Barbara Brenner, Former Executive Director
When I looked at the scheduled presentations for today, I could tell that I wouldn’t be spending too much time sitting looking at slides and listening to someone talking through a microphone. But sometimes I learn more by having one-on-one conversations, and today was one of those days.
My morning started with breakfast with Stefanie Jeffrey, a breast surgeon and breast cancer researcher at Stanford. Stefanie is developing technologies to better characterize and understand circulating tumor cells, with a focus on killing cells that kill patients. This is a perspective that, while represented in places at this meeting, is rarely stated so clearly.
The next person I ran into was Larry Norton, pre-eminent breast oncologist at Memorial Sloan Kettering, and someone who has been thinking innovatively about breast cancer for a long time. Like other honest practitioners, Larry feels that, at the moment, he knows less about breast cancer than ever. While I didn’t have the chance to explore with him what he meant by that statement, it is certainly my sense that the breast cancer field is in turmoil, with folks going down lots of different roads that have been paved by the basic research in genomics, molecular biology, and systems biology. The road map, however, is not yet clear.
And Larry told me a great story. He had just made a presentation on cancer to a group of people, when someone in the room stood up and said that what we need to do is focus on cancer prevention by getting people to do what he does—run 10 miles a day, eat low on the food chain, and other healthy behaviors. Larry told the man that he had just described why he was likely to get cancer. By engaging in behaviors that reduce the risk of heart disease and stroke, the man may live longer, but he’ll get cancer eventually, because we all die of something, and heart disease, stroke, and cancer are the leading causes of death in industrialized societies. After all, death is not optional.
We all have to die of something. The point of this meeting should be about how to prevent premature death from breast cancer. (It’s too much to hope or expect, given the pharmaceutical influence at this meeting, that the focus would also be on primary prevention.) Unfortunately, I heard little today that has direct application to the lives of patients now.
Focus on survivorship (Plenary 5)
Charles Loprinzi, the guru of survivorship, gave an overview of survivorship issues. The slide presentation, online at www.sabcs.org day 3 presentations, is worth a look. While Loprinzi provided a long list of symptoms that arise from toxic treatments (see slide number 3), his talk focused on hot flashes, vaginal dryness, libido loss, fatigue, and chemo-induced neuropathy, as well as on the interventions—largely pharmaceutically based—that have been evaluated for addressing these challenges. The only non-pharma intervention that got a positive nod in this presentation was the use of Wisconsin ginseng (1000–2000 mgs/day) to treat cancer-related fatigue.
A doctor I was talking to at the end of this presentation wondered why we needed a 45 minute presentation to learn about these treatment-related symptoms in breast cancer patients in 2007.
Sentinel Node Biopsy—the beat goes on
There were several presentations (Abstracts 51 through 54) on issues related to sentinel lymph node (SLN) biopsy. The first two presentations were focused on the clinical impact of these biopsies, and the latter two looked at molecular methods of examining SLNs.
Of these presentations, the one of interest to patients making decisions about treatment now focused on the impact of micro-metastasis in the sentinel nodes of patients with invasive breast cancer (Abstract 52). The study was based on the new 6th ed. American Joint Committee On Cancer (AJCC) staging criteria that define a negative lymph node N0 if it is negative on staining, pN0(i+) if there is a tumor deposit <0.2mm detected by IHC (immunohistachemistry) alone, a micrometastases as pN1mic as a tumor deposit measuring between 0.2mm and 2mm, and a macrometastases as pN1 with a tumor deposit >2mm.
The study found that the size of the micro-metastasis in the SLN was a significant predictor of Disease Free Survival (DFS) and Overall Survival (OS) when compared to women with negative sentinel nodes. The other conclusion of this study was that the presence of isolated tumor cells (ITC’s) or micro-metastases in the SLN do not affect DFS of OS eight years after surgery.
In this study, 66% of people with a negative SLN received chemotherapy. Far more people with positive SLNs also had chemo. At the end of the presentation, an Italian practitioner cautioned against using systemic therapy with increasing size of the SNL, stating that there are no data to support giving systemic treatment based on micro-metastases. This statement prompted the people sitting near me to laugh—I assumed because they thought I as I did that the lack of data to support an aggressive intervention often doesn’t stop oncologists from adding them.
Will the mammogram ever die?—Non-invasive detection methods
In a mini-symposium on molecular imaging for breast cancer diagnostics, Bruce Tromberg presented on the development of non-invasive optical methods for breast cancer detection and clinical management. He described using diffuse optics to detect breast cancer in dense breast tissue and to guide neo-adjuvant treatment. He showed the results of intriguing preliminary studies demonstrating the ability of the technology—which is portable—to distinguish cancer from non-malignant formations, and to monitor tissue response to chemotherapy. The work needs to be confirmed by prospective, larger trials. In the neo-adjuvant setting, the technology needs to be correlated to biomarkers that are in use and being developed.
Food, Glorious Food—the WHEL Study (Abstract 61)
In the only presentation here on non-pharmaceutical interventions for breast cancer, we heard a presentation about the results of the Women’s Healthy Eating and Living (WHEL) study. This study looked at whether increasing vegetable, fruit, and fiber intake and decreasing dietary fat affects risk for recurrent and new primary breast cancer or mortality in breast cancer survivors diagnosed with early-stage disease.
At 7.3 years of follow-up, the study showed no difference in DFS between the dietary intervention group, and the non-intervention group. Reductions in fat intake did not affect outcomes. The dietary intervention group did have lower circulating estrogen levels, but no outcome benefit was seen as a result.
Heard in the Halls
BCA convened interested advocates and activists over lunch today, which gave me a chance to talk at length to some of the people affected by the research reported at this meeting. Conversations ranged from issues regarding what the standards should be for drug approval for patients with metastatic disease, at what age screening should start for the daughters and sons of a woman who carries an BRCA2 mutation, and what guidelines doctors use (or ignore) in making treatment recommendations. It is humbling to realize how many people depend on and are affected by what we do at Breast Cancer Action.
The price of biotech drugs seems to vary depending on where you are, and what doctors you are seeing. One patient told me that the cost of her Herceptin is $1400 a week, which works out to $72,800 a year. Avastin for this same patient is $8400 per treatment, which works out to $100,800. In many ways it doesn’t matter what new treatments are developed, because their pricing means many people won’t be able to get them. The trend in drug pricing is simply unsustainable.