August and September 2014 Research Highlights

Jamie DePolo: Hello, everyone. I'm Jamie DePolo. Welcome to this edition of the Breastcancer.org podcast. We are going to talk about some Research News with Breastcancer.org’s medical adviser, Dr. Brian Wojciechowski. Dr. Wojciechowski, welcome. How are you today?

Dr. Brian Wojciechowski: Doing very well. How are you, Jamie?

Jamie DePolo: I'm good. So, we’re going to talk about four studies that came out over the last couple weeks. I’ll just give you a brief rundown now. The first one, we’re going to talk about an abnormal gene, the PALB2 gene. We found that it increases breast cancer risk more than we thought. We’re also going to talk about two studies that looked at bisphosphonates, and now we know that they really don’t reduce breast cancer risk.

We’re also going to talk about a study that looked at exercise and risk. And finally, we’re going to talk about a study that just came out a couple days ago looking at the type of surgery for breast cancer and how more women are having a double mastectomy if they have breast cancer in one breast, but survival rates are the same for those women as women who have a lumpectomy plus radiation.

So, let’s get Dr. Brian’s take on this. The abnormal PALB2 gene, we’ve known that that has been linked to increased breast cancer risk, but the research that came out now shows that it actually increases risk much more than we thought. And I guess what I'm wondering is, you know, when people do genetic testing, are they going to automatically now screen for the three genes? So, for abnormal BRCA1, BRCA2, and now PALB2?

Dr. Brian Wojciechowski: I think we’re moving in that direction, Jamie. We’re not doing it routinely at the moment, but in light of this new study, and in light of the forthcoming availability of testing for this gene, I think you're going to see it done routinely on genetic testing panels for women who are thought to be at high risk for familial breast cancer.

Jamie DePolo: And one thing, too, I know we’ve gotten some questions through our Facebook page and also on the Discussion Boards. There have been women who have a very strong family history but have tested negative for both BRCA1 and BRCA2, and it seems like they would potentially be good candidates to get PALB2 testing.

Dr. Brian Wojciechowski: I agree. The PALB2 is definitely going to capture some of those high-risk families that are not BRCA1- and [BRCA]2-positive.

Jamie DePolo: Okay, and, certainly, there could be other genes out there that we just haven’t discovered yet or haven’t been recognized yet, but this adds more information to the whole genetic panel.

Dr. Brian Wojciechowski: Yes, along with CHEK2, that’s another familial inherited syndrome that is getting on more and more people’s radar these days. I think the growing complexity of this field and the testing just reiterates what I’ve been telling my patients. That if you do think you're at high risk, you really should see a genetic counselor, someone who specializes and is certified in this field, because, you know, there’s more and more testing, it seems, every month that comes around that can be done, and it really needs to be done by a qualified professional.

Jamie DePolo: Okay, and just as some background for our listeners, could you tell us a little bit about the PALB2 gene? You know, what it does normally, what it should be doing?

Dr. Brian Wojciechowski: So, genes are made of DNA. DNA is the genetic code of the body that basically is an instruction manual, a blueprint for everything that your body does and is made of. And the PALB2 gene works with BRCA2 and provides instructions to make a protein that helps to repair damaged DNA. You see, when DNA gets damaged, that’s one of the things that leads to tumor growth. The body has a natural process by which it repairs DNA and therefore fights tumor growth, but when you lose the function of these proteins, the BRCA2 and proteins like the PALB2 protein, then the body loses its natural ability to repair DNA, and therefore that person is going to be more likely to develop cancer.

Jamie DePolo: Oh, okay. Okay. So, PALB2 sounds like its function is strictly focused on the breast and breast tissue since it works with BRCA2?

Dr. Brian Wojciechowski: I wouldn’t say that it’s exclusively focused in the breast, but mostly.

Jamie DePolo: Okay. Okay. Thank you for that, and now, bisphosphonates. I'm going to ask you to explain a little bit to the listeners what bisphosphonates are and what they do. And they’ve been used in breast cancer treatment for a while, and there was some anecdotal evidence that showed that they might reduce risk. But now this study seems to say they don’t.

Dr. Brian Wojciechowski: Yes. Bisphosphonates are medications that fight osteoporosis and strengthen the bones. Some of our listeners might recognize drugs like Fosamax and Zometa, and there’s a handful of other ones, as well. And let’s not confuse this study with the studies of these drugs in breast cancer itself, where there was some evidence that putting women on these drugs who already had breast cancer had a lower rate of recurrence. That’s not what we’re talking about. We’re talking about prevention here.

Jamie DePolo: With women who’ve never been diagnosed?

Dr. Brian Wojciechowski: Yeah, who’ve never had breast cancer. And the finding here was basically that they did not help prevent breast cancer. And the reason is, I think, because the reason these drugs help in women with breast cancer is because breast cancer cells hide out in the bone, and these drugs alter the bone environment and make the bone less hospitable to those breast cancer cells. A woman who’s never had breast cancer presumably does not have those cancer cells in the bone, and, therefore, she would not be likely to see a benefit from these drugs.

Jamie DePolo: Okay. So, if a woman who’s not been diagnosed and is taking a bisphosphonate for osteoporosis to strengthen her bones, it’s unlikely that the bisphosphonate is going to reduce her risk of breast cancer. But what we’re still seeing and what bisphosphonates are still used for, I want to make sure I'm understanding you correctly, is that if a woman has been diagnosed and she’s taking a bisphosphonate potentially to strengthen her bones, it may also help be reducing recurrence risk?

Dr. Brian Wojciechowski: That’s exactly right. Now, this has not become the standard of care for early-stage breast cancer in the United States because there is some controversy about conflicting data, but I have to say, when I treat a woman with early-stage breast cancer, I'm always glad if she happens to be on one of these drugs to begin with, because I'm one of the, I guess, experts that thinks that it probably does help.

Jamie DePolo: Okay, but right now, if a woman weren’t on a bisphosphonate, you wouldn’t prescribe one for her as an additional treatment?

Dr. Brian Wojciechowski: Not in early-stage and not as a preventative. Now, if she had metastatic disease, and she had breast cancer in her bones, I would definitely give that drug or a drug like it, because that prevents skeletal events, fractures and the like. That’s standard of care.

Jamie DePolo: Okay. That sounds good. Now, moving on to exercise. Many, many studies have shown that women who exercise have a lower risk of breast cancer and that, I think -- hopefully you would agree, because I think this is true -- is fairly well-known, and so women are often advised to exercise to reduce risk. And what doctors haven’t known is that how long does a woman have to exercise before she gets these benefits? You know, is it 6 months? Is it a year? Shorter? Longer?

And what they’ve found is that if you exercise regularly, you get the benefits pretty quickly, but the minute you stop exercising, you lose those benefits. And is there, I guess -- I don’t want to put you on the spot, but I'm going to -- why do you think that is, Brian? Is it that the body just says, oh, okay, we’re done. No more exercise?

Dr. Brian Wojciechowski: Well, I don’t exactly know, to be perfectly honest, Jamie. I think there’s a lot about exercise and what it does to the environment inside the body -- you know, the hormonal milieu, the improved circulation throughout the body -- that we don’t really understand, and there’s a lot of benefits that we still haven't explained yet, at least enough to say that here’s how it happens and here’s why. But, even though I might not be the most shining example of this in my own life, I always do recommend exercise for my patients. Whatever they can do is better than nothing.

Jamie DePolo: Right, and I know if you have never exercised -- and I completely understand it’s hard to get started -- but more and more research is showing that even just walking is a tremendous help, and if you can walk a half an hour to an hour a day, that is going to really, really help your body. And so we have a lot of information on this site about how to get started. We always recommend, if it’s tough for you, to stick to an exercise routine. Try and make time to do it with a friend, because if you know that somebody’s counting on you, then you're more likely to do it. If you want to find a trainer, that maybe that’s more pleasant for you to do, then we have resources about that. We’ve got resources about a ton of stuff about how to get started with exercise.

So, I, personally, would make a plea for everybody to do something every day, even if it’s just park a little further away, or walk to the store instead of driving, or doing something, because this research shows that it really does help, but you need to stick with it. And this study also, it was for postmenopausal women, so we’re not just talking about younger women. We’re talking about women who are older as well. So it benefits all women.

Dr. Brian Wojciechowski: Absolutely.

Jamie DePolo: And our final study, this one just came out, as I said, a couple days ago. It was published... let me just double check here. I believe it was in the Journal of the American Medical Association, the September 2014 issue. And it was a study done in California, and they looked at about 190,000 women, and all the women had been diagnosed with early-stage breast cancer in just one breast. And they compared the survival rates between women who opted to have a double mastectomy, have both breasts removed even though the cancer was only on one side, versus women who had a lumpectomy followed by radiation.

And what was found was that the survival rates between those two treatments were the same. Now, I know that that’s a very personal choice, the type of surgery to have. The researchers also found that many more younger women were having double mastectomy as opposed to lumpectomy. I believe the rate, in 1998 when they started this study, was about 3% of women younger than 40 were having a double mastectomy, and in 2011, when they finished the study, the rate was up to 33%. And I know there may be very good reasons for that, but we do want to put out this research that the survival rates are the same. And do you think that’s surprising, Brian, that the survival rates are the same?

Dr. Brian Wojciechowski: I don’t think it’s a surprise, because we’ve known for a long time that, from the studies where mastectomy was compared to lumpectomy, going back, you know, 35, 40 years now, we’ve known that the survival was equal between women who kept their breasts and women who had the breast removed. So I'm not surprised by the results of this study. I think it’s a very interesting study because of the sheer size of it, almost 190,000 medical records reviewed.

So, in that sense, it’s a very strong study, and so, even though it wasn’t a prospective study, they were just looking back at charts into the past, I think the study outcome really mirrors what I’ve seen in practice. And that is that, you know, number one, yes, women tend to do just as well whether they have a mastectomy or not, and also that the younger a woman is, the more likely she is to have that other healthy breast removed.

Jamie DePolo: And why do you think that is?

Dr. Brian Wojciechowski: Well, I think that if you look at a 40- or 50-year-old woman these days, if she’s otherwise healthy, she can have a pretty good assurance that she’ll be around when she’s 80. And women, I think, don’t want to wait 30, 40, 50 years for another cancer to come in that breast. Now, the risk in that healthy breast of another cancer is low, but you have to admit that having the breast removed means that they’ll never get cancer in that breast, and keeping the breast means that they could, and I admit that to my patients. Now, there’s no difference in survival. So, by having the healthy breast removed, a woman is not increasing her chance of living longer. I think it’s very important to understand that.

Jamie DePolo: Okay, and certainly, as I said, it’s a very personal choice, and so there didn’t seem to be a survival benefit. Would you say there are other benefits for a woman...you know, she’s been diagnosed with breast cancer. She’s weighing her surgical options. So she has breast cancer in just one breast. She’s considering a lumpectomy plus radiation. She’s considering a single mastectomy, or she’s considering a double mastectomy. Are there benefits beyond survival to having a double mastectomy in that case?

Dr. Brian Wojciechowski: Well, you know, she’s eliminating a very small chance of having breast cancer on that healthy breast, and there’s no different in survival mostly because we’re going to be watching that other breast. I never let a breast cancer patient graduate from my practice. I'm seeing her once a year for her life, and if it should come back in that breast, we’ll catch it early. We’re doing mammograms, and we’ll treat it, and we’re so good at treating early-stage breast cancer that we’re curing most women, and they’re living.

So, I think the advantage is A) peace of mind, and B) eliminating any chance of getting cancer in that other breast, because, while you might say, “Well, it didn’t make you live any longer, so why remove it?” But some people would say, “Well, I don't want to have the prospect of getting breast cancer and going through the treatment, and I don’t want the worry of thinking about the possibility of cancer in that breast for the rest of my life either.”

But I try to dissuade my patients from getting the healthy breast removed, because I feel that having a mastectomy is not a walk in the park. You have the potential for long-term side effects such as lymphedema. It’s a major surgery, and I think if you're going to have a major surgery, you should have a really, really strong reason to do it, and you should have a really strong potential benefit.

It’s a personal decision, and you know, I try to help my patients make that decision. I don’t try to tell them what to do, but I lean towards keeping the breast and opting for close monitoring.

Jamie DePolo: Okay, and we should point out that when we’re talking about this, we’re talking about women at average risk. Certainly, if a woman is at higher risk because she knows she has one of the genes that’s linked to higher breast cancer risk that we were just talking about, BRCA1, BRCA2, PALB2, CHEK2, then that’s a different case. Also if a woman has a strong family history, but maybe there’s no genetic component, because perhaps that gene hasn’t been discovered yet, then certainly that plays into the decision as well, because that woman’s at higher risk, and so the risk of breast cancer coming back or breast cancer developing in that other healthy breast is higher than it would be.

Dr. Brian Wojciechowski: That’s a great point, Jamie, and I'm glad you brought that up, because some women with higher risk definitely need a mastectomy, and they will benefit from that much more than a person with the average risk.

Jamie DePolo: Okay, and again, as Dr. Brian said, I do want to point out that having a double mastectomy is major surgery. The recovery time is longer than it is with a lumpectomy. There’s a possibility for more complications. And as we’ve both said, it’s a very personal decision, but what we’re trying to do is give you all the information that we know about so you can make the best decision for you, because everybody’s different. Every breast cancer is different, and so every situation is going to be different, and what’s right for you may not be right for your friend or your relative. So, as long as you have all the information and you feel you’re making a good decision for you, then we support you. All right, well, thank you...

Dr. Brian Wojciechowski: Rock and roll.

Jamie DePolo: Thank you so much, Dr. Brian. You’ve helped me understand a lot of this research, and we will be ready to check back in with you again next month. So, everybody, thanks, as always, for listening. This has been the Breastcancer.org podcast on Research News.