115: Breast Cancer Survivorship with Dr. Amy Comander

Dr. Amy Comander  00:00

Unfortunately, we're all getting older. And age is the number one risk factor for breast cancer which have to wrap our heads around that it is what it is. Certainly reproductive factors. So prolonged estrogen exposure over the course of our lives is a risk factor. So when I see a patient, I do ask about things like the age of menarche, if she's still menstruating. Has she ever been pregnant? If so, how many times? Did she ever take any, you know, exogenous hormones, such as hormone replacement therapy, etc. So we asked all of these questions to our patients, we asked about family history, of course, which is so important, we ask about prior breast biopsies. Some biopsies may indicate benign findings, but may, unfortunately, increase lead suggests an increased risk for breast cancer. But lifestyle factors are also really key. And so I know we're both really interested in this.

Narrator  00:50

Welcome to the Plant Based DFW Podcast weekly show with Dr. Riz and Maya, a show broadcasted from the Dallas Fort Worth area that focuses on lifestyle medicine. This is the use of evidence-based lifestyle therapeutic approaches, such as a whole food plant-based diet, regular physical exercise, adequate sleep, and stress management to treat, prevent, and oftentimes reverse lifestyle-related chronic diseases that are all too prevalent. Every week, They feature a guest who speaks on one of these lifestyle medicine pillars. This show is for you, the person who is seeking to improve your overall wellness and quality of life. So whether you are driving, walking, or relaxing at home, we hope this show will provide you one more tool for your wellness toolbox. Let's meet today's podcast guest.

Maya Acosta  01:42

Dr. Amy Comander is a hematologist oncologist, who specializes in the care of women with breast cancer. She received her undergraduate degree and a master's degree in Biology at Harvard University. She received her medical degree at Yale University School of Medicine. She completed her internal medicine residency training in hematology-oncology fellowship training at Beth Israel Deaconess Medical Center in Boston. Her interests include finding new treatments for breast cancer and helping her patients achieve and maintain a healthy lifestyle. After a breast cancer diagnosis. She is also board certified in lifestyle medicine. And in this episode, we will talk about the various subtypes of breast cancer treatments, as well as support for survivors. So we will talk about breast cancer incidence, we will also learn about the role that lifestyle medicine plays in reducing your risk for breast cancer but also in reducing the risk for recurrent and current survivors. So I hope that you enjoy this episode, remember to get your annual screening. And also Let's welcome Dr. Amy Comander.

Dr. Amy Comander  02:51

Thank you, thank you for your kind introduction,

Maya Acosta  02:54

I would love to know as we move forward, the steps, everything from when an individual is diagnosed with say a mass or a lump, all the way through what you really work in is empowering and supporting survivors. And then also if we can talk about how lifestyle medicine plays a role in all of this in either the prevention or the recurrence of breast cancer. So before we move on to all of that, can you tell us more about yourself, where you originally from, and some of your interests.

Dr. Amy Comander  03:27

Thank you. I'm so excited to be with you during this interview. So thank you for this wonderful opportunity. I'm always happy to provide education about breast cancer and also the role of lifestyle medicine. So getting back to me, so I grew up in the south, actually, I grew up in Savannah, Georgia. I lived there from age five until I graduated from high school. And then I was really excited to branch out. And that's how I ended up in Boston, which is behind me the beautiful skyline. So I was an undergrad, as you noted at Harvard, and loved it there. And actually, my focus in college was neuroscience, and psychology, and cognitive science. And I think a lot of those interests are very much still with me as I practice oncology and develop programs for breast cancer survivors. I went to medical school at Yale, and actually, that's where I discovered my interest in oncology and decided that I'd pursue internal medicine and eventually become an oncologist. And so I'm back in Boston now where I've been probably Gosh, for a while now, practicing breast oncology at the MGH Cancer Center. And one of my passions, as you noted, is also optimizing survivorship care for women with breast cancer.

Maya Acosta  04:43

And you're also a marathoner.

Dr. Amy Comander  04:47

So I'm happy to talk about that too, for an hour if you want. So one of my passions is running. And it is definitely something I've done since high school. I was never a competitive runner. I was never, you know, fast or anything like that. But I've always been running throughout college, medical school. And certainly now as a way for exercise, and also to help calm my mind, you know, running is like a moving meditation. And so yes, I discovered marathon running Gosh, in 2000, I want to say 2013. And my favorite is the Boston Marathon. And I've been running it for the past seven years for charity, including the virtual Boston Marathon last September, which was quite an experience. And I was really grateful to run that marathon with another colleague of mine, who's a leukemia specialist at MGH. So, yes, so that is definitely a true passion of mine and encouraging others to get excited about exercise. Definitely.

Maya Acosta  05:49

Do you have any marathons coming up soon?

Dr. Amy Comander  05:51

Funny that you should ask. Given the pandemic, there have been many challenges for racing, as you know, but it looks like there will be a Boston Marathon on October 11. An in-person and a virtual race for people who might want to run it virtually. So I'm planning to run that for a charity that I'm passionate about called the Ellie Fund, which supports women newly diagnosed with breast cancer here in Massachusetts.

Maya Acosta  06:18

Congratulations on you, you know, doing this physical exercise for your own health, but then you're supporting other groups as well. That's wonderful. Well, just one quick question about the virtual experience with your marathon is does that mean that you're running in your own location, but then you're logging in the miles I have? 

Dr. Amy Comander  06:34

Yes! So anyone can run the virtual Boston Marathon anywhere in the world and actually get a medal this year. So it's super exciting. And so there's that's what the virtual option would mean, when I ran it last September, my colleague and friend was running her very first Boston that she had trained for, obviously for April, but it got postponed because of the pandemic. So we actually did go out to Hopkinton, her, that's the starting line, by the way. And we started there and ran our 26.2 miles into Boston. So she would have the real experience. And every step along the way, I tried to tell her what it was really like to run Boston and tried to remain positive for her, which I joke with everyone. I remain positive for her for 25.5 miles that last point seven, maybe not so much. We're both hurting a lot. Right? Oh,

Maya Acosta  07:29

That sounds like a wonderful experience, you will perhaps be coming to close to the Dallas area to lecture for the Lifestyle Medicine conference. Is that something that we might still be able to look forward to?

Dr. Amy Comander  07:41

Oh, yeah, I mean, I obviously we're all hopeful for the return of in-person conferences as soon as it as it's safe, and I'm really looking forward to hopefully being there in person, but if not, you know, the virtual conferences, you know, certainly a compromise at this challenging time.

Maya Acosta  07:58

Okay, so can we get started by you kind of explaining a little bit just in case some of our listeners are not aware of what a hematologist oncologist is? I know that in the treatment of breast cancer, you have you know, the breast surgeon and then you have the radiologist who's a radio, what is it radiation oncologists and you have just a whole team? But what is specifically your role?

Dr. Amy Comander  08:22

Sure. Um, so just to start off, why I agree with you that this topic is so important. You know, we recently got statistics for the numbers of cancers that will be diagnosed in the United States for 2021. And actually, for breast cancer, breast cancer is the leading cause of cancer in women in the United States, and there's estimated it'll be about 280,000 cases diagnosed this year. So this topic is very important. So I'm glad we're talking about it. Um, so in terms of breast, there's a multidisciplinary team, as you just noted, that is assembled to care for a patient newly diagnosed with breast cancer. Usually, the patient may see a breast surgeon first. And after that often, or sometimes we see them all together in a multidisciplinary clinic, which would mean that patient is seen by the breast surgeon, the radiation oncologist, and by a medical oncologist, which is what I do. And often, you know, there are so many other specialties involved a genetic counselor, social worker, you know, there's so many other members of our team which are so key. And together we meet we review the imaging, pathology, talk with the patient about her diagnosis and outline a treatment plan.

Maya Acosta  09:38

You kind of just explained a little bit which was one of my questions of what are the steps that people take from the time that you know, they have the initial screening, so they either go to their OBGYN or the primary position and schedule a mammogram, you might show in the initial mammogram that there's a mass or a lump, then they move forward to the next thing, the diagnosis and other things. Can you kind of guide us briefly through that?

Dr. Amy Comander  10:02

Yeah, that's a great question. I do want to put a plugin for screening because one of the unfortunate consequences of the pandemic is that cancer screenings are way down. And in particular breast cancer screening, certainly last year, and those the spring months when the, you know, the result, you know, essentially lockdown mammograms are canceled unless there was an urgent indication. So, we are still catching up on there was a recent article in The New York Times demonstrating, unfortunately, that there are more diagnoses of advanced cancers now, sadly, because of this decline in screening. So I'm so glad we're getting out this message, especially to women, please get your mammogram. so important. Um, and so that's a great question. What age should that start? You know, certainly, I'd say for women in their 30s they should start discussing with their gynecologist or their primary care physician, you know, what their risk factors may be in terms of family history of breast cancer, other risk factors, so some women may start at age 40. If a woman truly has no risk factors, it would be reasonable to start at age 45. With annual mammographic screening, some women may require more intensive screening with breast MRI. And that really depends on other risk factors that I'm noting, most importantly, family history. Um, but your real question was, okay, so let's say a woman has her mammogram, they find something, what are the next steps. And so, really, the next step is really a biopsy, which is done by the radiologist on and then we, you know, await the pathology. And if it, pathology does reveal a diagnosis of cancer, then often, the patient would be referred as the next step to a breast surgeon. And sometimes the patient may see a breast surgeon alone or sometimes you know, at MGH we see many of our patients in a multidisciplinary clinic where the patient sees not just the breast surgeon, but also a radiation oncologist and a medical oncologist, the whole team at once, which is pretty amazing for a newly diagnosed patient. And then we figure out the next steps. Sometimes surgery is the next step to remove primary cancer. Or sometimes there may be other treatments that are indicated as the first step such as chemotherapy, which is something I would administer. So as you can see, it's a multidisciplinary approach, which is so important for formulating a treatment plan for a woman newly diagnosed with breast cancer.

Maya Acosta  12:33

Thank you for explaining that. It's so important to focus on screening every year. As a matter of fact, in preparing for our conversation today, I kind of message all the women in my family and basically asked do you get a yearly mammogram? And so I was really pleased to hear some of the women in my family said yes, and one of one sister said every January, you know, it's like, just like how we want to check our labs when we're, you know, consuming plant-based foods and we want to make sure that we're okay, it's like well to do the mammogram as well.

Dr. Amy Comander  13:03

Absolutely. So important. And so I'm so glad that you reached out because I tell my patients that too. You know, now that you have this diagnosis, please reach out to your close friends and family members and make sure they're getting their mammogram because especially right now during this pandemic, we're not paying attention to our own self-care, which is so important.

Maya Acosta  13:23

Now, I've heard you say that there are different types of breast cancer, can you touch on that as well?

Dr. Amy Comander  13:28

So I think that's a really important question. So thank you for asking. Certainly in the media, we hear breast cancer like that's the term or another celebrity has breast cancer. But breast cancer is not one disease, breast cancer is actually many diseases, there are many different subtypes of breast cancer. So when I see a patient, I will help her sort of break this down so that patient understands specifically what type of breast cancer she has. And some of the really, the key factors that we need to look at are something called the grade of the tumor, which refers to what the cells look like under the microscope, the architecture of the cells and hormone receptors is the tumor driven or influenced by the female hormones, estrogen, and progesterone. And is the tumor driven by a gene called HER2 or her two, which can encode a protein that basically her two positive cancers comprise about 15 to 20% of breast cancers in this country. So these are some of the features we look at the hormone receptors that her to status, the grade, of course, other factors such as the size, etc. But that really, all of these features are very important to the team in terms of evaluating a patient with a new diagnosis of breast cancer.

Maya Acosta  14:46

So you mentioned I think, you know, that genetic component of it, should we be running out and get in, you know, having this genetic testing to see if we have the BRAC gene or anything, any other gene that can put us at risk.

Dr. Amy Comander  14:59

Such a great question. Another interest of mine, of course. So it's really important for women to know that there are genes that can confer an increased risk for breast cancer. But I think it's also important to know of the 280,000 breast cancers diagnosed this year, only about five to 10% are going to be due to a gene that we currently in 2021 contest for. So only five to 10%. And of that five to 10%. probably half of them will be due to what you just said the BRAC gene or BRCA one and BRCA two, those are the names of them. So I think what's, that's a great question. Should every woman be tested? There is debate about that at our conferences, some would argue Yes, every woman should be tested. Currently, we do have specific guidelines for who should be tested. I think every woman should be aware of her family history. And certainly, if there's certain criteria in a family history that would indicate the need for testing, such as having a family member who was diagnosed with breast cancer under age 50. Or if there's a male family member with breast cancer, if there's a strong family history of multiple breast cancers, ovarian cancer, certain ethnicities, such as women of Ashkenazi Jewish ancestry, these features are all really important. When you're PCPs and OB-GYN and family medicine doctors and other health care providers are taking a history from a woman just to figure out Hmm, does this patient meet criteria for genetic testing? And these guidelines are well outlined, you know, in various resources that can help various practitioners determine if their patient should be referred for genetic testing,

Maya Acosta  16:44

it's good to know that there is some debate within the industry as to whether this should happen or not. I read in one of the abstracts that you sent me that about 40% of the cancer incidents here in the United States are really related to lifestyle.

Dr. Amy Comander  16:58

Yeah, there are so many factors that can play a role in why a woman may be diagnosed with breast cancer. And obviously, this is still an area of active research. And, you know, we all want to understand when we see a patient, why did this patient get breast cancer many times, we do not have an explanation. It's a very complicated conversation in my clinic, you know, for a woman who has no family history, who's, you know, been getting her mammograms every year, like, why did this happen? And so I think there are certain factors that we do know play a role such as age, unfortunately, we're all getting older. And age is the number one risk factor for breast cancer, which have to wrap our head around that it is what it is certainly reproductive factors. So prolonged estrogen exposure over the course of our lives, is a risk factor. So when I see a patient, I do ask about things like the age of menarche, if she's still menstruating, Has she ever been pregnant? If so, how many times? Did she ever take any, you know, exhaustion as hormones, such as hormone replacement therapy, etc. So we asked all of these questions our patients, we asked about family history, of course, which is so important, we asked about prior breast biopsies. Some biopsies may indicate benign findings, but may, unfortunately, increase lead suggest an increased risk for breast cancer. But lifestyle factors are also really key. And so I know, we're both really interested in this. And in the United States, I think we all have to acknowledge that one of the major lifestyle factors that contribute not only to breast cancer but to many other cancer diagnoses, is obesity. We have an obesity epidemic in the United States. And, you know, I read a recent statistic, I think, on the American Cancer Society website, that now obesity may potentially contribute to 11% of new cancer diagnoses in this country. So, you know, I know as both of us are interested in lifestyle medicine, this is an area that we all need to work together to focus on to help, you know, help everyone be at healthy body weight. So bodyweight is a risk factor. Particularly I should say, for postmenopausal breast cancer, she get that caveat. That's where the data is the strongest for postmenopausal breast cancer. Other factors, alcohol intake, I mean, nobody likes to hear this, but like alcohol is a risk factor for breast cancer, and, and many other cancers. So if one wanted to be, you know, American Cancer Society specifically says alcohol is a risk factor for cancer, it is best not to drink at all. But if you want to drink or you know, women should really limit it to one alcoholic beverage per day. Um, and then the physical activity is another big one, which I know we're both interested in as well and regular physical activity is felt to also be associated with a lower risk of breast cancer.

Maya Acosta  19:47

That's kind of part of the program as well that you develop with Dr. Beth Frates. In terms of, you know, not only continuing to offer support for survivors, but also just in general to help prevent breast cancer. At the risk of developing breast cancer, can you tell us just a little bit more about how obesity plays a role?

Dr. Amy Comander  20:06

So that's a really interesting question. So how does obesity increase the risk of postmenopausal breast cancer? What is the mechanism? So many smart scientists? And obviously, epidemiologists and many other researchers are truly trying to answer this question. And getting to that point, when I mentioned that there's, you know, in this recent publication, looking at the breast cancer of all cancer incidents in the United States for 2021, the incidence of breast cancer actually is going up point 5% each year. And one of the possible reasons is obesity, and perhaps delayed fertility in this country, but so we really need to pay attention to obesity. I know we both agree about that. So in terms of mechanisms, I mean, you already gave some great examples of things that are being researched. excess estrogen, we know that adipose or fat tissue has the enzyme aromatase, which is responsible for converting androgens into estrogen. So excess adipose tissue, likely providing excessive estrogen is one mechanism. Another mechanism you mentioned was, you know, is there something related to other hormones such as insulin-like growth factors, etc? Is there some kind of metabolic state in the body and individuals who are obese that potentially can also explain the increased risk for breast cancer? I think this is a really interesting area of research. And then also there's been studies looking at breast tissue and looking at the biology of the breast tissue itself. And there may be, you know, signs of inflammatory mediators in the breast tissue itself, when there's excessive adipose tissue that potentially can explain this. So I think we're still trying to learn the mechanisms. It's a really interesting and active area of research. Same with alcohol, like how is alcohol increasing risk of breast cancer and certainly many studies in animal models and trying to figure out what alcohol is actually doing at a cellular level, but likely also related to hormonal fluctuations, inflammation, direct toxicity to the cells on the breast tissue, I think we're still trying to understand this better.

Maya Acosta  22:15

Okay. So obesity, alcohol intake, diet in general. And also exercise, there are a variety of different breast cancer types. And then so can we talk about treatments. And then I have also heard you speak about which I found very interesting for chemotherapy, it might be for chemotherapy to prevent hair loss, it's the scalping,

Dr. Amy Comander  22:38

So just sort of a general thing about treatment. So obviously, the treatment for breast cancer is complicated. And really, as we already talked about, we take a multidisciplinary approach at the MGH Cancer Center. When we see new patient and breast surgeon, radiation oncologist, medical oncologists, we all put our heads together to formulate a treatment plan, and then on and so it really depends on the subtype of breast cancer. But I can generally say that tumors that overexpress estrogen and progesterone, which by the way, that's a good prognostic factor, if a woman's breast cancer is hormonal II sensitive, we like to see that, but those women will benefit. You know, after surgery from anti-estrogen medications. I know you've heard of tamoxifen. Another class of drugs we use are called aromatase inhibitors. So those are very important in terms of lowering risk of disease recurrence, lowering risk of a new breast cancer and improving overall survival. So anti-estrogen treatments such as tamoxifen, so important. Sometimes chemotherapy is needed. And, um, we both know that that can cause a lot of side effects. And there are tips from lifestyle medicine that can really help our patients tolerate chemotherapy and get through that. But one thing is hair loss you mentioned. So it is, you know, sometimes when I tell a patient about the side effects from chemo, of course, like the worst thing is losing one's hair, like let's acknowledge, like, many women will be like nausea, whatever fatigue, whatever, but my hair like that is bad, you know, and we can all relate to that. So one really exciting thing over the past few years is the use of scalp cooling. And, you know, you might say what is that basically, it's what it sounds like, a woman wears a cap that like freezes her scalp, certainly for a period of time before chemo, during the treatment and after the treatment. And it in many cases, not all but in many cases can prevent hair loss, which is a game-changer and so wonderful for so many of our patients in terms of quality of life, and actually just, you know, feeling so much better about oneself going through treatment of one doesn't have to lose their hair. There's many different companies that provide this service at the MGH Cancer Center. We work with Paxman, scalp cooling and love them but there are many other companies And certainly ways that women can do it themselves that their cancer center might not offer that there's various companies can provide it to the patient directly, so she can take it to her cancer center. So that's pretty, pretty cool. Sorry for the plant. It's pretty cool. Again, I wish it worked for every chemo regimen. And maybe someday we will be in a situation where we have options for women with who received some drugs, that it doesn't work as well. But for many regimens, it's been a game changer. I know for many of my patients that, you know, there's so much support out there, through various types of social media, etc. So many of my patients learn about these options, through those types of groups, or through their research for maybe, you know, at cancer centers, they have partnered with a specific company, like in our case, Paxman, but you know what another Cancer Center, they may be working with a different company that provides that kind of service for their patients. So we're very fortunate to have it in Boston, I know it's probably not available everywhere. But there are ways that women can research this and investigate it if it weren't for their particular regimen. 

Maya Acosta  26:04

So we talked about treatments. And now we're going to talk about something that you're very passionate about. And that's survivorship where you create support, and, and you continue to offer resources for cancer survivors. And so you developed a program called the paving the path to wellness for breast cancer survivors with Dr. Beth Frates, who wrote the Lifestyle Medicine Handbook. And I'll show it because I always like to kind of brag that I have a copy and I love it, and anybody can buy this, I think it's available on Amazon. So I'm a believer of self-empowerment and knowledge and, and really teaching ourselves the best, you know, all of these modalities that come from lifestyle medicine, can you tell us what that is the paving the path for to wellness,

Dr. Amy Comander  26:53

I love that you have Dr. Frates' book, by the way, it is awesome. And I also love that you use the word self-empowerment because that's essentially how I view this program. So many women will tell you after they go through their breast cancer treatment, which is so intense, right, many appointments with your oncologist or nurse practitioner, their chemo, their surgery, their radiation, like it's so intense for months, and then all of a sudden, they're done. And maybe I'm like here, start your tamoxifen. And you'll see us in, you know, three months or four months or something like that, and the patient, you know, she's like, what, I don't come back for three to four months, like what do you mean, and that's just like, you know, you're done with your primary treatment. So you don't need to come back. And so, but the patient herself doesn't feel like she's done, you know, she might be feeling having significant fatigue, she may still not be eating well, she might not be sleeping, well, she may have some aches and pains related to the recent chemo, she may still she doesn't have our hair back yet. You know, there's so many factors that, you know, a woman's experience when she finished his treatment. And just to say, See you in three months, you know, we can do better than that. And we need to do better than that. And so I was really fortunate. It's funny to say to think back when it was but maybe like, might have been years ago, I was I just happened to attend, you know, a Harvard Medical School course on lifestyle medicine out of my own personal interest, as you know, as a runner. And that's when I met Dr. Frates, and she gave an amazing presentation about lifestyle medicine. And I talked to her afterwards. And I was thinking, Well, you know, these tools are so important and can really help our cancer survivors, we need to figure out a way to adapt these tools to help, you know, breast cancer survivors, which is my area that I focus on. And she was so excited to meet me as the witness. Sorry, she is. She's so wonderful. And we met since at that time, and she told me about this amazing program she developed for stroke survivors, because she's a physiatrist and works at the Spaulding Rehabilitation Center here in Boston and had developed Paving the Path to Wellness for stroke survivors to help that population, you know, improve their health and wellness after something traumatic like a stroke. And so a lot of the tools that she used could really be easily adapted to a breast cancer survivor population. So paving is actually an acronym for physical activity, attitude, variety, investigations, nutrition and goal setting. And then there's steps but steps is two s's. So it's stress management, timeouts. I want to make steps energy, purpose, sleep and social connection. So as you can see, there's 12 steps of the program. And you can just tell that well all of these are so important for all of us, but in particular, they can be so helpful to focus on for a cancer survivor. So I've been fortunate to collaborate with her as well as with Dr. Michelle Tollefson, who you may know, as well from the lifestyle medicine organization. And we've developed this program for women with breast cancer, and I'm currently offering it actually, I initially offered it in person at our hospital, and we had dinner together. And it was very interactive, and so wonderful. But during that pandemic, like all of us, we were forced to enter the virtual world. And so I remember like, literally March of last year finger, like, Oh, my God, I need to set up a zoom account, how do I use zoom, I don't even know how to do it. Like it was honestly new to me. But thankfully, I figured it out with the help of my 10-year-old son. And so now I've been running it virtually. And it's been a really rewarding experience, certainly for me, but also for the participants.

Maya Acosta  30:51

Some of the survivors are actually finding that they're even more connected, and more available for one another because they don't have to travel, worry about parking, and finding the location and all of that, they're just able to come together and continue to offer support to one another.

Dr. Amy Comander  31:08

It's so interesting that you say that, like I can tell you with my first paving group, the women really bonded with one another. And then they kept meeting on their own without me or a social worker, anyone from our group, and formed this really special connection with each other. So when I started the virtual group in the spring of last year, and the height of the pandemic here in Boston, it was crazy, but we kept it going. Those women, despite being on a screen together, really bonded, and they're continuing to meet together as well. And they're, it's just really fabulous. I don't you know, it's interesting, like, it's certainly there's a lot of benefits, right, don't have to leave your house, you can be in your pajamas, if you want to your kids can be running around, you'll have to worry about childcare, like that kind of thing. on there, I think are real advantages. I mean, of course, being in person has major advantages as well, I'd like to give me dinner, but um, I use there are some fun things, I'm sure you've because of being on zoom, so much breakout rooms, that chat box, other ways to make it interactive and fun. And I feel like I'm getting more of a hang of it now. And I think there are ways to really get people to bond even on a screen. So it's been working out well. But I will look forward to when we can actually do things in person.

Maya Acosta  32:22

Now I know you have kind of an interest in psychiatry, and this program itself kind of offers this positive psychology aspect to it as well, of really focusing on overall wellness, staying positive finding support, and also connectivity, and so that myself feel I really believe that that's what cancer survivors need. Is there always this fear that lies there that the that the cancer might return?

Dr. Amy Commander  32:52

Yeah, such tough questions. And you're so right, I think, first of all, it's so no one ever wants to hear the words you have cancer, it's very lean, I mean, telling a patient that it's very difficult, certainly for me to tell a patient that but then if I put myself in her shoes, I you see how traumatic it is to hear those words. And I think everyone certainly handles that information in different ways, as we both know, and certainly I'm sure you have friends and family, you know, I hope not too many, but like who've had been through something like this. So some people choose to be very private and don't really want to share with anyone except their immediate family. And some are very much wide open about it and want to be in groups and want to share or want to, you know, post about it to share their experience. So I think everyone's different. But I do think are thinking about what you just said about shaking someone's hand and how you're like, Can I shake this person's head like, this social connection piece is so important for all of us. And I think especially after a cancer diagnosis, having that support from others who really understand what you're going through, and what's going through your mind late at night, like you just said, fear, anxiety, stress, like, you know, I think the social connection part that's evolving from, for example, from the paving program, or other support groups that are out there is so beneficial to people and they may not realize it at the outset. But once they are in a program like that they really see the significant benefits. And I've heard that feedback from many of the women who have been in my program, like I'm so glad they did the program. But actually, I think the best gift I gave them was like that they met these other people that they're continuing to meet with on their own for that really important social support piece.

Maya Acosta  34:37

Yes, definitely. So let's talk about this education initiative kind of work that you've been doing to reach out to even a greater number of women.

Dr. Amy Comander  34:47

Yes, I think that's an important thing for all of us as women to know that again, let's just state the facts. Breast Cancer is the most commonly diagnosed cancer in the United States and there'll be 280,000 cases this year. We'll say that looking at that recent publication on that, thankfully, our treatments for breast cancer have improved dramatically over the past, you know, four decades actually with significant improvements in survival from breast cancer. So, I want to express that we've made great strides, you know, screening advances, and of course, advances in treatment. But yes, each woman walking down the street has a one eight lifetime risk. And as one gets older, that risk does, you know, go up just because of aging, I mean, the risk for any kind of cancer pretty much goes up as we get older. So, I think for your listeners, screening, so important, if you have missed your mammogram, especially because of the pandemic, please schedule it after you listen to this. If you have a strong family history of breast cancer, or ovarian cancer, or if you're asking as a Jewish ancestry, talk to your gynecologist or PCP, should I see a genetic counselor, because genetic testing is important to help us figure out if other screening modalities such as breast MRI should be used. And then think about your lifestyle. And I know this is something we're both really interested in, and the American Cancer Society, you can go on their website has very clear guidelines for steps we can all take to lower our risk of breast cancer. So these are actionable things we can do. And there's actually a paper with references, if some of your listeners like to get into the nitty gritty details, but really, I'm just going to go over them now doing our best to be at a healthy body weight. I know this is a challenge, especially during the pandemic. Many of my own patients are like, well, I've gained the COVID-19. You know, like, it's not funny, like, it's really a problem now, because many of us are sedentary, working from home, can't go to the gym. So we all have to be kind to ourselves, we just went we're in the midst of a global pandemic, but like, let's try our best to, you know, try to get back to being a healthy body weight. That's so important. Physical activity is so important, you know, what are the guidelines, 150 minutes of moderate aerobic activity each week, you don't have to go out and run a marathon, you know, you can do 10 minute walks throughout the week. And that adds up to 150. So important not just for cancer prevention, but for cardiovascular health, preventing other chronic diseases. on healthy eating, I know this is a passion of yours as well. Eat those fruits and vegetables, those whole grains, those lagoons limit the red meat limit the processed meat, you know, supplements do not prevent cancer, I think that's another important message. Limiting alcohol, we kind of touched on this earlier, when really should limit alcohol to no more than one drink per day. And then another really interesting part of the guideline, which you will like, given the work that you do is community support, helping the community adopt healthy habits. You know, the communities we live in plays such an important role in our health behaviors? Like, is there access to healthy food? Is there a safe place to go take that walk outside, like, so the community support and infrastructure is also really important. That's actually part of the American Cancer Society guidelines. Now, the recent guidelines that were published last year.

Maya Acosta  38:17

Thank you for that, especially emphasizing community because it's so difficult, but just as you explained with your paving program, it's successful right now, virtually. So what can we expect the American College of Lifestyle Medicine's annual conference will take place not far from us in Dallas, in November, and you will be part of it in terms of offering a lecture specifically on women's health, can you kind of give us a glimpse of what to expect for that.

Dr. Amy Comander  38:45

I know, I'm so excited about this opportunity. And I really hope I get to visit your city and see you in person. That would be really wonderful. It's been a long time since I've been in Dallas, but I do go to San Antonio, actually, well, not last year, but every other year, because we have a major breast cancer meeting called the San Antonio Breast Cancer Symposium every December in San Antonio. But anyway, um, so I'm so honored to have the opportunity to speak at the ACLM conference. And, you know, I haven't, you know, made my talk yet, but I'm thinking I'll talk a lot about the relevance of lifestyle medicine for women with regard to prevention of breast cancer, and then how we can support women during treatment during the survivorship phase and our patients who have advanced breast cancer, what does the data and evidence from lifestyle medicine say to help support not just quality of life and function, but also overall outcome from breast cancer and these populations? So I'm really excited to talk about that, but I welcome your feedback if those are good topics.

Maya Acosta  39:43

Definitely, Well, okay, so I'm a lay person and I'm able to attend the conference, right? So it's pretty much open to anyone who's interested in really, again, self-empowerment and learning about these different modalities or pillars of lifestyle medicine, you know, further dive into it when we've On my husband and I split up, and we try to go to various different lectures so that then we can come back and share notes and insights as to what we learned. So I enjoy conferences, and I'm looking forward to it as well. Do you have any kind of other online programs that are coming up or any kind of video that our listeners can view? I saw that you had one. You were part of an online and I think it's offered through the set the medical center where you're at, fight cancer with your fork, and it was on mindful eating. Do you have more programs like that? Or can you tell us about this one.

Dr. Amy Comander  40:35

That particular talk was so much fun, I was collaborating with two of our amazing MGH Cancer Center nutritionists who I'm so privileged to work with, and I learned from them every single day. Carol Sullivan and Samantha Bateman, and that video is there's been a lot of us. I think I just said it's an adaptation to how much interest there is in learning about nutrition as it relates to cancer prevention and survivorship. So that was a really fun one. And certainly, I would love to work with them on more topics in the future. I think it's such an interesting topic. What am I working on network current patient group is going on with virtually but it is trying to keep it small. It's actually a little bigger than I want it to be. But, but that's one thing we're trying to keep a little small. I feel like in this pandemic, I've been planning so many virtual kind of webinars for related to cancer-related topics. I am working on one and end of April to the MGH Cancer Center with my colleague, Hannah chef ski, who's a music therapist, you'll find this interesting. We have music therapy at the MGH Cancer Center. She is so gifted and talented and has helped so many of my patients manage stress, insomnia, fatigue, helping them exercise just by introducing them how music can help with these particular issues. So we are working together to talk about cancer related fatigue, which is actually the number one sort of symptom experienced by cancer survivors on fatigue. I mean, fatigue is just so common, and there's so many different factors that can contribute to that, unfortunately. So we're looking forward to that to the end of April to the MGH Cancer Center. And then we're planning some for June to but I don't have the exact dates yet. Okay.

Maya Acosta  42:18

Oh, you know, I forgot to ask about men. So we know that men can also have breast cancer, when should they start screening? How do they know if they are at risk at all? Is that the same thing? As you know, what women would face? 

Dr. Amy Comander  42:29

So male breast cancer is certainly rare. In the United States, there are about 5000 cases per year. And, you know, currently, we do not screen men for breast cancer, per se, but I think men should know if there's men listening to this, that men can get breast cancer. So just like we encourage women to be aware of their bodies and, you know, do a self breast exam, you know, maybe once a month, just pay attention like men should as well like pay attention to their chest wall, and how that feels because most breast cancers in men are identified by a man palpating a lump or maybe the primary care when listening to a man's heart will be like, Ooh, there's a little lump there, you know. So I think it's really awareness of one's body which is true for men and women, but we currently do not recommend mammographic screening for men. Getting back to your genetics question earlier, because male breast cancer is more of a rare diagnosis. Any man with breast cancer any age 48 years old, whatever the age should have genetic testing, because there's at least a one in 10 chance that he would potentially carry a BRCA one or two mutations. So that's another important part of family history. If a woman's like, Oh, my father had breast cancer or my uncle had breast cancer, like, you know, it's important for the PCP or gynecologist to explore that further to see if genetic testing had been done.

Maya Acosta  43:52

So I'm glad that you mentioned that because I you know, when we wonder should women tests get genetic testing Well, for men, it is recommended, like you said, so many topics to touch on. I had a list of myths, but I've heard you talk about kind of go through them before. And a lot of them continue to be myths, what you addressed earlier, are more important, like whether you've had hormone replacement therapy that can impact your risk as well as early menarche. But other things like breast implants and deodorants and underwire bras, those kind of things from what we know of today, do not play a role in the risk of developing breast cancer. Is that right?

Dr. Amy Comander  44:33

We don't have definitive evidence for that. That is correct.

Maya Acosta  44:36

Cool and then oh, I wonder if you can touch a little bit on soy. It's always this controversial topic and it in the past when we held in person events, we were always asked about soy. But can you explain just for our listeners where Phyto estrogens are and if so is still okay to consume?

Dr. Amy Comander  44:54

Yeah, that's a great question that often comes up so soy is obviously a plant-based estrogen, also known as Phyto, estrogen, and there is this, you know, concern that ingesting soy with potentially increased risk of breast cancer or potentially increased risk of breast cancer recurrence and somebody who's had breast cancer. And the data actually does not suggest that interestingly, in Asian countries when there's a lot of soy consumption, like, you know, lots of tofu and other soy products, you know, there appears to be an association with a lower risk of breast cancer. And so, and certainly in United States and in western countries where this has been analyzed, it does not appear to be consistent with an increased risk of breast cancer or increased risk of recurrence. In fact, some studies suggest that soy consumption may be associated with a lower risk of breast cancer. So I think your listeners should not be fearful of soy, I usually tell my patients however, you know, Whole Foods, soy products, like edamame is okay, but don't buy the protein powder, you know, at your grocery store that soy protein like concentrated protein powder, like, first of all, we can debate whether protein powder is a good thing or not. But like I would avoid like concentrated soy, but thinking about whole food plant based sources of soy, such as edamame and things like that.

Maya Acosta  46:13

So Dr. Comander, is there anything else that you would like to share with our listeners about breast health? 

Dr. Amy Comander  46:18

First of all, this has been such a wonderful opportunity, it's want to thank you again, I just think you mentioned many of your listeners are women. And I just want women to know, especially at this challenging time of a pandemic that your own self-care should be a priority. As women we take care of others, we take care of our children, our spouse, other family members, we look out for our friends, but sometimes we neglect ourselves. Taking care of yourself should be a priority. Get your mammogram focus on the steps you can take to optimize your own health. And really, that's my most important piece of advice for today.

Maya Acosta  46:53

Thank you so much, and what is the best way that our listeners can learn more about you and your work?

Dr. Amy Comander  46:59

I'm working on a website but for now I'm on Twitter Amy Comander and I'm on Instagram Dr. Amy Comander and I don't mind if folks want to reach out to me through those different types of social media. But eventually I'll have a website Oh, work in progress. We're all a work in progress, aren't we?

Maya Acosta  47:18

I appreciate you taking this time to teach us out about breast health and how to reduce our risk for breast cancer. Thank you so much, Dr. Comander.

Dr. Amy Comander  47:26

Thank you Have a wonderful day.

Maya Acosta  47:28

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