Facing radiation therapy as a breast cancer doctor and survivor  

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Hello, my name is Melissa Mitchell, and I am a professor of Breast Radiation Oncology here at MD Anderson Cancer Center. And I'm excited today to have Dr. Jennifer Litton, who is a professor of Breast Medical Oncology here at MD Anderson and also our chief clinical research officer. And this is the Cancerwise Podcast. So, thank you so much for being here. Welcome to the podcast. 

Jennifer Litton, M.D., Chief Clinical Research Officer Thank you so much. I think this is going to be fun to talk about. So much going on in breast cancer, in medical oncology, surgery and radiation. And you know, I think sadly, because I got to see a lot of it firsthand for the first time, which is certainly interesting when you've spent decades working in a disease that you end up being diagnosed with. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Oh, I'm so sorry that you had to go through this, but I'm sure it's so wonderful for our listeners to hear a little bit about how it's been for you to go through this experience. Are you able to share a little bit more about that? 

Jennifer Litton, M.D., Chief Clinical Research Officer I sure, well, first of all, it always is great by having wonderful colleagues and physicians like yourself. So, everyone, Dr. Mitchell was my radiation oncologist. And, you know, this conversation really comes out of a conversation you and I had really looking at so much that has changed in radiation. You know, there were so many options. And I think the research has been really intriguing. I got my mammogram every year from 40, which is, to everyone on the podcast, please start at 40 or earlier if you're in a high-risk situation. And I'd had several biopsies before, and this time when I saw those calcifications in my left breast, I knew. I knew pretty quickly, and, and what was interesting for me is seeing it from the other side. I had to have, I had a screening mammogram. Then a diagnostic. Then a stereotactic, and they saw other things. And then I had an ultrasound and then got called back for an ultrasound-guided biopsy. And then at the end, because there was so much going on, that I needed an MRI. And that is a lot. And that's not what everyone needs. But just every time they looked, they were finding something. And so, I think I was feeling like every time they looked, the, the other she was going to drop. There was going to be something more. And I don't know if part of that's just because I'm, I've treated so many patients over the years who who have experienced that. So, as we got more information, I will say it was a lot. And I was trying to schedule it through my workday, which is a little crazy to begin with. Plus, you know, caring for some sick family members from afar. And I was also, you know, trying to really push research forward in all aspects right now. And I will say, we're doing, there's a lot of exciting things going on. And so, there was a lot going on, and trying to add that in was really stressful. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology And also being in the field, like, you knew a little bit about why those things were happening and, you know, why we had to go to all the steps. But I'm sure for patients that don't have that background knowledge, it's very difficult to every day find that you have to do another test. And why don't you have a plan to move forward? 

Jennifer Litton, M.D., Chief Clinical Research Officer Why aren't you ready? You know, I think about that a lot in the last two years. And I think the last time I did this podcast, I shared my father's story with stage IV lung cancer. And I think it's very, very true. Even as I would say, a savvy medical person, it is hard to navigate multiple systems, especially from afar. Though I will say everyone's been kind and wonderful to my parents and myself, and I just, it really made me think how hard this is for patients, exactly like you said, who don't know what's probably coming next. And they're trying to take care of their kids, get them to school, do this and make all of these different appointments and you just want the next available. So, you're scurrying all the time. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Yeah. And I'm sure as a patient it feels like this should be an emergency. Like, why can't I just go to the E.R., and like, get this taken out right now? 

Jennifer Litton, M.D., Chief Clinical Research Officer And I think to that end, one thing for the folks who are listening to the podcast is, my message to you is that you do have time to take a beat. And I needed all those tests. Not everyone does. Because they kept finding things, that, luckily, turned out not to be important. But you have time to get all the information so that when your surgeon and your radiation oncologist go to do the treatment, we have the most information we need. I see that sometimes when people are rushed to go do something immediately and then we're scurrying to to try to, well, we should have done chemo here. We should have done this, or the surgery should have looked like this because we didn't have the genetic counseling. And so, my message is, you know, really, it's stressful and I get that. But it's better to get all the information and get one plan. And what we do, I think, really resonated. You have all the information. You have the diagnostic imaging. You have the surgeon and the radiation oncologist and the medical oncologist all talking to each other. So, you get a plan and then we move forward and that takes time. But that time is stress. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology No, definitely. And especially as we move into more personalized medicine and being able to be very nuanced with how we treat each patient, it's not a cookie cutter process. Not everyone gets the same treatment. I think that's so important, like you said, to have all of those pieces at the start. 

Jennifer Litton, M.D., Chief Clinical Research Officer I want to say one thing about that is that, you know, this was my journey. It was found on screening. It was able to be handled with surgery and radiation up front. I really want to be clear that everyone has their own journey, and it isn't that, oh, if you didn't find it screening, you've done something wrong. The biology is different. Screening is different. This was my journey. But you know, breast cancer is thousands of different diseases that just happen in the breast. And, and I think one of the exciting things is that we are getting to much more individualized, tailored therapy. I've spent my career in medical oncology pushing forward, doing new therapeutics, adding more when, in fact, is just as important as that, is doing the research on when we can pull back. When we can get the same results with less toxicity, less therapy. And that really was eye-opening to me when we met, because for my whole career, it was six weeks of radiation with a big booster, and I saw women's skin so red, and seeing radiation therapy from the other side on the table was, you know, quite an experience. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Yeah. We try so hard to prepare our patients for what to expect when they go on that table. And, you know, I have a lot of patients that say, you know, with chemotherapy, you know, I was there with my friend holding my hand. And radiation is a very different experience for a lot of our patients. And despite our best efforts to kind of translate what we've been told by other patients, sometimes we just can't really prepare our patients. I don't know if you're willing to share a little bit more about your own experience to kind of help our future patients. 

Jennifer Litton, M.D., Chief Clinical Research Officer You know, it was interesting. I was with two patient advocates who'd both had radiation two days before, and I asked them what to expect. And I think that was really helpful because you would think I would know, and I did not. I'd never even, I've maybe walked into the room and looked inside once or twice, but I've never been there. And one of my friends said, "Oh, you better start stretching that arm now." I'm like, "What do you mean?" And she goes, "Yes, it's the glamor pose because you have to put your arm up." And you have to stay that way very still for 45 minutes to an hour as they're doing the simulation. And that's taking all the pictures and making sure, because what you do is so very precise. And you've just had surgery, and you haven't been thinking to stretch that arm out. And so, that was a really important piece of advice for me. They also said, take a couple Tylenol before you go in. And I was like, well, really? Really do I need? And then I was like, oh, you do. Because your arm, you are really stretched, and you are so still that that it does. And you're nervous. You're tense. You're, you're, you're doing that. But I will say that everyone was so nice. And they, you do a lot of neat things to try to relax people too. There's a lovely scene on the ceiling, and I got asked whether I was in the MRI or in the radiation, what did I want to listen to? And I was like, well, what do you mean? And then after the first time I was like, I want to listen to Taylor Swift, and I want to listen to the Beatles. I like both of those. And by the, you know, third or fourth day, they knew what I wanted to listen to. And I came in and there's, you know, it was kind of fun. They knew who you were and, and were tailoring to you. Tailoring. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Yes. 

Jennifer Litton, M.D., Chief Clinical Research Officer You know. So, I thought, you know, and you're doing all these breathing exercises while you're on the table, which is really important, to maybe you could tell about why that's so important? 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Yeah, definitely. So, these days we have much different ways of monitoring patients on the table to make sure that we can be very precise and accurate with our treatments. There's these great infrared cameras that can see the whole surface of your body and really make sure that if you do move, it can see that it can see if you're in a different position when you come in from day to day, and that it can also monitor your breathing. And one of the reasons we really care about breathing is if you're able to expand those lungs and move that breast away from the heart and the other important organs, it can really reduce the toxicity of treatment. And that's been a big game changer for radiation therapy to be able to be more precise and accurate with how we deliver our treatment. 

Jennifer Litton, M.D., Chief Clinical Research Officer Yeah. And, you know, avoiding the heart always seems like a good idea. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Yes, that does seem like a good idea. I think we, we caused a little bit of detriment in the past when we didn't have that knowledge, so we didn't used to have 3D pictures of the inside of the body. And back in the early days of radiation therapy, they just shot through part of the heart, which gave radiation a bad reputation for a long time. So, we're very excited that we don't have to do that for our patients anymore. 

Jennifer Litton, M.D., Chief Clinical Research Officer And one of the things that I thought was really interesting, and since that I've gone back to actually read the papers, is the clinical research around the delivery of radiation therapy, and that I think it's very clear that radiation decreased recurrences. And I, I went in absolutely, I was going to do radiation. But the data's really been evolving with clinical trials. So, we have good randomized clinical trial data supporting newer techniques and shorter courses. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Yeah. It's it's been amazing. You know, when I was a young attending, everyone, whether they were 20 or 80, stage 0, stage III, they all received six weeks of radiation, and it was always to the entire breast and was with techniques that had hotspots. So, they would have, you know, red, burned skin and blistering skin. And there's been an explosion of randomized trials over the last decade or two where we've really found that we can customize treatments so those patients with early-stage disease now have options to do one week, very targeted therapies just to the tumor-bed area. Not having to treat the whole breast leads to much less toxicity, less time off work, better cosmesis long-term. And then even patients with more advanced disease, we're finding that we can do maybe three to four weeks of treatment, which again, more time with their families and not having to be going through radiation treatment, which has been fantastic. 

Jennifer Litton, M.D., Chief Clinical Research Officer That's great. And I mean, you know, any time I hear clinical research and clinical trials, because I do believe this is how we are doing better and better. In fact, you know, just a couple weeks ago, we hear from the American Cancer Society that more and more people are living with cancer longer and better lives. And I think that just shows the absolute importance of clinical research, clinical trials, and that we're moving new therapies, but we're also figuring out how to do a lot of things less invasive, less toxic, and just better for patients. And, you know, I really experienced that firsthand. I was able to come in at seven in the morning, do the radiation treatment, and I was some days in the clinic right after that. I will note, though, that the fatigue is real, which is so much better than what I expected. You know, I, I, we, as, you know, women, often, we've got kids. We both have twins. I'm going to share that with the podcast. So, we have this bonding moment that we both have a set of twins. And you're running around all the time. And, you know, I think a couple days, the week after, and you told me, you said, "Jennifer, you are, two weeks, three weeks, you're going to you're going to feel that fatigue." And there was like a 4 o'clock, I crawled into bed and I didn't get out until the next morning. And it was, in the land of side effects, this is what I will take, you know. So, so, I think we have to as, as on the patient side, sometimes let ourselves be patients, which is really hard. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology And I do think it's a lot like you mentioned. As women, we're always doing everything for everyone else. And our buckets are often empty. And then the radiation just, you know, really tips that over. So, I do it, it's hard for patients because they're not used to that fatigue. So, I'm glad that you shared that so patients can be aware. 

Jennifer Litton, M.D., Chief Clinical Research Officer And it's OK. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology That, that's okay. Yes. And it's okay to say, you know I'm not going to like, do dishes and laundry. I'm going to go take a nap. So, it's you know, we need to have that self-care for our patients so that they can really, you know, do what they need to take care of themselves and heal from all the cancer therapy. 

Jennifer Litton, M.D., Chief Clinical Research Officer Absolutely. And I will say that I started my first endocrine therapy yesterday. So, we'll see how that goes. I gave myself a couple weeks after the end of radiation, so yesterday seemed like a good enough day to start, and I'll plan to do that for the next five years, watching for all the side effects that go with that. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology And as a medical oncologist, I know you've counseled patients on those side effects for many years. 

Jennifer Litton, M.D., Chief Clinical Research Officer So, we'll work on it and it'll, it'll be another stage for me to understand firsthand what my patients have been going through. You know, Melissa, you are besides being a wonderful clinician, you are really spearheading a lot of research at MD Anderson. And I, I really was hoping that you could share some of the work in addition to tailoring the doses and how you're delivering it, you know, maybe you could just tell us a little bit about what you're working on that's really exciting. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Sure. So, personally, as you've mentioned, we see these side effects in our patients. And so, we wonder, are we doing too much? So, my passion has always been de-escalation, as you mentioned. It's a little bit of a challenge sometimes because many of our patients want to maximize, right. They want to do everything they can to make sure this cancer doesn't come back. But we recognize that there's, you know, oftentimes when you're doing too much, patients probably don't need surgery and radiation and medical therapy for their tumors. So, personally, I've been most interested in those times when maybe we can scale back on radiation therapy, trying to figure out who that population is. One of those places is patients who've had chemotherapy first, and we find that the medicine works really, really well. You know, I used to have patients come into my clinic and say, you know, I did the chemotherapy. I went to surgery. I just saw the surgeon, and she said the cancer was gone. Why are you in my, why am I in your office, right? So, based on those patients coming in and telling me that I was like, you know, we really need to ask these questions. Why are we doing the radiation therapy? So, that's been my biggest interest. And interestingly, I think all of us across the spectrum, like you said, surgeons, medical oncologists, radiation oncologists, we all are recognizing that maybe we're doing too much. So, right now is a great time for our patients with early-stage breast cancer. We have basically the ability to personalize how you want to de-escalate your therapy. I know one of my colleagues, Simona Shaitelman, she did a survey of patients, and not everyone wants to de-escalate in the same way. So, some patients, they're afraid of the surgery because, you know, they've had friends that have had issues with anesthesia, or they just don't want anything cutting their body or changing how they look. There's other people that are terrified of the radiation. They had family members who had radiation back when we sent radiation through the heart, and they just don't want those toxicities and side effects that they heard about. And, of course, there's some patients that hear about that endocrine therapy and the hot flashes and the joint aches, and they want to try to avoid that. So, it's great right now because we really do have studies for our early-stage patients in all of those areas where if patients would like to de-escalate one of those components of care, they can. We don't advise skipping all of them, but, you know, there's studies for each of those. 

Jennifer Litton, M.D., Chief Clinical Research Officer But don't you think that's the importance of having this close connection between the radiation oncologist, the surgeon and the medical oncologist? You know, we can't work in a vacuum. We have to be thinking about this in the totality of the patient. And I think that's where we really excel at MD Anderson, you know, how many times have you just picked up the phone or sent me an email going, you know, we need to sit and talk about this. Something's changed and we just stop and figure out together. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology No, I definitely agree. I think it's so important that we recognize that all of these questions are important. And also, again, the patients have different opinions. So, we could pick one thing to study. But then there's a population of patients we're leaving out. So, I do think that's important that we're all very connected in, not just how we're treating our patients and discussing all of our cases, but also the research questions that are important for moving the field forward. 

Jennifer Litton, M.D., Chief Clinical Research Officer And the field's moving so fast now. You know, when I first started, I was a study coordinator before I went to med school. And, you know, we had a couple chemos and we figured out, you know, maybe we could give the chemos this way or that way. And now it's happening so quickly, where every year we're adding brand new, very targeted, very engineered therapies. And it's changing the landscape so quickly. And exactly as you said, as, as we're getting better targeted therapies, we're able to treat patients and have a large portion of patients where the cancer's gone by the time they go to surgery. And I'll say, in medical oncology, we're looking at the same thing like, right. We always say, you can't cure someone twice at the same time, right? So why keep pushing toxic therapies if you've gotten the desired results? There's a lot of trials we're looking at as saying, okay, once we get the desired result, do we keep going as the traditional or do we hold more therapy? Is more just more? I think these are really important questions, and, and they can't be done in a vacuum. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Yeah, I most definitely. And we're trying to copy you all. I know with medical oncology you guys have had Oncotype for 20-plus years now to help guide your decisions, which is a genomic assay. And so, finally in radiation oncology we're, you know, developing these assays where we have a new, new study coming out where it's looking at basically, protein expression for patients with DCIS. And they, you know, expect that this assay will help patients predict whether or not radiation actually matters. So, if it says, you know, the radiation matters and that will be great. The patient gets radiation. It reduces their risk of recurrence dramatically versus if it doesn't, then those patients can actually skip the radiation therapy. So, things like that I think are going to be fantastic as well. So, really again, personalized medicine and figuring out who really needs the treatment by using this genomic approach. Yes, exactly. 

Jennifer Litton, M.D., Chief Clinical Research Officer Very very exciting times in breast oncology right now. So, on behalf of me, I want to thank you. You took wonderful care of me and I'm so appreciative of everyone here. And to the folks listening to the podcast, know that we are here to keep pushing the needle to cure more people and to do it with less toxicity. That's all our goal. So, thank you. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Well, it's been an honor to be able to take care of you and to be a part of this podcast, and it's wonderful to be part of MD Anderson, where we are able to provide great care to patients and have all the resources that are in place to do that as well, while those again, keep pushing that envelope forward. 

Jennifer Litton, M.D., Chief Clinical Research Officer Right. Thank you. 

Melissa Mitchell, M.D., Ph.D., Professor, Breast Radiation Oncology Thank you so much. And thank you for tuning in today. If you enjoyed this episode, be sure to follow or subscribe on Apple Podcasts, Spotify, YouTube, or wherever you get your podcasts. And don't forget to comment or review. For more information or to request an appointment at MD Anderson, call 1-877-632-6789 or visit MDAnderson.org. Thanks for listening to the Cancerwise Podcast.