September and October 2014 Research Highlights

Jamie DePolo: Hello, everyone. Welcome to the Breastcancer.org podcast. This is the October 2014 Research News Podcast. And our guest, as always, is Breastcancer.org’s medical adviser, Dr. Brian Wojciechowski. I’m Jamie DePolo. I’m the senior editor here at Breastcancer.org, and we’re going to talk about some of the studies that came out this month. Welcome, Dr. Wojo. How are you today?

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

Jamie DePolo: I’m good. I’m good. We’ve got four studies that we’re going to talk about today. And the first one probably a lot of people heard about it. It did get a lot of press, and it was about a medicine called Perjeta. And they found that it increases overall survival in women who are diagnosed with HER2-positive metastatic breast cancer.

So, Brian, I’m going to ask you to explain a little bit what Perjeta is and also why it’s specific to HER2-positive disease, and then also if you could tell us why overall survival is so important in this kind of a study.

Dr. Brian Wojciechowski: Sure. Perjeta is a drug that is similar to Herceptin. And both drugs are what we call targeted therapies. It’s sort of the next generation beyond chemotherapy, because targeted therapies are specially designed drugs that go right to the tumor cell and have minimal effects on healthy cells in the body.

Herceptin came out a number of years ago to be added to chemotherapy for women who are HER2-positive and have metastatic breast cancer. Now, Herceptin can only be given to women whose tumor is HER2-positive. It’s personalized medicine. And the same is true for pertuzumab.

Jamie DePolo: Perjeta. [Editor’s Note: Pertuzumab is the chemical name of Perjeta.]

Dr. Brian Wojciechowski: So, when Herceptin came out, it was a major milestone, and we all felt, you know, this represents a new era in breast cancer treatment and indeed it did. It made a major impact, and in that study, in that initial study with Herceptin years ago, when you added Herceptin to chemotherapy, the progression-free survival was increased by 6 months. So what is progression-free survival?

So, that’s the time that a patient lives where their cancer is not changing and not progressing. And that’s great, but it’s not as good as overall survival. Overall survival, if a drug has that benefit, has an overall survival benefit, that means the patient is actually living longer, not just living longer with disease not progressing, but actually living longer, actually getting to another birthday.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: So, this study is significant because the addition of pertuzumab, or Perjeta, to the standard, which was docetaxel, which is a chemotherapy also called Taxotere, plus Herceptin, added 16 months of overall survival.

Jamie DePolo: That’s pretty long. That’s like a year and a half almost.

Dr. Brian Wojciechowski: Yeah. We’ve never seen anything like that in metastatic breast cancer. It’s dramatic. It’s pretty remarkable. And especially when you consider how big of an impact we all felt that 6 months of progression-free survival, which is even as good as overall survival, was when Herceptin first came out.

I think when that study was followed out to completion, the overall survival benefit for Herceptin was only about 7 or 9 months, so adding Perjeta just kind of blows Herceptin out of the water.

Jamie DePolo: But it has to be given with Herceptin, right? Nobody would ever get just Perjeta.

Dr. Brian Wojciechowski: Well, the indication for front-line therapy is Perjeta, Herceptin, and Taxotere together, the three drug combination.

Jamie DePolo: Okay. Okay. I didn’t want people to think that, say somebody out there listening was diagnosed with metastatic HER2-positive disease, I wouldn’t want that person to think that Herceptin was not good for him or her or useless. It’s still… Perjeta is given in combination with the other two medicines, and it just makes them more effective, it seems like.

Dr. Brian Wojciechowski: That’s right. That’s right. The three together is more powerful than the two, but there certainly remains a significant role for Herceptin, and Herceptin is still an excellent drug for most women.

Jamie DePolo: Okay. Yeah. And that’s really good news because I know there’s been a lot of research and studies done on early-stage disease and looking at medicines for that, and I know folks who’ve been diagnosed with metastatic disease sometimes feel like they’re not getting the research focus that they deserve. And so this is exciting because it was looking specifically at metastatic disease.

Dr. Brian Wojciechowski: Sure.

Jamie DePolo: Okay. So, our next study, this is all about debunking a myth that we’ve seen on our Breastcancer.org Discussion Boards. We’ve seen it floating around other areas of the Internet, I think I’ve even seen it in a couple of magazines. And for a couple of reasons, many people seem to believe that wearing a bra was linked to breast cancer risk and that if you wore a bra, especially an underwire bra, your risk of breast cancer was higher.

And so there was a study done by researchers at the Fred Hutchinson Cancer Research Center that found that there was absolutely nothing about wearing a bra that was linked to breast cancer. And that included cup size, how many hours a day a woman wore a bra, whether the bra was underwire or not, or when a woman first started to wear a bra regularly. So there was no difference, say, if you started to wear a bra when you were 12 or you started to wear a bra when you were 16, there was no difference.

And from what I’ve read, Brian, it seems like a lot of people think that there’s something about the constriction of a bra, it’s building up toxins, it’s not letting the lymph fluid out, or that things are leaching out from the underwire. Have you heard about this? Are your patients concerned about wearing a bra? Has anybody talked to you about that?

Dr. Brian Wojciechowski: I haven’t been asked specifically about a bra. One person asked me about breast massage and if that should be done to sort of push toxins out of the breast toward the axilla, so they could go up the lymph channels and get out of the body. But I haven’t heard before this study about the specific concern about wearing bras.

Having said that, you could almost come up with a reasonable theory, a proposed mechanism whereby the normal flow of lymph and toxins from the breast up the lymphatic channels to the armpit to the bloodstream and out the body through the waist, might be slowed down or constricted by wearing this constricting piece of clothing, this garment, because remember, for most of human history, women probably did not wear bras. So, you can almost imagine a mechanism by which this would make sense. But that’s a far stretch from actually having a good study, some scientific evidence, to prove that mechanism. And this study does not provide any suggestion, any evidence that the claim about bras is legitimate.

Jamie DePolo: Okay. And that’s good to know, because most of us do wear bras. And the other thing I wondered, I know that there is a link between being overweight and breast cancer risk for sure. And several different studies have shown that, and so I wonder, too, if because if a women is heavier, she more likely has to wear a bra than somebody who may be a little bit thinner and could get away without wearing one all the time if she felt comfortable doing so.

So, I wonder if that’s why maybe people seem to… it just keeps coming back. I know we have information on the site about, “there’s not a link,” and some people think that, “oh, the bra manufacturers paid for this study,” but they didn’t. It was just done by Fred Hutchinson Cancer Research because they really just wanted to kind of put this myth to bed once and for all. And certainly, people will believe what they want to believe, but as Dr. Brian said, there’s no scientific evidence to link that.

Dr. Brian Wojciechowski: Yeah. There’s no evidence. I’m not going to go tell my patients, you know, one way or the other at this point. I mean, if a woman says, “I think there could be something to this. I don’t want to wear the bra,” I might answer her by saying, “Well, the best studies that I’ve seen have suggested that there is no link, and I don’t feel strongly that you don’t need to wear the bra.” But if she doesn’t want to wear it, I also don’t see the harm.

Jamie DePolo: Okay. That sounds good to me. I’m all for that, because probably like men wearing ties, I personally hate bras and pantyhose, so any excuse to not wear them, I’m down with that.

Dr. Brian Wojciechowski: I feel the opposite way about undergarments, personally.

Jamie DePolo: [Laughter] You like wearing ties?

Dr. Brian Wojciechowski: We’ll leave it at that.

Jamie DePolo: Okay! So, our third study was also very interesting. It was looking at breastfeeding and childbearing in Black women. It was a study done by the AMBER Consortium, which is a group of several research groups, and they’re putting together all these studies that are looking specifically at Black women and breast cancer risk and looking at environmental factors, genetic factors, all sorts of risk factors.

And this study was interesting for a couple reasons. So Brian, I’m going to ask you to kind of explain what was going on. I mean, we know that breastfeeding reduces risk in all races of women. I mean, I think the research shows that. And now, this study pulled out another thing that showed that having more children increased breast cancer risk.

Dr. Brian Wojciechowski: Yes, and both of these factors were previously known.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: It’s been well-established that breastfeeding in general decreases the risk of breast cancer, and having a child, your first full-term pregnancy, before age 30 decreases the risk, but as women have more and more children, the risk tends to go up a little bit.

Jamie DePolo: Is there a biological mechanism behind that? Is it just that the breasts are being used to make milk so much more often, or is that not known?

Dr. Brian Wojciechowski: There’s some theories about that, that the process of breastfeeding somehow brings the breast to a more mature state that it wouldn’t get to otherwise. And when you have immature cells, those cells are more likely to mutate and differentiate and become cancer cells. That’s the theoretical explanation.

And you know, almost all of these risk factors have something to do with hormones and the exposure of breast cells to estrogen. So generally speaking, anything that increases the breast exposure to estrogen such as early first period, late menopause, more and more pregnancies, more and more estrogen, estrogen replacement, that sort of thing, would increase your risk. So most of it has to do with hormones.

Jamie DePolo: Okay. So it’s the estrogen, the levels go up when a woman’s pregnant, and that’s one theory or whatever, that’s the reason why the risk for breast cancer goes up with having more and more children.

Dr. Brian Wojciechowski: That’s correct.

Jamie DePolo: Okay. Okay. I’m sorry. Go ahead.

Dr. Brian Wojciechowski: Well, that’s all I have to say about that.

Jamie DePolo: Oh, okay. Okay. Okay. I didn’t want to interrupt you. Now, we know that breastfeeding is a very, very personal choice, and we also know that it reduces breast cancer risk. So if it’s available to you, that might be something to consider. It might be something you want to talk to your doctor about if you’re pregnant or considering getting pregnant and trying to decide whether you want to breastfeed or not.

Dr. Brian and I were talking before we started the podcast, there are also other benefits beyond breast cancer risk reduction. It’s good for the baby. I believe it passes along antibodies from the mom. It can reduce allergies. It just makes the baby healthier. It’s also good for the mom. But again, we know it’s very personal, so talk to your doctor. Find a solution that works best for you. But if you are looking to do everything that you can do to reduce your risk of breast cancer, breastfeeding might be one thing that you want to consider.

Dr. Brian Wojciechowski: There’s a lot of good reasons to breastfeed.

Jamie DePolo: Yes. Yes. Our fourth study is looking at, again, going to pregnancy, or staying around the pregnancy topic, fertility is a big concern of many younger premenopausal women who are diagnosed with breast cancer, and are they going to be able to have children after they go through treatment.

And there was a study that suggests that a medicine that’s called Trelstar that, if it’s given along with chemotherapy, some women might find it easier to get pregnant after chemotherapy ends. So, I was hoping, Brian, you could explain a little bit how this might work. Is it that the Trelstar is sort of turning off the ovaries? Is that what’s going on?

Dr. Brian Wojciechowski: Yeah. It puts the ovaries into sort of a dormant state. You could almost call it a drug-induced menopause, which is temporary.

Jamie DePolo: Okay.

Dr. Brian Wojciechowski: And the theory goes that if the ovaries are dormant and the eggs are basically asleep, that they would be less susceptible to damage by chemotherapy.

Jamie DePolo: Okay. Okay. And so I guess help me understand this a little bit. I know that a lot of women stop menstruating during chemotherapy and this Trelstar would also, I assume, sort of a medically induced stopping of menstruation. So help me understand the difference. Like if the chemotherapy is stopping it, how is this more protective if you have Trelstar? That’s what I’m not understanding.

Dr. Brian Wojciechowski: Well, if Trelstar resulted in more women being able to resume having their cycles, then presumably more women would get pregnant.

Jamie DePolo: Oh, I see. So, it kind of like turns it off before the chemotherapy even starts.

Dr. Brian Wojciechowski: Right. And when the Trelstar wears off, then the ovaries would start cycling again.

Jamie DePolo: I see, I see. Okay. Okay. That makes sense. That was one thing I was wondering about with that study.

So, if anybody out there is a younger woman, a premenopausal woman who has been diagnosed, it doesn’t work for everyone. I will say that in full disclosure. The research found that it did not work for everyone, but it’s something that you may want to consider if you’re looking to have a family after treatment and want to explore all your options.

Certainly, there are other options. You can bank your eggs, you know, have mature eggs removed from your ovaries before treatment starts and then have them frozen or stored. But certainly talk to your doctor about all your available options if you want to have children after treatment, because there are many options available out there right now.

It seems like this is kind of a big area of research, Brian. Do you think that’s fair to say? It seems like people are looking at more and more ways to do this.

Dr. Brian Wojciechowski: There’s a lot of questions still in the air about this particular strategy for preserving fertility. There’s been a lot of studies that showed promise and some studies that showed not so much.

So, I would not consider this to be a standard of care necessarily, but I think they’re doing it in some places and maybe not in some others, and it is worth, I think, at least a discussion about it with the physician.

Jamie DePolo: Okay. That sounds good. Anything else you’d like to add about any of these studies today, Brian?

Dr. Brian Wojciechowski: That’s all I have.

Jamie DePolo: Okay. Great. Thank you so much for joining us as always. This has been the October 2014 Breastcancer.org Research News podcast. We’ll be back next month to talk about some of the research that comes out then, and as always, thanks to everybody for listening. I’ll talk to you next month, Dr. Brian.

Dr. Brian Wojciechowski: Okay.

Jamie DePolo: Take care.