When prevention fails. An unexpected cancer diagnosis. Episode 10

Monika Rachtan
I invite you to listen to the podcast. Patient first.

Monika Rachtan
Good morning, I would like to welcome you very warmly to another episode of the programme. Patient first, and today my guest, but above all your guest, is Katarzyna Pogoda, MD, PhD, from the National Institute of Oncology in Warsaw. Good morning, and welcome. Doctor. Doctor, today we are going to talk about breast cancer. This is a terrible disease. A disease that affects not only the woman, but also the whole family, because both her children and her partner. So the subject is a little difficult, but a lot has changed in Poland. A lot of positive changes, so we are going to talk about these changes, and at the very beginning I can say that we will want to convince our listeners that breast cancer is not a sentence.

Catherine Pogoda
I would like to disenchant cancer in general. We also need to be clear that cancer is going to be one of the most common cancers. It is even said that every second Pole will develop some kind of cancer during their lifetime. So we must not think all the time that these are some kind of diseases far away from us. It's just that cancer really is a very common disease, just like cardiovascular diseases, other diseases, conditions, cancer really is common too. And it's not that cancer is always a sentence. Often enough it can be, for example, only local treatment, surgery, and the patient is cured. So cancer is unequal. I, in my clinical practice, focus on the treatment of breast cancer patients. And indeed what needs to be said about this cancer, it is the most common cancer of Polish women. It is estimated that one in eight women will develop breast cancer. So that brings me back to this again. This is a really common cancer, like we think 20,000 a year. What is that? It is a drop in the ocean of Polish women living, yes. On the other hand, if we think that over a lifetime one in eight will get sick, then when we think of our circle of friends in our family, it is already very close. So let's really not think that these cancers are a very distant disease, but really many of us can get ill. I in my clinic have as much as possible in the nursing medical community. We have people with breast cancer and that is probably a bit of the most. We far from feel that there are these cancers, they really are. So we definitely have to take care of ourselves and think about, what can I do? What can I do to make sure I don't get various cancers? There's this very cool European Cancer Code. Again, it is the word fight. I would rather say prevention, the kind of action we can do to protect ourselves in a sense. There is a lot we can do, but of course it is not always the case that something if we live even a super healthy life, we will not get cancer. It doesn't work that way, but we always reduce that risk. And among other things, the recommendations that are out there are that, for example, preventive screening, which is mammography once every two years, that is the screening that is recommended, reduces the risk of death from breast cancer. So let us remember that. Preventive examinations do not mean that we will not get a particular cancer, but if it is statistically detected, it will be at a much earlier stage. Then the treatment methods are definitely less aggressive, the treatment results much better.

Monika Rachtan
Doctor I will ask you right away. How can I carry out such a preventive examination, because you said that they are available and now who is a candidate, where can they carry out such an examination? What does it look like?

Catherine Pogoda
As far as women are concerned, precisely, in terms of breast cancer prevention, it is mammography. At the moment, it is a test dedicated to women between 50 and 69 years of age, so that they have this mammogram once every two years. That is, a woman is healthy, feels nothing in her breasts, everything is fine, but she wants to check herself. Then you don't need a referral. You just need an identity card and, in fact, go to a centre which performs such examinations. On the website of each National Health Fund, there are facilities that carry out such examinations. So access to these tests is really wide. All you need to do is to call to such a facility and go with your identity card and simply have such a test performed. What is also important is that it is a good idea to have such examinations in one facility. The radiologist then compares the examination that was done two years ago to the new one. Has anything changed? So I would definitely recommend doing this in one facility of my own, a proven one, where I want to go and do these examinations regularly. Well, but that's the thing about women over 50. And there are a lot of ladies, obviously younger ladies as well, who can get breast cancer.

Catherine Pogoda
Generally speaking, there is now such a debate in Europe as to whether this age for mammography should not be changed, i.e. lowered? From the age of 45, such examinations will be carried out. In addition, since we as women are living longer, not just 70 years of age, the European Union has already made such recommendations, for example, to extend this period to 75. And I know that discussions are also under way in Poland on whether to extend this age. It is certainly worth doing this, because it is the most common cancer. And this is, in my opinion, a very good option for women who care about their health and want to carry out this examination, because what else is worth paying attention to? Unfortunately, audibility for this test is very low in Poland.

Monika Rachtan
How many women come forward for these tests?

Catherine Pogoda
Currently, it is about 40% only. That is, see how many Polish women, however, do not perform this test. Sometimes it is the case that not all tests are registered either, especially if a woman performs it in private facilities. But still, this percentage is really far from ideal.

Catherine Pogoda
So here there is also a very big emphasis on prevention campaigns, those pink ribbons that are everywhere. And it's not just October, Breast Cancer Awareness Month, but really it's all year round. So I think it's important to incorporate a little bit of self-discipline if it comes that time 50. to start preventive screenings. I'm talking about mammography. On the other hand, it's not that a woman can't do anything more. Breast examination itself is definitely an important topic. And here, as it were, there are various videos on YouTube, for example. We are now in a world of social media, which are everywhere. You can find such a video, you can go to a midwife, you can go to a gynaecologist, a GP, who should teach you how such an examination should look like. The idea is to examine both your breasts. First look at them, because often by just looking at them we can see some dimpling, thickening, redness, that something in this breast has changed. This is actually already such a sign. It can be worrying that something is going on. Of course, you also need to massage these breasts, examine one breast in a circular motion lengthwise, then across. You can also do this while lying down, in bed or in the shower, for example. In fact, which method is most suitable for a woman and do it regularly once a month? Then really very small changes, very subtle ones, we are also able to detect.

Monika Rachtan
You talked about this preventive screening programme being aimed at older women, but you also encouraged younger women to do it themselves, to have a breast self-examination. And what was the youngest patient at the clinic that you treated for breast cancer?

Catherine Pogoda
I think it was a girl, a young woman, 22 years old. Such women can also get breast cancer. And always, when we have young patients, the family and the incidence of cancer in the immediate family is also an extremely important topic, because it often shows up in these young ladies. There may be positive genetic tests and then a genetic background, especially mutations in the brca1 brca2 genes, which greatly increase the lifetime risk of breast cancer or ovarian cancer. It is in such women that mutations occur and that. So when a young patient comes to us who has been diagnosed with breast cancer, we perform such genetic tests on her. In fact, it usually involves drawing blood and this sample goes for analysis. It is an analysis for mutations in these two genes, because if there is such a mutation, then unfortunately the lifetime risk of developing breast cancer or ovarian cancer is very high.

Monika Rachtan
And can such a woman pass on this risk to her daughter

Catherine Pogoda
daughter, but also for the son so here it kind of carries over. We inherit so half the genes from each parent. So here it's kind of like this genetics. As much as possible. These are hereditary issues. And then I often, I'll be honest, I have ladies who don't even think about themselves, whether they have the gene, it's more about they say I've got children, yes, and I'm worried about whether I'm passing on a gene, whether my children have inherited it from me. So then, if a woman has an indication for genetic testing, we test the breast cancer patient initially. If this mutation comes out, then the next of kin is also invited by the geneticist. But we test adults, because these cases of breast cancer are almost non-existent.

Catherine Pogoda
As far as younger people under the age of 18 are concerned, but later on as much as possible. It's also about living a little, but in peace and quiet, yes, until the age of 18. If there is no anxiety needed in this situation. However, later on, people of legal age have genetic tests carried out, and if there is a mutation. It is then possible to carry out preventive surgery. This is what we call it. These are surgeries that reduce the risk of developing breast cancer.

Monika Rachtan
What do they consist of?

Catherine Pogoda
These are operations in which the surgeon actually removes the glandular tissue, i.e. the breast. And immediately during this operation, implants can also be inserted. That is, the patient actually enters the operating table with her breasts and also leaves with her breasts.

Catherine Pogoda
I make no secret of the fact that I sometimes hear that this new breast is even better. They are implants,

Monika Rachtan
This surgery is reimbursed.

Catherine Pogoda
Yes. We have had reimbursement for a few years now, so these are really treatments that are available to our Polish women.

Monika Rachtan
I would also ask whether, as a young woman who believes, for example, her mother or her grandmother had breast cancer, but it is known that the diagnosis you said genetic may not yet have been available, may not have been carried out on such a mother. Would it be appropriate for me, too, to be tested, and I am not talking here about a preventive test or a breast self-examination, but about a genetic test. Should I carry out such a test?

Catherine Pogoda
Initially, a patient who has had breast cancer should go to a geneticist, for example. The geneticist takes a history, how many people have developed the disease, what age the lady was when she developed breast cancer. If he sees indications, it is then that the woman who has developed breast cancer is examined in the first place. If no mutation is detected in her, then there is really no need to do so in her daughter later on either. On the other hand, if someone is still unsure, or, for example, if the parents are no longer alive, then it is perfectly possible to go to a geneticist. The geneticist takes a history and then decides whether genetic testing is advisable for that person.

Monika Rachtan
and then such an examination is also reimbursed.

Catherine Pogoda
Yes, definitely yes, But these are certain specific criteria that the geneticist checks.

Monika Rachtan
I understand. Okay. Well, we have already said a few words about this prevention, but are there also situations like this? Do you know of any situations where a patient has had regular check-ups, done preventive examinations, lived a healthy life and still developed breast cancer?

Catherine Pogoda
I know and so do many of my patients. They definitely do. It is not the case that if we take full care of ourselves, we will definitely not get sick. And that's the sad thing. Yes, in general, yes, Well, because that's why we take care of ourselves, to be healthy people. But we also need to look at it from the other side, that we should do everything we can to ensure that if cancer should occur, it should be at this very early stage. Now is the chance of treatment, of treatment and cure. Definitely a higher chance of cure. So certainly it's the preventive screening that we're talking about. The examination itself is extremely important. In some women it's also worthwhile to have a breast ultrasound as much as possible, and it's such a common examination when you go to the gynaecologist, for example. Young women as much as possible. Women should go to a gynaecologist and the gynaecologist can then definitely recommend such an ultrasound examination, which also evaluates the structure of the breast. I would even say that this ultrasound examination is better for young women because their breasts are more glandular and this is when there is a better assessment. Mammography, on the other hand, is better for older patients, because these breasts are already a little more fatty and there is not as much glandular tissue.

Monika Rachtan
You said this ultrasound, and I have to say that this examination is probably the standard among my female colleagues when it comes to such examinations, which they do for anniversaries, as we laugh, because we always say that just, and the next year of life was a birthday, then this next month with just such a month when we realise these, all these preventive visits, well, and among other things, just signing up to the gynaecologist for such a standard examination. I also think that many young girls are already signing up for breast ultrasound. And I think it's a very good trend that I'm taking care of my health in this way.

Catherine Pogoda
Definitely yes, Because what we're really aiming for is, if even a cancer is to be detected, it's one that I can't detect, I can't yet feel on my hand, because then it's such small lesions that we can't feel. And then actually nodules, half a centimetre, a centimetre. It's a completely different treatment than, for example, when a patient comes to me who has a tumour of 10 centimetres,

Monika Rachtan
And these also happen.

Catherine Pogoda
I definitely have ladies like that too.

Monika Rachtan
I now ask what should be done if, during this self-examination of the breasts, I sense a worrying change? What is the course of action? Who should I go to?

Catherine Pogoda
It must be made clear at the outset that not every breast lesion is cancer. And that is the key of this programme actually. A lot of ladies really do have fibrocystic cysts. What kind of lesions are these? Benign. When we feel something for ourselves, let's just check that it's definitely that. This fear can't paralyse, it can't make me wait 3 months or will something happen to it? Really here, time is key, so you should go. In my opinion, the first such doctor is often the gynaecologist, who will order an ultrasound if necessary and a mammogram and then on this examination is assessed such a birads scale if something is worrying requires a biopsy, then by all means.Does he himself order such a biopsy? The patient can also go to the oncologist to the surgeon, who will order the appropriate tests. It is most often the first verification test if there are such indications that is the biopsy of this lesion.

Monika Rachtan
I'm going to ask about timing a bit more, because I recently had a situation where I was forced to help a person who had just such a worrying lesion, only it came out to us in the mammogram was described as one that needed further verification, to go down that pathway. Fortunately it was such a lesion, which turned out to be just a simple fibroid, but the stress was very high and I remember the moment we held the result of that mammogram in our hands and called for an appointment with a gynaecologist on the National Health Service, it stopped making sense at all. Later, when we went to the GP and found out that he could write a referral for such a breast ultrasound, we didn't know that either. But then again, we were in time for the next door, because the appointment for the ultrasound was three or four months away. Does this woman have that much time? But would it have been worth acting sooner here?

Catherine Pogoda
Are there these fast tracks and these are already blazed trails in various oncology centres, where they actually deal with such a fast diagnostic pathway, So then I would even look for an oncology centre that we simply have it set as such a priority for our action, a fast diagnosis and then in fact the patient, at least at the Institute where she works, at ours it looks like this.The first doctor is the surgeon and the surgeon. In fact seeing this result he immediately orders an ultrasound mammogram, which is really done in a quick time. And then after that mammography result there are further decisions as to whether the patient requires a biopsy. So here I would really look for centres that have that rapid oncology diagnosis and definitely those appointments are more accessible.

Monika Rachtan
I will now ask you about centres of excellence, because you said centres that carry out rapid diagnosis, and these are probably also the same centres that are such centres of excellence. What do these centres do and is it really crucial for a patient whose lesion turns out to be a cancer that requires further treatment? Is it crucial for her to go to such a centre and continue her treatment there?

Catherine Pogoda
A huge advance is the creation of dedicated wards where we treat patients with one particular cancer. At the institute where I work, this has actually been the case since the dawn of time that we have. Each floor is dedicated to specific cancers. I work in a clinic where we only deal with breast cancer, so we have a lot of experience in treating this particular cancer. I don't really deal with the treatment of other cancers on a day-to-day basis at all. This is also the reason for the enormous amount of knowledge that oncology offers, the incredible progress and the need to follow these reports, so that we focus only on this disease entity for our patients and can really put these advances into practice in our clinical practice. And various units are now being set up this Breast cancer in unit, or these breast units. This is the very beginning of such government clinics dedicated to patients with one particular cancer. And in my opinion, this is a very important thing, this is also the global trend, simply results. It has been proven that treatment outcomes in such a centre are better than in a general clinic that treats all cancers. This progress is so incredible. It's not like a patient comes in, gets chemotherapy of any kind and two or three regimens, what will be there. Now really every situation is very different and sometimes it's extremely important to have those nuances, but to get at it all and offer the best possible treatment.

Monika Rachtan
I will also ask about surgery, because patients are probably most afraid of this surgical treatment and the loss of the breast. Does every operation, can every operation, does every breast cancer involve her being radically excised?

Catherine Pogoda
And this is again some such myth that we definitely need to dispel. It is as I have observed over the years that I have been working as an oncologist. These mastectomies are really much, much less than they used to be. It used to be that it was the leading operation and it was also awareness, and also surgeons will cut off the whole breast. Certainly the cancer cells wouldn't be there. Patients often expected. For them it was unequivocally I got cancer, there will be a mastectomy. Really, over the course of a good few years or so, this situation has completely changed. Now it is very common to perform sparing operations, that is, only a small part of the breast is cut out. Where the cancer was. Often we start with surgical therapy, that is, for example, chemotherapy with various targeted therapies that cause this tumour to shrink and only the small fragment that is still left such a remnant of the tumour is cut out. So there are really a lot, a lot more of these sparing operations at the moment and our treatment is mainly just aimed at having as many of these operations as possible. But back to the ladies who are berc mutation carriers. In them, however, mastectomies are performed more frequently, but with reconstruction. Well, because we do everything to reduce the risk of cancer developing in the remaining breast, or in this other breast. And this is where mastectomy with reconstruction is the best procedure.

Monika Rachtan
So again implants, again implants. OK, so again the ladies are leaving with beautiful breasts from your clinic. Let me ask you one more time whether a patient who. Can a woman who is pregnant get breast cancer?

Catherine Pogoda
Yes, women who are pregnant can definitely get breast cancer. In my opinion, we are going to have more and more ladies like that, because it is a bit due to the fact that, as slightly older Polish women, we now have children. It used to be that the woman who was in labour was under thirty, Now there are actually women in labour at the moment. It is difficult to say about thirty or forty. This is an older woman, but the age has gone up a little bit, which also means statistically that the older a woman is, even though she is still young, the risk of developing breast cancer also increases.It is a little bit higher for a patient of, say, 25 than for a woman of 40, so we are observing. We have such ladies who have become pregnant and untreated for cancer.

Monika Rachtan
Before I ask if this treatment is safe, I would ask how do you examine your breasts when pregnant yourself? Because it seems to me that this can be a challenge.

Catherine Pogoda
It's definitely a huge challenge, but also the breast ultrasound is it safe? Absolutely. After all, we perform the examination so that we can see the baby. So, too, breast examination by ultrasound is advisable for women who are pregnant, but also for breastfeeding women. She is pregnant, but also in women who are breastfeeding.

Monika Rachtan
ok, then I will now ask about this treatment method. Can women who are pregnant and develop breast cancer be treated safely? Is it, is this treatment safe for the patient, but also for her baby?

Catherine Pogoda
As far as chemotherapy is concerned, we can start it from the second trimester of pregnancy. That is to say, we have to wait for this most sensitive period, when this little baby is developing. We have to wait until the first trimester, but in the second or third trimester we can start chemotherapy. It is also the case that we cannot use certain targeted therapies, such as anti-HER 2 therapy, which is important in HER 2 positive cancer, because this increases the risk of complications in the child, so certain therapies are contraindicated, but this does not mean that we cannot treat such a woman. So I also have such patients in my practice who I have treated for breast cancer during pregnancy and these ladies gave birth to healthy children. So here we have really great therapeutic possibilities. And even if a woman is pregnant and she senses something, you can't really rely on the fact that it's already a remodelling of the breast tissue and that can't be cancer. Maybe that's why surely then the first quick examination is a breast ultrasound.

Monika Rachtan
Let me ask about another situation when we talk about young women. Can a girl who has contracted breast cancer, say at the age of 30, and who has not yet had children, or who has already had a child, when she recovers, can she safely become pregnant?

Catherine Pogoda
Maybe provided I talk to her about it at the beginning.

Monika Rachtan
Okay.

Catherine Pogoda
It is the case that when we start our oncological treatment, one of the first questions, if there is a systemic treatment planned. I am thinking right now of breast cancer patients. You have just to ask, have you made your maternity plans yet? And I get different answers, very different. We also have some ladies who are around forty and they say like I have now planned my pregnancy. It's hard to limit yourself to any particular age when this question is worth asking, because it really has changed a lot over the years. But it has to be asked and then, in that situation, the woman can decide on fertility preservation methods. That is, we then send such a patient to a gynaecologist who deals with fertility preservation methods. And here there are various methods. The freezing of ovarian tissue, collection, freezing of embryos. It is up to the patient to decide. It is, as it were, her choice. We have to inform at the very beginning that we can do it. What is a certain risk in terms of reduced fertility during our therapy is precisely one of the drugs that we often use in breast cancer.

Catherine Pogoda
He can damage those ovaries a bit, I would say. Rather bring them closer to the menopause, that afterwards they don't work enough to take action for a woman to get pregnant. But definitely more There is a growing awareness among female patients when it comes to these fertility preservation methods. And a large proportion of ladies are actually opting for it. Whereas I think it's also a big challenge to ask this question at all. Because some of the women who start treatment, who hear cancer, this subject is unrealistic for them at all. Here I am now going to fight for my life. Whereas they don't think about what will happen in 5 10 years. So showing that kind of space and asking if the lady still wants to have children? And if she decides, it is a subject that is important to her. Really also this treatment goes completely better that this woman goes home, says Well, yes, well, we still talk to me about this fertility, I still have a chance to be a mother. So my prognosis is not so bad. So there's definitely that pressure here as well to do it at the very beginning, even before, if there are indications, chemotherapy will be given, for example.

Monika Rachtan
I think it's very much up to the doctors at the moment, but we're on a patient programme here and I think it's worth us talking about that very thing. And also I think I talk about many times in this programme that there are no silly questions from patients and that if our doctor hasn't informed us about it, asking him or her a question about whether I'm going to be able to have children after treatment. Or doctor, madam, can we do something so that I can still get pregnant in the future, is a perfectly valid question and absolutely nothing to be ashamed of, Fear. The question simply needs to be asked.

Catherine Pogoda
Is that, or is that not at all in terms of a silly question? I sometimes hear a very nice question asking if I can have a coffee?

Monika Rachtan
Really?

Catherine Pogoda
So it's a very natural question. I think that it is my duty as a young patient to talk about these things. I also have this feeling that we, as Poles, as contact with the doctor sometimes about these issues related to sexuality, about offspring, is a bit of a barrier, and for sure. However, we must try and ask our patients about it. Because this is also an extremely important area of their lives.

Monika Rachtan
I think that in Poland it is generally a taboo subject. It doesn't matter whether we talk to doctors, or to a psychologist, or even to friends. I think a lot of people don't talk about these topics, because they are, after all, important topics that make us happy. We definitely do, so it's important to talk about it and it's nothing to be ashamed of. Let me also ask you about a rather difficult situation. Was the woman who contracted breast cancer cured, or was it radically cured? Was she treated systemically and did the cancer not return? Could it come back in a few years, in 5, 10 years? Does this woman live under such stress all the time that this cancer could appear in her?

Catherine Pogoda
This cancer can come back at any time, even after 20 years. So here there is no such rule that we can definitely tell someone that at 100% this disease will not return. In my opinion, I would even say that it is a bit irresponsible if we give such an answer for sure, because we do not really know if a successful patient on 100% will not have this recurrence. In the same way as we do not know whether we will get the disease, so there are a lot of unknowns here. On the other hand, we always look at our management in terms of what the risk factors for recurrence are and then we tailor them accordingly, so for example, a higher risk of recurrence. I will use chemotherapy, if it is a cancer that has, for example, HER 2 receptors on it in large numbers I will use drugs precisely for this receptor. If the woman has hormone-dependent cancer, which is assessed in the pathological material, then I will use hormone therapy, i.e. we very much select the drugs that we use for the particular patient and, for example, the patient has a lower risk of recurrence. So I would use these tablets for 5 years, and if she has multiple lymph nodes involved up to 10 years. So it all very much depends here on what the pathological material will actually be.

Monika Rachtan
I understand that such a patient remains under the control of the clinic where she is treated.

Catherine Pogoda
Well, this is also the kind of topic where it is a huge challenge, because as we speak, I think the message has already gone out that the outcomes for breast cancer patients are very good. Every year 20,000 Polish women get sick. So when you multiply by the number of ladies who sort of have breast cancer or have had breast cancer, there really are in our society. There is a very large group of ladies who have been ill. We as oncologists don't grow us like that. Numbers. The doctors who deal with cancer are not so many. So this makes us really now face such a quite big problem that women who are in observation are very many and well, we are not able to provide this care so 100% for sure. So here. Well, and there's an ongoing discussion about how this systemic problem should be dealt with. Because as an oncologist, I really don't think in my opinion that I need to control ladies who were ill 20-30 years ago. Besides, these women need to be taken out of the environmental centre. Why should I go back? There are still these emotions coming back nerves, Stress that well, some ladies say they a few days before such a visit they just can't sleep anymore. So there's no need for us to act with stress. Definitely a part of such care is also to carry out preventive examinations, later such as those which assess whether something is going on in the breasts. However, we should be supported here by family doctors, so discussions are ongoing. I hope that we really will have a lot of support here, because I'm not hiding the fact that this is an area where I can see that every year we simply start to be less efficient.

Monika Rachtan
You mentioned a great many of these different medicines that we currently use to treat breast cancer. I know that most of these medicines, practically all of them, which you mentioned, are available in the drug programme, which is a bag containing all the therapies that you use to treat, to treat patients, to treat women. Well, exactly, but now I would like it to come out of your mouth, maybe, what does this treatment look like today versus what it looked like 5 10 years ago and why is it so good?

Catherine Pogoda
It's a gulf at all. What I would compare 5 10 years ago was a completely different oncology. It was oncology that was very similar for most people with the disease, when they weren't targeting different receptors like that yet. There was no immunotherapy, it was very different sometimes. Nowadays, we are treating with very modern therapies that are proven in clinical trials and which are amazing advances in the treatment of our patients. What I see most is this progress in the treatment of metastatic cancer, for example. It used to be that our lady patients who had a recurrence or who originally had distant metastases, the average survival time was 2 3 years. At the moment I, for example, have such patients who are on one drug treatment for 7 years and such observations. We really have a lot of patients in our clinical practice, so it shows how much these new drugs are improving the prognosis of patients. Those ladies who have been fortunate enough to catch on such therapy, for example, that the disease is controlled, the metastases have decreased. They are working normally, playing sports, going out with their families, having that time with their grandchildren. This is amazing progress. In the past we certainly wouldn't have said that. At the present time. In some patients we certainly do. We can say that metastatic cancer is a chronic disease.

Monika Rachtan
And I would also like to ask whether, after oncological treatment, despite the fact that the ladies live a normal life, some complications can nevertheless arise? And do they limit the patient's life to any extent?

Catherine Pogoda
There are quite a lot of complications of cancer treatment and it all depends on what drugs the patient has been taking or if, for example, she is currently on some kind of therapy. Because, as we discussed, in the case of, for example, hormone therapy, it is pill treatment of 5 or even 10 years. Often patients complain of bone pain, hot flashes. So when you think for 10 years with these symptoms you have to function is quite difficult. So here it's really about thinking about what I can do to reduce the severity of these complications. There are various methods that unfortunately sometimes don't quite allow that these symptoms are reduced. But I also think that a lot depends on how motivated the patient is, that she wants to take the drugs, that she is convinced of the therapy and actually functions a little better, even with certain symptoms. So here a lot also really depends on the psyche of the patient I am treating.

Monika Rachtan
I would also like to ask whether, if a woman already knows that she has breast cancer, knows that she will have oncological treatment and that this will be systemic treatment, that is, in the form of infusions or tablets, can she prepare her body in some way so that she can better tolerate this treatment, or can she somehow change her behaviour? What principles should guide her?

Catherine Pogoda
I always say that a cancer illness is actually a revolution in life anyway. You can't make a second revolution with your life rules with a new one, because it will be too much. Of course, if you have been living a very unhealthy life, I strongly recommend a healthy lifestyle. However, that's not it. It's also not about changing your diet completely, but also giving yourself time for some pleasures. Because chemotherapy itself, for example, causes a taste disorder, a lack of appetite, really a certain aversion to food. So if here even someone wanted to introduce some diet based on something they totally dislike, it would be pointless. So I always recommend common sense in all of this and trying to function on the basis as before.

Monika Rachtan
I will come back to this wide range of therapies that we have in the drug programme, because we know that this treatment is set up in the following lines. Yes? That is, if we have one treatment, it doesn't work, it stops working. That's another line of disease, metastasis. Another line of treatment. How many such lines of treatment can a patient take?

Catherine Pogoda
It depends. Some of the medicines, as we speak, are the medicines in the drug programme. This is the kind of document that describes specific therapies that we can use. These are very modern therapies that have certain definitions, indications, inclusion criteria, exclusion criteria. And, of course, we always check whether we can qualify a given patient, and currently in the drug programme it is the case that we can often use several lines of treatment. However, it is also not the case that I am limited to these drugs only. There are a lot of other drugs, e.g. chemotherapy, which are not in the drug programme, they are normally in the catalogue and I can also use them freely. So it's just more about making sure that the patient is on the strength so that I can have a chance to use these many lines of treatment. Because sometimes it is the case, though, that there is actually rapid progression after one drug, after another drug. This can happen, and then the patient does not really live to see these multiple lines of treatment. However, it should be clearly stated that these therapies of recent years are sometimes really groundbreaking for some patients. I now have an appointment with another patient, the hundredth infusion every three weeks. And these are really also such great joys for us, for the oncologists, that we write down such a hundredth therapy. It's such a little celebration.

Monika Rachtan
Well, just a few years ago I think we could not even dream of it. I asked the clinical trials. Well that's right, because that's another part of it again. These resources that you have, that give the patient even more chances. And I know that in Poland, at the National Cancer Institute, there are very many such clinical trials going on.

Catherine Pogoda
Yes, and this is also such an element of treatment that is very much needed. Often, it's in the clinic where I work, we have, we decide to do these trials, which are drugs that are proven, that have a really high potential that the patient's outcome will be much better than this standard therapy that I can offer the patient. And the drugs that we often use in clinical trials are later already registered as these advances in oncology, and we wait, for example, for the reimbursement stage. So the fact that a patient is treated earlier with a very modern therapy is a benefit to her, the benefit that she has had the chance to have such a very modern therapy applied before the drug appears on the European market.

Monika Rachtan
I think to myself, when we are healthy and we hear about a clinical trial and a drug that has not yet been used in anyone, for example in Europe or in a few people. Then I would say no, no, no, I would rather not go for it. But on the other hand, when there is cancer and we know that this drug may be for us to be or not to be, I guess all that remains is to strongly encourage women to nevertheless strongly consider this option, if it exists.

Catherine Pogoda
You have to distinguish between clinical trials. There are early-phase clinical trials and also at the institute where I work, we have such a department that deals with this. It is also a much-needed centre, because often these clinical trials are dedicated to patients about whom nothing can already be offered as standard. And then it is actually the introduction of these new therapies in individual patients for whom many oncologists in Poland would no longer have anything to give. Then it is such an additional option. The patient may well do well on this new therapy. However, in phase III clinical trials, such as those we are often asked to conduct in our clinic, these are drugs that have already been tested on a smaller group of patients in previous studies and have shown very high potential and efficacy. And now they are being tested in a larger clinical trial, such an international one. So it is also important to distinguish which study we are dealing with.

Monika Rachtan
But I think it is also safe to talk to your doctor about it, to ask, even if he doesn't offer us, just to ask if there is a clinical trial. And I think, because the clinics, if I remember correctly, exchange patients, that if, let's say in Warsaw such a study is not carried out, but it is carried out in Olsztyn, there is no contraindication for the patient to travel to Olsztyn.

Catherine Pogoda
This is where the patient really decides whether they want and are interested in such treatment.

Monika Rachtan
We have said a lot of good things about this breast cancer treatment, but perhaps there is a positive story that has stuck in your mind that you would like to tell our listeners specifically about breast cancer treatment?

Catherine Pogoda
Yes, I think such a very positive one. Such positive stories are the ones from clinical trials, because it is often the case that if we do a lot of research, for example in metastatic disease, and we know that in some clinical situations we can offer very little, but when we have clinical trials with a new therapy, I can see that the patient, for example, has been treated with a given drug for a year, which until now would have been completely unattainable. These are our little successes, when we see another imaging study, because in studies there are often imaging studies, for example, every three months or a little more often, and still the tumour shrinks, or it doesn't grow further at all, So you can see if, in the end, this is the kind of therapy that really controls the disease. And these are the kind of advances in oncology that we actually see every day. So it gives us a lot of energy as well, and you can really see it on our patients.

Monika Rachtan
Doctor, I will now ask you for the three most important things that every woman listening to our programme today should remember, that she can do for her health and for her, for her breasts.

Catherine Pogoda
The first thing I think of, which is also difficult for me. I keep reminding myself that one in eight of us will get breast cancer. I don't want to scare anyone, but nevertheless, no one is going to get it somewhere. The second thing I can do a lot to detect this cancer, possibly a lump of some kind, at a very early stage. Therefore, what we should really be doing is the breast examination itself. We take care of ourselves, we perform. If we are already at the age when mammography is due, we definitely do mammography. We can opt for breast ultrasound beforehand. And the third thing let's take care of our mothers, our sisters, our aunts. Let's ask when they had a mammogram, because sometimes it really seems like such a cliché to us. But sometimes it's worth asking the question and definitely take care of the people around us as well.

Monika Rachtan
And also. About one issue just related to mammography. Because I remember that there used to be these letters coming to my mum inviting her to go for a check-up, and there was always this quite important moment, because she was invited, so she also felt more that she should go. She was motivated by whether these letters continued to be sent.

Catherine Pogoda
Unfortunately not, because we are in the era of RODO and these letters have indeed been. They have been discontinued. So this is really the stage when you have to take your health into your own hands and write it down. It's also the case that it's a biennial survey, because that's the way we'd think of it every year somewhere specific. But we need to think about even and odd years, when we perform this examination, so that it is simply such a permanent element of taking care of our own health.

Monika Rachtan
This is now going to be the last question in our programme today, because a partner of our podcast, of our programme, is the Institute for Patients' Rights and Health Education, which talks a lot about the humanisation of medicine. And I would like to ask you what the humanisation of medicine is for you from the point of view of this speciality, this work that you do

Catherine Pogoda
As oncologists, we are often not just cancer doctors. We treat female patients, so there is a lot of psychological sensing involved: what mood is the woman in, what can I do, is there anything else behind the anger which, unfortunately, they sometimes display towards the whole world? Sometimes directing them to a specific specialist to help them. And sometimes to show that she can ask about various things. So here, certainly these elements such beyond hist pat results, receptors, very complicated treatment. It's really that contact with the patient. And this is an amazing moment for me now. As we took off the masks, I can finally see my patients fully, because before it was very difficult. That's what I had, only the eyes I could see often I couldn't see the whole face. So I am now, for example, getting to know my lady all over again and it is amazing. I can see straight away what mood she is in, whether I should do something more. So in general, the work of an oncologist is definitely also about working with emotions, which are sometimes very difficult, especially when you start treatment. And then it's also such long-term care. We often treat these ladies intensively for many years at first, and then have them under observation. So it really is such a long way together and there are many psychological elements.

Monika Rachtan
Doctor, I think that all the patients that you treat are very lucky to be in your hands, because I see this great commitment and I thank you very much for it, because I think that, especially in cancer, it's very important that this doctor is not only a doctor, but also a little bit of a conversation partner, a little bit of a psychologist, and sometimes a little bit of a friend that you can confide in about things. And it's when these relationships are built that I think it's even the whole family. You, the doctor, are probably getting to know you. Thank you very much for our conversation today. I hope we convinced all the ladies together to check when they had their last mammogram. And if they are younger, they will have a breast self-examination in the near future, or go to their gynaecologist for such a check-up ultrasound, because that's what we wanted today.