BEAUTY, BODY & SPIRIT

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by Rebecca Moroose, MD, Director Cancer Clinical Trials, Director Cancer Genetics, Orlando Health UF Health Cancer Center

“Innovation drives progress” is the mantra of the FDA’s Center for Drug Evaluation and Research (CDER). Each year, CDER publishes a list of new drug approvals. Multiple new agents with novel mechanisms of action have been approved for treating early- and later-stage breast cancer in recent years and some breast oncologists refer to this plethora with the idiom “an embarrassment of riches” from a 1726 French comedy. This idiom connotates an overabundance of something or “too much of a good thing.” I consider this plenitude an “abundance of blessings” paving the way to treat each individual’s breast cancer with therapy more specific to his or her tumor and less toxic to the system.

AS A REMINDER, treatment of breast cancer used to be a “one-size-fits-all” approach — typically surgery, chemotherapy, sometimes radiation therapy, and often anti-hormonal therapy. With the advent of the Human Genome Project and better understanding of genomic and biological mechanisms of disease, scientists can identify the molecular hallmarks of cancer and design treatment specific for those aberrations. We currently evaluate the status of three receptors on breast cancer cells: the estrogen hormone receptor (ER), the progesterone hormone receptor (PR), and the Her2neu receptor (Her2). The presence or absence of these receptors allows subclassification of breast cancers which we call the cancer “phenotype:”

ER+ PR+ Her2- = endocrine (anti hormone) sensitive breast cancer that is Her2 negative. ER+ PR+ Her2+ = both endocrine and Her2 positive breast cancer, also called triple positive, that can be approached with anti-hormone therapy as well as Her2 directed therapy.

ER- PR- Her2+ = Her2 driven cancer that is amenable to Her2 directed strategies.

ER- PR- Her- = triple negative breast cancer (TNBCV) which traditionally was dependent on chemotherapy for treatment until new breakthroughs in immunotherapy and antibody drug conjugate treatments were developed.

The subclassifications of breast cancer continue to expand and use of genomic testing aids in our understanding of predicting treatment responses or providing a prognosis. Studying the acquired genomic alterations in cancer cells also leads to a molecular signature that may be exploited with targeted therapies.

Some of the significant innovative treatments for breast cancer approved by the FDA in the last few years include:

• Margetuximab-cmkb — a monoclonal antibody to treat patients whose tumors overexpress the HER-2neu receptor. This novel antibody has been engineered to bind to Her2 positive cells and to help activate the immune system to enhance antibody dependent cell-mediated cytotoxicity against tumor cells.

• Fam-Trastuzumab deruxtecan-nxki — is an antibody-drug conjugate. The antibody is directed to the Her2 receptor and carries a toxic payload of chemotherapy that is released into the tumor, generating less toxicity to the patient compared to giving chemotherapy alone.

• Sacituzumab-govitecan-hziy — this is another antibody drug conjugate that was first approved for triple negative breast cancer and targets a common protein on cancer cells (TROP-2) and carries a potent chemotherapy payload into the tumor cell.

• Two oral small molecule inhibitors have also been approved for treating

Her2+ breast cancer: • Neratinib — an oral small-molecule irreversible inhibitor of Her2 and members of this receptor family (EGFR1 and Her4) • Tucatinib — an oral reversible small molecule inhibitor more selective for the Her2 receptor that has been shown to treat systemic disease and active brain metastases.

• Olaparib and talazoparib — for patients who carry a genetic predisposition to develop breast cancer due to an inherited mutation in BRCA1 or BRCA2. These drugs are polyADP ribose polymerase (PARP) inhibitors and have proven successful in inducing lethal damage to tumor cell DNA when the BRCA1/2 proteins are dysfunctional and cannot repair the damage. This process is known as synthetic lethality and takes advantage of the dysfunctional BRCA1/2 DNA repair pathways in the tumor cells with less toxicity to normal tissue.

• Atezolizumab — approved for patients with advanced/metastatic triple negative breast cancer in combination with chemotherapy in patients whose tumors express the PD-L1 protein.

PD-L1 is the programmed death ligand 1 which when present blocks the patient’s immune system from identifying and attacking a tumor. If

PD-L1 is blocked the immune system surveillance and clearance of the tumor is enhanced. The VENTANA PD-L1(SP142) laboratory assay must be used to identify patients who are candidates for this treatment.

• Pembrolizumab is another PD-L1 inhibitor approved in combination with chemotherapy for unresectable or metastatic TNBC in conjunction with chemotherapy in patients whose

PD-L1 status is determined by Dako laboratory’s immunohistochemistry test 22C3.

• Cyclin-D kinase 4/6 inhibitors comprise a new class of drugs, including abemaciclib, palbociclib, and ribociclib — oral small molecular inhibitors that help to stop cancer cells from proliferating in patients with ER+, PR+,

Her2- unresectable or metastatic breast cancer in conjunction with anti-hormone therapy (abemaciclib also has been studied as a single-agent therapy).

• Alpelisib — approved in 2019 for patients whose metastatic tumors have an acquired mutation in the PIK3CA gene. Mutations in this gene lead to a defect in a protein called P110alpha.

P110a controls cellular growth and division and, when defective, contributes to uncontrolled cell growth.

Alpelisib inhibits the defective

PIK3CA to reduce its activity. It is currently used for patients whose tumors are ER+/PR+/Her2neu- with a

PIK3CA mutation.

This is by no means an exhaustive list of the tools we have in our armamentarium to treat breast cancer. Many of these new agents are also being studied in earlier stages of breast cancer and in different breast cancer phenotypes. A pipeline of agents is currently under investigation to improve our success in controlling or, in some cases, curing breast cancer. This is no embarrassment of riches!

with Deborah Harding, MD, Harding Medical Institute

In this new series, Dr. Deborah Harding will answer readers’ health questions.

I am excited to hear that collagen is finally receiving the attention it deserves. Before collagen supplements were “trendy,” I started recommending them to my patients years ago — due to the thorough and impressive scientific data on collagen supplements. Collagen is one of the body’s building blocks. It helps with the healing process, muscle tone, skin rejuvenation, anti-aging, and much more. Taking a collagen supplement can be a great addition to your routine for many reasons. For instance, ongoing data shows it can help support things like: tendon and ligament self-repair, stem cell rejuvenation, joint lubrication, connective tissue maintenance, and healthy hair, skin and nails. If you exercise frequently, have had any sort of injury, have lost weight and worry about skin elasticity, or want to help maintain plump skin — collagen is something you should be considering taking daily.

However, finding a high-quality collagen supplement is very important. Many overthe-counter products are a blend of different ingredients and fillers. You want to research the specific ingredients you are putting into your body. The collagen supplement I personally reccomend is made up of Type 1 and ‘Type 2 collagen from high-grade raw materials, with scientific clinical trials to back its effectiveness. This specific form of collagen can support the healing process, rather than simply (and temporarily) block joint pain or discomfort. I take a collagen supplement daily; I like to use it in the powder form as an easy addition to my smoothies or morning tea or coffee.

I suggest having your annual physical done first so you can get updated lab work and testing, can get a baseline on where all your numbers are, and can set some goals with your physician. During this appointment, also discuss if there are any routine screenings you may be due for (or missed), such as a mammogram, pap smear, skin cancer screening, ultrasound, etc. Get those on the books ASAP. Also, plan to head to your local pharmacy if you are due for any immunizations (such as the pneumococcal vaccine, shingles vaccine, hepatitis A and B vaccine, tetanus booster shot, etc.) You do not usually need an appointment for these. Additionally, any procedures or appointments you had put on hold during the pandemic should get scheduled. Try to make a checklist of all the items you would like to get done over the course of a few months or the year so you can mark off as you schedule them. As you see different doctors and they refer you to have any additional testing or procedures done, you can keep adding to your list and keep your appointments organized.

In the meantime, make sure to keep taking your vitamins and supplements, eating heathy, and getting back on a good exercise regimen!

You are right, there are so many options out there and it can be overwhelming. Ultimately, you have to find what will work best for you, your lifestyle, and your unique body! Here are my top three “go-to” tips for dropping those stubborn last 15 pounds that I tell my patients about: 1 There are many “diet fads” that come and go. However, the regimen I always see to be most successful across-theboard is going back to the basics: a

exercise plan. At a minimum, it is important to get in your steps each day (I aim to take at least 10,000 steps daily for my body). I also suggest two days a week of some sort of strength training.

Try to come up with fun ways to exercise that could be good for the whole family as well. Some ideas include: a nature hike, an outdoor scavenger hunt, or even taking up a new sport such as tennis, golf or running.

2 Another favorite routine my patients often find success with is incorporating healthy smoothies into their day. A good tip is replacing one meal a day with a protein smoothie. (Some of my patients

eventually replace two meals a day with smoothies). Then, have your final meal be a sensible dinner.

Your smoothie should consist of a liquid “base” such as water or milk. I personally enjoy using a milk substitute such as almond milk, cashew milk or oat milk. Next, add high-quality ingredients including plenty of vegetables, and a handful of fruits into your smoothie — if possible, try to use organically sourced ingredients. Finally, add a protein source into each smoothie. (In addition to whey protein, there are some great protein powders made from ingredients like egg whites, brown rice and green peas—something for everyone!) Most importantly, to be considered a “meal,” make sure it contains enough protein for your body type.

Another success I often see with my patients is intermittent fasting, where you eat in a smaller window of time each day, instead of the traditional 10-12 hours per day.

3 A lot of my patients are loving Zerona® fat loss laser treatments for body contouring and stubborn fat. This is the first laser specifically designed for body contouring and fat reduction with NO bruising, swelling, freezing or downtime! You can easily have a treatment on your lunch break and head back to the office after a quick 40-minute session.

The best part is you can target the area (or areas) you are looking to specifically treat, such as “spot treating” your inner/outer thigh, abdomen, back, etc.

While this laser has given my patients much success, you must continue to incorporate your healthy diet and exercise plan to maximize your results.

No matter what method you choose, always remember to stay hydrated and get a good night’s rest. To your best health!

Deborah F. Harding, MD, is board certified in internal, sleep disorder and anti-aging medicine. The Harding Medical Institute is located in MetroWest. Learn more at hardingmedicalinstitute.com. If you have a question for Dr. Deb, email it to kate@orangeappeal.com.

Yamile Luna is like most of us — career driven, loving mother, devoted wife, community advocate — but her journey with cancer has taught her some important life lessons about success and self-awareness. It makes her acutely qualified for her role at AdventHealth as Vice President for Organizational Culture and Well-being.

Her responsibilities include leading the wellness team for the Central Florida Division, which encompasses 16 hospitals, medical offices, Centra Care facilities and AdventHealth University. “I oversee employee wellness from the benefits side all the way to programming that we do on our campuses,” she adds.

This includes caring for AdventHealth employees in mind, body and spirit — from connecting them with chaplains and nutritionists to more importantly and most recently, mental health services.

“Through the pandemic, it’s obviously been a huge toll on the mindset of our employees. We actually have licensed mental health practitioners as well as our wellness teams out in the units,” she explains.

Throughout her 37 years with Advent-

Health, Yamile has held multiple leadership roles. “I tell people I started when I was 5,” she laughs. But she explains that she is proud to be a second-generation team member — both her parents retired from the company — and now her daughter and son are third-generation employees.

Oh, and her husband has been with the company for 38 years as well. “What has kept me with AdventHealth is our mission. Our mission is to extend the healing ministry of Christ and it very much resonates with my personal beliefs. It’s easy to be authentically yourself every day when you come into a place that is more than just a job,” she says.

She appreciates the team members she’s gotten to work alongside — many who stepped up during her battle with breast cancer. “I was diagnosed in October of 2012. I was actually leading the [Florida Hospital] Cancer Institute at the time, along with other areas. It was a very surreal experience because of the work and programs we were setting up to help other community struction. “I was out of commission for about a year, but being the superhero that I thought I was, I continued to work. I remained as a vice president but worked part time,” she explains.

About 10 months after she returned to work full time, she started having severe headaches. She thought she had a brain tumor, but it was actually a tumor that was wrapped around her heart and in the middle of her chest. Determined inoperable, Yamile went through another round of chemotherapy, a new experimental treatment for this type of tumor. “I told people the good news is I knew what was going to happen and the bad news is I knew what was going to happen,” she says.

“I did decide in my second go around that I would take the time off. I learned from my first time that while I was trying to be all things to all people, I recognized that the bad days were spent with my family — I was sick as a dog, and they would care for me — and the good days I spent at work. And I was like, there’s something wrong with this picture, right? I love the fact that I was able to step back and put my family first,” she says.

Yamile shares that she continues to receive chemo treatments on a regular basis and feels very blessed to be in this position where she can affect others with her story.

and team members,” she shares.

Her mammogram revealed a stage III aggressive tumor in her right breast and Yamile opted to have a double mastectomy. She then went through chemotherapy (hair loss included), radiation and recon-

As a speaker at the Orlando Women’s Conference, she will be elaborating further on her journey as well as providing some practical takeaways for women to better care for their minds, bodies and souls.

“Even when our careers are on the rise and we feel like we can do everything, we’re not superheroes. We think we are, but we must make sure that we are not only taking care of ourselves but realizing success is more than just a title at work,” she reflects.

A health navigator is a specially trained registered nurse whose job is to make life easier for each and every woman through expert clinical assistance and educational, emotional and spiritual support. All calls are confidential; anyone can self-refer; and insurance is Doreen Forsythe, not required to talk or meet. BSN, RN

AdventHealth for Women’s health navigators provide complimentary services that help you coordinate your overall care and answer any questions you may have. These services include: • Finding a care provider • Answering your health care questions • Assistance with scheduling annual office visits and screenings • Resources and support for you and your family • Coordination of care among multiple providers and facilities

Janelle Grall, BSN, RN, CPN

To contact the Health Navigation Team, call 407-720-5191 or visit HerHealthNavigator.com