Information Session: Breast Cancer and Breast Health

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On May 14, a panel of MSK experts addressed your most pressing concerns and answered your questions about breast cancer and breast health.

Show transcript

MSK Information Session for Patients and Caregivers:

Breast Cancer and Breast Health

May 14, 2020

Corporate Speakers

  • Larry Norton; Memorial Sloan Kettering Cancer Center and Evelyn H. Lauder Breast Cancer; Medical Director
  • Tobias Hohl; Memorial Sloan Kettering Cancer Center; Chief, Infectious Diseases Service
  • Tiffany Traina; Memorial Sloan Kettering Cancer Center; Medical Oncologist, Clinical Expertise - Breast Cancer
  • Melissa Pilewskie; Memorial Sloan Kettering Cancer Center; Breast Surgical Oncologist
  • Atif Khan; Memorial Sloan Kettering Cancer Center; Radiation Oncologist
  • Kate Keenan; Memorial Sloan Kettering Cancer Center; Nurse Practitioner

Presentation

Operator: Good afternoon and welcome to the Memorial Sloan Kettering Information Session on Breast Cancer and Breast Health.  Our host and moderator for today's call is Dr. Larry Norton, medical director of the Evelyn H. Lauder Breast Cancer and Memorial Sloan Kettering Cancer Center. 

I will now turn the call over to Dr. Norton.  Please go ahead.

Larry Norton: Oh, thank you so very much.  And it's a pleasure to meet you all electronically here.  As you heard, I'm a medical oncologist with a specialty in breast cancer for many decades.  Also, the medical director of the Evelyn H. Lauder Breast Center here at Memorial Sloan Kettering.

And we have a terrific assembly of experts here to answer your questions.  There are hundreds of you who are joining our call today.  And I just want you to know that we're delighted to be able to serve you, we're here to help you.  We have never stopped taking care of people with cancer during this whole COVID experience, but we've had to make some changes.  And the changes are really to safeguard you, need to take good care of you and protect you from getting ill from COVID, to take care of you if you have COVID and to take care of your cancer problems. 

And it's not just in Manhattan, we're throughout the tri-state area as many of, you know.  We've heard that many of you feel particularly vulnerable during this time.  And we certainly understand that, it's a very unsettling time.  And in particular things have happened, such as rescheduling appointments, some changes and treatment plans.  A lot of questions that we received already about, does treatment for cancer make you more susceptible to COVID?  Or is – are the therapies that we're using and somehow influencing the COVID experience if you should happen to catch it, and we'll be talking about that.

Let me just introduce the experts that we have.  I'll just introduce him by name and then you'll hear their names throughout this whole discussion as we go to the – as many questions so we could possibly get to in the time that we have. 

We have a superb surgeon who's also the director of our High Risk Screening Program, Melissa Pilewskie, we called the RISE Program.  Tiffany Traina has joined us.  She's a medical oncologist who specialized in triple negative breast cancer and is actually the section head of our Research Program in that area.  Which she's also the vice chair of the Department of Medicine involved in many things related to the organization of our medical care throughout the whole center.

Atif Khan, our premier attending – our radiation oncologist with extensive experience and knowledge in this area.  Kate Keenan, is a nurse practitioner, and she's the manager of our Advanced Practice Providers Group and has a lot of interest including our Survivorship Program.  Our ability to keep our patients healthy after they've been treated for breast cancer. 

And we're also had the pleasure of being joined by Tobias Hohl, who's the chief of our Infectious Disease Service, who is particularly prepared to answer questions about the current in viral infection and we were very much aware of.

And I just want to remind you that you also have your own doctors and care teams at MSK and if you don't yet, you can obtain those by contacting us.  And we can connect you to the right doctor, the right care team.  And that's your primary way into getting answers to your questions.  We have the patient portal, you know about that, if you don't, we can educate you about that.  And everything you need to know basically is on our website, and this mskcc.org, which contains enormous amount of information for you, specific to this time, just pulled up breast cancer in general.

But something that's really right at the top of our minds, and I bet you'd like to ask Tobias really right away.  Tobias as the head of infectious disease who has been on the front line of all of our efforts in the COVID-19 situation.  And he is, you know, coordinating a lot of our activities in this regard.  And one of the major questions that we've been getting is about testing, testing for the virus testing for antibodies.  Tobias, could you tell us a little bit about those tests that are available and what they mean?

Questions and Answers

Tobias Hohl: Yes.  Hi, Larry, I'm very happy to discuss how we diagnose COVID in our patients.  But I want to start with the message that we have treated hundreds of patients with cancer, including breast cancer for COVID.  And the vast, vast, vast majority, have done extremely well, have recovered from the illness and are now back in their lives as best as they can. 

So, if you develop symptoms of COVID, for example, a fever or a cough, and you're evaluated at our urgent care center, or at a physician's office or at any of our regional sites, you will get a test for the virus itself.  That is not an antibody test.  That is a test in which we use a swab in order to look for the virus in your upper respiratory tract.  The good news is that we perform this test at all our sites with a very rapid turnaround.  Most individuals get their tests back within six to eight hours.  And it'll tell you whether you have evidence of the virus and whether the virus is causing your symptoms.  So that's what we do for the very rapid diagnosis of COVID-19.

The antibody tests do not directly test for the virus, but they test for the sign produced by your own body that you had the virus in the past.  So, antibodies are formed, typically one to two weeks after you have had COVID.  And what that test allows us to do is to say whether someone had COVID in the past.  And as I mentioned before, the vast majority of patients with breast cancer do very well with COVID recover from the illness and are able to go on with their lives within short period of time.

So, the two tests are used quite differently.  The nucleic acid test is used to diagnose acute COVID.  The antibody test is used to understand whether an individual has had COVID in the past and is not used to make a diagnosis of COVID in the acute symptomatic phase.

Larry Norton: Tobias, we get a lot of questions about that antibody test because some people feel that if they do develop antibodies, if they've been exposed to COVID, they have had real symptoms of progress and then they get the antibodies, that means that they have protected and they don't have to do go through the procedures of hand washing and covering the mouth and that sort of thing.  Is that – is that true?

Tobias Hohl: I think we're learning a lot about the antibody tests and certainly they're in the news a lot right now.  There is some emerging scientific evidence that COVID does induce the production of antibodies which are likely to neutralize the virus.  That is very new scientific data.  And but that really needs to be confirmed in larger studies. 

The question that I think everyone is asking themselves is, if I had had COVID, am I protected from a second reinfection?  And the answer is likely yes, but it is not yet proven.  I do want to state that it's really important though, to continue to use hand washing as an important a disinfectant measure, even if you had COVID already, because you want to avoid many other pathogens that are circulating in our community, other respiratory viruses besides COVID that can be …

Larry Norton: You mean – excuse me, by pathogens, you mean like germs that can cause infection?  Right?

Tobias Hohl: Exactly.  Yes.  I just want to be very clear on that.  That I think it's an important to continue to wash hands frequently and to obviously to continue with social distancing at this time.

Larry Norton: Do you have any evidence that people who are undergoing cancer treatment has a particular susceptibility to COVID or particular susceptibility to getting very sick if they get COVID?

Tobias Hohl: So, we are studying this question at MSK.  And the good news is, is that cancer patients, we've had experienced now treating hundreds of cancer patients with COVID.  And as I said, in my introduction, most – the vast majority of cancer patients do very, very well. 

And I think it's very important for cancer patients to continue the best possible therapies for their cancer, because that's generally the cancer, is generally a greater concern to me than COVID, because I can help my oncologist treat COVID in cancer patients.  And we want our patients to get the best possible care.  So, the kinds of therapies that we typically use in breast cancer patients, for example, surgery, radiation and forms of chemotherapy.  We have not seen in our data that that makes patients particularly vulnerable to COVID or to have a higher likelihood of adverse outcomes.

Larry Norton: That's really great news.  Somebody who has is undergoing cancer treatment and they're not sick with COVID.  But they have to be out in the world, they have to go back to work.  They follow the same precautions as everybody else, correct?  They don't do anything special or do they?

Tobias Hohl: I think they should follow the same precautions as everybody else.  I think obviously if patients have the ability to work from home, not all patients have that, but that would be obviously the preferred choice.  Very important to wash hands, I can't emphasize that enough.  The virus is inactivated and destroyed simply by using soap and water.  Very good data on that.  So, that is the best way to, get rid of any exposure to the virus.  And also, just maintaining the proper social distancing, the recommended distance being about six feet and – at the workplace.

Larry Norton: Yes.  I'm really impressed just from watching people how often people touch their face.  You know, wasn't really aware of it that much until this happened, but not touching your face a good idea too, is that right?

Tobias Hohl: I think you're absolutely right, Larry.  Yes.

Larry Norton: Yes.  You know, in addition to all the usual things, Memorial has done quite a lot to make sure that we're protecting people, both the staff and the patients who come into our building.  Can you run through some of the things that we've done that are special to make sure that people with cancer or worried about having cancer can come to our facilities and feel reassured?

Tobias Hohl: We've done a number of things.  I think one very important thing is that we thought very hard about which patients even need to come to MSK.  We have converted many of our visits into televisits in which you can interact with your doctor over a video live stream.  And so, in that case, you don't need to leave the safety of your home.  And I think patients are arranging those individually with their provider teams.  And we strongly support this. 

Now, some patients do need to come and see us, because they need to get therapy.  They need to get a procedure.  And what we would like – and what they – what patients will notice is that you will notice that the facilities that look a little bit different, they might look even a little cleaner than you might be used to because we have enhanced the cleaning, there are cleaning crews everywhere disinfecting surfaces. 

And the other thing you'll notice is that the seating arrangements are different, where the chairs now are spaced much more widely apart.  So we can maintain social distancing in all areas of our hospital, not just the treatment suites.

And you will also notice that the individuals who come in contact with are wearing masks and gloves.  And so, we are using physical barriers, enhance cleaning.  And when we can, we don't want patients to have to undergo transportation to the hospital and just minimize their exposures outside of their home.  So, these are sort of the three pillars that we're using to minimize and mitigate risk of COVID-19 exposure for our patients.

Larry Norton: And the evidence that we have so far and so working.  And in other words, that we are really doing a very good job of protecting our patients, from anything you've described before?

Tobias Hohl: Yes.

Larry Norton: Tiffany, you're on the cutting edge of what the medical staff is doing.  We already mentioned the telemedicine aspect of this.  And I'm going to ask you about that in a second.  But a lot of questions that we received are about like postponements of appointments for examination or postponements for certain kinds of procedures.  What was the thinking about that right now?

Tiffany Traina: Sure.  Thanks so much, Larry.  And I think before jumping into that, I just wanted to wish all our listeners and their loved ones well.  I know as Larry mentioned, this is such a service can be a really stressful time for folks and there's a hunger for information.  And we do have a lot of up to the minute information available to you through our website and calls like this. 

And so, I think we get this question a lot about when are we going to resume normal cancer care?  And it makes me want to mention really a few things.  Number one, we've been here throughout COVID caring for our patients and those that are newly diagnosed with cancer in the midst of this, need a procedure or surgery, need active treatment.  So, we haven't gone anywhere.  But we have, you know, had a philosophy all along of really balancing risk and benefit in the best interest of our patients.  And it's for their safety.

And so that balance really has differed depending on whether somebody has active cancer and it needs ongoing therapy.  Versus those that are maybe have a history of cancer, enter an active surveillance.  Or those who are appropriately health conscious and wellness is important and they're focused on screening. 

So, you know, while we had hoped that COVID would be an incident that we would quickly pass, it really feels like COVID and cancer may be coexisting longer than we had hoped.  And cancer remains a real concern, as Dr. Hohl said.

And because this is such a concern to the well-being of our community, it really is time to restore, to recover.  But when you asked about returning to normal cancer care, I think that we're in a time of innovation and (peri)-pandemic growth, if you will.  That we're creating the new normal to respond to what our patients need. 

Dr. Hohl has mentioned, telemedicine, which we can come back to.  But just strategies on site to create a really safe environment, because treating somebody's underlying cancer is really critically important, so that we all have the best outcomes possible.  So, I think in short, you know, reaching out to your doctor, reaching out to your oncologist, they're going to have your best interests at heart and the best information in terms of risk benefit balance.  We are here, we are available for doing your imaging, your exams.  And the telemedicine piece can really be an – a way to triage to keep you safe at home.

Larry Norton: OK.  Tell me more …

Tiffany Traina: Yes?

Larry Norton: … about that telemedicine part.  Because, you know, isn't really a good substitute for many of the visits that we in the past have been doing in person?

Tiffany Traina: Yes, terrific question.  So telemedicine is not really new.  Memorial had been using this tool for some time to be able to deliver care to those who couldn't get to us.  And we were able to do that in a limited fashion, practice for dermatology, views of a rash when you may not be in the same location as your dermatologist.  And there were barriers to doing that, that were more regulatory and licensing related.  And those barriers have been removed. 

So now, you know, in the same way that you are probably communicating with friends and family at a distance by Zoom or FaceTime.  We have that technology to be able to see our patients.  And I think a very positive experience with this.  And it's actually quite intimate.

You know, I was just speaking with a patient from the comfort of her home and I was able to meet her small children.  She says they're normally in school at the time.  And you're able to we're really able to meet our patients where they are in a more comfortable, safe environment in their home.  And certainly a lot more convenient than the travel that they might need to do otherwise.

I think we've realized that much of what we do in medicine really comes from listening to our patients and hearing what it is you have to say.  So, having that video interaction, having a conversation about what's going on, can then help us to triage, and say what diagnostic testing might you need to come on site for?  What labs might you need to come on site for?  And what could maybe wait a couple of weeks or a month.  And that risk benefit balance can be enhanced by the telemedicine piece of it all?  It's another tool that helps us in delivering care.

Larry Norton: Yes, it's really remarkable how much you can gain from the telemedicine route, I must say is.  And you're right, from the conversations I've already had with my patients via telemedicine has been really very, very productive.  And in many ways better than I could have had in-person because we were focused, there's no distractions and we can zoom in on it. 

I've also been impressed actually with how much the physical exam is actually visual.  You know, you look in your eyes, you look at their neck, you look at the – you know, even look at parts of the body.  And you think that it's very tactile, but a lot of what we – a lot of the information that we gain can be just obtained from looking at somebody carefully, which we can do with telemedicine.  Of course, not everything.

Tiffany Traina: Exactly.

Larry Norton: And I also really, really think it's important the point that you made about that you have to individualize decisions about what can be postponed, what is safe to do at a later date.  Sometimes choice of medications is appropriate in our (inaudible), what could be done orally or smoke could be done intravenously.  But when you get to surgery, that's when you're getting really hands on.  And so, I'd like to ask Melissa a question, because we've been getting a lot of questions about postponement of certain surgeries, such as like rescue construction.

You know, my breast reconstruction was delayed, what does this mean?  Is it going to be delayed anymore?  You know, when am I going to get that done?  Melissa, what’s the current status of things now with that?

Melissa Pilewskie: Great, thanks, Dr. Norton, for the invitation to participate in this call.  And I just want to start by emphasizing what we're hearing from all services and that.  In the Department of Surgery, our priority remains delivering the best cancer surgery, while maintaining a really safe environment in the operating rooms and our clinics.  And so, during this time, we've been really fortunate to be able to continue to offer all cancer surgery.  And we're currently performing all aspects of breast cancer surgery, including things like lumpectomies and mastectomies with the initiation of reconstruction with tissue expanders.  We're doing lymph node surgeries.  And now we're also doing surgeries for precancerous lesions and high risk breast lesions.

Currently, the only procedures that remain on pause right now are the purely benign or elective surgeries that we perform.  But we do have plans to reinstate these in the very near future.  So, specifically with regards to breast reconstruction for surgery like implant exchanges or flap reconstruction, their current plan is that that will resume in June.  And while all of these dates are slightly fluid, that's the plan right now. 

So, I would say this is coming a in the very near future.  And if you're a patient who has a surgery scheduled in the next couple of months, I think it's just best to follow up with your doctor's team to ensure that there are no changes in that at this time.

Larry Norton: Yes, it's actually – even though I'm in the system, also impressed by watching the system with all of the safeguards that have been put in place.  And all the precautions, calling people before their appointment to make sure that they're OK before they came in and so on.  It's remarkable how we have, you know, a full set of services, we could offer patients very, very safely. 

I think this applies not just to surgery, but also to radiation oncology, radiation therapy.  Atif, if you're on the line.  You know, people have wanted to know that they're scheduled for a radiation therapy, can they get it now or, you know, what changes have been made with the radiation therapy to adapt them to the situation.  And basically what was the scheduling like with radiation oncology?

Atif Khan: Great, thank you for the question, Larry.  And let me just – very simply say that there is no reason, absolutely no reason for radiation treatments to not proceed as scheduled.  Now, and certainly in the coming weeks and months.  The indications for post operative radiation therapy, whether it's after a lumpectomy or after a mastectomy, are well-established.  And we're not compromising in any way on that.  We're not compromising on the utilization of radiation therapy when indicated, nor on the accepted and usual timelines for initiating that treatment. 

So, I guess I want to just reassure the questioner and everyone else who's listening, that radiation treatments will proceed as planned.

Larry Norton: I mean, that's great.  And I think the, you know, the integration of the surgery, of the radiation going smoothly as we always have traditionally done that, I think is something that I've been impressed with how it's working.  And I think it's very, very encouraging.

You know, we also have people who (passed) therapy and we're trying to keep them healthy.  And that involves things like mammography or for identifying new problems if we have to take care of them.  And I'm wondering Kate, Kate Keenan is a nurse practitioner and is very much involved in keeping patients who've had cancer in the past healthy.  We're getting a lot of questions about people that like a month or two ago were rescheduled for mammogram and we said that we should postpone it.  Where do we stand on that right now?

Kate Keenan: Thank you, Dr. Norton.  I'm happy to answer this question.  I understand the concern that patients have of delaying their mammogram because they've ever been told to do their mammogram on time.  But during this acute COVID crisis, we put things on pause for their safety.  We will be back up and running shortly in the next month, by early June, we'll be back up and running.  I do want to …

Larry Norton: Yes, that's with screening mammograms, correct?

Kate Keenan: Correct.

Larry Norton: And you're talking about?

Kate Keenan: I do want to …

Larry Norton: You're talking about people without symptoms, right?

Kate Keenan: Correct.

Larry Norton: And it just, right.

Kate Keenan: Yes.  I want to take the opportunity to just to distinguish the difference between a diagnostic mammogram and a screening mammogram.  So, a screening mammogram is for women over the age of 40, with normal – who's had a normal mammogram within 12 months, without breast complaints.  And those are the ones that we've actually pushed out.  So, those are normal mammograms without breast complaints.  And they – those ones are going to be back up and running in early June. 

A diagnostic mammogram that's performed, when there's either a concern for a new breast symptom or abnormal imaging for the previous mammo, were never delayed.  We've always been doing diagnostic mammograms.  And we continue – and we will continue to do it through the entire COVID pandemic.

Larry Norton: Terrific.  I mean, I just to make sure that people are there, you know, who think they have a lump or been told they have a lump, don't delay the diagnostic mammogram and the therapy of that, if it turns out to be something that we have to take care of.  You know, because, you know, we all know that taking care of the cancer is the most important thing, even in this COVID environment as Tobias has really mentioned.  I'm glad to hear that our capability of doing that and all of our systems are in place to accomplish that. 

Sometimes when people have had successful surgery, successful therapy for the breast cancer, they do have a certain side effect, which is called lymphedema.  And that's something that we're very much aware of.  I guess I'll ask Melissa that question, because you're a surgeon and you're involved in this.  Some patients developed lymphedema and they hear that physical therapy has been cancelled.  Where do we stand on having patients (come) back in for treatment?

Melissa Pilewskie: Right, thanks.  So, we recognize that lymphedema assessment and treatment as well as other physical therapy and occupational therapy services are really important for our patients following surgery and potentially radiation or other treatments.  But our goal is to resume full capacity of these services for our patients. 

And currently, we're offering in-person services at select MSK locations both in the city and at the majority of the regional locations with some modifications on the dates and times.  And so, this can all be obtained through your doctor's office.  But there are ongoing efforts to increase in-person availability as well as to have telehealth capabilities, to broaden availability of these services.

So, I would encourage a individuals to contact your doctor's office regarding resumption of lymphedema therapy at this time.

Larry Norton: That's great.  And I think the advice of contacting your doctors to get advice specific to you is really very important.  I mean, right now, we're talking about generalities in a call like this, but we have the experts, your doctors, the expert in your care, and that's the best way to get the information.

One question, Tiffany, I want to get back to you for a second.  Because we talked a little bit earlier about chemotherapy treatments, and their impact on COVID risks.  And basically, we have good data that we don't have to worry about that, we can take care of that.  I just want to mention tangentially that MSK has been – was a pioneer in the use of something called granulocyte colony-stimulating factor Neupogen Neulasta, ways of keeping blood counts normal during chemotherapy. 

And so, a lot of our programs have that built into it, which I think is another reason why we're not really worried about immunosuppression of cancer treatment in the environment of COVID.  But some people are taking pills and a very common pill is Tamoxifen.  And we had one question that was asked is that they heard that estrogen has a protective effect against COVID-19.  So if that's the case, if they're taking an anti-estrogen by Tamoxifen, is that something they have to worry about?  What are your thoughts on that?

Tiffany Traina: Thanks so much.  I think that, you know, there's a lot of interesting information coming out.  But it's a leap to say that being on an anti-estrogen for the best benefit of your breast cancer would pose any particular risks related to COVID.  So, you know, we'd like to be evidence based in our guidelines know that there's really good experience and beyond observation to make any conclusions. 

So, with the absence of any peer reviewed evidence that a drugs that is so life saving like Tamoxifen, or the Aromatase inhibitors like Letrozole and Anastrozole, and Exemestane.  And those are still life saving in the setting of breast cancer that we would not recommend stopping those.  There is no evidence that there's worse outcomes related to COVID as a result of those therapies.

Larry Norton: That's very reassuring.

Tobias Hohl: And Larry, may I jump in quickly, this is Tobias from the infectious …

Larry Norton: Oh Tobias, please.  Tobias, please.

Tobias Hohl: … disease perspective.  As an infectious disease practitioner who treats COVID patients, I could not agree more with what Tiffany said.  We will – God forbid a patient should develop COVID.  We are there to back up our oncology colleagues.  But we think it's absolutely essential that patients with breast cancer get the best possible therapies.  And we do not have any evidence in the infectious disease literature that taking any of these drugs, of impact COVID-19 outcomes.  So, I just really want to emphasize that point also from the infectious disease perspective.

Larry Norton: Terrific, terrific.  I mean, it's really great news all around.  And I think that that is really important, really important to know, and really important to say. 

And we have some similar questions about radiation therapy, that they're, you know, there is information out there.  And by the way, I just want to say is that, the vast amount of information that's available on the internet that's going around and on Twitter, you know, is of questionable reliability.  You know, we have sites that are really reliable, that are really written by experts that are really carefully worded and have that information.  If you come into the MSK sites, mskcc.org, for example, as a way of getting there, you're going to get really accurate information. 

Please don't be misled anybody out there by misinformation that's coming from disreputable sources, because I get a lot of questions like that, for my own patients, and for really all around or countries around the world indeed.  Make sure you go to reliable sites.

One of them that's out there is that the dangers of radiation therapy, because it causes scar tissue and the scar tissue may influence a patient's response to or recover from COVID-19.  Atif, you're in that space.  What's your thoughts about that? 

Atif Khan: Yes.  Well, Larry, I'm getting this question quite a bit actually lately, as you can imagine.  And the reality is that in 2020, the technology behind these radiation machines has gotten so advanced.  I mean, these machines are just so sophisticated, so efficient and so elegant that we can really bend the radiation dose to conform to the anatomy.  And we can really carve out the underlying lung and other structures.  That tech has just, it's just gotten so good, that we can now do things that really were unthinkable even five years ago.

And, obviously, because we're MSK, we have the latest and greatest tech, you know, that's out there.  And I think this really explains why the background rate of, for example, lung inflammation with breast radiation has become so exceedingly rare.  And I just don't believe that it really figures into the calculus for treating patients during the pandemic or even in regular times.

Larry Norton: It's really good.  It's really good news.  And it just outlines something, I think it's very important for people to know.  Because a lot of the information that is out there is based on very old data, you know, information that goes back many years.  And the – our ability to improve our therapy, you know, rapidly, especially in the last decade of last two decades is such that things are very different now than they were even just a few years ago.  And it's good to hear that's true in radiation oncology as well as in medical oncology.

The major question we're getting, I'm going to go back to Tiffany for a second.  The major question that we're getting with in terms of cancer therapy actually concerns your area of expertise.  So I'm glad you're on the line.  And it's about triple negative breast cancer.  You know, people know that with estrogen receptor positive breast cancer hormone responsive breast cancer, we've got drugs.  We talked about Tamoxifen, just a few minutes ago.  And with HER2 positive breast cancer, we have three very effective drugs. 

And a lot of people are particularly concerned about triple negative because they don't have those obvious targets.  This is your area.  My impression is very active area of investigation and very rapid area of progress.  What's going on in that space right now?

Tiffany Traina: So, it really has been an exciting time where we just recently had FDA approval of a new, exciting compound for the treatment of advanced triple negative breast cancer, where this medication takes an antibody, right, that fight – target on breast cancer cells and it's attached to a tiny bit of chemotherapy.  And has proven to be highly effective in triple negative breast cancer that has been treated already with at least two or three other prior chemotherapies.  So, this is a really exciting advance. 

That's a drug called Sacituzumab, that is now FDA approved and available.  There are incredible advances in looking at immunotherapy and recruiting your own body's immune system to fight triple negative breast cancer.  And right now, drugs FDA approved for a subset of patients that have a particular marker called PD-L1 which helps to predict for benefit from adding this immunotherapy to one of our best chemotherapy backbones.  And many other areas that are under investigation.

So there's another subset of triple negative breast cancer that appears to be driven in fact by hormones but by androgen rather than estrogen.  And …

Larry Norton: And androgen is the male – androgen is the male …

Tiffany Traina: Exactly.

Larry Norton: … hormone?  Correct?  Right.

Tiffany Traina: Yes, yes.  But, you know, in fact, women have a little bit of both male hormone and female hormones and men do too, and it's a matter of proportion.  So, there are some triple negative breast cancers put driven by this androgen and we have a rich research program looking at anti-androgen therapies to fight that particular subtype. 

So, really an exciting area.  And many clinical trials going on even during this period of the pandemic, where we're able to utilize that telemedicine we were talking about earlier, to bring trials into the home.  And so something to keep an eye out for as time goes on.

Larry Norton: Yes.  I mean, it's, you know, so – it's so important to know that these advanced therapies are available.  They're available right now, they're available today to patients and as a research that has led to these advances, that research is still ongoing.  So it's, you know, even though we've had this COVID in the background for the last couple of months, is that we're still making progress these important areas. 

Of course, you know, we're talking about treating the cancer by killing the cancer cell and improve the situation.  But one of the things Memorial has really, and the breast program in Memorial has really emphasized all along is the totality treatment of the patients.  And the many different aspects is that not just treating the cancer, but actually treating the totality.  And that cancer causes a lot of emotional issues, we know that.  And COVID causes a lot of emotional issues.  Some of our patients are very concerned about those things. 

But one part of that is the visitor situation.  Often people like to have visitors come with them for support and comfort.  What's our policy on that right now Kate?

Kate Keenan: Well, to respond to the outbreak of COVID-19, we had to update our visitor policy which took effect in late March.  We actually started this, where we don't allow patients to have visitors.  We've taken this action to protect and the health and safety of our patients first and foremost.  It was actually consistent with health advisory issued by the New York State Department of Health. 

At MSK, we are well aware that when a patient is diagnosed with cancer, they have a team of people in some instances an army.  So, we have resources available when patients come in for their chemotherapy or their clinic appointment, to use technology to actually assist patients, loved ones to join them remotely via tablet or phone to actually sit in on the conversation remotely, so.

Larry Norton: So with telemedicine, this thing which is, you know, basically doctors communicating with patients and nurses communicating patients.  It also can be used for the healthcare team to communicate with others as well.  Is that what you're saying?

Kate Keenan: Yes, correct, absolutely.

Larry Norton: And actually, that's – I mean, we're, you know, when we come out of this and we will come out of this, you know, that COVID will be part of our history, it's not going to be part of our existence forever.  With more rapid advances that are happening, we're learning a lot about other ways of taking care of patients, but that probably are going to improve our care in the long run.  I think all of us who've been doing a lot of telemedicine, for example, and looking at guidelines and looking at other things.  You know, think that this is going to be a learning experience and that as we progress through this, we're going to get better and better at what we're doing, along with all the other advances in that regard.

Some people are really extremely challenged in the mental health resources during this period.  How are we doing on that, Kate?

Kate Keenan: So, first and foremost, I think our patients need to know that they're not alone.  We're here to help their patients and we're obviously always here for them.  The entire globe is dealing with this pandemic and no one's unaffected.  So, I'm just going to recommend to each and every one of them to reach out to a trusted health care professional whether it's their oncologist, their primary care doctor or a mental health professional if they're really struggling. 

Here at the Breast Center, we have our wonderful social workers (Roz) and (Susan), who continue to provide support for our patients with virtual support groups.  They're doing one-to-one counseling.  We have our counseling center that's available.  If psychiatric services are actually deemed necessary by your healthcare provider.  All of these support services have continued and will continue through the entire COVID process.

I just want to echo Dr. Norton, what you had just said.  I think the one thing that comes very clear to me is through telemedicine is that our care might look different right now.  But the physicians, the advanced practice providers, the nurses, the social workers, are all doing using technology.  But we're here, we're always here, we're still the same dedicated staff that has been here and always will be here to take care of you.

Larry Norton: Yes.  If anything, I think the level of dedication and the level of involvement of the entire hospital, I mean, all aspects.  I mean, as mentioned earlier that, you know, our facilities have always been immaculate or look even cleaner.  I mean, the fact is that the staff that does that has been especially dedicated to that during this period of time.  So everybody's risen to the challenge. 

And, you know, it's important that the world know that we're here for you and taking care of your cancer is not something that needs to be postponed, not something that should be put in the back shelf that we're here to take care of you.  We're connected and that these are important times to take care of yourself in totality, avoid getting COVID, get treated successfully, if you have COVID.  But also to take care of the cancer which is something that we're ready to do or get up to do.  We're experts and, you know, we are not letting COVID get in the way best possible care and also the safest possible care at the same time.

You know, some people been cooped up for a long time also, by the way, Kate, I just, you know, you remind me of something when you’re talking just a minute or two ago.  About people have been cooped up or, you know, stay-at-home orders, which I should say are about to be lifted (and stayed).  You know, what else can people do to improve their health in general?  And there seems to be quite a lot of data on diet and exercise in breast cancer.  You know, what's the story on that?

Kate Keenan: Yes, there is actually great data to support both dietary modifications and increased physical activity to increase overall health as well as reducing risk of breast cancer.  Our own Neil Iyengar, one of the medical oncologists actually has all of his research focused in this arena. 

Some of the guiding principles for diet modifications are just following a general well-balanced diet, consisting of whole grains and legumes, limited refined grains, avoiding sugary foods, protein with low saturated fats and avoiding processed meats.  For exercise, I think general moving is good.  But we do recommend at least 150 minutes of physical activity a week.  And that's kind of the bottom.  And we go up from there.

There's a lot of information on mskcc.org.  So, I'm going to actually just direct everyone there because that's – there's a vast amount of information on the website.

Larry Norton: Yes.  And Tobias, is it possible to go walking outside and protect yourself, right?

Tobias Hohl: Yes, absolutely.  I think that the benefits of physical exercises are very important.  And we've just simply, I think the best strategy would be before you go outside, wash your hands, wear a mask.  And when you as soon as you return home, wash your hands again, after you've taken off the mask.  And that provides, you know, with social distancing, I think a very safe environment to get physical activity that is so important.

Larry Norton: Yes.  It's so interesting that a simple thing like washing one's hands is so important at this particular time.  And I'm delighted that right (hearing to) these health principles that you can get outside, you can exercise, you know, and you can stay healthy and you can stay focused.

I think we're approaching the very end of the time that we have together, that's gone extremely quickly for me.  I want to thank everybody who submitted their questions and everybody who's listening and all of you.  I hope that you found this useful to you.  Certainly my heartfelt thanks to all the speakers, such a knowledgeable group and it was a pleasure, you know, hearing this conversation.  And I found it very reassuring myself.

For the audience there I think, you know, we've enjoyed doing this and we plan to host more calls like this.  And so I'd like to hear from you if you found this useful, or what else we can do to be useful for you.  This particular one will be replayed, has been recorded.  It will be on our website.  And you can, you know, hear it there.  It's on mskcc.org, which is the primary place where you can get reliable information about your health.  And remember that you know, stay in contact with your doctors, with your healthcare team, with your nurses, with your advanced practice experts who can keep you healthy as we move forward.

Please, everybody, thank you all for being there.  Stay safe, stay informed and stay connected.  Have a great day.

Operator: This concludes today's call.  Thank you for joining this information session for patients and caregivers.  Have a good evening.