We talk a lot about screening and treatment in the breast cancer space. What we do not talk about nearly enough is what happens after. What happens to a woman's fertility, her vagina, her relationships, her body image, her mental health, her cardiovascular health, and her sense of self when treatment ends and everyone expects her to simply be grateful to be alive.

Dr. Eleonora Teplinsky is a board certified medical oncologist specializing in breast and gynecologic cancers, head of breast and gynecologic medical oncology at Valley Health System, and author of the new book Beyond the Pink: Navigating Life, Health, and Breast Cancer. Her work has long focused on young women with cancer, sexual health, and survivorship. And this book is her answer to a question medicine has not been asking loudly enough: how do we help women not just survive but thrive?

We cover a lot of ground. Hormone therapy after breast cancer, including the nuanced conversations around hormone receptor positive versus negative disease, vaginal estrogen, testosterone, and Duavee. Bone health, body composition, sarcopenia, and the emerging data on GLP-1 medications and breast cancer recurrence risk. The difference between a local and distant recurrence and what ongoing screening actually looks like years after treatment.

We also discuss the racial disparities in breast cancer care that begin with clinical trial enrollment and run all the way through treatment decisions, drug access, and who gets believed when they report pain. The medical distrust that Black women carry into the oncology office for very good reason. And what it means to practice truly patient centered care when the healthcare system was not designed to make that easy.

Survivorship does not begin when treatment ends. It begins at diagnosis. And you are more than your breast cancer.

Highlights:

• Vaginal estrogen is safe for the vast majority of breast cancer survivors, including those on aromatase inhibitors.
• Testosterone may actually act as a tumor suppressor in hormone receptor positive breast cancer.
• GLP-1 medications show early signals toward lower breast cancer recurrence risk.
• Black women are underrepresented in clinical trials and undertreated in guideline-based therapies.
• Survivorship care starts at diagnosis, not when treatment ends.
• Bone density should be checked right after chemotherapy; weight-bearing exercise, calcium, vitamin D, and body composition monitoring are all part of survivorship care.
• Black women are underrepresented in clinical trials, undertreated in guideline-based therapies, and underbelieved when reporting symptoms; medical racism in breast cancer care is real and documented.

Get in Touch with Dr. Teplinsky:

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Hey y'all, it's me, Dr. Smeenerman Gyno Girl. Welcome back to another episode of Gyno Girl Presents Sex, Drugs and Hormones. I'm Dr. Smeener Ramon.

Okay.

I think it looks good. I like it. I think it looks much better than my all you know.

today we have a great conversation that you are going to really enjoy. We're gonna talk about breast cancer, but I wanna have a little bit of a different conversation because we know that we're very good about talking about screening and diagnosis and treatment options. And we've actually built a whole pink movement around breast cancer awareness. But what happens to women behind the diagnosis? What happens to their fertility, to their vulva, to their vagina, to their relationships, to their body image, to their mental health, to their cardiovascular health?

what happens when treatment ends and everybody thinks that she should just be grateful to be alive. That's why I'm so excited to talk to today's guest who has a new book coming out called Beyond the Pink: Navigating Life, Health, and Breast Cancer. Dr. Eleanor Templinski is a board certified medical oncologist specializing in breast and GYN cancers. She's head of the breast and gynecologic gynecologic medical oncology at Valley Health System and a clinical assistant professor of medicine at I

ICANN School of Medicine at Mount Sinai. Her work has particularly focused on young women with cancer, sexual health, and cancer survivor survivorship. And Beyond the Pink asks something I think medicine desperately needs to ask. How do we help women not simply survive but to thrive after cancer? So, Eleanor, welcome. I'm so excited to have you.

Yes, so thank you so much for having me. I'm thrilled and I think this conversation is something we don't talk about enough, so it's gonna be great.

Awesome. So I my my tagline and I am guyno girl on Instagram. I love comics. I love a backstory. I love a good backstory, why you know, who the person is behind the, you know, what we see online. So tell me your backstory, what brought you into oncology, and why did you write this book?

Yeah, so I I've always always been interested in medicine. My grandmother was diagnosed with ovarian cancer when I was sixteen and that really, really sparked a lot of my interest in the field. And she was diagnosed in 2000 where there was nothing. I mean there was chemo, there were no targeted therapies, we weren't talking about genetics.

quality of life, like none of that was, you know, it was just you got chemo and if it didn't work, you got more chemo and you got more chemo and that was that. And so I knew, you know, even from that point, like, there's gotta be more, right? How are we we gotta think about quality of life. We have to think about what a diagnosis does to people. And that from that point I really wanted to do women's oncology and breast and ju and kind of, you know, they they go together in a way. and back back in the day

couldn't really do GYN oncology unless you were a surgeon. And so it kind of was a natural fit for me to do both. and so I that was something that I, you know, followed. I minored in women and gender studies in college. So this has always been something that has been very important to me. And, you know, so went through training and did fellowship and graduated and started practicing medicine and realized like, my gosh, there's so much more, you know

Yeah.

I didn't understand it. You know, you see patients 15, 20 minutes in the office, and then you're done, you move on to the next patient, and they go on to their lives, and you don't really know w how cancer affects them. You you don't see that part. You don't see them at home, at work, and how they're functioning. And as I started educating on social media, I realized, my gosh, there's so much I don't know. and so I started listening more to the conversations that were happening online, to the community.

and so this book is everything that happens after diagnosis and treatment that we don't talk about. what happens to your bones, your brain, your heart, your sexual health, your mental health. And I don't have the lived experience, but I so in the book it was really important to me to have the stories and the voices of survivors and thrivers and previous and their lived experience. So it's evidence, the stuff that I share is all based on science.

but then it's people's perspectives and experiences which I think I really feel make the book stronger and hopefully as people read it they will identify with those voices.

That's wonderful. and and why did you call it Beyond the Pink?

Well, you know, it's hard to come up and you know, I'm sure it's hard to come up with a book title. It is very, very hard. But to me it was really important that the book signified that we're moving beyond just the basic com breast cancer conversation, beyond you know, and beyond what the branding that the pink ribbon has become, right? Everyone knows pink ribbon is breast cancer, but to talk about what happens after.

Wow.

what happens that is not discussed, right? And these are the hard conversations. I mean, I have a whole chapter on sexual health because it was so important to have that in there. So my hope is that it's how do you move beyond that? How do you thrive after a diagnosis, whether or not you're living with disease or not? and so that's kind of how it naturally came to be. And I I have a lot of mixed feelings about the pink ribbon. And so this was my way of saying we're gonna move

Yeah.

that and and really thrive as much as we can.

Wonderful. okay, well, I have a lot of questions for you that the audience needs to know. So what should woman know before cancer, before breast cancer? You know, we know about mammogram screening at starting at age 40 and earlier if you have a high-risk condition. you know, what should we talk about when we talk about cancer prevention of breast cancer and cancer screening and you know, try to get, you know, we're doing such a great job, I think, nowadays in, you know, diagnosing it earlier and getting patients.

even, you know, cured in some respects. but h what should patients listening know about like their own sort of because breast cancer screening and and risk factors.

Well, I think that's it, right? We don't talk as much about risk assessment. So I think that we've done a lot about screening and getting your mammogram, although there's now so much misinformation about that. But putting that aside for now, is risk assessment. there is a lot of fear about breast cancer. And I think where we start is understanding as best as we can, because it's not perfect, but trying to understand your risk based on family history, genetic testing, lifestyle, breast

Mm-hmm.

density and and other factors and I find that so often there is continued misconception that if you don't have a family history that you're not at risk. And we know that the majority of patients don't have a family history and don't have a genetic mutation. So I really like to think about what are ways that we can optimize our health to lower breast cancer risk. That comes through movement and diet and alcohol intake and others. But at the same time it's all yeah it's all interconnected.

That's good for your heart, it's good for your breast, right?

But at the same time also know that we shouldn't let our fear of potential breast cancer diagnosis get in the way of taking care of your health. And, you know, we talk a lot about this with hormone therapy. And I see so many women who don't have a diagnosis, maybe are at a little bit of a higher risk and are suffering and have been told you can't go on hormones. And so really understanding what that risk is as best as we can, but then also understanding we ultimately can't fully prevent it.

we can do a lot of things to lower our risk. and so I think that's important. I think I I don't want people to put aside other areas of their health because of this breast cancer fear. and I think we have to have really nuanced conversations around it.

Yeah, of course. I do a lot of that in breast cancer risk assessment in my office with my patients and and you know, we do genetic testing for them, you know, if they have a family history and it's sometimes a tough buy when I get a younger patient like in her mid twenties who has seen her mom die of breast cancer and she knows she should get it done, but then at the same time she doesn't wanna know. I'm like, We're you know, we know you're already at an elevated risk. We just wanna know if you have one of these. And so and so sometimes it's it's hard.

How would you try to like, you know, allay those anxieties if if you could in in in those patients?

it it's so hard, right? I think sometimes it is easier not to do the testing. and so I think partly is there's always a lot of fear of well what if I have a mutation? and so I think n having a very clear plan about what we're going to do if a mutation is identified is important. With that said, sometimes people in their early twenties are not ready. they're they're not ready to do it. And in those cases one things I feel we want to do is

screen them and test them as if they have a genetic mutation. So we might start doing that MRI if they may be at risk for ovarian cancer, for example, we might do tumor markers and you know things like that. So we kind of act as if they might have a mutation if someone in their family first degree relative did and they're not ready to get tested. But I think it's really laying out what could happen, what are the results we might get and how are we going to act on that result.

And a lot of it too depends on when someone in their family was diagnosed. So if someone was diagnosed at 28, right, that's a very different, we want to really try to get that testing early. If someone has a genetic mutation and was diagnosed at 55, we have a little bit more time. Again, none of this is perfect, but I think, and it's not just one conversation. so often, you know, people are saying, I'm nervous, I'm not sure if I want it, and then they just kind of get put in this box of, well, they're not getting it.

rather than revisiting it and saying, Are you everywhere? Right? Are you comfortable talking about this now? What are you scared of? Working with our genetic counselors and also I think connecting to those communities. Sometimes talking to someone else who's gotten tested and had the results, right? Talking a peer can be remarkably helpful of saying

We every year we revisit. Yeah.

You know, I was scared but I did it and here's how I feel about it. So I I think there's a lot we can do, but it's hard. I mean, these are such challenging decisions to make.

a hundred percent. and I think, you know, dealing with breast cancer, you know, we have some good screening mechanisms and discussions around and lifestyle modifications we can talk about. I think, you know, with cervical cancer, you know, we have so much we can do in terms of, you know, PAP smears and and HP V vaccines. and uterine cancer, I think, you know, we get so many symptoms early on that we can actually like, you know, really get that early as well. And I feel I

ovarian cancer gets put in that bucket just like you were talking about your own grandmother is so challenging right because you know I I I envision all the patients I took care of as a resident with with ovarian cancer on my G1 oncology rotations. And you know, and this is the fear that most patients have, right? Like we don't have a great way to screen, we don't have a great way to like you know prevent except for removal of the tubes like we can talk about that. But like how

Are there are are there advancements that are coming along in terms of how we can screen better for ovarian cancer? Where are we in the pipeline for that?

Yeah, I mean it's a great question. So I think screening for ovarian cancer is this elusive topic. We've tried. There have been large studies that have shown that on a population level, as you know, screening doesn't make a difference. And I think the challenge for this is all screening recommendations are driven by benefit on a population level. And so are there people that benefit from getting that ultrasound? Yes, there's always gonna be that person who says, I got an ultrasound and picked up something early and and

But on a population level, I think that's a different conversation. I'm very encouraged by this you know, newfound discussion in the media about removing the fallopian tubes. it's something we've done for a long time. I personally haven't done when I had a hysterectomy a couple of years ago. And but it's nice to see that it's despite the fact that the guidelines have recommended it for a long time, right? Where now people are talking about it. and so I think that's something

Yeah.

Yeah. I mean we've been doing it in our offices for you know, since the data came out. I guess that we just haven't been loud enough about it. I think that's one of the problems in OPGY and we're just not loud enough about stuff that we already know about.

Yeah. They already do. And so hopefully this will the coverage in the media and the New York Times, you know, will help people go to their doctor and say, you know, I'm having my uterus removed. I wanna you know and I think that the GYNs are doing it. I think where there's less of a conversation if someone is getting like their hernia fixed or their gallbladder removed, right? They're not getting it done by a gynecologist. So I think there's less discussion there. How do you handle so you know, when we've been talking about this online, a

of people have reached out to me and said, I just want to get my fallopian tubes removed. I'm not having any surgery. I just want to have surgery to remove my fallopian tubes. How do you approach those questions or comments?

You know, we I I'll t have a candid conversation. Some people are done with childbearing. You know, a lot of these patients, you know, would wanna get their tubes tied but they have an IUD, you know, so you're like, Well we can just you know, we don't who who ties tubes anymore? We just remove them usually, right? And so I think that that is and and again, it's kinda like when people want their tubes tied at age twenty because of you know, they they know they're not gonna have a baby. It's

It's very patient driven. It's a nuanced conversation. It's understanding what risks of surgery are and you know, what have you had ten surgeries in your abdomen going in through a scope? It might be a little more challenging and you know, so just understanding what what what that's about. But I think, you know, most gynecologists that I know would probably move forward with a patient who had a real fear of ovarian cancer. Maybe they have a family history or, you know, remote history and they want to get their tubes removed. I think I I I know very few people 'cause it's

not a complex surgery usually in in a in a patient with without a history of surgery, right? Like it's and it's the same day surgery and so it's it's much easier to get done. let's talk a little bit about when we talk about you know some of the misinformation online about about mammograms and about breast density and these Q tests whatever you know there's so many miss there's so much misinformation I have patients

Easy. Yeah, I mean

I'd rather just get a thermography. I don't want the radiation. Like, how do you negotiate this with people? I mean, I know sometimes by the time you see them, they're already like they have the cancer. But like I'm talking in my office or other clinicians that listen, you know, people are coming in with their, you know, data that they see on Instagram for their testing. And I'm always like, We don't that's not our recommend, you know, you you try to talk to them. Well, this is the only thing I'm gonna do. I'm only gonna do thermography. And I'm like, right.

Yeah. So it's so hard, right? Because the challenge too is a lot of times people promoting this misinformation are also doctors. So how do you right, we always say, okay, how do you spot misinformation? Well look for their credentials, but the some of the people that are promoting this misinformation have the credentials. So it becomes even harder, right? Like how do you know who to trust?

Mm.

Right.

I always think what I said if every other person online and if you're the guidelines from multiple organizations are telling you to do one, and then there's this one voice or two voices that are saying, Don't do this, right? To me, you have to think about what do they gain from it. And very often they are gaining financially because they are promoting something that they are either financially invested in or benefit from. And you know, we've seen

some of the reports that come from these alternative imaging, QT, thermography, and they'll say you need to get a mammogram. you know, something abnormal. And I think, and the sad part is that we hear every day about people who didn't get the pr recommended breast imaging and are diagnosed with a cancer, you know, two years later that may have been caught much earlier. and the challenge is, you know, you people are saying, well, I had not

Mm-hmm.

Most mammograms are going to be normal. So if you get a thermogram or you get QT imaging and it's normal, people are like, cool, I don't need a mammogram. But there are ones that are normal and there is a cancer. And so I think this is so hard. I really point people to guidelines to multiple professional societies that come from the OBGYN societies and that come from the cancer societies and come from medicine and say, look, this is what they say.

Ultimately, I think it's important that we support our patients. So if they choose to get something else, then we don't give up on them and that we don't ever put blame or shame on people who have gone with something else and maybe something has been diagnosed and now they're getting a mammogram. I think we have to respect people's choices. I think our job is to do is to educate, to shout it from the rooftops about the safety of these tests. but ultimately we have to support people and

you know, trust people are making choices that they that they feel comfortable with.

percent yeah but you always have to meet a patient where they are and then try to like you know navigate from yeah well I want to talk to you a little bit about you know what what we hear about a lot you know in the in the early survivors the survivors who were now you know early menopause and they have all these issues that come with being an early menopause. first of all who do you think

Exactly. Yeah.

Yeah. Yeah.

menopausal when you talk about menopausal we you I've I've had so many conversations on this podcast about menopausal hormonal therapy and debunking sort of you know the risks associated with breast cancer that we've always thought. How do you look at menopausal hormonal therapy in post cancer patients? Like five plus years, whatever.

Yeah, so a great question.

And this is changing. know, if you'd asked me this five years ago, I mean I think we're really becoming, hopefully becoming a little bit more open, a little bit more nuanced. So the first kind of thing that we're looking at is hormone receptor positive or hormone receptor negative. For our patients that are hormone receptor negative, we're much more comfortable with using menopausal hormone therapy. I will say ideally we'd like a few years to go by to make sure there's no recurrence, because again, you know, but I I will say I have some patients that are

you know, two years from treatment, they have their ovaries removed because they have a brachomutation, they had a triple negative breast cancer and they are suffering. I'm not gonna make them wait. You know, we go over risks and benefits. and we try to pick menopausal hormone options that are maybe a little bit safer. So if they had their uterus removed, we're gonna try to do estrogen alone, which we think is a little bit safer than adding, you know, we'll try to do a

micronized progesterone rather than a synthetic progesterone. You know, we're trying to mitigate risk wherever we we can. And I think that that's becoming more accepted. And they think the bigger, much bigger controversy is what do we do in the patients with a hormone receptor positive breast cancer? And this is really challenging because these are cancers that can recur 15, 20 years in the future. And I think it really starts with three things. One is okay, what are the menopausal symptoms and

Have we tried non-hormonal options? What has been the res response to them? What are we doing for our lifestyle? Number two is what is the risk of recurrence? you know, and this is very different. If somebody has to was diagnosed with a stage three can't breast cancer two years ago, I'm gonna be nervous about that. on the other hand, if it's been, you know, 10 years and it was very low risk, right? We we're gonna feel differently about that.

But at the end of the day, number three is it's balancing and everyone has a different risk tolerance. Some people will say to me, I will do everything that I can to never get breast cancer again. I I that that's it. And other people say, Okay, I know that I might have a slightly higher risk of recurrence as a result of going on hormones, but my quality of life is worth it, is more important to me. You know, I'm gonna willing to accept that risk. and again, I think

We have to have those conversations. I don't think it's a blanket no for anybody. I think it's talking through, well, what are the risks roughly? What do we think are gonna look like? and how do we, you know, what have we tried? What symptoms are you having? I think the we're also starting to be more comfortable with testosterone. and and with and I think that can be really helpful.

Right, right. I think it's

and what's really interesting is that the data show that if you're hormone receptor positive, you know, we've always been concerned if we give someone testosterone and they have microscopic cells that we can't see, the testosterone is going to bind to the receptor, the androgen receptor, and stimulate growth. what we actually know is that although some breast cancer cells can express the androgen receptor, in hormone receptor positive breast cancer, that androgen receptor can work as a tumor suppressor.

So we feel a little bit more comfortable. It can be actually tumor-promoting in triple negative breast cancer. So I'm a little bit less comfortable with testosterone in my hormone receptor negative, a little bit more comfortable in hormone receptor positive. So I have some patients who we've decided we're not yet comfortable together about going on estrogen and progesterone, but they're on testosterone. And that has helped them feel better and they feel really comfortable with that plan.

And so, you know, it's really nuanced. I work with you know, my menopause specialist because I don't prescribe the hormones, but we get, you know, we're the ones that have the conversation about what what should we think about, what to do. and so I think this is gonna change. I'm really encouraged. There's a lot of good doctors trying to do some research on this and I'm hopeful that we're gonna see more data on it.

Yeah. Yeah, it's very exciting. I think yeah, and and I think, you know, when I have a patient who is a breast cancer survivor asking for the menopausal hormonal therapy, I would love to get my the oncologist involved in the discussion, of course. and I think that, you know, it really I always ask the patient, like, well, tell me how you felt when you were getting treated for breast cancer, right? Like what was going through your mind, how did it how did it feel? Because

Yeah.

You know, like recurrences can happen and and so I just want to have you understanding like what ends up what happens if you end up back in that place? Like what's gonna happen for you? And then if most of most of them are like, you know, I'm willing to take the risk because I'm X, Y, and Z miserable, you know? And so then, you know, as long as the oncologists have sort of signed off, you know, depending again how many years out are you, what type of cancer it was, dah dah dah. Did you get, you know, endocrine all the things.

Exactly. Yeah. And I think that, you know, also understanding what a recurrence is going to mean, because sometimes we you know, the a recurrence may mean the development of metastatic disease, you know, cancer that spread to bones, brain, lungs, you name it. And that becomes very you know, that impacts life expectancy, that impacts treatment. So as we think about recurrence, you know, we're really thinking about what all of that could entail, a local recurrence, a distant recurrence.

and so I think that has to be part of the conversation. And the challenge is that, you know, this this is a conversation that takes 30 to 45 minutes, right? This is not something that happens in 15 minutes. And so this is where our healthcare system, it prioritizes 15 minute appointment. And so very often patients are met with resistance and someone tells them no, and it's because there's just not enough time to like dive into

I know, it's right.

Yeah. I know. I always say our healthcare system is just meant to fail both the clinician and the patient.

one hundred percent. And this is not talking about vaginal estrogen. We love vaginal estrogen. Good to go. This is the systemic hormones.

Right. Yeah. Yeah. And I guess one of the things that I find you know, kind of more difficult is when a patient's no longer in the care of their oncologist 'cause it's, you know, maybe seven, ten years out, whatever. And so, you know, depending on what organs they have remaining, it's like, you know, well, how are we screening for a potential recurrence even, you know, seven, ten years out, you know?

Yeah. Okay.

Exactly. And I think that we're, you know, there's some ongoing technology with circulating tumor DNA, looking for, you know, microscopic DNA fragments that are present. And this is really evolving technology. But I do think in five to ten years we're gonna have very different understanding of who's at risk and how to think about these things. And so that also can play a role, not quite there yet, but I think we'll get there in terms of how we think about candidates and who's, you know, better

Candidate for our hormones.

If someone has had like a lame sectomy and they're trying to figure out like, okay, you five, seven years out, if w how do you screen for like recurrences in those patients? Do you do MRIs? Do you do I mean obviously clinical exams?

So no, yeah, I mean, th this is the million dollar question. And the current data that we have has shown that screening with like CAT scans or PET scans or MRIs does not make a difference in long-term outcomes. So you might find something, you know, a month or two before someone had symptoms from it, right? So you might find a lesion in the bone and before the patient had pained from that lesion two months later. But realistically, we're gonna start on therapy two months earlier and it may just be two more months of really hard therapy.

That wouldn't have made a difference in the long run. So generally, imaging is not routinely recommended in the absence of symptoms for patients who have breast tissue remaining. so had a lumbectomy, then we do mammograms and MRIs for some people. And if you've had a bilateral mastectomy, generally we don't do imaging. if you have implants every five years, you do need an MRI to look for implant to make sure the implant hasn't ruptured. If you have silicone implants,

And then sometimes people who have a mastectomy, sometimes the surgeon will say, you know what, we there's a little bit more tissue left behind. And so those are patients who might get an MRI. But generally, if you've had a bilateral mastectomy, you're not getting routine imaging. Again, unless you feel something, something doesn't feel right. But with circulating tumor DNA, which is again this novel technology, we're that can we're starting to do that more. So it's a really fancy tumor marker in a way.

and we're starting to do that a little bit more, especially in higher risk situations. So I I think that this is a pit we're at a point where things are gonna change very rapidly and very quickly.

That's good email. okay, well, let's talk about sex because I know you and I both like doing that. I think, you know, it's come a long way with you know, genital urinary syndrome of menopause related to, you know, cancer treatments. and I think we've have all been shouting it from the rooftop that, you know, local vaginal estrogen can be for everyone, or local vaginal DHEA. Do you still find that there are oncologists or, you know, I I mean I still see it in the community, but I just want to see how much.

Yeah.

you're seeing in your location that there is some hesitation around it. is there hesitation around, you know, I'd rather you do the four microgram versus the ten microgram or, you know, that kind of thing. I don't want you to have the DHEA if you've been on, you know, aromatase in hymn, whatever. You know, where where are you seeing it at these days?

I mean, I think it's better, but there's still a lot of hesitation. and where I see a lot of hesitation is people are still being recommended, they can't be on it if they're on an astrazo, which is based on very flawed data. They're being told you have to try non-hormonal things first and only then, and you have to really not do well. Like there there's still a lot of resistance. I think it has gotten better with the removal of the label or you know, what's happening with that, but

Still so many patients are being met with resistance. and and so they're suffering. you know, I I think I prescribe I prescribe vaginal estrogen and bone densities like candy. Like just come and we'll everyone can get it. I think that we shouldn't wait for people to suffer. you know, and I think one of the challenges too, and I see this, patients will say I'm not sexually active right now, but

Yeah. Yeah.

Right.

they're getting UTI after UTI after UTI. So we have to remember, you know, a lot of my older women will be like, No, no, I haven't seen them in six months and they'll come in and they'll say, I had three UTIs since I last saw you and no one has talked to them about vaginal estrogen, which is wild.

Yeah, exactly. Exactly.

Yeah.

Right. Right. I know. And I think I think the pendulum's swinging a little bit, but it's, you know, it's a little more pervasive than it was, you know, maybe I think the terminology GSM started in twenty fourteen. So I feel like it's a little more pervasive, but still. you know, I still have patients who you know, you know, breast cancer survivors are like, I'd rather just do the Mona Lisa touch. I don't wanna you know, so I think there's a lot of still hesitancy among certain patients, but I

Yes, yes.

Mm. But I do think overall we have a better look at things in terms of generally during health.

And and I think I'm right. I mean, I do have patients who say, I know you've told me it's safe, I know the data, but I'm still more comfortable not using it, and that's fine. You know, and I'll say if you do your mind, you let me know. I'm happy to prescribe it. Start with non hormonals if that is what they prefer. but I think it's important to have that conversation very early on about we can do this, it's safe, you know, all of that.

Mm-hmm.

Yeah. and tell me about, you know, how you see patients post you know, the young especially the younger patients who end up in this early menopause. how do you counsel them around bone health and these kind of things?

So everyone gets a bone density. that's one only one piece of it, but everyone should get a bone density. And we usually do it after so we do the bone density right after they finish if they're on chemo, like right after they finish chemotherapy. That's when we try to do the bone density. I actually just applied for a grant to allow to get funding to do a pre and post chemo bone density so that we can really monitor what's happening.

Mm-hmm.

Because sometimes we get the bone density and they're already at osteoporosis, and you wonder how much did chemo affect them and all of that. So bone density, we're making sure that we're talking about weight-bearing activity, calcium and vitamin D, medications if needed. But the other part of it is body composition. And this is very new. I think we're finally starting to understand that our breast cancer treatments can cause muscle loss, they can cause muscle function loss, sarcopenia.

And patients with sarcopenia have a harder time tolerating the medications. It impacts insulin resistance and inflammation and all of that. So we're really starting to think about how do we assess body composition and making sure patients are counseled on that, right? There's a lot of interesting data about GOP1 medications and impact on breast risk and all of that. but we just purchased a in body like body composition scanner for our

I was gonna ask you about that next. I was gonna ask you about that next. Yeah.

So I'm hoping that we'll start monitoring people after chemo or during chemo or on endocrine therapy to get a sense of what is happening with their muscle function and skeletal muscle.

Yeah, that's great. tell me about because I I remember seeing after like I actually I live like blocks away from ASCO. Asco comes every year to my neighborhood and descends. But I think I remember hearing about or reading, you know, it's having yet come on my Instagram about the data on GLP ones and breast cancer survivorship. can you talk a little bit about that?

Yeah.

Yeah, so this is really an exciting area right now. there have been a number of studies and the challenge is they're all retrospective, so they're looking back, but they're saying that there is a signal between patients who go on a GOP one and lower risk of breast cancer recurrence and not just breast cancer and other cancers too. And the big challenge is we don't know what the mechanism is. So is it simply due to weight loss? Is it due to impact on body composition and insulin or

People lose weight and they feel better, so they're able to exercise more. or is it something specific to the GLP one itself? So these are all questions that we don't know yet. there are a number of ongoing clinical trials that are looking at, you know, specifically looking at risk of recurrence and what that will do. But I think so far, you know, and I think the big challenge is that these are studies of patients who met the current criteria for a GLP one. So I have patients who will say,

Yeah.

Right. Yeah.

No, I don't meet the criteria, but can I go on a GLP one? And and I because I for a breast cancer benefit and we're not there, you know, currently. and then the you know the questions of well, how long do you have to be on the GLP one? Do you see the benefit if you go on it for six months and come off it? Is it lifelong? Like these are all questions that we haven't figured out yet. We don't know. Yeah.

We're not there yet. Right, exactly. Yeah.

We don't know. Right. But there's I think it's an exciting drug. I think we've seen so much in other spaces as well. We see s you know the impact of some sexual dysfunction is patients. And you know, we have patients who are endometriosis and you know, mass selective all these patients who might see some interesting benefit. So I think it is an exciting space to be in. We just I think you're just right, we just don't know the mechanism of some of these. Is it anti inflammatory? What's happening here? But I think it's exciting.

Yeah.

also t tell me your take. How do you w how do you approach a patient, or when do when do you use Duave in your office, do a V to see you know, do you think that this is gonna be the new thing that we should do for all DCIS patients? Like w how are where are you at right now?

Yeah, well duo V I think is a great option for the patient who ha is more of a risk of a local, you know, so people with atypical hyperplasia who are at much higher risk than the average person, but they haven't been diagnosed. So atypical hyperplasia is a duo V is nice because we know that the basadoxifene acts as an antiestrogen in the breast, and so we might have some lower risk or certainly won't increase risk.

you know, again, DCIS is one of those where if we're gonna use hormone therapy, d having a diagnosis of DCIS generally increases your risk of a recurrence or a new event in the breast, not elsewhere in the body. And so we we're gonna use hormones, duo V is a nicer option. And there's some very early studies about that. I think the challenge, and this is something that I've learned recently, just due to some of my patients who've been on Duo V, is they find and you would know this better than I would, but

No, no.

they find that the dose of the estrogen isn't it's not enough. And so then they say, Well, can I add more estrogen? And we just don't know that that dose of basadoxifene is going to be protective, you know, with that. So I think that's one I be I was really excited about duo V and I had a few patients on it and they're like, Well it's nice, but not enough. It's enough.

Not enough.

Right. Right.

But it's not Yeah. Yeah. And I think that I remember one of the conferences when one of the original researchers on Duave was at I think the Menopause Society and think you said some of the data was from like a point six two five Premier and so you maybe there's a little wiggle room with you know the Premeron potentially, but again, it's having them understand that, you know, I don't know is this protective effect gonna be gone? I don't know if it's gonna

know, not then give you unopposed estrogen in your uterus, like, you know, these are effects that we just we don't know. So so

Yeah. It's it's hard. I I think these are questions and the the challenge is to answer them. You need studies and research and trials. And so we're kind of flying without data here.

That's so true. And I and and I guess that's the case for so much of breast cancer, right? Survivorship. There's been s it's it I I always look at it like pregnant, like people are afraid to like do research on patients who are pregnant because we don't know. And and so the same thing like think happens in the breast cancer world is like they're they're afraid to do the research or maybe they don't have the means to you know, I don't know. Breast cancer gets a lot of funding, but I mean

It's a couple of Yeah. But they don't but it doesn't get a ton of like survivorship funding. It gets a ton of drug funding. And you know what's really interesting is that in twenty like fourteen there were these studies. There were studies with testosterone, there were studies like a couple years ago with GTA and then all of the studies have kind of just like stopped. I was like we c you know, there was this clearly focus back ten years ago of like what we need to bring that back.

Yeah, yes. Right.

Yes, you're right.

Yeah.

Yeah, that's true. I wonder what happened. That's interesting. so I was part of this conversation like two weeks ago. there's this this Onko Menopause symposium consortium that Dr. Lisa Larkin does. And so I brought on two of my colleague friends, Dr. Janine Anderson who who is a social psych social scientist, and Dr. Kudze Dumbo, who's also an OBGYN and

Yeah, I know.

Yeah. Yeah.

We we brought into the conversation this discussion among many of the oncologists that were present the idea of the most high-risk breast cancer survivors and patients and and where we should go with that. And so we talked really about centering the black woman's voice in breast cancer because, you know, again, there's so so much nuance to why they have a higher rate of you know aggressive disease, you know, why they have lower rates of survival.

Mm-hmm.

and and you know it was a it was a very I think it was a great conversation. We we opened up a lot of eyes about, you know, the idea of whose stories are believed, who's gonna get those treatments, you know, because we know that medical racism and bias exist because the systems are in place that have allowed this to perpetuate for years and years and years. So I mean, tell me what how you kind of then negotiate this when you might have a black patient in front of you who is

worried about this, right? She knows she has a lot of medical mistrust because why wouldn't she? Because of everything that we've, you know, our the the medical's history has shown for black women entering the space, has distrust, feels like you're gonna judge her in a different way, you know, whatever the case may be. How do you try to like I mean this is a hard question, right? Like how do you try to connect better with this patient or make sure that you hear them?

because I think this is a an issue we don't address enough and it's like a larger issue of like systems that we can't annihilate at this point, but like we have to address.

Yeah, and I actually I mean I write about this in the book, but I a couple of years ago I had a woman, a black woman who had come to see me and she knew breast cancer and I was telling her about a new drug that was just approved and that you know we wanted to add to part of her treatment plan. And she looked at me, she Well, what do we know about the drug in black women? I I mean I thought you it was such a good question. And I didn't know because when you looked at the trial, there was two percent of black women in the study. and it just wasn't representative. And I think that's where a lot of

Yeah.

Mm.

a lot of this starts is that and it dates back, right? Because there is is medical distrust d you know, d at the Henrietta Lax and all I mean, all of these the history. and so it becomes harder

Right. All the things, yeah. Yeah. The Mississippi appendectomy, the like, you know, countless slaves that were, you know.

Exactly. All of all of these things. And and then you think about well, how do we increase there's been a big push to increase clinical trial diversity. One of the problems with this is where are clinical trials held? And a lot of them are held in academic institutions. They're not held in com you know in communities where the majority of patients get treated. And so it creates this, you know, di difference in access. So I think there's a lot we do about

Right.

Yeah. Yeah.

You know, I'm very honest with patients and I tell them and I think when as I was doing research for the book, one of the the some of the studies that have been done have been shown that if black women were to get access to the same drugs, you actually see some of these gaps, you know, be mitigated. but they're not you know, there's so many situations and so many studies where black women are not being offered the the drugs that are guideline based. And then we also have tests like oncotype that we use to

you know, make chemotherapy decisions. It does not work as well in black women. And yet we use it. Right. So we're already using a test that is not as effective. genetic testing, all of those results are generally based on databases that are predominantly white ancestry. So, you know, it's start and you know you start from the beginning. It starts with getting that mammogram and follow up on that mammogram and it's systems in place that are

really stacked against very often, you know, black and brown women. And so I I think it's so important that we speak up about this. And I'm very honest with patients. I think recognizing that there are access and equity gaps and talking about the higher rates of mortality, but what are we going to do to fix you know how do we how do we test? How do we screen? What are the molecular test things that we're doing? What are the drugs we're gonna use? There is an incredible

incredible community called For the Breast of Us that is, you know, really focused on black and brown women with breast cancer and they are the most dedicated. I mean, they're just fantastic people and they're really committed to fighting this.

That's really nice. I didn't know about that. no, that's great. And I think that like part of the issue is, you know, of course, you know, there's not enough people getting doing the studies, there's not enough people enrolling in the studies, right? And then, you know, the access issues that come with it. and I find that also like my friend Janine, who was in it sort of leading the talk, talked about her research in like

Mm-hmm.

The South and the Deep South, where she sees a lot of Black women who survive cancer and they're on adjuvant endocrine therapy. And many of them, you know, they have like some of the highest discontinuance discontinuance rates. And some of that is related to sort of their ability to discuss this or not discuss this with their oncologists, right? Like they're not addressing their sexual function or they think.

that person should not be having sex, you know, whatever the case may be. It's like, you know, based on the environment. And so, you know, or they're labeled non-compliant and they're written off versus like having an engaging conversation, like, let's try to do this. And so I think there there still exists, you know, and she talks about epistemic injustice, which is where her where your known, you know, feeling about your own body isn't enough to be believed by the person who has is the expert, knowledgeable person that you defer to.

and so I think we have a long way to go with that. But it it was a it's really compelling research on, you know, even how we label patients and how we discuss with them and and and and so

Mm-hmm. And medical racism is really real. In the book I share a story about a woman who's an an incredible breast cancer advocate and she was having bone pain from her b booster shot after chemo. And she was having such severe bone pain and no one would believe her. And to the point where she ended up in the ER and people were like, Well, why are you here? Your pain shouldn't be this bad and she was split and written off and she said if

Dr. Sameena Rahman (43:48.258)

Yeah.

The me the me now, if that me now could advocate for the person, you know, for myself back then, but she was vulnerable. And you know, no one believed her. No one believed her that her pain could be that bad. They attributed her to seeking drugs and you know, and I I this is one story out of so many. and so I think we have to we we have to listen to women. We we just, you know, we have to keep speaking up about this.

Yeah. Yeah.

Yeah.

Yeah. Yeah. And I think as as clinicians it's so important. We talk about this a lot at Ishwish is like really our reflexivity on who we are in relation to that person and where we are in in in life even and how we can relate and how we can reflect on our state such that at least, you know, you take a minute back and you try not to we all have biases, right? This is just known evidence, right?

But we have to really just how are we gonna check that bias at the door and try to like really relate to the patient to the point where sh she might feel more comfortable telling you why she's off the endocrine therapy, you know, like you know, and I think that that is an important message that we have to kind of like push through and push forward. because you know, these are the women I and it it's I J you know, Janine's whole point was, you know, if we center the most high risk patients who have the highest rates of death, the highest rates of

you know, mortality and morbidity, then everybody gets helped in the process, right? Like everyone's cancer journey becomes better. But you know, really looking critically at that element in your if you're a clinician listening to this or if you're the patient, like how to best advocate yourself. But but we have to be critical about that aspect, I think, of breast cancer survivorship.

Yeah, and I agree, recognizing our own biases is so important every single day, right? Being able to see, wait a second, this is my reflux you know, this is my bias. How do you I need to stop that and kind of center with wh who I'm talking to and where I am right now.

Mm-hmm.

Yeah, yeah.

Right. And this is again where our medical system fails us 'cause it's hard to do on a fifteen minute visit. It really is, you know.

Not possible. It's just not possible, right? Like I I think we're in this we're no in a no win situation, unfortunately.

Yeah, absolutely. well, Eleanor, I do this thing called a vagilante verdict, which is like a hot take that you want to leave the listeners with. Like, what is it that you think this under I mean, you know, like one of my when my book comes out, one of my biggest messages is really like dismissal is harm, right? Like this is the biggest thing. But I think a lot of that is the same as what you're seeing. But where what what is your hot take? What's the message you want people to gain from from your book and and the work that you're doing?

What what sh what's your message?

I think, you know, surviv I mean, I would I would really say that survivorship care is you know, it starts when you're diagnosed. and there isn't this moment of you know, we we like to think about a medicine, well now you're in survivorship, right? What does that mean? A patient said to me the other day, she's like, I don't understand what this means. Like I'm so I'm in survivorship now. What should what should I be doing? I don't feel like I'm doing the right things.

Yeah. Yeah.

And so and after I finished writing my book, I realized I was like, I don't even use I use the word survivorship like twice, you know, I didn't touch and and it's because survivorship to me is it's from the day you're diagnosed, whether you're living with disease, whether you have metastatic disease, whether you were treated 10 years ago, it it's everything that comes after. And how do we thrive? How do we take care of not just the breast?

Yeah.

and the breast cancer, but how do we take care of everything else? Because you are more than your breast cancer. the part of you it is not your entire identity. And so thinking about right, how do we take care of our physical and mental health beyond that brain, bones, heart, muscles, like all of our organs. and I think we sometimes don't do that very well. and I certainly have been guilty of it in the past too and I try every single day, right, to

Yes.

How do we help our patients as much as we can? and so I'm hopeful that the book will help people advocate for themselves to do that, will help them go to their doctors and say, I wanna talk about my heart. How are we gonna take care of that? and it doesn't happen overnight. It's it's a process.

Yeah. Yeah, no, it's so true. And I th I think there's like this concept of clinical gaze, which is like how we silo medicine so much that the only thing that we see, like I used to joke, I don't I don't want to say this anymore because I do treat the whole patient, but like, I'm a gynecologist, I only treat from the belly button to the mid the you know, like but like, you know, of course, but it hormones affect every part of your body. Like this is something that we have to look outside of and and and I'm not saying that I would I treat, you know, all sorts of fields, but I can

Yeah.

Yeah. Yeah.

introduce concepts and and looking at the whole thing and prevention. and I think that's so important that you're not your tumor, you're not your vulvar disease, whatever, you know, you are a person that is living with something, but you're more than that. And we have to address all those issues.

Mm-hmm.

Exactly. So I think I think we're getting there slowly. It's gonna take time. But I really believe in that shared decision making, patients working with their healthcare teams. And I think it starts by having conversations like this, right? We are in although the healthcare system is tough right now, this is what we're in. So we have to how work in it?

Yeah. Yeah. Yeah. And then we should address it. Well, thank you so much, Eleanor. This is great. I can't wait to get your book and I'm super excited that you have have have written it, honestly. But I don't think we have I mean, from a medical oncologist who sees this all the time, like, you know, we have a lot of I think breast cancer books out there. But you know, just to really focus on this aspect is awesome.

Well, thanks for having me and I'm excited for your book as well.

thanks. all right. Well thanks everyone for listening to Guy No Girl Presents Sex, Drugs and Hormones. I'm Dr. Samina Rahman. Remember, I'm here to educate so you could advocate for yourself. Please join me next week.