Tailoring Breast Cancer Treatment in 2022

Transcript

00:00 --> 00:02Funding for Yale Cancer Answers is
00:02 --> 00:04provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers with
00:08 --> 00:10your host, Doctor Anees Chagpar.
00:10 --> 00:12Yale Cancer Answers features the
00:12 --> 00:14latest information on cancer care by
00:14 --> 00:16welcoming oncologists and specialists
00:16 --> 00:18who are on the forefront of the
00:18 --> 00:20battle to fight cancer. This week,
00:20 --> 00:22it's a conversation about innovations
00:22 --> 00:24in the care of breast cancer
00:24 --> 00:25with Doctor Eric Winer.
00:25 --> 00:27Doctor Winer is a professor of
00:27 --> 00:28medicine and medical oncology
00:28 --> 00:30at the Yale School of Medicine,
00:30 --> 00:32where Doctor Chagpar is a
00:32 --> 00:34professor of surgical oncology.
00:35 --> 00:37So Eric, you and I have
00:37 --> 00:38known each other for a while,
00:38 --> 00:41but I was hoping that you could tell
00:41 --> 00:42everybody a little bit more about
00:42 --> 00:45yourself and how it is that you
00:45 --> 00:47became a breast medical oncologist.
00:47 --> 00:51Oh gosh, it was a long time ago that
00:51 --> 00:55I decided to be a breast cancer doctor.
00:55 --> 00:57As a medical student,
00:57 --> 00:59I was actually interested in
00:59 --> 01:02cancer and did my thesis in medical
01:02 --> 01:04school on a breast cancer subject,
01:04 --> 01:07but I didn't necessarily think I would become
01:07 --> 01:09a breast cancer doctor and then for a while
01:09 --> 01:11I actually thought about being a
01:11 --> 01:13psychiatrist, but decided that
01:13 --> 01:16wasn't probably quite what I wanted to do.
01:16 --> 01:19And as a resident I just found
01:19 --> 01:22cancer to be the most interesting
01:22 --> 01:25area that I dealt with.
01:25 --> 01:27And so I was actually
01:27 --> 01:29here at Yale as a resident.
01:29 --> 01:32And then I went to Duke as a fellow.
01:32 --> 01:34And in truth I was interested
01:34 --> 01:35in breast cancer,
01:35 --> 01:38but it was also an opportunity
01:38 --> 01:41because the job opened up as someone
01:41 --> 01:44to really take care of most
01:44 --> 01:46patients with breast cancer.
01:46 --> 01:48At Duke in those days,
01:48 --> 01:51it was a time when we knew
01:51 --> 01:53much less about breast cancer,
01:53 --> 01:56and when a very young doctor
01:56 --> 01:58could suddenly become
01:58 --> 02:00the breast cancer expert,
02:00 --> 02:01which is certainly not the
02:01 --> 02:03way it would be today.
02:03 --> 02:04And that was now 30 years
02:04 --> 02:06ago and I have to say,
02:06 --> 02:11it's been an incredible journey.
02:11 --> 02:14And it's been a really
02:14 --> 02:15perfect profession for me.
02:17 --> 02:19So tell us a little bit
02:19 --> 02:20more about why you say that.
02:20 --> 02:23I mean, because many people when they
02:23 --> 02:26think about the perfect profession
02:26 --> 02:29they would think about something that
02:29 --> 02:33is highly lucrative that does not
02:33 --> 02:37require a tremendous amount of effort.
02:37 --> 02:41And where everybody around you is
02:41 --> 02:44happy and doing well, but when we think
02:44 --> 02:47about cancer doctors in general,
02:47 --> 02:50these are people who work incredibly hard.
02:50 --> 02:53They have very long hours.
02:53 --> 02:55They may not be remunerated
02:55 --> 02:57as well as one would think,
02:57 --> 03:00and the people around them and
03:00 --> 03:02the patients that they have,
03:02 --> 03:05although sometimes do well, sometimes don't.
03:05 --> 03:07So how do you square that?
03:10 --> 03:13I'll pick that apart a little bit and
03:13 --> 03:15answer it in a number of ways.
03:15 --> 03:19So first I have to say I've always
03:19 --> 03:22been paid more than enough to meet the
03:22 --> 03:25needs that I have and my family has,
03:25 --> 03:32so that's been fine. In terms of
03:32 --> 03:34wanting a job where I might not have
03:34 --> 03:37to work so hard that was never really
03:37 --> 03:39part of my vision and I'm somebody
03:39 --> 03:42who likes to work hard who likes to
03:42 --> 03:47get involved and so working hard in
03:47 --> 03:49an area where you really love what
03:49 --> 03:52you're doing is pretty easy for me.
03:52 --> 03:54And I think the reason it's been
03:54 --> 03:56such a perfect profession is that
03:56 --> 03:58it has been the perfect mix for me,
03:58 --> 04:03of both patient care and research
04:03 --> 04:04and education.
04:04 --> 04:09And in some administration or leadership.
04:09 --> 04:12And the proportion of those various
04:12 --> 04:14components has varied overtime.
04:14 --> 04:17But I have to say that I've always
04:17 --> 04:20loved taking care of patients. I've
04:20 --> 04:23learned more than one can
04:23 --> 04:27imagine from taking care of people.
04:27 --> 04:29And at the same time,
04:29 --> 04:30I've loved doing the research
04:30 --> 04:32I've done because if all I did
04:32 --> 04:34was take care of patients,
04:34 --> 04:35I think it would be fine.
04:35 --> 04:38But I wouldn't feel like I was
04:38 --> 04:41making the kind of improvements that
04:41 --> 04:44I would like in the field.
04:44 --> 04:47So you know, I think one of the things
04:47 --> 04:49that you point out is something that a
04:49 --> 04:52lot of people in cancer medicine feel.
04:52 --> 04:56Which is there is a certain
04:56 --> 04:59pride, a certain humility and
04:59 --> 05:02and a certain joy in being able to not
05:02 --> 05:05only help patients on a 1 to one basis,
05:05 --> 05:07but also to help patients
05:07 --> 05:09writ large in the future.
05:10 --> 05:11Doing the kind of research that
05:11 --> 05:13can move the field forward.
05:13 --> 05:15So can you tell us a little bit more
05:15 --> 05:17about the research that you've been
05:17 --> 05:19involved with over the last 30 years?
05:20 --> 05:23I do want to make one comment first though,
05:23 --> 05:26which is that the place where I feel as a
05:27 --> 05:30person most centered is when I'm in a room
05:30 --> 05:33with a patient and the door is closed as
05:33 --> 05:38of course it always is for privacy and
05:38 --> 05:40I can just focus on that individual
05:40 --> 05:44and for me time stops and I'm really
05:44 --> 05:46doing nothing but paying attention
05:46 --> 05:48to what's going on in there.
05:48 --> 05:50And that's a feeling that I don't
05:50 --> 05:53often have in other aspects of my
05:53 --> 05:55life where many people will say,
05:55 --> 05:57you know, are you paying attention?
05:57 --> 06:00And I may not always be,
06:00 --> 06:01but I always am when I'm in
06:01 --> 06:02the room with the patient.
06:02 --> 06:05But in terms of research,
06:05 --> 06:08my research has really been
06:08 --> 06:11clinical research and translational research.
06:11 --> 06:12Translational meaning
06:12 --> 06:15clinical research that begins to touch
06:15 --> 06:19on what's going on in the laboratory,
06:19 --> 06:23but my focus has been on trying to
06:23 --> 06:25improve treatments for women and
06:25 --> 06:28occasionally men with breast cancer,
06:28 --> 06:30and that's really gone in two directions.
06:30 --> 06:34It's gone in the direction of identifying
06:34 --> 06:38treatments that are truly more effective
06:38 --> 06:41and that allow people to live
06:41 --> 06:43longer and better lives.
06:43 --> 06:47And it's also involved work looking at
06:47 --> 06:50when can we do less treatment and
06:50 --> 06:52spare people side effects that they
06:52 --> 06:55don't need and that too has been
06:55 --> 06:57very satisfying because
06:57 --> 06:58of course,
06:58 --> 07:01the best treatment for anyone
07:01 --> 07:04is the treatment that they need.
07:04 --> 07:05Not too much, not too little,
07:05 --> 07:07but just the right amount.
07:08 --> 07:10And so let's dive a
07:10 --> 07:13little bit more into both of those.
07:13 --> 07:15So one of the things that we've kind
07:15 --> 07:18of noticed over time is that we have
07:18 --> 07:20gotten more effective treatments and
07:20 --> 07:23not only have they been more effective,
07:23 --> 07:25they've been more personalized.
07:25 --> 07:29So we've seen this burgeoning of
07:29 --> 07:31personalized medicine of genomics
07:31 --> 07:34of targeted therapies, talk a little
07:34 --> 07:37bit more about the genesis of that.
07:37 --> 07:38And where do you
07:38 --> 07:40think things are going in terms
07:40 --> 07:40of breast cancer?
07:41 --> 07:44For years we knew that
07:44 --> 07:47not all breast cancer was the same,
07:47 --> 07:49but a patient would ask what kind
07:49 --> 07:51of breast cancer do I have and
07:51 --> 07:53what I would be able to tell her,
07:53 --> 07:56and this is now 25 years ago,
07:56 --> 07:57I'd be able to say you have
07:57 --> 07:58stage one breast cancer.
07:58 --> 08:00You have stage two breast cancer,
08:00 --> 08:01which really doesn't say what
08:01 --> 08:03kind of breast cancer it is.
08:03 --> 08:06It just says how much breast cancer
08:06 --> 08:08there is because stage is essentially
08:08 --> 08:11a measure of amount of cancer.
08:11 --> 08:12But what we've learned,
08:12 --> 08:13and we've learned this
08:13 --> 08:16both through clinical trials and through
08:16 --> 08:18laboratory research that's been done,
08:18 --> 08:20is that there are really multiple
08:20 --> 08:22different subtypes of breast cancer.
08:22 --> 08:24It's not one disease,
08:24 --> 08:27it's a family of diseases and exactly
08:27 --> 08:30how many family members there are,
08:30 --> 08:32that's still a little bit unclear,
08:32 --> 08:35but there are at least four very
08:35 --> 08:38distinct types of breast cancer,
08:38 --> 08:41and these are all treated in a different
08:41 --> 08:45way and in a way that is much more
08:45 --> 08:47personalized than was the case
08:47 --> 08:4910 or 20 years ago.
08:49 --> 08:52And that's allowed us to give
08:52 --> 08:56therapy that is effective and needed,
08:56 --> 08:59but not a waste of time because
08:59 --> 09:01it's simply causing side effects
09:01 --> 09:03without producing benefit.
09:05 --> 09:08And so the other aspect that you
09:08 --> 09:11had mentioned is this whole
09:11 --> 09:14concept of deescalation.
09:14 --> 09:17Can we get the same results or perhaps
09:17 --> 09:20even better results by doing less therapy?
09:20 --> 09:22So less of the therapies that may
09:22 --> 09:25not be as effective or as needed?
09:25 --> 09:28Can we cut down on how much
09:28 --> 09:30surgery we're doing?
09:30 --> 09:31Can we cut down on how much
09:31 --> 09:32radiation we're doing?
09:32 --> 09:35Can we cut down on how much chemotherapy?
09:38 --> 09:41I think there may be some people
09:41 --> 09:43who may say,
09:43 --> 09:45who wants more therapy,
09:45 --> 09:50but others may be a little bit apprehensive
09:50 --> 09:52thinking that corners may be cut.
09:52 --> 09:54Are we really getting the
09:54 --> 09:56same results by doing less?
09:58 --> 10:02Sure, you know it's interesting,
10:02 --> 10:05there are both patients and doctors
10:05 --> 10:07who are worried about backing off,
10:07 --> 10:11and in some cases I think they don't
10:11 --> 10:14appreciate that some of our therapies
10:14 --> 10:19have really profound consequences and
10:19 --> 10:23have side effects that one can easily do
10:23 --> 10:26without and may last for years and years,
10:26 --> 10:30so doing less may be doing more in some
10:30 --> 10:34cases if the therapy itself isn't needed.
10:34 --> 10:36Medical oncologists, people like me,
10:36 --> 10:39tend to take credit for this whole
10:39 --> 10:42concept of deescalation or backing off.
10:42 --> 10:44But in truth it's the surgeons
10:44 --> 10:46who really started it.
10:46 --> 10:50And if people remember back 50 or
10:50 --> 10:5360 years ago, radical mastectomy was
10:53 --> 10:56a terribly deforming operation,
10:56 --> 10:57performed routinely,
10:57 --> 11:01and it was through a series of
11:01 --> 11:04experiments, of clinical trials,
11:04 --> 11:06that people find that you actually could
11:06 --> 11:09do much less in the way of surgery.
11:09 --> 11:12Radical mastectomies became modified
11:12 --> 11:13radical mastectomies,
11:13 --> 11:17and then it was demonstrated unequivocally,
11:17 --> 11:18absolutely,
11:18 --> 11:21unequivocally that for women who are
11:21 --> 11:24appropriate candidates for an excision alone,
11:24 --> 11:26or a lumpectomy
11:26 --> 11:29plus radiation is entirely the
11:29 --> 11:32equivalent to a mastectomy.
11:32 --> 11:33And then more recently,
11:33 --> 11:34over the past decade,
11:34 --> 11:38we've learned that in many cases we can do
11:38 --> 11:41far less in the way of lymph node surgery.
11:41 --> 11:44The radiation oncologists have
11:44 --> 11:46also looked carefully at who needs
11:46 --> 11:49more and who needs less and have
11:49 --> 11:50been more personalized.
11:50 --> 11:53And again in medical oncology,
11:53 --> 11:57now that we have identified subtypes of
11:57 --> 12:01breast cancer and can reliably do that,
12:01 --> 12:03we have found that there are
12:03 --> 12:05many areas where we can or many
12:05 --> 12:07patients for whom we don't need to
12:07 --> 12:09use treatments like chemotherapy,
12:09 --> 12:11where we can use hormonal therapy
12:11 --> 12:14alone and in the setting of 1
12:14 --> 12:16subtype of breast cancer,
12:16 --> 12:19what's called HER2 positive breast cancer,
12:19 --> 12:21we've found that
12:21 --> 12:23oftentimes very limited courses of
12:23 --> 12:26chemotherapy can be every bit as
12:26 --> 12:29effective as something that's more extreme.
12:30 --> 12:32And so a lot of that,
12:32 --> 12:36though is really predicated on generating
12:36 --> 12:40the evidence that underpins that rationale.
12:40 --> 12:42That yes, you can do less and
12:42 --> 12:45achieve same outcomes,
12:45 --> 12:49and that really goes to clinical
12:49 --> 12:50trial participation.
12:50 --> 12:53But some patients might be a little bit
12:53 --> 12:55reticent to participate in clinical trials,
12:55 --> 12:58so how do you talk to patients
12:58 --> 12:59about clinical trial participation
12:59 --> 13:01and how important it is to move
13:01 --> 13:02the field forward.
13:04 --> 13:06Well, ultimately a trial has
13:06 --> 13:09to be right for a patient and
13:09 --> 13:12in truth, there's nothing that
13:12 --> 13:15should ever compel or force a
13:15 --> 13:17patient to participate in the trial.
13:17 --> 13:19It has to be voluntary,
13:19 --> 13:23but in general, with clinical trials,
13:23 --> 13:25we're actually trying to do better.
13:25 --> 13:28So in some cases we're doing randomized
13:28 --> 13:30clinical trials that compare a
13:30 --> 13:32standard with something that we hope
13:32 --> 13:36is better than the standard and
13:36 --> 13:38much of the time,
13:38 --> 13:41we're testing new
13:41 --> 13:44treatments that actually do turn out
13:44 --> 13:47to be better or certainly not worse.
13:47 --> 13:50And in clinical trials that may not be
13:50 --> 13:53randomized still there the intent,
13:53 --> 13:56of course, is to
13:56 --> 13:59develop a treatment or an approach that
13:59 --> 14:03is better than the standard approach.
14:03 --> 14:04Having said all that,
14:04 --> 14:06there are patients who just want
14:06 --> 14:08the standard therapy they're
14:08 --> 14:10comfortable with what is known,
14:10 --> 14:14and they don't want to stray beyond that.
14:14 --> 14:17And that's that's OK.
14:17 --> 14:19I will say, however,
14:19 --> 14:22that all of the improvements that I
14:22 --> 14:25talked about a few minutes ago all
14:25 --> 14:28came about as a result of clinical trials.
14:28 --> 14:32If you're backing off on therapy
14:32 --> 14:34and trying to do less,
14:34 --> 14:36that should be done as part of
14:36 --> 14:37a clinical trial to demonstrate
14:37 --> 14:38that that's safe.
14:38 --> 14:40If you're looking at a new therapy,
14:40 --> 14:42and I don't want people to think
14:42 --> 14:43for a minute that although we
14:43 --> 14:45do is back off on therapies,
14:45 --> 14:47we still need to develop
14:47 --> 14:49new and better therapies,
14:49 --> 14:51hopefully therapies that don't
14:51 --> 14:54have a great deal of toxicity.
14:54 --> 14:56But when we're doing that,
14:56 --> 14:59that's part of a clinical trial as well.
14:59 --> 15:02So local trials are really absolutely
15:02 --> 15:04critical for moving the field forward,
15:04 --> 15:08and the reason we have made so much
15:08 --> 15:11progress in breast cancer is that
15:11 --> 15:12mostly women,
15:12 --> 15:14because unfortunately even the men
15:14 --> 15:16who have breast cancer are often
15:16 --> 15:18excluded from the clinical trials,
15:18 --> 15:21but women have very
15:21 --> 15:24generously participated in trials.
15:25 --> 15:27We're going to
15:27 --> 15:30pick up this conversation right after we
15:30 --> 15:33take a short break for a medical minute.
15:33 --> 15:35Please stay tuned to learn more about
15:35 --> 15:37innovations in Breast Cancer Care
15:37 --> 15:39with my guest doctor Eric Winer.
15:39 --> 15:41Funding for Yale Cancer Answers
15:41 --> 15:43comes from Smilow Cancer Hospital,
15:43 --> 15:46where you can view videos from their
15:46 --> 15:49survivorship team by searching for the
15:49 --> 15:52smilow survivorship playlist on YouTube.
15:52 --> 15:54The American Cancer Society
15:54 --> 15:56estimates that nearly 150,000 people
15:56 --> 15:59in the US will be diagnosed with
15:59 --> 16:01colorectal cancer this year alone.
16:01 --> 16:03When detected, early colorectal cancer
16:03 --> 16:06is easily treated and highly curable,
16:06 --> 16:08and men and women over the age of 45
16:08 --> 16:10should have regular colonoscopies
16:10 --> 16:12to screen for the disease.
16:12 --> 16:13Patients with colorectal cancer
16:13 --> 16:15have more hope than ever before,
16:15 --> 16:18thanks to increased access to advanced
16:18 --> 16:20therapies and specialized care.
16:20 --> 16:22Clinical trials are currently underway.
16:22 --> 16:23Federally designated comprehensive
16:23 --> 16:26cancer centers such as Yale Cancer
16:26 --> 16:29Center and its Milo Cancer Hospital
16:29 --> 16:31to test innovative new treatments for
16:31 --> 16:33colorectal cancer tumor gene analysis
16:33 --> 16:36has helped improve management of
16:36 --> 16:38colorectal cancer by identifying the
16:38 --> 16:41patients most likely to benefit from
16:41 --> 16:43chemotherapy and newer targeted agents,
16:43 --> 16:46resulting in more patient specific treatment.
16:46 --> 16:49More information is available at
16:49 --> 16:50yalecancercenter.org you're listening
16:50 --> 16:52to Connecticut Public Radio.
16:53 --> 16:55Welcome back to Yale Cancer answers.
16:55 --> 16:58This is doctor Anish Chappar and I'm joined
16:58 --> 17:00tonight by my guest doctor Eric Weiner.
17:00 --> 17:02We're talking about advances in
17:02 --> 17:04the care of patients with breast
17:04 --> 17:06cancer and right before the break,
17:06 --> 17:09Eric, you were telling us a little
17:09 --> 17:11bit about clinical trials and about
17:11 --> 17:13how various advances had been made
17:13 --> 17:15as a result of clinical trials.
17:15 --> 17:18But that, really, this is a very
17:18 --> 17:19personal decision for patients.
17:19 --> 17:21Some patients want to
17:21 --> 17:23participate in clinical trials.
17:23 --> 17:27That potentially could positively
17:27 --> 17:29impact them, because as you say,
17:29 --> 17:32we're always trying to do better and
17:32 --> 17:34potentially positively impact future
17:34 --> 17:36generations of breast cancer patients.
17:36 --> 17:38On the other hand,
17:38 --> 17:40other patients may feel more
17:40 --> 17:42comfortable with standard of care.
17:42 --> 17:43The tried and true,
17:43 --> 17:46and I think that that applies to many of
17:46 --> 17:48the decisions that are made with patients.
17:48 --> 17:52So can you tell us a little bit more
17:52 --> 17:54about how patients make decisions about?
17:54 --> 17:57Karen and a little bit about
17:57 --> 17:59what that relationship is,
17:59 --> 18:02what that interplay is between the
18:02 --> 18:04the doctor and the patient in terms
18:04 --> 18:07of coming up with a plan that is
18:07 --> 18:10individualized and right for a given patient.
18:10 --> 18:11Decision making
18:11 --> 18:16really varies from patient to patient and.
18:16 --> 18:19I think that one of the one of the
18:19 --> 18:22real keys for doctors is being able
18:22 --> 18:25to adjust to the patient and to
18:25 --> 18:27understand how involved she wants
18:27 --> 18:30to be in terms of the decision.
18:30 --> 18:32There are patients.
18:32 --> 18:35Who truly don't want a great deal
18:35 --> 18:38of information and as much as one as
18:38 --> 18:41a doctor may may try to provide it.
18:41 --> 18:44Really want the doctor to make the
18:44 --> 18:46decision for them and just in,
18:46 --> 18:49and let them know you know what
18:49 --> 18:51the treatment is going to be.
18:51 --> 18:52I don't think that's the majority
18:52 --> 18:53of people anymore, though,
18:53 --> 18:55and I think that most individuals
18:55 --> 18:58with breast cancer really want to be
18:58 --> 19:00actively involved in the decision.
19:00 --> 19:02They want to know what the choices are.
19:02 --> 19:04That's certainly true when it comes
19:04 --> 19:07to decisions about surgery and
19:07 --> 19:09whether someone has a lumpectomy
19:09 --> 19:11or whether they have a mastectomy.
19:11 --> 19:14But it's also true in terms of the
19:14 --> 19:16decisions about about medical therapy,
19:16 --> 19:18about hormonal therapy and chemotherapy.
19:18 --> 19:21And so I think that.
19:21 --> 19:22As clinicians,
19:22 --> 19:25we really need to be able to
19:25 --> 19:27talk to our patients,
19:27 --> 19:30understand where they're coming from,
19:30 --> 19:32and understand how we're going
19:32 --> 19:34to get to a decision together,
19:35 --> 19:38and so you know when you think about that,
19:38 --> 19:40though, I mean, it certainly brings up
19:40 --> 19:44a myriad of ethical, potentially issues,
19:44 --> 19:49so you know patients who may be of certain
19:49 --> 19:51cultural backgrounds where, for example.
19:51 --> 19:53Male members of the family may
19:53 --> 19:55come up to you before you go into
19:55 --> 19:57the room with the patient saying,
19:57 --> 20:01please don't discuss anything to do
20:01 --> 20:04with my wife's diagnosis with my wife.
20:04 --> 20:06I will manage all of the decisions.
20:06 --> 20:10So how do you? How do you manage that? Ohh,
20:10 --> 20:13you know that's a really hard question
20:13 --> 20:15and it's a really hard situation and
20:15 --> 20:18it's one that I have quite honestly
20:18 --> 20:21struggled with for years and years.
20:21 --> 20:25In general, my feeling is that as much
20:25 --> 20:28as one has to respect someone's culture
20:28 --> 20:32and how they want to approach a problem,
20:32 --> 20:34there are also ways in which we take
20:34 --> 20:37care of people in the United States.
20:37 --> 20:40And for me it's not OK,
20:40 --> 20:43not telling someone what their diagnosis is,
20:43 --> 20:46and it's not OK, not involving them
20:46 --> 20:50in any way in the treatment decisions.
20:50 --> 20:52I certainly can modify my approach
20:52 --> 20:55and I want to listen to the family
20:55 --> 20:57and respect the family.
20:57 --> 21:00But I also feel like we have to be
21:00 --> 21:03respectful of the way we feel that people
21:03 --> 21:08need to be taken care of in, in, in a.
21:08 --> 21:10Humane way here in this country.
21:11 --> 21:14You know it brings up another whole
21:14 --> 21:17Pandora's box of the issues in terms
21:17 --> 21:20of the fact that even in this country
21:20 --> 21:23different people are treated differently.
21:23 --> 21:28Whether we consciously know it or not.
21:28 --> 21:31But there are disparities in terms of care,
21:31 --> 21:33racial disparities, ethnic disparities,
21:33 --> 21:38disparities based on income and insurance.
21:38 --> 21:40And a whole myriad of other issues.
21:40 --> 21:43Can you talk a little bit about how those
21:43 --> 21:45disparities play into the management
21:45 --> 21:48of patients with breast cancer?
21:48 --> 21:50And perhaps some of the things that
21:50 --> 21:53are being done or being contemplated
21:53 --> 21:55to reduce those disparities?
21:57 --> 21:59So this is an absolutely
21:59 --> 22:01huge issue for the community.
22:01 --> 22:05It's a huge issue for us at Yale,
22:05 --> 22:08and in fact I will share that.
22:08 --> 22:11Just yesterday we had a strategic
22:11 --> 22:15planning retreat and at least 50% of
22:15 --> 22:18it was focused on community outreach
22:18 --> 22:21and issues related to disparities.
22:21 --> 22:25If we look at the medical literature,
22:25 --> 22:29it is very clear that anything.
22:29 --> 22:33That makes someone a little bit different,
22:33 --> 22:35puts them at risk for getting
22:35 --> 22:37less than adequate cancer care.
22:37 --> 22:40That's true in terms of race.
22:40 --> 22:44It's true in terms of sexual orientation,
22:44 --> 22:46education, income.
22:46 --> 22:50Disabilities and on and on.
22:50 --> 22:55And if we did nothing but eliminate
22:55 --> 22:57all the cancer care disparities
22:57 --> 22:59for women with breast cancer,
22:59 --> 23:01we would probably save at least half
23:01 --> 23:04of the lives that are lost each year.
23:04 --> 23:06And I there's no study that actually
23:06 --> 23:08has come up with that figure.
23:08 --> 23:10That's my own guess.
23:10 --> 23:12But I think that it's probably
23:12 --> 23:14quite accurate.
23:14 --> 23:15Umm?
23:15 --> 23:18So this is really a critical issue for us.
23:18 --> 23:20It's going to be an even more
23:20 --> 23:21critical issue over the course
23:21 --> 23:23of the next decade as we develop
23:23 --> 23:25better and better therapies,
23:25 --> 23:26not just for breast cancer,
23:26 --> 23:28but for all cancers.
23:28 --> 23:30The challenge for us as cancer
23:30 --> 23:32doctors and as cancer researchers
23:32 --> 23:35is going to be to make sure that
23:35 --> 23:37we get the care to everyone,
23:37 --> 23:40and that's not going to be simple,
23:40 --> 23:42but it's something that that we're
23:42 --> 23:45really going to have to work on with with.
23:45 --> 23:47Really full intensity.
23:48 --> 23:50You know, address addressing
23:50 --> 23:52disparities is something that I
23:52 --> 23:53think many institutions are are
23:53 --> 23:56looking at and trying to tackle,
23:56 --> 24:00because it is such a complex issue,
24:00 --> 24:03but I think one of the things
24:03 --> 24:07that kind of underpins it is this
24:07 --> 24:10concept of financial toxicity.
24:10 --> 24:14We know that cancer care is incredibly
24:14 --> 24:18expensive and that really the care that
24:18 --> 24:20individual patients can afford
24:20 --> 24:23varies based on their income
24:23 --> 24:26based on their insurance status.
24:26 --> 24:28And yet as we develop these newer
24:28 --> 24:31therapies that come down the pike as
24:31 --> 24:33we were talking about before the break,
24:33 --> 24:36they tend to be pretty expensive,
24:36 --> 24:39so what can we do to reduce financial
24:39 --> 24:42toxicity that can really help many
24:42 --> 24:44patients and kind of level some
24:44 --> 24:47of the playing field?
24:48 --> 24:50Well, you can think of financial
24:50 --> 24:52toxicity in a couple of ways.
24:52 --> 24:57One is of course is just the
24:57 --> 24:59sometimes substantial out
24:59 --> 25:03of pocket costs for copays,
25:03 --> 25:06but also for things like parking and
25:06 --> 25:09days off from work and childcare
25:09 --> 25:12and everything else and
25:12 --> 25:15we can certainly do our best to
25:15 --> 25:18try to help patients with that by
25:18 --> 25:20connecting them to services in
25:20 --> 25:23the Community and using,
25:23 --> 25:25at times philanthropic funds to
25:25 --> 25:27cover some of those expenses.
25:27 --> 25:31I think the bigger issue though
25:31 --> 25:34is that the cost of cancer care in the
25:34 --> 25:37United States has become truly overwhelming.
25:37 --> 25:41It's bankrupting for virtually any individual
25:41 --> 25:44who doesn't have adequate insurance.
25:44 --> 25:47New drugs cost in the range
25:47 --> 25:50of 100 to $200,000 a year.
25:50 --> 25:50I mean,
25:50 --> 25:55these are numbers we can't even fathom.
25:55 --> 25:58And so I think this is really a policy
25:58 --> 26:01issue and at some point we're going to
26:01 --> 26:07have to change our approach to the way we
26:07 --> 26:12look at drug development and the
26:13 --> 26:15way we look at the Pharmaceutical
26:15 --> 26:19industry as a whole as people may be aware,
26:19 --> 26:22many drugs are much less expensive in
26:22 --> 26:25other countries and we really don't do a
26:25 --> 26:29very good job of regulating drug prices.
26:29 --> 26:31So this is all going to have
26:31 --> 26:34to change in the years ahead.
26:34 --> 26:36We're going to need a new approach.
26:36 --> 26:38What I don't want to see
26:38 --> 26:40is a decision that we're suddenly
26:40 --> 26:43going to stop developing new drugs
26:43 --> 26:45because they're too expensive.
26:45 --> 26:49Because of course we still do need new drugs,
26:49 --> 26:50not just in breast cancer,
26:50 --> 26:52but for many many different types of cancer.
26:54 --> 26:56Yeah, but you bring up a good point.
26:56 --> 26:58Which is, you know,
26:58 --> 27:01these drugs are very critical in
27:01 --> 27:04terms of spurring on innovation to
27:04 --> 27:07help us to conquer cancer as it were.
27:07 --> 27:09But the cost really can be
27:09 --> 27:11prohibitive here in the United States,
27:11 --> 27:14which brings up another issue which is
27:14 --> 27:17there are many places in the world
27:17 --> 27:19low to middle income countries where
27:19 --> 27:22people still get cancer and yet
27:22 --> 27:25the cost of these newer therapies
27:25 --> 27:26if it's prohibitive here,
27:26 --> 27:29in the United States one can only
27:29 --> 27:31imagine how completely out of reach it
27:31 --> 27:34is for patients in other parts of the world.
27:34 --> 27:38So what responsibility do you think
27:38 --> 27:42we have here in the first world
27:42 --> 27:44to help our fellow human beings
27:44 --> 27:46in other parts of the globe?
27:46 --> 27:48And what do you think should
27:48 --> 27:49be done in terms of that?
27:50 --> 27:54Yeah, so I think we have a very
27:54 --> 27:56significant responsibility.
27:56 --> 27:58I do want to say that I think our very
27:58 --> 28:01first responsibility is making sure
28:01 --> 28:04that everyone in the United States
28:04 --> 28:06gets the care that they deserve.
28:06 --> 28:08But I think we also have to
28:08 --> 28:10focus on people around the world.
28:10 --> 28:15There are efforts that are going on with
28:15 --> 28:17professional societies in different
28:17 --> 28:19countries trying to make sure that
28:19 --> 28:21that drugs are available to people
28:21 --> 28:24and this is something that is really
28:24 --> 28:26very much a work in progress,
28:26 --> 28:28but the better our care gets,
28:28 --> 28:30the more tragic it is that care
28:30 --> 28:31isn't delivered to everyone.
28:32 --> 28:34Doctor Eric Winer is a professor
28:34 --> 28:36of medicine and medical oncology
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu
28:42 --> 28:45and past editions of the program
28:45 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:55cancer here on Connecticut Public radio.
28:55 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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August 7, 2022

Yale Cancer Center

visit: http://www.yalecancercenter.org

email: canceranswers@yale.edu

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