On Thursday evening, I heard this amazing thought voiced when I attended a FREE public lecture, exploring the history, current practice and future of breast cancer treatment hosted jointly by the Victorian Comprehensive Cancer Care Centre (VCCC) and Breast Cancer Network Australia (BCNA).
Held at Peter MacCallum Cancer Centre (VCCC), the CEO of BCNA, Kirsten Pilatti, introduced Dr Eric Winer, the keynote speaker and one of the world’s foremost and highly regarded breast cancer specialists from the Dana-Faber Cancer Institute in the United States.
It is not the first time Dr Winer has visited Australia to share the knowledge he’s gained from clinical trials he has designed and conducted, the results of which paved the way toward the more personalised treatment of breast cancer patients and move away from the ‘one-size fit all’ approach of previous years.
Kirsten praised Dr Winer’s commitment to ‘treating the patient not the disease’, an approach shaped by his own cancer journey, which enabled him to draw on empathy as well as expertise.
Improving Breast Cancer Outcomes: Past, Present and Future
When Dr Winer, diminutive, grey hair and glasses took over the podium, he apologised if he fell asleep or stumbled during his presentation because he had only arrived in Melbourne that morning after a long flight from Boston.
However, his well-researched presentation delivered efficiently and with aplomb, showed no sign of fatigue and he held the audience spellbound.
The Past – 1990
1990 was the beginning of Dr Winer’s career concentrating solely on breast cancer, or as he explained ‘that year was the last time I treated a patient without breast cancer.’
His reflections and observations:
in the USA there were 150,000 cases recorded and 44,300 deaths
it was a monolithic disease – doctors could only determine the stages, not the type
most cases presented as a lump or mass
treatment was extensive and debilitating surgery
psychological and physical distress for the patient
chemotherapy and other adjuvant treatments, not an option
women were scared, uninformed and felt victims – some felt shameful
breast cancer advocacy was in its infancy and sadly, even today, some women still feel or are made to feel ashamed
lymphedema was common whereas although it can be a problem today it is not as severe as in the past
metastatic treatment was limited, toxic, barbaric and ineffective
hormonal therapy limited and it too barbaric compared to nowadays
there was poor pain control and patients spent lots of time in hospital
breast implants and reconstruction experimental
wards were run like ‘concentration camps’
Today it is totally different.
- there’s a recognition that one woman’s breast cancer not the same as another
- a better understanding of biologics heterogeneity (2001 study – genetic differences across tumour types)
- a better understanding of cancer biology and differences within subtypes
- a growing appreciation of the tumour micromanagement
- massive drug development – many new ones on the market with real improvement and better outcomes
- a better understanding of hormone receptive tumours, they grow slowly and survival rate is high if therapy used
Studies divided tumours into high grade and low grade, and negative and positive to various hormones
Clinical trials and researchers looked at:
the microenvironment, macroenvironment (the host), diet and exercise
In the last 30 Years
- Less extensive surgery and more breast preservation
- Far fewer lymph node dissections
- Use of several adjuvant therapies to decrease surgery
- Reduction in early and late toxicity using modern techniques
- More convenient fractionation schedules
- Improvements in reconstruction
- Individualised therapy based on patient preferences
- Radiation more accurate with better protection of the heart and lungs
- ⅔ of women eligible to have lumpectomies choose this in the USA
- Small number choose bilateral mastectomies
- Advances in chemotherapy and supportive care
- Widespread use of drugs for cancer deemed hormone therapy receptive with a substantial decline in mortality
The magnitude of late (6-20years) recurrence after an initial diagnosis of ER+ breast cancer disease has shown the value of extended hormone therapy but he is aware of the side effects of this therapy.
Adjuvant treatment is additional therapy after primary surgery to kill or inhibit micro-metastases. Primary surgery for breast cancer is accomplished by lumpectomy followed by whole-breast irradiation or by mastectomy.
In patients at increased risk, chemo, immune or hormonal therapy, kills hidden cancer cells – adjuvant therapy has proven effective in various cancers especially if lymph nodes are involved.
He designed this USA study of 2006-2010.
It was one of the first large scale trials to examine a methodology for personalising cancer treatment.
“Any woman with early-stage breast cancer age 75 or younger should have the 21-gene expression test and discuss the results with her doctor to guide her decision to the right therapy.”
Dr Sparano MD, associate director for clinical research, Albert Einstein Cancer centre New York
The role of chemotherapy for some tumours is still unclear but the data “… confirm that using a 21-gene expression test to assess the risk of cancer recurrence can spare women unnecessary treatment if the test indicates that chemotherapy is not likely to provide benefit.”
The findings of the trial significant:
Most women with early breast cancer do not benefit from chemotherapy – that is 70% of women with the most common type of breast cancer
Women with hormone receptor (HR) – positive, HER2-negative, axillary lymph node-negative breast cancer, the discovery that treatment with chemotherapy and hormone therapy after surgery is not more beneficial than treatment with hormone therapy alone.
There is now greater attention to the quality of life and symptom management of those diagnosed with breast cancer.
- There are a plethora of anti-HER2 drugs, these new drugs combat the adverse drug reaction patients experience
- Targeted approaches that augment hormonal agents – an array of hormonal and chemotherapy approaches
- Advances in radiotherapy
Immunotherapy Trials for triple-negative breast cancer
- Immunotherapy is more used for the treatment of melanoma and lung cancers
- It may be useful for metastatic breast cancer
Mortality rates from breast cancer have dropped 38% in the USA
During the trial, the combination of adjuvant therapy and screening compared and the findings show screening is important but can lead to overdiagnosis and overtreatment.
Some cancers may never bother you in life but are picked up by screening
- 276,480 cases of invasive disease
- 48,539 new cases of DCIS (ductal carcinoma in situ – the earliest form of breast cancer which is non-invasive)
- 50,000 deaths
- Therapeutic resistance exists – this a major cause of death in developing countries where there is limited access to screening and drugs
- Brain metastasis is a major problem for 50% of patients with HER2+
- Need for better treatment for some cancers and reduction of chemotherapy
- Overtreatment is an issue – causes substantial morbidity, not death
For anyone following USA politics, health equity is a big issue. Dr Winer let it be known he couldn’t imagine anyone in the room liking or supporting President Trump, or his acceptance of the current health inequalities in the USA where there is inadequate and unequal access to healthcare
Dr Winer certainly didn’t support Trump, he was ‘from Boston and no one supports Trump there!’
Health equity is a fundamental social problem and screams discrimination.
Race, poverty, limited education, lack of health insurance and health literacy all contribute to inequity.
Whether it is because of poverty, race, ethnicity, sexual orientation or being considered overweight – statistics show if you are a 30-year-old lesbian or a woman over 80, if diagnosed there is a high risk of dying from breast cancer!
Racial disparity in breast cancer persists with people of colour suffering higher rates of death.
In her introduction, Kirsten mentioned the problem in Australia regarding Aboriginal women’s access to health services. In the USA, Dr Winer said it is the African-American population who suffer, and ironically the worst equity is in Washington!
Less than optimal care can cause death from almost anything that makes a person have less access to healthcare available.
Health inequity may cause up to 30% unnecessary deaths
Regarding clinical trials – there is a low participation rate and Dr Winer wants more engagement with clinicians and better communication so there is meaningful interaction between patients and clinicians about the importance of clinical trials.
Aboriginal and Torres Strait Island Possum Skin Cloak – Peter MacCallum Centre acknowledges and pays respect to the Wurundjeri People, the traditional owners of the land on which the hospital stands.
Possum skin cloaks are one of the many expressions of traditional south-eastern Aboriginal and Torres Strait Islander peoples. Cloaks aid healing and wellbeing by connecting Aboriginal and Torres Strait Islander people to their culture and identity and spiritual healing.
We thank the Aboriginal and Torres Strait Islander Women Survivors of Breast Cancer and other cancers that created this beautiful healing cloak, intended for use by Aboriginal and Torres Strait Islander people and their families while at Peter Mac.
In creating this healing cloak, we acknowledge the Peter Mac Foundation and our partnership with Breast Cancer Network Australia.
DRUG COST 2017
These are the amounts drug companies estimate it costs for production of various drugs used in breast cancer treatment (a year’s supply):
- Dr Winer said the drug development costs 2-5 times more in the USA than anywhere else, therefore the profit margin is not reasonable.
- The government prohibits negotiating around the cost of drugs, Dr Winer believes there should be control and regulation for the sake of health equity.
Dr Winer looked at the future and made some predictions:
Next 10 Years
- More detailed understanding of the disease
- Real improvements in survival and quality of life
- Less surgery,
- Advances and better-targeted radiation
- Decline in deaths
- Increase in those considered “cured”
- Health equity may improve in the next decade
- 25-40% reduction in deaths
- No movement in prevention
Next 25-30 Years
- We’ll be treating breast cancer with antibiotics
- Death will be rare – a 50-80% reduction
- Prevention treatment may be possible
Questions from the audience
- A man in the audience suggested dragon boat racing, which many women take up after surgery, is effective in reducing the risk of recurrence because it is good exercise and helps with weight loss and improved strength. He had attended another talk where a doctor had said that 10,000 breast screens only saved one life and wanted to know if that statistic was true.
Answer: Dr Winer said that breast screening was a less useful tool than people assumed. People have to consider their general health and quality of life and detect cancer early and choose the best treatment available.
Screening mammograms can often find invasive breast cancer and DCIS that need to be treated, but possibly some of those cancers would never grow or spread.
Dr Winer is aware that many of the hormonal therapies have horrible side effects and more work needs to be done in deciding who will benefit from it and in reducing side effects.
- How Do You Prevent Breast Cancer?
Dr Winer admitted his reply was the ‘impossible dream’ and with a slightly facetious smile rattled off the following:
- Have first child before the age of 18
- Avoid weight gain if post-menopausal
- Avoid excessive alcohol intake
- If the disease is in your family have regular check-ups
- Take Tamoxifen (however, this has side effects some people find distressing!)
The forum was on the 7th floor of the cancer centre – an amazing view of the city you don’t often see.
I chatted with two women while waiting for the forum to start.
One had a mastectomy plus lymph bodes removed 28 years ago. She was on a trial and her chemotherapy resulted in many weeks in the hospital. Cancer, returned 11 years later but it is now 17 years since the recurrence. The other survivor had a bilateral mastectomy 27 years ago. Now in her 80s, she has decided to resign from the committee of the VCCC. She fundraised and campaigned to have the centre established.
As Dr Winer said, clinical trials and learning from the vast amount of data over the years is very important. Both these women have given so much to help clinicians understand and treat breast cancer and improve survival rates.
We all stand on the shoulders of those who have gone before.
Just as I saw the city in a different light that evening, I also saw the effectiveness of breast screening in a different light. Apparently, only 30% of breast cancers are picked up by screening and unless interpreted correctly can lead to unnecessary interference, overtreatment and a lot of angst.
Both my cancers were first detected by a routine mammogram – how lucky was I?
I left the VCCC more enlightened but with plenty to mull over on the train trip home while acknowledging my privilege.
The Peter MacCallum Centre is world-class, and the treatment I have had for breast cancer (both times) at Cabrini has been excellent and Peter Gregory, my breast surgeon, is a caring specialist who communicates well with his patients.
A big thank you to Melbourne University and the Breast Cancer Network – both organisations promoted the forum to me.
Walking down Elizabeth Street to Melbourne Central I counted my blessings, enjoying the balmy evening in our very livable city!
It is good to know my daughters and others in the future will benefit from the dedicated clinicians and researchers working towards that amazing goal of an antibiotic for breast cancer!