Advanced Breast Cancer Treatment

>> lori casey:coming up next on being well, dr. reuben boyajian from effingham will be my guest this week.dr. boyajian is a surgeon who specializes in the treatment of breast cancer. we'll belearning more about how breast cancer is diagnosed and how the treatment has evolved over theyears. we'll also learn more about how the treatment is customized based up several factors.we've got a lot of information to cover, so let's get started.[music playing] >> female speaker 1:production of being well is made possible in part by sarah bush lincoln health systems;supporting healthy lifestyles, eating a heart-healthy diet, staying active, managing stress, andregular check-ups are ways of reducing your

health risk. proper health is important toall at sarah bush lincoln health system; information available at sarahbush.org. alpha-care specializingin adult care services that range from those recovering from recent hospitalizations tosomeone attempting to remain independent while coping with a disability, chronic illness,or age related infirmity. alpha-care, compassionate, professional home care. additional fundingby jazzercise of charleston. >> lori casey:well i am so pleased that dr. reuben boyajian from effingham has come to visit being wellfor the first time. >> dr. reuben boyajian:thank you. >> lori casey:thank you so much for coming this way. tell

us a little bit about your practice and thetypes of cases that you deal with. >> dr. reuben boyajian:well, we do general surgery, which it's the run-of-the-mill, you know, gallbladders andhernias and endoscopies. but my main interest always has been breast cancer, particularlywith breast cancer issues. >> lori casey:and tell us about your role as a director of the women's wellness center at saint anthony.>> dr. reuben boyajian: that has been a very rewarding program; westarted that a few years ago to emphasize the issues of prevention, you know, earlydiagnosis in breast cancer, other breast illnesses, and motivating women to get their mammogramson time and regularly. it's amazing how many

women do not get the mammograms as a routine,you know, diagnostic and screening method to detect breast cancer at the early stage.>> lori casey: well i don't want to say you've been aroundfor awhile, but you've-- we were talking earlier before we started taping about there has beena lot of changes in breast cancer and breast cancer treatment and care and surgery. doyou want to talk about some of the big things that have happened? that you've seen in yourtime in the field? >> dr. reuben boyajian:i think being older, usually the advantage of looking in the past and learning from experiences.and also, witnessing a tremendous amount of progress in the field. in the-- i trainedin new haven, in connecticut, late 70s was

a time where the changes were so impressivesuch as introduction of chemotherapy for the first time.>> lori casey: that didn't happen until the 70s?>> dr. reuben boyajian: the late 70s.>> lori casey: all right.>> dr. reuben boyajian: of course, this was a trial by bonadonna fromitaly, introduced the cmf type of chemotherapy that made a major difference in patients withadvanced breast cancer. and at the same time, the mammography came along, became more sophisticatedas a diagnostic method and for a screening of breast cancers, and then, throughout dr.fischer's research, the transformation from

radical mastectomy into lumpectomies withbreast preservation. so, all this happened in a relatively short period of time. fromthere on, we witnessed all the advances in genetics, you know, more sophisticated targetedchemotherapy designed exclusively for particular situations because the breast cancer is differentat every age, different racial groups and they extent of disease, the type of cancer.so, it's been definitely tailored to the needs of the person, the women and sometimes men,because we do get breast cancer as well. >> lori casey:can you give us-- right now, what are our current breast cancer statistics here in theunited states? >> dr. reuben boyajian:they are frightening let's say.

>> lori casey:okay. >> dr. reuben boyajian:we still-- in the year 2015, we expect to diagnose over 230,000 cases of breast cancer.and an additional 60,000 cases of pre-cancer situations called dcis.>> lori casey: okay.>> dr. reuben boyajian: and of this group, about-- unfortunately,40,000 women will die from disease still. >> lori casey:is that number going up? the number of women dying from it, or are we doing better at-->> dr. reuben boyajian: that has improved.>> lori casey:

since the mid-90s, the death rate has decreasedto over 34%. and the diagnosis has increased and now it's kind of plateau.>> lori casey: we talked earlier about that they?re are somerisk factors that you can control, and some that you can't like genetics. can you talkabout the risk factors for breast cancer? >> dr. reuben boyajian:there are some risk factors that are out of our control. for example, being a woman isa risk factor, first one. the racial, the caucasian and the western civilization hasa higher incidence of breast cancer. the age of the first menstruation or period, calledmenarche, the younger the age, the higher the risk; late menopause, meaning past age55; lack of pregnancy, nulliparous, meaning

no pregnancies have occurred is a high risk.first pregnancy after the age of 30 is also a higher risk. obesity, smoking, alcohol,all the fun stuff, then we want to take away. >> lori casey:it seems like some of those factors, when we had dr. philip dy on, who's a colleagueof yours, a while ago; some of the same risk factors for breast cancer are similar forovarian cancer that he talked about. >> dr. reuben boyajian:that is very true. >> lori casey:and what is the connection between the period and ovulation and getting cancer later inlife? what does-- i don't understand kind of how that those work hand-in-hand.>> dr. reuben boyajian:

i call it the fertilizing atmosphere.>> lori casey: you know, because this is a time of life wherefertilizing hormones, such as estrogen or progesterone will actually be consumed byrapid growing cells, they love that. and the majority of cancers are hormone sensitive,particularly in the years of, you know, a normal menstruation or otherwise. and therefore,it becomes an issue of tremendous importance that realizing that the breast cancer in theovaries are two areas of the system in a woman that is constantly undergoing changes. allright, the ovaries are producing the ovulation and then they have to retreat, you know, thenthey have to-- i call it they expect a pregnancy, most of the time it doesn't occur. the breasthas to gear up to producing milk, and that

may or may not happen. so, the changes arejust very rapid and constant, month after month.>> lori casey: so, it's that hormones up and down, and upand down-- >> dr. reuben boyajian:right. >> lori casey:that cancer likes. is that kind of a way to put it?>> dr. reuben boyajian: correct.>> lori casey: okay, that's interesting. another thing thatwe hear a lot about is the genetic testing and the brca gene. talk a little bit aboutthat-- clarify that for our viewers.

>> dr. reuben boyajian:well so far, as well as we know the current knowledge and that is well established, isthe brca one and two are-- these are genetic tests that are readily available with a highdegree of accuracy. however, it's very important to know that the majority of breast cancersare not hereditary. >> dr. reuben boyajian:and only 5-10% maximum will be, you know, affected by heredity of being transmissible.and of course, you know, as the general public, you know, has a lot of-- we all have fearwith the "am i going to get it or not" or if you have heredity of a close relative thathad the cancer, is it going to increase my risk. so, all these issues are clarified throughconsultations and if the-- if we follow the

guidelines and the candidate is qualifiesfor the brca test, then we make sure we schedule it.>> lori casey: and is that-->> dr. reuben boyajian: and it's an expensive test.>> lori casey: so, do you recommend that to patients?>> dr. reuben boyajian: we try to educate them, they are qualifiersand there are not. for examples, if the cancer occurred in a woman younger than 45, the testingis recommended. >> dr. reuben boyajian:if the person has the cancer at an age younger than 50, but there is a close relative, let'ssay a sister or mother that had breast cancer,

we recommend the testing. and then there'salso the male sector or the male factor. if there are some families that don't have manyfemales in the family and they're all boys, and then you assume that there's no breastcancer here. but if there is a history of pancreatic cancer or aggressive prostheticcancer that means that the brca gene could be in the family and we look at those issuesas well. >> lori casey:and as you said earlier, men can get breast cancer.>> dr. reuben boyajian: right.>> lori casey: it's not very common, correct?>> dr. reuben boyajian:

well for, it's for every 100 women that willhave breast cancer, only one man will have that's interesting. talk about-- breast cancer'snot just breast cancer, there are different types.>> dr. reuben boyajian: and different places, can you clarify thatfor our viewers out there? >> dr. reuben boyajian:the most common cancer is the invasive ductal carcinoma, that's about 70-80%. then there'sa smaller percentage, the one that follows, is called lobular invasive cancer. and there'sa number of other names like tubular, medullary, mucinous, there's a lot less frequent, sothe majority of cancers are called invasive ductal.>> lori casey:

are those different types-- is one more aggressivethan the other or harder to treat than the other?>> dr. reuben boyajian: the invasive ductal takes the lead, it's usuallythe more aggressive. there's also another variety that is not very common called metaplasticand that could be very aggressive. >> lori casey:so, you had talked about that one of the biggest changes is in the treatment plan. that's it'snot just, you don't go through a checklist and go, okay you have this this is how we'regoing to do it. you have-- the treatment has really become customized to the patient. so,why don't you talk a little bit about how you as doctors determine the treatment planfor a woman who has breast cancer?

>> dr. reuben boyajian:we don't just go from the consultation room to the operating room. you know, that usedto be done in the old days, it's still done in some areas, but it-- we do the-- we followthe multidisciplinary approach. so, the patients are seen by the oncologists following thediagnosis, who call biopsies usually. and then depending on the pathology report, andlooking at all decisions that we talked about, is the tumor hormone sensitive, you know,is her two new, which is a protein that stimulates growth, is it positive or not, is a triplenegative cancer. the age of the woman, the size of the breast, the size of the tumor,is the person a candidate for breast conservation, can we just do a lumpectomy and keep all theprofile and the normal feminine anatomy as

intact as possible. does the patient needlymph node sampling and to what extent? so, these are all large number of variables that-->> lori casey: and that's-- that is when you come into play.>> dr. reuben boyajian: you're the surgeon and so you consult withthe patient over their options. so, it's not just radical mastectomy done.>> dr. reuben boyjian: correct, in fact the majority of the cancersare not treated by mastectomy anymore. >> lori casey:is that something that has, you said, has changed?>> dr. reuben boyajian: yes.>> lori casey:

lori it has, mostly because-- due to the factthat the discovery of cancer at the time that we find the tumor has evolved from large cancersto very small ones. the ideal is to find the cancer when it is less than two centimeters,or less than one inch, in diameter. the smaller the cancer the higher the probability to cure.and also, you know, when the cancer is a small one, we have to remove less breast tissue,obviously. >> lori casey:when does reconstruction come into play, because that's a, you know, having-- that's part ofa woman's identity. >> lori casey:when-- i'm guessing that's a common question that they get.>> dr. reuben boyajian:

how do you decide when someone can have thereconstruction? >> dr. reuben boyajian:it all depends; here we follow the lead of the patient, the woman and the family. andalso, we have to match the implications of the treatment and what is it going to do tothe system and what potential deformities will occur. and then the reconstructions arealso tailored, you know, the woman is very large breasted let's say, and she also wantsa breast reduction of the opposite breast, then we have to consider that. and some ofthe reconstructions involve placement of tissue expanders that are later changed into theprosthetic, and then the nipple is recreated. some of the reconstructions are based on freetransplants of tissue into the area. it's

also affected whether the patient will havechemotherapy and or radiation or not because those treatments can affect the healing ofthe-- and the timetable of the reconstruction as well.>> lori casey: so how-- where does the chemo part and theradiation part come into play and how do you determine if a patient needs one or the otheror both after surgery? >> dr. reuben boyajian:thank you for asking that question. well, see the results of the lumpectomy or partialmastectomy, these are equal terms, to the traditional mastectomy are equal as long asthe patient has radiation treatment after the partial mastectomy. so, this is-- that'sthe main role of the radiation.

>> dr. reuben boyajian:in some cases with the lymph node involvement is significant, let's say axillary or in theneck, then radiation treatment to those areas are also-- is also provided.>> lori casey: what about-- when does chemo come in? or isone used more than the other? is one more-- >> dr. reuben:chemo-- i'm sorry. yeah, chemotherapy is also a very customized treatment, you know, ifthe tumor is estrogen sensitive, we have easy-- i mean, medications that are easily takenlike tamoxifen that blocks the hormones, and it's simple as that. if the tumor is the triplenegative, so called, it's not hormone sensitive, then more aggressive chemotherapy is indicated.it also makes a difference if the tumor is

reoccur, if it metastasis, or spread to otherareas as well. >> lori casey:i was going to ask about cancer spreading. does breast cancer have, like other cancers;kind of a typical path if it's going to spread it's generally going to go here, here, andhere? or is it-- don't you know? >> dr. reuben boyajian:actually, it does, actually it does. the breast likes bone and it doesn't like to go to the,let's say, gastrointestinal system. it may go to the liver, sometimes brain, but boneis a very frequent site for metastasis. >> lori casey:how about the-- what about the lymph nodes? you often hear of women who have maybe thesurgery and then they also have a few lymph

nodes taken out. why do you do that?>> dr. reuben boyajian: it's really for staging and trying to seeif the horses are out of the barn or not. >> dr. reuben boyajian:you know, because the lymph nodes are a barrier, a defense, so the network of-- the lymphaticdrainage of the breast is so rich and most of it goes to the axillary area. so, thathas evolved into doing a very limited sample, called sentinel node, so we only need to takeone, two, or three nodes to really figure out if it's spread to the lymphatic stem hasoccurred or not. and that could be a modifier as far as the treatment whether the patientwill need chemotherapy or not and or radiation therapy as well, so.>> lori casey:

i wanted to ask you, what are the most commonconcerns or questions that patients ask of you when they find out that they have thisdiagnosis? it's very scary and maybe you're going to have to have surgery, what are somethings that you hear? >> dr. reuben boyajian:it's a very difficult time, obviously, and we try to place ourselves in the positionof the patient, and try to understand their environment, their support system. they wantto know if they're going to be cured or not. second common question, is the fear of rejectionor losing their job, their source of income, you know. and the insurance is a huge one;then, the cosmetic implications. so, those are very common questions. and if we try to--we try to analyze the patient's social situation

as well, there's also fear of rejection bythe spouse or significant other. so, all these things do appear but the leading questionis always, you know, the probability of cure. is the cancer ever going to come back? isit going to be transmitted to my family? and should i get genetic testing? so, those arevery common questions. >> lori casey:how do you determine-- is breast cancer-- i guess i should ask this first, is breastcancer staged like lung cancer and ovarian cancer? does it have stages that you giveit? >> dr. reuben boyajian:yeah, we have a precise staging system based on the size of the tumor, the spreading tothe lymph nodes and/or other organs.

>> lori casey:okay, so can you talk about cure rates or survival rates based on the stages?>> dr. reuben boyajian: great question.>> lori casey: i'm going to put you on the spot.>> dr. reuben boyajian: great question, i need to consult the conceptof dcis, ductal carcinoma in situ. in situ means that the cancer has not broken throughthe membranes of the tubing of the tubes that form the breast. so, when those are discovered,the cure rate is almost 100%. the second is the cancer less than two centimeters or lessor half an inch or less than with lymph node negative the cure rate is 93-95%. you know,with lymph node involvement it goes down to

70%. if there is metastasis, now we are droppingto 20%. so, it's-- it has a lot of importance in predicting the potential outcome and alsoprepare the-- and customize the weaponry, knowing those probabilities.>> lori casey: and it sounds like you have a lot of thingsin your arsenal to help with. >> dr. reuben boyajian:right, yeah. >> lori casey:surgery, chemotherapy, radiation, that sort of stuff. i want to get back to mammogramsa little bit. it seems that sometimes in the popular media, there's this debate, and maybein the medical community. mammograms every year, and then it came out now it's everycouple of years or they're not great at detecting

breast cancer in younger women. sometimesas a woman, you're just like i don't know what to do. what should we do?>> dr. reuben boyajian: lori, i have a large number of patients thathave the normal mammogram the year prior, and the next year they have a tumor that isdiscovered. knowing and having experienced that, i refuse to step back and say that themammography can be done at increasing intervals. so, mammograms after age 40 yearly, is thestandard. this has been challenged by some of the government agencies task force, andyou know, through our societies, the american cancer society, we are very strong and wehave fundamental issues with it that mammography should continue after age 40 on a yearly basis.>> lori casey:

in fact, i have a letter sitting at home tellingme it's, you know, my year is up and i need to go in. so, after taping this i think i'mgoing to make my appointment and get that taken care of.>> dr. reuben boyajian: sure, and modifications are introduced. let'ssay if the person is brca positive or a strong family history, even if the brca is negative,then we start mammography at an earlier age, 25-30 sometimes.>> lori casey: does the mammogram show-- can it show everything?even those tiny-- >> dr. reuben boyajian:no, it doesn't. and i'm glad you asked that question because the density is another buzzwordright now.

>> lori casey:yes, i've heard that many times. >> dr. reuben boyajian:yeah, it started in the state of connecticut, there's a history behind that. but the densityof the breast is the increased-- it will increase the risk for breast cancer. and it makes thediagnosis more difficult. you have a thick breast tissue that looks all white on themammogram and you can't tell. so, those persons qualify for ultrasound of the breast as ascreening method, and sometimes the mri. >> lori casey:and i'd imagine the technology in mammography, just like the technology in what you're doingtreatment wise, is always getting better. >> dr. reuben boyajian:it's getting better, we're going to 3d mammography

now. it's got its drawbacks too. example,3d mammography, a lot of patients are asking for it, we are getting it in effingham, butyou know what, when it comes to calcifications of micro-calcifications, it's not as accurate.so, we have to use all this technology wisely and there's not one recipe for all.>> lori casey: i wanted to ask you as we wrap up here, whatadvise can you give to a woman who's just newly diagnosed? what would you say to them?>> dr. reuben boyajian: i would say, first of all, reassure and be--have a lot of transparency and comparative in what we're doing. we issue copies of thepathology report to all the patients, share all the findings with them; we give them instructionsin the form of printed material and accessibility

to websites. and i think education is veryfundamental. and you know, that knowledge gives power to realize that it's not the endof the life, and transform the fear into an energizing factor. and we have situationswhere the patient becomes an advocate, helps other patients and faces the treatment withmore optimism, and ready to go on. >> lori casey:well, dr. boyajian, thank you for coming to the show. you've provided some great informationfor our viewers that i know they'll appreciate. and we hope to have you back again sometimesoon. >> dr. reuben boyajian:thank you, i do appreciate the opportunity and the interest that you have expressed.so, thank you very much.

>> lori casey:thanks. >> female speaker 1:being well is also available online at our youtube channel, youtube.com/weiutv. justlook for the being well playlist. here, you can view current, as well as past, episodes.production of being well is made possible [music playing]