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The Curbsiders (00:00.258) All right, Molly, this is an attempt to be Matt and Paul right now, but what do you get when you cross a robot in a tractor? Hmm. A Tesla truck? Oh, so good. Those cyber trucks are so uggo. No, you get a transformer. Get it? Like a transformer, but a farmer. It's always really good when you carefully explain the details of the pun. So. The Curbsiders podcast is for entertainment, education, and information purposes only, and the topics discussed should not be used solely to diagnose, treat, cure, or prevent any diseases or conditions. Furthermore, the views and statements expressed on this podcast are solely those of those and should not be interpreted to reflect official policy or position of any entity aside from possibly cash -like moral household and affiliate outreach programs. If indeed there are any, in fact, there are none. Pretty much we are responsible if you screw up. You should always do your own homework and let us know when we're wrong. The Curbsiders (00:57.294) Welcome back to the Curbsiders. I'm Dr. Molly Hoidlein, joined by my co -host, Dr. Ira Krishnasgaya. On tonight's show, we discuss breast cancer for the PCP with our guest, Dr. Sandhya Pruthi. Unfortunately, Dr. Watto and Dr. Williams couldn't be with us tonight, but don't worry, we'll be channeling their spirit in our episode today. Ira, will you remind the audience what we do on the show? Sure, Molly. We are the Internal Medicine podcast. We use expert interviews to bring you clinical pearls and practice changing knowledge. We have a fantastic conversation with our guest, Dr. Sandhya Pruthi. Dr. Pruthi is a consultant in the Department of General and Territal Medicine and a professor of medicine. Her research and clinical expertise is in breast cancer prevention and management of women at increased risk for breast cancer, hereditary breast and ovarian cancer risk, and providing preoperative counseling to women newly diagnosed with breast cancer. She is the Mayo Clinic PI on several national breast cancer prevention and biomarker trials aimed at reducing the risk of breast cancer. Dr. Pruthi teaches us so much about the initial management of breast cancer today. We ran through two cases, one on DCIS and one on invasive ductal carcinoma. She really teaches us some great techniques of how to counsel our patients who are newly diagnosed, how to share that information with them, and how to think about breast cancer across a spectrum of favorable, like DCIS, to more concerning types of high -risk breast cancer. So without further ado, let's get to it. Dr. Prithi, thank you so much for joining us. We're really excited to talk with you today. Are you okay if we call you Sandhya for this recording? Absolutely. And you said it beautifully. Yes. Thank you. Well, just to get to know you a little bit, can you tell us a little bit about yourself, a hobby or interest outside of medicine? Yeah, absolutely. Actually, medicine has been my hobby for the, what, the last 28 years that I've been in practice. But I would say, My newest hobby is playing golf. Nice. How did you get into that? Yeah, I raised two sons who are actually really good golfers, really proud of them. And I would take them to all their golf meets and introduce them when they were just toddlers. And I love the sport. And so it wasn't until this year where my husband said, look, you need to do something when you retire. The Curbsiders (03:18.734) since you love golf and you never play it, why don't you start playing? And so I said, well, you buy me a new set of golf clubs. And he did. And that's how I got in. Got back into the game. Yes. Yeah. And I'm curious how, as an internist, you got into this realm of working in breast cancer. Yeah. So my training has actually been in family medicine was I did my residency at Mayo Clinic in family medicine. And it just so happened that the year that I graduated from family medicine, a breast clinic had been opened in the Department of Medicine. And it was the Department of Medicine chair who was probably one of my greatest mentors who met me and said, hey, we're looking for women who do women's health to work in a breast center. And at that time they were having physicians rotate from OB -GYN. and FamilyMed and internal medicine because it was a breast health center that they had created and developed within the Department of Medicine. And he said, you have everything I was looking for, a primary care provider with an interest in women's health, being a family doc, trained at Mayo, would you start working here? And that's how it took off. I love that. I feel like there's so many times in our careers where... It's not necessarily a path that we see it from the long view, but then it just really shapes where you go in the future. And I love that there was like a gap or maybe an opportunity and your kind of journey just opened doors. Yes, exactly. And I got along the way some other mentors, oncologists who I had met in my training who had said, we actually would like to have a primary care doc who's interested in breast to take on the prevention trials. The STAR had just opened the large prevention trial with tamoxifen with comparing Riloxafen for high -risk women and the oncologist said it doesn't belong in oncology, it belongs in the high -risk breast clinic and The Curbsiders (05:33.632) would you take on that trial? And she opened doors for me in ways that I couldn't have imagined to continue to build my expertise in prevention trials with not only STAR, but went on to lead MAP3 and numerous other ones in the prevention space, all because of an oncologist who said, this is a great match for you. And the timing again was right when my career in the breast clinic was... starting to take off and my interest in research. Well, that's amazing because I also feel like it gives a lot of support for embedded primary care clinicians in kind of maybe subspecialty worlds and that integration, how successful it can be and also how timely it sounds like when kind of you were at this, the breast clinic was opening up and you were kind of seeking or finding that opportunity. Within this amazing career that you've had, I wonder, Cindy, would you be able to share kind of the most meaningful advice you've ever received during that very star -studded career? Yes. So back to the mentor who actually had the vision to develop the breast clinic. He's a cardiologist and his name is Dr. Bob Fry. He told me when he hired me, he said, I'm going to give you some advice. that I hope you will respect, but also take it on as you look forward as to what your career at Mayo could look like. And he said, I know from all of your reviews and your training, your evaluations, you are an amazing clinician and you have great physician -patient rapport, but you will need to do more in your career so you don't get burnt out as a clinician. and I ask you to start looking at other scholarly research administrative roles that will, within medicine, that will provide you with other avenues to grow and not just practice medicine, patient clinician care as a sole part of your career at Mayo. The Curbsiders (07:44.238) And I said, wow, that's not, somebody has never told me that. He said, because we all train to be doctors and we stay in the field of medicine. He said, you'll do that. And no one's asking you to stop that, but start to expand your horizons early and look at those opportunities to avoid future clinical burnout. Love that. And I think absolutely that's what we really love about academic medicine is that opportunity just continue to grow and continue to learn. And, being able to just keep exploring new things and keep advancing your career in different ways. Let's move on to picks of the week. Does anyone have something they want to share? A piece of media or just a recommendation for the audience? Molly, I love that you threw it out there as if I didn't have a pick of the week or I was going to pause for effect. I will highly recommend folks see the Renaissance tour movie. So it's Renaissance, a film by Beyonce. And basically she kind of, it's a documentary that she wrote, directed and produced actually, and catalogs her tour, but specifically focused on her shows in LA. And it is incredible. It's... It made me cry, it made me laugh, it made me dance. I feel like I learned more about Beyoncé, her inspiration for the seventh album, Renaissance, and kind of the ballroom dance scene into the 1970s, especially the black dance music and the kind of ball culture. And I learned a lot about her, kind of the making of the tour. There was like... almost a documentary style of it. Kind of like you saw how the stage got set up, how there are multiple stages, how those stages were in transit in between her tour dates. And it's just a really incredible kind of visual companion to her music. She usually releases some sort of visual album or music video along with her albums. And this was just that. I think everybody was waiting for that. And... The Curbsiders (09:43.886) So just highly, highly recommend whether it's in theaters or whichever streaming service it goes to, that people check it out. I don't know, Molly, if you have one or? I have sort of an unusual one. So my kids and I have a garden together and we love to work on it. And now that it's winter, we obviously can't be doing too much there. So we were looking to kind of think about what we're going to plant in the spring, which luckily in California comes not too far away. So I wanted to recommend the Hudson Valley Seed Company. They just have these really beautiful art seed packs. And so they get artists to make these kind of abstract or different take on the plants. And they're just really artistically beautiful. And then they just have unusual and heirloom types of seeds. So we got some purple snap peas and these little birdhouse gourds and just a weird variety of things. So we'll see how they go in the summer. Well, let's jump into a case from Cash Slack. our hospital here, Casheulic Memorial. So our first case is that you're reviewing your inbox and find the following results on your patient, Sophia. Her screening mammogram shows the breast is heterogeneously dense, which may obscure small masses. There is a 20 millimeter group of coarse heterogeneous and amorphous calcifications with a few linear calcifications in the left breast upper inner quadrant by red sore. She gets a core needle biopsy of these calcifications, which shows ductal carcinoma in situ, DCIS, is present on multiple cores with a linear span of at least 3 .5 millimeters. So I think all of us in primary care have probably gotten these results that are in box. And just to kind of take a step back, what is DCIS? And can you give us just a brief overview of sort of the most common malignant diagnoses that may come back on an abnormal breast biopsy? Yeah, that's a great case, and I probably see one of those a week. Here's what I would like to think of it in terms of a way to make it less anxiety -provoking when a cancer diagnosis like DCIS is given to a patient. I will always start with a reminder that breast cancer is a very heterogeneous disease, that not all breast cancers are the same. The Curbsiders (12:00.526) And I come back to this term that I think really resonates with patients. It's called the biology of breast cancer. And understanding the biology of your cancer type will help us make sure that we're providing the right treatment with the right recommendations that are based on the biology of the cancer. And when you think of DCIS on that spectrum, we have very favorable great prognosis, cancers, biology, and on the other spectrum there can be very aggressive poor biology, poor prognosis cancers. And if you think of that spectrum, DCIS falls on the very other end of the favorable good prognostic cancers. And I come back to the first thing I'll tell them when they get that diagnosis is that, would you throw away the word chemotherapy out of your words in your brain and let's not even go there. And that is just a huge relief right away, because I start with that, because they're waiting to hear that and they don't want me to forget to bring it up. And I'm like, we're not even talking about it in DCIS. So once we set that up, and I say we don't use chemotherapy in the treatment of DCIS. And then I talk to my patients about DCIS. as being a contained cancer within the ducts of the milk glands and milk ducts within the breast. And these contained cancers are contained. They don't break out of the duct. And we get into sort of the treatment where surgery is recommended. And we talk a lot about, you know, the extent of DCIS will then factor in. is this a case where lumpectomy is an option followed by radiation or is a mastectomy needed because of the extent of disease. So those are important sort of information pieces that patients need as we're talking through their diagnosis. We then will get into radiation and the different types of radiation and followed by anti -estrogen treatment. Is tamoxifen an option? The Curbsiders (14:24.448) Are there newer treatment options around low dose tamoxifen for patients with DCIS? And so it's an important thing to sort of remind patients that there's a treatment course and we will talk about each one of these based on their personal needs and their values as we talk through the treatment from surgery to radiation to taking a drug. Sandy, that was super helpful, because I feel like I've never had DCIS explained so clearly. And also kind of with those maybe alarm bells removed. And speaking of alarm bells, I can imagine if I got this result in my inbox, there would be a lot of alarm bells. And I'd be like, Ira, how are you going to do this? How are you going to talk to the patient? And I wonder if you can maybe take a step back before that amazing conversation that you just laid out and share maybe. Is this something that when you get this result, you're calling somebody over the phone, you're asking them to come in person urgently, and maybe what's the actual language you use when you talk about that spectrum that you just beautifully laid out and letting people know chemo is not what we're thinking about right now? So to follow up on that very important first comment you made, how do you make that call when you're in primary care and you get that report? We always say it's best to talk about a cancer diagnosis, even if it's non -invasive versus invasive in person. But sometimes that's not possible. And one thing that I have done in preparation for a patient going on to a breast biopsy for calcs is to advise them that there are three different possibilities that could come out of your biopsy. We may find benign fibrocystic. changes, we may find atypia, which is known as a precancerous change, or they may find DCIS, which is this contained cancer. So if I do that in advance, making that phone call, if it's the only chance I have to get to that patient, is a lot easier because the words have been discussed before they go to the biopsy. So I think as a primary care provider who gets that call, knowing that calcifications on the mammogram could represent The Curbsiders (16:39.06) anywhere from benign fibrocystic to DCIS, which is why we're doing the biopsy, to get a better understanding of which of those three categories you may fall into. So when we talk about DCIS and I mentioned the concept of contained cancer, that is a cancer that stays within the ducts and does not break out of the ducts, therefore we don't worry about lymph node involvement. in DCIS, we remind them that people often tell us that DCIS is behaving a lot like a pre -cancerous lesion before the kind that they're more concerned about, which is the invasive cancer that has a tendency to spread. Ductal carcinoma in situ is actually not as common as invasive cancers. When you think about in the United States, we estimate about 50 % of thousand women will get in situ diagnosis and 200 ,000 will get an invasive cancer diagnosis. So that's important to remind patients. But when DCIS is caught early, I will tell them on the phone that you are in a better position to make surgical decisions that are right for you. Yeah. And what do we understand now about the biology of DCIS? Is it actually a precancer? Like if we didn't treat it, would it turn into invasive cancer? You know, Molly, it's actually interesting talking to oncologists, and I'm not an oncologist, but I work with many. I have presented at national meetings where there are a lot of oncologists in the room, and I've heard and listened as I've watched how people describe DCIS. Yeah, you're going to get an interesting sort of a separation around how those who feel it really is just precancerous and We should not be over treating DCIS to those who say, you know, the biology tells us there is an invasive risk of this cancer over time transitioning from in situ to invasive and therefore we must be aggressive and treat it like we would treat surgical options and discuss that for an invasive cancer. There's no doubt in my world when I'm talking to patients, I will tell them DCIS is a form of a cancer. The Curbsiders (19:02.222) Yes, it's a contained cancer, but it's caught at an early stage because those calcifications brought this to our attention because of the value of a screening mammogram. And getting your mammogram for this exact reason, I would rather be telling you you have DCIS than telling you have invasive because we did not detect early when the opportunity could have shown on a mammogram that this is something that was already starting within your breast. So there again is my opportunity to talk about the value of screening mammography and getting annual mammograms because I'd rather catch it at this stage when they can see those calcs, confirm on a biopsy, it's DCIS, and then provide you treatment options that, yes, would avoid chemotherapy. It sounds like it's pretty controversial still about the risk of progression from DCIS to invasive carcinoma. I've seen some protocols locally for active surveillance for DCIS rather than aggressive treatment. Is this something that should just be part of a clinical trial or is this happening in prime time and who would might be an appropriate candidate for that? Yeah, so that's great. That's known as the Comet trial. I was one of the PIs for Mayo. We brought that trial to Mayo. It was open, I think, across 40, 50 sites in the US. It's a closed, it is a trial that was specifically designed for women diagnosed with DCIS, low to intermediate grade, and hormone receptor positive cancer. And they were randomized based on that pathology to an active surveillance arm, which included having a mammogram every six months for five years versus usual treatment, which could go on to surgery. surgery plus radiation, surgery plus radiation plus medication. On the active surveillance arm, the patients were not only given the mammogram surveillance every six months to watch those calcs, and if those calcs progressed and became more than five millimeters in terms of the measurement of calcs, we would rebiopsy them. The Curbsiders (21:16.462) and reassess them and decide if it's still DCIS, low to intermediate grade, continue with active surveillance. If anything further than that, they would go to surgery. And in the active surveillance arm, we were also able to offer them anti -estrogen as a medication that they could take. The trial occurred very well. It's closed, and we're waiting for the data analysis. But having put many patients on the trial and been part of the study team as a PI for Mayo, I was really excited to see the active surveillance arm being watched. Yes, I watched several patients on trial and the calcs don't always progress and they remain stable. And sometimes they may be less obvious on a mammogram over time. So yeah, it makes you wonder as you talk, Molly, as to the DCIS, why some... change over time and others may not. Again, back to the biology of that specific individuals, DCIS, you know, is it one of those that are going to not become a problem in her lifetime? So yeah, we're waiting for the results, but it opened my eyes to some women who say, what if I just want active surveillance, would you watch me? And having the six month mammogram in the protocol, as a nice sort of reminder that it's good and it is a good technique to monitor the calcs. It allows us to watch them. The clip is there and they can see them. The radiologists are really helpful in guiding us saying, hey, these have changed, let's rebiopsy them. So there are opportunities that will come out of this trial. I hope that not every woman will have to make a surgical decision. Any expectation of when we'll see those results? Not yet. I know that... We're still looking at about another year potentially, I think, to seeing those results. But the study has closed. I feel like there's a lot of application of this potential study trial. And just to kind of not to totally anchor on this incredible education module that you have, but I wonder when you're going through that, are there areas that most of your patients end up pausing or asking for more clarification? The Curbsiders (23:37.582) And have you found that maybe that's around the question of, do I need the surgery or can I just be surveilled of sorts? And what do you say with the trial not being out yet as an option for your patients? Yeah, no, actually, I do want to bring that up. There's this another set of guidelines called Choosing Wisely, where you may not need radiation after a lumpectomy. again, back to the tumor biology, the age of the patient, where radiation is not going to add any more. And those are the questions patients say, what if I just had this removed? If you're not as worried about it, do I have to have the radiation? So that's something to think about that has come up. And I think that there are conversations occurring right now with radiation oncologists where some DCIS after the excision may not need additional radiation. So I think that... I'm waiting to hear more on that because that's probably the most significant question patients have who have a lumpectomy. Why do I have to have the radiation? So for years, we would say that lumpectomy with radiation is equivalent to mastectomy in terms of preventing a recurrence of that cancer. But if there are some very low grade DCIS where radiation isn't indicated, I think that's going to really also... change the paradigm on how we treat some DCIS. That's amazing that we're learning so much more about how to really risk stratify women and not just be extremely aggressive, but be able to minimize the harms of treatment. So really exciting moves forward. There is this whole concept of deescalating therapy is really exciting when I'm actually in the room with patients counseling them across a lot of these, again, back to the biology, their age. the tumor type when saying, you know, we may not need to go after a sentinel lymph node based on some of the cancers that are being diagnosed, because that's another concern is when do I have to have that sentinel lymph node biopsy? Well, Sophia, our patient, has been very happy to learn a lot about her diagnosis, and she's feeling a lot more confident before seeing her oncologist and really pinning down that plan. But she is worried because her mom was diagnosed with breast cancer at age 58, and she has two daughters. The Curbsiders (25:58.99) She wants to know if she should think about genetic testing or should her daughters think about genetic testing. So what are current recommendations around who should be referred for that? So at this point, our patient Sophia, under the age of 60, being diagnosed with a cancer, DCIS or invasive cancer, any kind, we should be recommending that she meet with a genetic counselor to pursue genetic testing herself. We know that she alone, having a cancer before age 60 are the guidelines that are used to say all of these women should be offered genetic testing. Now, her mother's history does play a role, obviously, and the mother's age of diagnosis would be another factor in deciding if the mother herself should be tested. And if Sophia didn't have cancer but was at high risk because of atypial or another benign breast biopsy, knowing that her mother had cancer, a history of age of diagnosis again would factor in what I offer my patient a genetic test. I would want her to have had her mother at least consider testing. And if the mother doesn't want to do it or is not alive or someone she is in contact with, then we would offer Sophia, our high -risk patient, genetic testing because... Now, genetic testing is much more affordable and easier to do than in the past, which was a $3 ,000 test, is now a $250 multi -gene test. So why wouldn't we want to at least have her exclude her risk of having a high -risk mutation or identify it? So yes, we're having those conversations more so now than ever before that any woman who has... Strong family history, young onset affected relatives with breast ovarian cancer or relative with breast and ovary or a male with a breast cancer in their family should be considered for testing. And Sandhya, besides BRCA1 and 2, are there other genes that we should be kind of aware of that are highly linked with breast cancer and maybe The Curbsiders (28:10.668) you know, to allow your pre -planning with the biopsy diagnosis, is there something that we should be telling patients this is what we're looking out for? Yeah, absolutely. I tell my patients today it's more than just BRCA1 and BRCA2. Obviously, those are the two with the mutations that have the highest lifetime risk of developing breast cancer. We're more aware now about CHECK2, PALLB2, ATM mutations for which are now known as moderate to high -risk penetrant genes that we should be aware of in the, again, the reason for the multi -gene testing rather than just BRCA1 and BRCA2, which reminds me to talk to my patients about this as well. If they say, oh, my mother tested five years or longer ago, we also now know that those multi -gene tests didn't include all of the newer genetic mutations. and we're asking that they retest and go back and have the new genetic panel done because of the larger number of genes that are now being tested. And there can be anywhere from 20 to 30 genes, again, depending on the family history, that may include not just breast, ovary, colon, pancreas, melanoma, sarcoma, all of those family history cancers that you get from your patient. You're gonna be wanting a genetic counselor to... to decide on what panel should be offered based on that family history. Well, before we move on to the next case, anything else that you think important for us to know in primary care about DCAS or about genetic testing? No, I think those are the main things I wanted to get across. Great. So let's move on to our second case from Kashuk Memorial. We have another patient, Sarah, who's a healthy 62 -year -old. She's coming in because she's concerned that she noticed a breast lump. She felt it about four weeks ago. It wasn't painful and it hasn't really changed in that time. She has no personal or family history of breast cancer. Her last mammogram was 18 months ago and was by reds one, normal. On exam, you note slight dimpling of her skin in the upper outer right breast and feel a firm fixed three centimeter mass. She has no palpable adenopathy. The Curbsiders (30:29.614) So this is obviously somebody you'd be pretty worried about given her age and exam. What would you recommend to her as the first steps to evaluate this? So Molly, she was how old? 62. OK, so she's had a mammogram over a year ago. 18 months ago, it was normal. We definitely are now in a situation where we have a new breast concern. So she would not. And that is something I educate patients and I want my colleagues as well and peers to be aware that we have to order a diagnostic mammogram here. You do not order and tell her go and get your annual because you're overdue. She needs a diagnostic mammogram. That happens more than I like where patients are just told, oh, go get your annual, which is putting her at a disadvantage because now the radiologist doesn't know if your patient actually has a symptom, a new lump. So a diagnostic mammogram would be ordered. It would definitely be a bilateral diagnostic mammogram, which in the process of diagnostics in most breast centers will include an ultrasound as a next mammogram, followed by the mammogram built into the same slot. Most centers are doing that when you order diagnostic because now the area of palpable nodularity needs. a focused ultrasound on that to look at it. Why? Because we know that mammographic density, unfortunately, even in a 60 -year -old with a dense breast, and could be read as a normal mammogram even on a diagnostic, and that's why a follow -up ultrasound is always included. When I... I talk to my patients as well when I'm ordering this. I also remind them that when you get a diagnostic mammogram and an ultrasound is obtained, regardless of the results, I will still have to see you and review the report because sometimes the mammogram and ultrasound could come back normal and the patient makes the assumption that that lump is nothing. Why am I bringing that up is because I've seen it where then, The Curbsiders (32:49.166) We can and have seen lobular, invasive lobular cancers missed on a mammogram and ultrasound just by the biology of a lobular cancer. That patient needs to be brought in, reassessed, and make a decision to do a short -term follow -up of that or, based on my clinical exam, recommend a surgical consult. So you wouldn't be moving towards an MRI or like an FNA? It would be for a surgical consult. In this scenario, that's a great question. Would I, if my clinical exam was pretty concerning that this is a discrete mass and my imaging is not helping me and they say they have no target, which is what I would like from the radiologist, if they're saying they have no target, then I need a surgeon to put a needle in and give me tissue. Getting an MRI is not going to help me. as much because even if the MR is negative, we still have a palpable that we need a tissue diagnosis. But more so than ever, most of us want to order the $5 ,000 MRI and you're welcome to, but that's what that is. At this point, we need tissue. We need to know what this is. So I talk to my patients if it is a clinical suspicion of low formal malignancy based on my exam, then a short -term follow -up or an MR. would be something I could talk about, but I'm not going to use that to make the decision if this is a discreet mass that's got skin retraction concerning fixed firm, we need a tissue diagnosis. I feel like, Sandhya, you're reminding us about choosing wisely in all fronts, and especially around the diagnostic memo. kind of initially and then also bringing that person back to say kind of what is my clinical judgment tell me? Well, for Sarah, she does listen to you and she has a diagnostic mammogram, plus minus the ultrasound at the center that she's at. It does show a mass that's BIREDS4 recommended for a biopsy and the pathology does come back showing invasive ductal carcinoma. The Curbsiders (34:49.742) And just wondering, what do you look at first when you're kind of seeing that pathology report? Are there certain kind of markers? What are you, the size, what are you specifically looking at? Great question. Pathology reports are now more comprehensive. They are not only including the type. So if it's invasive, is it ductal or lobular? The two most common types. And then of course there are less common types. Like is it a ductal, is it... Mucinous is an anaplastic, more metaplastic, more aggressive types. So we really want to know which kind it is. So if it's ductal or lobular are the most common. I also look at the grading, which is now being reported on the core. And then they're running receptors. They're running the estrogen and progesterone receptor and the HER2 for the markers. which I'm waiting for. So often I'll even tell the patient that those may take an additional two days, even though I'm calling you to tell you you have invasive cancer until I have the markers. We can't really make any decisions right now. I'd like to wait for those to come through. And then that's when you want to know if we're dealing with hormone sensitive ductal invasive cancer or hormone negative, HER2 negative. triple negative breast cancer because at this point, treatment's going to change very drastically based on does this patient need chemo upfront, again, based on the tumor size and the tumor type. And are you looking at other markers to evaluate aggressiveness? I've seen like sort of proprietary things like mammoprint or oncotype. Yeah. So no, not initially. There are other markers and I thought, Molly, you were going to get to KI67, which is a proliferative marker. Again, some sites do it, some don't. Mayo does do it on all our hormone positive tumors. We do check that the KI67, it's a proliferation marker. Are there some treating oncologist surgeons who are managing patients who may want to know the oncotype off the core? The Curbsiders (37:06.382) To decide on the chemo that is, again, very practice -specific, different for different institutions, we do not order an oncotype or a mammoprint off the core for our initial management of patients. That is something that would be done after surgery to decide if they are looking at, is this a chemotherapy recommendation, or is this patient going to benefit from adjuvant hormonal therapy? So she is ER, PR positive and HER2 negative. And she's scheduled to see her breast team in a couple of weeks, but she's understandably pretty anxious and wants to sort of know what her life is going to look like over the coming years. How does the initial treatment for invasive ductal carcinoma that is hormone positive differ from DCIS and what will her treatment look like over these coming months? So she's looking at with an invasive cancer, hormone sensitive, again, back to the biology, her two negative, ERP or positive, that she's on that more favorable tumor type. Again, I remind patients that they're on that spectrum for which at this point, surgery would be recommended as first line. Surgery, again, lumpectomy with radiation as one option versus mastectomy. Here in this scenario, as we're doing the preoperative discussion, we may actually bring an MRI in. The MRI will help us also understand the extent of disease. Sometimes with dense mammograms, we really want to know is this truly 1 .5 centimeters or is it 2 .5? And having a pre -op MRI has helped a lot in the decision making. The downside to a pre -op MRI is that you may end up chasing other false positives. And I prepare my patients that we may end up seeing something else on that breast or on the other breast. We will have to biopsy it because we're going to need to know as we move further. So I do talk about pre -op pros and cons in the conversation, working with our surgeons and oncologists to get a feel for what they prefer. And they often say, based on your patient, the density, the tumor type, her decision, is she leaning towards a lumpectomy? The Curbsiders (39:30.35) but you're worried about the close margins then to the skin or if it's a fixed mass to the underlying pec, should we be doing an MR to get us a better pre -op understanding before they operate? So let's say she's ready to move ahead with a lumpectomy, then the decision is about the sentinel lymph node biopsy, which is now going to be recommended. Some institutions are doing axillary ultrasound to look pre. operatively at the axilla to see if the lymph node is enlarged and may offer a final aspiration if needed. Others don't, so again, that's very institution dependent. And then talk to her about radiation, which would come next. Again, options could include what is now known as hypofractionation, which is shortened radiation three weeks with a boost, and then followed by a conversation about hormonal adjuvant therapy such as tamoxifen or the aromatase inhibitors, which you would then take for five years. And again, depending on the biology, they may recommend 10 years of hormonal therapy. The complexity around tamoxifen versus the aromatase inhibitors are very dependent, again, premenopausal versus post, but bone density. managing hot flashes, night sweats, does she have an intact uterus? We go through a lot of those, sort of which is the right hormonal drug at this time for that patient. Need to know other risk factors like the history of blood clots that would, you know, obviously eliminate tamoxifen as an option. So yeah, we do have to go through a lot of those. And I do get bone densities. I actually help my oncologists preoperatively, especially in these women. who I know are looking at an AI to get a bone density on the books early, rather than waiting until after when they're there going, why didn't you just get a baseline bone density? We need it to know where your bones are in terms of deciding between TAM or an AI. And Sandy, this is super helpful. And I may have missed this, but the way that you talked about DCIS, where you told people, like, chemo, get that off your mind. That's not what we're talking about. How do you talk about chemo in this situation for Sarah and her kind of... The Curbsiders (41:52.974) you know, hormone receptor positive or her two negative tumor. So great question, Ara. Again, we're talking around the fact that we know that hormone sensitive tumors with the target of an anti -estrogen such as the tamoxifen aromatase inhibitor, they do very well with these cancers. So I actually bring that up as upfront that you're looking at an oral medication like the anti -estrogens. The only time where chemo may be indicated and I prepare them is if the node is involved. You may be looking at chemotherapy, that's when they'll run the oncotype. Again, that has changed the staging of the patient's cancer where I prepare them that in terms of your surgery, we wait till we finalize what the outcome of your lymph node status is because that is something I've... got to be careful because sometimes chemotherapy may be recommended for some of those where nodes are involved. Well, in the interest of time, I just want to move us along a little bit. So Sarah completes her five years of hormonal suppression therapy, or maybe 10, and comes back to see you complaining about some back pain for six weeks. That doesn't seem to be resolving. Being a thoughtful PCP, you remember that she has this history of invasive ductal carcinoma five or 10 years ago. And so you order an MRI, which unfortunately does show spinal metastasis. So just trying to think, how do we explain to patients about if they can ever be considered cured and how long out potential recurrences can occur for this type of cancer? So this is great and you are correct, Molly. This is exactly where primary care doctors play a significant role. We see these patients come back years later complaining of new symptoms. And I always remind my primary care colleagues that you're thinking of breast can metastasize to brain, lung, liver, bone. So if you hear these are new symptoms, yes, get the imaging. In this case, an MR showed METS. The Curbsiders (43:57.006) The next step just to follow through is we are re -biopsying the site of the metastasis because we've learned that the biology of the cancer can change over time. What may have been hormone sensitive may not be the case here. So our oncologists are asking that we re -biopsy the site of the MET or somebody, oncologists do it, or in the primary care at least get things set up to get that checked. Once we know what they're dealing with, then of course the treatment will be directed to that tumor type. Yes, recurrences can occur. The good news is that if we know the biology and we know what we're treating, if this was a HER2 positive now, we're gonna have newer targeted therapies. So that does improve the cure of these cancers and outcomes are better for patients because of the newer treatments. targeted therapies, understanding the biology of the tumor. So I try and give as much hope as I can to these patients. That doesn't mean that by having a MET that you're looking at, you're gonna be looking at metastatic disease that's gonna continue to spread and your prognosis is going to be poor. I remind them that because we were able to get this done early and test it, understand what you're dealing with, the newer drug therapies are going to improve your chance of even a cure. after metastasis. And other than bony meds, are there other things primary care docs should be looking out for as most common sites for late recurrence? Yeah, so the simple questions I always ask, have you been experiencing new onset headaches, new onset shortness of breath, new bone pain that doesn't go away, and it's bone pain that wakes them up from sleep, and new changes in their weight, unintentional weight loss? Those are things that I remind patients. I ask every survivor when they come in to see me these questions, because I think those are things that we should have our awareness up in the primary setting as a survivor comes into your clinic. If these are the case, then case there are explaining, complaining of these new symptoms to get the appropriate test to exclude metastasis. Obviously, it depends a little bit on her risk, but what would be a general life expectancy after that? The Curbsiders (46:20.494) You know, it's a great question and I don't treat those recurrences in the bones, so I'm not going to speak to the numbers, but the patients that I do see. And again, with the right targeted therapies, they're under the care of the oncologists, but many do very well when they're treated. Hormone sensitive tumors respond very well to bone mass and there are newer... anti -estrogens that are these CDK1 inhibitors that are coming out. So they're using newer medications that have become even more impressive in the treatment of metastatic cancer. Sandi, this has been amazing. And we've learned so much. And not to totally do a 180 pivot, but because we've covered so much about diagnosis and treatment, I was hoping to just take a quick step, many steps back. to something you brought up around screening and kind of the updates that have come up. And just wanted to pick your brain because we've seen a lot of dissenting opinions regarding lowering the screening age to 40 years for breast cancer with mammography and hoping to just hear your perspective on all this for, let's say, Sarah and Sophia when they were 20 years younger. Great question, Ara. And I did and was quite involved when that. from what we were interpreting with the US Preventive Task Force Guidelines, changing the age to 40, there has been, and we are seeing, younger women diagnosed with cancer now more than ever. I think that that trend is showing that women are getting diagnosed in their 30s and 40s and 50s. So the idea of initiating mammography at age 40 is extremely important, and I'm glad that that happened. We at Mayo, by the way, had always been screening beginning age 40 and not waiting till they're 50 to initiate, even with those guidelines from the U .S. Preventive Task Force saying, wait till you're 50 and screen every other year. We were following ACS guidelines, NCCN guidelines. And remember, that's one of the challenges as primary care providers is we're struggling with many guidelines that are interpreting different ways in which to initiate and frequency of screening. I think it's the onus of the provider to... The Curbsiders (48:40.878) to make sure their patients are aware that guidelines are controversial and take their patient's personal values into play. If they are asking, I want to start at 40, I have a family history, obviously you would start at 40. Or they say, I have no family history, but I have seen my friends get breast cancer in their 40s, I want to start at 40, we should be screening at 40. I also want to emphasize the value of annual screening versus biannual screening. I think that especially in dense breast tissue, Why wouldn't I want to see a change in the mammogram every year versus every other year? If there is that subtle change on an annual mammogram, is that by having that annual mammogram in someone who's dense, is it going to see something that may have shown a change? Why wait two years to find out that it's further along? That's important. I also want to counsel and talk about just to touch on when to stop screening, because we in primary care get that question a lot. I really love to come back to the, you know, what's my patient's five to 10 year life expectancy. And if my 85 year old is walking in, she has a great five to 10 year life expectancy, I'm going to order an annual mammogram and I will tell her we're going to order it. She says, could we back off to every two years? I'd say, fine. You know, you want to do it every two years in your eighties, fine. But you know, you have that conversation. But to stop at 75 doesn't feel right to me. if someone has a five to 10 year life expectancy and can make a decision. A patient with multiple comorbidities, other very much more severe medical history where you know that a mammogram may not, and making decisions about going to an operation may not be in this patient's best interest, then you can back off screening. So you really need to know your patients and talk with them. Those are some of the most interesting conversations when I have it with a patient saying, we are in a position where we can talk about where should we stop screening you. And I think as your primary care who knows your patient's history best, I would rather that happen there than them coming to a clinic with me. And now they've got like, you know, they're on anticoagulation with triple vessel heart disease and had a stroke and now they've had, you know, a mammogram that shows DCIS and they're asking me to counsel them on options. And I'm like, The Curbsiders (51:06.734) Why do we have a crown? No, just kidding. So, you know, those are things you have to be very aware of. Well, I think it is a complex conversation and helpful to think about looking at it from those multiple different angles of the different guidelines. And I know you have to go, but thank you so much. This has been amazing. Any last take home point or? There's one I want to share. If I could leave one message is that. Even though breast self -exam technique was taken away from all of us with those beautiful shower cards that we used to take, remember in high school, there's still some value to breast self -awareness. If you feel something different, I tell my patients, I don't care if your mammogram is normal and it's read as a normal mammogram, if you feel something different, come to me and let me see you. And in a primary care setting, that is even so much more valuable than to say to them, oh, go get your mammogram. No, if the hemogram is normal, that doesn't exclude that that exam that needs to be done by us in primary care because if a patient's feeling something, it's worth further investigating it. The Curbsiders (52:20.238) This has been another episode of the Curbsiders, bringing you a little knowledge food for your brain hole. Still hungry for more? Join our Patreon and get all our episodes ad free plus twice monthly bonus episodes at patreon .com slash curbsiders. You can find our show notes at thecurbsiders .com and sign up for our mailing list to get our weekly show notes in your inbox, including our Curbsiders Digest, recapping the latest practice changing articles, guidelines and news and internal medicine. Until next time, I'm Dr. Molly Hoibland. And we're committed to high value, practice changing knowledge, and to do that, we need your feedback. So please subscribe, rate, and review the show on YouTube, Spotify, or Apple podcasts, or email us at askcurbsiders at gmail .com. Reminder that this and most episodes are available for CME credit for all healthcare professionals through bcuhealth at curbsiders .bcuhealth .org. Special thanks to our whole Curbsiders team. Our technical production is done by team at PodPaste, Elizabeth Proto runs our social media, Stuart Brigham for composing the music. Until next time, I've been Dr. Ira Krzysztofska. Thank you for letting us bring you all these delicious knowledge nuggets. Mmm, is that good?