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CHRISTIE FLEITES: Good evening, everybody. Thank you so much for joining us this evening. Welcome to our MCI physician webinar. We're very excited that you all have taken the time to join us here today for our panel of experts on Miami Cancer Institute's high-tech, high-touch approach. My name is Christie Fleites. I'm with Baptist Health South Florida Physician Business Development.

I'm very happy to introduce to you all our moderator, Dr. Jane Mendez. Dr. Jane Mendez is our Chief of Breast Surgery at Miami Cancer Institute. She is board certified by the American Board of Surgery and fellowship trained at New York's Memorial Sloan Kettering Cancer Center. Dr. Mendez does specialize in the treatment of breast cancer and does perform all types of breast surgical procedures.

She received her undergraduate degree from Harvard University, and her medical degree is from Mount Sinai School of Medicine in New York. Prior to joining Miami Cancer Institute, Dr. Mendez gained extensive experience as a surgical oncologist at Boston Medical Center, where she served as president of the medical and dental staff.

She has contributed to notable breast cancer research, and her findings have been widely published. Happy also to share that Dr. Mendez is passionate about education and advancing breast cancer awareness and prevention in the community as well at national meetings. She is a board member of the American Society of Breast Surgeons as well as the Medical Advisory Board for the Promise Fund. She does cochair the Health Equity and Disparity Committee of the American Society of Breast Surgeons.

With that, I would like to turn it over to Dr. Jane Mendez so we can start our webinar.

JANE MENDEZ: Thank you, Christie, for that kind introduction. And it's my pleasure to welcome you all to this evening's webinar. As you say, Miami Cancer Institute's high-tech, high-touch approach. So again, thank you for joining us. And now it is my privilege to introduce Dr. John Diaz. He's the Deputy Chief of Gynecologic Oncology and Lead Physician for Clinical Trials in Gynecologic Oncology in Miami Cancer Institute. He's board certified. And obviously, he works here at Miami Cancer Institute. He provides comprehensive care for women with endometrial, ovarian, cervical, and other types of GYN cancers. He has extensive training and experience in minimally invasive surgery.

He completed his fellowship training at Memorial Sloan Kettering Cancer Center in New York, and there he earned the award of the Department of Surgery's chairman, and he served as associate professor of the Department of Gynecology at FIU. He also is the leading physician in the excellence of minimally invasive gynecologic surgery, and he does a lot of robotic surgery and actively participates in important clinical trials. His research interests include, among others, innovating cancer techniques, including hypothermic intraperitoneal chemotherapy and immunotherapy.

Furthermore, he has received significant awards for his research. He received, in 2019, $1.8 million in grants for immunotherapy and PARP inhibitors for treatment of cancers. And he's been also widely published, as you can see here. So needless to say, it is my honor to introduce John as our first speaker in this panel. And he will be addressing Gynecological Oncology-- the MCI Difference. So John, thank you for coming today.

Next, we have Dr. Kalogera. She is another gynecologic oncologist. She just joined us at Miami Cancer Institute. She came from the Mayo Clinic, where she did her fellowship training. There she also worked as an assistant professor in gynecology at the Mayo Clinic. She actually is passionate about gynecologic oncology as well as research, and wants to help patients at a broader level. She has presented at numerous national and international conferences, and has been published in peer-reviewed journals.

Furthermore, Dr. Kalogera did some research fellowship when she was at the Mayo Clinic, and earned a significant award for her work on Enhanced Recovery in Gynecologic Surgery, which revolutionized and has resulted in models for errors or enhanced recovery after surgery. She believes in the compassionate approach to cancer care and the importance of responding to the patient's needs. Her work as a gynecologic oncologist is important to help navigate their families in these challenging times in their lives. And she will be addressing the issues of the outpatient hysterectomy, AKA same-day hysterectomy.

To follow, I have the honor of introducing my colleague Starr Mautner, Breast Surgical Oncologist, who is also a board certified surgeon. She has expertise in breast surgical oncology, and obviously works at the Miami Cancer Institute, part of Baptist. She specializes in all sorts of different breast cancer options, including skin-sparing mastectomies and nipple-sparing mastectomies.

She completed her breast surgical oncology fellowship at Memorial Sloan Kettering Cancer Center in New York, Manhattan, and had the general surgery residency at New York Presbyterian Cornell Medical Center in New York. She also completed a research fellowship, also at Memorial Sloan Kettering Cancer Center, where she looked at tailored ways to look at women with lobular carcinoma in situ as well as issues having to do with life after contralateral prophylactic mastectomy.

She earned her medical degree from the University of Miami, and she is a member of multiple society organizations, including the Society of Surgical Oncology, the American Society of Breast Surgeons, and the Association of Women Surgeons. And she will be addressing Miami Cancer Institute high-tech, high-touch.

And the last speaker will be Dr. Ana Sandoval, one of our colleagues in medical oncology, who will be addressing issues pertaining to breast cancer prevention. And Ana joined us from the Miami University, where she actually received her medical oncology training. She actually is interested in systemic therapies as well as research, and she's very active in her research practice as well. And she leads the efforts in our breast cancer prevention clinic, which she'll be addressing at this time. She has been widely published as well, and has a keen interest in clinical research as well.

And Ana will be talking about breast cancer prevention. So with that, I'd like to have John kick us off this evening. So John, looking forward to hear your talk on Gynecological Oncology-- The MCI Difference. So thank you, John.

JOHN DIAZ: Thank you, Jane, for that introduction. And thank you, everyone who joined us today after a long day of work.

So I'm John Diaz. I'm now the Chief of GYN Oncology here at MCI. And in the next 8 to 10 minutes, I'm going to try and discuss a little bit of what we do here uniquely for our patients with GYN oncology.

So we have many people joining us from outside of South Florida. So this is what our building looks like. We're located here in Miami, Florida. This is the Miami Cancer Institute. It's 500,000 square feet, making it the largest Cancer Center in the state of Florida. Over 100,000 square feet of that is dedicated to clinical research. And we're also members of the Memorial Sloan Kettering Alliance, which is something I'm very proud of. And we're the only members of the Alliance outside of the Northeast.

And a lot of people ask me, John, what are the benefits to Baptist Health and South Florida with this Sloan Kettering Alliance? And one of the things are the treatment pathways. We all know that medicine is not black and white, and there's a lot of gray. And if you look, sometimes, at the National Cancer Care Network recommendations, they can range from surveillance, to chemotherapy, to chemotherapy with radiation therapy. And so with the help of Sloan Kettering, we've helped to develop our treatment pathways which mirror what the recommendations are from Sloan Kettering.

We have a group of six GYN oncologists, making us the largest group of GYN oncologists in the state of Florida, trained from Mayo Clinic, Sloan Kettering, the University of California Irvine, University in Miami, Johns Hopkins. So we all brought our own bias to the division. And so this has been really helpful for us to concentrate and come up with treatment plans that, again, parallel the recommendations patients would get at Sloan Kettering.

The other big advantage is clinical trials. Many of us in South Florida know that, oftentimes, patients of means, if they got sick, they would often leave South Florida and go to New York or Boston or Texas, but most patients can't do that. And so by partnering with Sloan Kettering, we can bring the clinical trials offered in New York right here to our patient population in South Florida.

And then the other component is educational partnerships. We've been very fortunate, before COVID, to bring down many national and international speakers who are attendings at Sloan Kettering to speak at our symposiums. Likewise, many of us have been invited to speak at Sloan Kettering on our expertise. I've spoken on robotics and HIPEC. And this has continued during the COVID. So this has really helped to increase access to some of the experts in Sloan Kettering in partner presentations.

So in the next seven to nine minutes-- I know Jane is going to keep me on course-- I'm going to talk a little bit about our GYN oncology program, what are some of the novel therapeutic options we offer here at Miami Cancer Institute, and perhaps the most important thing is the MCI patient experience.

So robotic surgery is something that we are all very much familiar and skilled with. I had the ability to be at Sloan Kettering when they first introduced robotics back in 2007. And so I've been using the robotic platform for over 10 years. And as many of you know, robotics allows us to perform complex, minimally invasive surgery, allowing patients the benefit of surgical approach but with less pain, less blood loss, and a quicker return to work.

And so this is a robotic hysterectomy. The instrument you see there is what's called the vessel sealer. And that is a bipolar energy device that both seals and then has a knife that can cut through.

And so, again, all of us are pretty well equipped, and familiar, and experienced with robotic surgery. Most of our surgical procedures is performed via a minimally-invasive technique.

And about 50% of what I do is benign gynecology. And so complicated GYN surgery was referred to us because of our surgical expertise, and it's something I enjoy doing. And again, taking these surgeries that would otherwise be done via an open approach through a minimally-invasive approach, give them the benefits of going home the same day-- and my partner Dr. Kalogera is going to talk more about the same-day hysterectomy-- less narcotic use, and for those cancer patients, they're able to start their adjuvant therapy sooner than they would through a traditional incision, which we know has demonstrated improvement in outcomes.

So robotic expertise is something that we're really proud of here at MCI. South Miami Hospital, which is part of the Baptist Health system, is the only hospital in South Florida that's a center of excellence for minimally-invasive gynecologic surgery. Actually, not Baptist Main, not University of Miami, and not Cleveland Clinic-- no other hospital in South Florida carries this designation.

And I lead this program, and it's really important. We capture our metrics. We prospectively look at our outcomes to ensure the best possible outcomes for our patients. And although South Miami Hospital is one of our smaller hospitals in our health system, we perform more robotic surgery in this hospital than any other hospital in the state of Florida. And so we're very proud of that fact.

One of the things that robotic surgery allows us to do is to perform lymph node dissections through a minimally invasive approach. And here, in my right hand, you see, are the robotic scissors that have energy. In my left hand there, I have the bipolar device. So we've opened up the retroperitoneum, and we're going to perform a routine lymphadenectomy. And as we know, lymph node metastasis is perhaps one of the most important prognostic factor for GYN cancers, particularly in cervical and endometrial cancer.

And in the past, we would perform a complete pelvic lymph node dissection, which you see here. But really, when you look and see, particularly in endometrial cancer, which is the most common GYN cancer, most women present at an early stage. Most women are low-grade tumors. And their risk of lymph node metastases is only about 3%.

So we're performing these extensive lymph node dissections in women despite the fact 97% of women really derive no benefit from this procedure. And again, we're all excellent surgeons, and no surgeon thinks to have their morbidity. But the reality is these procedures have operative time, have increased blood loss, have the potential for vascular or nerve injury.

And so when I was at Sloan Kettering, I worked with the breast team, particularly Mary Gemignani, who was a GYN oncologist who later developed an interest in breast cancer-- really transitioned her practice to breast surgery. And we borrowed, from the breast team, the idea and the concept of sentinel lymph nodes.

And so this was one of the first papers ever published in the United States looking at the feasibility of sentinel lymph node mapping in early-stage cervical cancer. And this, for a long time, was the paper that was cited in the NCCN as this move from experimental into standard of care.

And this is a sentinel lymph node dissection being performed robotically. You can see here, we're in the white light. Then we injected a green dye into the cervix. That green dye then travels to that first sentinel lymph node. You can see that here when we toggle to our near-infrared. And so we're able to identify that first draining lymph node. We're able to remove just that one lymph node by decreasing the morbidity of lymphedema, decreasing your risk of vascular nerve injury, and actually increasing our detection rate of lymph nodes because these lymph nodes then go to pathology and they're looked at differently.

A regular lymph node is looked at, they cut it once, they stain it, they look for any evidence of metastatic disease, they move on. With sentinel lymph nodes, they do additional pathologic evaluation. And because of that, we're able to identify additional metastatic disease that would have been missed.

And the really aha moment you have with this-- I had a patient that we did an article in the Miami Herald who was an early-stage endometrial cancer and underwent sentinel lymph node mapping, and had her lymph nodes being evaluated routinely the way that pathologists normally do. They would have missed the metastatic disease inside her lymph node. Instead, because of the ultrastaging protocol, we identified. She went on to receive her adjuvant therapy. And I just saw her two weeks ago. And she completed her five-year disease-free interval. And this is someone who we would have initially missed-- would have likely recurred, and would have been puzzled why an early-stage endometrial cancer occurred.

So these are one of the things that I brought back from New York to South Florida. All my partners are very well-skilled in this. And again, it's one of the metrics we look for through our MSK alliance.

One of the unique things that we offer here at MCI is hypothermic intraperitoneal chemotherapy. And essentially what this is, at the time of a cytoreduction procedure when you remove all of the cancer, you then do a heated bath inside the peritoneal cavity with chemotherapy. And this has a couple of different advantages. One is, normally, after a big surgery, patients wait four to six weeks before starting their adjuvant chemotherapy. And a study from Sloan Kettering and MD Anderson demonstrated that, a lot of times, the cancer may have grown back in that time period.

So now we're giving chemotherapy right at that moment. It's after the surgery. We removed all the tumor, so the tumor burden is less that the chemotherapy has to work. By heating it, we get deeper penetration into the tissue. And this is something that I've been performing since 2012. And really, we're one of the few centers in South Florida that has such expertise in this.

So I did an initial pilot study we presented at SGO, looking at our initial experience for recurrent ovarian carcinoma. And these were our survival outcomes. And these were in heavily pretreated women. So this was very encouraging.

And based on this, me and one of my co-fellows from Sloan Kettering along with a group at Sloan Kettering developed a randomized phase II trial looking at HIPEC. And this was run through our alliance. So again, that clinical trial we have. It was ourself, Sloan Kettering-- actually, the Mayo Clinic also participated. And this trial was presented at ASCO two years ago, and just came to publication in JCO, which, for us, as oncologists this really is the Holy Grail for where we'd like to publish our research.

And so this is a proof of concept that the Alliance can run clinical trials, even a randomized controlled trial, and can get published in the most prestigious of oncology journals. And so we're very proud of this work.

While we were doing this, a group from the Netherlands presented their work on HIPEC in the upfront setting for women who underwent neoadjuvant chemotherapy. And this demonstrated a progression-free and overall survival advantage. So this now has been added as standard of treatment for the NCCN guidelines. And thankfully, again, we have a lot of experience performing this.

And so we've incorporated this into our management for GYN malignancies. And so we have a peritoneal disease team here at MCI, and it consists of myself-- I lead this team-- surgical oncology, the colorectal surgeons, thoracic oncology, and our medical oncology colleagues. And we treat GYN malignancies, mesothelioma, appendiceal, and select colon and gastric cancers. Again, we're one of the few centers in Florida that offers this multidisciplinary peritoneal disease team, which we're very proud of.

One of the other things that really separates us is our clinical trials program. We have phase I trials, phase II, phase III, cooperative group trials. And I'm very proud of the robust clinical trial program that we've developed.

Just this year at ASCO, we were part of a phase I team that presented a novel drug in ovarian cancer that are called ADCs, or Antibody Drug Conjugates. And basically these are like a Trojan Horse. So they have a receptor that binds on the outside of the cancer cell. It then gets brought into the cancer, and that's where it delivers its payload. So that's why I use the Trojan Horse analogy.

So this was a phase I trial which we participated in. We presented at ASCO. And in fact, this drug has now been fast tracked through the FDA for accelerated approval because of how encouraging the phase I results are.

We're now working in opening a phase II trial for this, as well as looking at these drugs in combination with other traditional therapies. So again, this is our phase I program developing and being presented at, again, the American Society of Clinical Oncology, which, again, is our most prestigious oncology meeting.

I also presented my phase II trial this last year with the preliminary results. This is a trial that's looking at immunotherapy in combination with PARP inhibitors for recurrent cervical cancer. I received a grant for this trial. We've also partnered with Florida International University for our basic science component. And actually, we've identified a novel pathway called the Fanconi anemia pathway that may be predictive of those women who are going to respond to immunotherapy.

So right now, immunotherapy is a pretty exciting treatment for cancers. And some of the markers that we use are what's called MSI-high, PD-L1, and tumor mutation burden to help predict which patient is most likely to respond to this.

Well, working with our colleagues at FIU, we've identified another potential bio-identifier for who's going to respond to this therapy. And this trial is ongoing, one of are our phase II trials. And we've had numerous phase III and cooperative new trials which have been published.

And the reason it's so important, as you see here, is research for ovarian, cervical, uterine cancer is among the most poorly funded research. And so it's so important to be able to bring these clinical trials to South Florida and allow access to women in South Florida to get the latest technology and opportunities of these new drugs.

One of the things that's so important that has changed the way we treat ovarian cancer is understanding patients and their tumors' BRCA mutation status. So all women with ovarian cancer are recommended to go both germline and somatic mutation. All women are referred to our team of geneticists here. And we have the largest collection of geneticists under one roof here at the MCI, where they undergo genetic evaluation, the appropriate genetic testing, as well as tumor testing to help really tailor their maintenance therapy.

And again, the most important thing is the MCI patient experience. And that includes a multidisciplinary approach. We partner with our radiation oncology team. We work very closely with them, our tumor board, we have radiation oncology present, the geneticists, or clinical trials team, our pathologists who have done a fellowship in GYN pathology at Johns Hopkins. So we really have the best of the best here. Our genetics team. Patients participate in cancer rehabilitation. Dr. Adrian Cristian, who comes from Sloan Kettering, leads this program. And our patients who are getting chemotherapy and are a little bit frail, we can refer them to cancer rehab to improve their performance status and also get them ready for a clinical trial that may be available to them.

We also have our psychiatry and neuropsychological teams-- again, all under one roof. Nutrition is imperative. We know most women with early-stage endometrial cancer don't die from endometrial cancer, they succumb to disease as a result of the obesity that caused the cancer, which leads to diabetes, hypertension, and other diseases. So it's so important to not only treat the cancer but treat the whole patient.

We have an alternative medicine program with acupuncture which has been shown to help with pain control, nausea. Our survivorship clinic, which is led by Dr. Beatriz Currier, which focuses not only on what we focus on in clinic, which is your cancer or what do your PET scans show, or recurrence. This focuses on life after a cancer diagnosis and how to live with that. And especially our nurse navigation system-- each patient identified and given a nurse navigator, who's another resource for them they can contact that helps guide them on when is their next appointment. If they have difficulty with transportation, if they need help with social work or finance, our nurse navigators work side by side with-- in the clinic, seeing these patients.

Our community programs like this, like our cooking classes, our Zumba classes, all these things that patients can participate in which is offered at a large cancer center like this, and of course, pastoral care, all of this under one roof. So I want to thank you. I know I covered a lot of topics. And Jane is probably upset that it took more than 10 minutes, but I thought it was really important to just highlight some of what we do here at Miami Cancer Institute and what really separates us and the care that we give our patients. So thank you for your attention, and thank you, Jane and Claire, for this opportunity.

JANE MENDEZ: Thank you, John, for such an informative talk about all the things that we can provide here at Miami Cancer, from clinical trials, to research, to the bedside, as well as all the holistic approach that we have, as you alluded to, under one roof.

So with that, it is my pleasure again to introduce our second panelist. And that's Dr. Eleftheria Kalogera. And she'll be talking about the outpatient hysterectomy, a.k.a. same-day hysterectomy. So Dr. Kalogera, welcome.

ELEFTHERIA KALOGERA: Thank you very much for attending our webinar today. Thank you for the kind introduction, Dr. Mendez.

So my name is Eleftheria Kalogera and I am a gynecologic oncologist here at the Miami Cancer Institute. I am excited to be discussing with you today one of the important services that we provide to our patients, which is the outpatient hysterectomy, or what we like to refer to as the same-day hysterectomy, which means that the patient's coming in the morning or during the day for their surgery, they have a major surgery, they go home the same day.

So the two things that I would like to focus on are, first of all, why does it matter, why it is an important service. And the second element that I would like to be discussing today is what are the key elements that makes us successful in being able to provide this service in a safe manner to our patient population.

So first of all, why do we take great pride in being able to offer this surgery to our patients? So there are a number of reasons, and first and foremost, that there is an increasing demand in the need for hysterectomy, for benign but also for malignant indications. And our ability to expedite the discharge of the patient and even bypassing the overnight stay puts is in a great position to be meeting this demand in a more timely manner.

In addition, hospital stays have been shown to have some inherent risks associated such as increased hospital-borne infections with multidrug-resistant microorganisms, or increased risk for diabetes and blood clots due to prolonged immobilization. So it has been shown to be a safe practice in terms of outcomes.

And especially in this day and era, it has also been shown, through research, to be a cost-effective practice, and very importantly, puts us in a position to truly optimize how we utilize our hospital resources, our inpatient hospitalizations, and our hospital staffing.

And importantly, it has been consistently shown that it is associated with high patient satisfaction. And while we have been offering this service for quite a while-- and definitely before the pandemic-- to our patient population, you can imagine how critical it was during a worldwide pandemic when we were truly very limited in our ability to provide some of the important surgeries that we're providing that were especially tied to an inpatient admission and offer oncologic-based surgery to our patients despite the pandemic.

But what distinguishes us and what places us in a unique position to be able to offer these surveys safely? So there are three major elements that we'll be briefly reviewing. The first thing is, first of all, how do we care for our patients perioperatively? And there is a pathway that we'll be discussing with you called the Enhanced Recovery After Surgery pathway, which determines what we do before, during, and after surgery for the patient. This is called, as abbreviated, as ERAS.

So the second element of success is the type of surgery that we perform, so not only how we care for the patient perioperatively but how we do the surgeries. And we are using the robotic approach. The third element of success is the fact that we are able to come together and work very closely in a collaborative fashion across a number of different teams. And this is absolutely critical.

So starting, first of all, with the first component, the Enhanced Recovery After Surgery, you may be familiar, you may have heard, or you might not, especially if you are not working in the surgical setting. So the Enhanced Recovery After Surgery pathway, or ERAS, is a truly modern, evidence-based approach to perioperative care that has really revolutionized how we care for our patients. And it was first introduced back in 2011, in gynecologic surgery in the United States. And I have had the opportunity to be part of the founding team at the Mayo Clinic, at that time, to be introducing it in gynecologic surgery.

So the concept of this approach that was initially introduced in colorectal surgery to actually replace all the traditional but untested practices of what we do perioperatively for the patient with practices that research had shown to accomplish one of three things. First of all, decrease the bodily stress response to surgery. Secondly, enhance the recovery of the patient. And thirdly, reduce surgical morbidity.

And some of the key components that are particularly relevant for gynecologic surgery-- because these can be tailored based on the type of surgeries that we do-- I have included it here. So the first key element is patient education. It's absolutely very critical to educate the patient and engagement in the recovery and set the expectations of what will happen before, during, and after the surgery.

The second important part is reducing the fasting period. So they can have solids, for example, until midnight; liquid fluids, clear fluids, until two hours before surgery; with a big deviation off the traditional practice that the patient had to fast for several hours, became dehydrated and in a fasting and starving state.

We do not give any bowel preparation, even for bowel surgery, even for oncologic purposes. We are shooting for euvolemia perioperatively. The patients do not leave the OR with empty tubes, very rarely any drains for oncologic purposes. For this setting, the Foley catheter comes out at the end of the surgery, before the patient even goes to the PACU. We use a number of different non-opioid medications that target different receptors so that we can minimize opioid use. They are up and moving the same night of surgery, before they go home. They eat and drink right after surgery, before they go home.

And research has consistently shown, in gynecologic surgery as well as across other surgical practices, that there are very important benefits to be gained by the use of the enhanced recovery pathway. There is excellent pain control, and it's very impressive the amount of opioid reduction that takes place. There is early return of bowel function, significant decrease of the frequency of nausea and vomiting after surgery.

There's reduction in time of oral intake, very important, very relevant for what we're trying to accomplish here-- reduce hospital stay in this particular setting. It allows us to actually discharge the patient to home the same day. Significant reduction in cost. But importantly, excellent patient satisfaction and no change in the risks of the morbidity and the mortality after surgery.

And finally, and very important, they do go home the same day, but they do not come back for readmission later, which means that it is successful in accomplishing what we're trying to accomplish.

As Dr. Diaz mentioned earlier, the robotic surgery has truly revolutionized the field of minimally-invasive surgery. Briefly, I know that Dr. Diaz referred to these. This is the robotic console-- the robot. I apologize. These are 1, 2, 3, 4, the robotic arms. The instruments are introduced through the robotic arms, through the abdominal incisions inside the patient's abdomen. As compared to laparoscopic surgery, where the surgeon operates next to the patient, the surgeon actually sits in the console. The view is through these eye fields, and operates through the joystick and controls the instruments inside the patient's abdomen.

And there are very unique and interesting technical advantages that the robotic approach offers. And first and foremost, it truly gives a very enhanced 3D visualization in a magnified fashion, similar to what you will happen during open surgery. It does give the depth perception that laparoscopic surgery lacks.

Another very important benefit is, as you can see, the robotic instruments articulate in 360 degrees of freedom, similar to what the surgeon's hands would do during an open surgery. And when you take these two components together, you can imagine that it offers a unique opportunity for great precision. And that allows us to do high-complex surgery through small incisions.

And the benefits associated with robotic surgery is, first, shorter hospitalizations. In our case, we can perform major surgeries through an outpatient setting. There are smaller incisions, and that results in less pain and discomfort. There is faster recovery. The return to the normal activity is quicker. There is less risk for infection. Interoperatively has been shown to reduce the risk for blood loss, transfusions.

And minimal scarring-- especially sometimes in oncologic surgery, there may be need for future surgeries, so minimal scarring is also to our benefit. The last component that is absolutely critical is not only how we care perioperatively, it doesn't only matter how we do the surgery, but it is making a very big difference how we work together through a number of teams, collaboratively, to be able to reach our goal.

And all the members of our team, from our nursing, our advanced-level providers, anesthesia during surgery, our administrative staff, the surgical team, it's absolutely very critical. And we're able to work very closely to be able to safely do a major surgery and get the patient safely home the same day and continue the recovery at home.

But the most important member of the team-- and I would like to close by saying that the most important member of the team is the patient. And the patient education that actually starts from the time of the consult, to the preoperative area, during surgery and the recovery, as well as after the time the patient has gone home, it's absolutely critical because it is important that they know what is the expectations and how they can be actively involved in their recovery after surgery.

And with that, I would like to thank you for your attention. I'm happy to answer any questions at the end of every presentation. Thank you.

JANE MENDEZ: Thank you so much, Eleftheria. That was very exciting that we can provide all those services for our patients at Miami Cancer Institute. And I want to remind all attendees that we'll be taking questions at the end. So please submit those through the chat function and the Zoom presentation so that, that way, we can get to all your questions at the end of all these speakers.

And now it is my honor to introduce my colleague and fellow breast surgeon, Dr. Starr Mautner, who will be talking about Miami Cancer Institute's high-tech, high-touch approach. So hi, Starr. Welcome.

STARR MAUTNER: Hi. Good evening. Thank you so much, John, for inviting me to speak. And thank you, Jane, for that introduction. Thank you for everyone who is joining us this evening. I had the opportunity to look at the list of people who had signed up to join us, and a lot of the names are very familiar and are local gynecologists that may have been already referring us patients. Some people are from further away, and so we want to give you an introduction as to what we do within the walls of this 445,000 square foot facility.

If you are local, then chances are that you've driven by our facility, which is on Kendall Drive. And it's a huge building. It's beautiful. It's very modern. But you may be less aware of what actually goes on within these walls.

And so specifically for the breast service, I'm going to give you an overview this evening and talk to you a little bit about what of programs and resources we have to offer our patients here. And I'm going to try to advance the slide. There might be a short delay. There we go.

So this is our Breast Surgical Oncology team. We have six breast surgeons. And many of you may be familiar with Bob DerHagopian. He still practices here and comes to the office a couple of days a week to see his own patients, but is no longer operating. And then the rest of the surgeons are operating-- Gladys Giron, Cristina Lopez-Penalver, Jane Mendez, who you've heard from tonight, Nadia Nocera just joined us recently and completed her fellowship training at Tampa, at Moffitt, and then me on the end here.

And we usually are the first members of the team that patients will encounter when they're referred for a breast cancer diagnosis, but we work with several other counterparts within the building. And everyone that's listed here on the right is actually under one roof here at Miami Cancer Institute. And so we work very closely with Medical Oncology and Radiation Oncology, along with our breast radiologists here, the Genetics team, we have psychiatry support services, reconstructive plastic surgery, fertility preservation for premenopausal patients who are interested, physical therapy, acupuncture, and massage therapy, just to name a few. And there's even more support services such as nutrition and exercise classes as well.

And it's very common for patients to come and see us, and not only see us, but have other appointments in the same day. And so, oftentimes, I may see a young patient diagnosed with breast cancer who has a family history of breast cancer as well. And we say, well, it would be very important to get genetic testing done. And so sometimes we can refer them to the genetics team and they're seen the same day, and the blood is drawn, and that process is started.

Along the same lines, our plastic reconstructive surgeons who we work very closely with are just down the hall from us. And so especially if patients are traveling from far away to see us, I try to get them in to see plastic surgery, in the same day if possible, if they are interested in reconstructive surgery.

One thing that differs between us and gynecologic oncology is that we do not operate with robots. So we're very hands on. But I realized, during John's presentation, that one of the disadvantages of that is that I don't have the really cool videos that he has. But I will be trying to show some pretty pictures later on in the presentation. But we do not operate with robots, but operate hand in hand with our reconstructive plastic surgeons, and really are able to offer patients very nice cosmetic results on top of offering them excellent outcomes in terms of their breast cancer diagnoses.

So our breast cancer clinic is arranged in three different clinics, actually. And so the breast surgical oncologists are at the top here. And we deal mainly with patients who are diagnosed with breast cancer, but also those patients who have benign neoplasms that require surgical excision. So a patient that may have, let's say, atypical ductal hyperplasia or a potential phyllodes tumor would still need surgical excision and would see a breast surgical oncologist.

And those patients who have genetic mutations that are opting for prophylactic surgery we see as well. And we prioritize these patients.

Within the last couple of years, we've been able to open two other clinics that are really beneficial to patients in the community that don't necessarily meet the criteria to be seeing a breast surgical oncologist but need that specialized care. And so later on this evening, we are going to be hearing from Ana Sandoval about our high-risk breast cancer prevention clinic. And in this clinic, she sees high-risk patients that are not requiring surgery.

And then, lastly, our benign breast clinic-- and so, very often, we are receiving referrals from our general gynecologists in the community to see patients who either have breast pain or breast cysts or BIRADS 2 or 3 benign imaging. And while these patients do require some reassurance at times and review of their films, oftentimes, they are not surgical. And so we really saw a need to have a benign breast clinic.

And so we now run this on Fridays with Deepa Sharma, who is one of our internal medicine breast specialists, along with Dora Escobedo, who is one of our nurse practitioners. And so patients really have this resource. If they do have benign breast disease, they can still be seen here at Miami Cancer Institute.

I'd like to highlight that we also use a very high-tech, high-touch multidisciplinary approach. So oftentimes, while the surgeons will be the first person that the breast patient may see, we work hand in hand with Radiation Oncology and Medical Oncology.

And it is rare for a patient to only need breast surgery when they're diagnosed with a breast cancer unless it's extremely early stage 0 and they undergo mastectomy. Most patients are going to require some sort of multimodality treatment. And so I do think it's very important that we're able to communicate with our colleagues, that we are under one roof, we're all on the same electronic medical system.

And we also meet, every single Friday, for a Tumor Board meeting where we discuss complex cases. And everyone is at the table there to discuss the case from different viewpoints. Radiation Oncology is there, even Genetics is there, Medical Oncology and our breast radiologists as well.

And recently, we've gotten our colleagues from Sloan Kettering to come in quarterly and participate in these Breast Tumor Board meetings to make sure that what they're recommending is in line with what we're recommending as well.

I promised to show some pictures. And so I think one of the things that we have been offering patients that we should really highlight because it's not being done everywhere is the technique of nipple-sparing mastectomy. And so not all patients are candidates, but there are a number of patients that either are undergoing prophylactic surgery-- so they don't have breast cancer, but they have a genetic mutation and they want to reduce their risk of developing breast cancer-- or may have small tumors that are peripherally located. And as long as the patient, anatomically, is a candidate and the cancer is not near the nipple-areolar complex, they may be a candidate for a nipple-sparing procedure.

And while this is not done robotically, we are able to hide the scars at the inframammary fold and offer a superb cosmetic result. Not every single patient has a result like this. But when it comes out this nice, the patients are very happy and we are very happy as well.

And so with the pandemic, we actually have been sending a number of patients home the same day. So similar to same-day hysterectomy, we've been doing some same-day mastectomies. Once again, not for everyone. Most of our patients do stay overnight one night. But for the healthy, young patient, we're able to accomplish this as an outpatient procedure.

Our plastic surgeons do a nice pectoral muscle block, and patients are actually comfortable and sent home, and with a very, very low readmission rate. And so I think that this is one thing that is now becoming more and more popular, patients are asking for it, and if it's done safely, can offer a really superb cosmetic result for those patients who are candidates.

I'd also like to highlight radiation oncology. And so our Radiation Oncology department is very special here at Miami Cancer Institute. Not only do we offer proton beam radiation therapy, but more importantly, we have every single modality that's available to treat a patient with radiation therapy under one roof. And we're one of the only places, if not the only place, in the world that has this capability. And because of that, they employ this idea that the optimal modality should be given to every single patient. And so I think they really try to tailor care to the patient and decide which is going to be the best modality to use.

When it comes to breast radiation, we traditionally think about whole-breast radiation therapy with photons. That seems to work very well, but there are certain patients where photons would cause unnecessary radiation to the heart and lungs, especially for a left-sided cancer in someone who requires chest wall or nodal radiation. And so for those patients, we are able to offer proton beam radiation therapy, which is more precise, and avoid scatter radiation to the heart and lungs.

We can no longer say that we are the only proton beam radiation center in South Florida because there are two others now, but we are the largest and the most experienced. And so we've treated over 1,200 patients with proton beam radiation therapy. And we also have three gantries here at MCI, which means that there are three separate huge facilities here within the building that can treat with proton beam radiation daily. And the other centers that exist, one in Miami and one in Palm Beach, only have one gantry each.

Additionally, we're able to offer some patients who qualify partial breast radiation therapy with either brachytherapy or protocols that employ external beam partial breast radiation that may be given over one week instead of three weeks or six weeks. And so there are a lot of different tailored options for patients when it comes to radiation therapy and breast cancer treatment. In addition, systemic therapy, our medical oncology colleagues, we really try to employ a holistic approach. We have art therapy here, acupuncture, nutrition services, massage therapy, and exercise classes.

This is a photo-- and I don't normally, as a breast surgeon, go up to the chemotherapy suite, but I had a very young patient who was 29 years old, diagnosed with breast cancer, and was engaged to get married. And within a span of a couple of months, we performed nipple-sparing mastectomies on her, and she started chemotherapy, and then got married after her third session of chemotherapy here.

And so you can see, in the picture, she's wearing a cold cap, and that's to freeze the hair follicles on her scalp so that she wouldn't lose all of her hair. And ultimately, she'll probably lose 50% of it or a little bit more when it comes down to completing her chemotherapy, but for the first three sessions of chemotherapy, she hardly lost any hair. She was able to go to her wedding and look like someone who was not receiving chemotherapy. And that meant the world to her.

We had nurses that came by during this treatment to throw her a party for a bridal shower. We had-- the art therapist came by and brought her a bouquet of flowers. We had her acupuncturist come by and see if she needed anything. And so really, I was very impressed with what was going on in the chemotherapy suite, as I know our patients are as well. And we have very special patients that require very special care. And I'm so happy that we're able to offer these services.

We see a lot of young patients here at MCI for whatever reason. And I think those reasons need to be investigated further. But in the meantime, we do have resources for them, such as fertility preservation resources. And so a young patient who's premenopausal that may not have even started her childbearing or may not be done with childbearing can be referred to oncofertility support services.

In addition, we have a new sexual health clinic. So many of the treatments, whether it be chemotherapy or endocrine therapy, really affect women in terms of their sexual health. And there was such a need for this. And so I'm so happy that this was just opened for our female patients. And we also have a separate male sexual health clinic as well.

And lastly, we offer survivorship. And so once a patient has completed treatment, we refer them to our survivorship clinic, in which case they are given a summary of all of the treatment they received, what their treatment plan is going forward, and any side effects that are currently being experienced during treatment are gone over to see if we can help with those side effects. So it's a really nice summary that's given to patients at the end of their treatment.

Lastly, I would like to talk a little bit about research and innovation. John already touched on the important aspects of the MSKCC Alliance that we have with Sloan Kettering. Through that, we are actually able to open clinical trials. And there are a couple of interesting ones that are in the pipeline that I'm working on with our breast surgical oncology colleagues at Sloan Kettering to bring here. Both of those trials aim at decreasing the morbidity of treatment of breast cancer. And so we're looking at seeing who can we safely omit axillary lymph node dissection on.

A number of years ago now, a important seminal study called Z11 came out showing that not all women that had lymph node involvement required a complete axillary lymph node dissection if they were undergoing lumpectomy followed by radiation therapy. And we're now seeing if we can expand that criteria to other women as well that would traditionally require axillary dissection.

Ana Sandoval is going to tell us more about her breast cancer prevention clinic, but she's running a trial in which we analyze how patients make decisions about undergoing chemoprevention or preventative care to decrease the risk of breast cancer. And our medical oncologists have a number of trials that they're able to offer patients that are living with metastatic breast cancer. Specifically through the Sloan Kettering Alliance our radiation oncologists have several trials where they're able to radiate patients with certain metastases. And there is a very interesting trial going on, right now, analyzing protons versus photons for patients who have internal mammary nodal involvement, looking at cardiac endpoints.

And so I think that we are just starting off. This cancer center is only about five years old, and we've done a lot of work in those first five years. And so I'm looking forward to seeing what the next five years holds.

I would like to thank everyone for attending. One of the criticisms that I've heard for referring patients to a very large cancer institute like MCI is that sometimes it's hard to get your patients in. And that should never be an issue. If you have a patient that has been diagnosed with breast cancer and needs to be seen, you should be able to get them an appointment within 48 hours. Our scheduling number is at the bottom of the page, but I also listed all of our email addresses because I'm happy to give anyone my cell phone or email address just to make sure that you have no issue getting your patients in to be seen in a timely manner.

Thank you. And I hand it off now to Dr. Sandoval to tell us more about the high-risk breast cancer prevention clinic.

JANE MENDEZ: Thank you, Starr, for such a thorough review of the services that we can offer for our breast cancer patients and beyond. So now it is my honor to introduce, again, Dr. Ana Sandoval. And Ana will be talking to us about breast cancer prevention. Thank you, Ana. Welcome.

ANA CRISTINA SANDOVAL LEON: Hi, everyone. I'm Ana Sandoval. I'm a breast medical oncologist at Miami Cancer Institute, but I'm also a-- I see patients with breast cancer, but I also see patients that are high risk of developing breast cancer in our breast cancer prevention clinic. So this is an outline of my talk.

I'm going to talk who do we see in our breast cancer prevention. Then I'll go over of some of the things that we do during the visit for our patients. So we need to know first what are the risk factors. We calculate their risk using different mathematical models. Then, based on this, we decide who should get MRIs. Then we discuss chemoprevention. And we can also assess who needs genetic testing.

So who do we see? We see patients that have a high risk of developing breast cancer. And this can be due to different reasons. Sometimes they have genetic mutations that increase their risk of breast cancer. They can also have a strong family history of breast cancer with no identifiable mutation.

If patients have a lifetime risk over 20%, they are also candidates to be seen in the breast cancer prevention clinic. And we cannulate this with a Tyrer-Cuzick model. Patients that have history of mantle cell radiation or patients that have underlying high-risk breast lesions like lobular carcinoma in situ or atypical hyperplasia.

What are some of the risk factors? I mentioned some of them-- age, genetic mutation, family history, radiation, these prior breast biopsies. But also it's important to know that patients with dense breasts are at risk of developing breast cancer. This is usually shown in the mammograms. Now it's part of the report. Patients that are Ashkenazi Jewish are also at risk of developing breast cancer hormonal factors like having your first menses before age 12 or a late menopause after 55. Also, having kids after 30 or not having kids is a risk factor.

There are some modifiable factors. And these are the ones that we have to consult our patients and educate them. Some of them are obesity, alcohol use, and hormone replacement therapy for over five years.

So using all these factors, they have many mathematical models develop. The ones that are routinely used in the clinic is the Gail and the Tyrer-Cuzick. The Gail model is the most comprehensive model. It's a very long list of questions that we ask, and it can take some time. It's important to know that-- we ask about breast density and we ask an extended family history, so not only first- but also second- and third-degree relatives. We ask the age of the family that had breast cancer if they had bilateral breast cancer and if there was ovarian or male breast cancer in their family.

This model tends to overestimate the risk in patients with atypical hyperplasia, LCIS, or patients with dense breasts. Usually we get a 10-year risk or the lifetime risk, and the lifetime risk is the one that we use the most to decide which patients would benefit from MRIs on top of the regular mammograms and ultrasounds. Many reports also-- including in our institution-- now incorporate, in your mammogram, what is your typical risk, your lifetime risk. So it's easy for clinicians to know which patients can be referred to a breast cancer prevention clinic.

The Gail model is much shorter. It's just a few questions. It takes like a minute. And I use it to determine which patients would benefit from chemoprevention. Why? Because this was the model using the majority of the chemoprevention trials. They use a five-year risk of over 1.67% for the patient to be eligible to participate in the trial.

So who should get breast MRIs? According to the American Cancer Society, patients that have some genetic mutations that put them at higher risk of breast cancer should get breast MRIs routinely, on top of their regular mammogram an ultrasound. It's not instead. It's both of them. Usually we stagger them so the mammogram and ultrasound, and then, six months after, we have the MRI. So we have some sort of image every six months. As mentioned, patients that have a lifetime risk of developing breast cancer of over 20% and patients that have prior breast radiation.

Chemoprevention-- this is a summary of the chemoprevention trials. As you can see, there have been many trials. The NSABP-1 is the larger one. It included over 13,000 patients. And patients were randomized to either placebo or chemoprevention. The patients were allowed to participate if they met different criteria that they consider high risk. And one of the criteria was a Gail, the five-year risk, of over 1.67.

As you can see, all of them show that chemoprevention works. There is a risk ratio of 0.69 for tamoxifen, for raloxifene. In this meta-analysis, it was 0.44. And for aromatase inhibitor, it was 0.45. It's important to note that there was a study, the STAR trial that compared tamoxifen to raloxifene, and it seemed that tamoxifen was superior.

What about safety? Raloxifene and tamoxifen can be good for your bones, and they have shown to decrease the risk of fracture. So if you have a patient that is high risk and have osteoporosis, probably these are the medications that we can consider prescribing them. Tamoxifen and raloxifene were associated with an increased risk of thromboembolic events compared to placebo. And this is one of the main reasons why patients are reluctant to take these medications.

Tamoxifen seems to have more adverse events than raloxifene. Tamoxifen was also associated with higher risk of endometrial cancer and cataracts. And all these medications-- tamoxifen, raloxifene, and aromatase inhibitors-- were not associated in this particular meta-analysis of increased risk of coronary heart disease or strokes. Symptomatic events vary among the drug. And this is also another reason why patients will be reluctant to take these medications or will stop the medications.

So what do the guidelines say? There was an update in 2019 of ASCO and USPSTF. But mainly, the recommendation is that clinicians should offer prescribing these medications to women that are high risk and are over 35 years. This is the cutoff for patients that were included in the trials, and patients should have completed childbearing.

Who should get genetic testing? So we know that Ashkenazi Jewish are at higher risk of developing breast cancer. So they should be offered genetic testing. Patients that have a probability of mutation of BRCA1 or 2 of over 5%-- and you can calculate with models like the Tyrer-Cuzick.

Patients that have a family history of breast cancer and also somebody in their family or the same person that was diagnosed with breast cancer if they had ovarian, pancreatic, or prostate cancer. And patients that have first- or second-degree family member with history of breast cancer-- and that person should receive genetic testing. And this is a very long list, but these are the guidelines for patients that have breast cancer. So if the patient had a family member who had breast cancer and met criteria and did not get genetic testing, that patient can get genetic testing.

So what do we offer in the breast cancer prevention clinic? As you can see, we individualized breast cancer health plans for each patient. We do a risk assessment, if pertinent, to each patient. We decide if they need enhanced monitoring with breast imaging and breast exam. We discuss lifestyle modifications. It's extremely important to talk about diet and exercise. Because as you can see, obesity is one of the modifiable risk factors for these patients.

We discuss about chemoprevention, and we discuss if they are eligible about surgery, and then refer them to our colleagues that are here in our meeting. If they have a BRCA1 and BRCA2, they surely will see surgery on [INAUDIBLE]. We also offer them genetic referrals if needed. And we have a great, supportive team that I have mentioned already several times throughout this meeting of nutrition, psychology, psychiatry, exercise physiology, among others.

Finally, for patients that have high-risk lesions-- not for all high-risk patients, but for patients that have atypical hyperplasia or lobular carcinoma in situ, we currently have a clinical trial, non-therapeutic, that is looking at a tool to help patients make the decision regarding taking or not chemoprevention. So if patients get access to this tool, they can estimate their risk graphically. They also have to answer questions regarding their preference about taking medications and about the risk of breast cancer, and then they have a lot of educational materials. When they complete this, we get an action plan, and on the six-month visit, we discuss with the patient, and then the patient decides if they want or not to take chemoprevention. Thank you.

JANE MENDEZ: Thank you, Ana, for such a superb description of the services we offer the breast cancer prevention clinic. And with that, I'd like to thank all our speakers for their superb talks.

So now it's time for questions. And I have the first one. And it's for you, Dr. Kalogera Somebody would like to know, when are patients not good candidates for the same-day hysterectomy? Not good candidates.

ELEFTHERIA KALOGERA: That's a very good question. Of course, I will speak in general terms, but if the patient is cleared for surgery, if they have some comorbidities that can be controlled before they're discharged-- so that includes even older patients, patients who may have even some cardiac disease or arrhythmias, diabetes, all these are things that we can control, then they can go home the same day.

So age is not a limitation, comorbidities is not a limitation as long as they can be activated away, have all all their vital signs appropriately managed before they go home. If they're a candidate for robotic surgery-- for example, if they have a surgical history that allows for a robotic surgery, that doesn't mean that they cannot have had surgeries in the past, but if we think that we can safely do robotic surgery despite the surgical history, that would be another candidate for an outpatient hysterectomy.

And then it really depends on what happens with surgery. If everything goes well, there are no unforeseen intraoperative findings, if everything goes as planned, then they can go home the same day. So for the most part, as long as we can safely do a robotic surgery and the surgery goes well, and there are nothing that comes up interoperatively or postoperatively in terms of the comorbidities and how they're managed perioperatively, they can go home the same day.

I would say the vast majority of the patients that are in the clinic we feel that they are reasonable candidates when we counsel them are able to go home the same day. Very rarely, something will come up that will make them require an overnight stay. So this is very far and few in between.

JANE MENDEZ: Thank you so much. Next question I have is for John Diaz. Somebody would like to know when you would treat somebody with the HIPEC. So what would be some indications? And if so, how can they refer a patient for the HIPEC therapy?

JOHN DIAZ: That's a great question. So right now, the NCCN guideline recommendations are, in those women who have ovarian cancer and are being treated with neoadjuvant chemotherapy-- in other words, for whatever reason, we felt they weren't a good initial surgical candidate-- after they received three to four cycles of the adjuvant chemotherapy, they're reevaluated. And at that time, they're considered good candidates for interval cytoreduction, that's where we would use Hypothermic Intraperitoneal Chemotherapy in the upfront setting.

In the recurrent setting, it's less clear, but those patients who have a platinum free interval of greater than six months and are considered to be good candidates for a secondary cytoreductive procedure, we also offer HIPEC in that setting.

For nongynecologic cancers, it depends on the disease status. So the low-grade appendiceal cancers, pseudomyxoma, pelvic mesothelioma, and select gastric and colon cancers, we perform those surgeries in collaboration with our surgical oncologist and our colorectal surgeons. But I'm always happy to see a consultation.

It always throws my team off a little bit when I have male patients in the waiting room who are coming to see me for HIPEC. Everyone's a little bit confused by that. But we have a very proactive program that's supported by institution. And so happy to see any patient you feel maybe a candidate for HIPEC.

JANE MENDEZ: Thank you, John. The next question is for Dr. Mautner. And there's some interest in learning what might be some contraindications to the nipple-sparing mastectomy, what patients might be not good candidates for that procedure.

STARR MAUTNER: So when we see patients that are interested in nipple-sparing mastectomy, there are two different factors that we look at. One is from the oncologic perspective, what would make them not a candidate, and the other is from the plastic surgeon's perspective, what could make them not a candidate.

And so from the oncologic perspective, obviously, if there's nipple-areolar complex involvement, that is a strong contraindication to nipple-sparing mastectomy. In general, we say that if there's calcifications or a mass within a centimeter of the nipple-areolar complex, that also is a contraindication to nipple-sparing mastectomy. We can use MRI to differentiate if there's any enhancement leading up to the nipple, but that's not always accurate.

And so I always tell patients that, if we're going to attempt nipple-sparing mastectomy, we are going to take a nipple margin of tissue just beneath the nipple-areolar complex. And if that were to come back positive for malignant cells, then I recommend that we go back to the operating room at a later date to remove the nipple areolar complex. That is rare, but it can happen.

And then, from a plastic surgeon's perspective, patients anatomically may not be a good candidate for nipple-sparing mastectomy depending on where their nipple is located. And so if the nipple points downward beneath the inframammary crease, that's considered ptosis. And those patients cosmetically just don't come out as well because the nipple won't be in the right position when we do a nipple-sparing mastectomy.

And so there are some ways around that. If this is a prophylactic case so that you have all the time in the world to plan this out and it's truly elective, you can stage the procedure and have the plastic surgeon do a mastopexy to lift the nipples and do a reduction and put the nipples in the correct position prior to doing the nipple-sparing mastectomy. And I usually do that six to eight weeks before the final surgery. And so that would be considered a staged procedure.

But I would say the ideal nipple-sparing candidate is someone who's relatively small-breasted, has no ptosis, and either does not have breast cancer and is doing this preventatively or has a small cancer that's far away from the nipple. We are expanding criteria more and more as we do more and more of these cases and see what can safely be done.

The other criteria is I really don't like to do these in smokers because they have impaired blood flow to the skin and nipple due to nicotine and vasoconstriction. And so you have a higher risk of complications in terms of skin and nipple necrosis in patients who are heavy smokers. And so I think that, if a patient is interested, they have to make criteria not only from the surgical oncologist but from the plastic surgeon as well.

JANE MENDEZ: Thank you, Starr. That's great to create that awareness. Again, it's great from the cosmetic [INAUDIBLE], but we have to keep all those other factors into consideration.

Next question I have is for Dr. Sandoval. There's a question pertaining to aromatase inhibitors. Somebody would like to know if it is seven days versus five days after five years of aromatase inhibitors. They don't specify-- is this in the chemoprevention setting or is it in the cancer setting? So if you can address both, please.

ANA CRISTINA SANDOVAL LEON: So for chemoprevention, all the trials were done for five years. There was a small Italian study that used a lower dose of tamoxifen, no aromatase inhibitors. The regular dose of tamoxifen is 20 milligrams. They use a 5-milligram dose that we don't have in the US. And they use it for three years. And there was also decrease in the risk of developing breast cancer.

This is different for the indication for patients that had breast cancer. The patients that had breast cancer should at least get a five years of endocrine therapy, either tamoxifen or aromatase inhibitors. And some patients benefit from extended endocrine therapy up to 10 years.

So more than 10 years, there is really no data. And now there have been developed different genomic assays that we use, for example, initially. We use some of them to decide about chemotherapy.

Now some of them-- one is called the breast cancer index. It can help us decide which patient will benefit from extended endocrine therapy if they have breast cancer.

JANE MENDEZ: Thank you. So with that, I'd like to thank all the attendees for spending part of your evening with us. It's been great to share this time with you and at least make you aware of all the things we can offer, high-tech high-touch, at our Miami Cancer Institute, all under one roof.

So looking forward to working with you and answer any questions that you might have. And thank you for Christie Fleites putting this program together and inviting all of us. And thanks to all my colleagues for their wonderful presentations. So with that, all, have a great evening, and thank you for your time. Thank you. Bye bye.

Video

Miami Cancer Institute's High-Tech High-Touch Approach

Miami Cancer Institute's High-Tech High-Touch Approach

Join our experts for a panel discussion on Breast Cancer & Gynecologic Cancer
Originally Webcast: Thursday, October 21, 2021 | 5:30-6:30 PM

Topics to include everything from breast cancer prevention, to state-of-the-art holistic treatments, and advances in gynecologic cancer care, including robotics and therapeutics.

Related Presenters

John Diaz, MD.

John Diaz, MD

Chief of Gynecologic Oncology
Miami Cancer Institute

John P. Diaz, M.D., is a board-certified gynecologic oncologist at Miami Cancer Institute. Dr. Diaz provides comprehensive and compassionate gynecologic cancer care for women with endometrial, ovarian, cervical, vaginal or vulvar cancer. ...

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Starr Mautner, MD.

Starr Mautner, MD

Breast Surgical Oncology

Starr Mautner, M.D., is a Board-certified surgeon with clinical expertise in breast surgical oncology of the Breast Center at Miami Cancer Institute, a part of Baptist Health South Florida. Dr. Mautner specializes in breast surgical procedures ...

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Ana Cristina Sandoval Leon, MD.

Ana Cristina Sandoval Leon, MD

Medical Oncology

Ana Sandoval Leon, M.D., is a medical oncologist specializing in the treatment of breast cancer. She cares for patients diagnosed with all types and stages of breast cancer, including non-invasive and invasive, recurrent and advanced breast ...

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Eleftheria Kalogera, MD.

Eleftheria Kalogera, MD

Gynecologic Oncology

Eleftheria Kalogera, M.D. M.Sc., is a gynecologic oncologist at Miami Cancer Institute. Dr. Kalogera specializes in treating gynecologic cancers, including the surgical and medical management of ovarian, uterine, cervical, vaginal and ...

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