Research Highlights From the San Antonio Breast Cancer Symposium, December 13, 2013

Jamie DePolo: Hello everyone, this is Jamie DePolo. I’m the senior editor at Breastcancer.org. I’m joined by Dr. Brian Wojciechowski, who is Breastcancer.org’s medical adviser. We are down in San Antonio for the third day of the San Antonio Breast Cancer Symposium. We heard some very interesting research today, a lot of it pertaining to chemotherapy regimens and also some interesting new results from a study looking at the incidence of breast cancer after hormonal fertility treatments. But first, we’re going to start with the keynote presentation this morning, which talked about the psychosocial issues that women who’ve been diagnosed with breast cancer face during and particularly after treatment, because survivorship issues are becoming huge in the breast cancer community as more and more women are living longer and longer after being diagnosed with breast cancer.

So, some of the things that were discussed and, Brian, please feel free to jump in at any time, anxiety and depression are some of the top two issues that people face during a diagnosis and after, fatigue, lymphedema, hot flashes, and there was also a strong call for really good communication from healthcare providers.

Dr. Brian Wojciechowski: Yeah, and for me, the take-home message here was that, we, as physicians, need to utilize other healthcare professionals, counselors, social workers, nutritionists, more, so that our patients' well-being can be enhanced. Because if a patient is not well, she is not going to be able to tolerate her treatment, for example, or finish her hormone therapy. And if that’s the case, then, there’s less of a chance that we’re going to be able to help her, whether it means cure her cancer or keep her alive longer.

Jamie DePolo: Right.

Dr. Brian Wojciechowski: This is really important to me, and I’m definitely going to be more proactive addressing these issues even before treatment.

Jamie DePolo: That’s great, and I think that’s really what people are looking for, because one of the things mentioned was that psychosocial issues used to be one poster in the very back corner of the poster room, and this morning it was the keynote presentation. There were several presentations on it. There were several posters on it, and great changes are being made and there’s more research in this area and more things are being done.

So that’s hopeful, but certainly more things can be done, especially in the area of metastatic breast cancer. We really need to address that issue because more and more women are living longer and longer with metastatic breast cancer, too, and they have some special needs of their own. So, while things aren’t perfect, I think we can say that more research is being done and things are looking up. These issues are starting to be recognized.

Dr. Brian Wojciechowski: Yes, and as opposed to just worrying about right diagnosis and right treatment, doctors -- and I can see myself doing this -- are starting to have survivorship clinics. I can imagine a dedicated survivorship visit where a patient meets with me and my nurse practitioner, and we discuss what it means to be a cancer survivor. Anyone who’s been diagnosed with breast cancer is a cancer survivor, and, as you said, women are living a long time with the diagnosis. So there’s a lot of issues, there’s a lot of things they need to know about how they can manage long-term side effects and reduce their risk of having another cancer.

Jamie DePolo: Right. So, as we said things are not perfect by any means, of course, but things are looking up and everyone seemed very hopeful that more positive changes are going to be coming.

Then, we moved onto several sessions on chemotherapy regimens and looking at whether adding different chemotherapies or different combinations of chemotherapies would help particular types of breast cancer. And the first one we’re going to talk about was whether adding carboplatin, which is a type of chemotherapy, it’s a platinum chemotherapy, and/or Avastin, which is a targeted therapy, to a before-surgery Taxol regimen. And then that was followed by Adriamycin and Cytoxan. And what the researchers ultimately wanted to see was whether all these combinations of chemotherapies would have an affect on pathologic complete response. We talked about that in an earlier podcast, but just in case somebody didn't listen to the early podcast, Brian, could you explain pathologic complete response again?

Dr. Brian Wojciechowski: Yes. Pathologic complete response is an endpoint we use in the clinical trial for women who get their chemotherapy before surgery, also called pre-operative or neoadjuvant therapy. The advantage to this endpoint is that you get meaningful data at a much earlier timeframe. So, as opposed to waiting 5 or 10 years to get meaningful results, they do the chemo before the surgery, and if the chemo shrinks the tumor away completely, you have a pathologic complete response. And that is, we’re learning more and more, that that is a meaningful endpoint. It correlates well with overall survival, that is, a woman’s chance of having her life saved by the treatment.

Jamie DePolo: Okay. So in other words, if the chemotherapy makes the cancer go away before surgery, that translates to a better prognosis, better outcomes, for the person.

Dr. Brian Wojciechowski: That is what seems to be emerging, especially… We had some data this year at San Antonio correlating the complete response rate before surgery to overall survival, so that’s coming out.

Jamie DePolo: Okay. So that’s great and then, this particular study was looking at these chemotherapy regimens for triple-negative breast cancer, correct?

Dr. Brian Wojciechowski: Yeah. Triple-negative breast cancer is a special challenge because women with triple-negative are not eligible to have hormone therapy or HER2-directed therapy, such as Herceptin, so the treatment options are more limited and the cancer tends to be more aggressive. So they were looking at this study adding in new drugs to see if any of these drugs would help women with triple-negative breast cancer.

First of all, they looked at Avastin, and there was really no benefit for Avastin, that’s the targeted therapy. Bevacizumab, it targets VEGF, which is an angiogenesis.

Jamie DePolo: Okay. You’re going to have to explain that for us.

Dr. Brian Wojciechowski: Yeah. So, angiogenesis is when the tumor grows its own blood supply. Tumors need oxygen and nutrients just like we do to grow, so this drug inhibits the blood supply to the tumor.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: It’s been a rough couple of years for Avastin in terms of breast cancer. They lost their indication for metastatic breast cancer from the FDA, and unfortunately it continues to be…it’s another bad year for Avastin, really no benefit here. But the good news for women with triple-negative breast cancer is that this study did show a benefit for carboplatin, and carboplatin is a standard chemotherapy drug. It’s not a targeted therapy.

Jamie DePolo: Okay. Is it commonly used to treat triple-negative breast cancer now, or is it kind of well, we’ll try it if something else doesn’t work?

Dr. Brian Wojciechowski: I think at this point it’s mostly used in clinical trials. We don’t use it much in the clinic right now, but now that this data is coming out and the study will go through the peer review and publication process, we may be using it more in the future. You know, if a woman has triple-negative breast cancer and she’s interested in being in the clinical trial, she should ask her doctor if there are any clinical trials, which means drugs like carboplatin.

Jamie DePolo: Okay, and I’m assuming that all the platinum kind of chemotherapy drugs would end in a -platin like this one, is there a similar name?

Dr. Brian Wojciechowski: There’s a few other drugs, but they’re not commonly used in breast cancer.

Jamie DePolo: Okay. So carboplatin would probably be the big one to look for.

Dr. Brian Wojciechowski: I would think so.

Jamie DePolo: Okay. So, yeah, if someone has been diagnosed with triple-negative breast cancer and is interested in being in a trial, maybe is not responding to current treatments that her doctor is trying, this may be a good option to talk about with your doctor.

Dr. Brian Wojciechowski: Yeah. I would bring it up.

Jamie DePolo: Okay. Now, the second one we heard this morning is very interesting, it was called the I-SPY 2 trial, and I thought this study was interesting for two reasons. One, because of the combination of new drugs, experimental drugs, but also because of the study design. Can you tell us a little bit about that one?

Dr. Brian Wojciechowski: Yeah. This is a great, very clever study designed by Hope Rugo and her colleagues.

Jamie DePolo: Who is a member of the Breastcancer.org Professional Advisory Board, I should point out, so we only have the best people here.

Dr. Brian Wojciechowski: Yes, she is. This was very clever because they were basically looking at a bunch of different drug combinations and a bunch of different tumor subtypes, and as soon as one combination showed any promise in any given subtype, it basically graduated from this study and then goes onto a higher-level study to prove its efficacy.

The first combination that graduated this study and showed promise was a combination of veliparib, which is a PARP inhibitor, and carboplatin in triple-negative breast cancer. So, another study showing the benefit of platinum chemotherapy in this very difficult-to-treat subtype of patients.

Jamie DePolo: Okay. So that’s two studies that showed a benefit for carboplatin on triple-negative. The veliparib, now that’s an experimental...either targeted therapy, is that a targeted therapy?

Dr. Brian Wojciechowski: Yes. It’s a tyrosine kinase inhibitor. I don’t want to get too far into the exact details of the mechanism.

Jamie DePolo: Sure.

Dr. Brian Wojciechowski: Suffice it to say, it’s a category of drugs, the PARP inhibitors, that there has been a lot of excitement about.

Jamie DePolo: Okay. But it’s not available yet, it’s only experimental, you could only get this particular medicine in a clinical trial.

Dr. Brian Wojciechowski: Correct.

Jamie DePolo: Okay. Yeah, and it was for triple-negative breast cancer, again, which is really good, and as Brian said, the researchers were looking at all different types of breast cancer. So they had it separated out whether it was hormone-receptor-positive, and HER2-positive, and HER2-negative, and hormone-receptor-negative, and all the various combinations you could have, and whichever group was shown to benefit by the medicines, then it got moved out and potentially could go onto a bigger clinical trial and potentially get into the marketplace faster.

Dr. Brian Wojciechowski: Yes, and they’re doing it before chemotherapy, as well.

Jamie DePolo: Before surgery, right?

Dr. Brian Wojciechowski: I’m sorry, before surgery, as well, so basically, we’re getting more clever about testing drugs, developing new methods for getting the information, and we’re getting it quicker.

Jamie DePolo: That which is great because that’s what everybody wants, is, "Let’s find out which treatments are beneficial and if they are, let’s figure out who they help and get them out there faster so we can help more people as quickly as possible." So that was very, very cool. Maybe we’ll see more studies that use this kind of design. Again, I know they mentioned it was a very special type of algorithm they were using. I don’t really understand all that, but it sounded pretty cool.

Dr. Brian Wojciechowski: Yes, I’m sure it was very sophisticated computer algorithm, but if this works out, it’s going to be groundbreaking.

Jamie DePolo: That’s great. Now, another study was looking at the numbers of circulating tumor cells and how that number can be used, or whether that number was going to change if different chemotherapy regimens were tried. Brian, can you help me understand a little bit exactly what a circulating tumor cell is.

Dr. Brian Wojciechowski: Yeah. So in women with stage IV breast cancer, that’s the metastatic, tumor cells will actually break off and circulate through the blood stream. And there’s a very sophisticated type of blood test we can do to detect those circulating tumor cells.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: It is known that women with high levels of circulating tumor cells have a worse prognosis. So they don’t live as long, their cancer is more likely to be aggressive. And in metastatic breast cancer, we’re treating to prolong a woman’s life, not to cure her of the cancer, it’s not curable. So often times when I’m treating a woman, I will be using one drug or drug combination until it’s not working anymore. And so her cancer is growing despite being on that drug, and then I’ll switch treatments.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: So it’s important to know when the drug stops working. And you can use different strategies. Classically, you do a scan every now and again, and when the tumor's growing, you change. But there’s other ways to do it. You can send tumor markers, which are simple blood tests, a number of a certain protein in the blood that may indicate the cancer getting worse, or you can use these circulating tumor cells.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: Now, this can cause a lot of anxiety for patients, because oftentimes, the circulating tumor cells can rise over time.

Jamie DePolo: Even if the tumor isn’t growing?

Dr. Brian Wojciechowski: Even if the tumor is staying the same size.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: So you can imagine a situation where a woman with stage IV breast cancer is getting this test checked every month, and the circulating cells keep going up and up and up, and she’s beside herself.

Jamie DePolo: That’s really scary. Yeah.

Dr. Brian Wojciechowski: That’s really scary, and then we do a scan and the cancer’s the same size. So, the investigators in this study were trying to find out if doing this test, this circulating tumor cell test, was any use in terms of helping us treat our patients.

So, what they did was, they started chemotherapy, and after one round of chemo they would check for the circulating tumor cells. And if the circulating tumor cells were high above a certain range, they would switch to a different chemotherapy. So that was one group, and the other group would just stay on the same chemo regardless of the circulating tumor cells, and they would stay on that chemo until their tumor got bigger. And that’s the usual way that we do it.

So when they analyzed the two groups, they found that there was no difference.

Jamie DePolo: Oh, okay. So it wasn’t a really good indicator?

Dr. Brian Wojciechowski: Yeah, it really wasn’t a good test. All it really does is kind of confuse the situation, lead to more anxiety and more scans for the patient. So, not every practice has used circulating tumor cells. We were using them for awhile in my practice, and I did get the sense that they were causing more anxiety than anything else. But it’s good to know now that really, it didn’t make any difference. So, for me, personally, I will not be using these tests.

Jamie DePolo: Okay. While it’s not the best result, it’s definitely good to know, to keep in mind.

Dr. Brian Wojciechowski: Certainly.

Jamie DePolo: We did have one study, well, more than one study, but this next study had some positive news. This was a meta-analysis, which I’m going to let Brian explain again, but we do know that this is one of the top types of studies. So when a meta-analysis study says something, it’s usually very, very accurate.

The researchers were looking at the number of breast cancer cases that happened after hormonal fertility treatments, because we know this is kind of a scary issue for many women. If they do want to have a child and they are having trouble conceiving, they may want to do this, but then, there’s been a concern that this may increase the risk of breast cancer. But we had some positive news, right?

Dr. Brian Wojciechowski: Yeah. This was a very big analysis of a bunch of smaller trials. You combine all the data and basically analyze it as one huge trial, and that’s called a meta-analysis. And that is considered to be the highest level of evidence.

Now, this is a meta-analysis of a bunch of trials that are observational trials, so it’s somewhat weaker than other meta-analyses.

Jamie DePolo: When you say observational, that means that they just watched to see what happened. They didn’t have one group do one thing and one group do another thing.

Dr. Brian Wojciechowski: That’s correct. You know, they might be looking at old charts, for example. So it’s not the best type of study here, but it’s probably the best that we have so far on this topic.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: What they basically found was, looking at the group of women who got the hormonal treatments versus the ones that did not, there was no major difference in the risk of breast cancer.

Jamie DePolo: Well, that’s great. That’s really good to know.

Dr. Brian Wojciechowski: Yeah. The author of the study today said women should not be alarmed about the risk of breast cancer with fertility treatments, so that’s a good thing. Now, what we should bear in mind is that some studies have shown a risk, some studies have not shown a risk. There was a trend toward a higher risk for breast cancer in the studies that looked at 10 years and later. So it’s hard to truly rule out an effect there, especially over the long term, but if there is an effect, it’s probably not a large effect.

Jamie DePolo: Okay. When you say over the long term, does that mean that somebody would be continuing to get these hormonal therapy treatments for 5 or 10 years, or is that just 5 or 10 years after you’ve had the hormonal therapy, the fertility treatments.

Dr. Brian Wojciechowski: Yeah. It’s 5 or 10 years after you’ve had the hormonal therapy, because I think when you actually get the drugs, it’s short-term.

Jamie DePolo: Well, that’s what I thought, but I just wanted to double check, because when she was talking about that, I’m like, "Wow, that seems like a long time for somebody to stay on fertility treatments."

Dr. Brian Wojciechowski: Right. Right.

Jamie DePolo: Okay. Thanks for clarifying that.

Dr. Brian Wojciechowski: But I think it’s mostly reassuring.

Jamie DePolo: Yeah, that’s great. And the last research we wanted to talk about was actually something that’s very close to home. Breastcancer.org’s President and Founder Dr. Marisa Weiss presented a poster this morning, and it was all about prevention, which is a topic that is very, very important to her. She’s very passionate about helping women reduce their risk of breast cancer. She and her colleagues surveyed a number of women wanting to know what they would be willing to change in their lives that would reduce their risk of breast cancer.

The results were a little bit disappointing, because women weren’t really willing to change a whole lot of things. Some of them were willing to change some exercise things. Some of them were willing to change their diet and maybe lose weight, and Marisa thought this may be because a lot of women are trying to lose weight or diet pretty much their whole lives, so it was familiar, it was comfortable, it wasn’t really a big change.

The one thing most women were absolutely not willing to give up was alcohol, and while it’s probably not surprising because, you know, you have a hard day at work, you want to come home, you have a glass of wine. Most of our social functions involve alcohol. It’s considered, you know, you have a lot of memories with alcohol and your friends and you do a lot of things together, you go to parties, you go out. So that’s going to be a tough one for anyone, but we do know that drinking alcohol increases the risk of breast cancer.

So, it was very well received. She talked to a lot of people this morning. I happened to be there for part of her presentation and she’s going to move forward with it, and I believe the next part of the study is going to look at, okay, now that we know what women might be willing to change and what they’re not willing to change, how can we motivate them? And that’s always a very tough thing, too.

With exercise, most women will say they know that exercise is beneficial for them in so many ways, whether it’s heart health, breast health, overall health, but they don’t have the time. And that’s a tough one, because you have to convince somebody to give up something else. So I believe that’s the next phase of the research going forward, is how do we motivate people to make these changes that they might be willing to do, or that they’re interested in doing, but maybe don’t know how, or need a little bit more help to do.

Dr. Brian Wojciechowski: Yeah, and we’re not trying to blame the victim.

Jamie DePolo: Oh, absolutely not. Absolutely not.

Dr. Brian Wojciechowski: I think it’s important to realize that number one, you don’t have to cut your alcohol to zero.

Jamie DePolo: Right.

Dr. Brian Wojciechowski: Generally speaking, the data shows that anything over three alcoholic drinks per week is what increases your risk, but also to bear in mind that even if you never touch a drop of alcohol, you can still get breast cancer.

Jamie DePolo: Exactly.

Dr. Brian Wojciechowski: And you can’t control all the risk factors, and I think an individual woman has the right to know what could increase her risk of breast cancer even if it’s just a small amount, and she should make an informed decision.

Some people might say, well, instead of cutting back on my alcohol, I am going to lose weight and exercise and get myself down to a healthy body weight. And if my patient said that to me, I would accept that.

Jamie DePolo: Yeah. I mean, nobody’s going to be perfect. I think everybody realizes that, but it was, I believe from Marisa’s viewpoint, it was kind of good to know the areas that women were willing to make changes in, so you can kind of focus your efforts on those areas. Like okay, if exercise and losing weight and diet is the area where people are willing to make changes, then yeah, let’s focus on that. And we know that over a certain amount of drinks per week will increase risk, but if people aren't willing to change that, okay. Let’s focus on the other stuff that we can change, and that’s what we tell people all the time, too, is focus on the things you can change and you’re willing to change and go from there.

Dr. Brian Wojciechowski: Yeah, and we’re about education at Breastcancer.org, and if a woman knows these risk factors and knows these things, she’s ahead of the game.

Jamie DePolo: Exactly. Well, thank you everyone for listening. We really appreciate it. This has been the wrap-up of the third day of the 2013 San Antonio Breast Cancer Symposium. This is actually our final podcast from this year’s breast cancer symposium, so we will talk to you in the future and again, thanks for listening.