More women are surviving breast cancer than ever before yet, the statistic remains that breast cancer is the second leading cause of cancer death in women. In this episode, Dr. Abi Siva, a MUSC Health breast oncologist, explains the latest offerings in treatment and early detection from MUSC Hollings Cancer Center, that are helping more women live longer, healthier lives after a breast cancer diagnosis.

[00:00:54] Abi Siva, MD: Thank you so much for having me here.

[00:01:16] Abi Siva, MD: If you look at the cancer statistics, one in eight women unfortunately will encounter the diagnosis of breast cancer in the United States. So that's the general statistics. But the risk actually varies by somebody's age and other biological and genetic factors. The most common age the incidence is more frequent in the sixties to seventies. Unfortunately we do see way younger patients sometimes coming to us with the breast cancer diagnosis. Sometimes it could be related to certain high risk genes in their family, such as BRCA1 or BRCA2 or CHEK2 mutation that you may have heard of. Sometimes it's independent of these genetic changes. On average, the incidence actually peaks in their 60s.

[00:02:00] Abi Siva, MD: I think it's very important for women to know about the risk of breast cancer so we can create awareness, and also we can increase the rate of screening measures such as mammograms. Because this is a disease that if it's caught early on it can be well managed and very high chance of cure. So if somebody is going for annual mammograms as they should be, and getting screening done, and you can detect breast cancer, that cancer could be stage one or sometimes stage two. The chances of taking care of this cancer and curing this cancer is very, very high. Whereas if we wait for symptoms to appear and then they seek attention, which could be stage three, stage four, more advanced disease, then the chance of cure may be lower. And stage four setting, if it's metastatic and spread to other parts of the body, then we can't even talk about curing the cancer. So therefore I think creating awareness about breast cancer and the need for mammograms is very, very important.

[00:03:15] Abi Siva, MD: Very good question, a lot of our patients and their family members ask us this all the time. When it comes to self breast exam, there is some controversy there about what age you should start and how reliable is it, because in a younger woman, in their twenties, thirties, there's always these cyclical changes happening in the breast tissue. Sometimes it's very hard for them to tease out what's normal and what's not. But again, self awareness is, I think, important. So I always tell patients just to know what's your norm. And when you see something abnormal happening, this is not your norm, this is not how things were before, and there's a new change happening, then you are the first one to detect and bring it to your provider's attention. So always be vigilant about any changes that's happening in your body, and anything that's concerning. Just bring it up to your provider. But our American Cancer Society recommends mammogram as the main tool for screening. Usually we start recommending screening even at the age of 40. So 40 to 45, it's sort of an option that women could choose to start screening every year. But 45 are recommended to get annual mammograms. Some guidelines do say maybe beyond the age of 55, every other year is okay, but at the end of the day, you know, it's good to keep up with the mammograms on an annual basis to detect any new changes. When it comes to guidelines also, there are multiple different guidelines we have on recommending different things. So American Cancer Society recommendations are the ones that I just mentioned, but the U. S. Preventative Task Force may have a different recommendation. So talk to your doctor, talk to your gynecologist, your primary doctor about what is the age that they are recommending you to start screening and then follow their guidelines you know, every year. And in some women, if they have a significant family history or a genetic predisposition, they may have to start early on, or they may need an MRI or an ultrasound to go with it. So therefore, again, talk to your providers and be aware of the necessary steps that you need to go through to detect things early on.

[00:05:26] Abi Siva, MD: That question is a hard one to answer, because the field is evolving. Some guidelines do say that you could stop screening at a certain age, but in our practice, I think age is sort of a... it's a hard number to go by because not every 75 year old woman is going to be the same way or just have the same life expectancy, you know. There are other factors that we have to look into. So if somebody's very healthy and active and they have a pretty long life expectancy, then we would suggest them to continue the screening because even a stage one diagnosis can be pretty morbid in their seventies to eighties. So that's a sort of an individualized question based on the patient characteristics and comorbidities. And again, that's why you continue to follow with your primary doctors who can sort of guide you through the necessary steps.

[00:06:26] Abi Siva, MD: That is where I think most of our focus should be. So in the general population, what are the things that we can do and we can educate our general population to follow so we can reduce the risk of breast cancer. So exercise, it's been well studied that routine exercise will decrease the chance of developing breast cancer. So when we say exercise, it's hard to quantify, but the American Cancer Society is recommending that in a week, about 150 to 300 minutes of moderate intense workout. Or about 75 to 150 of vigorous activity, like going to a gym and running on a treadmill, something really vigorous to increase your heart rate and your sweating. Something like that is what's necessary in a week for you to sort of meet that expectation. That's what studies have shown in terms of reducing the chance of breast cancer. Another big factor that we worry about is alcohol intake. From one of the studies showed that about 12 percent of new breast cancers are actually linked to alcohol. So we can certainly work on that. You know, if you ask me, I would say no alcohol whatsoever, but of course, people have to have their life too. So the recommendation is at least under, you know, one drink or less. In a week, you know, six to seven drinks a week is the most that they would recommend for the general population. Anything more than that could increase cancer risk, including breast cancer. And smoking, as we all know, can increase multiple different cancers, including breast cancer. So we always counsel our patients about that.

[00:08:08] Abi Siva, MD: Oh, this is one of the best meetings that we have in our breast oncology world. So every year in December we go to San Antonio to attend this huge breast cancer meeting. It's the largest internationally, I would say. And researchers, scientists, doctors from all over the world attend this meeting to present their research work, to talk about new drugs, new way of treating cancers. Scientists bring their new ideas to the table and many doctors do follow these experts and learn from them. And then they bring these ideas to their clinic and start implementing , and using their treatment. This year there were multiple new breakthroughs. So I try my best to attend this meeting every year, so I could bring our ideas to the table, but also we could learn so much from others and bring it to our clinics.

[00:09:05] Abi Siva, MD: So yeah, I can list a few, you know, studies that were presented at this meeting. We are expecting them to be actually practice changing for us. There was a study called the Inova 120 clinical trial where they talk about a novel medication called Inavolisib and when they combined it with hormonal treatment in the metastatic breast cancer patients they found out that they could prevent the recurrence for longer. Another new drug that they discussed was called the Dato DXd. It has a very long name, but this drug, again, is used for hormone positive metastatic breast cancer patients. And it was also, again, improving the life of our patients and we are adding a new option in our armamentarium. They also talked about some previously discussed studies and updated the results, and again, reassuring us that what all these new drugs that we are doing in clinical practice is increasing the life expectancy, or if it's an early stage patients, reducing the risk of reoccurrences in the future. There was another study that looked at omitting radiation in specific selected patients who may have had lymph node positive disease. These are a group of studies that look at how can we deescalate some of the treatments because we know sometimes when we do surgery and radiation and certain treatments like that, it can cause side effects like lymphedema or problems with mobility. So we are also doing studies to see in which patients can we omit such morbid treatment and give them a better recovery, and in which patients do we really have to give such treatments because we don't want the breast cancer to come back. Our field is moving towards deescalating in the right patient, therefore we don't have to expose the toxicity to many of our patients, and some of these questions were also addressed at the meeting.

[00:11:03] Abi Siva, MD: Our team that's taking care of our breast cancer patient is an excellent team here. First of all, the multidisciplinary approach is very unique and it's very, very important. Breast cancer is not a diagnosis where just one doctor can see the patient and make the treatment plan and go forward. You need multiple different specialties to be involved to come up with the best treatment for the right patient. So a surgeon is mainly involved as the person who is going to remove the cancer and tell the patient, Hey, you are cured. Whereas a medical oncologist like me is important to come into the team and say, what other interventions like hormonal treatment or chemotherapy or targeted therapy may be necessary to reduce the chance of this cancer ever coming back. And then comes a radiation doctor who has his or her role to offer in the treatment of the same patient. Not only that, then there is a social worker, there are supportive physical therapists is important to help them recover from a surgery, your radiation, integrative medicine, psychologist, financial counselor. So, you need a big team of people who are excellent in their own field to bring the expertise to the patient as a team, and also we all see them on the same day when they come as new patients. So we talk to each other, we discuss their case in the morning, so there's a good communication going between all of us. We all help each other, educate each other, and come up with this best plan for the patient. So that type of treatment planning is very important, very unique, and that's how the field is going. And patients who come to Hollings Cancer Center will get that first class approach.

[00:12:42] Abi Siva, MD: It is very, very convenient for our patients, and they appreciate all this attention that's given to them when they come in that day. They are here, they're spending almost the whole day with us to see all these different doctors, and knowing that we all talk to each other and we all agree with each other, gives them such a big peace of mind. And not only to develop the standard treatment plan. Let's say clinical trials, you know, being one of the biggest academic institutions in the whole state we have access to multiple clinical trials with novel drugs, including phase one, which means these are very, very new drugs in development where you don't have any other access to get it. Those are other ways to improve our patients' outcomes. and that's available at Hollings because it's an academic institution.

[00:13:38] Abi Siva, MD: I'll tell you it is one of the toughest times of their lives. You know, when I see a patient who's recently newly diagnosed with breast cancer, coming with their loved ones to meet our team. You can see that, you can feel that anxiety and the worry in their faces and in their loved one's faces. So, you know, we completely understand what they're going through. And I tell patients the first day when you meet all of us, we're going to tell you about all these steps. It's going to feel like so overwhelming and so complicated, but I tell them take one step at a time. Go through surgery, for example. Then you come back to me. I'll talk about hormonal treatment. Then you go to the radiation doctor, they'll initiate the radiation process. So when we first meet them, we give them the overall plan, and then we sort of walk them through every step of the way. That way they don't feel like it's so much to process and go through. And they find it, you know, easier when they take one step at a time without worrying about the future, what's going to happen. We have great breast cancer navigators at our Hollings Cancer Center. They also keep a very close eye with these patients. They talk to them frequently, So the navigators are there as their first line of contact to call and talk to them, ask any questions, and the navigators will then come back to us. We will answer those questions back to the patient. So there's a lot of good communication and support available here. So I say, just don't hesitate, call us. Using our communication system, using our navigators, using us as your resource should help take some of that anxiety away and then taking just one step at a time to get through the complexity would also help.

[00:15:20] Abi Siva, MD: The breast cancer field is evolving. Every year, there's so much research happening, and so many new drugs are being approved. Because of that, our patients are living longer and longer. And we are all very proud to say that the field is advancing in the right direction. Just to give you an example, just in this year, starting from January to December, we have seen multiple new drugs approved by FDA so we could use them in clinical practice to help these patients. Elacestrant, abemaciclib, sacituzumab. I'm just listing, you know, a few of those drugs that came up, but the field is going towards the right direction and so many new drugs are coming. So I tell patients, I know nobody wants to face this diagnosis. It's very hard to go through this, but the field right now, the direction it's going, our goal is to the quantity of your life and quality of your life. It's not just, we want to cure you and leave you out there with all these side effects. We want to make sure you recover well, you go out as a thriver and get back on with your life without worrying about this ever happening to you. So that's our ideal goal in our mind and that's where the field is going. So please, anybody with this diagnosis or your loved ones with this diagnosis, don't give up. Don't feel like you don't have anybody, don't have the right resources. You have us here. Come to us, we will get you through the right step.

[00:16:48] Abi Siva, MD: Sometimes as doctors, busy physicians we sometimes forget to take care of our own health. But since I joined MUSC my main goal is to join a gym and make sure I attend at least three sessions a week. So that's my goal. Plus we joined for a family karate class with all my kids and my husband. So It's a black belt program so we are all doing it twice a week. So hopefully with all that, I'll get my health back in shape.

[00:17:29] Abi Siva, MD: You're very welcome. And thank you so much for having me here.