Treating Metastatic Breast Cancer


good morning everyone good morning I'd

like to ask everyone to please take a

seat we're gonna get started in just a

moment we'll have everyone get their

coffee and come on in and get

comfortable well good morning everyone

and welcome my name is Victoria village

co and the senior vice president at

Susan G Komen headquarters in Dallas

Texas it's welcome everyone here to the

historic National Press Club it's it's

been really interesting to spend some

time here in the hallways this morning

to see all the photographs of you know

important moments in history but I would

like to encourage the National Press

Club to put a picture of all of you up

on the wall uh-huh yes right thank you

this is right because we're making

history right now it's because of the

metastatic breast cancer community that

we are witnessing a sea change in how

breast cancer organizations are now

talking about breast cancer it's because

of you that we are now shifting away

from conversations about awareness to

finally taking action putting a laser

focus on demanding more research more

community support and more education

about those who are living with

metastatic breast cancer and it's

because of your advocacy that

groundbreaking partnerships are now

evolving to be in service of what you're

asking us to do including the unique

partnership that we've had with our

colleagues that living beyond breast

cancer to bring this symposium to you

all today but the partnerships are

becoming much more deep and much more

complex living beyond breast cancer and

Susan G Komen are very proud to be

members of the metastatic breast cancer

Alliance you know in concert with lots

of other organizations that are evolving

to better serve this community so I want

to thank you all for making that happen

and helping us develop our shared

commitment to listening to your voices

and elevating attention on what you're

asking us to do as Anika bonnez had

mentioned elevating those voices all

also means communicating to communities

in the way that they feel most

comfortable which is why we're so

excited to have a session entirely in

Spanish at this conference today we've I

want to thank our friends one wave Evita

who have helped make this happen and

encouraged us to really elevate the

conversations in the language we're feet

people feel most comfortable expressing

themselves and talking about their

journey so we're excited to make that

happen too we're also excited about the

response of this symposium we've had

over a hundred and eighty registrants

and I want to point out that we also

have a number of healthcare providers in

the audience and caregivers so again

thank you to all of you for coming and

standing with this community it's

incredibly important but also we're

live-streaming for those of us who

aren't able to join us in DC through a

sponsorship from Astra Zeneca we're

making it possible for our folks to

watch our program today via Facebook so

thanks also go yes hello hello folks at

home so hello ok so everyone's gonna be

able to participate so I want to stop

and just you know make this announcement

as well for those at home and for those

right here in the audience you can ask

questions and interact with our

presenters today via text message so I

know you're supposed to silence your

cellphone's but it's ok if you have your

cell phones out on the table because if

you want to ask questions that's how

it's gonna happen in my colleague Aaron

hear wave Aaron she's going to help

moderate the questions for us so the

number for text messaging and again

Janine's gonna mention this again but

you can get your cell phones out now

it's 610 three six five seven five three

two so I also want to thank our sponsors

who are making this morning possible

today Pfizer Lilly oncology and Celgene

so thank you for your support


but most importantly the people that we

have to thank are the metastatic breast

cancer community and advocates who have

helped craft this program it's my

pleasure to introduce one of the

strongest advocates I know her name is

Jamil rivers and she is a member of the

living beyond breast cancer Board of

Directors a member of Coleman's

metastatic breast cancer patient

Advisory Council she serves as a

research advocate she serves as a public

policy advocate and she's also doing all

this while she's raising a family of

three boys

yes she's amazing now I'm not saying

she's Wonder Woman but I've never seen

the two of them in the same place at the

same time so it is my honor to introduce

Jamel rivers Thank You Victoria


well as a board member of living beyond

breast cancer I bring greetings from our

home base in Philadelphia we are really

pleased to be working with Susan G Komen

to bring an educational program on

metastatic breast cancer to this region

lb BC has a rich tradition of

programming and support for people

living with metastatic disease if you

are available April 5th through 7th

straight up head straight up route 95 to

Philadelphia and attend our 13th annual

conference on metastatic breast cancer

today's program is an extension of our

ongoing commitment to people like me

living with Mets and while we have

planned a day of education for you we

also expect to learn from you what kind

of ongoing programming you want to see

in this region going forward I want to

send out a thank you to the comedy jones

foundation Tigerlily and no Ava Vida 3

wonderful nonprofit organizations for

helping us build today's audience we

also had members of the local community

helping to shape today's program I'd

like to introduce you to to those

members Julia MELAS and Roxanna Guerra


hello it's really nice to see so many

familiar faces and people that I've met

over the years I feel like this is a

very special day and it's a very special

place to be yet I want to especially

mention two groups of people one is

three friends that passed away this week

so how Nancy ray I think about you all

the time and Delia and also the other

group of people that I want to recognize

is everyone out here that does not have

cancer if you're a caregiver if you're

working for lb BC if you're a doctor my

doctor is here and I thank her for

dedicating her life to improving our

lives so it's really really important

for us to have partners that are here

and if your spouse a friend a researcher

and you're here on your own time because

you this matters to you and not because

you have cancer and you kind of are

stuck with this reality thank you

so I also want to thank komen and I'll

be received for bringing us patients to

this planning we had many things to say

and they listened and they made changes

and it's very important that we are

included in these conversations because

we we have a voice we we want to be

included in the decisions that affect us

like a friend once told me if you're not

at the table you are on the menu and we

want to be at the table so how I'm

excited for everything else that will

happen today Roxanna will talk about

everything that will happen in the

Spanish session thank you


- das bienvenidos universe Roxanna

Guerra yo mmm be Tyrone and guru poem el

BBC comment for a party oil you that

means air - Latinas he said was Piraeus

oil hot gossip on amputation bicep

artist committee tambien Korea

Dillons Tammy enjoys la primera vez que

tenemos esta confidence en espanol e toy

muy Feliz estoy parte de esto tiene la

porta Nia para todos que podemos express

our nose a connoisseur diferentes gente

soy yatras amigas amigos familiaris e1 a

burst upon cerca Cano Toni SOT Rose II

when suerte para we're okay with letting

muchas from SEO Noi gracias thank you so

much to our speakers for setting the

tone that this is really for the

patients by the patients of the patients

about the patients I want to announce

we're gonna be starting our first

session but no hablo espanol but I'm

going to try so pyrolysis Jana and

espanol por favor seiga Anna

kinesio Sesame Street's okay so my

Spanish is terrible I tried my very best

for those who would like to participate

in the Spanish session please join on in

the back of the room and she'll take you

right next door to the Mara room okay uh

unless they send you no you're very kind

we're very excited to be able to have a

special session for our guests next door

okay so we're gonna get started in this

room with dr. Isaacs and Jeanine so I'm

gonna switch over hi everyone my name is

Judy and gwiyomi no and I'm the senior

director of programs and partnerships

that living beyond breast cancer and

we're so happy to have all of you here

today so happy as Julia said to see so

many familiar faces and to meet some new

ones so thanks so much for being here so

we are gonna start with our plenary

session which is called treating

metastatic breast cancer and in addition

to all of you as as Victoria mentioned

we do have hundreds of people joining us

on the live stream so why don't we give

them a good morning and say hi so that

they know we're here and that we

appreciate them thank you so much for

being with us I'll be moderating this

morning's discussion with my colleague

Victoria and we're very fortunate to

have with us Claudine Isaacs who is a

medical oncologist at the Lombardi

Comprehensive Cancer Center at

Georgetown University so thank you for

being with us dr. Isaacs we have a lot

to cover in the next hour and a half

we're excited to talk to you about new

treatments available today and clinical

trials as well as what you can be

expecting down the pike and the way

we're going to organize our discussion

is to talk about the disease by subtype

and we'll be taking your questions

throughout so just to give you that text

number one more time it's six one zero

three six five

seven five three two and you can put

that in your silenced phone and text us

questions throughout that Erin can take

throughout our conversation with that

said as I said we're going to talk about

each of the subtypes

we'll start with hormone

receptor-positive than triple negative

and then her2 positive but as many of

you I'm sure know we think that there's

probably many many other types of

metastatic breast cancer so I wanted to

start dr. Isaacs with asking you why do

we organize things in this way still and

why is it important so the reason that

we organize it first of all thank you

all for being here you know I represent

many people and I think as you know

people who try and make a difference

what we're really trying to do is

through research and through advances to

really increase benefits and increase

treatment options for all stages of

breast cancer but metastatic breast

cancer is an incredibly important stage

for us to be looking at and what we're

trying to do is to find better and newer

and more tolerated treatment options to

hopefully one day increase the chance

for cure and improve just outcomes in

general so I thank you all everyone's

here on a Saturday morning and so I

really thank you for being here we

talked about breast cancer and subtypes

because they allow us to think about

more specific targets I think everyone

is hearing this concept of

individualized or tailored therapies for

cancer in general right and and what

that really means is that drugs are

developed that hit a specific target

that might be important for the cancer

cells to allow them to grow and to

spread and to do all these things that

we don't want cancer cells to do so what

we try and do and what we've done for

breast cancer really for many decades is

is have different subtypes that have

specific targets that we understand are

important and that drive the growth of

the cancer cells so we divided into a

hormone receptor positive because

hormone receptor positives are tumors

that are either estrogen receptor

positive progesterone receptor positive

or both and that is an important target

for the cancer cell

so we have a series of drugs that have

been developed that target those

receptors her2 positive is another

target that's really important for

growth of the cancer cells and I've been

doing this for long enough that I

remember when her2 positive was really

the most aggressive subtype but with the

advent of therapies that target her to

target that protein that is

overexpressed in about 15 to 20 percent

of breast cancers by targeting that

drugs have shut that down have really

changed outcome for people and then

triple negative is a subtype that we're

really really focused in terms of trying

to develop and identify targets because

right now the only treatment that is

currently available our standard chemo

therapies but there's a tremendous

amount of work right now trying to

develop drugs that target triple

negative breast cancer and I think as

you were alluding to at the beginning is

yes these are groups but within them

there are many different subtypes that

we're trying to tease out and so we know

that they can be additional drivers in

some subtypes that we could think about

targeting so they're not these are the

groups that we currently have today in

2019 but we're starting to subgroup them

and we're starting to try and develop

additional targets for the different

subsets and we'll probably talk more

about that throughout throughout our

conversation today a question that we

often get is how often people with

metastatic breast cancer should get a

biopsy or rebuy op seed and and when so

that's a great question and and one that

is evolving so the good news about

medicine is that it is changing an

incredibly rapid clip so what I say

today will probably be different than

what I would say or what we as

healthcare providers will say in six

months or 12 months or two years or

whatever we used to just biopsy many of

us were taught to biopsy initially at

the time that somebody was at the time

that we suspected that somebody had

metastatic breast cancer because we

could think that that's what it was but

you need to be a hundred percent sure

because it's obviously very important to

figure out whether somebody has

metastatic disease or not and then we

also were taught to biopsy to make sure

that the hormone receptor status and the

her2 status

the same as on the primary and we have

good information now that while most of

the time it's true somewhere between

about 5 to 20% of the time the receptors

change and they change on the site of

metastasis compared the site of the

primary so it's really important to sort

that out so that was what we had been

doing for quite a while as biopsy at the

time of initial recurrence to confirm

that but increasingly as we're starting

to find additional targets people are

thinking about by up seeing more

frequently at the time of maybe deciding

about next type of treatment and part of

that is because we can now send

specimens off tumor specimens and

there's some data that's there there's

some studies looking at at blood

specimens as well to look for specific

mutations or alterations that we could

target right now that's actionable in in

some cases in standard of care but it

also makes a big difference when we're

thinking about clinical trial options

that are looking at some of these newer

targeted therapies as well so some of

what we find now tells us that we should

be thinking about immunotherapy and

breast cancer there are some rare cases

where there are some drugs that are

approved for specific alterations in the

tumor and we can only find that out in a

clearer way in breast cancer right now

by doing a biopsy but obviously we'd

prefer to be doing as a few invasive

things as we could so we're also looking

at looking at circulating tumor DNA and

tried to figure out just on blood tests

if we could determine that sure and for

people who need a biopsy of the tumor

itself what are some of the

considerations about why you would do

that or why you would not do it why we

would do a biopsy or not do a biopsy so

that's that there are a number of things

that come into play there we are always

thinking about the impact of a biopsy

how accessible is the tumor can you

actually can can one of my colleagues it

wouldn't be anyone like me who would be

doing something like that it's typically

interventional radiologists who who do

these biopsies or breast imagers or

people like that so we always try ferret

is it actually feasible and then over

the places that it might be feasible

which place would be the easiest for the

person the laced painful the least risky

comes into it and then we also try and

make sure that the biopsy if you're

going to subject somebody to a biopsy

you want it to have something that we

can actually act on is it going to get

enough tissue for us to be able to

interpret it to potentially act on it

we're not just doing these things for

academic purposes we we need it to have

an impact so for instance if if we have

a choice of different sites we tend to

avoid biopsy in bone because for a

pathologist to handle the bone specimen

they have to do something to get rid of

the bone right so they have to do a

process that decalcify zur gets rid of

the bone but that can also change what's

expressed in the tumor so it can give us

false negatives so you know we're really

trying to figure out if it's feasible

and what you know what will be the least

intrusive for somebody is really a big

thing so whenever I'm thinking of it I

tend to pick up the phone and I know

we're all supposed to text and do all

these things which I do okay but I find

that talking to people is actually

better so I pick up the phone and I

speak to our interventional radiologist

and I say could you could you have a

look at this and tell me what site do

you think would be amenable to biopsy

and what would be the easiest for

somebody to be subjected to sure sure

thank you for that and for explaining

the role that interventional

radiologists it kind of shows the

importance of having a team approach to

treating it and I think when you're

talking about a team you there are a lot

of people behind the scenes there's the

interventional radiologists it's a

pathologist people that people never see

but that are really important to the

whole health care team that's trying to

help us approach this sure sure

so let's move into talking a little bit

about hormone receptor positive breast

cancer because so much has happened over

the last few years for this you know

this is the most common type of

metastatic breast cancer either on its

own or coupled with a her2 positive

diagnosis today what are the standard

treatments that someone could expect if

they're diagnosed with an ER positive or

pr+ breast cancer so I again maybe to

set the framework of this again when I

when I and and my colleagues think about

how we would approach metastatic breast

cancer the good news is that there are

lots of effective treatments okay there

are tons of them and the choice that we

as a team should make so your healthcare

provider with you should make is really

of the options that are out there which

are likely to be most effective and of

the ones that are likely to be most

effective which one is best tolerated

okay cuz what we need to do is provide

the best quality of life that we can

with the less impact the least impact on

symptoms that we can because we want

people to be thriving and to be living

as well as they can okay so in terms of

hormone receptor-positive breast cancer

when I first started we had we were

taught that if anyone had any evidence

of metastasis beyond into organs like

liver or lung we should be using

chemotherapy mercifully we've come a

long way from there and so now for most

women with hormone receptor-positive

metastatic breast cancer we're really

thinking about hormonal therapy or

endocrine therapy and I I wear a

teaching program I teach our fellows and

our residents and our medical students

that the default now should be hormone

therapy maybe with something and there

might be instances where were you think

that's not the right thing but most of

the time it is the right thing at least

to start with and so we're thinking

about hormone therapy and it really

depends on the line that we're talking

about so the standard first-line

treatment for hormone receptor positive

her2 negative metastatic breast cancer

is a combination of some sort of hormone

therapy which is really an anti estrogen

therapy plus what is now a it's still a

relatively new class of drugs but a

class of drugs known as cdk4 six

inhibitors that gained FDA approval very

rapidly one after the other and they're

three in that class that are all very

effective treatments that are given in

conjunction with the hormone therapy

that the reason that they really jumped

to the forefront here as opposed to a

hormone therapy alone

is because they do carry relatively

little in terms of side-effects not

nothing so I don't want to minimize what

we're what we're talking about but

they're very generally they are well

tolerated therapies their oral therapies

they allow people to you know live their

lives not attached to infusion centers

and and that's really what we're trying

to and they added significantly over and

above what we could do with standard

hormone therapies so they caused a

greater number of women to have a

response to it and to have a more

durable response so a significant

prolongation in time until the cancer

progressed on the therapy so that's our

standard first-line therapy today is to

use for women who have metastatic

hormone receptor-positive disease to

think about hormone therapy alona the

hormone therapy partner can be a number

of things the things that we have

evidence for that are FDA approved for

this indication are really any one of

what we call the a eyes or aromatase

inhibitors drugs like that and all our

drugs have to Danes right just to make

everyone even more confused we have tons

of drugs than they have you know their

their marketing name and then their

standard names so I'll say both okay but

drugs like letrozole which is also known

as firm ara anastrozole that's also

known as a remedy X and X the mustaine

that's known as aromasin so those drugs

are drugs that we can think about giving

with these cdk4 six inhibitors and there

are three cdk4 six inhibitors and then

there's also another endocrine therapy

that is an injection that's known as

full vestment or fast Lindex that you

can give as a partner with it so that's

really our sort of first-line

armamentarium for where we're going so

you talked a little bit about the

reasons why you might choose one over

the other another question that we get a

lot is particularly with the CDK

inhibitors is if you've taken one and

you have a progression can you try a

different one and I'm wondering what the

guidelines are for that today so the

guidelines today are that we don't have

any evidence that we should continue a

CDK 4/6 inhibitor upon progression on a

cdk4 6 inhibitor there are studies that

are looking at that there

studies that are adding other drugs that

we think might reverse resistance to the

endocrine therapy and/or the cdk4 six

inhibitor so again it's it's you'll hear

this over and over again I'll try not to

say it too many times although I

probably will you know research clinical

trials our would have gotten us to where

we are today but they're going to get us

somewhere further tomorrow and and I

think that it's not only the medical

community but III think that the patient

community has I think we all understand

they're they're used to this feeling

that people were being guinea pigs and I

think what we've really understood is

that by carefully thought-out clinical

trials where people really think about

the pluses and minuses and how it

applies to them if they feel comfortable

on it or not that's how we'll continue

to make advances but there are a series

of drugs that are being looked at to try

and overcome resistance to cdk4 six

inhibitors but generally the standard of

care as if somebody has had appropriate

therapy was able to get enough with a

drug in you would not switch to another

there are some caveats medicine is like

it's not a black and white thing okay

you probably have guessed that already

but there are some instances where

people really because the side effects

can't tolerate one of the cdk4 six

inhibitors and come down to really what

we think might be some therapeutic doses

so doses where we might not be able to

see really the benefit or the effect and

so sometimes then we do change and we

try another one because we think

somebody hasn't really gotten a fair run

of one or they were changed because of

something that wasn't entirely clear

whether there's these was really

progressing and whether that was the

right call but that the standard thing

would be that except in the setting of a

clinical trial we shouldn't continue cdk

for six inhibitors okay thanks for

answering that question and you know

it's just a really quick one you know

you mentioned in most of these clinical

trials of MIT done and women I'm

wondering whether we know anything

specific about using anti estrogen

therapies in in male people with male

breast cancer so I probably misspoke

many of these trials have only been done

in women but I think increasingly these

trials are being done in men as well

and obviously it is rarer for men to

have breast cancer but it does occur we

have some data on males and we're part

of one of many institutions that strive

to get a male breast cancer registry and

hopefully through that registry

eventually be able to carry out

international trials with a large

proportion of men so that we can really

understand that better we know that some

of the drugs work so tamoxifen is

effective in males we actually don't

have great data on aromatase inhibitors

or AIS in males although it's something

that we sometimes consider nor do we

have good data on for Vesper turf


nor do we have good data on cdk4 six

inhibitors that being said our general

approach to breast cancer in men is to

do the same thing as you would do in

women because the studies that have been

done to date suggest that it's the same

when you're talking about hormone

therapies it gets a little more

complicated because obviously male

hormones are different than female

hormones but when we're talking about

drugs like tamoxifen we have good data

there's no reason to expect that cdk4

six inhibitors wouldn't work as well in

men as and women so those types of

general principles apply thanks for

answering that and again just kind of

pointing out the importance of clinical

trials and having people be involved so

I see we have a number of younger women

with us today and I'm wondering if you

can talk a little bit about some

differences in treatment for pre

menopausal women with er-positive breast

cancer absolutely I'm so for pre

menopausal women with er-positive breast

cancer the the hormone therapy that has

been most studied is tamoxifen our other

hormone therapies so the AIS and and

facile Dex are full restaurant only work

in women who are menopausal that's just

because of their underlying mechanism of

action so the AIS are drugs that block

non ovarian production of estrogen so

somebody is pre menopausal and they have

ovarian production of estrogen the AIS

are not going to work and full vestment

is a drug where at least at the dose

that's approved we think only works at

that dose in in in postmenopausal women

so for pre menopausal women one of the

things that we can always think of is

tamoxifen but we can also use

they're mechanisms to make premenopausal

women postmenopausal so the standard

recommendation for pre menopausal women

is that we can use the same drugs as we

would use in postmenopausal women that

add on ovarian suppression as treatment

so we make those women effectively from

a hormonal perspective postmenopausal

and then can offer the same therapies

great thanks for answering that and is

there a role for surgery as well in

terms of ovarian suppression yes yes yes

there is um I again we all practice

probably a little bit differently I I

tend to start out so there too well

there are three ways to suppress the

ovaries one way we don't do very much in

the u.s. at all but you can radiate the

ovaries but that's not something that we

do but it's one of the things that you

may see that people are talking about

the other way that we do it more

commonly is to give an injection a shot

either monthly or every three months to

turn off that hormonal axis okay and

then the third way is surgically and the

surgery against peak is a non surgeon

you know it's a relatively

straightforward surgery in the realm of

surgeries though for people it is it is

generally a relatively easy surgery it's

a laparoscopic procedure and it tends to

have a rapid recovery for most women um

I tend to start off women with a shot to

see how they tolerate because it's all

about it's all about quality of life -

you know this is this is you know I

think of every decision at every point

with somebody with metastatic disease

that you're really trying to think about

amongst all the options what are they

okay what makes most sense among them

how does somebody's personal take come

in on this okay so if somebody wants to

go to the beach and has a beach vacation

for a month it would be foolish to

choose weekly chemotherapy that's like

really messes things up and that's not

what we're trying to do okay so to get

back to this whole concept of how you

how you shut down the ovaries I tend to

start with a shot because then somebody

can see how they tolerate it

you can't put the ovaries back in okay

but you can stop the shots so I tend to

start with the

and it depends on where somebody is age

wise so somebody is relatively close to

menopause and they're doing great and we

think they're going to get a long run of

hormone therapies then it can get a

little tedious to come in for monthly

shots and one could do the surgery but I

think that's a personal decision it's

not your doctor's decision or your

healthcare providers decision it's your

decision about how do you balance coming

in monthly for a shot if you're coming

in monthly for something else that might

be better then thinking about some

surgery but surgery can come into play

and for people who live far away from

healthcare places you know it can come

it can weigh differently so again I

think that's a very personal decision

great thank you very much for that and

so we've talked about a number of

different things there are some other

treatments that are being studied in

hormone receptor-positive breast cancer

we've heard a little bit in the past few

months about pi3k pathway inhibitors and

I'm wondering if you can talk a little

bit about about those and some other

things that we might expect to see I

think you're gonna see a lot of drugs

with unpronounceable names you sort of

have to get the cadence right after

awhile yourself do I figure out how to

say these drugs so these pi3 kinase

inhibitors are we know that pi3 kinase

is actually one of the mutations that

has found our changes so mutation is a

change okay it's a variation in the way

that a gene is is cop is is red or

spelled these mutations are quite common

in pi3 kinase in hormone

receptor-positive breast cancers so

there has been a lot of research and

developing pi3 kinase inhibitors to try

and get at that molecular pathway in the

cancer cell so I think there are some

encouraging phase 3 trials which are the

last generation sort of the more

definitive type of clinical trial these

randomized clinical trials that have

randomized women to receive endocrine

therapy alone or endocrine therapy plus

1 of this PR 3 kinase inhibitors and

they're showing promise particularly in

women who have tumors that have these PR

3 kinase mutations and so I think that

it is likely that we will start that in

the not-too just

in future we'll have some of these drugs

available there are also studies looking

at drugs with akt inhibitors which are

other inhibitors along those pathways

and a variety of other genes or proteins

that can be targeted as potential

treatment options so this is really I

you know we are right now what we don't

have good evidence for in medicine is

what to do after somebody has had

disease progression on a cdk 4-6

inhibitor we have our standard

treatments and that's what we do but we

don't have good clinical trial data to

tell us what is the best option so

there's a lot of activity in that space

to try and figure that out and a lot of

trials are using these prsut kinase

inhibitors akt inhibitors look in a

variety of other things other drugs that

could reverse resistance of cdk 4/6

inhibitors oral versions of fast blood X

or full vestment are being looked at so

there's a lot of activity going on in

that space and it's really exciting

because there was kind of a long period

where most of what we were hearing about

were other types of metastatic breast

cancer and now it seems so there's quite

a few clinical trials open and available

that are really looking at these

questions and it actually brings up a

question that I was talking with a

colleague about before the program a

question about whether to enter a

clinical trial before you have

progression if you can even do that or

wait until you have progression and it's

actually a question that that you know

we hear quite a bit people who are

interested in going on a trial before

they're even showing progression in the

cancer so generally I would not advise

that I mean my my general take is to

keep on going and don't don't rock a

boat unless you need to now somebody is

not tolerating their current therapy

that's that's one thing but if you're

tolerating it and things are going well

then I tend to say let's let's keep on

going on that as long as we can and you

know we're we're the good news is that

I'm really bad at predicting the future

on an individual basis you know there

are there are many people who are you

and doing well on the same treatment

that if you'd asked us to give the stats

that wouldn't be the case okay so you

never know and you really want to try

and and keep on going on that because

maybe you know by the time that somebody

has disease progression we'll have

something approved that's different and

we'll know about it um there are some

trials where they are looking at

specific targets and sometimes if

somebody sometimes we pre-screen the

tumor to see if it has that target so we

can be thinking of it as the next step

but I always tell people you know who

knows whether you know that trial might

be closed by the time that we're

thinking about that for you so I tend to

not come off something but if somebody's

not tolerating something wants to look

at something yes looking at trials make

sense but again the trials trials have

lots of rules and regs on them and it's

not just because they're being pains in

the neck okay they sometimes are but

it's because you have to be that the

conclusions would not be valid if you

kept on bending the rules of who went on

and who you allowed on the trial so

these trials are quite rigid in terms of

the various criteria that allow one to

participate in them and they typically

some of the trials might say it's not

you have to have had prior disease

progression on a drug in order to go on

so it's not because somebody didn't

tolerate it necessarily sure sure and

thanks for talking a little bit more

about that I know that that many of the

advocates in the room are also working

with FDA to talk a little bit more about

ways they can become more eligible for

clinical trials because of this Dan I

know and a lot of us are working on that

as well you know we recognize the

barriers that we create so I think

increasingly as we're designing clinical

trials I know many of the groups that

I'm part of an hour at our institution

we always you know we talk about these

clinical trials with our with the breast

cancer advocates we're fortunate julia

is is one of the wonderful advocates at

Georgetown and we have an incredible

group of women who really helped us with

that but a lot of the organizations and

a lot of the organizations that we're

part of and that many people are part of

have integrate and I think what we have

learned over the years is don't throw in

some criteria that really doesn't matter

you know something that doesn't make

sense as an eligibility you're in

eligibility criteria because that's that

can exclude some people that we

shouldn't be excluding absolutely I

think we're gonna take a breath here and

see if Aaron has some questions for us

from the audience yes we've been

receiving quite a few questions and one

good one theme that is arisen of a

couple questions have been asked about

the role of surgery so a couple

scenarios one person is asking in the de

novo diagnosis settings so initially

diagnosed with stage four is it

recommended to have breast surgery and

then there's someone else who has is now

did treatment as stable its that should

that conversation come back into the

treatment conversation so so those are

great questions and we don't know the

answer to that yet we actually have them

again I guess I'm gonna sound like a

broken record we you know there have

been a series of clinical trials that

have tried to address that question and

they've had a really hard time enrolling

because we all have biases and it's not

it's the clinicians and the patients and

everyone who has biases and they you

know to do a clinical trial like that

you have to be you have to randomize

people to it and you know lots of people

don't want to be randomized or lots of

doctors think that they know the answer

to the question so don't want to enroll

people on those trials so we don't yet

have a clear answer for somebody who is

diagnosed with metastatic disease that's

their first diagnosis we do not know

whether doing surgery on the breast

changes outcome there are some what are

called retrospective studies so people

looking back in their databases or

collecting information

looking back suggested that the outcome

of women who had surgery who were

diagnosed with what we called de novo

metastatic disease that those women did

better but that has biases right because

you you know people are only the people

who are having surgery are healthier

because you're sending them just you

know you wouldn't send a surgery if they

weren't and people wouldn't agree to

surgery so we still don't know that

being said we have to make decisions

okay in the absence of good data

sometimes so it really depends and I

think it is a contra se

that people have to have and I

particularly think about it in people

who have a few sites of metastatic

disease or long disease control like the

second part of your question was that is

a time where that conversation should

come back and and you know you and your

healthcare provider should say should I

be thinking of surgery now for the

breast and there's also a discussion for

people who have relatively few sites of

metastases whether we should be doing

more definitive local therapy for that

should we be thinking about either

surgery or radiosurgery

or something like that in conjunction

with the whole body treatment thank you

that was a great question and we go to

the next question yes so someone is

asking about the difference in

treatments in terms of ductal and

lobular cancers so bringing that into

the conversation - thank you

so lobular cancers tend to more commonly

be hormone receptor-positive and tend to

get a little bit less benefit from

chemotherapy so we haven't talked to it

all about chemotherapy for hormone

receptor positive her2 negative breast

cancer but it is one of the treatments

or one of the groups of treatments that

we think about and that we use because

what we tend to do is start with hormone

therapy and we keep on going with

hormone therapy as long as we can

because that's usually better tolerated

than chemotherapy but there are some

chemo therapies that aren't so awful

okay and at times some of these other

drugs these you know fancy new drugs

might have side effects that are similar

to some of the chemotherapy so you

really need to think about what the best

option is but lobular tends to be a

little bit less responsive to

chemotherapy so it might push one even

more to think about hormone therapies

than chemo therapies thank you do we

have another question Erin we do have

many but linking to the conversation

about clinical trials wondering if

there's any promising clinical trials to

pay attention to and in this space with

hormone and positive metastatic breast

cancer or going on so there are I think

that the pi3 kinase inhibitor trials

takt trials

there are also trials that are getting

underway with immunotherapy which is

something I think will come to when we

were talking about some of the other

breast cancer subtypes hormone receptor

positive breast cancer has been more

traditionally thought of as what we

think of as a cold tumor meaning that it

is not responsive to immunotherapies but

there are trials underway or planned

that are going to try and address

whether one can think about using

immunotherapy or which subsets of

hormone receptor-positive disease might

one be able to consider immuno therapy

as a viable target thank you let's take

one more question one question is about

testing for the CDs the inhibitors is

there any sort of test or how is that

monitored - I'm not sure if it's asking

the questions asking if if it's working

or if you're a good candidate for that

something about testing and are there

any biomarkers probably any way of

knowing someone's more likely to respond

to the treatment so that's a great

question and that's been looked at and

there are no biomarkers that we can find

so far aside from hard on receptor

positivity there has been a lot of the

clinical trials have looked at that so

you might also be aware that most of the

clinical trials tried to gather some

sort of what we call biospecimen in the

really technical term meaning either

tumor tissue or blood or something

because what we recognize is that while

treatments might work in some people

they don't work in everyone and we need

to figure out who those some people are

we also need to figure out the people

who they don't work in why they don't

work so maybe we could overcome that and

figure out how to get around that

blockade so in the trials with the cdk4

six inhibitors there have been a lot of

trial a lot of further study on the

material that was gathered as part of

those trials to identify predictors of

response or non-response and nothing has

really panned out so far so we don't

stratify we don't we decide that

everyone basically what we do today is

everyone with hormone receptor positive

her2 negative breast cancer we're

thinking about using the cdk4 six

inhibitors the other thing that I wasn't

sure of in your question is was the

monitoring actually what do you do when

somebody is

on a cdk4 six inhibitor and there is

some laboratory monitoring that you need

to do on that these drugs typically

suppress the white blood cell counts so

one needs to have complete blood counts

done to follow that so there's a certain

amount of monitoring that goes on as

part of treatment on cdk4 six inhibitors

great thank you for that question thanks

for all of your questions I'm just gonna

quickly give the text number out again

for folks who may want to ask questions

it's six one zero three six five seven

five three two and with that Victoria is

know that you have some questions as

well we're gonna move on to talk about

triple negative breast cancer so we

started out talking about a breast

cancer that's defined by what we know

about it but triple negative breast

cancer has the unique distinction of

being defined by what we don't know

about it and that would be like me

trying to describe dr. Isaacs as well

she doesn't have red hair she doesn't

have blue skin and she's not wearing

yellow but if I did that you wouldn't be

able to pick her out of this room

because that describes pretty much all

of us so so we've seen some exciting

things in the past year and past

developments about how this can be

changing we're learning more about it we

taught we we say that triple negative is

defined by the lack of targets but I

think it's better to say that it's

defined by the lack of known targets

that's changing so but to start off

let's talk about what standard treatment

now and then we'll move into how that's

changing and that now might be changing

in a few weeks right so to bring your

analogy further I guess you we want to

be able to say that dr. Izak says you

know short hair as a Canadian accent if

anyone picked it out in the crowd and

various other things so we do know that

triple negative breast cancer is way

more than one thing okay so we do know

that it encompasses a variety of

subtypes within triple negative breast

cancer and there is a lot that is again

being done to try and target those

subtypes so when we talk about biopsy

and we go back to the question that that

we talked about a little earlier you

know that question about biopsy and

looking for targets applies to basically

all breast can

or subtypes there right now the standard

treatment is chemotherapy and

chemotherapy has been around for a long

time it can be effective it has variable

side effects or toxicities based on the

chemotherapy itself but we haven't had

anything else beyond that and we don't

yet have anything else beyond that but

there was a recent large trial and they

will probably be another trial at its

heels soon that will see the results on

looking at the role of immunotherapy

for triple negative breast cancer and so

there's a trial that was just the

results were just released a few months

ago that looked at adding immunotherapy

to one of the chemo therapies for a form

at a static breast cancer it was a

randomized trial and it showed that

there was a significant prolongation in

time to disease progression with the

addition of immunotherapy but only in a

subset of women with triple negative

breast cancer so that subset were women

whose tumors Express PDL one and and the

concept here is that you know our immune

systems are supposed to recognize

non-self okay that's what they're

supposed to do they're trained that if

you have a virus or a bacteria you know

goes on into full gear it goes and

isolates that and it destroys it and

cancer cells have somehow figured out

how to fall under the radar screen

because cancer cells are are not us

they're not self okay but they figured

out a cloaking mechanism see if they

figured out how to hide themselves from

the immune system and one of the very

potent mechanisms is is a whole pathway

that involves PDL PDL one okay and so

there have been a series when we're

talking about immunotherapies many of

the immunotherapies are anti PD one or

anti PDL one because that's a way of

uncloaking of letting the cancer cell

not be able to hide from the immune

system so one of the things that can be

tested on cancer cells is to look or

actually it's not only the cancer cells

it's the it's our blood cells that are

surrounding the cancer cells as well

that can be part of that

cloaking mechanism and so there is a lot

of hope that for women with triple

negative tumors that our PDL one

positive or the the infiltrating tumor

associated cells or our white blood

cells that are around there that are

really the cells that that recognize and

fight non-self that if we add an

immunotherapy to that there is a greater

benefit so there was a significant

prolongation and benefit and in survival

in women with triple negative breast

cancer whose tumors or tumor environment

cells Express PDL one so I think that's

gonna be you will see this we think if

we can read the tea leaves of the FDA

okay we think that this will probably

approve be approved within the next next

couple of months we hope and maybe even

sooner and there are a series of other

trials that are looking at that and and

the thing is that this will be a völva

field right this is the first trial but

we need to understand more and sometimes

trials give slightly conflicting

information or measure things a little

bit differently but there are also

trials looking at some of the other

drugs that we've talked about their

trials with some of those same akt

inhibitors those cross different breast

cancer subtypes so there are trials

looking at some of these akt inhibitors

their trials with different types of

chemo therapies looking at whether they

might be more effective so there is a

lot of work being done trying to look at

different targets some triple negative

breast cancer cells Express the androgen

receptor which is a receptor that's

found that's a male hormone receptor and

so their trials looking at using

androgen receptor inhibitors and a

variety of things that are really

ongoing it's a very rapidly evolving

field so you talked a lot about the

emerging drug that none of us will be

able to pronounce so one of there's a

one class of drug that has been in

clinical trials and those are PARP

inhibitors so would you like to share

with everyone what the letters PARP

stand for remember what PARP stands but

I can tell you her on the high I don't

know I'm probably I can't remember what

part I'm little aged too okay so I can't

remember everything anymore I had a much

better memory when I was 25 and I do now

so PARP inhibitors were actually a class

that I hadn't

- yet it actually is not just restricted

to triple negative breast cancer so PARP

inhibitors are our drugs PARP is an

enzyme that helps to repair from DNA

damage okay so PARP inhibitors earn

drugs that inhibit that so it causes if

you use a pop inhibitor the cell cannot

repair from DNA damage cells are


they usually have more than one pathway

okay so they're not just relying it's

like I'm not gonna be very good at some

analogy but you know you if you're I

understand hockey

okay so I'll do hockey for you probably

you guys don't understand but you

wouldn't just have one goalie cuz you

know if your goalie was out you'd be in

problem and that applies to soccer and

I'm sure a lot of other things that you

might know about so you know cells are

smart and they have more than one

pathway they're not just relying on one

thing because if you knock that one

thing out and they're done that doesn't

work very well okay so there are lots of

mechanisms to repair DNA damage and but

PARP inhibitors hit with one of those

mechanisms and it might seem to you that

if you don't allow the cell to repair

DNA damage is that good or bad and it's

actually ends up if the cell cannot

repair from DNA damage the cell will die

okay and that's what you want cancer

cells to do so the place where PARP

inhibitors have been approved is in

women who have metastatic breast cancer

who have mutations have inherited a

mutation in either brca1 or brca2 okay

brca1 and brca2 are are genes that code

for proteins so genes code for proteins

okay so somebody who has inherited a

mutation in brca1 or brca2

has a change in their DNA in the gene

that's coding for brca1 or brca2 and we

say that when somebody has a mutation it

means that that change in the gene

doesn't allow the protein to be made a

defective protein is made or no protein

is made at all so you effectively do not

have brca1 or brca2 and brca1 and brca2

are proteins that repair from DNA damage

it's a different pathway than PARP okay

so if you have a woman who has a tumor

that has a brca1 or brca2 mutation that

tumor cannot repair from one aspect of

DNA damage but it's relying on another

and then if you give the PARP inhibitor

you're hitting that rescue pathway okay

so the cell cannot repair from DNA

damage so relatively recently there was

approval of PARP inhibitors for women

with metastatic breast cancer who

carried a mutation in brca1 or brca2 it

was approved for women who had triple

negative but it was also approved for

women who have hormone receptor positive

her2 negative breast cancer which is

something that you know people often

forget about but that is that is where

the approval is and that is where the

data for benefit is and and the trials

that were done basically randomized

women who were going to receive

first-line chemotherapy ond at

chemotherapy for metastatic breast

cancer with brca1 or brca2 mutations

randomize them to either get a

chemotherapy that would be any one of

the appropriate chemo therapies that we

have as options or these oral PARP

inhibitors and the trials with the two

PARP inhibitors that have been approved

to date showed that the PARP inhibitor

was better it prolonged the time to

disease progression and generally

because it's an oral therapy it's a

little bit more tolerable and so those

drugs have now been approved there is

ongoing work to see if these PARP

inhibitors might work beyond brca1 and

brca2 carriers because that's a

relatively small subset of people so we

and others have trials looking at PARP

inhibitors in women who have either

inherited a mutation another gene that

affects the ability of cells to repair

from DNA damage and that's a very

complex pathway and there are lots of

different genes that can do it and then

the other question that has come up is

does the person have to have a genetic

change or could it just be in the tumor

and so the trials that we have open

right now and that there are some other

trials across the country also looking

at that is looking at the role of PARP

inhibitors sort of beyond our standard

beyond brca1 and 2 carriers where we can

give it and I you know we can prescribe

it we don't write prescriptions anymore

obviously so

we type these things out but where we

can prescribe it in safety approved but

the trials are actually looking at

whether we can broaden them because it

really makes sense that it would apply

beyond that it could apply to mutation

that somebody has inherited in other

genes in that pathway or if the tumor

itself when we send it off for that

molecular profiling shows that there's a

change in one of those genes in the


maybe these PARP inhibitors would work

there too but we have to look at it and

we have to prove it there's one thing

I'm learning just from this morning

alone and I think every woman in this

room knows this that one size does not

fit all

especially with breast cancer this is

incredibly complicated incredibly

complex to plan the treatment journey

for each individual this is all about

personalized medicine and you talked to

me that ago about you know depending on

which chemotherapy someone started with

and what drug happened next can you talk

a little bit about the timing and the

importance of you know what chemotherapy

starts what treatment comes next and how

that might dictate or how that might

contribute to outcomes how do you decide

what comes first so in some cases we

have evidence in some cases we know we

usually have a menu of options okay

sometimes studies have told us that it's

better to do one first then second or

third but in many cases we don't have

that certainly for the chemo therapies

we often don't have that we typically

start in the metastatic setting with

drugs like taxanes are often our

first-line therapies sometimes for

triple negative breast cancer we also

have evidence that a different drug a

drug called carboplatin or cisplatin

might be more effective in that subtype

of breast cancer but typically again

we're thinking about how somebody's

other symptoms health is are there other

things that would push us more to one or

the other and then at other times the

thing that I always think of as how does

it impact somebody's life okay what else

are we doing if we have we have a couple

of oral chemo therapies so you know my

my comment if somebody you know has

three weeks at the beach well and we

know that it's in three months and we

have to change

therapy's well maybe we should think

about an oral chemotherapy here because

that lets you on the beach and not come

back to the infusion unit I mean so

that's sort of that that's part of the

equation too if we don't have good

evidence that one is better than the

other and in fact it really just depends

on when some of these drugs were

developed because the clinical trials

are going to look at them in different

spaces and may not because some were out

of the blocks a long time ago might not

have looked at the sequencing with other

drugs so for some of these we have clear

indications but for many of them we have

a choice and and the choice needs to be

individualized and personalized I know

we had a lot of questions from the

audience I want to be sure that Aaron

has a chance to answer as mentor ask as

many as possible that are on her life

might have you ask answer them to write

ask an answer one-stop-shop we have

they've been flowing in so a few

questions to follow up on the

conversation about PD and well one so

the first question is what share of

patients or what percentage of triple

negative patients are is the is there

any estimation of how many people fall

in that category and then that's the

related question on that as someone's

tumor was tested to be not positive for

PD and one but would that potentially

change over time so the answer to would

it potentially change over time is is

yes tumors can change and it also looks

like the site of biopsy could

potentially influence the likelihood of

detecting PDL one positivity

okay so again this what I would what I

want to say as a general caveat is that

our information keeps on changing okay

so please don't take what I'm first of

all don't take what I say is gospel

anyhow but don't take what I'm saying

now as being what we might say in three

months or six months or a year because

our information keeps on changing but

there's some data that suggests that

liver biopsies are more likely to be PDL

one negative then lymph node biopsies

again that's based on today's

information but so we don't know whether

that's really true but there's some

suggestion about that

so that could influence things but it's

also possible that over time the PD l1

status changes and again we don't have a

ton of information on how frequently

these tumors are PDL one positive from

one of the trials the suggestion is

somewhere around 30 to 40% my PDL one

positive but I think we need to gain

more information we have another trial

that is coming out soon and and then the

final thing that I just want to say

about this that's really important is

that as a medical community we spend a

lot of time there are lots of different

tests out there to determine whether

something is PDL one positive or you

know pi3-kinase mutation what do you

mean by a pi3 kinase mutations so the

actual the technical aspects of it

matter it can change from tumor subtype

there are different assays that have

been developed and that's something that

we are going to need to figure out how

to standardize so that we understand and

when her to first came out I can't tell

you how many studies were out there to

try and figure out how do we what do we

mean when we say a tumors her2 positive

what what assay is being done to

determine that what level what's

positive is positive above X percent or

Y percent or so there these are not

these are while they sound rather hard

and fast it's actually there's a lot

behind that and I don't think we get

have the standard way to measure PDL one

and I'll tell you that different

companies have developed different

assays as companion assays and so it'll

vary and different tumors have different

ways of measuring it so in breast cancer

right now when we're talking about PDL

one positive we're not talking on the

tumor we're actually talking on the

cells that are surrounding the tumor the

the white blood cell components that are

surrounding the tumor so it's not

actually the tumor cells but for other

cancers they're looking at the tumor

cells so again this is a very new Austin

complicated space so we've had a lot of

great conversations about clinical

trials one person has commented that

their doctor has not

been very enthusiastic about their

questions about clinical trials and said

to take them with a grain of salt so

what are and but this this person is

really looking for resources on on

clinical trials you've mentioned a

number so what are some resources how

can we direct where's a good place to go

to find out what clinical trials are

available for you to navigate that what

resources could we recommend for that

I'll answer that I know really oh well

go down we'll go down the line this is

this is really important because we know

the studies have been done to show that

of the patients that would actually

benefit from clinical trials less than

20% are actually enrolled and far fewer

representative from our communities of

color the number one reason why this is

happening is simply because patients are

not being asked and it pains me to hear

that someone is you know feels that you

should take it with a grain of salt

after dr. Isaac's has talked so

passionately about the importance of

investing in discovery and participation

so if you are interested in clinical

trials we're going to go down and go

down the row here komen has actually a

clinical trials helpline where you can

call one of our trained oncology social

workers and they will talk to you about

your eligibility for a trial and give

you questions to ask your doctor and

that's available toll-free at one eight

six six go komen 24 mile not 24 hours a

day but quite a long time during the day

I'll pitch to you at all no problem I

wanted to mention metastatic trial

search which is available both on komen

organelle BBC org it's a it's a trial

search engine only for people with

metastatic breast cancer where you can

put in the subtype and you can even put

in the site of metastasis and it'll

match you to trials within your region

and I also wanted to mention MBC Connect

which is a new product by the metastatic

breast cancer alliance that's going to

connect with the the trial matching

service so it gives you a number of

surveys that you can answer about your

experience and about your subtype and

the next version of this which is going

to come out in a couple of months will

actually match you

trials that are in the metastatic trial

search so those are two good resources

that you can can try and then there's

the government psych clinical

which you know can be a little bit of a

challenge for all of us to navigate but

it is you know it does pick up a lot of

the trials and it's just a matter of

understanding some of the lingo which

you really have to you know make sure

that you're looking at trials that are

actively recruiting subjects because it

will have trials that are closed as part

of it it has a geographic basis it has a

subtypes but it can be a bit cumbersome

and I know that they're trying to update

it and to make it a little bit more

user-friendly I also want to mention

emerging med and then something kind of

unofficial which is social media if you

go on social media and and ask your

fellow patients with metastatic breast

cancer about particular trials that

you're looking for you will find a

goldmine of information of other people

who are also looking for that

information so I would encourage you to

to ask ask your peers another thing I

want to mention about getting connected

to clinical trials you know we talk

about informing the patient about where

to find this but we also have to address

the other toxicities and lifestyle

issues that prevent people from going on

and staying on trial it costs money to

go to the trial site every single week

somebody has to watch her kids while

you're there you need to take time off

of work to get your treatment and

there's a lot of complexities as to why

people don't stay on maybe you're having

side effects but your insurance doesn't

cover that that medication so it's

important that when we're talking about

resources that we also address those

issues both of our organizations have

help lines that connect you to sources

of financial support to support groups

and to other ways that you can access to

keep you on your treatment we have to

think about the whole patient experience

and what's happening with you your

personal experience your family and your

work as well and most institutions also

you know we we have social workers we

have people who are trying to help with

all of this obviously we know we often

refer out to organizations but there

our organizations that can help because

we all recognize that off in clinical

trials do require more of people they

require more frequent visits they

require longer visits they require a

bunch of screening and pre-screening and

a variety of things but I would urge you

that if your if your clinician is is is

telling you they're not interesting

clinical trials and take it with a grain

of salt you know ghosts go and ask

around and you might decide you know

clinical trials there might not be good

clinical trials there the clinical

trials that are there might be good for

somebody but not for you and you might

not want to do that and that's that's

fine okay but you need to know what all

your options are and you know

particularly in this era where we really

you know we just have new things coming

out all the time it's really important

to know about it and you could

potentially make yourself not eligible

for a clinical trial that you might have

wanted to participate in by starting on

a new treatment so you know and thinking

back to one of the questions that you

you asked me earlier how do you choose

which treatment you know honestly I

think I sometimes find myself playing

chess and thinking okay if I start this

now what clinical trial might I make

this patient not eligible for tomorrow

if I do this drug so if I have a choice

of three drugs and if I choose one drug

I know that I might make somebody

ineligible for it that a trial for the

next line of treatment I'm and I have

three equal options I might not choose

that I always I tend to have that

conversation out loud with with the

patient who's in the room so they

understand what I'm thinking and I'll

say you know I don't know whether that

trial will be open at the time that we

need it but I'd hate to make you not

eligible for it

because of a decision that I'm making

today so that's it's gotten increasingly

I think complicated to think about what

because you have to know what then the

next generation of things that you might

be able to offer somebody what its

companion might be and what the you know

25 eligibility and ineligibility

criteria might be so I always urge

people that when it's at a time of

decision about next therapy don't

usually there is not an urge

see like you don't have to switch

chemotherapies today you really I mean

the most again they know all was is a no

Nevers in medicine okay so usually the

vast majority people have time to sit

back and think about this for a little

bit and that gives you time to explore

what are other options and I always tell

people that you know the reason with

clinical trials these days there's a lot

of there's a lot of things that are

standard of care that we can write that

are fda-approved and that people can

give to you that your clinician can give

to you but the clinical trial might only

be an option in this point in time so

you know say okay don't don't change my

chemotherapy today or are there clinical

trial options what's going on this place

and it might be that there isn't

anything okay but don't feel like you

have to be rushed into a decision at

that moment because that might post some

doors for things that you might have

been interested thank you so much for

saying that it is becoming more complex

on our physicians as well as the

patients we do talk a lot about patient

education and patient advocacy but we

also need to support our physicians in

you know understanding the huge

explosion of information that's coming

out it really is a partnership which is

nice for us to be having today so any

further questions from Erin to link on

the theme of partnership we did get a

question about the role of patient

advocates and some of those FDA

decisions that is there any way that

advocates and and the broader metastatic

breast cancer community can help

encourage faster FDA turnaround those

sorts of things so any tips maybe from

the whole panel but many strategies

around increasing the urgency for

forgetting these drugs available to

everyone so there are a lot of

opportunities for patient advocates to

be able to participate in the process

and as an advocacy organization living

beyond breast cancer and also Susan G

Komen can let you know about

opportunities where you may be able to

write letters or actually testify before

FDA to make your voice heard so that is

is one piece of how you can contribute

another is to be active both with your

personal physician and healthcare team

and institution and on social media

where it is appropriate to apply some

polite pressure to have changes made and

to make your voice heard and I would say

a third strategy is to talk to

organizations like ours and give us your

input tell us what it is you want and

that you need both as Victoria said this

morning both of our organizations are

members of the metastatic breast cancer

alliance and this is a priority for our

alliance is to address some of the

barriers to clinical trial participation

and to make sure that your voices are

heard about what you want and what you

need and what the outcome should be so

there's a lot of people who are really

interested in working with you and

advocating with you to have changes made

so I'll talk a little bit about advocacy

you said polite pressure but sometimes

sometimes impolite yes bring your

pitchforks and torches to the capital of

everyone but we do need to have a

feeling for that yes my advocacy team

knows I've said this it's true right you

know sometimes we're a victim of our own

success in this in this advocacy space

that they're in there has been progress

but we all know in this room the work is

not done

we need to continue to put pressure on

our elected officials and continue to

participate in raising the voice and

participating in research for progress

to happen so I can't over or

underestimate the importance of the

advocacy space komen has an advocacy

event our colleagues at metavivor have

the metastatic stampede which is

happening in October which is an

incredible opportunity to bring lights

specifically on the need to raise the

profile of metastatic research of all

types the letter writing is also

important but I want to go back to

participating in the research Enterprise

one of the challenges we have in getting

drugs to the market is the lack of

people participating

trials sometimes that's because people

aren't asked to participate and

sometimes it's because the trial has

been designed not to have the patient in

mind it's really important that our

research advocates like Jamil work with

our researchers and with our industry

colleagues on how to design a trial

that's most conducive to patient

participation now you all can weigh in

that hey me coming to a trial site five

days a week is not going to happen let's

design this so it's more friendly to the

patient so we can ensure accrual we can

assure that we get the answers that we

need and that we also can ensure that

we're representing a diverse population

this is one of the challenges that we

have in the drug development enterprise

that a lot of the work and the studies

are being done with people who look just

like me and that doesn't represent the

face of breast cancer it's really

important for us when we're talking

about drug development and approvals

that were assured that what's out in the

marketplace works for every member of

the community and if that doesn't work

what can we identify that does know it's

a little bit different off the topic of

FDA approval but I'm very passionate

about this because we need to represent

everyone who is facing breast cancer

whether it's women or men or any other

member of the community the drugs need

to work for everybody so advocacy is

very important and and I will tell you

participating a number of groups that do

do breast cancer research and do design

clinical trials the good news is that I

think a lot of us have gotten this yep

we have as active members at the table

breast cancer advocates so you know

we're part town we have a group just for

our own institutional trials I

participate we participate in what's

known as the translational breast cancer

research consortium that has a big

advocacy group that is part of it and

there is on each conference call for the

subtype of breast cancer and we're

discussing it as part of ice by two and

a variety of other trials the

co-operative groups have advocates on it

so I think everyone increasingly gets it

which is good because you know all of us

can be a little tone-deaf sometimes and

there are also clinical trials at

institutions often that are trying to

see if there has

been good representation broader

representation to try and look at the

safety of that drug in other groups so

for instance my colleague Philippe

Alan's who's in some other room close by

speaking Spanish which I can't do you

know just ran a trial looking at the

cdk4 6 inhibitors in in women in black

women because they typically have lower

white count to start with it's called

benign ethnic neutropenia so it actually

doesn't mean anything and it's not

clinically impactful but because these

drugs can cause a white blood cell count

to go down there was a set cut point for

a white count to be able to participate

in that trial and excluded people

because of that so you know she just

completed a trial looking at the safety

of cdk for six inhibitors and people who

have benign ethnic neutropenia to show

that they were safe in that space and

that's often what we need to do and so

there there are lots of different places

where people can think of that and I

guess that just one other plea and I

guess I know clearly I wear a clinical

trials hat but you know participating in

clinical trials is critically important

because when we're talking about doing

something better better means a lot of

things okay better obviously first and

foremost means better outcome but if we

could get the same outcome with less

toxicity that would be even better so

there are trials you know what we we are

always trying to do better okay that's

what we want to do we want a different

future tomorrow than we have today and

that's really where clinical trials get

us thank you so much for other shout out

for the importance of clinical trials

it's imperative especially for this

group that we need future discovery we

need discovery now we need it sooner so

thank you so much I just want to give a

shout out again for the the phone number

for the questions via text it's six one

zero three six five seven five three two

and erin is standing by waiting for your

questions but I think we're ready to

move on Janine absolutely so speaking of

clinical trials let's move into talking

a little bit about her2 positive breast

cancer where clinical trials have really

revolutionized the treatment of

of this subtype of disease as you were

reflecting when we first started talking

so you spoke a lot in in the er-positive

setting and in the triple negative

setting about how we sort of pick and

choose the order of treatments in her2

positive metastatic disease we actually

have some guidelines about the order of

treatments why is it so much different

in her2 positive breast cancer again it

it probably has to do with the the place

we are right now okay and the trials

that really revolutionized the treatment

of her2 positive breast cancer there now

you know five years old or six years old

or seven years old whatever wherever we

are and all of that so there has been

time to get data on doing what next so

we have we have clear guidelines on

first line and second line therapy

because we've gotten there but we don't

have guidelines on third line and fourth

line and fifth line therapy and that's

where there's a lot of active work in

clinical trials to try and define that

so you know maybe to get back to the

concept of clinical trials I always say

that today's clinical trial opens up

tomorrow's question you know it answers

one thing but we then need to figure out

what we do next based on that so the

reason that we don't have guidelines I

want to do in hormone receptor positive

her2 negative after cdk4 six inhibitors

is there too new okay and we haven't had

time to gather the data and the good

news is that often when you introduce

these drugs they change outcome for

people so you have a period of time

where you people have have long

stability and we're not even able to

scientifically and medically address the

question about what the next best

therapy is so for her to positive breast

cancer in the late 1990s when I was

first starting there you know

trastuzumab or Herceptin came along and

totally revolutionized the treatment of

her2 positive breast cancer trastuzumab

or Herceptin is an antibody that is

geared towards her2 positive disease or

to the her2 positive aspect of the

disease subsequently to that there was a

trial that came out in I can't remember

when 2012 ish or something like that


that looked at adding another antibody

on top of I'll call it Herceptin because

that's what most people know it as and

the other antibody I think most people

know it as per Jetta its other name is

purchase map and so there was a large

international trial that randomized

women who were receiving first-line

therapy for metastatic her2 positive

disease to either do chemotherapy plus

Herceptin which was then the standard of

care versus humo therapy Herceptin and

per jetta so asking the question very

clearly what does per jetta add over and

above and it added a ton it it prolongs

survival for about fifteen or sixteen

months which was really huge in it and

those women had in general disease

stability for on average about five

years which is you know not great but a

whole lot better than what we were doing

before but after that we had no idea

what to do after people progressed and

then trials came out with another drug a

drug called TDM one orchid sila that

showed that it was very effective in

that space and that's become the second

line therapy for people who have disease

progression so now we have a very clear

algorithm for first thing and second

thing but we don't know what to do third

and fourth and for a long time the good

news was that we couldn't really even

study it because people were doing so

well that we weren't able to actually

get studies designed in a crude to

address those questions but there's a

lot of activity in that space right now

so there are a lot of new drugs that are

making their way fairly far along in

clinical trials that are looking at

different ways of targeting her too

there's another drug out there there's a

drug called lapatinib Burton kirb which

is FDA approved so there are other drugs

that we can use but there are also novel

antibodies drugs that hit the her2

pathway in a different way that are

being looked at so there's a lot of

activity and what again if I you know I

myself I know I'm saying this over and

over again but if somebody has her2

positive disease and has received

projeto already and TDM one I would

strongly urge you to think about

participating in clinical trial at one

of these other drugs because yes I you

know what we do then when somebody has

has disease progression on that is to

use her

ceptin again with a different

chemotherapy but again we we think that

some of these new drugs might be better

and we won't get those answers unless we

can study them and really look at some

of these newer drugs but there there are

now you know there are a number of drugs

and immunotherapy is also being looked

at in this space because her2 positive

breast cancers might be more immuno

genic might by that I mean might be

likely to respond to immunotherapy so

there's a lot of there's a lot of

research activity going on there to try

and define the next best things but we

have really great and effective

therapies in first line and second line

are there any particular agents that you

anticipate in the next couple of years

maybe on the road to approval mm-hmm

there are a few some of them have you

know just letters for their names so

they're not very they're not very

recognizable there's there's an oral

drug called - catnip that people are

really excited about the concept of

immunotherapy there are other drugs that

have you know des I can't remember its

numbers after that so there there are

other drugs out there that are really

exciting that are making that have made

their way into more definitive phase

three clinical trials that have shown a

lot of promise so I think there's a lot

of activity there and I guess the one

other thing that I thought of as you

were asking me this question may be

taking us back and I know I'm melting

the subtypes a little bit but there's

some general principles you know I tend

to right now I don't I don't put

everyone on clinical trials so if we

have great standard of care there

there's no way I would want to risk that

for something shiny and bright that

looks like it might be better but might

not be okay so I think right now in

hormone receptor positive her2 negative

you know first-line I do a cdk4 6

inhibitor and endocrine therapy there

may be trials that are asking about

adding something over and above that and

that might be worth it but I would think

of that as you know the standard thing

that one would want to do to start with

because it really has we do have great

standard therapies and we have a number

of great Serapis and her2 positive I

would do the projeto Herceptin and

chemotherapy for the you know as as the

first standard and maybe there are


are gonna be looking at adding

immunotherapies and that might be worth

it too but I you know again would not

think about changing something that is

really tremendously effective for

something new and fancy that we think

might be because sometimes those things

don't pan out it doesn't mean that one

should ignore clinical trials in that

space that's not what I'm saying but

make sure that your healthcare team

explains to you what that clinical trial

is and how it compares to today's

standard of care because you really need

to be making an informed decision and

you have every right to ask those

questions and to ask those questions

about what is the standard of care and

the consent form should say how what the

standard of care is and you know those

are rules and regs and all clinical

trials go through a lot of regulatory

processes to make sure that in the

consent form and your healthcare team

should tell you what would be the

standard of care and what would I be

trading off by participating in a

clinical trial absolutely absolutely so

thanks for for addressing that and you

had mentioned about her to pause her2

negative estrogen receptor-positive

cancer what about for people who have

both hormone receptor positive and her2

positive disease is there there's there

seems to be some suggestion there that

that type of cancer may respond

differently what what is the the

standard of care now and and what is the

research into looking at so-called

triple positive breast cancer it's a

great question so many great questions

so triple positive has all of the

targets right so like which target do we

choose to hit because we have lots of

good options and we feel that her2 is a

really important target to hit because

it is a it is a very um it is a very

potent driver and we want to shut that

pathway down okay so the standard of

care answer where are we February still

like February 2019 would be to do

chemotherapy for a certain period time

we're talking about first-line here so

therapy for a certain period of time

with the Herceptin and the projeto and

then after about six to eight cycles of

chemotherapy you dropped the

chemotherapy and at that point would

start the hormone therapy okay and that

would be the standard answer right now

you could say me why do I have to give

chemotherapy with it because like who

wants chemotherapy and could I just do

hormone therapy with it and and we don't

have good trials now to show us that

that's as effective but there's a lot of

research that's going on there to see

whether we could get rid of the

chemotherapy aspect of it because

hormone therapy is better tolerated but

if you have a clinical trial that shows

you with chemotherapy 15 month or 16

months prolongation and survival you

know it's a little hard to risk losing

that benefit right but we're trying to

figure out if if we can do that okay so

the standard would be to do the

chemotherapy with the Herceptin and

pajetta after the chemotherapy is done

after about six months or so or six to

eight cycles you drop the chemo part you

add the hormone therapy there's also a

question okay I've told you in hormone

receptor-positive breast cancer we

should be using cdk 4-6 inhibitors you

know like should we be doing that too

and her2 positive or not um so there are

trials there's actually a big trial a

national trial that is looking at that

question it's having a really hard time

accruing but it's a really really

important question

so it's randomizing women who have

triple positive breast cancer after they

finished their first you know six cycles

of chemotherapy and are dropping it

should you be just doing the endocrine

therapy and the Herceptin projeto or

could you add the c-46 inhibitor on top

of it because that's not standard right

now and we don't know how to integrate

cdk4 six inhibitors and her2 positive

disease so we really need to look at

that but that's how we generally

approach it is to start that way and to

treat to try and figure out how you

treat both can be complicated and really

it's one of those things that I think is

very individualized but the good news is

there's tons of targets okay and there

are tons of active drugs there so

so really you know that that gives

somebody a lot of options of treatments

dr. Isaacs what is the name of that

trial do you it is called give me a

second it is called the patina trial

patina trial but somebody should check

that for me who has a smartphone on them

different names but it's P atin a patina

thank you thanks for that so one of the

challenges of her2-positive metastatic

breast cancer and also sometimes in in

the other subtypes as well is is brain

metastasis and I wondered if you could

talk a little bit about the treatments

that people might face after a

progression in the brain so again a

really good question and and a you know

a clinical space where we really need to

think hard about the best thing to do so

typically when we're treating metastatic

breast cancer we need to think about

treating the whole body right but there

also may be times where there is a

specific site of disease that is causing

a particular problem that we need to

address and then we need to think about

addressing that specifically and and one

of those instances is with brain

metastases and I mean if we think about

it right are we have innately in all of

us we have what's called the blood-brain

barrier and it's there because as you

can imagine we want to our body is

designed to keep bad stuff out of our

brain right we don't want everything

going there we don't we want to protect

it so it's considered what we think of

or what we often call as a sanctuary

place so chemotherapy would like count

as bad stuff right and so chemotherapy

doesn't get in to the brain we don't

know that drugs like Herceptin and

pajetta which are relatively big

molecules whether they cross the

blood-brain barrier so it's a sanctuary

site where our standard treatments may

not get and again not all of this is

truth okay that's what we think but it's

possible that with brain metastases that

that blood-brain barrier is disrupted so

maybe our standard rules or our standard


standing doesn't apply to things but we

can often see in women with her2

positive often we can see in women with

her2 positive breast cancer the disease

elsewhere the brakes are on it it's

shrunk and things are good but a brain

net pops up or some brain Mets pop up

and so we need to deal with that and the

way that we typically deal with that

today is more in a focused local therapy

approach so that's where surgery and

radiation might come in and again it

depends on how many brain Mets how big

are they where are they what sort of

problems are they causing but usually we

can't ignore them they might be

teeny-tiny in which case we can watch

them but if they're more than teeny-tiny

usually we feel like we need to address

them to prevent symptoms from developing

or progressing if there are already

symptoms present at that time

so typically we turn to I turn to my

neurosurgical colleagues in my radiation

oncology colleagues our radiation has

gotten better okay so we now have

growing data we used to only offer

what's called whole brain radiation

which had a fair amount of toxicity with

it and particularly on the long-term

could have effects in terms of cognitive

function but increasingly we have data

that our radiation oncology colleagues

can do what's are called stereotactic


so there are lots of different Mac

methods you know our our institution

uses CyberKnife that's one of the more

common methods but there are other

methods to do it so they're really

pinpointing the tumors more specifically

so they're not hitting all the normal

tissue but they're hitting the tumors

themselves and we used to only do fibrin

we I'm not a radiation oncologist either

need the medical community I'm used to

only do CyberKnife if there were you

know just one or two and now there's

data that you can do it up to ten maybe

and depending on how big they are and

what's going on so sometimes that's what

Sun there's also for women who need

whole brain and radiation there's

increasing work that shows that you

could be able to spare the memory part

of the brain what we call the HUD

Picatta hypo campus so there are some

techniques where they spare that with

whole brain irradiation

so the decision about what to do is

really based on a number of factors um

there are also some of these drugs that

target her - one of the reasons why we

have a lot of interest in drugs like -

catnip is that it's a small molecule and

we think it crosses the blood-brain

barrier so we have some suggestion that

some of our whole body treatment might

actually also be able to get into the

brain because it's small enough that it

can bypass that mechanism that keeps it

out so there's a lot that's going on but

but typically we need to pause we need

to treat the brain Mets and then we need

to assess does that impact our whole

body treatment or not or can we continue

it so uh you know I have a number of

patients where we pause we treated the

brain map we kept them on their same

whole body and you know they kept on

going and things kept on going made

they've done very well for a long period

of time so the other thing that I would

urge people to know is sure you you know

brain Mets has scary but what's out

there in the literature suggests that

it's associated with a really short

lifespan and that's not true you know

things are much more complex than that

and people can be living for years and

years and living well having had treated

brain Mets and so I really want to make

sure that everyone understands that and

knows that and one of the reasons that

in the breast cancer world and in in

oncology in general were trying to again

two trials that minimize toxicity with

radiation so you know we want people to

be living well functioning well for

those years to come so that's why it's

so important not to impact cognitive

function not to impact somebody's

day-to-day living with the treatments

that we're doing and I you know you all

know you more than anyone know the side

effects of what we do but I want you to

know that we as providers are thinking

about them too and we're really trying

our best to pick the one that minimizes

the side effects because you know we

understand and what we're trying to do

is again having people thrive and live

as well as they possibly can thanks for

that dr. Izak that's wonderful

think we probably have some folks in our

audience who are thinking may they they

want you as there would be my guess so

with that I'm I'm gonna go to Aaron and

see if we have some questions is where

we're getting close to the end of our

time together following up on the brain

Mets conversation one person is asking

what is the symptoms of a brain

metastasis they they comment that's

their experiences that insurance those

are often denying MRIs but so what

so symptoms and then what would be the

process to detect if if you do have Mets

to the brain so symptoms of brain Mets

could be varied because it depends very

much on location our brain is really

mapped out that they have specific sites

that control language or movement of

your right hand and all of these things

so it could be anything that typically

it could be more

something like weakness or funny

sensations and a more what we call focal

way usually one side and not bilateral

both sides you know the brain is

actually the opposite it controls the

opposite side okay so typically if

somebody has a brain metastasis and

there's impact on function or weakness

or sensation it's one sided because it's

in a particular location it could impact

speech there could be headaches there

could be nausea and vomiting there could

be a variety of things you know the

question about how we detect them MRI is

is clearly the the most precise to

identify even very small areas but if

somebody is symptomatic a CT scan with

IV contrast typically would pick

something up and you know these are

pretty good scans as well so they would

pick up something that was big enough to

cause symptoms most typically but most

of us would go to MRIs our first choice

but CT scan with IV contrast is also a

good study to look at thank you yes

so a question about the role of liquid

biopsies in monitoring for progression

what's your thoughts on that

so liquid biopsies can mean a lot of

things it's it's a great term

okay liquid biopsy means something on a

blood test right is what it means and

there are lots and lots of different

techniques that have been developed to

look at markers of either response or

detecting a specific mutation or other

things probably the the probably an

old-school liquid biopsy which is not a

liquid biopsy is to think about tumor

marker tests that have been around

forever now and those are markers that

can be elevated in the blood that can

track with disease status they can be

extremely reliable in some people but

hugely unreliable and others so again

that's a very individual thing the

fancier types of liquid biopsies are

looking more at either circulating tumor

DNA so DNA from the tumor that shed into

the blood stream that can be measured or

looking at circulating tumor cells that

we abbreviate as CT seized and the CTC

number or cut point and response in

terms of therapy has been shown to

predict outcome in people but these are

not standard of care right now these are

really more being integrated CTCs for a

brief while we're being covered by

insurance but not anymore because it's

not clear what their role is compared to

other tests so it's very hard to do them

routinely in practice because they're

very expensive and not covered but

increasingly techniques are being

studied to try and have markers that we

could measure on blood as opposed to

subjecting somebody to a biopsy

but right now they typically are not

standard of care they're typically

within the setting of clinical trials

thank you for that

Erin we'll take another question um we

didn't receive a question about natural

healing as an alternative to to

traditional medical treatment for

metastatic breast cancer is there ever a

case where that would give you the and


we give you positive outcomes in terms

of controlling metastasis

so for going any sort of treatment for

natural healing sort of what is the

recommendation and there was a comment

about the few are to get traditional

doctor that right yes that I think they

bring some evidence of this traditional

doctor right and I just a quick comment

I think there was a comment about the

fears of all of the side-effects of

chemotherapy and sort of balancing that

and there is a lot of you know thoughts

about including natural healing as an

alternate an alternative but also as a

complementary therapy may be talking

about how to use both practices to

manage side-effects and and the evidence

we know about not doing any treatment

absolutely so let me talk first about

the the alternative instead of yeah okay

which is which is very different than is

in complement with or complimentary so

we have very effective treatments that

we know prolong life and I know I've

been sort of somehow we've we haven't

talked about the standard chemotherapy

but it is part of the treatment okay and

it is an important part and we have we

are 2019 and we have great drugs to help

manage the toxicities of chemotherapy

not all of them and none of us should

suggest that there is nothing it is not

nothing but there are a lot of people

out there and many of you might have

been in in those shoes at some point who

have gotten chemotherapy and people

would pass you on the street and and

would not know that you were getting

chemotherapy so there there are a lot of

very active chemotherapy drugs out there

that can be well tolerated or can be

well managed or whose toxicities only

start to appear after a certain period

of time at which point in time you know

the decision is made that this is not

tolerable and we need to do something

else but one can get some mileage out of

it so I don't I don't want to leave here

with this concept that we should not I

would be lying and not be you in terms

of things chemotherapy is part of our


at some point for most subtypes of

breast cancer we're going to be talking

about it but there are a number out

there that are manageable okay

alternative therapies instead of

standard therapies

you know I we've all seen people who

have come to us after that but there's a

study that just came out that looked

across cancer types and showed a much

higher mortality rate and quicker

mortality lower survival and people who

chose alternative versus standard

treatment so we actually have data now

to back it up and that was sometime in

the last year that this article came out

that that looked at across a large swath

looked at that as an outcome

complimentary I think is different okay

and I think it depends on what we're

talking about in terms of complementary

you know we have to exercise some

caution with some of the complementary

therapies right there oh you know our

chemo therapies are derived from some of

our chemo therapies come from plants

okay so so plants are not nothing plants

are compounds and chemicals they're

they're packaged in there they're more

appealing okay but they're not nothing

and they can impact things and they can

have side effects too but they can

impact the way that one's body

metabolizes any other treatment that

you're getting so it's possible that by

doing some a lot of complementary stuff

at the same time as standard therapy

they're either reducing the potential

for efficacy of the treatment and/or

increasing the risk of toxicity because

the enzymes that break down these drugs

you know they they can they often use

similar enzymes to break down lots of

drugs or lots of compounds let me call

them compounds compounds are drugs and

complementary and all sorts of things so

there is a risk of minimizing some of

the efficacy and a risk of increasing

toxicity by some of these drugs so I

tend to tell people you know just be

careful okay

you know multivitamins are fine the

other thing about complementary is that

it's not well regulated so what you get

one place might be chemically very

get somewhere else and so that can be a

problem um but we have evidence for

evidence the evidence for efficacy for

some of complementary stuff like we have

we have really sound clinical trials now

showing us that acupuncture manages

symptoms okay and they're really well

done clinical trials that have shown

that hot flashes are reduced by

acupuncture joint

achiness from a is is reduced by

acupuncture and that's well done

clinical trials that did compared

randomized women to acupuncture at the

right spots which I have no idea where

they are versus sham acupuncture so

basically somebody was you know putting

the needles in the wrong spots for those

symptoms and the right one made a big

difference and the wrong one made less

of a difference okay so it's it's real

and I think things like that you know

your your healthcare team should be

talking to you about that to help manage

some of the side effects but I do

exercise some caution with you know

complementary medicine I certainly I

would not do it instead of standard

because the standard stuff prolongs life

okay and I would exercise some caution

to make sure you tell your team if

you're doing complementary stuff what

complementary stuff there are a couple

of really great websites that look at

the potential for interaction and the

safety of some of these complementary

products to look up and to see and that

many of us use I mean so sloan-kettering

has a great complementary medicine

website which which we use all the time

when people talk to us about that or we

suggest that they look and see how that

interacts because sometimes people come

with shopping bags right of of

complementary things and you know

there's not enough time for us to go

through all of that but before you start

that shopping bag full of stuff go to

that website and see how it might

interact with what you might be on but

make sure you tell your healthcare team

as well absolutely and and I was just

gonna add for those who are interested

in integrative care there are some

places that you can go some healthcare

facilities that actually have

integrative care programs so you'll

you'll meet with physicians who may have

more experience using some of these

modalities or using nutrition as part of

the treatment but as dr. Isaac said

what's really important is that if

you're interested in these types of

therapies to discuss it with your health

care provider because just because

they're natural doesn't mean they don't

have an impact can I just make a comment

about some of those so I feel more

comfortable with integrative sites that

are part of the standard health care

community not these standalone sites

some of them are great okay but make

sure that they're not telling you don't

do this and don't do that

that is standard because we're not you

know we're we're not doing what we're

doing in the traditional medical

community to you know we are main

thought is to improve your outcome okay

I could bring you stories of things that

I don't understand I don't know why this

this standard treatment or this

experimental treatment worked in one

patient but not another but that's not

fair we shouldn't be practicing

anecdotal medicine it's not it's not

evidence-based so some of these places

promise things and say these things but

we could all bring out examples and say

it's because I'm such a great doctor

that mrs. Jones is doing well that's not

true okay there are factors that are

beyond what I understand and I should

not be using that as a promotion so

please be careful please think of these

things please talk with your standard

healthcare providers about things

because anecdotes is not evidence-based

and it does hurt you know we this is

complicated stuff and we don't

understand it and we shouldn't we're not

trying we shouldn't be trying to sell

something and hopefully you're you you I

hope that you trust your healthcare team

that they're not trying to sell you

something cuz that's you know hopefully

we went into this because we want to be

making a difference and we want to be

prolonging people's lives and and

helping them thrive well with it thank


Erin I'm gonna go to you for one last

text question so this is a question

commenting with those living with

metastatic breast cancer are living

longer and may have many scans over

their their life so is there any impact

to having exposing your body to to those

ongoing scans and

comments on that you know another great

question that we don't have a good

answer to so we think about that and we

often prolong the interval between scans

if people are doing well okay but we

also don't want to let it go too long

which is also why we're trying to

develop liquid biopsies so all of I

think it's part of you know that's a

great question it's a question that

we're asking ourselves that we're trying

to figure out how we can minimize I you

know I think for the time being it's

what we have as the standard and it's

really we have to monitor things because

we don't want to also be exposing people

to ongoing side-effects of therapies

that are not effective and we that's the

way that we figure out whether our

treatments are being effective but we're

working hard to develop different means

to help complement that and then on an

individual basis if we have somebody

who's been coasting for ages and doing

really well on a treatment then we do

you know expand the period of time

between scans often thank you for that

and Victoria and I would like to thank

you dr. Isaacs is there anything you'd

like to add before we wrap up our

program no just thank you to all of you

and for your organization's who make

such a difference in to all of you who

are here Thank You Victoria Thank You

Jenni for moderating an incredible

session so we're gonna say goodbye to

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