1. The Oncologist in You Drs. Banu Arun, Don Dizon, Susan Love
Workshop H: Saturday, March 7th at 11:30 a.m.

2. Scenario 1:
Your patient is a 34 year old breast cancer survivor who had Stage II, ER+ disease. She is premenopausal and has been on Tamoxifen for 3 years, without ovarian suppression. She hears about the results of the SOFT trial and asks you whether she should be having ovarian suppression and/or whether she should switch from Tamoxifen to an AI. What would you tell her?
Some described brand as an intangible asset, and a promise that conveys who you are, what you do, and why that matters.
Others felt that a brand captures the persona of an organization and represents its very soul or essence.
Yet others identified brand in terms of not only what is projected but also what is perceived.
Last, brand was seen as a source of efficiency because it acts as a time-saving device, providing a shortcut in the decision making of potential investors, customers, clients, and partners.
Brands can initiate action and create emotional connections. They can focus efforts and attract attention. Attention from potential members, donors, volunteers and media. And a strong brand ensures this attention will last a lifetime.

3. Scenario 2:
Your patient is a young woman with Stage I triple negative breast cancer. Because of a significant family history for Alzheimers disease, she is reluctant to have chemotherapy because she has heard about “chemo brain.” What do you tell her?

4. Scenario 3:
As we know, breast cancer in young women is uncommon in the absence of family history or genetic predisposition. There have been a series of case reports involving multifocal, invasive breast cancer in young women who stored their cell phone in their bra. None of these women had a genetic predisposition to breast cancer and their tumors arose in the same places that their phones had been stored. To date, studies have failed to establish a relationship between cellular devices and cancer. What is your opinion on the likelihood of cell phones stored in the bra causing or contributing to breast cancer? Are there any other potential environmental causes or contributors to breast cancer that young women (especially if they’ve already had breast cancer) need to be mindful of?

5. Scenario 4:
A young woman with a history of triple negative breast cancer presents with metastatic disease several places in her bones. The location of the mets are such that it is difficult to biopsy them. Would you assume the mets are ER+ or ER-? How would you treat her?

6. Scenario 5:
A young woman with ER+, HER2+ breast cancer, Stage III, is concerned about her fertility and for that reason is resisting your recommendation of chemotherapy and Herceptin. She asks you what, if anything, can be done to protect her fertility during treatment. She is 35. What do you tell her?

7. Scenario 6:
A young woman in your office is seeking a second opinion on the recommended chemotherapy regimen. She is triple negative, BRCA+, believed to be Stage II although she has not yet had surgery. Another oncologist is recommending dose dense neoadjuvant AC, followed by Taxol. Do you agree?
a. Is neoadjuvant better for young women? Whether ER+ or TNBC
b. Is dose dense still recommended for young women?
c. What about parp inhibitor, platinums, clinical trials?
MENSES

8. Scenario 7: Hormones Ultrasound
A young woman newly diagnosed with Stage II triple negative breast cancer is deciding between a mastectomy and lumpectomy. She has heard that there is a higher rate of local relapse for young women who choose a lumpectomy, although no survival difference between the two surgeries. She does not have a family history of breast cancer and her BRCA testing was negative. She is leaning towards a double mastectomy and asks you the following questions: a. does local relapse impact overall survival? b. did the data which showed no survival difference between the two surgeries include young women? And how long was the follow-up? c. what do we know about the long-term effects of radiation on young women? d. Same situation, but the patient does have a significant family history of premenopausal breast cancer, although testing shows no BRCA mutation in her or her family. Does this change your response at all?
Hormones
Follicle Stimulating Hormone (FSH), estradiol, inhibin B
Antimullerian Hormone (AMH)
Ultrasound
Ovarian volume, antral follicle count

9. Scenario 8:
Your patient is 25 years old and newly diagnosed with stage I, ER+ HER2- breast cancer. Her tumor was 1 cm and nodes negative for evidence of cancer. She is premenopausal. Is endocrine therapy alone an option for her? What form of endocrine therapy would you recommend and for how many years should she take it?
a. Would your response be any different if she was 35? 45?
Must be considered in the context of age and your medical history
Does not predict ability to become pregnant
Just tells us how easy or difficult it might be

10. Scenario 9:
You have a patient who was 30 years old at diagnosis of Stage III ER+ breast cancer. She underwent chemotherapy and has been on Tamoxifen for one year. She would like to have a child and asks you if she can stop taking Tamoxifen to become pregnant. She would also like to know if it is safe for her to have a child. What do you tell her?
THEN, your patient does indeed have a child at the age of 33 and breastfeeds that child for one year. While breastfeeding, she did not take Tamoxifen. She asks you if she can remain off Tamoxifen so that she can try to conceive another child. At this time, she is now 34 years old. What do you tell her?

11. Scenario 10:
A young breast cancer survivor with a history of ER+ breast cancer has seen her gynecologist with complaints of sexual dysfunction, pain during intercourse, and loss of interest in sex. The gynecologist has prescribed her a product which contains some estrogen. She asks you, her oncologist, whether it is safe for her to take it. What do you say?
a. Would your opinion change if the young woman was currently living with ER+ metastatic disease?
b. Would your opinion change if she had had triple negative breast cancer?
No guarantees about anything
Must consider effects of treatment on other aspects of health
Pregnancy in general is a stressful condition
Consultation with a Maternal Fetal Medicine (MFM) Specialist
Preconception counseling
Management of medication
Management of coexisting medical conditions

12. Scenario 11:
A young woman with metastatic disease presents with mets in her bones, liver, and brain. Her records indicate that her initial breast cancer was ER+ and HER2+. Would you take biopsies of her mets and if so, how many and in what locations? a. Would your answer (about biopsying the mets) be the same if the mets developed while the woman was on tamoxifen?

13. Scenario 12:
A 35-year-old woman presents with stage I ER- HER2+ disease.  You treat her with neoadjuvant chemotherapy, and surgery confirms that she achieves a pathologic complete response.  What, if any, further treatment do you recommend? 
Survivors who become pregnant do not appear to suffer worse outcomes than those who do not
Meta-analyses
Azim et al
14 studies with 1244 cases and 18,145 controls
For overall survival, pooled relative risk was 0.59 (95% CI: ), favoring survivors with subsequent pregnancy
Valachis et al
9 studies
Pooled hazard ratio of death was 0.51 (95% CI: ), favoring survivors with subsequent pregnancy
Similar findings for women with estrogen-receptor positive tumors
Limitations of the data

14. Scenario 13:
A 32-year-old woman with three children under age 10 presents with metastatic disease upon initial diagnosis.  She has questions about her quality of life, how to talk to her kids, and how to plan for the future with her spouse.  How do you deal with these questions?  To whom do you refer her?