Thanks for joining me,
Doctor O'shannessy.
Happy to be here with you.
So can you just tell me what
is inflammatory breast cancer?
Inflammatory breast cancer
is a form of breast cancer,
an aggressive form of breast cancer
that looks like an infection.
It's, it's an inflamed breast and so it's,
it's quite unique, it's very uncommon,
quite rare, less than 5% like one
or 2% of breast cancers and so,
but it presents. An infection,
it looks red and hot and swollen,
and so that's where the name
inflammatory breast cancer comes from.
But it's got a unique biology,
like how does it get to be read?
You know, it's because the cancer
cells have this innate ability to
invade into the lymphatic channels
that basically permeate the skin.
So they're,
they're in these lymphatic channels
in the skin and so they're blocking
up the lymph flow of the skin and
so everything backs up and turns.
Read an inflamed,
but it looks like an infection,
but that's why it was called inflammatory
breast cancer because initially I thought,
well,
is it infection related or is how is
inflammation really tied in there?
But it really is just a
form of breast cancer.
What are some signs and symptoms
of inflammatory breast cancer?
It can be quite subtle Jennifer,
but it can also be really
quite fulminant you know.
But generally speaking the breast
starts to feel kind of full.
And heavy and there's some redness there,
but it can be a little sneaky because
it can look kind of pinkish and
it's you really can't fill a mass.
Unlike breast cancer where people,
you feel the mass, you really can't
feel a mass because it's more diffuse.
So it kind of looks like you might
have had an infection, you know,
like if you had a blocked milk duct,
you know, women who are nursing,
for example, will get a blocked milk
duct and all of a sudden it's sore and.
Read some inflammatory breast cancer is
classically you want to see 1/3 of the
breast, at least red or pinkish. Reddish,
you see the it's like an orange peel.
The skin looks swollen,
it's like an orange peel.
And usually the breast is larger,
but it's this redness and the orange peel
that's kind of the clinical features.
But then most importantly when
you do a skin biopsy you see the.
Inflammatory breast cancer cells.
You see the breast cancer cells in
plugging these lymphatics of the skin.
Inflammatory breast cancer is
a very distinct entity.
It happens generally in younger women,
can be older, can be post menopausal ladies,
but generally under 40.
But it's this heavy.
Red breast that's swollen.
The skin looks like an orange peel.
You can't feel a mass.
But I think where a lot of the
diagnostic problem comes in
is when you can't feel a mass,
you can't see it on mammogram,
you know,
and because it doesn't act like
regular breast cancer.
Yeah. Which was the case for me.
Yes. Yes. So therefore, you know,
we're all taught right to do self breast
exams and to get our annual mammograms.
But neither of those picked up mine, in fact.
Right before I was diagnosed with
stage 4 inflammatory breast cancer,
I had had a clear mammogram.
So that's pretty typical.
Is it? Yeah.
That that it's being missed
in self exams and mammograms?
Yes. So self exam, you know,
it looks like an infection,
right? So if a patient suspects
inflammatory breast cancer.
So in my case, I suspected it even after.
I was told that it was probably an
infection and that was just because I did.
What so many people do is got on the computer
and started Googling some of my own symptoms.
So how might a patient,
if they suspect they have
inflammatory breast cancer,
which is far more serious,
rule this out?
Like what can they be saying to
their doctors or team of medical
professionals to rule it out first,
First off?
You know, they're just,
they're just needs to be really
a simple algorithm from the
point of view of the patient,
the woman and and her doctor,
which is it's entirely reasonable and
really kind of expected that if a woman
presents with these odd symptoms, you know,
that are unusual and she's not nursing.
If she's nursing,
it's likely to be a blocked up,
but not necessarily.
You can still get inflammatory breast
cancer of course when you're nursing,
but it's OK to give up.
A weeks course or a 10 day
course Max of an antibiotic.
But the key is the follow
up and the next step.
If it doesn't,
get entirely better and stay entirely better.
Then the next step is a breast surgeon,
our ducks even if they're not
nursing our ducks are open to
the outside and so we can get,
we can get an infection.
So that's just a general
infection is fairly common.
It's not not I wouldn't say it's
common but it's way more common
than employment or breast cancer.
You know it does happen.
It can't happen even if somebody's
not nursing you know so
you you've mentioned a couple of
times younger women which wasn't
necessarily the the case for me.
What what it what is a typical demographic?
So younger women is or is there
a typical demographic that that
you see more inflammatory breast
cancer in than any any other?
So it's generally women under 40,
but it can be women in their 40s,
it can be postmenopausal women as well.
It's a slightly more common in African
American women than in non African
American women slightly because it
tends to go along with the aggressive.
Kinds of breast cancer,
triple negative breast cancer,
her two positive breast cancer.
You know, in your case it was
estrogen receptor. You didn't,
you didn't quite check the standard boxes,
you know, in terms of because yours
was estrogen receptor positive.
It can be,
it can be any subtype of breast cancer,
but it tends to go a little bit more
along with triple negative breast cancer.
And African-American premenopausal
women have a predilection for
triple negative breast cancer.
Unfortunately,
that's an aggressive subtype, you know.
So those are some some characteristics.
There's not a lot else because it
it's it's a tends to be a fluky deal.
It tends to not be a genetic deal you
know for example it doesn't tend to be,
it can be part of a of of an
inherited predisposition,
but it doesn't tend to be basically.
So the cause of it is really not known.
Why somebody would get this is not known.
We don't have as much data
on this as we would like,
but I've been a fan for a long time,
as you know,
about optimizing our own
physical health in terms of.
Controlling the breast cancer
and preventing recurrence.
I'm a big, big fan of avoiding weight gain,
ideally getting into ideal body weight
and staying there consistently.
We don't have as much data on that.
We're waiting on data to see, for example,
if somebody's overweight or obese,
if they lose weight 10% or more
and stay there sustained,
whether that's going to improve
their cure rate.
But for sure,
avoiding 10% body weight gain,
we know that that does increase
the risk of recurrence, you know.
And exercise three,
very important and then avoiding,
you know, significant alcohol.
The occasional drink of alcohol is fine,
but not everyday.
Yes,
these are these are very
important lifestyle factors that
I really do believe can optimize
a woman's long term outcome.
How could
we educate more doctors on
inflammatory breast cancer,
those that maybe haven't seen
it in their career to date?
How how might we go about educating?
You know, um, because it's
something that is so rare.
If there's a question about the breast,
just refer, refer.
There's any question,
but it's really bringing,
bringing people back.
So I don't think you can actually.
Educate about inflammatory per se.
I think that's very difficult because
people never see it until, you know,
they're 20 years into practice.
There's no way they're gonna remember it,
you know.
And when when Doxie red breasts
are inflamed and a young woman,
they're going to think infection,
they're not going to go and do a
search in the medical literature to
see what the differential diagnosis is.
And that's fine. Actually.
It's actually fine to give a a week,
10 days of antibiotic as long as woman
comes back in two to three weeks.
To see if she's completely better,
yeah, that's the key.
And then when you know it's not 100%,
then she needs to go see
a specialist, right.
Right. So in my case,
we did what's called neoadjuvant
trimodal treatment, correct.
Yes. How important is that
within inflammation?
Can you explain that?
And then how
important is that?
So when a woman has inflammatory
breast cancer, what that means is
the breast is basically largely.
Involved with the cancer,
it's diffuse in the lymphatics, OK.
So you can't do surgery first because
in with surgery that's only if it's
kind of localized in the breast, OK.
Even if you do a mastectomy,
it's it's all over the skin
and it's in the lymphatic since
you can't get clear margins,
it's it's too diffuse.
You have to dramatically decrease
the amount of it before surgery.
So you have to give therapy before surgery.
That's called pre.
Operative the other word for that
is NEO adjuvant and just simply
means before surgery and it always
involves chemotherapy and if if it's
her too positive it's chemotherapy
with two antibodies that block the
her tube and if it's triple negative
breast cancer it's chemotherapy
plus an immune activating medication
called pembrolizumab KEYTRUDA.
So it's it's immune therapy plus.
Chemotherapy.
If it's triple negative,
it's chemotherapy +2 anti her two antibodies.
If it's her two positive,
and if it's estrogen receptor positive,
it's chemotherapy preoperatively.
Always stay out.
You have to shrink it way, way,
way down before you can go to surgery.
Surgery is always a mastectomy.
You can't do a lumpectomy because
if the cancer is too diffuse in
the breast and you always have to
do a full axillary dissection,
you can't do Sentinel lymph node biopsy.
You have to take.
You have to do a full accelerated
dissection because the cancer loves
the lymphatics and then you have to
always do comprehensive radiation therapy,
the chest wall and all the
lymph nodes around the area.
And so that's it's very,
it's sort of the most aggressive
form of everything we have
Jennifer for inflammatory breast
cancer. What's the future hold
for inflammatory breast cancer
in terms of treatment trials.
Sort of hope is out there
for those of us diagnosed
so.
Inflammatory breast cancer.
Unfortunately, because it's so rare,
it's hard to do clinical trials,
just inflammatory breast cancer.
Although thankfully there are some
centers in the US, Dana Farber,
MD Anderson, for example,
where there are specialized
inflammatory breast cancer clinics
and there are faculty experts who
spend their whole life thinking
about what's the best clinical trial.
So first of all,
women should know about that.
And they should consider either an
in person or if possible a telemed
consultation to see what trials
are available to them you know,
so that's that's the first thing
to say is that they're, it's rare.
So there's not a lot of trials
specifically focused on inflammatory
breast cancer but there are,
there are some and there are some
experts who do nothing but think about that.
But in general we think of inflammatory
breast cancer as some of our.
In in those we haven't cured yet because
we still thankfully cure probably,
you know, 70% of women who present with it,
but still that's a third of
women that we're not curing.
You know what's on the horizon in in general,
in general for these aggressive
breast cancers that have not been
cured by our standard therapies.
OK. And. I think the.
We're gonna see more use of immune therapy.
We're hoping to get good results this
year for the aggressive form of hormone
receptor positive breast cancer like
like you had with immune therapy.
Big study,
we're waiting on the results.
So that would be awesome.
It also improving upon immune therapy
for the triple negative where it's
already shown improvement in outcome.
It's still not 100% by any means,
but it's it's been a a leap forward now
there's going to be building upon that
you know for example we're waiting on.
They approval for hormone receptor
positive breast cancer of an
important agent called Capital CERTID.
It's an oral blocker of the AKT
pathway that's an important resistance
pathway in breast cancer in general
and inflammatory breast cancer.
So that's an A very important agent
that we're looking forward to.
We're looking forward to the FDA
approval of better anti estrogen medicines.
We're hoping for FDA approval in
February of a of an oral medication.
Called Ella Sestran T which is a
better form of an antiestrogen therapy.
It's it's like fulvestrant faslodex
which is an intramuscular injection
in the gluteal muscle,
but it's an oral therapy and it's
it's more effective than the than the
the faslodex you know for example.
So in some ways it's better therapies
against the estrogen receptor,
but it's new therapies against the
AKT pathway you know for example
bringing immune therapy into the
aggressive estrogen receptor positive.
Breast cancers,
that's very important and there's
a whole field of understanding
how exactly the cancer falls down
on repairing DNA.
All cancers can't repair their DNA correctly,
so you can find out exactly what it can't do.
There's a resulting dependency on
a different DNA repair pathway.
Knock that out. That's a big area
of research it's working now for.
Women who have been inherited a BRACA
mutation, a braca one or two mutation,
we have PARP inhibitors for them because
the breast cancer when it loses track
of one or two it needs parp big time.
When you knock it out,
it's very, very effective.
That's made a big impact in the cure
of women who have inherited a bracket
one or two mutation, the cure rate.
So that's an example of how going
after that DNA repair vulnerability
can make a big impact.
So that's another big important area of
research. Absolutely.
Gives us a lot of hope. Yeah.
There's a lot going on.
Yeah. A lot has changed
even since I got that.
Yeah. Six years ago.
Yes, it has, yes.