Hello, my name is Melissa Mitchell, and I am a professor of
Breast Radiation Oncology here at MD Anderson Cancer
Center. And I'm excited today to have Dr. Jennifer
Litton, who is a professor of Breast Medical Oncology
here at MD Anderson and also our chief clinical research
officer.
And this is the Cancerwise Podcast.
So, thank you so much for being here.
Welcome to the podcast.
Thank you so much. I think this is going to be fun to talk
about. So much going on in breast cancer,
in medical oncology, surgery and
radiation.
And you know, I think sadly, because I got
to see a lot of it firsthand for the first time,
which is certainly interesting when
you've spent decades working in
a disease that you end up being diagnosed with.
Oh, I'm so sorry that you had to go through this, but I'm
sure it's so wonderful for our listeners
to hear a little bit about how it's been for you to
go through this experience. Are you able to share a little
bit more about that?
I sure, well, first of all, it always is great by having
wonderful colleagues and physicians like yourself.
So, everyone, Dr. Mitchell was my radiation
oncologist. And, you know,
this conversation really comes out of a conversation you
and I had really looking at so
much that has changed in radiation.
You know, there were so many options.
And I think the research has been really intriguing.
I got my mammogram every year
from 40, which is, to everyone on the podcast, please
start at 40 or earlier if you're in a high-risk situation.
And I'd had several biopsies before,
and this time when I saw those calcifications
in my left breast, I knew.
I knew pretty quickly, and, and what was
interesting for me is seeing it
from the other side.
I had to have, I had a screening mammogram.
Then a diagnostic.
Then a stereotactic, and they saw other
things. And then I had an ultrasound and then
got called back for an ultrasound-guided biopsy.
And then at the end, because there was so much going on,
that I needed an MRI.
And that is a lot.
And that's not what everyone needs.
But just every time they looked, they were finding
something. And so, I think I was feeling like every
time they looked, the, the other she was going to drop.
There was going to be something more.
And I don't know if part of that's just because I'm,
I've treated so many patients over the years who
who have experienced that.
So, as we got more information, I will say it
was a lot. And I was trying to schedule it through
my workday, which is a little crazy to begin with.
Plus, you know, caring for some sick family members
from afar.
And I was also, you know, trying
to really push research forward in
all aspects right now.
And I will say, we're doing, there's a lot of exciting
things going on.
And so, there was a lot going on, and trying to add that in
was really stressful.
And also being in the field, like, you knew
a little bit about why those things were happening and,
you know, why we had to go to all the steps.
But I'm sure for patients that don't have that
background knowledge, it's very difficult to every
day find that you have to do another test.
And why don't you have a plan to move forward?
Why aren't you ready? You know, I think about that a lot
in the last two years. And I think the last time I did this
podcast, I shared my father's story
with stage IV lung cancer.
And I think it's very, very true.
Even as I would say, a savvy
medical person, it is hard to navigate
multiple systems, especially from afar.
Though I will say everyone's been kind and wonderful to my
parents and myself, and I just, it really
made me think how hard this is for
patients, exactly like you said, who
don't know what's probably coming next.
And they're trying to take care of their kids, get them
to school, do this and make all of these different
appointments and you just want the next available.
So, you're scurrying all the time.
Yeah. And I'm sure as a patient it feels like this should
be an emergency. Like, why can't I just go to the E.R., and
like, get this taken out right now?
And I think to that end, one thing
for the folks who are listening to the podcast is,
my message to you is that you do have time
to take a beat.
And I needed all those tests.
Not everyone does.
Because they kept finding things, that, luckily,
turned out not to be important.
But you have
time to get all the information so that
when your surgeon and your radiation oncologist go
to do the treatment, we have the most information we
need. I see that sometimes when people are rushed
to go do something immediately and then we're
scurrying to to try to,
well, we should have done chemo here.
We should have done this, or the surgery should have looked
like this because we didn't have the genetic counseling.
And so, my message is, you know, really, it's stressful
and I get that.
But it's better to get all the information
and get one plan.
And what we do, I think, really resonated.
You have all the information.
You have the diagnostic imaging.
You have the surgeon and the radiation oncologist
and the medical oncologist all talking to each other.
So, you get a plan and then we move forward
and that takes time. But that time is stress.
No, definitely. And especially as we move into more
personalized medicine and being able to be very nuanced
with how we treat each patient, it's not a cookie cutter
process. Not everyone gets the same treatment.
I think that's so important, like you said, to have all of
those pieces at the start.
I want to say one thing about that is that, you know, this
was my journey.
It was found on screening.
It was able to be handled with surgery and
radiation up front.
I really want to be clear that everyone has
their own journey, and it isn't that,
oh, if you didn't find it screening, you've done something
wrong. The biology is different.
Screening is different.
This was my journey.
But you know, breast cancer is
thousands of different diseases that just happen in the
breast. And, and I think one of the exciting things
is that we are getting to much more individualized,
tailored therapy.
I've spent my career in medical oncology pushing
forward, doing new therapeutics, adding more
when, in fact, is just as important as that,
is doing the research on when we can pull
back. When we can get the same results
with less toxicity, less therapy.
And that really was eye-opening
to me when we met, because for my
whole career, it was six weeks of radiation with a big
booster, and I saw women's skin so red,
and seeing radiation therapy
from the other side on the table was,
you know, quite an experience.
Yeah. We try so hard to prepare our patients for
what to expect when they go on that table.
And, you know, I have a lot of patients that say, you know,
with chemotherapy, you know, I was there with my friend
holding my hand. And radiation is a very different
experience for a lot of our patients.
And despite our best efforts to kind of translate what
we've been told by other patients, sometimes we just can't
really prepare our patients. I don't know if you're willing
to share a little bit more about your own experience to
kind of help our future patients.
You know, it was interesting. I was with
two patient advocates who'd both
had radiation two days before,
and I asked them what to expect.
And I think that was really helpful because you would think
I would know, and I did not.
I'd never even, I've maybe walked into the room
and looked inside once or twice, but I've never been there.
And one of my friends said, "Oh,
you better start stretching that arm now." I'm
like, "What do you mean?" And she goes, "Yes, it's the
glamor pose because you have to put your arm up."
And you have to stay that way very still
for 45 minutes to an hour as
they're doing the simulation.
And that's taking all the pictures and making sure, because
what you do is so very precise.
And you've just had surgery, and you haven't
been thinking to stretch that arm out.
And so, that was a really important piece
of advice for me.
They also said, take a couple Tylenol before you go in.
And I was like, well, really? Really do I need?
And then I was like, oh, you do. Because your arm, you are
really stretched, and you are so
still that that it does.
And you're nervous. You're tense.
You're, you're, you're doing that.
But I will say that everyone was so nice.
And they, you do a lot of neat things to try to
relax people too.
There's a lovely scene on the ceiling,
and I got asked whether I was
in the MRI or in the radiation, what
did I want to listen to?
And I was like, well, what do you mean?
And then after the first time I was like, I want to listen
to Taylor Swift, and I want to listen to the Beatles.
I like both of those.
And by the, you know, third or fourth day, they
knew what I wanted to listen to.
And I came in and there's, you know, it was kind of fun.
They knew who you were and, and were tailoring to you.
Tailoring.
Yes.
You know. So, I thought, you know, and you're
doing all these breathing exercises while
you're on the table, which is really important, to maybe
you could tell about why that's so important?
Yeah, definitely. So, these days we have
much different ways of monitoring patients on the table
to make sure that we can be very precise and accurate
with our treatments. There's these great infrared cameras
that can see the whole surface of your body and really
make sure that if you do move, it can see that
it can see if you're in a different position when you come
in from day to day, and that it can also
monitor your breathing.
And one of the reasons we really care about breathing is if
you're able to expand those lungs and move that
breast away from the heart and the other important organs,
it can really reduce the toxicity of treatment.
And that's been a big game changer for radiation
therapy to be able to be more precise and accurate with how
we deliver our treatment.
Yeah. And, you know, avoiding the heart always seems like
a good idea.
Yes, that does seem like a good idea.
I think we, we caused a little bit of detriment in the past
when we didn't have that knowledge, so we didn't used to
have 3D pictures of the inside of the body.
And back in the early days of radiation
therapy, they just shot through part of the heart, which
gave radiation a bad reputation for a long time.
So, we're very excited that we don't have to do that for
our patients anymore.
And one of the things that I thought was really
interesting, and since that I've gone back to actually read
the papers, is the clinical research
around the delivery of radiation therapy,
and that I think it's very clear that radiation
decreased recurrences.
And I, I went in absolutely, I was going to do
radiation.
But the data's really been evolving
with clinical trials.
So, we have good randomized clinical trial data supporting
newer techniques and shorter courses.
Yeah. It's it's been amazing.
You know, when I was a young attending, everyone, whether
they were 20 or 80, stage 0, stage III,
they all received six weeks of radiation, and it was
always to the entire breast and was with techniques that
had hotspots. So, they would have, you know, red, burned
skin and blistering skin.
And there's been an explosion of randomized trials
over the last decade or two where we've really
found that we can customize treatments so those patients
with early-stage disease now have options to do
one week, very targeted therapies just to
the tumor-bed area.
Not having to treat the whole breast leads to much
less toxicity, less time off work, better
cosmesis long-term.
And then even patients with more advanced disease, we're
finding that we can do maybe three to four weeks of
treatment, which again, more time with their families
and not having to be going through radiation
treatment, which has been fantastic.
That's great.
And I mean, you know, any time I hear clinical research
and clinical trials, because I do believe this is how we
are doing better and better. In fact, you know, just a
couple weeks ago, we hear from the American Cancer Society
that more and more people are living with cancer
longer and better lives.
And I think that just shows the absolute
importance of clinical research, clinical
trials, and that we're moving new therapies, but
we're also figuring out how to do a lot of things less
invasive, less toxic, and just better for patients.
And, you know, I really experienced that firsthand.
I was able to come in at seven in the morning,
do the radiation treatment, and I was
some days in the clinic right after that.
I will note, though, that the fatigue is
real, which is so much
better than what I expected.
You know, I, I, we, as,
you know, women, often, we've got kids.
We both have twins. I'm going to share that with the
podcast. So, we have this bonding moment that we both have
a set of twins.
And you're running around all the time.
And, you know, I think a couple days, the week after,
and you told me, you said, "Jennifer, you are, two weeks,
three weeks, you're going to you're going to feel that
fatigue." And there was like a 4 o'clock, I crawled
into bed and I didn't get out until the next morning.
And it was, in the land of side effects, this
is what I will take, you know.
So, so, I think we have to
as, as on the patient side, sometimes let ourselves
be patients, which is really hard.
And I do think it's a lot like you mentioned.
As women, we're always doing everything for everyone
else. And our buckets are often empty.
And then the radiation just, you know, really
tips that over. So, I do it, it's hard
for patients because they're not used to that fatigue.
So, I'm glad that you shared that so patients
can be aware.
And it's OK.
That, that's okay. Yes. And it's okay to say, you know I'm
not going to like, do dishes and laundry.
I'm going to go take a nap.
So, it's you know, we need to have that self-care
for our patients so that they can really, you know, do what
they need to take care of themselves and heal from all the
cancer therapy.
Absolutely. And I will say that I started
my first endocrine
therapy yesterday.
So, we'll see how that goes.
I gave myself a couple weeks after
the end of radiation, so yesterday
seemed like a good enough day to start,
and I'll plan to do that for the next five years,
watching for all the side effects that go with that.
And as a medical oncologist, I know you've counseled
patients on those side effects for many years.
So, we'll work on it and it'll, it'll be
another stage for me to understand firsthand
what my patients have been going through.
You know, Melissa, you are
besides being a wonderful clinician,
you are really spearheading a lot of research
at MD Anderson.
And I, I really was hoping that you could share some
of the work in addition to tailoring
the doses and how you're delivering it, you know, maybe
you could just tell us a little bit about what you're
working on that's really exciting.
Sure. So, personally, as you've
mentioned, we see these side effects in our patients.
And so, we wonder, are we doing too much?
So, my passion has always been de-escalation, as
you mentioned. It's a little bit of a challenge sometimes
because many of our patients want to maximize, right.
They want to do everything they can to make sure this
cancer doesn't come back. But we recognize that there's,
you know, oftentimes when you're doing too much, patients
probably don't need surgery and radiation and
medical therapy for their tumors.
So, personally, I've been most interested in those times
when maybe we can scale back on radiation therapy, trying
to figure out who that population is.
One of those places is patients who've had chemotherapy
first, and we find that the medicine works really, really
well. You know, I used to have patients come into my clinic
and say, you know, I did the chemotherapy.
I went to surgery. I just saw the surgeon, and she said the
cancer was gone. Why are you in my, why am I in your
office, right? So, based on those patients coming in and
telling me that I was like, you know, we really need to ask
these questions. Why are we doing the radiation therapy?
So, that's been my biggest interest.
And interestingly, I think all of us across
the spectrum, like you said, surgeons, medical oncologists,
radiation oncologists, we all are recognizing that maybe
we're doing too much. So, right now is a great time
for our patients with early-stage breast cancer.
We have basically the ability to personalize
how you want to de-escalate your therapy.
I know one of my colleagues, Simona Shaitelman, she did a
survey of patients, and not everyone wants to de-escalate
in the same way. So, some patients, they're afraid of the
surgery because, you know, they've had friends that have
had issues with anesthesia, or they just don't want
anything cutting their body or changing how they look.
There's other people that are terrified of the radiation.
They had family members who had radiation back when we
sent radiation through the heart, and they just don't want
those toxicities and side effects that they heard about.
And, of course, there's some patients that hear about that
endocrine therapy and the hot flashes and
the joint aches, and they want to try to avoid
that. So, it's great right now because we really do have
studies for our early-stage patients in all
of those areas where if patients would like to de-escalate
one of those components of care, they can.
We don't advise skipping all of them, but,
you know, there's studies for each of those.
But don't you think that's the importance of having
this close connection between the radiation oncologist,
the surgeon and the medical oncologist?
You know, we can't work in a vacuum.
We have to be thinking about this in the
totality of the patient.
And I think that's where we really excel at MD
Anderson, you know, how many times have you just
picked up the phone or sent me an email going, you know, we
need to sit and talk about this.
Something's changed and we just stop and figure out
together.
No, I definitely agree.
I think it's so important that we recognize that
all of these questions are important.
And also, again, the patients have different opinions.
So, we could pick one thing to study.
But then there's a population of patients we're leaving
out. So, I do think that's important that we're all very
connected in, not just how we're treating our patients and
discussing all of our cases, but also the research
questions that are important for moving the field forward.
And the field's moving so fast now.
You know, when I first started, I was a study
coordinator before I went to med school.
And, you know, we had a couple chemos and we figured out,
you know, maybe we could give the chemos this way or that
way. And now it's happening so quickly, where
every year we're adding brand new, very targeted,
very engineered therapies.
And it's changing the landscape so quickly.
And exactly as you said, as, as we're getting better
targeted therapies, we're able to treat patients
and have a large portion of patients
where the cancer's gone by the time they go to surgery.
And I'll say, in medical oncology, we're looking at the
same thing like, right.
We always say, you can't cure someone twice
at the same time, right?
So why keep pushing toxic therapies if
you've gotten the desired results?
There's a lot of trials we're looking at as saying, okay,
once we get the desired result, do we keep going
as the traditional or do we hold more
therapy? Is more just more?
I think these are really important questions,
and, and they can't be done in a vacuum.
Yeah, I most definitely.
And we're trying to copy you all.
I know with medical oncology you guys have had Oncotype for
20-plus years now to help guide
your decisions, which is a genomic assay.
And so, finally in radiation oncology we're,
you know, developing these assays where we have a new,
new study coming out where it's looking at
basically, protein expression for patients with
DCIS.
And they, you know, expect that this
assay will help patients predict whether or not radiation
actually matters. So, if it says,
you know, the radiation matters and that will be great.
The patient gets radiation. It reduces their risk of
recurrence dramatically versus if it doesn't, then those
patients can actually skip the radiation therapy.
So, things like that I think are going to be fantastic as
well. So, really again, personalized
medicine and figuring out who really needs the treatment
by using this genomic approach.
Yes, exactly.
Very very exciting times
in breast oncology right now.
So, on behalf of me, I want to thank you.
You took wonderful care of me and
I'm so appreciative of everyone here.
And to the folks listening to the podcast,
know that we are here to keep pushing the needle
to cure more people and to do it with less toxicity.
That's all our goal. So, thank you.
Well, it's been an honor to be able to take care of you
and to be a part of this podcast, and it's wonderful to be
part of MD Anderson, where we are able to provide great
care to patients and have all the resources that are in
place to do that as well, while those again, keep pushing
that envelope forward.
Right. Thank you.
Thank you so much.
And thank you for tuning in today.
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Thanks for listening to the Cancerwise Podcast.