Young Women’s Clinic for Breast Cancer Patients

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland Clinic Podcast for medical professionals exploring the latest innovative research in clinical advances in the field of oncology.

Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic, overseeing our Taussig Phase 1 and Sarcoma programs. Today, I'm happy to be joined by Dr. Stephanie Valente, medical director of the Breast Center at Cleveland Clinic Fairview Hospital. Stephanie joined us for a previous episode of this podcast to discuss advances in lymphovenous bypass surgery. That episode is still available. Today, she is here to talk to us about the Young Women's Clinic, so welcome back Stephanie.

Stephanie Valente, DO: Hi. Thanks for having me.

Dale Shepard, MD, PhD: Absolutely. So remind us a little bit again about your role here at Cleveland Clinic.

Stephanie Valente, DO: Sure. So I'm a breast cancer surgeon. I see patients on the West Side of Cleveland, and I'm the medical director of the Fairview Hospital Breast Programs.

Dale Shepard, MD, PhD: Very good. So we're going to talk about the Young Women's Clinic today, so I'm going to start really simple. What do we consider young?

Stephanie Valente, DO: It's all relative, right?

Dale Shepard, MD, PhD: Yeah.

Stephanie Valente, DO: So, just to put it in perspective, the average or the median age for a woman to get breast cancer is 63. So that means half of the women who get breast cancer are over that age, half are younger than that age. Young women can be anybody under the age of 50 but when we think specifically about young women as far as pregnancy and childbearing, we focus on the under 40 population.

Dale Shepard, MD, PhD: Okay, very good. So let's just jump in. Tell us a little bit about the clinic.

Stephanie Valente, DO: Sure. So it's a concept instead of oh, you have breast cancer and you're under the age of 40, you only come into a certain building or a certain day. So the clinic is a concept where if we have a woman who is diagnosed under the age of 40, it's a multidisciplinary team approach to seeing this young woman in a multidisciplinary fashion, and usually it happens on the same day, if that woman is able to get out of work or whatever. And so what that looks like is when they come in, they will see the breast surgeon, the medical oncologist, the radiation oncologist, a plastic surgeon, a geneticist, a fertility physician if necessary. They will have their imaging reviewed by a radiologist and their pathology slides by a pathologist before the consultation. And a breast psychologist, if they would like.

Dale Shepard, MD, PhD: So very comprehensive.

Stephanie Valente, DO: Yeah. And so when the young woman comes in, it's really just to help her understand. When you get a call and it says you have breast cancer, I mean you think your world's over, and so really we start out with going over imaging. Exactly what are we seeing? How big is the cancer? What stage do we think it is? And then what we call tumor biology, what type of breast cancer is she dealing with? And whether or not we think it's moved or metastasized outside of the breast into either the lymph nodes or any other part of her body, based on that understanding, just to get the patient at some level of breast cancer knowledge then, as a group, we go over our treatment recommendations.

Do we recommend surgery and do we recommend it first? Do we recommend that she received some type of systemic therapy, like chemotherapy, and would that be recommended first? Do we think that radiation in her case is necessary or is that an option? And whether or not plastic surgery, once we do surgery to remove the cancer, to help restore the symmetry to her body, would be necessary. So again, young women, higher risk of some type of genetic component. About 10% of women have some type of gene that increases their risk of getting breast cancer on the other breast or something like that, so they meet with the genetics counselor. Importantly, fertility is a component to some of these women, so whether not they wish to have more kids or haven't even thought about kids but want to look at that in the future, looking at the options so that if they want to later on in life, they can become mothers.

Dale Shepard, MD, PhD: And so just from the biology of breast cancers in this population, are they more likely to get particular types of breast cancer?

Stephanie Valente, DO: That's a good question. So usually screening mammograms start at age 40 because under the age of 40, these women just have really dense breast tissue and mammogram isn't really the best screening method. We don't have a good screening method. And so 80% of women under the age of 40 actually present with a palpable mass that they find themselves, and so if you're finding a mass that you feel, usually it's a lot larger than something that would be caught on screening mammograms. So it's not necessarily that they have a more aggressive type of breast cancer, it's just that by the time it's found, it's at a more advanced stage.

Dale Shepard, MD, PhD: And so you mentioned mammograms at 40. It seems like a really confusing topic, I must say, because you hear 40 and you hear 50. Are most women getting mammograms at 40 at this point?

Stephanie Valente, DO: So the recommendations by the Cleveland Clinic, and a lot of the national American Society of Breast Surgeons, and Cancer Society are to begin screening mammograms at age 40 and to continue those as long as a woman is in good health. And we truly believe that you can see changes in the breast tissue from year to year, and it's a simple test to do, so we do recommend screening annually beginning at age 40 in addition to just knowing your breasts, knowing what your body feels like so that if you do feel something or notice something different, that you'd be able to bring it to your physician's attention.

Dale Shepard, MD, PhD: So I guess just again, when we're thinking about young women with breast cancer, from an incident standpoint, how many women in that clearly half or less than 63, which is the median, how many are in that 40 and around that younger age?

Stephanie Valente, DO: Yeah, and that's a good question. So if you look at the National Cancer Institute, they say it's roughly around 4 to 7% of women under the age of 40 get diagnosed with breast cancer. So what does that look like? The average woman over her lifetime, we say just because women have breasts, their risk of getting breast cancer is 1 and 8, which is around 12 to 13% lifetime risk. If you break that down, you say a woman age 40, her risk of getting breast cancer is about 1 and a half percent, so 1 out of 65 women. Under the age of 30 is about 5%, so that's 1 in 204 women. So not that common in 30, but it does increase to age 40, and then age 50 is 2 and a half percent, so 1 in 42 roughly.

Dale Shepard, MD, PhD: So I guess in some other cancers like colon cancer, there seems to be a shift toward younger patients. Do we see an increase in a similar way where more younger women are being diagnosed with breast cancer? Now, clearly as we screen younger people, we get more, but is there a trend toward more young women getting breast cancer?

Stephanie Valente, DO: There is, and the trend, I don't know if it's as extreme as colorectal cancer. So we know in 1970s, it was 1 out of 10 women got breast cancer, so overall about 10%. Now, that's up to 13%. So we know it's about less than half percent per year increased overall, and we're seeing it more and more in younger women.

Dale Shepard, MD, PhD: When we talk about some of the things that are unique with younger women, you mentioned things like fertility issues. What are some of the other factors that are really important to address in younger women?

Stephanie Valente, DO: One of the things that younger women get, some younger women are at an increased risk for a genetic mutation called BRCA, especially the BRCA1 gene, and that's a triple negative breast cancer. So that means that this cancer's growing abnormally, so not in response to estrogen, which normally breast tissue grows. So that's one of the more aggressive breast cancers that we can potentially see in younger women. And again, younger women with breast cancer, and they're presenting at later stages because they're not getting screened, so a lot of these women are getting chemotherapy recommended, rightfully so, but chemotherapy does have harmful effects on the ability to ... it decreases the ability to have kids in the future because it has cytotoxic effects on the ovaries. So looking at whether or not these women actually want to undergo egg harvest prior to systemic therapy.

Additionally, for women that are estrogen receptor positive, the recommendation after chemotherapy and surgery is to be on what's called a tamoxifen, it's an estrogen receptor blocker, and that's for 5 to 10 years after therapy. And so a lot of these women young are getting put into menopause. So again, that's bone loss, hot flashes, night sweats, so that whole spectrum. Additionally, looking at it from a body perspective, some of these women are not married, don't have a spouse. So it's tough to be in the dating scene in general, but to be undergoing that. We also have young women that are raising kids and their husband's just as fearful as they are about having to raise kids alone, but to try and juggle not feeling well from chemo or multiple appointments and childcare or getting children to and from places. A lot of women have jobs and they're young in their careers, so a lot of them don't have the extended time off that they can take that's necessary. So a lot of them are, again, juggling a lot of different factors in this situation.

Dale Shepard, MD, PhD: From a treatment standpoint, we oftentimes think about altering therapies for older patients because it may be tolerance and things. Are there similar differences in either treatment choices, treatment options, how we might stage things in younger women because of their age?

Stephanie Valente, DO: Yeah, and we try and keep it objective, and evidence based saying okay, we're treating this tumor, again, you don't want to over-treat somebody because they're younger. From a surgical standpoint, a lot of younger women do tend to look at the more aggressive surgery, which would be, again, based on their stage, but some of them are choosing mastectomy, bilateral mastectomy, especially if they have the genetic mutation, the ability to do immediate breast reconstruction. Understanding that the more aggressive surgery doesn't make them live longer, it's the tumor biology and the stage that the cancer presents itself in. So we go over those options with women because young, old, some people think that if they pick the largest surgery, a mastectomy compared to a lumpectomy, that makes their survival better, and that's really not the case. So just understanding that even though women sometimes have a choice in how they surgically want to remove their breast, it's really not improving their odds, so to speak.

Dale Shepard, MD, PhD: Sounds like there might be some educational opportunities. I mean, it's understandable.

Stephanie Valente, DO: Yeah, and so a lot of the Women's Clinic and those conversations are with the women because, again, there's a lot of anxiety around this and breast cancer in general in all ages. And so our first job as clinicians is to help women understand exactly the stage and the type of breast cancer that they have so that, as a group, we can really help make decisions that are grounded in evidence. And I always tell women, "I'm not the one that's lying awake at two o'clock in the morning, you are. So let's help design a treatment plan that makes you feel comfortable but, again, is the right treatment plan for you."

Dale Shepard, MD, PhD: How does the Young Women's Clinic incorporate things like support groups, or 4th Angel program, or things like that?

Stephanie Valente, DO: Yeah, that's a great question. So there are a lot of support groups available for women in general and young women, a lot of community resources as well. So we do utilize the 4th Angel program. When our breast cancer patients come in, they receive a blue folder full of a lot of information, and the 4th Angel program booklet and how to enroll is in there. It's a big program for breast cancer patients and so what the 4th Angel program is, for women who don't know, is it's like a big sister program and it's for all types of cancer, but for breast cancer specifically. They try and pair up with a similar type of tumor, similar age, who's been out of cancer treatment for about two years or so who is paired up with that woman, and contacts her, and says, "When you go to chemotherapy, make sure you bring a blanket," or something like that.

Because as much as I know about breast cancer, I've actually never sat in the chemo chair myself or had a drain after surgery, so that human interaction is very important and positive as well. There's a lot of community resources that are out there. One that we use quite frequently is called the Gathering Place, and it's on both the east and west side of Cleveland, and they do have in person and online young women support groups specifically. We also have exercise programs, physical therapy, and then again, our breast psychologist,. We have two breast psychologists in our department, and they're really helpful. How do you tell your kids? When do you change their life? Because a lot of people that undergo chemotherapy, unfortunately, for breast cancer do lose their hair. So a lot of times how they look changes a lot for their kids, and so walking through that with them is really important.

Dale Shepard, MD, PhD: So certainly people that would be seen in this Young Women's Clinic have, we would like, with effective therapies, a long life expectancy in many cases. How do you approach survivorship in this group since there may potentially be a much, much longer period of time for them to pick up issues related to their therapy?

Stephanie Valente, DO: So our goal for survivorship in these women is double, and so that's our goal. And we say, "You know what? Most women are breast cancer survivors and our job is to make you in that group." So when survivorship women are followed closely, they're followed by the breast team. In the beginning, every three to four months after they're completed with therapy, and then it moves to every six months. The women are taught how to identify if they do have a recurrence and things to look for like that, but there also, again, is a really big survivorship group.

When we talk about moving forward in survivorship from breast cancer, sometimes patients will describe it as the collateral damage after chemotherapy and surgery, and starting over with the new you, and again, that's where support groups are really helpful. But just understanding when does the neuropathy go away? How long do they have to deal with that? And just getting assessed with intimacy issues, and body image, and stuff like that. So we do spend a lot of time in survivorship going over those things, healthy eating, getting back to exercise and lifestyle, and really helping women identify the things that they can control. Because a lot of cancer care, some things have decisions, but a lot of it is not in their control, and so trying to identify what they can control and really keeping positive because that's what these women need.

Dale Shepard, MD, PhD: It's good to hear that you have good psychology support because I can imagine that fear of recurrence is probably pretty prevalent in this group.

Stephanie Valente, DO: It's tough because you say, "Oh great, you're cancer free, but there's a chance it can come back. But go ahead and move forward with life." It's really tough and I think a lot of these women, even though you try and move forward, you do come back to that, and I think it sometimes can be a mind game for some of these women. Oh, my elbow hurts. Well, our elbow hurts all the time, we don't think we have cancer, but their elbow hurts and is it or is it not? Do I need to call my doctor? And so it is a lot for these women and I think a majority of them do a fabulous job. It's tough, for sure.

Dale Shepard, MD, PhD: Yeah. So what's on the horizon for the clinic itself or management of patients in this younger category?

Stephanie Valente, DO: The clinic is a big place and there's a lot of young women out there. And so we're working in our Young Women's group, and we haven't even touched upon it, pregnancy associated breast cancer. So making sure that women, and this is with maternal fetal medicine, and their children or their unborn child are getting their appropriate care at the right time, and that we're not under-treating pregnancy associated breast cancer in these young women. So again, just really looking at care paths, which are standard, evidence-based pathways that we treat young women and pregnancy-associated breast cancer. And making sure that if patients want to get treated out here at Fairview, or at the main campus, or down in Wooster, that they're getting the same Cleveland Clinic care wherever they're getting, so that the physicians all are understanding evidence-based medicine and that they're providing the right care, that all women are getting fertility, preservation options, and things like that. So really just making sure that all the care provided is equal among all sites.

Dale Shepard, MD, PhD: Well, you're doing really good work and I appreciate you being with us for some good insight today.

Stephanie Valente, DO: Well, thanks for having me.

Dale Shepard, MD, PhD: To make a direct online referral to our Taussig Cancer Institute, complete our online cancer patient referral form by visiting clevelandclinic.org/cancerpatientreferrals. You will receive confirmation once the appointment is scheduled. This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's cancer center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening. Please join us again soon.