Transcription:
Breast Cancer Care and Disparities

Dr. John Leonard: Welcome to Weill Cornell Medicine, cancer cast conversations about new developments in medicine, cancer care and research. I'm your host, Dr. John Leonard. And today we will be talking about breast cancer surgery and health disparities. Today's guest is Dr. Lisa Newman. Dr. Newman is a Surgical Oncologist and Chief of the Section of Breast Surgery at Weill Cornell Medicine and New York Presbyterian Hospital. She leads a multidisciplinary breast cancer program, which is dedicated to providing patients with personalized care and innovative treatment and reconstructive options. She also works closely with the breast surgical oncology teams at New York Presbyterian Hospital locations in lower Manhattan, Brooklyn, and Queens. Additionally, and importantly, Dr. Newman is the founding medical director for the international center for the study of breast cancer subtypes or ICSBS, which studies breast cancer tumor biology associated with a complex genetics of globally diverse racial and ethnic groups, while also investing in the health services of impoverished and underserved communities in Africa. So, Dr. Newman, Lisa, thank you so much for joining us today. There's really a lot to talk about. So I appreciate you being here and sharing some of your thoughts with our audience.

Dr. Newman: Thank you, Dr. Leonard.

Host: I first want to get to what led you to start your work and what drew you to the area of breast cancer surgery and as part of that, or as a connection to that, the issue of breast cancer disparities, which is clearly also an important area in the world and in the field?

Dr. Newman: Well, the things that led me into those areas are actually closely aligned. In the first phase of my career, after graduating from medical school and then going on to do a surgical residency, I had a practice that was in general surgery.  And I practiced general surgery in Brooklyn, New York for seven years,  but being in Brooklyn with Brooklyn's a robustly and beautifully diverse patient population. One of the things that really struck me in my own practice was with regard to the breast cancer patients that I was caring for.

A lot of those breast cancer patients were African American and tended to see the most biologically aggressive cancers, the most difficult to treat cancers in my African American patients compared to my white American patients. So I was very intrigued by these differences. It's also heartbreaking to see those types of differences. Some of the patterns that were readily visible were the facts. That's my African American breast cancer patients tended to be younger than my white patients. And my career ever since then has focused on surgical management of breast cancer by bringing together all of the different disciplines that we now can take advantage of in conquering breast cancer for our patients, and I do still have a very strong research focus looking at African ancestry as an actual risk factor for biologically aggressive forms of breast cancer.

And we've learned a lot over the past couple of decades regarding better ways to treat breast cancer. And we've learned a lot over the past couple of decades regarding the causes of these disparities in breast cancer, between black women and white women.

Host: To talk a little bit about breast surgery in general. I mean, I think that most people would recognize that surgery is probably the key form of treatment or at least some component of surgery is the key component of treatment for if not the majority, a high percentage of patients with breast cancer. So can you just kind of briefly describe the different types of surgery that a patient with breast cancer might have? It seems to me like woman diagnosed with breast cancer is going to encounter surgery of one form or another fairly commonly. And so it's just kind of the range of possibilities where you might interact as a surgeon with a patient with breast cancer.

Dr. Newman: Yeah. So you are absolutely correct in stating that the high majority of breast cancer patients will need surgery. And surgery is definitely an important aspect of the cancer management. When I talk to my newly diagnosed breast cancer patients, I always explained that in general, we have three principles that we have to address when we come up with that surgical plan. The first principle is indeed the most logical principle you want to get rid of that cancerous growth. And this is the same principle that we address, regardless of whether we're talking about a cancer in a woman's breast, a cancer in the colon and the ovaries, you need to get rid of that tumor. And this is where some components of surgery will come into the picture for the management of most breast cancer patients. The second principle is actually a bit more unique to cancers that we do diagnose in a woman's breast.

And this is the principle that we will generally need to treat the entire breast as an organ and treating the entire breast is important because even though we might diagnose the cancer by doing a biopsy of a particular abnormality in that woman's breast, most women will actually have microscopic amounts of the breast cancer hiding and completely normal appearing breast tissue on that side. So you want to do whatever you can to eliminate the risk of those microscopic cancer cells, continuing to progress and turning it to other lumps or other abnormalities on future mammograms. So it's the first two principles that guide the surgical planning for the breast itself. The third principle is the staging of the cancer, or getting an idea of how aggressive the breast cancer is. And one of the ways that we decide how aggressive the breast cancer is, is by evaluating the lymph nodes or the glands of the underarm area.

Which is typically a procedure that we call a Sentinel lymph node biopsy, where we remove just the few most important lymph nodes in that woman's underarm, to see whether or not there are breast cancer cells that are hiding in those glands, those lymph nodes. And that information helps us to decide which patients need treatments like chemotherapy and which patients do not going back to the first two principles, however, and the surgical planning for the breast, the oldest form of treatment for breast cancer is mastectomy surgery, where we are completely removing the breast and thereby addressing those first two principles in one fell swoop for the women that are going to face mastectomy, and sometimes that's because of the patient's personal preference. Sometimes it needs to be the recommended surgery because of the pattern of disease.

But if the woman is facing the mastectomy, we have wonderful ways of performing breast reconstruction to restore the breast appearance, where we work in partnership with our plastic surgery colleagues, and often we can perform what's called a nipple sparing mastectomy. And the surgical team at Weill Cornell are truly pioneers in developing some of the most cutting edge versions of a mastectomy with nipple preservation and performing the surgery through a special incisions that give a beautiful, beautiful, cosmetic results in partnership with the plastic surgeon. So with the nipple sparing mastectomy and breast reconstruction, you can get an absolutely beautiful cosmetic result, but many women will certainly prefer to not have to undergo mastectomy at all. And this is why we have the alternative surgical option of breast preserving or breast saving surgery, where we perform a lumpectomy that focuses on just removing the cancerous lump that was biopsied. And then we give radiation treatments to the breast to kill any of the microscopic cancers cells hiding in other parts of the breast. So those are the two basic surgical options that are available for managing breast cancer patients today.

Host: So one of the key aspects of breast cancer care as you've alluded to is the multidisciplinary nature of it. And I know that a big part of your role as serving as one of the leaders of the multidisciplinary team here at Weill Cornell in New York Presbyterian and breast cancer, which obviously involves a number of different components. And I was wondering if you could just tell us a little bit about A, why that's so important? And B, what sorts of collaborators you have that represent the different disciplines that a patient might encounter as you set out to decide on and implement the plan for an individual patient's care?

Dr. Newman: Thanks, I'd love to say a few more words about this, and multidisciplinary management of breast cancer is the key in explaining why we've made such wonderful progress and improvements in breast cancer outcomes. And today the majority of breast cancer patients will indeed have a good outcome, and we will be able to treat the cancer effectively because of these wonderful improvements in care, but it really does take all different specialists working together to focus on that breast cancer management. So here at Weill Cornell, we are in a wonderful position of having an incredibly talented specialists, representing all different disciplines that focus, their full time career is focused on managing breast cancer. So we bring all of those different services together to confront the breast cancer at all levels.

We have exciting surgical techniques, dedicated breast surgical specialists that focus on the cancer operation. We work in partnership with dedicated breast plastic surgeons, that their full time program is looking at and managing breast cancer patients and the reconstruction issues. We have medical breast oncologists that focus on the medical or what we describe as the systemic treatments for breast cancer. And systemic treatment for breast cancer, these medical approaches are also very important because in any woman diagnosed with a breast cancer, we are always worried about the possibility that she might have microscopic breast cancer cells that have already broken away from the tumor, gotten into the bloodstream. And that might be hiding in other organs, such as the liver or the lungs or the bones. And that's actually the aspect of breast cancer that is potentially the life threatening aspect of the disease, the risk of the disease, traveling to other organs and damaging other organs.

So with partnerships, with our breast medical oncologists, we can define medical treatments that will eliminate completely obliterate the microscopic cancer cells hiding in other organs. So we can prevent that patient from ever having to deal with metastatic breast cancer. We also work very closely in partnership with radiation oncologists, and radiation oncologists are critical in breast saving surgical options, where we give the radiation after the lumpectomy surgery. Sometimes we will need to rely upon radiation treatments in managing metastatic disease when it does occur in a breast cancer patient, or sometimes we will need to give radiation when a breast cancer recurs, when it goes back on the chest wall, after a mastectomy, but all of us, again, work together in partnership at Weill Cornell. We make sure that from the time that we meet every newly diagnosed breast cancer patient, we sit down in a conference and review that patient's entire case.

We also review it not only with each other, but we discuss the patient's pathology with our breast pathology specialists, where we go over all of the biopsy material. We review all of the patient's imaging, mammogram ultrasound, sometimes MRI with the breast radiologist. We want to make sure that the entire team of specialists from different disciplines, that we're all on the same page and that we take full advantage of each other's talents to provide the patients with the best possible treatment options. And sometimes those treatment options include participation in clinical trials and research, which is extremely important in continuing to develop even better treatments for breast cancer in the future.

Host: So you've outlined a number of different options for patients and getting input from a number of different specialists. It seems to me that there's a lot of, I don't want to say flexibility, but a lot of individual choices that can be made for many situations where you're saying, well, you could do option A, which has, you know, these pros and cons or option B that has those pros and cons. And you've alluded to some of them earlier, how do you and the team kind of approach presenting and helping a patient work through the individual options that they might have, so that they come to the best decision for their situation, from their perspective?

Dr. Newman: Well, and that situation that you described can certainly be tricky and it's a journey for every patient and every patient will follow their own pathway and progress through that journey, bringing a whole host of different emotions and background experiences with them. And all of those experiences and perspectives will have to come to bear as they make their treatment decisions. So our job as clinicians is to try to make sure that we present the safest treatment options to each patient. And often, thankfully, because we have made many advances, they will be options that are equally likely to give a good result. Sometimes we do have to try to encourage a patient to follow one path versus another path, whether it's with regard to the surgical plan or the medical oncology systemic therapy plan, but often there will still be options for a patient.

And the education of the patient is also multidisciplinary in nature. So we want to make sure that patients take full advantage of information from our social service support staff, so that they can come up with a treatment plan that makes sense. And in terms of their lifestyle and their resources, we want to come up with a treatment plan that the patient can review with their nutritional support team, the patient navigation services, genetic counselors, a lot of different perspectives and patient education are necessary so that the newly diagnosed patients can understand the options that they have and the options that will fit best into their particular lifestyle.

Host: So breast cancer seems to be an area where many women are very worried about the risk. And this can be risk based on family history. We're going to get into disparities and other factors that may play into risk, but concerns about risk based on family history, based on other risk factors, based on their personal history of having dealt with it and being worried of either a recurrence or another breast cancer. And I wonder just briefly, if you had some thoughts on, you know, how best patients can, and obviously these risks are very individualized and have to be approached it seems to me in a fairly multidisciplinary way as you've described, but just how patients should think about their risk and what to do about it? 

Dr. Newman: Yeah, those are great questions in terms of a woman that has not yet been diagnosed with breast cancer, each woman, especially in the United States where breast cancer is so prevalent. Unfortunately, each woman of adult age does need to consider her own individualized risk of developing breast cancer. And that will have an impact on her screening practices. In general, for average risk American women, we recommend that each woman start having their annual mammogram at age 40 to look for a cancer that might be hidden in her breast tissue. And she should continue those mammograms every year thereafter. Now there is some debate from different people regarding alternative screening practices, but this is the screening practice yearly mammogram starting at age 40 that we adhere to, that we advocate for at Weill Cornell and our breast program.

And that's the screening program that is advocated by the National Comprehensive Cancer Network and other highly respected cancer organizations, women that have higher risks, such as women with strong family histories, as you mentioned of breast cancer, ovarian cancer, these women may need to start getting their mammograms that even younger ages, the rule of thumb that we use is that if you do have a strong family history of breast cancer, start getting your mammogram five years or so younger than the earliest age of breast cancer diagnosis in your family. If you had relatives diagnosed younger than age 45, and women that have strong family histories may also want to get additional screening in the form of a study called the Breast Magnetic Resonance Imaging or breast MRI, other women will utilize whole breast ultrasound to evaluate their breast tissue in addition to mammograms.

So understanding risk is definitely important for women in terms of screening practices, understanding risks for women that have been diagnosed with a new breast cancer is also important because these women have to decide whether they want to undergo more extensive surgery versus less extensive surgery in preventing future breast cancers. So we do see here in the United States that there has been increasing interest over the last 20 years or so of women who opt to have a bilateral or a double mastectomy after they've been diagnosed with one single breast cancer. And women who choose to undergo bilateral mastectomy surgery for prevention purposes, do need to understand that while a double mastectomy is definitely the most aggressive thing that she can do to reduce the chances of getting a completely new breast cancer in the future.

It's not 100% protective because you can have breast tissue hiding in the skin or in the underarm tissue. And it's also important for breast cancer patients to remember that preventing a future breast cancer doesn't necessarily translate into a survival advantage for the vast majority of women who have a diagnosis of breast cancer, the survival rates, the likelihood of beating that cancer is going to be driven by the aggressiveness of the very first cancer that's diagnosed. But risk, as you alluded to is very, very important for women to understand whether they have never been diagnosed with breast cancer, in which case they need to be screened for breast cancer. And if they have been diagnosed with breast cancer, because some of these women will be interested in prevention surgery.

Host: So I want to move now to issues around health disparities and, you know, this is an area that is getting more and more, and I think for good reasons, more and more attention, and obviously an area you've worked in for a very long time. But I think that that is probably under-recognized amongst the general public, that there are really major differences in breast cancer risk as well as many other diseases. And we've been seeing that with the COVID crisis as well, that really result in different rates of disease incidents as well as different outcomes. And I wonder if you can just kind of tell us in the case of breast cancer, what sorts of factors might make different populations of patients have either different incidences and different outcomes with their care, with regard to breast cancer?

Dr. Newman: You've brought up several really important points. And the term systemic racism is something that is in nearly everybody's vocabulary at this point in time for a lot of different reasons. And in healthcare systemic racism refers to the fact that over the past several centuries, socioeconomic disadvantages have been so disproportionately prevalent in the African American community, that it has tragically led to a lot of health inequity there's unequal access to healthcare for many, many years for several centuries in the African American community. And that has translated tragically into higher death rates from a whole spectrum of diseases, diabetes, hypertension, obesity is more prevalent in the African American community, asthma, variety of pulmonary diseases. For a variety of different diseases African Americans suffer disproportionately compared to other populations subsets.

Now there are other factors that can contribute to health outcome differences as well. And this is where breast cancer disparities become an incredibly complicated discussion to have. With breast cancer, we know for certain that socioeconomic disadvantages play a role in contributing to the 40% higher death rates from breast cancer that we see in African American women compared to white American women. And we see more advanced stages of breast cancer in African American compared to white American women, likely related to a lot of the socioeconomic disadvantages and delays in the breast cancer diagnosis often delays in completing treatment for that breast cancer. But when it comes to the specific problem of breast cancer, there are also many reasons to suspect that other factors aside from socioeconomic disadvantages are also playing a role.

 

For example, black women are more likely to get breast cancer at younger ages compared to white women. We see more biologically aggressive patterns of breast cancer in black women compared to white women. And here I'm referring to a particular pattern of breast cancer that we call triple negative breast cancer cancers that are negative for three important proteins that we look for on any biopsy material, the estrogen receptor progesterone receptor and the HER2 new marker. Those three proteins are typically negative. They are not expressed in the cancers of more black women with breast cancer compared to white women with breast cancer. And these triple negative breast cancers are inherently more aggressive than non triple negative breast cancers. These triple negative tumors are twice as common in African-American breast cancer patients compared to white breast cancer patients. So this also contributes to the higher death rates that we see from breast cancer in black women.

So it becomes important to try to determine what is accounting for these different patterns of disease in black women. Another poorly understood effect is that male breast cancer is actually twice as common in African American men compared to what we're seeing, male breast cancer and white American men. Another piece of that, we need to look at other issues aside from socioeconomics and explaining breast cancer disparities. Our International Breast Cancer Research Program has been studying the genetics of African ancestry as a heritable risk factor for developing these different patterns of breast cancer. And so we have been working with different cancer treating facilities in different regions of Africa to characterize the breast cancer burden of women from different regions of Africa compared to the breast cancer burden of African American and white American women.

And interestingly, what we have indeed found is that these triple negative breast cancers are even more common in Western Sub-Saharan Africa compared to what we see in the United States. And about half of the breast cancer patients in Western Sub-Saharan Africa have triple negative breast cancer in contrast triple negative breast cancer is less common in East Africa. And we think that this is again related to some of the genetics of West African ancestry. The transatlantic slave trade from 400 years ago brought the ancestors of contemporary West Africans across the ocean to serve as slaves in the Americas. And so African-Americans, we tend to have a much more shared ancestry with contemporary West Africans, and this probably accounts for the notably higher rates of triple negative breast cancer that we see in African Americans and also in West Africans.

The slave trade of East Africa actually brought East Africans further eastward over to the mid East and Asia. And so African Americans do not have quite as much shared ancestry with East Africans. And so the heritable factor that seems to associate African ancestry with the triple negative breast cancer is specifically related to Western sub Saharan African ancestry. So we've been continuing to do other genetic studies that have been honing down on the exact or a distinct precise genetic marker associated with a West African ancestry. That seems to be explaining these patterns.

Host: This seems like a very important research effort. And particularly given that certainly in the US, minority patient populations are relatively underrepresented in clinical studies, translational research, and clinical trials. And I would presume that in those patients in Africa, in the areas you described, probably are also underrepresented in clinical trials as well of treatment regimens. And of course may in some situations have many fewer options available to them. How do you see this affecting treatment decisions for these patients? 

Dr. Newman: Yeah, so we are indeed very excited about the potential of these international research efforts for many, many reasons. Related to cancer biology, this work is incredibly important because if you conduct a cancer genetic research in very homogeneous populations, you just getting a snippet of the genetic information that you can learn about cancer. And of course, all cancers are in some way, shape or form related to genetics. So you really do need to study broadly diverse cancer patients preferably globally, internationally diverse in order to get a more comprehensive definitive picture of the genetics of cancer. And so this type of work really is relevant to patients no matter where they live, because it is all about understanding the genetics of this disease so that we can develop better ways of predicting which patients are at higher risk for getting one cancer or another.

 

And so that we can get better ideas of the genetics of the cancer to be able to treat these cancers better. The whole concept of precision medicine and personalized medicine is based upon our ability to clearly define different cancer patterns. And again, you need broadly diverse patient populations in order to better understand the disease comprehensively. So from a research perspective, we're very excited about new avenues that it's the opening up for us in terms of being able to improve the cancer care resources available to under-resourced populations worldwide. This work has also been absolutely incredibly gratifying and rewarding. We do quite a bit of surgery whenever we travel on our research efforts to the different partnering facilities where we work in Africa.

And so we have the honor of being able to directly participate in the management of the breast cancer patients, where we work. And we travel on a regular basis every year to a variety of different countries in Africa to do this work and to participate in patient care. And with each of these visits, we are able to invest in the resources of those of these hospitals by contributing supplies, donations, by contributing to the education and the training of the cancer providers in these countries. It's all been very gratifying. We have a very robust academic training and exchange program so that we can contribute to the education of cancer specialists in these other countries. So it's been enormously rewarding on so many levels. And in the process, we've made wonderful friendships. We really learned tremendously from each other.

Host: And I'm going to give you a little bit of a shout out here and just let our audience know that at the American Association for Cancer Research, you, Dr. Newman were recognized with the 2020 ACR Minorities in Cancer Research, Jane Cooke Wright Lectureship, which for those who may not know ACR is really one of the leading cancer research organizations. And this is a very prestigious Lectureship to recognize an outstanding scientist for their contributions in cancer research, particularly with a focus in minority areas of cancer research. And so this is really, I think, a great Testament, and it's a real treat to have had you here sharing your thoughts and experience given your contributions and stature in the field. So it's also great to have you here at Weill Cornell, someone who's so focused in this area. So, thank you so much for joining us today.

Dr. Newman: Thank you Dr. Leonard, I really appreciate your interest in this work. It's a marvelous opportunity to chat with you and your audience today.

Host: So I want to close by inviting our audience to download subscribe, rate, and review Cancer Cast on Apple Podcasts, Google Play Music or online at weillcornell.org. We also encourage you to write to us at cancercast@eddotcornell.edu, with questions, comments, or topics you'd like to see us cover more in depth in the future. That's it for Cancer Cast, conversations about new developments in medicine, cancer care and research. I'm Dr. John Leonard, thanks for tuning in.

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