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Podcast Library > NextGen Advisors Podcasts > A Focus on Prevention – Breast Cancer Awareness, Mental Health and Covid-19 Booster Shots

October 26, 2021

A Focus on Prevention – Breast Cancer Awareness, Mental Health and Covid-19 Booster Shots

Every October, several advocacy and research organizations focus their efforts on building awareness and engagement with the public regarding diseases and conditions which have a large impact on our population. In this episode, NextGen® Advisors Graham Brown and Dr. Betty Rabinowitz discuss national breast cancer awareness month and national depression and mental health screening month, as well as developments at the FDA regarding booster shots for COVID-19.

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Graham Brown:

Hello, this is Graham Brown, Senior Vice President and a principal with NextGen Advisors. I'd like to welcome you to our podcast. I'm joined once again by my colleague, Dr. Betty Rabinowitz. Welcome, Betty. Good morning.

Dr. Betty Rabinowitz:

Hey, Graham. Nice to be here.

Graham Brown:

October is a unique month. One in which several advocacy and research organizations focus their efforts on building awareness and engagement with the public, regarding diseases and conditions which have a large impact on our population. October is both National Breast Cancer Awareness month and National Depression and Health Screening month. There's been some interesting discussion also in the past week or so at the FDA Advisory Committee, which is looking to update guidance regarding booster shots for COVID-19 vaccinations using a mixed dosing approach. So in the theme of prevention, we want to address a few different topics on today's podcast. Betty let's begin with COVID vaccinations. This potential approach of mixing doses from different vaccine manufacturers was foreshadowed last week when researchers presented findings of a federally funded mix and match study that the National Institutes of Health undertook. And they presented this information to an expert committee that advises the FDA. The study found that recipients of Johnson & Johnson's single-dose shot who received a Moderna booster, experienced antibody levels rising 76 fold over a 15 day period. That's compared with only a fourfold increase if those individuals received a third dose ... or sorry, a extra dose of Johnson & Johnson vaccine. So federal regulators met this week. Looks like they've authorized both Moderna and Johnson & Johnson to come out with booster shots. And soon, this mix and matching approach is going to be available. So would be really interested to get your perspective on what do you think some of the practical benefits are? But then also, potential clinical benefits for someone who's gotten one booster ... or sorry, one original round of vaccination and maybe a different vaccine for their booster?

Dr. Betty Rabinowitz:

So I think there's a variety of benefits. One is that it'll make getting the shots easier. So if there's issues with supply or availability or the logistics of getting the shots, it opens now an opportunity to get any shot that's available as your booster shot, rather than having to adhere very narrowly to the one you got before. Specifically for the Johnson & Johnson recipients of the original shot, this assures higher levels of immunity, which is exactly what we were trying to achieve. Johnson & Johnson performed a bit less well, originally. And this shows that with either Moderna, obviously, and Pfizer, there's a significant boost in immune response to them. So I think it's terrific news, both from a logistic perspective, but also the clinical efficacy of these vaccines is enhanced by this mix and match approach.

Graham Brown:

So kind of related to this, in the last couple weeks the federal government has determined that they're going to recognize these mixed dose vaccination regimens that have been undertaken in different countries. Not everybody was able to secure the number of vaccines that the United States, and didn't have the supply to be able to ensure folks got two courses of Pfizer, two courses of Moderna, et cetera. And so if the World Health Organization has already considered these vaccines to be effective in different countries, the US government is now going to recognize those individuals that might have a mixed dose as being fully vaccinated. So I'm personally glad to hear this news, because it means that my Canadian family members will now be considered fully vaccinated. Because some of them received an initial AstraZeneca dose, and then got either a Moderna or a Pfizer as their second dose. I guess the question here though is, does this to you seem like a rational step at this point, to open up our borders and open up our travel industry in recognition of this kind of protection from different vaccinations?

Dr. Betty Rabinowitz:

I think it does. Obviously, there's now data and evidence that these regimens have proven very effective. So yes, I think these people should be considered fully vaccinated. And the benefits of opening up tourism, both from, like for yourself on a personal level, but also an economic basis for the country as a whole are absolutely essential. We are approaching two years of this pandemic, and the toll in terms of the world economy and tourism as a specific industry has been staggering. So as soon as there's evidence and data to support the safety of it, we need to open our borders. It's also, it's enough that some travel is occurring, which is occurring ... to mean that we live in a global village. And that the occurrence of variants is going to travel very quickly across the world. And that really sealing borders at this stage of the pandemic is probably not a practicable or advisable approach.

Graham Brown:

Yeah. So when the time comes, if you get into the group that's eligible for a booster vaccine, do you think you'll get one? Is part A of the question? And if so, would you consider a mixed dose?

Dr. Betty Rabinowitz:

So, yes and no. So I would absolutely consider getting a booster. I got Pfizer as my first two doses. Interestingly for me, I like the notion of biologic tidiness and not taking on the additional small risk of mixing and matching. Which obviously, it just introduces new chemical vehicles. It introduces another structure, introduces some more inert and not active ingredients, on the one hand. And clearly, the Pfizer shots have shown to be very effective and the booster highly effective in increasing immunity. But that may have to do a little bit with my OCD as an internist. I like order. If someone asked ... if a patient or a relative or a loved one asked my advice, I would say that I think that the recommendation is a solid one. Certainly, if I had received Johnson & Johnson or in Europe, AstraZeneca or Canada, AstraZeneca, I would absolutely mix and match. There is no question that Moderna first, and then Pfizer have proven superiority over those vaccines. And mixing and matching there is really important.

Graham Brown:

It'd be really interesting to see how data continues to evolve and what we learn about the efficacy of combining doses. And whether, just as they've shown, with one dose of Johnson & Johnson and the subsequent dose of a different vaccine, that there is a higher level of protection, whether that translates when we think mixing Pfizer and Moderna or all of these different variable combinations. It'd be great to see the data on that. And that will really, I think, help inform folks as to what the best course of action might be.

Dr. Betty Rabinowitz:

Absolutely. And it might be that when we have this conversation a year from now when we get our annual booster, which we know ... obviously I don't have any information to support this, so this is speculative what I'm saying. I think it's likely that this will be a reboosted vaccine. It might be that by then we have enough information that overcome comes my OCD sense of order, and that I would choose, with the correct data to say, for example, does the immunity last longer? Does it decrease over timeless when you've mixed and matched than when it's the the same dose? So time will tell. My answer may change in a year from now. Those would be my thoughts.

Graham Brown:

Well, I know we'll continue to follow that topic let's shift to the other topics of October's month of focus, depression, and mental health screening. Depression's been associated with shorter life expectancy for individuals, particularly if they have other conditions. So individuals that have a complex chronic condition and also have depression, are shown to have a much shorter life expectancy. There's a lot of complications that go when those two conditions are experienced together. There's been some research that looks at quality-adjusted life expectancy. And would be interested to get your perspective on individuals that you've cared for that have depression and have other conditions, and how you go about understanding them and treating them. Because the complexity of their illness really is different from somebody who's just showing up with a single condition?

Dr. Betty Rabinowitz:

Absolutely. So the first thing is, is maybe to try and think about how that could be. How do we explain the fact that patients who have, for example, diabetes and hypertension, fare worse if they have diabetes, hypertension, and depression? We know that this research clearly identifies significant differences between those two types of patients. The one explanation is, we know that depression impacts the immune system quite powerfully. There is a whole body of work that shows immune changes in the context of depression with probably less effective immune surveillance for cancers and malignancies. And certainly a pre-disposition to less immunity for infectious diseases, other immune impacted conditions, which explain the excess mortality and morbidity. We also know the second reason is, that patients with depression have less volition, have less energy, and tend to take less good care of themselves. They are, even in the absence of suicidality, there is just an apathy and a lack of drive that creates delays in screening. Diabetic patients with depression tend to take less good care of themselves, less good control of their sugar values. And their excess mortality is explained by complications of the core chronic degenerative conditions that they have, compared with people who are not depressed. What that means is that the importance of screening for depression in patients with chronic illness becomes absolutely paramount. And that aggressive, proactive, continuous intervention for these patients, preferably in an integrated care setting, becomes critically important. And there's evidence for example, that patients with cancer in whom depression and emotional and spiritual needs are addressed fare better and postpone relapses of cancer compared with other patients. We know what needs to be done, but we need to, as clinicians focus our efforts doubly on patients who share these conditions. Depression, misery, and chronic disease do not go together well. And it's our responsibility to identify depression and other mental illnesses with effective screening and awareness and asking the questions when we see these patients. And then offering proactive care plans that include very aggressive attention to the behavioral health, emotional psychiatric aspects of their illnesses.

Graham Brown:

Yeah, I mean, as a layperson considering this, it really strikes me as almost so obvious that somebody who is inhibited around taking care of themself and the behaviors that go along with depression and how you can feel isolated and shut down and not motivated to go exercise, to eat healthfully, to do all of those things that actually have so many other corollary benefits with regard to chronic disease, can just put you in a situation where you spiral out of control. And so the importance of those joint approaches, to recognizing the behavioral aspects of chronic disease management and whole-person health, they're really pivotal, it sounds like, to being able to address some of these needs when they get into these complex situations.

Dr. Betty Rabinowitz:

Absolutely. And the kicker here is that some of these chronic conditions induce depression because of the limitations and the symptoms that they bring on. The trade-offs in terms of capabilities. People lose functionality around these conditions when they're out of control or severe. So one almost needs to assume that somebody with longstanding, severe impactful, complication-laden diabetes, by definition is going to be depressed. Whether or not they had a predisposition to depression prior to that, there's enough to be very distressed about with these chronic conditions when they're severe and not well controlled.

Graham Brown:

Let's shift to our third topic around today's podcast, Breast Cancer Screening month. Then there's been a huge amount of effort in terms of public awareness campaigns. And October is well recognized with the pink ribbon campaign. You see a lot of involvement and focus on this. It's really been great to see how that's gotten picked up over the last several years, a lot of awareness. Are there still barriers for individuals seeking breast cancer screening today? And if so, what are those?

Dr. Betty Rabinowitz:

So there are clearly patient-driven barriers and then system-driven barriers. The patient-driven barriers are reluctance to get screened because of concerns, or worry about getting a bad result, or worry about the test being uncomfortable. So those are some of the patient-driven barriers that still very much exist. And then there are barriers of access. There are cost barriers. Some states, New York state, where we live, has been very proactive in offering financial support, time off work. It has gone all out to support allowing women of all socioeconomic and access capabilities to get mammograms and have mobile units and campaigns to encourage women to get mammograms. This isn't the case in all states, obviously. So there are still populations, underserved populations, populations of color, where access and cost to our significant barriers to getting mammography screening. And therefore, still, some of the outcomes are worse in those communities. So diagnosis is made later and outcomes are poorer in those communities. So we have still, across the country, much work to be done to close those gaps. Another barrier that is not always recognized is the fact that there isn't clear guidelines around mammography. If you look at the US Preventive Services Task Force recommendations, they are recommending every other year mammograms between the age of 50 and 75. If you look at the American Cancer Society recommendations, they recommend biannual between 45 and 55, and 55 and on to do annual mammograms. So it is very ... every time two major clinical societies' voices differ in this way, we sow the seeds of confusion. Which gives women excuses, or just confuses them straight off to say, which is it? I don't trust these recommendations. You can't even agree about them. And the controversy around mammograms has followed my entire career, basically. The thing to do is to find your primary care physician, the one who you trust, the one who you create a long-term trusted caring relationship with, and to follow their recommendations. Because you can assume that they have synthesized the differences between these sets of recommendations and will come up with a tailored approach for your specific ... if you're an Ashkenazi Jewish woman, the risk is higher because of genetic predisposition. It'll be probably following a closer and more frequent guideline recommendation if you are not at risk, et cetera. Those are conversations one should really recommend women have with their primary care physicians. And if you don't have a primary care physician, October is a great month to go and get one and find one in your community. So I think that there is ways to get around this confusion, but it's a barrier. It requires a bit more effort on the part of patients to figure out what the right thing to do is.

Graham Brown:

But given those, both the differences and recommendations, but also the individual risk factors and all of those variables around family history, prior exposure to different things, lifestyle, et cetera. All of those, I imagine, are things that really put that conversation with your trusted primary care provider, central to selecting the appropriate screening approach for women today.

Dr. Betty Rabinowitz:

Absolutely.

Graham Brown:

Well, there's a lot of complexity to these conditions. And certainly the need for education and awareness around the risks associated with depression, mental health issues, breast cancer, et cetera. Certainly important enough that as a society, we designate a month each year to focus on these matters. Thank you very much, Dr. Betty Rabinowitz, for joining me today and sharing your insights and knowledge. If you've enjoyed today's podcast, consider subscribing. This is Graham Brown with NextGen Healthcare. Thanks and have a great day.