Welcome to Arkansas talks health.

I'm Cristina munoz.

For decades, cancer treatment often followed a more standardized approach.

If two people had the same type of cancer, they might receive much of the same treatment.

But that is changing.

Physicians can now learn much more about an individual patients cancer, including molecular and genetic characteristics that may help determine which treatments are most likely to work.

That increasingly individualized approach is known as precision medicine or in cancer care, precision oncology.

And while some of this may sound futuristic, much of it is already being used to treat patients today.

In an earlier Arkansas talks health, we looked at the fundamentals of cancer, how it develops, how it's diagnosed, and the major ways it's treated.

Today, we're taking that conversation a step further.

We'll begin by looking at what precision medicine is allowing doctors to do today and what still being studied.

Then we'll turn specifically to breast cancer, where advances in screening, diagnosis and treatment give us a particularly good example of increasingly individualized care.

Joining me today are Doctor Diane Wilder, medical oncologist at Karthi, and Doctor Sam McCool, medical oncologist and medical director of clinical research at Car-T.

Thank you both for being here today.

We appreciate you.

Thank you for having us.

Of course, of course.

So we also want to remind viewers that today's discussion provides general information and does not replace talking with your health care professional about your individual health and medical care and your needs.

So to get started today, I'm going to start with you, doctor McCool, a little bit about this precision medicine.

It sounds so fascinating, but describe what exactly does that mean.

It means that really we over the last couple of decades, we were able to uncover the genetic code of the human body.

And as you know, all of us inherited some of our genes from our mom, from the others, the other half, from our father.

The issue is that for a long period of time, we could not understand the genetic code until we started a project that is called the Human Genome Project that started in 1990.

It took us 13 years to uncover the genomic code.

We spent $2.7 billion on that.

Wow.

And six nations participated in this process.

In the end, in 2003, the Human Genome Project results were published from thereon.

We were able now having the blueprint of how our body is built.

We were able to go to the diseases now and see what goes wrong in our genes when we have cancer or other diseases for that matter.

So we were able now to compare what happens during the abnormal process to what happens, you know, in normal situations.

And that allows us to detect the minute small, small changes that happen to the genome that might involve one letter of that code.

And that would explain how the disease has developed.

So from there on, there was a plethora of discussions and work and research that allowed us to uncover a lot of the underpinnings of different diseases.

And here we're talking about cancer.

I'm going to refocus the discussion on cancer.

And we realized, actually what appeared for a long period of time to all of us as one disease, they started breaking down into multiple entities that are driven by specific genetic changes or mutations.

We call them sometimes or sometimes genetic alterations because some of them are mutations, meaning one letter was replaced by another.

Sometimes the genomes, you know, criss cross and then change material.

And that puts, for example, gene in an area that is not supposed to be.

And it becomes completely out of control driving the cancer process.

And it's interesting from the breast cancer standpoint, because if you look at the history and the continuum, back in the 1880s, breast cancer was treated with surgery.

It was thought to be cancer cells growing outward.

So the thought was get as much tissue as you can, get out the tumor, and that will keep it from spreading.

And what they found is that wasn't the case, that this really was a systemic type of process.

So then they would do surgery and added chemotherapy to try to clean things up.

Then they found that they didn't need to do these radical mastectomies.

They went out the door.

They were replaced with lumpectomy with radiation.

And the outcomes were similar.

So that put an end to this radical type of surgery.

So you see this sort of de-escalation of treatment along the way as we've, as we've had more information even back then.

And then back in the 70s, it was found that breast cancer was not one type of tumor that was treated all the same way, but that it had different characteristics.

And they found that some breast cancers are triggered by hormones.

And if we could block those hormones, then we could kill the cancer cells.

So that was the first precision medicine that was found back then.

And then about a decade later, we found the her two receptor on breast cancers.

That too could be blocked to kill cancer cells and eliminate the cancer.

So as we've gone along, we've evolved into this process of finding exactly what the tumor is made of was comprised, and then making our treatments tailored to those particular tumors using the information, doctor McCool said.

So with that knowledge, could two people with the same type of cancer have completely different types of treatments?

And the answer is biology or behavior, just as he said, because these genes are not all the same.

So let's just say you had someone for with hormone receptor positive breast cancer and they get different treatments.

How do we know when one needs one treatment or the other, when we're able to actually look into the profile of a tumor and look at the genes and determine what the behavior will be.

So maybe the cancer A is sort of indolent laid back, and then cancer B is more aggressive in these chemotherapy in addition to the hormone therapy to keep it from coming back.

So may look the same on the outside.

But we are getting into the driver's what makes it grow, what causes it to grow and spread.

This is so incredible and very revolutionary.

Like we said, it sounds futuristic, but talk about it in terms of you've actually been doing this and using it.

What have you seen?

Maybe even less treatment as opposed to more treatment based on the genetics?

Absolutely.

Actually, one of the in my opinion, major advancement in breast cancer was the discovery of the way that these genes are interacting in a specific disease.

And you will have, for example, one, if it's hormone driven.

I we have a test, for example, now for hormone driven breast cancers, we can get the results of the gene expression in that cancer.

And that will tell us whether this cancer can respond to chemotherapy or not, whether this cancer, for example, is a high risk for recurrence or not.

So we have the ability at this point to predict what type of cancer would respond to what type of treatment based on the genomic data that we collect that would allow us.

Also like if I want to get out a little bit of breast cancer to lung cancer, lung cancer for a long period of time has been one of the highest killer, actually in the nation.

And at this point we looked at it as we have two types non-small cell and small cell lung cancer.

Recently, thanks to the genomic analysis of the cancer, we identified about 15 types of the non-small cell lung cancer.

And we know exactly what gene is, the driver of the process.

And many of those genes.

Now we have a specific treatment.

That's why it's the precision ontology.

We have specific treatment that goes through that gene and turns it off.

And then cancer cells drop dead.

So let me give you an example.

If I have 100 non-small cell lung cancer patients, ten of them have mutation in gene A I have a drug that targets Gene A, but if I don't know any one of them, I treat all the 100 with this drug while the response rate is going to be 10%.

Right, right.

But if I those ten patients and I give them the treatment, the treatment response would be percent.

That is precision isn't it?

Yes.

Very, very precise and worth every penny of that research that you said it took to get this.

The nice thing about it is this is not in the future.

We do it every single day.

That is absolutely remarkable.

So two terms thrown around that if you could, in the most layman's terms as possible, that difference between genetic and genomic, what are you looking for there.

So genetic mutations look for mutations in a person's body.

In my body your buddy body I'm looking to see if any of my jeans have a mutation that would increase my risk for breast cancer or any other lung or any other types of cancers.

And I remember that because of the eye and genetic genetic is or the genes have to do with the genes in my body, I mean, and genomic has to do with the genes in a tumor and tumor genomic.

And so those then if we identify the genes, like we were saying earlier, then we know what the targets are and we know which drugs are more effective.

So genetic are the genetic mutations in a person.

And genomic are the genetic mutations in a tumor.

Very good.

Explain that very very well.

So I'm curious to know in practice, when you start explaining this to your patients who may or may not be aware of this, how has that been received for them, this personalized, precise treatment?

Well, it's like doctor McCool said, it is really the predominant way that we practice medicine now, which is so exciting.

And we're on a train ride that's just getting faster and faster because that's where the research is focused, and that's where we have more and more information.

So you can imagine the gratification we have when a patient comes in.

Because, you know, we talked about the progression of cancer and its treatments and things are moving so fast.

People don't know.

So they will come in and think that they have a cancer involving the lymph nodes.

That means chemo.

That means a poor prognosis that doesn't.

So we're able to say we do a lot of education and teaching where we are.

So we're able to say that isn't true anymore because of the new information that we have.

So we're able to relay just these very things, just like what we're talking.

And we're able then to help them to see that there's so much more hope than there used to be.

That is so.

And that's really what it comes down to, the patient care and how you can speak to them and how you can really help them.

I don't know anyone who hasn't watched a loved one go through a cancer or a cancer treatment of some sort.

It is just so predominant out there.

So this is really huge and could be so changing, life changing especially for your patients.

So it's ongoing right.

This research kind of continues.

So what is being looked at now I think the most important thing for example, let me give you the example of the genetic mutation that we first discovered in breast cancer.

Is the bracket one and bracket two in the mid 90s of the last century.

And the laboratory that discovered that put the patent on that discovery.

So they patent the gene and all the other laboratories.

Nobody could really go and sequenced the gene.

And the prices for the sequencing were extremely high.

So the Supreme Court struck down that monopoly.

And in 2013, and from there on, we started uncovering because other people were able to do it, other laboratories, excellent ones, were able to do the same thing.

So we know, for example, now we can't get the same test for much, much less cost.

And we started discovering other cancer genes that can predispose women, for example, to have breast cancer.

At this point, we don't anymore do like single gene.

We do a panel, we call them.

And the important thing actually difference between genetic and genomic that Diane has discussed before genetic can be passed down to the children.

Genomic.

It's it happens in that very cancer of the same individual.

It's not contagious.

It cannot pass be passed down to the children or or given to somebody else.

So this distinction is very important because when we discover, for example, genetic mutation that predisposes someone to cancer, we do what we call a cascade testing.

So we offer all the family members first degree, second degree, sometimes third degree, depending on the degree and the family tree.

We offer them genetic testing and we identify those who are carriers.

We call them.

They have not manifested any cancer yet, but those individuals that are healthy, they can be enrolled like in we have a high risk program, all those who are carriers of genetic mutation that predisposes them to cancer.

We follow them prospectively and with the first signs of cancer, we can probably intervene.

Or furthermore, we have what we call risk reducing mastectomy, for example, or risk reducing offer for the ovaries.

And sometimes we do risk reducing pancreatic.

Tommy, if we see some cysts there that are suspicious for cancer.

So all these interventions were not possible even 15 years ago.

And at this point this information is available at our fingertips.

Honestly, by the way, I wanted to tell you, you can sequence the human genome now for almost $1,000.

It takes one week to do that.

Wow.

It took us before 13 years, $2.7 billion and hundreds of researchers were working on it.

Now it's commonplace everywhere.

I mean, in good laboratories, I would say, well, this is the importance of research and continuing that.

And it really is remarkable information that you guys are sharing.

So this sounds I mean, it's so incredible for cancer treatment and moving forward.

And so along those lines.

So it's great that we're going to have this individualized and precise treatment.

But what other factors come into play when you're talking about treatment targeted therapies, immunotherapy, even though they're different now there may be other things to still do that are different for this individualized patient.

Is that right?

Yes.

And we certainly look at the cancer itself.

But we also now are learning to look at the microenvironment.

And that's really the neighborhood that goes around the cancer.

Cancer cells are smart.

They're not just a collection of cells, but they actually start to recruit.

They start recruiting all of the body's own forces to help build their blood supply, to get nourishment, to actually build scaffolding around, to hide them from the immune system.

And so we immediately send out immune cells when, when cancer is detected and the cancer cells take that and sort of flip them so that they don't work anymore.

And so we are able now because of tools that have come about in some of the drugs that we have now, we're able to identify those and found that in some places, this immunotherapy, basically a drug that comes in and those immune cells that are that are trapped by the cancer are then released by the cancer so that they really can fight the cancer.

So immune therapy is another drug that's available.

We're also able to alter the microenvironment of the tumor so that it's not as friendly to the tumor.

And so there are different avenues that way.

Certainly the tumor itself but also its surrounding.

Absolutely.

And so again let's talk a little bit about preventative because with or without this research, preventative has always been such a key when it comes to cancer.

So we're talking about screenings mammograms.

These are still key and still essential even with this genetic knowledge.

Is that right.

And like doctor said, it's even we even have more tools.

You can imagine how gratifying it is when someone comes in and we have tools and we're not limited like we used to be.

And we just say, wait, you know, the is coming because this is where all the international brains and research is and all the commitment is being done is to make more of this.

But yes, so that we have we have much to offer to people so that they are not without choices.

Absolutely.

Yeah.

To Diane points, we have a lot of tools now.

The point that we have learned also from other specialties, cardiovascular disease is for example, caused by we know that smoking, diabetes, obesity, hypercholesterolemia, we do have also risk factors for cancer.

And these risk factors are really important to mention to the public who is listening to us.

For example, obesity is a risk factor.

Tobacco is a major risk factor.

Sedentary lifestyle is another risk factor.

Sometimes, you know, I became a little bit personally interested in microplastic.

It seems like I changed all my plastic way into something different, because microplastics are now going into every living being in the fish and the beef and the lamp that we eat, whatever it is.

So there are a lot of things that we can't change.

What we eat as also is important, like red meat.

If you eat red meat every day, the risk for colorectal cancer goes up by 50%.

So there are things we can do ourselves.

We have agency.

It's not really something destiny that we have all to get there.

We can avoid it if we undertake the right behavior and make the right decisions.

And that is great news.

But there's a lot of education and awareness that goes with that, which is what we're doing to really inform the public about things that they can do.

How about advances in mammography and technology on that side of it?

Has that been going up as well?

Absolutely.

One of the most important findings, for example, we realized that mammography has decreased, actually the mortality from breast cancer by 20 to 25%, depending on the studies, which is amazing.

I want to say something about cancer that is so important.

In 1920, five year survival from breast cancer was 5%.

In 2025 five years survival is 92%.

Mammography is responsible of significant chunk of that.

In addition to therapy and other preventative agents that we use.

But the bottom line is that mammography is good but is not perfect.

So we have now contrast mammography.

We have sound and we have also MRI.

And we have discovered that there is something special, even if you don't have any predisposition to cancer breast density, for example, it's a very important risk factor for breast cancer.

And we now we have a law in Arkansas to mandate the mention of the density of the breast on the report that is generated, generated by our radiologist.

Thank God we have wonderful radiologists here and at Karthi, and they're on top of everything I'm telling you.

But the bottom line is that if we bring all this information together, we can design the plan for the individual patient.

And regarding treatment, Diane mentioned the microenvironment, but I want to mention something.

When you have heart disease, lung disease, kidney disease, all those are going to affect your ability to take treatment A versus treatment B. So when we look at the person, cancer is not only disease of that organ, it's disease of the entire body.

And we need to take all that into consideration as we design our management plan.

And I assume this is only more in the future.

Go ahead, go ahead.

Yeah, that's where the prevention comes in.

Not only preventing because we know someone has a genetic mutation and knowing that way, but also we know the value of nutrition and activity.

And more and more people will say, you're doing all this to me.

What can I do?

And will say, you are well equipped because we now know we have data that tells us that implementing those types of behaviors to eliminate alcohol, tobacco, but also to optimize nutrition and then to get the activity going, actually creates changes in the microenvironment.

It helps to boost the immunity and helps with treatment.

So identifying those people who are at high risk for prevention strategies who say with one arms treatment, one's prevention and they lock together, together.

Wow.

It's almost funny to sound so excited about something regarding cancer treatment, but it is exciting because there's so much there that can be so helpful to these patients.

So thank you so much for all your insights and your knowledge.

And still a lot more to come.

So stick around.

Stay with us.

We've been talking about precision medicine broadly, learning more about an individual cancer and using that information to help guide treatment.

Now let's make this more concrete.

Breast cancer gives us a particularly good example of precision medicine in practice.

And increasingly, individualized care can begin before treatment with how we assess risk and how we look for and detect cancer.

Joining our conversation are Miriam Karanja, director of programs for the Arkansas Cancer Coalition, and Doctor Stephen Rotten, breast imaging specialist at Car-T.

Thank you both for joining us, and thank you for sticking around with us.

An incredible panel of knowledge and wisdom right here.

So thank you so much for all for being here.

So we want to jump right in.

And doctor, I'm going to go to you first to talk a little bit about how different this has been for you compared to ten, 20 years ago, how this has really made a change for what you do in your day to day assessments.

So I'll say, you know, the the whole goal of breast imaging, it's early detection, right?

The earlier we find cancers, the smaller they are less likely they are to have spread and they're more highly treatable.

The imaging advances in mammography have been tremendous in the last 20 years.

I can tell you in the last 14 years that I've been in practice that, you know, when I was in training, we were hanging films, so little X-ray that you could hold in your hands and you could see, well, that might be really tough for a woman who might have dense breast tissue or a lot of scarring or so.

We went from those films to digital mammograms and then to a technology called synthesis.

That's what's commonly known as 3D mammograms, which are now the standard of care across the board.

And we have even newer technologies that we're using now, like MRI and contrast mammograms.

So I can tell you that just from an imaging standpoint, it's great in that I will tell patients, hey, it's easier for me to look through that tissue.

I will find cancers that may have taken me years to find, in a woman.

And now that we can find on our first mammogram, and again, I can find them smaller.

Well, and you've been doing this a long time.

Is there any way to quantify that difference between how many you might catch back then and how many you can do?

Not actual numbers, but just kind of that overarching the good news part of technology and screening.

Yeah.

So and it may vary just with a person's level of training or if they've done specializing in breast cancer imaging.

Older statistics for about for every 1000 women that got screened, you wanted, you were going to find about four women with cancer.

Now it's about 7 to 10.

So it's really about doubled.

Wow.

That says so much.

And for the future might even be more as we move on.

But I mean, what a great increase in technology.

However, that really doesn't help anyone if you're not getting screened.

So, Miriam, I want to go over to you and just talk about the importance of that and how you help get that education and awareness out there.

Well, it is so true that you can have the best technology, but if you have patients in the or people in rural communities where there is no transportation or no health care facilities, there's just way too far.

Or for example, what we found when we did our focus groups is that a lot of rural Arkansans have so many other comorbidities and other conditions that they are struggling with.

They have heart issues, they have diabetes.

There's a financial struggles, lack of insurance.

And so as a result, cancer screenings take a backseat.

And so you'll find that they'll discover cancer is discovered later and or not at all until the very last stages.

So big, big challenge.

And and that's where the Arkansas Cancer Coalition comes in.

We work with communities to help provide gift cards where people can get transportation and or designing actual transportation systems in partnership with local churches or local nonprofit organizations that can actually transport people into, for example, little Rock or West Memphis or other areas to get their screenings.

And we've talked a little bit about two.

There's a fear factor that goes along with this.

Sometimes the I don't want to know, which really doesn't, which really doesn't help.

Oh it's terrible.

It breaks my heart a little bit because there are so many people who say, I'm too scared to get a screening because I'm scared of what's going to be found out.

I remember one time was a state fair, and a young lady came by our booth, and this tickled me a little bit.

And I said, where do you work?

She said, you are a mess.

And I said, well, why do you just right across from me?

She's like, I don't want to find out.

And it took a lot of just conversations and screenings and said, what if you go and there's just nothing?

And so she promised me she would go, but she was just too scared to find out what what what may be there.

So she was just behind on her screenings, and she was afraid, even though she was right within the place.

One of the facilities that offer mammograms.

One of the best.

And I understand the fear, for sure, but there is that education and awareness element that, yes, that we absolutely have to get out there.

So you mentioned the state fair.

Talk a little bit about what you offer and how this works.

It's one of our most exciting, you know, opportunities.

Over half a million people attend the state fair every year.

So we have this big blow up colon.

We have a big blow up lung, which people are so excited by kids coming and play.

But as they do that, we are talking to their parents and we are asking them, hey, you know, how old are you?

Have you had your screenings for the different cancers?

And that's when you really realize that most people are like, what?

What are you talking about?

This just such a lack of awareness about screening.

So.

And sometimes we offer them like a blood pressure screening, and then we kind of gently move them along to their cancer screenings.

And we have a discussion information, but we also refer them directly.

For example, working with doctor McCall will refer them for their lung cancer screening.

So in other facilities.

So we have all these partnerships, but we really try to make it as tangible as possible.

We tell our own stories.

You know, our I was a patient at Qatar for a breast issue.

And so you share your own story and say, you know what, I am so glad I went in earlier rather than later.

And you just make it as personal as possible and they'll connect with you and ask you questions and, and really kind of kick in that, that interest kicks in.

And the coalition has a huge base of volunteers and many of them are survivors.

So they'll tell their stories as we give information and as we literally sign people up and then send those forms off to, say, doctor McCall's lung cancer program, and then they'll pick up from there and follow up.

Well, you really are taking it to the streets.

But we've also talked about, though, if someone can just get on that yearly or whatever the screening demands and to go to the clinic and to go to the doctor, both are good, both are needed.

But you really do want them to get those high quality screenings.

Oh, absolutely.

Actually, screening at this point is offered for breast cancer, lung cancer, colon cancer, prostate cancer and cervix cancer.

And we have data to prove that if you detect the cancer, early mortality from this cancer drops by somewhere between 20 to 30%.

Furthermore, I'm going to talk about screening for colorectal cancer because it's really so important that when we do that colonoscopy, if there is a polyp that is precancerous lesion and we remove it.

This will not become cancer down the road.

So as a result of starting the screening, for example, in the old days at age 50, we noticed decrease of incidence of colorectal cancer in the older than 50.

However, there was a rise in cancer in younger than 50, colon cancer in younger than 50.

And that's why we decided to move it down to 45 now.

So I think I urge everybody who is listening to us, please talk to your doctor and see if you are eligible for screening for colorectal cancer.

But lung cancer is not less important, by the way.

And I was involved in all this screening things actually, I had a patient who did not want to be screened because he told me I don't have insurance.

Doctor McCool, if you screen me and you find cancer and you tell me if you don't do anything, you die in two years.

And I don't have.

And now I don't know about it.

I would rather die in two years without knowing.

And that breaks my heart.

You know, I don't think that anybody should die of cancer without receiving the appropriate care.

That is truly deep belief in my heart, and we should all of us work to advocate for that.

Furthermore, I want to say, once we have detected the cancer early, guess what?

The price that we put actually to treat that cancer is way less than if the cancer is more advanced.

We know very well that most of our healthcare money are spent in the last year of metastatic cancer treatment, so why do we let them even go all the all that far, all the way to the metastatic stage for setting.

Right.

So I think in that regard, if we want to identify one thing that we can do to help Arkansans here is to make sure that everybody is talking to their primary care physicians, and everybody is receiving the appropriate screening for their age.

Such great advice.

Absolutely.

Well, sorry to interrupt, but not at all.

You mentioned that keyword that we've said a hundred times now screening.

Right.

And so some people will say, well, I'll just wait until I have an issue.

Right.

I'll wait until I feel alarm.

And when when you wait, then it's going to be a lot larger than than when I can find it.

You know, that's what's called a diagnostic visit.

And we do a lot of those.

If patients are ever having an issue or feeling alone, I say, please talk to your doctor.

Come in.

We need to check you out.

The difficulty with screening and you touched on that having people that maybe don't want to know they're scared.

Screening means you're healthy.

That means you're not having any any problems or anything you're aware of.

And that's tough, right?

Because who wants to go to the doctor when they're not having an issue?

I don't want to something.

Right.

And that's a battle we we we all fight, and we can only do that by outreach and by listening to our patients to say, hey, it is important because what is the biggest risk factor for breast cancer?

It's being female.

It's a it's a risk that that you're just you're just born with.

You can't change.

It's not it's not family history.

It's not environmental.

And that's why I'll say, hey, I and that's great that you may not have a relative.

You may not have any other risk factor.

You may not be having a problem.

Still come in for screening because this whole goal of early detection, early treatment, all these advances, all the advances in treatment, in medical imaging, none of them work if if we can't see the patient.

And one of the biggest myths, Christina, just to build on your point, is the idea that if I go in for a breast screening or any other screening, then I will be diagnosed with cancer.

So it's almost like inverted the way people, a lot of people think.

They're like, you know, they went in for screening and they died of cancer.

And I'm like, oh no, no, no.

So just trying to sort of say, you know, that's really not the way it works.

But there's a huge myth that, you know, mammograms cause cancer and this diagnostic test will lead to cancer.

And in some of the focus groups that we did, this just so much myth and sort of rumor, you know, my aunt went in and she just didn't make it, you know.

So I think that sort of, you know, just trying to demystify and bring and giving the right education, that really helps a lot.

Causation versus correlation.

Right.

So I think we all need to get over the fact that it can be a little annoying.

Like you said, when you're healthy to go set up an appointment, we got to get over it because a little annoying is way better than a diagnosis, treatment, death, all these things that can go with it.

And you mentioned you're not only saving lives, you're saving money.

And so it is so absolutely important.

So that is the key message out here today for sure is go get screened no matter what.

So taking it back to breast cancer Doctor Wilder, tell us a little bit about the types of breast cancers that you see and that are out there.

Well, I wanted to say that what you do is so important because it's true that there's misinformation out there.

But the other thing is there really are many, many people who are just trying to make it work.

You know, we see grandparents all the time raising their grandchildren on Social Security, and so their means are very limited.

And so by the time they get to themselves, all the resources have been extended, including energy and just commitment.

Also, there's a sense when you're that busy making it work throughout the state in different parts of the state that you just too tired to take care of anything, and it falls back as far as being important.

And so going out to these communities matter so much.

I love the state Fair because people are coming in.

But, you know, all of us, we saw in your cancer 101 that people we are reaching out.

For example, we at Karthi are trying to establish offices and cancer centers in the communities where people can come so that travel isn't so far.

So then it gets sort of in the in the water per se that we're talking about.

It gets to be part of the conversation and people who come and visit, then it gets to be part of the lingo.

So as we go and we permeate these areas where people haven't been, then we're able to start raising awareness and saying that you are important.

Yes, maybe you're the primary caregiver and the one holding everything together, but you are important.

And then teaching people to listen to their bodies because their their work, you know, they're getting it done.

And and then they tend to ignore what's going on because they have better things to do, which is so important.

We have so many families like that brave, courageous, wonderful families, but they're not taking care of themselves.

And so we're we're wanting to make it easy.

And we want to say this is part of the the whole story.

We can't bore from an empty cup.

Yeah.

You got to dig care of yourself.

So the breast cancer, the main subtypes that we have that we've been able to talk about, we have primarily the hormone receptor breast cancers.

They comprise about 70% of the breast cancers that we see.

And then about 15% are her to positive the protein that tends to drive more aggressive growth.

And then we have about 15% that are called triple negative.

They are not treated the same way as the hormone or the Her2.

They're treated primarily with chemotherapy.

And then like we talked about the microenvironment of those particular tumors, we know that the body sends lymphocytes in to fight those cancer cells.

And then the cancer cells lock them in so that they can't work.

And so we know and before surgery that if we give immunotherapy in the triple negative setting in combination with chemotherapy, we can unlock the gate so that your immune system can work in that.

Cool.

It's just so fun that we've got the tools that we do.

And it's so important about when things are caught and diagnosed.

Because even with the rumor mill, again, if you hear about a certain type of cancer, I had two friends with the same type of cancer.

One passed away at age 33 and one is completely fine today.

But it was a different, complete, different timing.

So not only is the different cancers pertinent than the different timing, and now we have the genetics to go with it.

But the treatment for each case can be very different.

And even within, say, the hormone receptor positive two cancers can look the same like we said earlier, but they can behave differently.

And that's where we have further testing, genomic testing to help us determine which cancer needs more treatment than others.

And of course, then you hear the terrible story of, well, I had cancer 15 years ago and I thought I was cured, and now it's come back and it's spread and, you know, everyone's talking now and hearing.

And so it's people are terrified because they don't know what that means.

So we talk about the particular cancers that have that propensity and then talk about what we do to decrease the risk of that happening.

So doctor McCullough, want to go back to you.

Earlier we talked about biomarkers and targeted treatments.

What can that look like specifically in breast cancer?

At this point, the probably the most important example is the breast cancer that happens occurs on the background of genetic mutation of bracken and bracket two BRCA one and two for those patients, for example, we know especially BRCA one it's more likely to be the triple negative variety BRCA two.

You have the entire spectrum like any sporadic we call them cancers.

So for the for those two types of cancers now we have drugs that specifically they are specifically designed to attack these cancers.

And add to the benefit that we can get from chemotherapy immunotherapy or hormone blockers.

And those drugs are specifically designed for this type of breast cancer.

Meaning if I give it to a woman who doesn't have one or BRCA two mutation, they're not going to do anything.

They might even cause some side effects for no benefit.

Hence the importance really, of always making sure that we have done our homework with the genetic testing to make sure that this patient has not inherited something from her family.

So that's what was the promoting factor for breast cancer.

And do the genome profiling potentially for certain cases to add more to the ability to treat those patients.

That makes sense.

So we've mostly been talking about women with regard to breast cancer.

But men also can get breast cancer.

I want to start over here with Doctor Roten.

What is the step for a man to do the screening process for breast cancer?

So so men don't typically get screening mammograms, right?

Men it'll be it'll be self-driven or by their doctor usually men filling a lump.

I see a few cases a year far out number by women.

So and we may take it on an individualized basis.

Some men are going to undergo genetic testing and may have a high, high risk factor for developing many different cancers.

And we may we may screen those men or men that have a history of breast cancer.

So we've got a good subset of patients at who are male breast cancer survivors.

So it is one that I that I reiterate to all just referring physicians and patients, that if a man is ever feeling a lump in his breast coming to the breast center and and I'll check him out.

And as far as advocacy goes, tuck to us a little bit about do you have men that that come to you and have questions?

We have we have seen quite a few men who have come to us, and we have the educational information out there.

And I think for them it's just saying there is nothing to be embarrassed about.

You know, you'd rather save your life than, you know, hide the fact that you are having any kind of issues or you have a lump and you're feeling something, and I will refer them to the center that's closest to them.

So we do see that.

I would like to add one thing for if you have a woman, for example, who was diagnosed with BRCA one or BRCA two mutation, her first degree relatives and relatives who are carriers of these mutations, males are at higher risk to have breast cancer.

And that can be really up to 6% of those might develop breast cancer.

So knowing this information is so important for these males in particular to undergo some form of assessment every once in a while.

And I want to reiterate something that that wrote to mention earlier screening is for people who don't have any symptoms.

Yes, all of us who are feel healthy don't have any symptoms.

Screening is for us.

And so, besides that, I think we if we need to talk about research a little bit, clinical research, I would say we have research now that is being conducted into the prevention area and the screening area and the treatment and survivorship areas, and all these parts of the journey of a patient with cancer are so important.

And we cover the entire spectrum of cancer care.

But the most important thing that we focus on now at this point in our program is truly the treatment of patients who are diagnosed with cancer.

And so clinical trial we if we if this is the time to talk, let's go ahead and do it.

We haven't yet.

And so we do want to talk about clinical trial and how this research and science is impacting clinical trials.

Exactly.

So the bottom line is once we started understanding the different drivers of every cancer, we realized that we need to test the drugs with, with the patients who carry that driver.

And the research results in the lab in the dish and cell cultures of cancer cell cultures.

And then we move to animals.

And then after that, the drugs that have proven some efficacy in these different environments are moved further to humans.

And we start with three types of trials.

We have phase one trial.

We call them toxicity trials or those finding studies.

Meaning we try to see if these drugs that worked in animals, are they going to be compatible with human beings?

What kind of side effects would they with humans get if we give it to them and then we identify those, that is probably effective.

We move it to phase two.

We call them efficacy trials and then phase three confirmatory trials.

We want to confirm the findings that we got from phase two.

It's very interesting to know I don't know if this is known to the public.

We have approximately 4300 drugs that are available on the shelf, and we cannot put them in humans because we don't have the infrastructure to do that.

Wow.

You ask me why?

Yeah.

Yeah.

No, that number alone is just kind of blow me away.

So why are they on the shelf?

Because actually, clinical trials focus are now focused practically in academic centers.

We're about 15%, 15 to 20% of cancer patients are seen, for example, in Arkansas.

Here, the number of patients who are seeing our wonderful academic center at UMS, for example, is probably somewhere 1,617%.

So the rest, more than 80% of the patients are in the community.

So and there is a complete reversal of the implementation of trials.

90% or more are done in academic environment and the smaller than probably 10% in the community.

We need to increase the clinical trial infrastructure in the community in order to answer these questions.

So how do we do that?

What are the next steps to make that happen?

What we have decided that we have a network of standard of care for cancer in Arkansas.

We have 18 locations, seven comprehensive outpatient cancer centers, and we have other clinics scattered around them.

We want to create also clinical research units in every one of these cancer centers.

So the patients would not have more than 2030 mile driving distance to get to a place where they can participate in clinical trials.

That would allow us first to accelerate the process, I mean, us and other states.

And I think I am pleading her here for a clinical trial and research in the community, basically.

So that allows us allows us to increase the discovery.

But also the important thing is that to be more inclusive, we have minorities and groups of our population that don't participate in clinical trials, and therefore the results of clinical trials that we are find from that were done in certain environment might not apply to the other environment or the other community.

So being inclusive is really the key to allow us to identify things that can work and vice and blacks and Hispanics and different ethnic backgrounds.

Right, right.

Let me give you one example.

BRCA one and BRCA two are common genetic alterations in white women when they have genetic background, okay.

In African Americans, for example, they are there too, and also in Hispanics and whatever.

But you have two other genes that are more common in African American women at 51 C and Rat 51 D. So if you have if in the old days when we used to do a one and BRCA two, we would miss these genetic mutations in African Americans having more inclusive process that allowed us to bring more black women to research, allowed us to uncover things that were completely hidden to us.

So and with that affect their prognosis and treatment?

Absolutely.

Yes.

Yes.

You bet.

And that also might affect their family members, children, parents, siblings and so on.

So the research, I think in order for it to be meaningful for the entire population, it has to be inclusive.

Yeah, that makes so much sense.

And since you mentioned family, I'm going to talk to you a little bit about cultures.

Yes.

My mother's from Chile and America, and we don't talk about anything medical or health related.

I know very little about a lot of it because it's not comfortable, it's not common, it's not really accepted.

So what kind of barriers do you see with regard to different cultures when it comes to family background and medical health?

Wow.

The secrets that we can't.

Thank you both because I'm a Kenyan and also because, families have such a hard time talking about it.

We did some amazing focus groups out in Hills, Arkansas, very rural, just far as you can imagine.

And you know, when people get comfortable, they really start telling stories.

And the issue of secrecy, you know, you'll know that an aunt died of something.

But when, when, when another family member is sick is when the family will start to disclose and tell those stories about, you know, and this happened to and this happened to our grandmother.

And I have a sister now who, has is battling colorectal cancer for the second time.

And so we began as a family to talk about.

Anybody in our family had cancer.

It had never been discussed.

And oh my goodness, the you know, this uncle died of a stomach cancer.

And we were like, what?

We didn't know.

We thought they just, you know, so secret.

And that's part of our education is really talking, asking family members to talk about it, you know, because it will save your daughters.

It will save your children, your sons, your daughters, your family members.

And and let me let me step back and piggyback on something that doctor said on clinical trials.

I think there's a misnomer when you when you use the word clinical trials, people in rural communities are like, are you just testing something on me?

And there is just that little, little fear of goodness.

What if you use this product on me and something happens to me?

So there's just almost like an automatic fear of of just the idea of participating in a clinical trial.

That's number one, one of the barriers.

And so what the Arkansas Cancer Coalition does is to really start with our health care providers to do during the Arkansas Cancer Summit.

During our quarterly meetings, we'll have an expert come in and talk about what a clinical trial is and break it down and what it isn't.

Yes.

And please refer people to these clinical trials that are available and especially in the most rural communities, also doing town hall meetings in different areas, really going down to the churches that in those rural communities and breaking it down and making it as easy as possible to understand, because people almost automatically shy, shy away when they think about, I'm going to be in a trial.

What does that even mean?

Why?

But we've seen countless of countless lives saved because they participated in clinical trials.

And you throw out that number again for some sitting on a shelf.

This could be the cure for cancer there that we just have to find out and get more research on.

And that's it's very encouraging, but I would love for people to see that side of it, as opposed to the fear and the and the Christian side of it.

That is true.

Doctor.

I'm going to go back to you, and I'm curious.

They're doing so much work, advocacy, education, awareness.

Have you seen numbers increase over the years with people actually coming and getting screened and doing what they're supposed to do?

Yeah.

And we're we don't just catch the cancers, but we're seeing more young women too.

We're we're not exactly sure why a lot of factors there.

And, and again, we're identifying people that may need to be screened earlier to with all this genetic testing we've talked about.

Now, what I like about that is I'll tell patients, look, I don't I don't want you to get overly concerned and, and find out that you've got all these risk factors and start making your will out.

Right.

What this what this means is this is, it's it's something that can cause some anxiety.

But to know, hey, maybe we need to start five years early and maybe we need to start ten years early.

Maybe we need to incorporate some other things like MRI in addition to your screening, because the whole goal is, I hope, I hope I don't have to find something, but if I do, I want to find it small and early.

Absolutely.

From the patient perspective what are you seeing.

So there's fear out there long before diagnosis.

But once there is a diagnosis how are they responding.

And is there some encouragement out there because of the research that is going on.

Well a couple of things before I get to that.

That's okay.

Number one is a genetic mutation can be passed on to any child.

So if I have a genetic mutation, many people will think only my daughters can have the genetic.

And that isn't true.

It can go to any.

Each child has a 50% chance in most genetic mutations of getting it.

So that's.

That's one thing that isn't clear.

Okay.

There's so much we do about misinformation.

And the same thing with the clinical trials.

People will come in at say, nine out of ten, say, I don't want to be a guinea pig.

And then we'll explain.

But you have access to wonderful drugs you will never get.

Not standard of care, but you may get something even better.

And so we just do a lot of explaining, because I think a lot of our job is, is explaining and correcting things that aren't clear because of course, any diagnosis arouses anxiety.

I think a little bit of it like a trauma event actually.

And so people just have their overwhelmed and they're emotionally flooded with everything that they feel.

And so we do a lot of information talking over and over, not even just one time, just trying to bring things in and certainly are supportive groups are wonderful to come in because now we're looking at all of the aspects.

We know that it is a physical, psychological, relational, emotional.

It's all of those things that sort of come to the table.

So we want to address those we do with our in our particular area, our resources, our resources that come in and bring in different types of support.

We certainly have physical therapies for people who have sequelae from breast surgery, if they have limited mobility, or they have any type of swelling or any asymmetry in the size of their arms.

Afterwards, we talk to people who have this sort of trauma response and can't seem to get past the anxiety.

But you know, what we say is we and we get to witness this is if we just say, just walk, walk the walk, just just show up and keep going because the soul is so resilient.

And in time we are just another habit going to the grocery store, going to get chemo, going to get whatever.

Because with the support, when you have the support and so many people come in, you know, one of my wonderful, I want to write something about this sometime, or the partners who come in and they sit there and they are oftentimes weeping because the patient gets all the attention, of course, but the partner loves that that partner so much that they're weeping and and they're brave and they're courageous and they've been told not to say a word.

Don't say a word.

Right.

And so everyone will turn and say, what do you think?

But but it is a beautiful picture of, I think, our state and the relationships that go on and the, the families that are there.

So we have all this rich resource here with, with the support that we have.

So we pull everybody in and we support the families, we support the patient with everything we can, and we do a lot of education.

And then we cheer them on.

And we're able to see from the beginning when someone's terrified to the end, when they say, this is what I've learned and this is what I've seen, because we say the trials are never wasted.

You know, if you commit them, they're not going to be wasted and you will be free, maybe of a bondage that was keeping you from something that you didn't even know about.

Or perhaps you see with new eyes through this journey.

And so, because we know that at the end we are able to come along and just put our arms around them, do what we can from the certainly from the clinical standpoint, but also from all the other impacts to and your type of resource is invaluable because it's all of us.

It's a really family approach to to get people through.

You all are so encouraging and and it is exciting.

And so, doctor McCall, before we go, I want to know what are you most excited about when it comes to the future?

I mean, maybe it's research, maybe it's trials, but I know you see a lot of what's to come.

What are you most excited about?

I think the most important thing is that we have people on, on now on the ground who are committed to moving that needle.

And I here I'm talking about the 140 oncologists in Arkansas, but also the radiologist, the advocates and the surgeons and so on and so forth.

We have a huge potential, in my opinion, to flip the situation in Arkansas from being in the bottom of the healthcare for cancer to somewhere close to the top if we work all together.

So I think what encourages me, first of all, the march of science is not stoppable.

It's going to continue.

And the believers in science and the goodness of people are the ones who are going to make the difference.

And I in that regard, I can salute all my colleagues who are working in this environment, all healthcare professionals, because we need this dedication.

It's not by chance that we are here.

We have been inspired, all of us by either personal story or somebody else's story.

And I think this energy and passion are going to lead us to the light.

And I feel the same way about all of you, because you all see not great things on the daily basis, but you're also positive and so encouraging.

So same question, Marion, to you.

What are you the most about the future?

Yes, I think the power of our partnerships, and I just can't say enough good things about Catie because I have been a patient there.

And so I've walked the walk on many, many days.

And just from being, as Doctor Wilder said, being absolutely terrified to kneeling down in their chapel and saying, God, thank you so much.

You know, I've really literally gone through those emotions, you know, on a couple of occasions though.

And so but I think the power of compassion that I know I received from Catie and the power of our partnerships and keeping each other encouraged and saying, Doctor Michael, could you be the keynote speaker and just teach us the latest about prostate cancer, just drawing into each other and leaning into each other and committing together to go to the most difficult places and the most hard to reach places.

And doing it together, I think, makes it easier for all of us and for our communities.

Well, I am absolutely inspired by all four of you.

Thank you very much for sharing all of your wisdom and insight today.

And I think it was very educational and very powerful for our viewers.

So once again, thank you for your time and your insight.

You're very much appreciated.

And for more information and resources from today's program, visit the Arkansas TV blog at Arkansas tv.org/blog and a reminder that today's discussion provides general information and does not replace talking with your health care professional about your individual health and medical care.

I'm Christina munoz.

Thank you so much for watching Arkansas Talks health.