A discussion by leaders of Yale Cancer Center’s Early Onset Cancer Program

Transcript

00:00 --> 00:22Announcer Funding for Yale Cancer answers is provided by Smilow Cancer Hospital. Welcome to Yale Cancer Answers with the director of the Yale Cancer Center, Doctor Eric Winer. Yale Cancer Answers features conversations with oncologists and specialists who are on the forefront of the battle to fight cancer. Here's Doctor Winer.
00:22 --> 00:50Eric Winer Tonight, we have a slightly different arrangement because I don't have one guest. I have two guests, and we're going to have a panel discussion talking about early onset cancer. There's been a surge in cancer being diagnosed in people who are between the ages of 18 and 45. And in fact, since 1990, the diagnosis of early onset cancers has has risen by 80%.
00:50 --> 01:24Eric Winer And it doesn't look like it's slowing down. Our guest tonight are Doctor Veda Giri, professor of internal medicine, division chief of clinical cancer genetics and director of the Cancer Genetics and Prevention program, as well as director of the Early Onset Cancer Program. And joining us, as well as Doctor Nancy Borstelmann, who is a licensed clinical social worker, assistant professor in the Child Study Center, chief of Family Behavioral and Health Services.
01:24 --> 01:44Eric Winer These are a lot of titles and co-director of the Early Onset program. Welcome, Nancy and Veda, thank you so much for being here to talk about early onset cancers. First, what's the definition of early onset cancers and what types of cancers are being seen in these younger individuals?
01:44 --> 02:11Veda Giri Yeah, that's such an important question. And this topic overall is of paramount importance. So when we think about early onset cancers, the definition would be an individual who's diagnosed at a cancer at a younger age. So for example, diagnosed at ages 18 to 45 typically encompasses most of these cancers and can actually go up to age 49 for some cancers, for example, for colorectal cancer.
02:11 --> 02:33Veda Giri And we're seeing this increase in early onset cancers across the spectrum of cancers. So for example, breast cancer, colorectal cancer endocrine cancers uterine cancer. So it's it's really being seen across the spectrum of of cancer types and really deserves to be looked at in this sort of broad cancer specific way.
02:33 --> 03:01Eric Winer And it seems like the two that have received the most attention are probably colorectal cancer, where there's been really a dramatic increase in the number of young individuals being diagnosed and a number of very high profile people, celebrities, others who have developed early onset colorectal cancer and then breast cancer, which for years everyone would always say, aren't there more diagnoses of breast cancer in young women?
03:01 --> 03:24Eric Winer And we would say, no, it's really pretty flat and it's not increasing. And then over the past decade or so, there has been this increase in breast cancer as well. It's really both disturbing and interesting to try to understand what's what's going on. Why do we think these cancers and young people are increasing?
03:24 --> 03:50Veda Giri Yeah, that's that's exactly right. Is that's sort of the crux of the question is why is this happening. And likely it's not going to be one silver bullet that's going to explain this rise and that it's going to be multiple factors or a multifactorial reason. And that can be different for different cancer types. But in general, some of the factors that are being looked at are for example, exposures.
03:50 --> 04:30Veda Giri So exposures over the lifespan, environmental exposures, other risk factors such as diet and other lifestyle factors certainly still keeping in mind the inherited genetics. So are there genetic mutations that could be inherited in families for a subset of those families to really have an increased risk of cancer, a really interesting phenomenon that's being looked at as a birth cohort effect that has been reported on where potentially these rates have been linked with rates of rise of early onset cancers for those individuals that were born in Gen X and B and and more recently, more recent cohorts.
04:30 --> 04:55Veda Giri So the millennials and then Gen Z compared to, for example, baby boomers. And so when we think about what changed in foods, in processing of foods, in exposures, in lifestyle, that's where a lot of the epidemiologic studies become really important is to think about what these trends point to, and then what could be the biologic and underlying basis and mechanisms for the rise in various early onset cancers.
04:55 --> 05:16Eric Winer And even in families where there's a genetic predisposition, for example, families with BRCA mutation, there's been the sense that over the course of the last hundred years, that these diagnoses of breast and ovarian cancers in those families are occurring at a younger age.
05:16 --> 05:44Veda Giri These genetic mutations can be really important in giving us an idea of which individuals might be at risk for cancers at a younger age. So, for example, with these BRCA mutations, we actually think about because of the younger age of onset, potentially starting screening even at a younger age. So those are the same for some key gene mutations, even in colorectal cancer, as we think of some of these top two cancers that we hear about in the news.
05:44 --> 05:46Eric Winer What about the microbiome?
05:46 --> 06:13Veda Giri Yes. It's a really important and hot topic of research right now. And and I think it's actually going to be a very fruitful area of research to think about the causes and connections, not only with early onset cancers, but cancers in general and other disease conditions as well. So the thought there is that the microbiome is connected with immune regulation, and there's actually a strong scientific evidence for that.
06:13 --> 06:31Veda Giri This immune regulation is important in surveillance or finding cancer cells, getting rid of them by the body or even keeping them in check. So this goes back to what are some exposures that can affect the our gut microbiome.
06:31 --> 06:32Eric Winer And that includes diet.
06:32 --> 06:41Veda Giri And that includes diet. Absolutely. And then how that can then affect cancer development again from a multifactorial process.
06:41 --> 07:11Eric Winer I'm going to turn to Nancy. And maybe you can talk a little bit about what's different about cancer care in somebody who's younger. So somebody who's 25 or 30 or 35 or 40, you know, how is that different than for the more typical patient waiting for cancer treatment in the waiting room who's in their 50s or 60s?
07:11 --> 07:14Veda Giri Such a key point to.
07:14 --> 07:53Nancy Borstelmann Make about what is it that cancer is still the context, and it's scary and frightening for most people. No matter what your age is, and it it changes your life in a lot of ways. However, if you are a younger person, say 2030s 40s, you're at a point in your own development that it is more particularly disruptive. So, for example, you may be dealing with planning a family, building relationships, a graduate school, or trying to get into work and building a career.
07:53 --> 08:00Nancy Borstelmann And maybe not as financially stable as someone who's in their 50s and 60s.
08:00 --> 08:07Eric Winer And maybe we'll get to that whole issue of financial problems a little later, because that's really important. But continue.
08:07 --> 08:33Nancy Borstelmann It's a pretty complex picture, because when you think about cancer care and the number of appointments and treatments procedures, how many times do I have to come into the cancer center? How do I arrange this around the rest of my life? So there's complex decisions for them to make about practical, logistical things, but also about very important milestones in their own lives.
08:33 --> 08:53Nancy Borstelmann For example, what about fertility? Am I going to be able to have a child? Can I have another child? A kind of decision making will that involved? How much will it cost? What does my partner think about that? And maybe do I need a testing and what is that going to mean for me? And what about my family?
08:53 --> 08:58Nancy Borstelmann So treating the cancer alone isn't enough. In cases like this.
08:58 --> 09:24Eric Winer It is oftentimes very different for young people. I'm reminded at the moment of someone I take care of who was in her early 30s at the time of cancer, her cancer diagnosis, her breast cancer diagnosis, and was also 35 weeks pregnant with her second child at that time. And that pregnancy, which was, you know, complicated enough, having a child, having a second child.
09:24 --> 09:36Eric Winer But suddenly there's this whole world of cancer treatment thrust upon her and her husband and her mother and her father and her daughter. And it's really complicated.
09:36 --> 09:44Veda Giri It becomes complicated very quickly. And for all of those who are not only the patient, but their caregivers and loved ones.
09:44 --> 10:00Nancy Borstelmann Paying attention not only to the patient, but also their network. So partners, family members, children, that's a topic that often comes up with younger patients because they may be raising children and thinking about, how do I talk about this? What about the impact on them?
10:00 --> 10:19Eric Winer So how are early onset cancers usually presenting for medical attention? Because oftentimes we don't do any cancer screening in younger people. So what does this look like for the patient and and for the clinical team.
10:19 --> 10:58Veda Giri In the average population there are recommendations on screening and what age to start screening for various cancers. And so therefore there are typically, you know, say 40 or starting at age 50 for various different cancers. Now when we think about younger individuals, they are often presenting with symptoms because screening would not have been initiated yet. And so, you know, some of these symptoms could be potentially underappreciated because these individuals are busy, they're living their lives, they're going to work, they're taking care of children.
10:58 --> 11:20Veda Giri But by the time the symptoms occur and they present to their physician or to the health care team, the concern is, could there have been a cancer that had potentially advanced or grown in the process? The key thing that we tell individuals, even at a younger age, is not to be alarmed by every symptom, but keep an eye on it.
11:20 --> 11:39Veda Giri And if it is persistent, if it is increasing, despite some conservative measures for taking care of some of these things, bring it back to the attention of your health care team. Because cancers can occur in younger individuals, it's not as common, but it can occur and therefore that advocacy becomes important.
11:39 --> 12:11Eric Winer Sure, you can easily imagine how a younger person doesn't think that it's very likely they're going to have cancer. They're busy, they have a symptom, they don't want to think it's cancer, and they attribute a symptom to something else. And on the flip side, when these people sometimes see their their doctors and many of them don't have such established relationships with doctors because they don't have medical problems on the physician side or the nurse practitioner side.
12:12 --> 12:20Eric Winer No one wants to believe that a young person has cancer, and so the symptoms are often somewhat dismissed by the health care team to.
12:20 --> 12:52Veda Giri Absolutely. And so therefore, this awareness really needs to happen from multiple angles in terms of to patients, to the public, and also to the health care community. And that work is really important from an education and awareness standpoint that cancers can occur in younger individuals. And what are the ways to not only think of screening in younger individuals and who those individuals are, but when symptoms occur, to really think about taking these symptoms seriously and follow through on the evaluations.
12:52 --> 13:20Eric Winer So I'm going to ask one more, what is not a quick question, but I'm going to ask you to give a quick answer. And then we're going to pick up on it in the second half. Should we be rethinking screening approaches for younger individuals and how should we do that. And what are the challenges. And maybe, you know, since we're a little short on time, you can give me a couple of sentence answer and then we'll pick up as we start the second half.
13:20 --> 13:33Veda Giri I would say the quick answer to that is risk based screening is really the way to think about this, particularly for younger individuals. That helps us to think about who to start screening at a younger age and the strategies for how to do that screening.
13:33 --> 13:44Eric Winer Well, we will pick up on just that point when we come back in a minute with doctors Veda Giri and Nancy Nancy Borstelmann talking about early onset cancers.
13:44 --> 14:05Announcer Support for Yale cancer answers comes from Smilow Cancer Hospital, where the early onset Cancer program provides care and support for patients from 18 to 45 years old. The program's mission is to reduce the burden of cancer and improve patients quality of life. SmilowCancerHospital.org.
14:05 --> 14:28Announcer It's estimated that over 240,000 men in the US will be diagnosed with prostate cancer this year, with over 3000 new cases being identified here in Connecticut. 1 in 8 American men will develop prostate cancer in the course of his lifetime. Major advances in the detection and treatment of prostate cancer have dramatically decreased the number of men who die from the disease.
14:28 --> 14:55Announcer Screening can be performed quickly and easily in a physician's office using two simple tests, a physical exam and a blood test. Clinical trials are currently underway at federally designated comprehensive cancer centers, such as Yale Cancer Center and Smilow Cancer Hospital, where doctors are also using the Artemis machine, which enables targeted biopsies to be performed. More information is available at YaleCancerCenter.org.
14:55 --> 14:58Announcer You're listening to Connecticut Public Radio.
14:58 --> 15:26Eric Winer Welcome back to the second half of Yale Cancer Answers. I'm Eric Weiner, and if you're just tuning in. I'm back with doctors Veda Giri and Nancy Borstelmann, who co-lead the early onset cancer program. We were talking about screening and younger individuals, and we said we would pick up on this. So risk based screening, that means that we identify individuals who are at higher risk and need to be screened, correct?
15:26 --> 15:52Veda Giri Yes. And how do we do that? There are some key factors for identifying increased risk for cancers. Some of these key factors are family cancer history. So knowing the cancers in our families, in our blood relatives. And when we think about this, let's think about it broadly. So we think about our mother's side of the family, our father's side of the family.
15:52 --> 16:12Veda Giri And also we think about males and females on both sides of the family. We think up to our grandparents generations and all the way down to children and nieces and nephews. So we think about this broadly, because there can be clusters of cancers that go together, that make us think that there is an increased risk of cancer in this family.
16:12 --> 16:36Veda Giri And that can also guide cancer screening recommendations just even based on family cancer history. The other important part of that is for guiding genetic testing. So cancer genetic testing for inherited cancer risk can be another really important tool to help us get an estimate of cancer risk in an individual. And if the cancer risk is high enough, there are actually recommendations to start screening.
16:36 --> 16:59Veda Giri For example, for, let's say, breast cancer in a female with a BRCA genetic mutation to start breast cancer screening in her 20s, and to change the strategy of screening or enhance that strategy. So not only to think about mammograms at the right age, but add in breast MRI, the same can occur and apply for colorectal cancer. So another cancer that is really on the rise.
16:59 --> 17:21Veda Giri And for colorectal cancer with specific genetic mutations or even with a family history of colon cancer, we would typically begin colon in a person's 20s for some of these genetic mutations, or ten years prior to having a close blood relative, like a parent or a sibling with colon cancer. So it really does impact the age to begin screening and the strategy for screening as well.
17:22 --> 17:44Eric Winer And I guess the other population of people, although it's not a thankfully a large population, are individuals who have had pediatric cancers, who are at risk for a variety of adult cancers. Oftentimes they're under the care of some team following them for their pediatric cancer, but oftentimes they they lose track of that team.
17:44 --> 18:17Veda Giri That's right. That's a very important point, because these individuals that have had childhood cancers really do need to be followed longer term for secondary cancer development could have been related to, for example, radiation that had been received for their cancer, potentially even chemotherapies that were received for their cancer or other types of therapies. So this continuum from childhood cancers, this adolescent young adult population into adulthood, and this early onset cancer population becomes an important patient continuum to think about.
18:17 --> 18:27Eric Winer Nancy, what went into the development of the early onset cancer program at Yale? Why why did you all develop this?
18:27 --> 19:00Nancy Borstelmann So as we've been talking about the rising numbers of cancer being diagnosed in younger patients, I think we kind of collectively wanted to respond to that with a pretty comprehensive view of what is going to be most helpful. So number one, looking at how to, as we've touched on earlier, supporting patients with the complexity of psychosocial, more unique needs of the younger of this younger population.
19:00 --> 19:28Nancy Borstelmann Thinking about what are some of the gaps in research that are out there and what can we influence with our own program, but also in partnership with others and community awareness? So we want to be able to do some education for those in the community about cancer risk. And finally thinking about physicians, clinicians, nurses and others where we might be able to help do some more informing about the key issues for these younger patients.
19:28 --> 19:35Nancy Borstelmann I think overall, our approach is to go wide, but also to think about how to be personal.
19:35 --> 19:51Eric Winer My understanding is that the approach here was to take a pan cancer view, that that if you were young and you had cancer, that you would be eligible to participate in this program to get services from it, and also to participate in the research that's offered.
19:52 --> 20:15Veda Giri And thinking about building an equity from the very beginning. So really making sure that we're addressing the needs of populations across the board. And that pan cancer model is really helpful because we can learn lessons from the various different cancer types in various populations as a model to address across the cancer types. While we still keep that personalized, that can lead to particular types of challenges for patients as well.
20:15 --> 20:34Eric Winer And for people who participate in the program, there's collection of data and blood and other sorts of things to tissue, tumor tissue. So to serve as a resource for researchers in the future. And we don't mean far in the future, near in the future.
20:34 --> 20:59Veda Giri Yes, we've launched research in that aspect to be able to follow individuals for questions such as what's causing aggressive cancers in some individuals with early onset cancer, and also what are the patient outcomes? How can we improve patient outcomes, whether they're clinical outcomes or outcomes that are important in the care of patients, such as fertility outcomes, various different things patients experience?
20:59 --> 21:07Veda Giri All of that does take banking of data and bio banking efforts to really be able to pull this information together and have it lead to meaningful results.
21:07 --> 21:49Eric Winer Yeah. You know, there are sort of two schools, one that says that these early onset cancers are really very different from all other cancers, and the other that says that they're arising in young people, but they don't necessarily behave so differently than the cancers in older individuals. The truth, from my point of view, is probably a little bit in between that there isn't something so terribly unique necessarily, but that obviously having cancer at a young age is is just a little different, and may suggest that the cancer itself is sometimes a little more aggressive.
21:49 --> 22:09Veda Giri I think I agree with you. I think it's it's really that it's somewhere in between. And I think we've all had experience with some with patients that have had cancers respond to our standard of care therapies and have wonderful outcomes who've been diagnosed at a young age. And we've also seen patients where the cancer was not responsive. And what was the reason for that.
22:09 --> 22:20Veda Giri So I think, again, it's going back down to that precision type of an approach, personalized approach. And I think we see patients, you know, across the board there when it comes to the cancer aggressiveness.
22:20 --> 22:43Eric Winer Yeah. We haven't talked a lot about prevention because prevention is still something that's a challenge across all of our and even more so for these early onset cancers. But I think that the concept of precision prevention, much the way that you want to target screening based on risk, is something that ultimately is very important.
22:43 --> 23:06Veda Giri Yes, I think that's really where there can be so much headway made, whether it's in precision prevention, improvement in clinical trials and helping us understand how better to treat these patients when they're diagnosed, screening to detect these cancers at a curable point. Really, all of these together is so important when we think about reducing the burden of early onset cancers.
23:06 --> 23:09Eric Winer So Nancy, what is connect.
23:09 --> 23:49Nancy Borstelmann So connect is one of our first initiatives in our program. And it's about personalized enhanced navigation. And what that means is we're reach out to new young onset patients and do a sort of special interview with them focused on what might be their needs, concerns, what's most important to help them with any essentially barriers that might be in that might be in the way of they're getting the best care possible, or that may be adding to distress or confusion or complexity.
23:49 --> 24:20Nancy Borstelmann So what one of our navigation specialists does is meet with them, go through it, really work on how to personalize a response to their needs and concerns, whether it's information, resources, services, either within Yale but externally as well, or nationally regionally, so that we really help them with what is most important and also reduce distress and maybe even prevent more issues for that patient.
24:20 --> 24:48Eric Winer Let's talk for a minute about money, because financial toxicity, as it's often called now, but the financial stress associated with having cancer is a big deal for many, many patients with cancer. But it's a particularly important issue for younger patients. You mentioned earlier that they may just not have the same resources that someone who is older and at the same time may have more expenses.
24:48 --> 24:51Eric Winer They're feeding their kids. They're all of this.
24:51 --> 25:16Nancy Borstelmann Yeah, that is absolutely essential to assess and to ask very specific questions to help patients who may hesitate to talk about financial stress. What we've been learning from our patients is how common it is. And we know from larger studies that are also done on financial toxicity that younger individuals are more affected by it than older cancer patients.
25:16 --> 25:28Nancy Borstelmann What we really want to do is have them say, here's what I'm really struggling with, and then can we work with them to find resources that might defray what they already have in terms of income.
25:28 --> 25:46Eric Winer The rate of people having to declare bankruptcy is shockingly high in young people with cancer. And of course, if you're worrying about how you're going to pay the next month's electric bill, it's just an added stress in addition to everything else you're going through.
25:46 --> 26:16Nancy Borstelmann That's so on point because they have to deal with their cancer, but they also have to think about mortgage rent. The kids need new backpacks, schools starting food and transportation, childcare that they hadn't expected. All while they may also be reducing the amount of time they're working or that their partner may be working because they need support. You have to look at the big picture and the whole context in which patients are living, so they can get the best care possible.
26:16 --> 26:20Eric Winer So, Veda, what are the research priorities in this area?
26:20 --> 26:43Veda Giri There's a lot there's a lot that can be done here to fill in the gaps and make some really true advances in this space for early onset cancer. So thinking about the key questions why are these cancers occurring? Who is at risk for developing these cancers at a younger age? How do we better treat these cancers for patients that develop cancers in this early onset age range?
26:43 --> 27:08Veda Giri And then how do we also help these patients into survivorship is a very big important aspect of care because we really expect these individuals to be, you know, living many decades beyond their cancer diagnosis. So it really spans a lot of different research areas such as basic science, epidemiology, clinical research, public health. So it's it's a vast area of work.
27:08 --> 27:23Veda Giri And it really takes dedicated research efforts within, for example, early a dedicated early onset cancer programs, but in collaboration and in partnership with researchers, you know, so that we can bring our minds together and think about this.
27:23 --> 27:26Eric Winer Just to just to end, where's this program headed?
27:26 --> 28:08Nancy Borstelmann Our our hope by expanding our outreach for for patients is that we'll be able to touch more younger patients lives. So not only locally, but across the whole state of Connecticut. And make sure that that we don't miss anyone. And we are hoping that we can be somewhat of a model for others just by talking about it, but also doing research, publishing, speaking, and also finding ways to partner with other cancer centers and other programs so that we collectively are strengthening the whole network of care for younger patients.
28:08 --> 28:37Eric Winer Well that's great. Well, we're going to have to close. I want to thank our two guests tonight, Doctor Veda Giri, professor of medicine at the Yale School of Medicine. Doctor Nancy Borstelmann, assistant professor in the Child Study Center, both of whom lead the early onset cancer program here at the Yale Cancer Center. And throughout Smilow. And to our listeners, talk to you again next week.
28:37 --> 28:56Announcer If you have questions. The address is CancerAnswers@yale.edu and past editions of the program are available in audio and written form at YaleCancerCenter.org. We hope you'll join us next time to learn more about the fight against cancer. Funding for Yale Cancer answers is provided by Smilow Cancer Hospital.

Information

Dr. Eric Winer speaks with other leaders of Yale Cancer Center’s Early Onset Cancer Program about the need for this program and how they are helping patients diagnosed with cancer ages 18-45.

Yale Cancer Center

Visit: https://medicine.yale.edu/cancer/

Email: canceranswers@yale.edu

Call 203-785-4095

14478

Guests

Veda Giri, MD, Director, Early Onset Cancer Program and Nancy Borstelmann, PhD, MPH, LCSW, Co-Director, Early Onset Cancer Program.

To Cite

DCA Citation Guide