In this episode, Dr. Slavin speaks with breast surgeon Dr. Allison DiPasquale, Director of Breast Oncology at Medical City Dallas and Board President of the Susan G. Komen Dallas County Chapter. They discuss the role of genetics in breast cancer treatment and prevention.
0:00:11.7 Dr. Thomas Slavin: I am Dr. Thomas Slavin Chief Medical Officer for Myriad Genetics. Welcome to Inside the Genome. Hi everyone, welcome back to the podcast. Today we have Dr. Allison DePasquale. She is the Director of Breast Oncology at Medical City Dallas. She is a fellowship trained Breast Surgeon within Texas Oncology. She is also a Board President of the Susan G. Komen Dallas County Chapter. Welcome to the podcast, Dr. DePasquale.
0:00:38.4 Dr. Allison DePasquale: Thank you for having me, Dr. Slavin.
0:00:40.8 DS: Yeah. Well, so you and I, we go back a long time to our California days. [chuckle]
0:00:48.0 DD: Yes.
0:00:49.6 DS: Yes, yes, yes, even though I still live there. But you have since moved. And I thought you'd be a great guest to have on, as why you chose breast surgery as a profession, your journey and how you're currently practicing, just for our listeners to have an idea of what it takes to become a breast surgeon and what the daily life of a breast surgeon is.
0:01:09.8 DD: Well, I always say they should do a show called The Cure, focusing on residents going through whatever their direction is, or cancer surgery. But for me, it was really a calling. Breast surgery and being a surgeon, it started at a young age. There are no doctors in my family. There's nobody that I know that's a surgeon. I grew up in a very small town in Wisconsin. I did watch a show called Slim Goodbody on PBS. [chuckle]
0:01:39.2 DS: Never heard that.
0:01:40.3 DS: So if you Google that I'm very sorry, but this show was a gentleman who was half veins, half bones, and he talked about the human body. So at the young age of three, I decided that I was gonna be a doctor because I loved it, loved everything about it. And then I loved surgery, 'cause I loved to sew and I loved the idea of being able to fix people with my hands. I thought that was just very neat. So that was about age seven. So, I'm a very early decider. Then I went through all my medical school and my training, all the above, and I got into my general surgery practice out in Boston. And I really wanted that patient connection, 'cause one thing about me during my journey is I always wanted to connect with patients. I didn't just want to operate and say good-bye.
0:02:26.0 DD: So I went through and did my whole General Surgery the first year, and it was hernias, gallbladders. The patient had an operation, maybe came back for a post-op appointment, and that was it. I felt like that was very impersonal. I then rotated with the breast surgeon, and she walked in and she gave a hug to every one of her patients. She knew where their kids went to school, 'cause she followed them with their mammograms after their cancer journey, keeping them cancer free. So for me as an intern, I early decider I said, "I'm gonna be a breast surgeon." And that's what I did.
0:02:58.6 DS: Yeah, that's great. And what does your current practice look like, your day-to-day?
0:03:03.8 DD: Yeah, so I'm with Texas Oncology. I'm 100% breast, meaning I don't do any general surgery or anything like that. My day-to-day is a combination of clinic, seeing patients with cancer or high-risk patients, which are really important. We'll get into that further with genetic testing, but there's a whole high-risk clinic that I see as well, and then I operate. So, really two and a half days a week of clinic, seeing patients, connecting with them, either on their beginning of their cancer journey or in their survivorship, and then OR is the other two and a half days of the week, where I'm really focusing in the operating room, removing cancer.
0:03:41.8 DS: That's great. And I heard you're doing some work with Susan G. Komen, you're the Board President for the Dallas County Chapter. What work are you doing with them?
0:03:50.9 DD: Well, I think that in breast cancer, especially here in Dallas County, it's quite evident the inequity that we have in healthcare, especially for breast cancer. The highest zip codes for those underserved areas have the highest rates of breast cancer, but yet the lowest rates of the ability to get a screening mammogram. And it's not just about getting a mammogram, if it's available. It's about the knowledge that, hey, you need to get it and you get it all the time, and cultural changes and cultural differences. So, working with Susan G. Komen really opened up my mind on that, and it allowed me to really help serve the underserved, to ensure that they are getting not only access to the mammograms, but financial support throughout their journey as well as education. Because you can put a mammogram, mobile mammogram machine anywhere, and it's not necessarily that patients will definitely come and get their mammograms done. They need to be educated to do it, it needs to be available when they're off work. It doesn't need to be available during their working hours. So, looking at my journey through breast cancer care and what affiliation and organization I really wanted to align with, it was Susan G. Komen because they look at the 360 approach to patients, they start with research, they do education, they help with screening and then with treatment. So it's what happens if you get a diagnosis of breast cancer if you can't pay for it, how does that help?
DS: So, I wanted to switch gears a little bit. So our podcast is inside the genome, and you did some genetics training with me at City of Hope. I just wanted to find out how has genetics really influenced your practice as a breast surgeon, and how are you using it in your day-to-day.
0:06:42.1 DD: Yeah, genetics has revolutionized breast cancer care and also just making people aware of what high risk is. We have the mammogram that's out there and they say you should start at age 40 unless you're high risk. Well, what does high risk mean? Not many people know.
0:07:00.8 DD: So... And genetics has a lot to do with it. So not just breast cancer, we know lots of other cancers are related to it. To breast cancer and puts you at higher risk. Like colon, ovarian, thyroid, the list keeps going on and on. And so genetics in general, genetic testing of patients has allowed patients to get a control over their genes instead of just waiting for something to happen.
0:07:24.9 DD: So I think this is really empowering patients with their own knowledge and saying, "Hey, my mom had this, my dad had this. It was terrible watching them just kind of wait and go through things. And I wanna take control of what I'm doing." So I run a whole high risk clinic on that standpoint where we will test patients all the time. And we now have good...
0:07:45.0 DS: Who don't have cancer.
0:07:45.4 DD: Medical information... That don't have cancer, as well.
0:07:47.7 DS: Yeah, that don't have cancer. Yeah.
0:07:49.3 DD: That don't have cancer. They just come in, because they have a strong familial link or may have had a lot biopsies, or have an unknown lineage. A lot of people say, "Well, I don't have a family history." But if you actually go in and say, "Well... What's going on?" They'll say, "Well, I was adopted." Or, "I don't know anything about my father's side of the family." And those patients too, can be in that high risk setting where they should get genetic testing. A lot of of patients coming in with positive genetics, either in my high-risk clinic or getting that information from their primary care or GYNs and taking control of what their genes may have given them. And doing prophylactic surgeries and doing it beautifully, before anything can take away their life and their womanhood. So it's really... Really interesting to see how the genetic testing of a patient has changed what we do.
0:08:43.3 DS: And what about when people get diagnosed with cancer, are you doing anything at that point with genetics to better understand their tumor?
0:08:50.8 DD: Yeah, so I'm a strong believer in, everyone should have genetic testing, especially if they have breast cancer. Independent of their age, their family history, gene mutations have to start somewhere... We have to... And so that patient sitting in front of me wants information on why they got cancer. And I wanna give them that information that, "Hey, it's because of your own genetics," or it's not. And you're one and eight women. But that information is definitely gotten on all of my breast cancer patients.
0:09:23.3 DD: And also genomic testing of the tumor itself has revolutionized care. I'm sure you've seen that from your standpoint prior to jumping in to CMO, but a lot of what we do nowadays is based off of genomic testing on the patient's tumor. So, looking at the genes, are they high risk, low risk, do they need other medicine besides a pill. Do they need chemotherapy. I think the main thing that we do with this nowadays is we can de-escalate care. We can not give everyone over one-centimeter high dose chemotherapy that may or may not work. We know that based off of this genomic evaluation.
0:10:05.4 DS: No, it's completely changing the face of how we think about not only prevention, but yeah, treatment now, so. Especially on even targeting chemotherapies, there's just... The field's really advancing. And on that front, how many patients do you think are... That you're using some targeted chemotherapy these days? I know that then the medical oncologist usually comes into play, but are you seeing that increase?
0:10:31.2 DD: Definitely. I would say within Texas oncology and my patient patient population, if there is a targeted therapy that is out there for any of these and their genomic test tells us to use it, it will be done. So I would say that we went from probably about maybe 5% to 10%, maybe five years ago, really only on trials that they could get these medicines. And now with this testing available widely, I would say that about 90% to 95% of patients who are eligible, will get it. So...
0:11:00.6 DS: Wow.
0:11:01.3 DD: It's really changed the way that we treat the patient's disease. It's not just everyone's getting the same thing and we run them through a mill. It is very personalized for each patient of their journey.
0:11:12.2 DS: Yeah, especially some of the recent studies with Olympia, which was looking at PARP inhibitor maintenance. I know people, especially for higher risk triple negative or looking at immunotherapies, just the field's just absolutely exploding.
0:11:27.4 DD: Yeah, and I think its... That goes along with kind of the less is more theme that we're trying to do here with breast cancer care. Is we are advancing the field forward by really looking at less surgery, less problematic surgery. Not taking out people's giant packets of lymph nodes and leaving them with lymphedema. We're using medicine to reverse the cancer to say, "Hey, we just... We're gonna remove less lymph nodes, because why take more if there are a negative now.
0:11:54.5 DD: We're looking at less radiation. We're looking at different techniques to really decrease the amount patients have to be undergoing radiation. And of course, we're looking at less traditional chemotherapy and using these targeted medicines that have less side effects. And it's more patient-centric, and more individualized per patient.
0:12:13.3 DS: No, that's a good synopsis of what's coming. There's kind of advances that are really far out in the future that we tend to think about, but really kind of like, "How is the field changing right now in front of us." And you just laid out a lot of the current use cases. Are there anything else of the things you just mentioned that are kind of on the near-term horizon that you see moving quickly into clinic?
0:12:39.8 DD: Yeah, no, I think that our ability to give everybody kind of that... What's called oncoplastic surgery, or the ability to look beautiful. We hide incisions. We give them reduction lifts at the same time. We do nipple sparing-mastectomy.
0:12:53.5 DD: So patients that come out of surgery look like themselves. So when they look in the mirror, they don't see cancer or big scars. They see maybe themselves or even a heightened version if they've always wanted a breast lift. So I think that where we're moving right now, where the future is going is again, how do we use these modern medicines to really modulate what we have to do surgically. Are we gonna be touching lymph nodes in the future? My thoughts are on that, are no. I don't think that we're gonna be touching lymph nodes in the next 5-10 years. I think that we're gonna be able...
0:13:24.7 DS: Interesting.
0:13:26.1 DD: To use the medicine that we have and the other techniques to be able to say, "Hey, we're not gonna touch these lymph nodes." That your risk of lymphedema is not 7-15%, it's zero.
0:13:36.8 DS: Yeah, that's great.
0:13:37.4 DD: Because we're not touching them. Yeah.
0:13:38.7 DS: Yeah, that'd be huge, 'cause that burdens so many people.
0:13:42.7 DD: Exactly.
0:13:43.9 DS: Yeah. Well, this is fantastic. I really appreciated you coming on the podcast today. And thank goodness for Slim Goodbody. [chuckle]
0:13:53.3 DD: Yes. Please Google him if you get a chance.
0:13:55.4 DS: Who put you down the right path.
0:13:57.9 DD: Google him. Okay.
0:13:58.0 DS: I'm gonna have [chuckle] to look this character up.
0:14:02.5 DD: Yeah.
0:14:03.5 DS: But no. We thank him for his service in bringing you into the field of [chuckle] medicine and then... Just shortly there after breast surgery. So, no keep doing all the good work that you're doing and helping your patients. And yeah, I can't thank you enough for coming on today and sharing some of your experience.
0:14:18.9 DD: Thank you, Dr. Slaven, I appreciate it.