Courtney Collen (Host): Hello and welcome to One in Eight. A new podcast series brought to you by Sanford Health. I’m your host, Courtney Collen with Sanford health News. We’re really eager to kick off this series all about breast cancer awareness because 1 in 8 women will be diagnosed with breast cancer in her lifetime. Today we’re talking with Dr. Anu Gaba at the Roger Maris Cancer Center in Fargo and our topic today is breast cancer research.
Dr. Gaba, thank you so much for being with us.
Dr. Anu Gaba: It’s my pleasure. Thank you.
Courtney Collen (Host): Tell us about your role as a medical oncologist in Fargo.
Dr. Anu Gaba: I started here in 2004 as a medical oncologist. As a medical oncologist, I see patients who come here for the treatment of their cancer. I specialize in breast medical oncology. So I’m a part of a treatment team here we deal with the patient has a whole, we aim to provide wholesome care. So when a patient comes in to get treated for breast cancer, they see the surgeon, they see the radiation oncologist, they see the medical oncologist, they also visit with the nurse navigator. They have to get their scans and imaging done. So our radiologists are involved, our pathologists work closely with them. So we do provide wholesome care and I’m part of a treatment team. What’s humbling is that patients come to us during a vulnerable stage of their life and I think it is an honor for me to be involved during that difficult period of their life.
What I like most about it is that I can be part of a great and wonderful team that is helping the patient in this community. I think being a part of Sanford Health makes me so confident that we can take care of the health of the patient almost entirely in Fargo at the Roger Maris Cancer Center and we constantly tell ourselves that the buck stops here. We have to take the responsibility of doing our best for our patients so that we don’t have to send them out to another place and we can prevent them traveling those extra hours of travel if we have my not sending them out.
Courtney Collen (Host): Yeah. That is so wonderful that you are able to provide that care all in one place up there in Fargo. Let’s move on to this topic of breast cancer research. When we discuss breast cancer research, Dr. Gaba, what exactly are researchers studying?
Dr. Anu Gaba: There are many different types of research. You can do research in the laboratory. You can do research in the clinic and, you know, most people have a sense that research means setting in the lab with test tubes and beakers and then trying to discover things. But clinical research is such an important part of a research in cancer treatments. And at Roger Maris, we do provide a lot of clinical trials for patients to be a part of. So when we talk about breast cancer research, we are trying to determine if we can improve on the current treatment for breast cancer. That is one category of research. So many times these trials are being conducted all over the United States and Roger Maris Cancer Center is an important part of that group. We bring the latest treatment here, but we offer it to our patients in a very controlled setting. The patients are being closely monitored, we watch for side effects, we watch for good results and after the treatment is done, we watch our patients very closely to make sure that they are not developing any complications or if they have a good outcome, we are able to document that. So that’s one aspect of clinical research.
There are phase three trials where patients who go on those trials are actually randomized into two groups where one group gets the current standard of care and the other group gets the current standard of care along with a new treatment, which we think is going to be better than the current standard. We also have phase two trials where it’s all the patients who enroll on that study get the same treatment, but it is a new type of treatment that we are studying for breast cancer.
Courtney Collen (Host): Who is involved in these trials?
Dr. Anu Gaba: So it really depends on the trial. If we have a phase three trial that is for treating breast cancer, the patients who go on the trial are patients who have been just diagnosed with breast cancer. They would have completed their surgery, or they may be getting treated before their surgery. These are patients that we would have given them chemotherapy for their breast cancer, but instead we give them the opportunity to take part in the trial. So even when they take part in the trial, they are still going to get chemotherapy. The difference would be that they might be getting a chemotherapy combination that we think is going to be better than the current standard chemotherapy.
Courtney Collen (Host): How important are these trials to continued breast cancer research?
Dr. Anu Gaba: You know, clinical trials in general are important. In fact, very important. And the reason is, it’s only because of the clinical trials that we can change our treatment. If we didn’t have clinical trials, we would still be practicing medicine the same way as we did it 50 years ago. The only reason we can change treatment is if it can be proven in a clinical trial that a new treatment is better than the one we are doing today, there is a very good quote that Sanford research has put out in certain patient areas. It says ‘the gold standard of today was a clinical trial yesterday’. And that is so important for all of us to realize as physicians and as patients, that the treatment that they’re getting today, it’s constant, the standard of care only because there were patients and physicians 10 years ago, who are willing to conduct a trial and patients who are willing to go on that trial, which ended up proving that the current treatment that we’re giving them today is better than what was being given 10 years ago. So, I think the importance of clinical trials cannot be stressed enough. That’s the only way we can make improvements in cancer care and it is the best way to make improvements in cancer care. We can’t just assume that a new treatment that comes out is the one that everybody should go to, unless we’ve proven it in a scientific way that it’s better than the old treatment and a clinical trial is the best method, a scientifically validated method to prove that a new treatment is better than the old treatment.
Courtney Collen (Host): How would you encourage a woman to be a part of one of these clinical trials?
Dr. Anu Gaba: You know, that’s so very good question. I think it really depends on how we put the clinical trial to the patient. We have to be honest with them and explain to them what medications they are getting. What can be the side effects, you know, if it is a treatment trial, and sometimes there are risks involved in a clinical trial. If we are trying out a new drug, there may be some side effects, which they may experience, which patients haven’t experienced before. And we have to be open to that fact, but we assure them that they’re going to be closely monitored by their treating physician. We also have research nurses who are really dedicated to getting the trial completed. They are watching the patients closely. We actually check on our clinical trial patients more often than we do with other patients because we know that they’re trying out something new.
The research nurses are constantly watching them when they come to the infusion center, when they come and see us, we check on their labs more closely. So we give these assurances to the patient and then we also tell them they might be getting the benefit of a new treatment that is going to become the standard of care two to three years from now and this is an opportunity to get that treatment. And then, you know, at the same time we should respect the patient’s wishes. There may be some patients that don’t want to go on the clinical trial and we need to be open to that and very accepting of that. And we also tell patients that even if they don’t agree and they don’t want to go on the clinical trial it’s not going to affect our relationship with the patient. We still want to do the best for them. We are still going to give them the standard of care.
Courtney Collen (Host): I love what you said about clinical trials advancing science and improving that standard of care. Talk about a few of those more significant milestones or medical advancements that researchers have made in the last five, 10, even 25 years.
Dr. Anu Gaba: Yeah. so I like the question since you want to go back even 25 years ago, so that is good. It’s good to reflect back on what advances have been made in breast cancer treatment. So, I would say in the last 25 years the biggest changes I’ve seen is in the extent of surgery. I would save 25 years ago, surgery for breast cancer was radical. It used to be called radical mastectomy. Patients had extensive surgery, a lot of the breast and the muscle underneath was removed. The lymph nodes used to be dissected completely from the axilla and almost all women would have lymphedema and that is swelling of their arm. But as time has gone, gone on surgeons have done such a terrific job of realizing that less is more, that we can get equally good results by doing smaller surgeries. So now we do modified radical mastectomies, or even just lumpectomies. You don’t need to take out the whole breast if you know exactly where the cancer is located. Good imaging has also helped with that. Surgical research has also shown that we don’t need to always take out all the lymph nodes in the axilla. Just taking out a few lymph nodes can give us as good results as taking out all the lymph nodes in the axilla. Then in the last 25 years, I would say that even radiation therapy has advanced significantly. Before, radiation therapy used to be extensive and not focused. So patients who are getting radiated to the breast would also have cardiac complications or lung complications. Radiation therapy has improved so much now and that the beams can be targeted just to the lump where the cancer is. In some cases, they might do the entire breast, but they really minimize the damage to the heart or to the lungs or to the other surrounding structures. In medical treatment, the number of hormonal therapies that are available for treating breast cancer has expanded. And even our chemotherapy it’s gradually become less intense. In some ways we are incorporating more of targeted therapy.
In the last 10 years, I would say that we are using more of genetics and genomics in the treatment of breast cancer. We do assays and the two more common ones are, one of them is called the Oncotype DX assay. The second is called the Mammoprint and these two tests they are done on the tumor sample after women have had their surgery, rarely they can also be done on their biopsies. They help tell us whether a patient would be benefited from chemotherapy or not. Or in other words, these tests, they look at the genomic makeup of the cancer and they can tell us if we can manage them, but just anti hormonal therapy alone. And if it would be safe to avoid chemotherapy, I think because of these tests, we have probably reducing the need for chemotherapy and almost 60 to 70% of breast cancer patients. We are now able to give chemotherapy only to those patients that actually need it. I think that’s been a big change in the way we practice breast cancer in the last 10 years.
In the last five years you know, for metastatic breast cancer, I think we’ve made a lot of progress. Women with hormonal receptor positive metastatic breast cancer are now living longer than what they did before. And this is because of the availability of a new set of drugs called the CDK 4/6 inhibitors. Patients might know them by the name of palbociclib and ribociclib or abemaciclib. So this is a group of drugs that’s really improved outcomes for metastatic hormonal receptor positive breast cancer. Then patients who have triple negative breast cancer, immunotherapy has helped. And a lot of research is still being done on how we can improve on the use of immunotherapy and determine which other groups of patients that we can use it for. Another development in the last five years is the use of next generation sequencing. We are doing it for women with advanced breast cancers. We take a biopsy and then analyze it for the presence of almost 300 to 500 genetic changes. And on the basis of that, we can determine whether there are targeted treatments that are available, which will benefit these patients.
So to summarize, you know, we do have a lot of advances that are going on and they will help in their own small ways in improving breast cancer care.
Courtney Collen (Host): We talk about the importance of getting a mammogram for breast cancer screening. What have we learned about early detection?
Dr. Anu Gaba: Women need to be aware of their breasts, they need to know what their breasts feel like so that if there is a change, they are alerted to it and then they should be contacting their primary care provider without any delay. We do recommend screening and currently the recommendation is to start at the age of 40 once a year. There is a lot of controversy about breast cancer screening. I think the controversy is in two areas. One is about 3D mammograms versus 2D mammograms is one better than the other. And the other bigger controversy is about the frequency of mammograms. At Sanford, we spent a lot of time discussing about it and we decided that we’re going to continue to recommend annual screening mammograms starting at the age of 40. But I acknowledge that, you know, there are some research analysis that has shown that even every other year mammograms might still be useful. So that’s why I think it’s important for us to take part in trials, which can resolve this issue in the long run. But definitely I would recommend that women continue to do their screening mammograms. And if they have a family history, then they should definitely let their providers know because then we might want to send them for genetic risk assessment and more frequent and more intense screenings. So if there is a strong family history of breast cancer, or we know that they have certain genetic mutations, which are hereditary, then in those women, we recommend not only annual mammograms, but we also recommend annual MRIs for screening purposes.
Courtney Collen (Host): We often hear people say that they want to find a cure for cancer now for breast cancer. What might that look like? Is this something that we would see in our lifetime?
Dr. Anu Gaba: That’s a tough question. You know, whether we’ll cure breast cancer in our lifetime I would say cure for breast cancer would be in two fronts. One is in women who have early stage breast cancer, a cure would be if we can treat it such that it never comes back, and we can be assured that it’s not going to come back … that would be one aspect of cure. The other aspect would be for women who have metastatic breast cancer and them, the goal would be to make it a chronic disease like diabetes or hypertension, where women can live a long time with the cancer, knowing that even though we cannot wipe it out completely, we can give, we can give treatments that don’t have many side effects, but can keep the cancer controlled. So I would say that these are the two main categories of treatment that we aim for that can really reduce the chances of women dying from breast cancer. The third aspect would be, you know, if we can find ways and means to prevent breast cancer in the first place. And you know, I think to some extent we can do that by dietary changes, lifestyle modification, but in spite of all our advances, we don’t always have an explanation for why some women get breast cancer and some don’t. Even in the absence of family history, you know, there are women who get breast cancer and many times we don’t have a good explanation for it.
Courtney Collen (Host): About five, 10, 25 years ago, where will research take us in the coming years?
Dr. Anu Gaba: I would say that it is a lot of different things. And you know, when, when developments happen when we realized, ‘wow, this is great, this is, this is going to change breast cancer’. It’s always been retrospective. It’s only after a treatment becomes successful, that we say, ‘well, that was a great milestone’. I think before that happens, we really don’t know where our research will take us. So right now for breast cancer, I would say there are many different avenues that are being looked into. One of them is definitely targeted therapy. I give an example of the CDK 4/6 inhibitors. We talked about next generation sequencing, which gives us the opportunity to try targeted drugs. But I think this is where there is a lot of research going on. We know that there are so many genetic mutations that are involved when a normal cell converts into a breast cancer cell.
Though, we are aware of these genetic mutations. We always don’t have a drug that targets those mutations. I would say we have targeted drugs for less than 10% of all the genetic alterations that occur in a breast tumor. So the research is to find drugs that can target all those various mutations. The second area of research is let’s say a patient’s tumor has 10 different mutations. The research is to find out which is the driver mutation, or which is the main mutation that is driving the cancer and what are the mutations that are just supporting that driver mutation. So that would be another area of research. Then I think immunotherapy has really brought about huge changes in the prognosis for many different types of cancers, especially melanoma, lung cancer, kidney cancer. And it has made inroads into breast cancer, particularly the triple negative breast cancers, but there is still research going on to see how can immunotherapy impact the other different types of breast cancer.
Courtney Collen (Host): October, as you know, is breast cancer awareness month. I’m curious, what impact does that 31-day period of heightened, national awareness actually have on advancing research for breast cancer?
Dr. Anu Gaba: By having a month dedicated to breast cancer awareness, I feel that it gives us an opportunity to talk more about it just like you and I having this putting this podcast together. So this probably in other institutes and other places around the country, so definitely raises awareness of breast cancer at the same time. It allows institutes research organizations to fundraise for breast cancer patients, as well as for breast cancer research and to provide supportive services to breast cancer. This is also a month where we take stock of the research trials that we have and see if we can improve on our research trials and offer more to our patients. We also look at this is the month where we organize our meetings for survivors. You know, so for women who have gone through breast cancer and are now doing well for women who are still dealing with breast cancer and undergoing treatment, we usually have different workshops for them. We have retreats for them where they can meet each other talk to experts, know more about their cancer. So I think having an awareness month definitely raises more focused on breast cancer. And it’s really a great opportunity for patients to learn more about it.
Courtney Collen (Host): Yeah, we know Sanford as a leader when it comes to its research and innovation, how many clinical trials related to breast cancer are available to patients right now?
Dr. Anu Gaba: I would say that overall, we probably have, I’m just going to say from the top of my head, maybe 80 to 120 trials and just in breast cancer, we have about 20 clinical trials. So Sanford and Roger Maris, we definitely want to emphasize clinical trials. And we encourage all patients to take part in them. This is one way of improving cancer care. Now I think patients should know that they are their best advocate and that we work as a team here the physicians, the nurses, the navigators, and that we are here for them, and we have their back.
Courtney Collen (Host): Dr. Gaba. It was great to have you as our guest and just incredibly fascinating to learn more about this continued research when it comes to breast cancer and all that Sanford is doing. And we appreciate all that you do for women in our communities as well.
Dr. Anu Gaba: Well, thank you. It was my pleasure.
Courtney Collen (Host): I’m Courtney Collen. Catch the next episode of One in Eight, our breast cancer podcast series coming soon. Stay well, have a great day.