Breast Cancer Flags

male: here we go, we're... [silence] teddy: hello, welcome to today's webinar. we are joined by dr. lisa newman. please note that all the lines are on mute. we will proceed with q&a following the presentation. ppe's, you may want to take some notes we have a great guest with us today. dr. newman is a surgical oncologist, professorof surgery

and director of the breast cancer center. sorry, the breast care center for the universityof michigan where she also serves as program director for the breast fellowship. dr. newman holds a master's degree in publichealth from harvard university where she also majoredin chemistry. she attended medical school and completedher general surgery residency training at the state universityof new york health science center at brooklyn.

dr. newman has recently been recruited toserve as director of the breast oncology program for the multihospital henry ford health system, a position that she will assume effectivedec. 1st, 2015. she will also serve as founding medical director for the newly created hfhs international center for the study of breast cancer subtypes. dr. newman's primary research has focusedon ethnicity related variation in breast cancer risk andoutcome

and evaluation and management of high riskpatients. and broadened applications for induction chemotherapy and special surgical techniques such as the skin sparing mastectomy and lymphatic mapping sentinel lymph nodebiopsy. her extensive research related to disparities in breast cancer risk and outcome has beenpublished in numerous peer reviewed medical journals and was recently featured on cnn's documentary

"black in america 2." if you didn't catch her there, you may haveseen her as the featured breast cancer medical expertfor nbc's "today show" or on "cbs' nightly news." dr. newman holds leadership positions in the most prominent of oncologic academic and advocacy organizations. currently dr. newman holds an appointmentto the cdc's advisory committee on breast cancerin young women

and she chairs it's working group on breasthealth messages for the general population. she also holds an appointment to the nih's clinical trials advisory committee. she maintains a very active community servicerecord and currently serves as chief national medicaladvisor for the sister's network incorporated, a national african-american breast cancersurvivor support organization.

as you can tell by now, highlighting dr. newman's great work would be a webinar unto itself. so without further ado, please welcome dr.lisa newman. lisa: thank you very much teddy, it's a pleasure to join everybody today. so every conversation that we have regarding health outcome disparities associated with racial ethnic identity

inevitably morphs into a discussion of thesocioeconomic inequities that exist in america. and let's see, oh here we go. is my screen showing up okay for everybody?alright. teddy: not yet. have you hit the play button? lisa: oh, okay. and everything's showing now? teddy: yes. lisa: okay great, great. so it is quite appropriate for us to alwayshighlight socioeconomic inequities because as we see

on the bar graphs from this slide, our two most common metrics are defining socioeconomic disadvantage, living below the poverty level and/or lacking medical insurance are two to three times more prevalent among our minority populations such as african-americans and hispanic latinos compared to the majority white american population.

now this next set of bar graphs demonstrate the fact that poverty is indeed an adverse prognostic factor following any cancer diagnosis and for bothgenders. what we see here is that within any racial ethnic subset of the population, the most impoverished communities, as depicted here by the red bars, have the lowest five year survival rates

compared to the most affluent communities in that racial ethnic subset as depicted here by the yellow bars. now if we look specifically at the burdenof breast cancer in african-american women, it's certainly logical to assume that these socioeconomic disadvantages will result in a more advanced disease stage by the time a woman reaches diagnosis

and by the time she gets treated. and ultimately this will unfortunately lead to higher mortality rates from breastcancer. now poverty and lack of health care coverage is often linked to inadequate access to breast cancer early detection tools such as screening mammography and diminished access to optimal medical as well as surgical treatments for breastcancer.

and furthermore, we often see poorly controlled co-morbidities especially those such as hypertension and diabetes in our socioeconomically disadvantaged populations and these issues will also complicate the ability to complete appropriate treatment for breast cancer. now there are some other socioeconomic factors that impact on breast cancer outcomes thatare more subtle

such as those related to subconscious discriminatory practices among health care providers and the demographics of our healthcare workforce. on this slide i'm actually referring to alandmark study that was published in the new england journalof medicine more than 10 years ago and it's actually basedupon cardiovascular health, but it carried somepowerful messages that are relevant to all fields of medicine.

the investigators that conducted this studyactually utilized professional actors whose photographs are shown on this slide and each of these actors were video recorded while presenting symptoms of chest pain in an emergency room. so these professional actors were specificallyinstructed to utilize similar verbal and facial expressions in demonstrating their symptoms

and discomfort from chest pain so that the major variables between them weretheir gender and their racial appearance. these video recordings were then shown tomore than 700 physicians that were attending some professional medical conferences and after viewing the tapes, the participating physicians were asked tocomplete a survey regarding how they would manage these

hypothetical patient scenarios. when all of the survey responses were compiled, a glaring result was identified. and this result was that the african-americanfemales were actually the least likely to be recommended for further medical evaluation of their chestpain in the form of special strategies such as cardiac catheterization. so this left the investigators with havingto conclude

that these patients, the african-americanwomen, were suffering from the dual biases related to their gender and their racial appearance. now i don't believe that the physicians participating in this study were being overtly discriminatory in their treatment recommendations. but i do believe that all of us carry aroundsubconscious biases that we are not even aware of and when we are trying to make

rapid clinical judgment calls in emergencysettings, sometimes these biases which can be harmful get interjected into the recommendations that we make for our patients. and so i applauded the investigators of this landmark study because of course the first step in eliminatingharmful biases is to simply acknowledge that these biasesexist at all. so these types of biases in healthcare practices

are now being studied in a variety of medicalspecialties including oncology. and on this slide i'm showing you the tabulatedresults from a study that i had the pleasure of beinginvolved with from the university of texas md anderson cancercenter, one of our premiere oncology programs in theworld actually. and in this study, all of us as investigators sought to determine whether or not there weredifferences in women being recommended to receive breastreconstruction

after they had undergone a mastectomy for a diagnosis of breast cancer based upon racial ethnic identity. and the lead fellow who conducted this work, jennifer sang, did a beautiful job, she did a very rigorous medical record review where she went through the medical charts of many hundreds of breast cancer patients of all racial ethnic backgrounds

and then she looked at for these women if they needed to have a mastectomy for their breast cancer, were they referred to a plastic surgeon? if they were referred to the plastic surgeon, was reconstruction offered? and reconstruction was offered, was the reconstruction actually performed? and at every level of the referral process

the african-american breast cancer patients were about half as likely to proceed onto the path towards breast reconstruction. now i worked at the md anderson cancer center for several years, i was quite proud of mycolleagues and of the services offered there. so i can certainly tell you from my personalexperience that these are wonderful oncologists. however, even in this renowned cancer center

we saw that there were biases and differences in the treatments that were offered to african-americans compared to white american patients. so again the first step in acknowledging theexistence of harmful biases is to document the factthat they exist. we also have a very unfortunate inadequatediversity in the demographics of our own healthcareworkforce. and these bar graphs are simply demonstratingthe fact that african-americans and hispanic latinoamericans

are woefully underrepresented among the physicianworkforce, the surgical workforce, and the workforce of cancer oncology clinical trials groups such as the american college of surgeons oncologygroup where you see that minority positions account for 2 to 3% of the healthcare workforce compared to 12 to 13% of their representation in the general population. so correcting these types of problems with

the diversity of our healthcare workforce is certainly important and it will take many years of aggressivementorship to fix this pipeline issue. and i'm definitely not somebody that goesaround recommending that every patient be matched by racial ethnic identity and gender to theirphysician. but i do definitely believe that our patients will have more confidence and trust in thehealthcare system

if they see a healthcare workforce that more accurately reflects the demographics of their own neighborhood. now many of my mentees continue to express ambivalence and concern about pursuing a healthcare profession as a career because they are worried about discriminatory practices and they are worried about simply difficulties in navigating the ability to be promoted

in the healthcare workforce. and this is where i like to quote for them a beautifully placed quote by dr. charlesdrew who is really a grandfather of african-americans in academic surgery and charles drew was chairman of the departmentof surgery at howard university for many years and a pioneer transfusion researcher. and he stated that excellence of performance

will transcend artificial barriers createdby man. so this is a very, very important message for our young people to take with them as they pursue their educational opportunities. yes there will be discriminatory practicesout there, and yes there will be biases from your colleaguesout there. but you have to simply keep your eye on theprize and remember that it is indeed worthwhile for our communities for us to stay the course

and continue to get more african-americans and more latino hispanic americans through that pipeline and in the healthcareprofessions. so since there are indeed so many well documented socioeconomic factors that can explain disparities in breast cancer related to racial ethnicidentity, it's certainly appropriate to ask the question of why we would bother investing these hardto come by dollars in healthcare in research to study race

and ethnicity associated variation in tumorbiology and in the pathogenesis of breast cancer. so here i think it is useful to look at somedata that i and my colleagues from the harvard school of public health were able to generate. and for this study which was the result ofa meta-analysis or a pooled analysis that we conducted where we basically looked at the findings

from all of the studies that had appeared in the published literature documenting survival rates from breast cancer for african-american compared to white american patients after accounting for some measure of socioeconomic status. so this pools analysis gave us a very robust patient population tostudy. more than 13,000 african-american breast cancerpatients

whose survival was compared to more than 75,000 white american breast cancer patients. and after adjusting for socioeconomic status as well as the stage of diagnosis, we saw that the african-americans had a nearly 30% higher mortality rate. so something seems to be going on relatedto african-american identity beyond socioeconomicdisparities. and if we look further at the characteristicsthat describe

the breast cancer burden of african-americans we indeed see that there are several characteristics that cannot be easily ascribed to socioeconomic disadvantage. first, african-american women actually have a lower lifetime incidence of being diagnosed with breast cancer compared to white americanwomen despite the fact that we have a higher mortalityrate from the disease.

but african-american women also have a younger age distribution for breastcancer. and so if you look specifically at americanwomen younger than the age of 45 years, breast cancer is more common in african-americans compared to white americans. and african-american women have a higher frequency of adverse tumor features which we will talkabout in more detail over the next several slides.

we have a higher frequency of tumors that we describe as being estrogen receptornegative, and tumors that we describe as being triplenegative. and both of these features indicate biologically more aggressive breast cancers. there is also a very poorly understood higherincidence of male breast cancer in the african-americancommunity. now male breast cancer is obviously very unusual, but again the incidence of male breast cancer

is higher for african-americans compared to white american men. now these bar graphs are depicting in a verysimple fashion the patterns of breast cancer incidents and mortality that we have seen over the past several decades for african-americans now, the incidence rates are depicted by the top two curves and this top curve isthe, in population based incidence rate of breastcancer

for white american women and we see that over the decades the population based incidence rates for breast cancer for african-american women has always been lower than that for whiteamericans. it's a different pattern however when we look at the mortality curves. for breast cancer mortality, these rates wereactually identical for african-americans and white...

[audio cuts out briefly] ...the early 1980's we start seeing significantdeclines in breast cancer mortality rates for whiteamericans. but those death rates from breast cancer for african-americans are largely unchanged. now what this is probably related to is thedifference in breast cancer biology between african-americans and white americans. in the late 1970's, a medical treatment forbreast cancer

became available in the form of endocrinetherapy. hormonally active cancer fighting pills forbreast cancer. and the impact of these powerful endocrinetherapies on breast cancer mortality rates therefore became apparent after the 1980's. now what we are seeing expressed here is the fact that african-american women are about twice as likely to have estrogen receptor negative breastcancers

compared to white american women. and the estrogen receptor negative breastcancers will not respond to hormonally active cancer fighting medication such as endocrine therapies such as tamoxifen. and this is probably why we start to see thedifference in breast cancer death rates between african-american and white american women. the advances that we began making in medical treatments for breast cancer

were simply not effective in the breast cancers that were more abundant among african-americans. lisa kerry and colleagues from the carolina breast cancer study group have gone one step further and they have now looked at the frequency of a tumor subtype called a triple negativebreast cancer. triple negative breast cancers are tumors that are negative for three

of the microscopic molecular markers that we evaluate on breast tumors. the estrogen receptor, the progesterone receptor, and the her2/neumarker. and these triple negative tumors are biologically inherently more aggressive cancers. triple negative breast cancers are about twice as common again in african-americanwomen compared to white american women

and they are especially more common in young african-american women. so the results of the lisa kerry carolinastudy group findings have now been replicated by many other investigators. as we see on this table, consistently throughoutmany different publications the frequency of the biologically aggressive triple negativebreast cancers is about two fold higher for african-american

and also interestingly this study at the verybottom of this table is showing the frequency of triple negative breast canceramong men with breast cancer. but again demonstrating that triple negativebreast cancers are more common among african-american men with breast cancer compared to white american men with breastcancer. so at the bottom of this slide i'm showingyou what it means

to have a triple negative breast cancer. we identify triple negative breast cancer by applying special stains to the biopsy material of a breast tumor. the triple positive breast cancers are thecancers that take up these stains nicely and so at the top we see a cancer that is positive for the estrogen receptor, the progesterone receptor and the her2/neumarker.

at the bottom we have a triple negative breastcancer that does not express any of those stains. so a triple negative tumor is something that has to be evaluated with a microscopic pathology report. it is not something that we can identify by looking at a woman's mammogram. it's not something that we can identify on physical examination of the breast.

and it's not even something that we can identify when we are looking ata tumor surgically in the operating room. the clinical relevance of having a triplenegative breast cancer again is related to the fact that these are biologically inherently more aggressive tumors. they are more likely to metastasize to otherparts of the body and to cause breast cancer mortality.

and the medical treatments that we have available for breast cancer in terms of targeted therapy targets those three markers that the triplenegative breast cancers fail to express. and so women diagnosed with triple negative breast cancers are more likely to need chemotherapy for treatment of their disease because they cannot receive targeted therapy. now this issue of african-american women being

more likely to be diagnosed with biologicallyaggressive patterns of breast cancer does have an impacton mammography screening recommendations. many of you in the audience may have heardabout a lot of the controversy regarding the age at which a woman should begin her mammogramscreening to detect a hidden breast cancer. and for many, many decades we routinely would recommend that all american women

begin an annual mammogram evaluation startingat age 40. the united states preventative services taskforce issued an updated screening recommendation in late 2009 where they recommended against starting mammograms in the 40's agerange and recommended that american women begin their mammograms at age 50. well unfortunately the task force never evendiscussed the impact that the mammography screeningguidelines

might have on disparities in breast cancer. and here i'd like to point out some data froma study that we conducted based upon the california cancer registry where we [audio cuts out] triple negative breast cancer are typically higher for african-americans compared to whiteamericans in all of these different age categories. and actually for women in their 40's, the incidence rates of triple negative breastcancer

in african-american women is higher than therates of these biologically aggressive tumors in white american women in their 50's. so if african-american women adhere to the task force guidelines and delay screeningmammography until they reach age 50, we are likely to significantly worsen thedisparity that already exists in terms of survival rates between african-american and white american

breast cancer patients because we will be delaying the diagnosis of these biologically aggressive tumors now the data regarding the population basedincidence rates of triple negative breast cancer have now been replicated on a national basis and in the recent annual report to the nation on the status of cancer, breast cancer subtypes were featured

and in this second graph labeled b we see that african-american women in allage categories have the highest rates of triple negativebreast cancer compared to white american women, asian women, and hispanic women. the characteristics that describe breast cancer in women with african ancestry, african-americanwomen are the same features that describe the breast cancer burden of women

with known hereditary susceptibility for breast cancer because they have mutations in the brca-1gene. those features being younger age distribution, the higher frequency of biologically aggressivecancer such as triple negative cancers and the higher risk of male breast cancer. so these common features then beg the question of whether or not african ancestry might beassociated

with some heritable marker for high risk breast cancer subtypes. and studying the patterns of breast cancerin africa where we have shared ancestry with african-americans may actually give us a unique opportunity to learn more about the etiology of breast cancer disparities and to understand the pathogenesis of triple negative tumors.

and so i've had the pleasure over the lastten years of partnering with the physicians at the komfoanokye teaching hospital in kumasi, ghana to characterize the breast cancer burden of women from ghana which is indeed a country of western sub saharan africa because of the patterns of the slave trade from more than 400 years ago. what we see in looking at several hundredwomen

representing white americans and african-american breast cancer patients from the henry ford hospital in detroit, michigan compared to the ghanaian african breast cancers is that there is the very young average age of breast cancer diagnosis among ghanaians, the eldest average age of breast cancer diagnosis in white americans and intermediate age of diagnosis in african-americans.

the biologically aggressive triple negativebreast cancers account for the majority of breast cancers in ghanaian women. the lowest frequency at 15, 16% in white americans which is similar to what we see in europe, and they account for an intermediate frequency of 26% in african-americans. in partnering with yet a different hospitalin ghana, the korle bu teaching hospital,

we again saw that triple negative breast cancers accounted for the majority of tumors, 58%. and so if you link together the studies frommy group as well as others that have looked at thebreast cancer burden of western sub saharan africa you consistently see these patterns. the eldest average age of breast cancer diagnosis for white american and european women in theearly 60's. youngest average age of diagnosis

for western sub saharan africans, intermediate for african-americans. now of course the average life expectancy is lower overall for africans and so thiswill impact on the average age of breast cancer diagnosis but mid-40's is an especially young age of breast cancer diagnosis for any population. in terms of frequency of male breast cancer, this is highest in western sub saharan africa,

lowest for white americans and european americans, and intermediate again for african-americans. again the same stepwise patterns when we look at frequency of triple negativebreast cancers, high grade tumors, and estrogen receptor negativetumors. and so if there is something associated with african ancestry that predisposes for certain patterns of breast cancer you would expect to see it most strongly expressed

in contemporary african populations. you would see it expressed to an intermediateextent in african-americans because of the four centuries of ad mixture that we've experienced genetically. but you will see it expressed to some extent in women around the globe because africa remains the founder population for all ofhumankind. so we've now gone on to study other markers of breast cancer pathogenesis and virulence

such as the mammary stem cell marker alvh1. stem cells are important in breast cancer because this is the particular populationof tumor cells that is responsible for the malignant metastatic potential of the tumor. and in looking at this mammary stem cell markeraldh1, we've seen that this marker is expressed to the highest extent in a ghanaian cancers to an intermediate extent in the african-american

tumors that we've evaluated, and similarly low extent in white americans and european cancers. interestingly we did also see that when therewas elevated expression of this marker in benigntissue from ghanaian women as well. we've also gone on to create a library of patient derived xenographs, which involves us taking fresh tumor tissue

from patients that we are operating on to treat their breast cancers in ghana and we take portions of these samples thatwe then implant into special laboratory immuno compromisedmice and then we are able to grow these tumors so that we have a renewable supply of thesetumors as the different generations of mice pass so that we can study tumor biology and novel treatments in mice

before we study these treatments in humans. now the ultimate goal of these types of international breast cancer research partnerships of course has been to study more about breast cancerbiology, but there are many other extremely gratifyinggains from these types of partnerships. we are able to invest in the healthcare of medically underserved populations aroundthe globe and we forged some very powerful friendships

and exciting opportunities for cultural and academic exchange programs. so this international registry has now expanded to where we are working in three differenthospitals in ghana, the sunyani teaching hospital and the tamale teaching hospital in addition to the komfo anokye teaching hospital. and we are also partnering with the saint paul's millennium hospital

in addis ababa, ethiopia and we are about to start looking at specimens from a hospital in new delhi and yet anotherone in china. here in the united states we are very, veryexcited about our ability to study african-americanbreast cancers by recruiting women from the sister's networkincorporated. the sister's network incorporated is a national organization of african-american breast cancer survivors and survivor advocates

consisting of more than 3,000 patients across 22 states in the united states. and these women have been absolutely phenomenal about embracing our research in trying tolearn more about the genetics of breast cancer related to african ancestry. so here i want to just show you a few slides, photographs of the facilities in ghana, simply so that you can get an idea

of the really heartbreakingly few resources that are available in these institutions, much, much less than we have available in nearly any hospital in the united states even though obviously we do have tremendousdisparities that exist across healthcare institutions in the united states as well. so this is the preoperative area, it's simplya hallway. the patients as you can see don't have anysheets

on their stretchers. the medical records, if we have them at all, are held in cardboard boxes. the recovery room similarly is lacking insheets for the stretchers, this is our pre-op pseudo-sterile scrub sink where we prep for surgery. if there is a power outage or if the runningwater is problematic at the end of the day, the nurses rinse our hands off

after we have scrubbed them with water thatis, i have to just call it pseudo-sterile that they pour on us from these buckets that actually look like trash basins. but you have to make do with the best resourcesavailable to you in order to deliver care for your patientpopulation. and so our research partnership has been a very exciting opportunity to invest into the healthcare of systems

such as the komfo anokye teaching hospital and the other facility where we've had the honor of being able towork. we are able to not only donate surgical andpathology supplies for the breast cancer program, but we are able to help out in other areasof the hospital. the pediatrics unit at the komfo anokye teachinghospital actually has a school there, and we are able to donate educational supplies

and toys to the kids in the pediatrics unit. which is always a highlight of every trip that we make to ghana. we've been able to establish an immunohistochemistry program at the komfo anokye teaching hospital so that the pathology staff is able to generate their own reports of immunohistochemistry looking at the estrogenreceptor, progesterone receptor and her2/neu markers

and we have a weekly telemedicine conference where we interact with our colleagues at the komfo anokye teaching hospital on aweekly basis via telemedicine and web services. these are some photos of the wonderful groups that we've worked with at the tamale teaching hospital in ghana. and these are some photos of the group that we work with in ethiopia,

the saint paul's millennium hospital in addisababa. and these are some photographs from some of the really exciting and fun breast education programs that we are able to conduct in partnership with the sisters network incorporated herein detroit we have an annual event called the sisterstrut where we are able to disseminate information about breast health awareness

to thousands of african-american women ona yearly basis. some more photographs from some of the conferences of the sister's network. and whenever i talk about breast cancer disparities i always like to close by showing these three different survival rates of 60%, 43%, and20%. but these survival rates actually don't haveanything to do with breast cancer, these are the survival rates for the firstclass,

the second class, and the third class passengers of the titanic. and it demonstrates that outcome from anyhealth threat is going to be completely dependent on accessto care. and so even though my research is based upon looking at the biology of breast cancer related to african ancestry, we have to address the fact that outcome is dependent on access to care

and it doesn't matter whether you're talkingabout access to the lifeboat that the third classpassengers did not have access to the lifeboats on thetitanic. or if you're talking about access to a screeningmammogram and a diagnosis of breast cancer. you will have a worse outcome if you do nothave access to care. and finally in closing, my favorite quote from the incredible reverend dr. martin luther king, jr.

"of all the forms of injustice, inequalityin healthcare is the most shocking and inhuman." and so i thank you and bring you greetings from the university of michigan health carecenter. but i also wanted to announce the very excitingtransition that i am about to make where i will be serving as the director of the several hospitals in the henry ford health system, representing the population of southeast michigan.

and i will also have the pleasure of serving as founding medical director for the henry ford health system internationalcenter for the study of breast cancer subtype. allowing me an opportunity to expand my internationalwork. and so i thank everybody for their time andattention, and if teddy says that we have a few minutes, i'm certainly happy to stay online for anyquestions that anybody might have.

teddy: sure thing, thank you very much dr.newman for a wonderful presentation. we have about ten minutes for questions andanswers, audience if you look on your control panel, your gotowebinar control panel you should see a questions box. please type in any questions you have fordr. newman. so we have our first question. do african-american males with breast cancer

also have higher rates at younger ages? lisa: the age distribution from what we seethus far seems to be similar to white americans, men with breast cancer. but there is the higher frequency of the biologically aggressive tumors. teddy: okay. and next question. lisa: that's a great question. teddy: how can we improve african-american

patient participation in cancer studies? lisa: well, i think that the most importantvariable is the physician and presenting the opportunity to participate in research in a clinical trial. in my experience and in the reported experience of many others, african-americans when they are offered the opportunity to participate in research are in indeed veryenthusiastic about being able to make this type of a contribution.

but unfortunately a lot of providers are reluctant to offer clinical trials because they are fearful that african-americans will be alienated from them because of fears of the historic horribletuskegee experience. and again this is where bias is on the partof the providers has a negative impact on our ability to provide optimal healthcare. but research opportunities need to be presentedto patients

regardless of racial ethnic identity. teddy: alright. our next question, when comparing ghanaian, african-american, and u.s. born african-american and white americanwomen were socio-ecological factors considered besides genetic factors? lisa: well certainly the ghanaians have farfewer socioeconomic resources no doubt about it compared to african-americans.

so there we did not have a way of measuring that directly because of the financial structure and the healthcare coverage is totally different. but as a general rule we can certainly saythat the socioeconomic advantages are far fewerfor the ghanaians. and so we did in fact see that the ghanaianwomen with breast cancer were more likely to bediagnosed with bulky cancers and the time to gettingtreatment instituted was far delayed.

but despite the issue of stage distribution this issue of basic tumor biology was a glaring difference and we see these higher frequencies of the triple negative breast cancers among the ghanaian women. and here in the united states even after you account for stage at diagnosis, triple negative breast cancers are more common in african-americans compared to white americans.

teddy: okay. and dr. newman what are yourthoughts on the new cancer screening guidelines released by the american cancer society. specifically regarding when mammograms should begin, at what age. lisa: yeah, thank you very much, i'm glad that that question was posed. so, as many in the audience probably heard the american cancer society recently updated

their recommendations regarding screeningmammography. the american cancer society has historicallybeen strong advocates that all women should startmammograms at age 40 and continue them yearly. in their updated guideline, they tried to emphasize the fact that breastcancer risk increases for all women as we get older. and so they said that a screening mammogram is a must for all women reaching the age of45.

however they were very specific in saying that they continue to advocate in favor of mammograms being available to all women starting at age 40. and that part of the guideline unfortunately was largely overlooked by a lot of the media promotion of the update and so i do want to specify the fact that the american cancersociety does continue to advocate in favor of access

to annual mammograms starting at age 40. but they basically said that it is a must to start mammograms by the time you reachage 45, again because of the fact that breast cancerrisk increases as we get older. teddy: dr. newman, has your research or haveyou done any studies showing the correlation between the diets of african-americans and canceroccurrences? lisa: yeah that's another great question.

we do know that diet plays some role in cancerburden, and obesity certainly plays a very significantrole in cancer burden here in the united states. obesity is a risk factor for breast cancer, especially in the post-menopausal age women and obesity is a risk factor for triple negative breast cancer. so it is definitely a possibility that obesityrates in african-americans impact

on risk of triple negative breast cancer. teddy: and we have a question about your workin ghana, are you working with any organizations inghana? the asker made a point to say that there is mistrust among ghanaians andphysicians. so are you working with organizations? lisa: the organized groups that i've had thepleasure of working with have been the medical groups. specifically the medical groups affiliatedwith the hospitals

that i've been working in. the person that asked this question made a very, very valid point. there are ongoing barriers to the populationin ghana receiving appropriate healthcare for any number of medical conditions because of the reliance on herbalists andtribal type of medical care and the healthcare institutions are working quite hard at trying to get patients

to come to hospitals more promptly to receive conventional medical care rather than relying on herbalists for care. but this is an ongoing struggle. teddy: okay and sort of to that point, how do you assess the spirituality in african-americans? does spiritual care support play any rolein your research? lisa: it does not play a role in terms ofanything that i am measuring or accounting for

in my particular research. but it is extremely important, it is absolutely, absolutely extremely important. we used to say routinely that stress and attitude really did not play a role in a cancer diagnosis or a cancer outcome. but we are now learning that there are many areas where stress related hormones and chemical imbalances overlap with the hormones

and the substances that circulate related to cancer biology. unfortunately we are not sophisticated enough with our understanding of these imbalances to be able to manipulate them. but stress does play some role in cancer progression. now unfortunately nobody knows the magic way to free ourselves of stress, but we do certainly want our cancer patients

to avail themselves of all types of supportnetworks so that they can minimize the amount of stress in their lives as they are going through cancertreatment. and spirituality is closely linked to theissue of stress. having a strong spiritual background and faith network is very, very closely linked to one's attitude going through cancer treatment. teddy: thank you. dr. newman, do you haveabout five more minutes for more questions?

lisa: sure. teddy: great, okay. what do you believe is the reluctance towards reconstructive surgery among african-americanwomen? lisa: i think that a lot of the differencein utilization of breast reconstruction is related to presentation of the options. in groups where reconstruction is offeredequally, reconstruction tends to be accepted by

african-americans equally. now there is a fair amount of variation between studies looking at utilization of breast reconstruction in african-american compared to white americans and so i can't say that the results are consistent. but in general and certainly anecdotally in my own breast cancer patient experience, i would say that african-american women

are just as interested in breast reconstruction as white american women. unfortunately because african-american women tend to be diagnosed with more advanced stages of disease this can impact on the types of reconstruction that are offered to them and that can also have an effect on whether or not reconstruction is utilized. teddy: okay. have you studied if offering

genetic testing to african-americans is different than the -- i'm sorry. have you studied if offering genetic testing to african-americans is different for whites since triple negative breast cancer is moreprevalent with african-americans are they being offeredgenetic testing? lisa: yes, that's another great question. we are just over the last ten years or so starting to generate stronger information

regarding some of the genetic mutations that predispose for breast cancer in african-americans. and before that, there was absolutely underutilization of genetic testing in african-americans and so we did not have a very clear understanding of the mutations that were more prevalent in the african-american community. with some of the more aggressive testing thatis being done, and as the questioner appropriately pointedout,

triple negative breast cancer is a red flag for hereditary susceptibility for breast cancer. and so genetic testing should actually beoffered more aggressively to african-american women because of the higher frequency of triple negative breast cancer. but we are just now starting to see that there are some mutations in the brca1 and 2 genes that are indeed more common in women withafrican ancestry.

judith hurley and her group in florida havedone some fabulous groundbreaking work identifying founder mutations in some of these genes that are specifically associated with havingafrican and caribbean ancestry. teddy: and along those lines have you looked at the rate of breast cancer or triple negativebreast cancer occurrence in african women of the diaspora? if so do you have a link to the study or informationon that?

lisa: yeah, so i'm so glad that this questionwas asked. as i noted we recently have started a partnership with a hospital in addis ababa, ethiopia. so we are hoping that our work in ethiopia will provide us with some representative breast cancers of east african women. and presenting some of our really new noveldata from this work at the society for surgicaloncology meeting in march of 2016,

so i can't go into great detail regardingthese findings. but i can say that the patterns seem to be a little bit different for the east african, the ethiopian women that we've seen compared to the western african ghanaian women. and if you look at the patterns of the slavetrade it makes sense that we might see differentpatterns here because the slave trade from west africa came to the americas.

the slave trade from east africa largely wentto asian countries. and so most of the shared ancestry that wehave for african-americans is with western africa. so it does make sense that we might see similarities between the breast cancer burden of african-americans and western africans but the patterns in eastafrica may well be different. teddy: two part question, do you have anyadditional information on triple negative breast cancer among latinos

and have you researched, have you done research in african-american survivors of triple negative breast cancer? lisa: so regarding the first question, it's also a great one regarding the breastcancer burden of hispanic americans and latinas and i personally have not been involved withthat work, but in looking at the literature that's outthere, i see tremendous variation because

there is so much heterogeneity in the hispanic latina population. many hispanic americans identify as hispanicamericans when they have spanish european background, or they may identify as hispanic americans because they have mexican or central american, south american backgrounds. some of them have a fair amount of africanancestry as well. so there's tremendous, tremendous heterogeneity

and difficult to cleanly define ancestry by geographic definitions related to that one global descriptor of hispanicamerican. and the other question i'm sorry? teddy: and the second question was have youdone research in african-american survivors of triple negativebreast cancer? lisa: oh, yes. so my research has mainly been looking atthe biology of the these tumors and has not involved follow-up.

but in studies that do evaluate follow-up, we tend to see that as long as the cancersare detected early and appropriately treated, african-american outcomes will be comparable to the outcomes of white americans. and so early detection is critical, especially if you are at higher risk for being diagnosed with a triple negative breast cancer. and so again i can't emphasize strongly enough

screening mammography i believe is that much more important for african-american women, but i think it's important for all women and i recommend screening mammograms beginning at age 40 for all women. teddy: age 40. lisa: if women have symptoms of any breastproblems however i do also want to emphasize that it's critical to seek medical attentionimmediately

regardless of when the most recent mammogramwas performed or what the results were. so symptoms such as a new breast lump, bloody nipple discharge, change in the appearance or inflammatory changes in the breast. these are all features that should send apatient immediately to seek medical attention. teddy: okay, thank you all very much for yourquestions.

we have a few more, sorry we couldn't get to all of them. so we're going to try to get through these last few very quickly. dr. newman is a very, very busy woman. so dr. newman, do you expect to see screeningguidelines modified for african-americans similar to people with brca genes? lisa: at this point in time it does not lookas though

any of the major organizations are heading in that direction and the u.s. preventative services task force has already begun their draft for yet again updated guidelines. it does not appear that they will be deviatingat all from their prior recommendation that women initiate mammograms at age 50. they are discussing in this draft update guidelines,

the issues of disparities, but it does notappear at this point in time that they will be looking at different guidelines for women of any racial ethnic identity. teddy: with the recent announcement of some processed foods being carcinogenic, are there any dietary recommendations that you can make for the average individual? also would you happen to know if alternativetherapies

such as acupuncture can be cancer preventative measure? lisa: yes, those are great questions. we definitely know that obesity is a riskfactor for post-menopausal breast cancer and it's a risk factor for triple negativebreast cancer. so in terms of diet, the most important message is moderation ineverything and try to the greatest extent possible

to follow a well-balanced diet that is relatively low in fat and to have a lifestyle that includes a lot of exercise and activity. acupuncture has been found to be very valuable in many studies in terms of controlling pain and adverse effects from cancer treatment. i am not aware of any data showing that acupuncture can prevent breastcancer.

teddy: and are there populations that showlow to non existing triple negative breast cancer diagnoses? lisa: i'm sorry populations that do not haveany risk of triple negative breast cancer? teddy: right, that show low to nonexistentdiagnoses lisa: no, i am not aware of any populations that have a zero risk of triple negative breastcancer. teddy: and finally, have you performed anystudies on dense breast tissue in minority groups

and do you recommend the same, i guess, procedure for those with dense breasts? lisa: yeah, this is another great question. and as the questioner probably is alreadyaware, many states have enacted legislation where mammographers are mandated to specificallyreport to patients if they see that there is a significant amount of density on the mammogram. breast density, very thick tissue on a mammogram

can make the mammogram a bit more challenging to interpret because the densities that welook for associated with cancer can be obscured bybreast density. and breast density in of itself is a risk factor for breast cancer, probably because of the fact that thick breast tissue can be a sign of very active breast tissue on a cellular basis, and so that can be a sign of hyper proliferativetissue

that's more likely to develop a cancer at some point in the future. we don't have any standardized recommendations, however, for routine changes in screening mammography practices or any other screeningimaging practices for women who have very dense breasts, but we do recommend that for women who havedense breasts they need to have a frank conversation withtheir doctors regarding whether or not it is indeed prudent

to pursue additional screening practices such as more extensive ultrasound imagingof the breast or breast magnetic resonance imaging, or one of the very, very exciting newer ways for performing mammography, 3d mammography or breast tomosynthesis. teddy: great, and really i'm sorry for allthe questions we couldn't get to. this is really the last question we have. and then dr. newman can you give some contactinformation

or resources after this last question? how common is diversity training in hospitals and how do we really begin to address the underlying disparities in healthcare? lisa: well, i applaud the organizers for putting together programs such as these, it's absolutely wonderful that the department of health & human services is investingresources into promoting these types of educationalefforts,

and we as an african american community havea responsibility to get the message out there to our neighbors,our relatives, our friends and loved ones regarding how to advocate on behalf of our communities with health in general, and certainly withbreast health. teddy: great. and how can our attendees getin touch with you or follow your work over in ghana? lisa: thank you very much. so my email address is lanewman@umich.edu.

unfortunately i do not yet have my new contactinformation for my new position at the henry ford healthsystem, but i can certainly be reached at the universityof michigan over the next several weeks or couple of months,at least. teddy: all right, great. thank you very much dr. newman for your presentation, it was really awesome for you to join us, and the ppes on the campuses, i'm sure they're very appreciative

of the information as well. and with that we conclude our webinar, thank you all for joining us, if you would like some more information onthis topic please contact me, my name is teddy owusu, my email address is towusu@minorityhealth.hhs.gov. and if you've missed dr. newman's email address i can provide that to you as well. so, thank you all and thank you dr. newman.

lisa: thank you very much, it's been a pleasureand an honor. teddy: great.