:35 --> 18:37the changes in the genes,
18:37 --> 18:37then we need to help, A.
18:38 --> 18:39decide, is it one
18:39 --> 18:40of those ones that is
18:40 --> 18:42associated with a really increased
18:42 --> 18:44risk of new primary breast
18:44 --> 18:45cancer, even they're in the
18:45 --> 18:46same breast where they had
18:46 --> 18:48the original breast cancer
18:48 --> 18:49or in the other breast
18:49 --> 18:51or contralateral breast as we call it.
18:53 --> 18:55And then should that, for that individual
18:55 --> 18:57woman, impact her decisions
18:57 --> 18:57around
18:58 --> 19:00doing more aggressive surgery? Often
19:00 --> 19:02women will consider not only
19:02 --> 19:03treating the breast where they
19:03 --> 19:04have the cancer,
19:04 --> 19:06but the other side in
19:06 --> 19:07terms of having a prophylactic
19:08 --> 19:08mastectomy,
19:09 --> 19:11so that they can decrease
19:11 --> 19:13the chances of a future
19:13 --> 19:14breast cancer event in that
19:14 --> 19:15breast. And of course, that
19:15 --> 19:16has a lot to do
19:16 --> 19:17with, well, what are the
19:17 --> 19:19risks of the first cancer?
19:19 --> 19:21Number one, hopefully if the
19:21 --> 19:23risks are low, that woman
19:23 --> 19:24will be expected to, you
19:24 --> 19:25know, live and live on
19:25 --> 19:27for many years, in which
19:27 --> 19:28case the idea of a
19:28 --> 19:30new cancer occurring in the
19:30 --> 19:31next five to ten years
19:31 --> 19:33would be super important, let
19:33 --> 19:35alone twenty, thirty, forty years
19:35 --> 19:36from then if you're talking
19:36 --> 19:37about a forty year old.
19:37 --> 19:39And so we often help,
19:39 --> 19:40you know, discuss these issues
19:40 --> 19:42with women. It's complicated because
19:42 --> 19:43some of these women haven't
19:43 --> 19:44finished their childbearing.
19:44 --> 19:45They might want to not
19:45 --> 19:46only just have a baby
19:46 --> 19:48but nurse that baby.
19:48 --> 19:49So some of these women
19:49 --> 19:51will say, okay, I have
19:51 --> 19:52a known hereditary predisposition.
19:53 --> 19:54I'm not just
19:54 --> 19:55gonna treat the side I
19:55 --> 19:56have to now,
19:56 --> 19:58but I'll think about doing
19:58 --> 19:59something on the other side
20:00 --> 20:01when I'm done with having
20:01 --> 20:01my children.
20:02 --> 20:03But, you know, some of
20:03 --> 20:04them are living with increased
20:04 --> 20:05risk even in the first
20:05 --> 20:07five to ten years,
20:07 --> 20:08and most of them if
20:08 --> 20:09they have a known predisposition.
20:10 --> 20:11And so that's kind of
20:11 --> 20:12weighing pros and cons
20:12 --> 20:13there, and it's important that
20:13 --> 20:14we support them to make
20:14 --> 20:16the best decisions for themselves.
20:16 --> 20:17The good news
20:17 --> 20:18is that at least in
20:18 --> 20:20the short term,
20:20 --> 20:23women aren't usually sitting on
20:23 --> 20:24a time bomb. They feel
20:24 --> 20:26like they are, but, generally,
20:26 --> 20:28you have some time both
20:28 --> 20:29to make these decisions when
20:29 --> 20:30you're treating the primary breast
20:30 --> 20:32cancer as well as to
20:32 --> 20:34to, you know, hold back
20:34 --> 20:35and not necessarily
20:35 --> 20:36do many prophylactic
20:37 --> 20:39things right at the beginning.
20:39 --> 20:41You usually have at least
20:41 --> 20:41a couple years and can
20:41 --> 20:43be watched very carefully even
20:43 --> 20:45with the highest risk genes.
20:45 --> 20:46And of course, for women
20:46 --> 20:48with BRCA one or BRCA
20:49 --> 20:49two mutations,
20:50 --> 20:51there's the
20:52 --> 20:54added risk of ovarian cancer,
20:54 --> 20:56which, of course, with many
20:56 --> 20:58of these gene changes,
20:58 --> 21:00people are at risk for
21:00 --> 21:01a variety of different cancers.
21:01 --> 21:03But ovarian cancer is the
21:03 --> 21:04one that is most notable
21:05 --> 21:06for some people. And that
21:06 --> 21:08also sometimes leads to questions
21:08 --> 21:10about prophylactic surgery.
21:10 --> 21:12So we've been talking off
21:12 --> 21:14and on about having
21:15 --> 21:17children after breast cancer, having
21:17 --> 21:18babies,
21:19 --> 21:19and fertility.
21:20 --> 21:22And maybe you could tell
21:22 --> 21:23us a little bit about
21:23 --> 21:24the study that
21:25 --> 21:26you conducted
21:26 --> 21:27looking at pregnancy
21:28 --> 21:30after breast cancer. Because for
21:30 --> 21:32years and years and years,
21:32 --> 21:33women have asked us,
21:33 --> 21:35is it safe to become
21:35 --> 21:37pregnant after breast cancer? And
21:37 --> 21:39the usual answer was,
21:40 --> 21:41we don't know that it
21:41 --> 21:43isn't safe. It's probably okay,
21:43 --> 21:44but we don't know the
21:44 --> 21:46exact timing. And then,
21:47 --> 21:48you and your colleagues were
21:48 --> 21:50able to do a
21:50 --> 21:51really landmark study.
21:52 --> 21:53So we
21:53 --> 21:54heard from our patients and
21:54 --> 21:56our patient advocates
21:56 --> 21:57and we knew
21:57 --> 21:58how important this was for
21:58 --> 22:00our young women and their
22:00 --> 22:00families
22:01 --> 22:02to be able to have
22:02 --> 22:04babies and also at
22:04 --> 22:04the same time not do
22:04 --> 22:06something crazy. Right? It's pretty
22:06 --> 22:08normal to want a baby,
22:08 --> 22:09and yet people want to
22:09 --> 22:10get good breast cancer care
22:10 --> 22:12too and good risk reduction.
22:12 --> 22:13And so what we did
22:13 --> 22:15was a single arm trial
22:16 --> 22:17where we said, okay. Let's
22:17 --> 22:19come up with a protocol
22:19 --> 22:20that seems reasonable
22:21 --> 22:22to your average
22:22 --> 22:25patient, patient advocate, and doctor
22:25 --> 22:26who cares for young women
22:26 --> 22:27with breast cancer.
22:27 --> 22:28And just to be clear, you say
22:28 --> 22:30a single arm trial.
22:30 --> 22:32I think people know that
22:32 --> 22:32oftentimes
22:32 --> 22:35there are randomized trials, which
22:35 --> 22:36are definitive trials,
22:36 --> 22:37but it is hard to
22:37 --> 22:39randomize people to getting pregnant
22:39 --> 22:41or not.
22:41 --> 22:42Yes, that would be a very challenging study
22:42 --> 22:44to do, a nonstarter.
22:44 --> 22:45And so we said, what would
22:45 --> 22:47women tolerate? And we actually
22:47 --> 22:48figured out
22:49 --> 22:50a schema, again, with very
22:50 --> 22:51heavy patient input
22:52 --> 22:53that women were willing to
22:53 --> 22:55take their endocrine therapy, but
22:55 --> 22:56really wanted to take a
22:56 --> 22:57break if we didn't think
22:57 --> 22:58that was crazy
22:58 --> 23:00and then get back on.
23:00 --> 23:01They were willing to get
23:01 --> 23:02back on. So the idea is
23:02 --> 23:04typically you treat for five
23:04 --> 23:05to ten years,
23:05 --> 23:07you know, straight through with
23:07 --> 23:09oral endocrine therapy and sometimes
23:09 --> 23:11with shots to suppress ovaries.
23:11 --> 23:12But we know that the
23:12 --> 23:14risk of breast cancer continues
23:14 --> 23:15for the hormone sensitive breast
23:15 --> 23:17cancer even further out. So
23:17 --> 23:18could we take a break
23:18 --> 23:19sooner than that five to
23:19 --> 23:20ten years,
23:24 --> 23:25support them to get
23:25 --> 23:26pregnant,
23:26 --> 23:27however they needed to get
23:27 --> 23:28pregnant and then get back
23:28 --> 23:30on and complete the full
23:30 --> 23:31duration of the therapy they
23:31 --> 23:32were going to take. And
23:32 --> 23:34the really good news is
23:34 --> 23:35that women all over the
23:35 --> 23:36world, you know, this was
23:36 --> 23:38a very big international
23:39 --> 23:40effort. We put on over
23:40 --> 23:42five hundred women around the
23:42 --> 23:42world. I think it was
23:42 --> 23:44eighty countries we enrolled from,
23:45 --> 23:46and we actually enrolled in
23:46 --> 23:47record time.
23:47 --> 23:49And what we showed at
23:49 --> 23:50least in early follow-up
23:51 --> 23:52is that this does appear
23:52 --> 23:53to be a safe approach.
23:54 --> 23:55So taking eighteen to thirty
23:55 --> 23:56months of your treatment,
23:57 --> 23:58taking a break for up
23:58 --> 23:59to two years for a
23:59 --> 24:00pregnancy,
24:00 --> 24:00delivery,
24:02 --> 24:03nursing if someone chose to
24:03 --> 24:04and is able to, and
24:04 --> 24:05then getting back on the
24:05 --> 24:06therapy.
24:06 --> 24:07When we follow these women
24:07 --> 24:08over time, they seem to
24:08 --> 24:10do just as well
24:10 --> 24:12with as few recurrences
24:13 --> 24:15as women who had not
24:15 --> 24:17taken that kind of break
24:17 --> 24:17for pregnancy.
24:20 --> 24:22It's admittedly a preliminary result,
24:22 --> 24:23but it's
24:23 --> 24:25really a much more definitive
24:25 --> 24:26study than has ever been
24:26 --> 24:28done and has really helped
24:28 --> 24:30in decision making around
24:31 --> 24:33this really challenging issue for
24:33 --> 24:34a lot of people.
24:35 --> 24:36Could we talk
24:37 --> 24:38for a minute about long
24:38 --> 24:39term complications?
24:40 --> 24:42So a woman goes through
24:43 --> 24:44treatment for breast cancer, and
24:44 --> 24:45a young woman
24:46 --> 24:49may live for another fifty
24:49 --> 24:49plus years.
24:51 --> 24:52What are
24:52 --> 24:54the long term implications of
24:54 --> 24:54a diagnosis?
24:56 --> 24:59So we know from anecdote,
24:59 --> 25:00actually, the long term implications
25:01 --> 25:01and from
25:03 --> 25:05some studies where we have
25:05 --> 25:07looked at kind of populations
25:08 --> 25:08overall,
25:09 --> 25:10but we don't have a
25:10 --> 25:11great amount of data
25:12 --> 25:14on very young women diagnosed
25:14 --> 25:15with breast cancer,
25:15 --> 25:17what's happening to them twenty
25:17 --> 25:19years out or thirty years
25:19 --> 25:21out. And in fact, I'm
25:21 --> 25:22excited that the study that
25:22 --> 25:23you and I launched now
25:23 --> 25:24twenty years ago
25:25 --> 25:27will actually deliver some of
25:27 --> 25:28that data in the years
25:28 --> 25:30to come because we've been
25:30 --> 25:31following a cohort of young
25:31 --> 25:31patients,
25:32 --> 25:34and we'll continue to follow
25:34 --> 25:35them hopefully for another, you
25:35 --> 25:37know, twenty, thirty years.
25:37 --> 25:39But for now, we worry
25:39 --> 25:41about their bones. We worry
25:41 --> 25:42about their hearts. We worry
25:42 --> 25:45about their mental health and
25:45 --> 25:47even their cognitive functioning over
25:47 --> 25:49time. And that's largely from
25:49 --> 25:50studies
25:50 --> 25:52that have looked at
25:52 --> 25:54not breast cancer survivors, but
25:54 --> 25:56women generally who've gone through
25:56 --> 25:57very premature menopause
25:58 --> 25:59for different reasons and
26:00 --> 26:02have shown in these studies
26:02 --> 26:03that there may be an
26:03 --> 26:04increased risk of some of
26:04 --> 26:06these chronic diseases, particularly bone
26:06 --> 26:07health and the risk of
26:07 --> 26:09premature cardiovascular
26:09 --> 26:10issues. That doesn't mean
26:10 --> 26:12we shouldn't use these treatments
26:12 --> 26:14because the near risk for
26:14 --> 26:16women is breast cancer.
26:16 --> 26:17We want them to become
26:17 --> 26:18long term survivors, and we
26:18 --> 26:19have to but it does
26:19 --> 26:20mean we shouldn't overtreat them,
26:20 --> 26:22number one. And number two,
26:22 --> 26:23we wanna follow them long
26:23 --> 26:24term and do whatever we
26:24 --> 26:26can to prevent these long
26:26 --> 26:27term and late effects as
26:27 --> 26:29we figure out how frequently
26:29 --> 26:30they occur and what we
26:30 --> 26:32can do to prevent it.
26:32 --> 26:34Well, in our last two
26:34 --> 26:36minutes, maybe we can touch
26:36 --> 26:38on a really important topic,
26:38 --> 26:39which is
26:39 --> 26:40screening.
26:40 --> 26:43And, of course, screening recommendations
26:43 --> 26:45typically start in women who
26:45 --> 26:46are forty or over.
26:48 --> 26:49For women who have a
26:49 --> 26:52genetic predisposition to breast cancer,
26:52 --> 26:53we often do start younger.
26:54 --> 26:54But for the
26:55 --> 26:56general population,
26:57 --> 26:58women who do not have
26:58 --> 26:59any kind of
26:59 --> 27:01strong family history or genetic
27:01 --> 27:02predisposition,
27:03 --> 27:04there's a lot of discussion
27:04 --> 27:05about what can be done
27:05 --> 27:06with screening in in young
27:06 --> 27:07women. And
27:07 --> 27:09what are the challenges there,
27:09 --> 27:10and where do you see
27:10 --> 27:11all that going?
27:13 --> 27:14Yes. That's a very complicated
27:14 --> 27:17situation. Right now, for general
27:17 --> 27:18population, there is no good
27:18 --> 27:19screening for
27:19 --> 27:21young women who are at
27:21 --> 27:22risk for breast cancer. And
27:22 --> 27:23basically, any young woman,
27:23 --> 27:24if she has breasts, is
27:24 --> 27:26at risk for breast cancer.
27:26 --> 27:27Yes. For the high risk
27:27 --> 27:28population, if they know they
27:28 --> 27:30have a gene in their
27:30 --> 27:31family that predisposes to breast
27:31 --> 27:33cancer, we'll start getting MRIs
27:34 --> 27:34and mammograms
27:35 --> 27:36earlier, and that's tailored to
27:36 --> 27:37the individual
27:38 --> 27:39and their family history.
27:39 --> 27:41But for, you know, general
27:41 --> 27:43population women, there actually
27:43 --> 27:44is not a great test.
27:44 --> 27:45So it's really about your
27:45 --> 27:47own breast health awareness.
27:48 --> 27:50And that's not a great
27:50 --> 27:51answer because many young women,
27:51 --> 27:52by the time they feel
27:52 --> 27:53a lump, they're diagnosed and
27:53 --> 27:55and they have higher risk
27:55 --> 27:56disease than they would like.
27:56 --> 27:58And so what we really
27:58 --> 27:59need to do is to
27:59 --> 28:00do more work to figure
28:00 --> 28:00out
28:01 --> 28:02who's really at risk for
28:02 --> 28:04breast cancer, to really understand
28:05 --> 28:05not just what is the
28:05 --> 28:07smoking gun, you know, one
28:07 --> 28:08gene that predisposes,
28:08 --> 28:10but, you know, more things
28:10 --> 28:11like polygenic risk scores where
28:11 --> 28:13we can understand the genes
28:13 --> 28:15and the environment interaction.
28:15 --> 28:17And until then, we need
28:18 --> 28:19better tests also. So we
28:19 --> 28:21need tests that are, you
28:21 --> 28:22know, better than a mammogram
28:22 --> 28:24because mammograms aren't terrific in
28:24 --> 28:25young women who have much
28:25 --> 28:26more dense breasts
28:27 --> 28:28than older women conventionally.
28:29 --> 28:29And therefore,
28:30 --> 28:32seeing a dense tumor different
28:32 --> 28:33from a dense breast is
28:33 --> 28:34much harder in a young
28:34 --> 28:35woman with a mammogram.
28:36 --> 28:37Doctor Ann Partridge is a
28:37 --> 28:39professor of medicine at Harvard
28:39 --> 28:40Medical School.
28:40 --> 28:42If you have questions, the
28:42 --> 28:43address is canceranswers
28:43 --> 28:44at yale dot edu,
28:45 --> 28:46and past editions of the
28:46 --> 28:48program are available in audio
28:48 --> 28:49and written form at yale
28:49 --> 28:51cancer center dot org.
28:51 --> 28:52We hope you'll join us
28:52 --> 28:53next time to learn more
28:53 --> 28:55about the fight against cancer.
28:55 --> 28:57Funding for Yale Cancer Answers
28:57 --> 28:58is provided by Smilow Cancer
28:58 --> 28:59Hospital.

Information

Breast Cancer in Young Women: Optimizing Knowledge and Care to Improve Outcomes with guest Dr. Ann Partridge March 23, 2025

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

call: 203-785-4095