The Teamwork Behind Breast Cancer Treatment (Live from the 2024 ASCO Annual Meeting)
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Welcome to Symptomatic. Today we're recording from the 2024 ASCO, American Society of Clinical Oncology, annual meeting talking about breast cancer. One in eight women will navigate a diagnosis of breast cancer during their lifetime, and it accounts for nearly one third of

all cancer cases in women. I am joined by two esteemed warriors in the battle against breast cancer, Dr. Nan Chen, breast medical oncologist at University of Chicago Medicine, where she is also an assistant professor of medicine, and Dr. Sarah Schubach, a surgeon who specializes in breast cancer,

also at the University of Chicago Medicine, where she is an assistant professor of surgery. Welcome, doctors. Thank you so much for joining me. Thank you. Thank you so much for having us. Before we even dive in, I would love to ask both of you, what drew you to breast cancer as a specialty? And Dr. Chen, why don't you start? Sure.

I initially became really interested in oncology because I really liked the idea that we were taking care of the whole patient. I just thought that it was really mentally fascinating. And then there really was no relationship that I enjoyed seeing more as a medical student than the relationship between a patient oncologist. They just felt really important in their lives. And I really felt like I wanted to be that person.

I think the simplest way to describe why I like breast cancers, I just really enjoy taking care of women. I just think it's such a special group of people. I can get along with them really well. I also like the fact that compared to some other cancers, there are a lot of things that I can do. There are a lot of options that I have and I feel like I can be more helpful. I really love it. Excellent. Dr. Schubach? Yeah, so I was first really drawn to surgery as a job because I like to have a one-day event where I fix something and that felt really satisfying to me.

Cancer, though, is this long-term relationship that also really grabbed my attention. And breast surgical oncology was the last thing I thought I would actually end up doing until I similarly fell in love with the idea of taking care of women. And I think mostly because what we do is pull people back from feeling like a puddle when they're usually the pillar in their family.

And so I think we often meet people on their worst day and get to watch women rise from whatever their ashes may be and become again that force, that strength, that pillar of their family. And that was ultimately what I fell in love with. And I think like so many of us, I have a lot of breast cancer in my family, and I always wanted the opportunity to be the one to do it right for people because I saw it be so hard for the people I loved. What do you both find remain the most important?

prevalent misconceptions or myths about breast cancer in general?

I think that one of the most common scenarios that we encounter is women, when we first meet them, think that they did something to cause this breast cancer, that some decisions that they made in their life have led them to here. And in the vast majority of cases, that's really not true. And so one of the things I think we do when we first meet patients is to almost unpack that guilt and make sure that we understand that this unfortunately just happens, as you mentioned before, in one in eight women. That's probably one of the most common misconceptions I see.

I also think that we think of breast cancer as one disease entity, but it really is a whole collection of diseases that interact with people's lives at different times of their life, of different scenarios.

And just because your neighbor had one experience doesn't mean you will. So I think a lot of what we spend time with is saying, you know, in 2024, this is each person has a different story. Each person needs different interventions. And trying to kind of separate what one woman is facing based on what maybe she's read or heard about is really important to give her clarity, to put her as kind of the captain of the ship and to allow her to make good decisions for her health.

Also, I should think that there is a misconception that we're just talking about lumps. Yeah. You know, less than 5% of cases, pain is actually an indicator. Yeah, I think when we consider how different women present, it's a whole host of things. You know, it's new nipple discharge that they hadn't noticed before. It's a size change. It's...

nipple retraction or dimpling of the skin. Things that just don't sit right with someone usually warrant evaluation. You know, we know our bodies best. And so I think that a lot of the women that Dr. Chen and I take care of are often too young for mammograms, right? Or are diagnosed before they would have started routine screening. So we're really relying on them or their doctors to just notice something is different and to feel that that difference might be a real health concern and to get it evaluated.

In what sense does timing still remain one of the most important weapons in your arsenal against breast cancer? We know in breast cancer, the earlier we find the cancer, the better

better it is. And I say better in many different ways. First and foremost, we know that your prognosis is better. The chances of you surviving this cancer are better. It also means in many cases, we can deescalate your therapy. If you have an earlier stage cancer, we can give you less treatment for it, which I would love. And so to Dr. Shubik's point, it's so important for women to know their bodies and to make sure that doctors and other providers are listening to these women when they mention things going on.

And also the timing in one's life. You know, we take care of young women who go on to live full lives, have healthy pregnancies, fulfill whatever it is that's in their goals and desires. We also take care of women later decades of life who have, you know, even shorter intervention periods for care. And that's because we're learning more that these diseases vary across a lifetime and vary based on the person. And then really, as Dr. Chen mentioned, the earlier we can find a problem, the less likely it is to threaten someone's safety.

And that is why early intervention, early identification is just critical and why screening has made so many improvements for women who are eligible for screening because we're finding breast cancers at earlier and earlier stages. And I believe that in stages one and two, 85% of the cases you diagnose are treatable.

I would actually say that 100% are potentially curable and really our therapies are getting better and better every year. And I think doing this at ASCO 2024 is just such a stark reminder of the progress we have made in breast cancer, even in the last decade and the progress we're continuing to make that

When I meet a woman, I say, "We can cure you right now. We can get rid of this cancer." The bigger problem and the bigger goal I have is to make sure this cancer doesn't come back. And we are getting better and better every day with our therapies to make sure that that doesn't happen.

And the whole concept that don't worry about breast cancer till you're 40 is dated. That is quite dated. And I would argue that's a really dangerous message because we aren't screening women usually before the age of 40. We can actually miss early cancers in younger women because we're not looking and those women are also not necessarily educated to know to look for these things in their body.

Unfortunately, the rate of young breast cancer is actually rising since like the early 2000s. And so another reason that we really need to be careful in the younger population. What do you attribute that to?

I think the short answer is really, I don't know. And the longer answer is I think there are a lot of things happening. Girls are getting their periods earlier. And so you just have a longer time in your life that you're getting hormonal exposure and that can increase your risk of developing breast cancer. This is actually, unfortunately, a trend we're seeing in other cancers as well, like colon cancer. So there's probably lots of reasons that are environmental and societal that are leading this, but it's a concerning trend that we should all very much be aware of.

I want to jump into the topic of collaboration. But before we even get there, Dr. Chen, despite breast cancer being fairly common, unfortunately, and straightforward in terms of the diagnosis,

Is there an individual aspect to each case you diagnose? So the road to individualizing cancer medicine is a long road that we are on and will be on for a long time.

We know in 2024, we are still over-treating some women, and we know in 2024, we are also under-treating some women. We are starting to become smarter using biomarkers and genomic tools to better thread that needle and make sure that patients are getting the appropriate amount of therapy.

But it can be difficult sometimes to figure out whether we're being too aggressive or not aggressive enough with a patient's cancer. And everything really should be tailored to each individual cancer. Two women sitting next to each other, even if they have on the surface very similar cancer features, stage, all a subtype, all of that, may still have very different tumors. We now can do genomic testing and molecular testing to really be able to dive deeper into how the cancer actually functions, the biological way that it works.

And Dr. Schubach, how do you emphasize the importance of teamwork? You know, a multidisciplinary team of doctors when treating breast cancer patients. And why is it crucial for all members of that medical team to work towards moving in the same direction? Yeah, the reason why I think it's particularly timely now is because the game is changing for the better.

In the origin stories of breast cancer, we thought it was a surgery disease. Just cut it out. And most patients are still kind of referred from their primary physician or provider to a surgeon when they have a new diagnosis. But very often, I'm not the first person at bat. So it's really figuring out for each person who their starting quarterback should be.

And so I think that's not really something that happens in isolation, right? Some patients need medical therapy first to make their surgery smaller. Some patients need surgery first to help understand how much medicine they need. And that's not one size fits all. That depends on who the patient is, what cancer they have, how much cancer they have, what can they tolerate. And so if I were to decide just all of those things, it's kind of like an electrician telling you what a plumber should do.

And I think there's a lot of value in constantly learning from one another and most importantly, holding the patient's values and what they can endure or want to endure or just how they're facing their journey as the centerpiece of our discussions. - And during a patient's treatment journey, there are many touch points in which decisions that I make will very much influence what Dr. Schubeck does

And things that she is thinking of will very much influence what I do. Just last week, I called you on my way home because we just had a list of patients where I was like, I want to give you some updates as to kind of what's going on to make sure that you're in the loop and that you can make decisions with the most up-to-date information that you have. And I think it's important to say, too, that the surgeries are getting smaller, right? So breast cancer surgery is a story of de-escalation almost uniformly, which I'm thrilled for. I can't wait to be put out of a job.

And I think that's because the medicines are not necessarily getting bigger, but getting more tailored. Right. So the medicines are getting more effective in the upfront setting, which allows me to do really small surgeries that lead to less disfigurement for people, leads to better function after surgery. We need to be supportive of our patients and getting the right intervention.

And so if that means in 20 years, there's no role for surgery in breast cancer, I'll retool. I'll be just fine. But how amazing would that be if that story and that trend continues? You mentioned team and you mentioned the different roles, plumber, electrician, you know, but ideally, who would you guys like to see on your ideal breast cancer management team?

You know, honestly, that team is as big as a football team. It really is. It's huge. It is both a surgical oncologist, a medical oncologist, a radiation oncologist, a reconstructive surgeon, potentially. It is a nurse navigator. It may be a genetic counselor.

a therapist who can help with a lot of the mental health struggles that women go through throughout this diagnosis. It is a physical therapist who can help maintain motion after surgery. It really is such a large team of people that we work with that would make up the ideal team. And often it's things like genetic counselors, right? It's risk reducing for the patient and also thinking about their whole families. It's

fertility doctors for patients who are getting fertility preservation before surgery. It's primary care doctors, right? It's the person who knows that patient before their diagnosis and is going to continue to care for them long after. So it's all of those people and more. And then if I had everything I ever wanted, it'd be the patient's family. It'd be the patient's employers. It'd be all the patients surrounding ecosystems so that we together can support that person in their journey. I think that we also all have to work for the same person and that's the patient.

So let's just talk about the importance of collaboration between specialists like oncologists, surgeons to enhance patient outcomes.

I think one of my favorite parts of our relationship is how open we are with each other and how even if something maybe didn't go as well as I wanted it to, I'm like, hey, this is what happened. This is where we are. This is how we go forward. Or it's like, oh, hey, I had this conversation with a patient. It kind of went off in the left direction and I didn't really like it. But just so you know, so when she brings it up, this is kind of what we discussed.

And I think there's no judgment on that part that this is life and we do the best we can. I think also one of the really breakthrough moments for me with Nan and our practice that we share is I was sitting at my kid's gymnastics class on a Friday night and she calls me. And usually there's a warm-up text message to say, we need to discuss impatience. But I just got this call and I had like two minutes where I was able to answer. I was otherwise wrapping up some work for the week.

And she called me and told me about one of our mutually loved, kind, young patients who was experiencing a devastating outcome from her breast cancer journey. And we just kind of sat there together in shock. One thing that Dr. Chen and I both do is we really emotionally invest our patience, maybe to a point where it's a bit much. And sometimes we lean on each other to pull us back.

And so in that moment, the exact person I needed to talk to was somebody else who was present with that patient, was connected to that person. You know, cancer is unfortunately still really unfair in so many ways to such beautiful lives. And so when things go really south, I know that I can call her and have that life raft. I was going to next venture into the emotional component of what you do. But before I even get there, how did your paths initially cross?

I consider myself so lucky that Sarah and I happened to start our jobs, respectively, at the University of Chicago at the same month, literally. And as we got talking, it was like our philosophies of how we care for patients and how we practice medicine are really, really similar. You know, there's a lot of times we call patients together on the phone. I've gotten really good at connecting people in through phone calls. And patients really are blown away when we're both on the phone.

But I think one of the hardest things about patient care is that often they're retelling their story to every single person on their team. And if we can sit there together and I can hear how they're interacting with what Dr. Chen is telling them, you know, and she can hear about my surgical take, it really helps a lot.

It's kind of forced us to meld together. And it's only making it feel more seamless, I hope, for our patients. And it feels more seamless for me. We're starting to sound like each other. We are. It's a little creepy. I sometimes say things that she does when she's not in the room. Yeah. Because it's fun. When we see patients together, if I'm just sitting and I have a few minutes, I'll just barge right in. And I'll sit on the bed and I'll listen. Because I want to know how she's explaining the same thing I'm trying to.

That is such, honestly, an intelligent approach, though, because you are saving time, but you are also protecting the patient from having to go through

their entire case history again. Yeah, I think that is a huge, a huge advantage because it's like a shared flock, right? Like it really has made it so that we're all getting the same information and we're really making decisions as a team with the patient in charge.

We touched upon the emotional aspect of what you do in terms of the heavy lifting of that personally, but what would you say remains the most difficult aspect of both of your work to navigate?

I see advanced breast cancer, which is not curable. And that means that despite for the vast majority of these women, despite what I do with the best treatments available, they are unfortunately going to pass from their disease.

To be perfectly honest, I am always very, very scared of that happening because I know it will happen and it's just part of my job. But it remains such a constant fear that I'm going to have to emotionally deal with that and have to kind of deal with what happens after, which is that I have to think about, you know, all the time we spent together and continue doing what I do on the other side.

I think almost similarly, but I'm even less helpless than Dr. Chen is, when patients cross over the line of being local, locally advanced to being metastatic, my entire job is to basically sit it out. I think that's really incredibly humbling because...

I then call on my teammate who I already burdened with my emotional needs and my, you know, collaborative needs and say, I've got nothing as a surgeon to help this patient. Cancer has this knack of being unexpectedly terrible when things are going okay. Oh, absolutely. You know, it has felt so often like these humans you see so full of life and so full of potential that's stolen by cancer. And I think that's motivating, but it's a really hard thing to carry. Yeah.

You know, there's so much to process in terms of receiving a diagnosis. How do you help patients navigate that emotionally, but also in terms of information overload? I think for that...

Sarah and I have wonderful teams of people that help us. And so, for example, if someone needs to undergo chemotherapy, I have a wonderful nurse who goes in there and spends another 20 minutes just discussing the logistics of chemotherapy. I have a breast cancer pharmacist who goes in there for 20 additional minutes and talks about these chemos to the last detail. There are also some visits where, you know, for example, on a first visit, there are certain pieces of information I want to impart, but sometimes I don't get to most of them because we're

we're just really upset and we're just trying to process. And this just isn't a good day for me to talk about exactly what chemo you need. And that happens. And if it does, then we'll see you in two weeks and we'll kind of have that discussion again. I've also adopted that if I get a bunch of messages about a person, I pick up the phone and I just introduce myself on the phone to people.

It's amazing how different the first visit goes when they just know that I'm going to show up and that I'm going to be a person too. And I feel like in so much in healthcare now, when you try to schedule a doctor's appointment, you talk to 42 people, but you don't know what you're going to get. And so often I just call them and I'm like, Hey, I'm Sarah Schubeck. I'm a breast cancer doctor. How are you?

Being a human is really valuable for people. And so I do it for myself, too, because I want to know who I'm walking into. I want to ask them who they're going to bring with them because then I know who's important to them. One of the hardest things is covering the stress of a cancer diagnosis, the next steps of it, and still getting to know a person as a person.

and being able to understand in that 40-minute conversation what matters most to them, what are they most afraid of, and how do they feel about this? Because usually that 40 minutes sounds like Dr. Chen and I rattling off medical facts to them.

And I always tease that my first favorite visit is the six-month post-surgery visit because they usually are themselves. And we've never met themselves. You know, we've never met them like they would be at the grocery store. They're scared. They're stressed. Their family's on edge. And then it's so much fun to really get to know them as we get them through survivorship. That's so much fun. 100%.

You mentioned having that support system present for some patients who have that go-to person with them. In what way does that help in terms of talking through risk assessment with patients? And how do you ensure that there is actual clarity in these conversations?

Having a support system is so, so huge. Sarah and I share a patient who, when she was diagnosed, she called on her gang of girlfriends, like a dozen of these women. And literally every time she came, there was a different girlfriend that came with her that was like diligently taking notes and asking us questions. And it was just the most beautiful thing to see. But

If a patient comes alone, I specifically ask, like, can we call someone? Because they're going to remember 2% of what I say. Maybe if there's someone on the phone, they're going to remember 10% of what I say. But having support, I think, is just so crucial. And I think, too, whatever that means to the person is fine with us. Yes. You know, I've walked into rooms where somebody has their neighbor, the ophthalmologist, their sister, the nurse, and their spouse with them.

Whoever is your army who's going to help you make a decision is great. But ultimately, especially as a breast surgeon, what physically happens to your body, right? The changes that are going to happen to your breasts, the way your breasts are going to look and feel afterward. The only opinion I care about is the patient's.

But I want everybody else in the room. You know, it's amazing. Sometimes I tell my patients that I'm going to be the first one to make their dad blush if he comes in. And I'm fine with that. You know, I'm a breast surgeon. We have to talk about what your body does. We have to talk about how your body is going to change. We have to talk about your feelings of whole self, your embodiment, your sexuality. All that has to happen. So as long as you're comfortable with the people you bring hearing all that,

I'm comfortable too. It can be your mailman, your Uber driver, your whatever, just whoever's going to show up for you in a time when you need them. I also to always ask if they are the person who usually is the one keeping it together in their life, because if they're the matriarch, right, if they're the pillar, this is not going to be a season of life where they get to do that. And so it's also a really nice opportunity to kind of say to everyone in the room,

Mom, sister, neighbor is not going to be the quarterback for a little while. She's going to be again because women are strong. But during that season, somebody else has to take control.

Going back to an earlier conversation, just in terms of confusion and misconception, there remains a lot of confusion surrounding genomic risk. Yeah. How would you break it down and how does it ultimately influence the treatment decision, particularly for early stage breast cancer? So I think that there are...

multiple genomic tests now that are available. I think the most important thing when we have a test is we need to use it appropriately, right? Because if we're not using it appropriately, then it's really hard to interpret what those results are. But genomic testing, especially in ER-positive HER2-negative breast cancer, has been so instrumental to helping us understand what are the actual treatments that are going to benefit patients and that they can spare patients toxic chemotherapy and other drugs.

It's also a great time to have a conversation with a patient because they always want to know what are the chances my cancer is going to come back. And I'm never able to say that with like 100% certainty, but I can say like, oh, I have these tests that can help me do a better job of estimating that for you so we can better tailor treatments.

It's often something patients ask me as a surgeon about, but I think what's so important about genomic testing is it's not necessarily what's happening right where we're cutting it out. There's this notion that like where it is, where we're cutting it out from is the only problem. But so much of this testing and so much of the therapy we give is for all of that possible confetti that's trying to make its way elsewhere.

So it's a hard thing for me, and I'm as confused often as our patients are about the newest genomic tests that we're doing, the newest indication for it. And so that's where it's incredibly critical for me as a surgeon to say to patients, hey, I get your surgery pathology back. I'm calling you first, and I'm calling Dr. Chen second. Because I want her to decide if we need specialty testing, if we need to do anything more so that she can set the dial right for the medical therapy, just as we worked hard beforehand to set the dial right for the surgical therapy.

In terms of the different types of prognostic testing available, how do they

ultimately influence the treatment plan for breast cancer patients? Generally speaking, if you have a higher risk cancer, we want to do things to try to mitigate that risk. And more often than not, that means more medical therapy or stronger medical therapy. This is something that allows us to say, we think that you have a high recurrence risk. That means that we need to give you intensive chemotherapy. Or we can say, oh, you have a low recurrence risk. We can just give you

"It's not Trasol for a few years, and we think you'll be fine." - This might seem a little bit redundant, but how do you go about identifying other risk factors for patients, such as through biomarker tests, and how do they shape treatment plans?

So there are genomic tests such as Oncotype that are run on pre-treated surgical samples, whether it's at the time of surgery, if Dr. Schubert goes first, or on the biopsy sample. These tests can give us a recurrence score, and this is a test that is both predictive and prognostic. Predictive to the benefit of chemotherapy and prognostic to their recurrence risk.

So these tests have been really helpful in the last decade in helping us better tailor therapies to women and helping us make sure that we are treating women appropriately to match their cancer risk.

When it comes to recurrence, there remains significant unmet need in the treatment of stage 2 and 3 hormone-receptive positive early breast cancer. Despite best efforts and the range of available treatment options, a concerning number of patients persistently face the risk of both long-term and short-term recurrence.

According to a study published in the Journal of Clinical Oncology, approximately one-third of individuals diagnosed with stage 2 hormone-receptive positive HER2-negative breast cancer are at risk of recurrence. The Mayo Clinic further states that women who have had breast cancer are more likely to experience a second occurrence. ♪

Regrettably, most recurrences progress to metastatic disease for which there is currently no cure. It is essential for patients to have access to treatments that allow them to live their lives to the fullest. Adherence to therapy is crucial in effectively reducing the risk of occurrence. However, considering that many patients will need to undergo therapy for years, their ability to tolerate the treatment becomes vitally important.

After the break, we'll resume our conversation with Dr. Chen and Dr. Shubeck delving deeper into the harsh reality of breast cancer recurrence and its unfortunate potential to evolve into metastatic breast cancer. We'll be right back.

For people with stage 2 or 3 HR-positive early breast cancer, it isn't just long-term recurrence that's a concern. Short-term recurrence is equally critical, even among those with little to no nodal involvement and despite endocrine therapy. Within three years of diagnosis, up to 1 in 9 people with no nodal involvement will face recurrence. For those with N1 disease, up to 1 in 8 are at risk. Most recurrences will be to incurable metastatic disease.

Now, back to our conversation with Dr. Nan Chen and Dr. Sarah Schubeck.

Now, you know, you just mentioned recurrence, but if you could, Dr. Schubach, delve into the reality of breast cancer recurrence and how, unfortunately, it can transform into metastatic breast cancer.

Sure. So I think when we think about the first journey through breast cancer, right, when we close that first chapter, my other favorite kind of analogy is to think of these as choose your own adventure books, right? So at the end of each chapter, we have to kind of push the reset button. And after...

the initial phase of treatment, whether that's surgery, medicines, and or radiation, we have to start over. And that means screening, being vigilant, listening to our bodies, you know, routinely seeing patients, taking whatever adjuvant medical therapies are required for risk reduction and to kind of have ongoing treatment for their breast cancer. But then very importantly, be vigilant when something changes. So a lot of times recurrence events are

basically found in breast imaging. So patients get their next mammogram or another MRI, for example, or they present with a palpable finding, something they can feel that's different along a scar line or something. When it's that kind of local event, often your breast surgeon's back involved straight away. We do biopsies, we facilitate additional imaging. And then very importantly, we often make sure it hasn't gone elsewhere because if patients have metastatic breast cancer, meaning it's spread outside of the local area, then they're not really a candidate for kind of

curative intent therapy in the traditional sense of surgery and medicines as a joint venture, but rather we lean on medicines as their solution and at least their treatment modality.

Breast cancer is unique in that this is one of the only cancers in which we do not do routine body imaging after they complete their curative therapy. And so a lot of us trying to surveil for recurrence is dependent on the patient knowing their own body. When I talk to patients, I give them incredibly vague instructions for the kind of things to let us know about. I truly say if you have any new symptom that lasts more than a few days and you're not sure what it's caused by, call me. Let me know.

Circling back for a second, because you touched upon it, but breaking down what it actually means. So hormone receptor positive, human epidermal growth factor two negative. It's a mouthful. It is. It is. I can see why it's abbreviated. But, you know, it's the most common subtype of breast cancer, accounting for over two thirds of all cases. Can you break down what it actually means and unmet needs in treating it early?

Breast cancer cells, just like our normal cells, have hundreds to thousands of flags on the outside. Estrogen receptor and HER2 are two examples of said flags. When someone is ER positive, HER2 negative, I think of it as estrogen is one source of food or fuel to help the cancer grow. The foundational way that we treat these cancers is with anti-estrogen therapies.

There are a portion of patients that may be, for example, are less dependent on estrogen signaling or have other high-risk features in which anti-estrogen therapy alone is very much not enough to prevent recurrence. There are newer drugs now that previously were used in the metastatic setting but are now being brought into early-stage breast cancer, which have shown successfully to be able to mitigate that risk for certain groups of high-risk patients.

So it's tricky in surgery because a lot of the role that I'm having to play is really in gathering information about hormone receptor positive HER2 negative cancer in the sense that we often do surgery as a bit of a diagnostic test, right? For a lot of patients, the surgery is really a fancier MRI. We go in, we remove the tumor, we understand the size of it, we check their lymph nodes that tells us how big it is.

And how extensive it is. And then that information gets fed back in to make treatment decisions. And so I think of surgery as really gathering more information instead of being a definitive treatment so that Dr. Chen can tailor therapies, especially in this hormone receptor positive group, because that surgery information sometimes can change the game so substantially. And there are some types of treatments.

breast cancer such as lobular carcinomas which are most commonly hr positive her2 negative where it can be really hard to tell in mammograms and mris exactly how big things are how much far things have spread and it may only be at the time of surgery that we truly discover the extent of disease and thus how risky the cancer actually is

We've talked about navigating the information overload that comes with the diagnosis and, you know, the educational hurdles that exist for every single patient. But we haven't really touched upon racial disparity gap, you know, in terms of Black women are 40% more likely to die from breast cancer than white women. How do you wrestle with that statistic?

One of the reasons that I came to the University of Chicago is actually to take care of Black women. In all of my training, I have always taken care of underserved populations. I find it incredibly gratifying

There are so many facts about Black women in breast cancer that are uncomfortable. You are correct that they are more likely to die of their disease. They are more likely to be diagnosed later. They are more likely to have triple negative breast cancer, which is the most aggressive subtype. They are more likely to have delays in treatment once they get started. They are more likely to not complete their treatment. And so there are many, many factors, both biological as well as socioeconomic, that

to that terrible statistic. Sarah and I think about this every day to not even be hyperbolic about it because of the patients that we see. A few months ago, we had a couple really terrible outcomes. And Sarah astutely was like, I feel like we're just seeing what young black breast cancer looks like

And that was just the simplest way to kind of describe what was happening. It's really, really terrible. And I think that as a community and as a cancer community, we really, really should be doing better. We also traditionally have not done a good enough job of recruiting women of color to clinical trials.

to providing everyone with the same opportunities for intervention, genetic testing, different surgical options, different reconstructive options. And so it's so many things that we have not done well enough to serve the whole breast cancer community. And like Dr. Chen, I think that really being able to take care of everyone and look at them and say, hey, this data, this brilliant science, this is exactly for you.

We don't have that right now for every patient, right? So some of our trials are north of 95% white women. And then we're extrapolating to all people. That's something that we really feel, especially at the University of Chicago, is a priority for us to offer every single patient to be on a cancer registry, every single patient to be in a clinical trial that's appropriate. And that's because we need to get those numbers to be reflective of the population we actually serve.

Serving people who are different from me for whatever reason is the greatest joy of my life. I didn't necessarily know that would be such a passion or such an important part of my practice, but it has been the greatest learning opportunity of working at the University of Chicago on the south side of Chicago.

There are patients who teach me every day about what they've been told to fear about doctors, what they've been told is not important enough to bring to your doctor. And I think that if we can break down those barriers and really empower people to look out for their own health across everything, we'll get there. It's interesting because you would use the word unfair to describe cancer. And that said, then it's compounded on what makes the outcome even more unfair for some of your patients. Yeah.

Absolutely. And I think patients who have social challenges, right? Women who are the one keeping it together for their family, the earner, the head of household, maybe somebody who's relying on social resources to support their children or their family members. And then we take her out of the fight. Man, that's really unfair. So we'll have young women in our clinic who are just starting their careers or just building their family or just, you know, just really starting life.

And they come in and they're these incredible humans. Now with this really terrible problem, that's when we call each other and we talk about exactly how unfair this business feels. You know, like I have these really incredible women come to my clinic and I'm just sitting there like, I just want to hang out with this person. I want to be best friends with this person. I just want to learn from her. I want to see what she's going to do in 30 years with her passions. Well, that's the other side of the same coin because today,

Breast cancer survival rates are much higher. Absolutely. How do you factor planning for life after cancer into the treatment journey? I think it is so hard for patients to even visualize the after cancer when they're in the thick of it because it just feels so rotten to be going through treatment, to be thinking about surgery, to be planning for post-surgical recovery periods.

I really like what Sarah said earlier about kind of six months afterwards, you really get to see them come out. It is the favorite part of my job to like see them getting back into their thing. I have patients who previously golfed and now like during treatment, they just didn't golf. And I saw her a few weeks ago. She's like, yeah, I kind of went out a couple of weeks ago. And I was like,

This is amazing. This is exactly what I'm hoping for. Our hope for everyone is that this is a speed bump, like it's a big speed bump and it's a horrible speed bump, but that it is a speed bump. And when we get through the other side, you are as close to the person that you were before as you can be, recognizing that you've now gone through this transformative, life-changing experience in the middle. I'm going to shamelessly steal a phrase from one of my patients who told me that she's decided her breast cancer is a rude bump in the road.

It's not going to derail her. It's not going to change her course, but it's a rude bump in the road. And I've ever since she told me that, and I hope someday she hears this to know how wise I think she is. I tell patients that because often patients will say to me, I don't care what happens to my body. I just want to live. And then to that, I say, hold on. I care what happens to your body because in six months, you're going to be really mad at me when you start to be a person again, your whole self.

If you have an ugly scar, if the first thing you think of when you walk out of the shower is your breast cancer, if your sexuality is impacted by what we put you through, I have to think and hold space for you to be a person again after breast cancer. And whether that's preserving your fertility so that you could have a pregnancy in a few years, if that's

putting your breasts back together in a way that you've always wanted, giving you a breast reduction, doing all those things that seem really trivial when you're facing cancer, but are really vitally important when you're facing life again. And that transition for some people is really rocky, but for others is really natural. When you are in a situation where someone isn't handling it well, how do you integrate the psychological impact of treatment?

I tell every single one of my patients that this is an extraordinary experience and that I personally feel that everyone should be getting psychological support because this is just so incredibly hard. Sometimes I feel like the best thing I can do for a patient during a clinical visit is just hear them out, hear what they're going through and just commiserate and validate that like, yeah, this sucks.

The emotional component of this, I think, is just as relevant as the physical part. It's just so overwhelming. I think also patients have perceived support from their family in a lot of ways, but their family, their friends are also going through something. The biggest kind of disconnect I see in my practice is when your family and friends have decided the fight is over, right? Treatment is done. That's a really lonely time for a survivor. And so I think people kind of unexpectedly fall off their cliff

at very different times. Some people, it's right away. They can say that they need support and we are like, yes, we have mental health resources available for you.

The harder thing is figuring out somebody who's maybe in survivorship or maybe just finished therapy and that their struggle is actually becoming a person again as opposed to a patient with cancer. And so the notion that support is really only during that active journey, I think, is a really misguided one and that we have to make sure patients understand that survivorship also is loaded because it's really full of trauma and history and physical scars and obviously psychological ones too. And it is such...

a loaded, breasts in general, really, what they represent to women, what they represent to society. So many things. But also to base one's femininity. Our gender expression, our sexuality, our embodiment, everything. Our maternal. It's such a personal part of our body. I often tease that it's amazing that everybody's going to have an opinion about your breasts, but we're not actually supposed to talk about them any other time.

right? Your neighbor will tell you to have a bilateral mastectomy, but man, have you ever talked to your neighbor about your breasts before, right? It's meant to be private. You know, it's a space where we judge one another about, you know, augmentation or how much we're exposing or, you know, and I think it's just really funny how then during a cancer journey, women are supposed to surrender that notion of modesty and allow us to kind of strip them of their femininity and in the name of heroism. But also while they're all

all the other things surrounding breast cancer care, meaning fertility. We have so many fertility conversations talking about vaginal health. It's just a lot of personal things. How do you navigate that fertility conversation, particularly with young patients?

One of the things I hate the most about this conversation is that on top of all the cancer stuff, you now have to think about this. Yeah. That you shouldn't have had to make a decision about this for years. And now you're sitting here in my beige box clinic and I'm asking you these horrible questions and you have to sit here and figure out way too early whether or not you want to have kids and whether how much you want to have kids is how that's going to impact your breast cancer care. And that's terrible. I agree with Dr. Chen. It's

Breast cancer so often robs people of their potential that they haven't even decided yet.

You know, often we'll see 25-year-old women and we're like, so, you know, on top of all this trauma, have you thought about having kids? And tell me now. Yeah, and tell me now in front of these seven people you've brought with you. Somebody who may or may not be in a relationship. Oh, yeah. Correct. Right. And I think, and it's so amazing to think about how, you know, we put people through this intense stress test of making all those decisions in quick succession because they feel that they're delaying their chemotherapy if they choose fertility. So then it feels selfish, but it's actually essential. Yeah.

You know, I always kind of think of it as like we have to do the 101 level course first, right? We have to do breast cancer 101. And then the graduate level course is all of this other stuff. And we have to build capacity in the patient to go to the next phase. So we have to have a shared foundational understanding of what she's up against, of what decision she has to make. And then on top of that, we put all of those things afterward that will make her whole again after cancer.

But at the same time, you guys are constantly reevaluating your role in the journey of treatment. You know, we've spoken about the current patient's journey and how it varies and differs and how your help in supporting them throughout that has to vary along with it.

But taking a step back for a moment in terms of doing what you do right now in this moment in time, what is the best thing in terms of the advancements that you've seen? I think that we've come so far. So I alluded to some family history earlier, and I have my grandmother's medical records from her breast cancer journey.

It's wild to read what this woman went through. I look forward a generation and I saw what my own mother went through. And nowadays she would have benefited from these genomic advances. She would have benefited from surgical de-escalation. She wouldn't have had to go through a lot of what she had to go through. My mom will say to me, do you do this because of what I went through? And I, you know, some of it is yes. And she's going to listen to this and get mad at me. But some of it is because I get to do better.

I get to let people live more often. And while, you know, we perseverate on the people who haven't done well because it takes a piece of our heart with them, so many of our patients are living full lives after this. And so I think how lucky are we that I, with all my breast cancer risk that I'm up against, my sisters, all the women I love in my family,

I believe in my heart we're going to be okay. And I don't mean to make light of the devastating journeys that some people are facing. But in 2024, most of the time, I can say with a straight face and with honest intention that you're probably going to be okay. And we get to think about life after this. That rude bump in the road is going to go away.

That's a purely surgical perspective because I don't take care of patients in the metastatic setting, which that is the weight of a medical oncologist journey. And I sit in awe of how Dr. Chen does that with such grace.

But I think most of the patients who sit in front of me are going to be okay. And what a gift is that from medical innovations, from screening innovation, from empowerment of people, right? From saying that it's good to speak up about your health. And so I think that's my take on the landscape is like, how amazing is it that how far have we come? All we can do is continue to amplify that messaging to say that the vast majority of people are going to be okay. So come forward and let us help you.

I started my oncology fellowship in 2018.

There have probably been at least a dozen, if not more, drug approvals on breast cancer since then. Wow. It is so much fun to be in this field and see how things are moving ahead. I tell patients, I hope by the time I retire, chemo is obsolete, that we have better targeted therapies to be doing this. I hope to be doing so much better in 40 years. And I very, very much share your optimism that I think we can do it.

All right. Now, in terms of that, in terms of the future, what developments and advancements do you guys see on the horizon for breast cancer treatment? And how are new medicines and therapeutics shaping the future of patient care? There is so much coming down the pipeline. There are new antibody drug conjugates coming down the line, both with different antibodies as well as with different payloads.

We are trying to better understand how immunotherapy fits into breast cancer and whether it can work in more patients than it currently works in. We are currently developing many novel endocrine therapies to disrupt the estrogen receptor in ways that

just weren't really thinkable a decade ago. There is so much happening in breast cancer. There's a lot of information being presented literally in two hours at this conference to really showcase all that we've done in the last year and kind of where we're going from here.

From a surgery perspective, I see a world with much less breast cancer surgery because the medicines are getting better. And I think that that is such a great thing. So I would love a world without breast cancer surgery because people are doing too well or we've learned who it's essential and who it isn't.

Breast surgery is really the backup move nowadays. And I think that that's really exciting because we're doing it better. Cancer is not a local problem. Cancer is a whole body problem. And so if the medicines can do the heavy lifts, that's going to be better for everybody. I'm really excited. I'm optimistic. And I think that optimism is what carries us into each room. So we can tell people with a straight face, this is what we're up against. These are the tools we have. We're going to throw everything we have at this and keep you whole.

Excellent answer, both of you. And lastly, if there is one thing that you hope people listening take away from this conversation, what would it be and why? The most important thing in breast cancer is early detection. So I'm going to be pretty expected and say that. Take care of yourself. Get your mammogram.

Take somebody with you to get your mammogram. Go to your primary care physician or provider and get a breast exam. Pay attention to your body. And I think don't be so scared of this possibility that you're not empowered enough to figure it out. And so that really for me is just take care of yourself.

I'm going to say on the flip side that providers really need to listen to women. Women know their bodies really well. If someone is telling you that something's not right, then we should figure out why that is. That's really important for the breast cancer journey. Dr. Chen, Dr. Schubach, thank you so much for joining me today. And thank you so much for this conversation. Thank you. Thanks.

Thanks for listening to this bonus episode of Symptomatic. Be on the lookout in the coming weeks for another special episode from the 2024 ASCO Annual Meeting. We'll be speaking with Dr. Mohamed Atik about the patient struggle against prostate cancer and the current state of treatment.

What we're having to learn and discover in the current field is the sequencing of these treatments, which one should go first, right? We know based on some data, you know, okay, well, yeah, we might start with X treatment and go to the next one. But then there's just kind of a mix of options, which can all be appropriate. Which one is the best to continue and lengthen their survival is kind of a big point of discussion.

And we'll be back next week with another all new episode of Symptomatic. Until then, we would love to hear from you. Send us your thoughts on this episode, or you can share a medical mystery of your own at symptomatic at iheartmedia.com. And please feel free to rate and review Symptomatic wherever you get your podcasts. We'll see you next time. Until then, be well.

For people with stage 2 or 3 HR-positive early breast cancer, it isn't just long-term recurrence that's a concern. Short-term recurrence is equally critical, even among those with little to no nodal involvement and despite endocrine therapy. Within three years of diagnosis, up to 1 in 9 people with no nodal involvement will face recurrence. For those with N1 disease, up to 1 in 8 are at risk. Most recurrences will be to incurable metastatic disease.

In either case, within 20 years of diagnosis, nearly one in three people will experience distant recurrence. Visit EBCRisk.com to learn more about the treatment gap and short and long-term risk of recurrence in early breast cancer. That's EBCRisk.com, a resource from Novartis for healthcare professionals.