Let's stop there. Being a soldier, it's exciting. You already know that. What you want to know is, what's in it for me? I wanted to learn leadership skills from the experts. I wanted to get paid to earn qualifications. I wanted more confidence. And now, look, I'm on the radio. That's what was in it for me. Get skills, get qualified, get confident. Army. Recruiting now. Search Army jobs. Let's stop there. Being a soldier, it's exciting. You already know that.
What you want to know is, what's in it for me? I wanted to learn leadership skills from the experts. I wanted to get paid to earn qualifications. I wanted more confidence. And now, look, I'm on the radio. That's what was in it for me. Get skills, get qualified, get confident. Army. Recruiting now. Search Army jobs. Behind the Knife, the surgery podcast. Relevant and engaging content designed to help you dominate the day.
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In fact, we designed the oral board review to replace these courses. Learn more by visiting BehindTheKnife.org and clicking on the premium tab. Hello, it's great to be back on Behind the Knife. My name is Alexa Glenser. I am a Chief Resident in General Surgery at UCSF. Today, our Breast Surgical Oncology Group will discuss the management of ductal carcinoma in situ. or DCIS, which has been evolving recently.
The standard of care approach is surgical resection with adjuvant endocrine therapy for patients with hormone receptor positive disease. However, there are large randomized controlled trials of active surveillance as a strategy for select low-risk patients. opposite end of the spectrum, immunotherapy is being tested in clinical trials for select high-risk patients.
We will discuss the evidence supporting our current management and what changes we may anticipate for the future. We'll divide the podcast into two different segments. The first segment will be a discussion with Drs. Alvarado and Maktar, breast surgical oncologists at UCS.
who have helped me to create our prior breast-focused BTK episodes. I will then interview Dr. Laura Esserman, professor of surgery at UCSF and director of the Breast Care Center. She is responsible for developing multiple clinical trials that have our approach to neoadjuvant therapy in women with invasive breast cancer. Today, though, we will interview her about her approach to DCIS. But to get started, let's...
have a discussion about our current paradigm and approaching the management of DCIS. Dr. Maktar. We have a variety of listeners out there, ranging from medical students or even pre-medical students up through faculty members. To get us started, can you just tell me about what defines DCIS and what is it in relation? to invasive breast cancer. Yes, I would be happy to. So I will start with the basics. So the breast contains ducts and glands, and these are surrounded by connective tissue.
stroma, fibroblasts, adipocytes, and this is where blood vessels and lymphatic vessels run. Inside the ducts and glands, there's a lining of cells called epithelial cells, and these are the cells that can become carcinoma cells. If these cells become carcinoma cells but are contained by the basement membrane, we call these carcinoma in situ.
These cells have no access to blood vessels and lymphatic vessels and therefore cannot spread beyond the breast. This is in contrast to if the carcinoma cell develops the ability to break through the basement membrane and
invade into the connective tissue or stroma of the breast, that is where we would make the diagnosis of invasive carcinoma. I will just add that DCIS Perhaps in the past was thought to be a homogenous growth in the breast, but we know now that there are different types of DCIS, and DCIS can be...
characterized by how abnormal its nucleus looks under the microscope. So that would be grade, and that would go from one to three, with one being the lowest or closest to normal appearing, and three being the highest or farthest from normal. We also look for expression of estrogen and progesterone receptors, and DCIS can be ER positive or negative, and similarly PR positive or negative.
DCIS can have the presence of necrotic material, what a pathologist might refer to as comedonecrosis, and that would be associated with a type of DCIS that would be considered more aggressive. And DCIS can be palpable or not palpable. So this can impact the way that DCIS is diagnosed. with palpable DCIS perhaps having a higher likelihood of progressing to invasive cancer. And non-palpable DCIS being more likely to be diagnosed based on screaming mammography. And we do know that when...
When screening mammography is introduced, we do know that the incidence of DCIS does go up, and this is part of what has led to some of the controversy in the way that DCIS is currently managed. Great. Thank you so much. And I'll turn to Dr. Alvarado.
discuss a hypothetical patient. You have a 60-year-old woman who's been sent to see you in breast surgical oncology clinic. She underwent a routine screening mammography, had calcifications noted on the screening mammo, had a diagnostic mammo core biopsy done that reveals intermediate grade DCIS. What is your approach to her management? What treatment options do you offer her? Is there any adjuvant therapy that you would incorporate following surgical resection?
Sure. So great question. So first of all, with regards to DCIS, I think it's important to recognize that similar... To invasive breast cancer, the two surgical treatments are typically either lumpectomy, with or without radiation, or mastectomy. And as we've previously talked about, the surgery depends a little bit on patient preference as well as the size of the lesion. So if we assume that the DCIS is small...
maybe a centimeter or a centimeter and a half, we would then talk to the patient about moving forward with surgical approach. Because for DCIS, the treatment is pretty much removing it surgically. And then, of course, we would talk about risk of recurrence and how we could potentially decrease that risk with adjuvant therapies, such as radiation or possibly adjuvant endocrine therapy.
So the surgical approach would be similar to that for invasive breast cancer. We would talk to the patient and counsel them about lumpectomy. the possibility of re-excision depending on the margins, and then we'd have them see radiation oncology to discuss the possibility of adjuvant radiation.
But likewise, a patient could have a mastectomy if that's what they desired. But again, similar to invasive breast cancer, we don't typically recommend mastectomy unless it would be technically not possible to perform the lumpectomy. Got it, okay So for this particular patient, you take her to the operating room. You are able to perform a lumpectomy. It's what she wants to do. You get your surgical pathology report back. You found that your surgical margins are negative.
What does that mean for DCIS compared to negative margins for invasive breast cancer? And why is there a difference? Yeah, great question. So... There are two different ways of describing a, quote, negative margin or, for example, no need for re-excision. So for invasive breast cancer... The guidelines are no tumor on ink. So one millimeter margin, half a millimeter margin.
A half of a half a millimeter margin. So for invasive breast cancer, no tumor on ink. But for DCIS, the guidelines from two groups, the Society for Surgical Oncology and... the American Society for Radiation Oncology. Those two groups came together and have developed a guideline saying that we need a two millimeter margin in general.
for lumpectomy before patients are considered to be not needing a re-excision. Now, the two millimeters... is a guideline and there are some instances where, for example, the anterior margin where you might write be right up against the skin or the posterior margin where you might be on the chest wall, you might not actually need a two millimeter margin. But I think in general, the guidelines would say two millimeter margins before moving on to adjuvant radiation.
And you'll hear a lot more later from Dr. Esserman because the treatment for DCIS has gone through a lot of changes and it's continuing to change. But pretty much the standard of care would be... to meet with a radiation oncologist to discuss the risks and benefits of adding post-
lumpectomy radiation to decrease the risk of a local recurrence. So that's what we would consider for DCIS. And then if this DCIS was estrogen positive, She could have a discussion then about potentially taking an oral anti-estrogen, both as a prevention model for... preventing future other breast cancers, and she probably would get a little bit of benefit in terms of risk of recurrence as well. Okay, great. Just a follow-up question specifically about radiation.
Do you refer all of your patients who've had lumpectomies for DCIS to radiation oncology, or are you selective about it? Which factors do you consider? Yeah, that's also a great question. I think... In our group, in our institution, we've been moving into... other treatments for DCIS, looking at risk, looking at benefit of radiation. So our group, myself, Dr. Mukhtar, and our partners are really good at kind of ordering different tests to look at kind of baseline risk.
to get a better idea of individualized risk. And I know Dr. Mukhtar will talk a little bit about that in a second. But once we have that individualized baseline risk, we feel very comfortable talking to a patient about, well, if your risk is... 10% recurrence risk in 10 years. And with radiation, it might be 4% or 5%. How do you feel about that? And so we do talk to patients about it, but...
I usually send the patient to the radiation oncologist just to have the discussion. I think that's a good practice to have to get that information. But we do start the discussion with our patients. Of course, there are going to be women that have. millimeter of DCIS that are over the age of 70 that
are not going to get any benefit really from radiation. In those cases, I may make the decision with the patient not to send them. But I think in general, we'll send them to the radiation oncologist. But I think as Dr. Mukhtar will mention, there are some things that we can do to really get him more. individualized risk even before we send them to see the other group. Absolutely. So Dr. Maktar, on that note, I'd like to talk about what metrics you use to
personalize your risk assessment for patients with DCIS. I've heard of the Van Nuys Prognostic Index score before. I've heard of and seen Oncotype DCIS used and Decision RT. What are each of these tools and when do you use them? Right. So one of the challenges with DCIS is that... We don't know which person who has DCIS is necessarily going to progress to developing invasive cancer. recommend surgical excision of that DCIS lesion because we are not
Currently, we are not super confident about being able to predict which DCIS is never going to progress and which is going to progress. And similarly, after we have resected that DCIS, There have been many, many efforts to try and predict what is the risk of recurrence so that, as Dr. Alvarado said, so that adjuvant therapy can be added to lower that risk of recurrence. Over the last several years,
People have gotten a lot better at risk stratifying DCIS. And when you talk with Dr. Esserman later, I think you'll hear quite a bit about this. But some of the early efforts really looked at... clinical and pathological factors. So the Van Nuys Prognostic Index was perhaps one of the first ways of risk stratifying GCIS. And this included nuclear grade. the width of the margin after resection, the size of the DCIS lesion, and in some scoring systems, age is also added in.
This leads to a certain number of points for each of those factors, and then you can categorize the DCIS as low, intermediate, or high risk. And traditionally, people would think about the low-risk cases perhaps being adequately treated with lumbar.
alone, the intermediate ones perhaps needing to add adjuvant radiation or perhaps doing a mastectomy instead of breast conservation, and then the high-risk DCIS lesions having a high risk of recurrence regardless of whether not you do breast conservation versus mastectomy there are some newer tests that
look at gene expression. So for example, oncotype DCIS is a gene expression assay looking at the expression of 12 different genes. This is kind of analogous to these molecular tests that have been used in invasive breast cancer, but for the oncotype DCIS...
score, this helps to predict the risk of recurrence with breast conservation with or without radiation. And as you mentioned, there's also a test called decision RT, which looks at some protein expression by immunohistochemistry in combination with other clinical features to try and risk stratify so that patients can decide whether or not they want to add radiation.
Okay, great. And then one final question that I have is about sentinel lymph node biopsies in patients with DCIS. When do we do these, if at all? And why do we do sentinel node biopsies in patients with DCIS, Dr. Mukhtar? So this is a very good question. I would say that if someone has DCIS, you do not need to do a sentinel lymph node biopsy. Now, here's the problem. The problem is that most of the time, DCIS is diagnosed with a core needle biopsy.
is when you excise that lesion on the surgical pathology, you find that actually there was already an invasive cancer there. And the original corneal biopsy was perhaps not the true diagnosis. So this risk of upgrade to invasive malignancy on final pathology occurs roughly 10% of the time when someone is diagnosed with DCIS based on a core needle biopsy. If someone has had a lumpectomy,
and you find out on final pathology that there was invasive cancer, you can always go back to the operating room and perform a sentinel node biopsy at that time. But if someone has had a mastectomy, it's much harder to find that sentinel node once the breast has... been removed. So if you're doing a mastectomy for DCIS, it is recommended to go ahead and do a central node biopsy just in case the final pathology shows that there was invasion. Fantastic.
Thank you both so much. Thank you. As a special feature of this podcast, we are thrilled to introduce our guest speaker, Dr. Laura Esserman. Dr. Esserman is a renowned breast surgical oncologist, director of the UCSF Breast Care Center. and co-leader of the UCSF Breast Oncology Program. She is a professor in both the departments of surgery and radiology.
She leads several innovative multi-center trials, including the iSpy2 Adaptive Platform Trial for Stage 2 and 3 High-Risk Breast Cancer, and the Wisdom Personalized Screening Trial. The hallmark of these trials is to find ways to harness biology and early endpoints. i.e. changing the order of treatments to learn faster and to get patients better treatments that are both more effective and less toxic, more for those who need it and less for those who don't.
I've asked her to speak on the BTK podcast about DCIS because she is... worked tirelessly to refine our management of these patients. She's maintained a registry of patients with DCIS who've elected not to initially pursue surgical resection.
Instead, they've participated in active surveillance consisting of endocrine therapy and serial breast MRI. For patients with high-risk DCIS, she has designed a study of neoadjuvant intralesional pembrolizumab and an mRNA-based drug that... encodes multiple cytokines to stimulate the tumor immune microenvironment.
I've worked with Dr. Esserman over the past 12 years at various stages of my career, and I had the opportunity to spend my two dedicated residency research years working on these exciting DCIS studies, ways in which the immune system regulates or fails to regulate premalignant lesions and the role it plays in the development of specific tumors.
This is what will transform treatment and prevention, and this work will be the focus of today's conversation. Dr. Esserman, welcome to Behind the Knife. Thank you so much, Alexa. It's so nice to be here. So as we know, DCIS is a non-obligate precursor of invasive breast cancer, meaning that it can become invasive disease, but that not everyone diagnosed with DCIS will develop breast cancer.
DCIS is biologically heterogeneous. However, our current standard of care treatment approach, consisting of surgery, possible radiation, endocrine therapy, for those with hormone receptor positive disease, applies a singular approach to every patient. Why is this the case and how can we improve? Well, I think that DCIS largely is a disease.
that surfaced because of screening. Prior to screening, maybe 3% of all cancers detected were DCIS. After the advent of screening, especially after over 60% of the population was screened, it now constitutes 25% of all cases detected. And so this could be either that we are finding these early lesions or...
that we're identifying disease that's surfacing that never would have come to clinical attention. And if you just take it out, you don't know which. And I think one piece of evidence is... that after a couple of decades of taking out 60,000 cases of DCIS, the invasive cancer rates have not dropped.
That's a distinction to what we see in cervical cancer when we were taking out the precursor lesions. And it makes you think, well, maybe we've got the wrong precursor lesion. So I think there's no getting around the fact that some of these cases are never going. to progress. I think what happens is maybe you see a case or two where it has progressed and then everyone gets nervous and everyone thinks, oh, it's DCIS, it's cancer, let's get it out.
And I've done my job and everybody's happy. But the person who has the treatment and maybe has a scar in their breath or they feel deformed and they've had radiation or maybe, you know, and then they get cancer. with invasive cancer down the road, are very frustrated. And people, the women themselves who read the literature, especially people with an engineering background, they find this very illogical.
People are very frustrated and not everybody wants to rush off and do something. I think it's just really important to say that if you do the same thing over and over again, there's no opportunity to learn or change. And for sure, DCIS is not an emergency. If you do nothing for months, it's not going to hurt you. And if you gave someone endocrine therapy for several months, we do this on invasive cancer. It's not an emergency.
If you don't give yourself a chance to learn and figure out who's got disease that's going to progress or not, you will never learn and you will never advance. And for me, in most of the studies I've done, Imaging is a catalyst, not, I mean, MRI imaging, because of its ability to look at both dynamic background changes and look over time is, I think, a really important catalyst to learn.
Thank you. Let's stop there. Being a soldier. It's exciting. You already know that. What you want to know is what's in it for me. I wanted to learn leadership skills. From the experts. I wanted to get paid to earn qualifications. I wanted more confidence. And now, look, I'm on the radio. That's what was in it for me. Get skills, get qualified, get confident. Army. Recruiting now. Search Army jobs. So, you didn't say it explicitly, but I know that you were...
thinking about active surveillance of DCIS, which is a controversial topic. Given that the upgrade rate to microinvasive breast cancer at the time of DCIS surgical resection may be as high as 20%, Why do you believe that active surveillance is a safe treatment option? And should there be eligibility criteria that determine who can enroll in active surveillance studies?
For example, in the three large RCTs currently being conducted to study active surveillance of DCIS, this is the Comet trial in the United States and the Lorde and Loris trials in Europe. All patients enrolled must be greater than 45 years old and have low-grade, screen-detected, and non-palpable disease. Do you think that these criteria should always be applied, or is there something better that we can do?
Well, I don't think there's any harm in waiting three months for anybody. If someone came in to me with a four centimeter invasive cancer that was hormone positive and molecularly... low risk, the standard treatment for them could entail three to six months of endocrine therapy. So if it's safe for someone with invasive cancer, how is it not safe? For somebody who has DCIS. I find that illogical thinking. And I think it's really important that if you, if you.
exclude those people then you learn nothing from those people you don't know who are the good responders and who are the bad responders but it is i think you know i think one of the things that we've learned is you know clearly someone who has hormone negative disease or, you know, probably HER2-positive hormone. A lot of the hormone-negative patients turn out to be HER2-negative. I mean, I'm sorry, a lot of the hormone-negatives turn out to be HER2-positive.
But clearly those patients need something different. And, you know, we'll get to that in a minute. But for the people who are hormone positive, I think it's important for us to understand not just for DCIS, but for prevention. and for invasive cancer purposes. Which are the cancers that can be intercepted, even if you had a 20% chance of having a little bit of invasive cancer? You're treating it just like you would invasive cancer. So how are you harming somebody?
And the whole idea is getting information about how systemic therapy reduces risk is really important. Who needs to take it? Maybe it's not making any impact. And then there's no point in just having someone take it for a long period of time. Most women actually want proof that something's going to work. They don't really love just taking stuff on faith.
And I think we owe it to them to do a better job of developing markers to find out when it works and when it doesn't work. And actually, who's really at risk and who's not at risk? It may be that your background genetic risk, polygenic risk. It helps us understand if you don't have elevated, some kind of elevated risk, that a little bit of DCS isn't going to bother you at all. I mean, how do you know unless you ask the questions, right? And I think that's how we get to better answers.
Absolutely. I think it's safe to say that there is significant complexity within DCIS that we don't yet understand. One question that's come up when I've discussed our various trials is really the question of how long can patients remain on endocrine therapy? If we have evidence that...
or DCIS is responding to endocrine therapy, how long do we keep them on it, and what happens if and when we take them off? Well, I think that's a great question, and we certainly don't know the answer to it. I think one of the things that we've found from the active surveillance study... This is what I wanted to learn before launching a multicenter trial. And that is, how soon can we tell that it's working? And what kind of protocol should I build?
Just watching and kind of wondering if someone's going to progress and what to do is, I think, kind of nerve wracking. And no one's going to really repeat that. So one of the exciting things we found is that really, right? I mean, you know this, that after. Um, three months really is sufficient, but you know, no, probably by six months, you're either going to be responding or not. So you're either. And I think what's also striking is that.
We discovered that people come in, there's different types of BCIS. Actually, if someone comes in and you do an MRI, and if you didn't know where the biopsy was, the radiologist couldn't tell you where. the DCIS was. And that everything is kind of lighting up and you've got a lot of background risk. What you're seeing is someone whose tissue is at elevated risk everywhere. And we know that background enhancement on an MRI.
is consistent with high risk anyway, right? So those people don't, they don't have surgical disease. There's no one area that you can cut out. I mean, if you then go cut that out, you're fooling yourself. And those are people who have long-term risk. What's remarkable is for a lot of those people, boom, you put the endocrine therapy on and everything goes away. Those are good candidates for active surveillance. And you know that they have high risk because we know that.
Background enhancement that's very elevated is like five-fold risk compared to normal. So that's a good person to put on hormone therapy. Probably five years. Do we know? Now we have to work out better markers. But you can take it off, and if it stays down, then you don't have to repeat it. Once we get on this pathway, we can figure this out. But if you then make the background go away, and then what emerges is a focal lesion.
And that doesn't go away. You basically got background in the background of your breast tissue is sensitive to endocrine therapy. But whatever that lesion is, is independent. It probably is on its way to, if it's not already invasive cancer, those people have. much higher risk, like 60 or 70%. So those are the focal, or if someone starts off with a focal mass and it doesn't go away. So I think these are the things you can learn and you can then...
take that tissue and study it with organoids or other models to figure out, okay, why is this resistant? What can I do that's different? Or why is the background not resistant? How can I develop better agents? And that's the opportunity. So it turns out 60 or 70% of people probably don't need surgery at all. And of those, probably at least half will have benefit from hormone therapy.
Trying to figure out who then doesn't need anything, that's another task. But what's exciting, of course, is that, you know, there are some now more tolerable endocrine medications that people, I think, will be... you know, will work. And I mean, that's, we don't know, but that's what we're going to test. Yeah, that really leads into my next question.
Entire conversation reminds me of how the approach to the management of prostate cancer has changed with active surveillance now being a valid approach for some patients. However, some have argued that there are greater risks related to prostatectomy than related to lumpectomy. They argue that lumpectomy is a very safe operation, which it is, and that it avoids leaving patients on endocrine therapy for an indefinite period of time.
which can be accompanied by its own impact on quality of life given the side effects of these drugs. Tamoxifen, most notably, is not an easy-to-tolerate drug for a lot of patients at the doses in which it's been used in the past. So how do you personally counsel patients with DCIS on the risk and benefit?
of surgery versus long-term endocrine therapy if you're offering, if you're giving them that option? And do you discuss active surveillance with most or every patient you see with DCIS? Well, for every patient that's hormone positive. I see that there's no risk in giving themselves three to six months to see if they're a good candidate or not. Gives them a chance to see if they tolerate the drugs. And for tamoxifen, there's now data that baby tab, five milligrams instead of 20.
is just as effective we know by imaging it's just as effective most people tolerate that just just fine so um um you know so i would say That's one thing, you know, the rum chase inhibitors can be for postmenopausal women can work fine and not cause side effects, but they can. So you have to balance that, you know. Not everybody wants to have surgery. And, you know, if you're, you know, one of the things that we found is the people who have this kind of global risk have risk over time.
that's not really impacted by surgery or radiation. It's impacted really by the endocrine therapy. So we've got to figure out which is which. You've got to figure out how to use your craft wisely. Someone who has a focal lesion, they're going to benefit from surgery. Someone who doesn't have a focal lesion, you're making yourself feel better, but you're not really doing any good. We have to learn to recognize that. Okay. So I'm just going to change topics because we've really...
only scratched the surface of the complexity of DCIS, talking about patients for whom active surveillance with endocrine therapy may be the best approach. What about patients with high-risk biology? Those patients with DCIS who are young, have palpable disease, high-grade disease, are hormone receptor negative or... triple negative and or HER2 positive, is there actually something different that we should be doing for them beyond surgery?
So first I would say that like once you get an idea, then you can learn to spread it. So one of the things that we're doing is this, you know, for the hormone positive patients, we're going to do a big multicenter study called DCIS recast or recast DCIS.
try and sort out what are the suitable conditions for, reevaluate the conditions for active surveillance that are suitable. In prostate cancer, when people had the courage to do it, 98% of people were still alive with that disease 10 years later. So if you don't have the courage to do things, that's you're never going to find out. And, you know.
The vast majority, I mean, we're still over 50% of people are getting mastectomies. This is not a trivial thing to do to somebody, especially if you don't need it, and especially if it's not going to benefit you very much. For the very big cancers that are high risk. What I think is remarkable about it, what's interesting about the biology, you have to ask, how does something, we used to think, wow, these are the bad DCIS. But if you compare a five centimeter DCIS to a five centimeter invasive.
triple negative breast cancer, they're like vastly different. One has almost no risk and one has like a ton of risk. Same thing for HER2 disease. One's lethal and the other's not. So you can say, wow, the body's almost figured it out. It's almost got it together to keep things there. And I think what we've learned is what's doing that are these immune infiltrates. If you have large palpable DCIS.
you're likely to have a lot of T cells infiltrating. And we know that that's associated now from our work with less of a chance of going on to invasive disease, which is very interesting. I mean, if you leave them there... Many of these people will go on to bad disease, and it's like you've got that window. But it made me think, wow, the body is so working so hard. What if we could just turn it on?
and add in just the right combination of things. Take the brakes off the immune system. We tried that with pembrolizumab alone, directly injecting it into the tumor. Brought in a lot of T cells, but they still couldn't get across the moat. And so now we've got this combination with, you know, these cytokines. And then we're to bring all these together.
have found and at least now we're just starting this combination and starting to see some very exciting results and watching things go away now it it's not trivial um it it's you know It makes people sick. You know, any of these kind of immune system things makes you, gives you muscle aches and fatigue, whatever. But if this really does work and could make things go away, that would be super exciting. But again, you know.
If you don't try anything new, nothing, nothing, you're never going to get a new, a different result. So it is really, my feeling is that. If you really work to understand the biology of the disease you're treating, and DCI is just as heterogeneous as invasive cancer, and we don't treat all breast cancers the same. And there are some cancers that are super low risk that don't need much therapy at all either.
And endocrine therapy, endocrine-driven tumors are not primarily driven by the immune system. But these are too positive. triple negative DCIS. The reason why they're still DCIS is because they have this immune infiltrate. And that finally was the catalyst to say, aha, we just have to push it over the edge. And we can train the body to destroy it. So that's my theory. We're putting it into practice. Stay tuned. Come and talk to me next year and I'll tell you if it works. Excellent.
Dr. S. Women, thank you so much for spending the time with us today. Oh, thanks so much for having me, Alexa. Be sure to check out our website at www.behindthenife.org for more great content. You can also follow us on Twitter at Behind the Knife and Instagram at Behind the Knife Podcast. If you like what you hear, please take a minute to leave us a review.
Content produced by Behind the Knife is intended for health professionals and is for educational purposes only. We do not diagnose, treat, or offer patient-specific advice. Thank you for listening. Until next time, dominate the day.