San Antonio Breast Cancer Symposium 2011: Day 1

We’re currently at the 2011 San Antonio Breast Cancer Symposium, providing recaps and analysis of information coming out of the symposium.

We’re here as patient advocates, as the eyes, ears–and mouthpiece–of breast cancer patients. We’ll highlight key findings from the sessions but we believe the most valuable contribution we can make is to raise questions patients have and provide resources to women trying to make decisions about their own treatment.

Let us know if you have questions about any of the material we post from the symposium. We’re here to be your eyes and ears—and mouthpiece.

Day 1: Tuesday, December 6, 2011

Summaries by Executive Director Karuna Jaggar

Controversies in Early Breast Cancer

We missed the full session but came in partway through to hear Dr. Angelo Di Leo from the Hospital of Prato presenting on “Adjuvant therapy in patients with borderline Her-2 status”. Without the benefit of the full presentation, there are still a few key findings to report to you.

  1. The core clinically relevant finding of the presentation from what we saw of it is that patients with borderline HER-2 status derive as much benefit from Herceptin after surgery as patients with strong HER-2 status.

  2. This is good to know, as we walked in to a slide highlighting the number of women with borderline HER-2 status and the discordance between labs—what Dr. Di Leo calls a “problem of replicability”. HER-2 status results were different between the local lab and the central lab for 13% of women in the study, and he noted that this is similar to when HER-2 testing was first rolled out. BCAction Board member Beverly Canin, who is also here at SABCS, noted that Dr. Di Leo didn’t stress the seriousness of this problem enough, not just for Her-2 status. There are differences in lab reports throughout the system, sometimes due to readings by different pathologists in the same lab and sometimes because of differences between labs. Patients should be aware of that and know that you can ask for “second opinions” on lab reports as well as clinician diagnosis.

  3. The presentation concluded by talking about some data that suggests possible benefit fro adjuvant Herceptin in HER-2 negative patients. There are a number of possible explanations for this including:

    1. The small numbers might not provide enough data to draw sound conclusions

    2. Perhaps the lab didn’t do a good job—and these were in fact HER-2 positive tumors

    3. Perhaps Herceptin works by an alternative method in HER-2 negative patients

    4. Or, perhaps—and there is data to support this—different parts of the tumor are HER-2 positive and negative, which is to say there is inter-tumor heterogeneity

And so, Dr. Di Leo concluded while being very careful to say this is not a practice changing finding, but a research hypothesis on use of Herceptin for HER-2 Negative patients.

“Challenges in the care of Special Populations with Breast Cancer”

Teresa Woodruf, PhD from Northwestern, began with a presentation on Oncofertility, which is a term they have coined to refer to oncology and fertility specialists working collectively to “solve a single problem”. Though cancer and fertility are intertwined—and may involve rapid growth of cells—it’s hard to see them as a single problem. More accurately, a problem with a number of cancer treatments is that they can negatively impact fertility, which is a significant issue for young cancer patients.

The presentation provided quite a lot of data on cancer broadly. Ten perent of cancer patients are under age 45, which is considered reproductive years. 11% of all breast cancer patients are diagnosed under 40 years—and Dr. Woodruff noted that these patients have been aggressive advocates on fertility issues. In 2006, they estimated that there were 1.7 Million women living with the effects of a cancer diagnosis before the age of 40, including trouble achieving a first planned pregnancy.

And 57% of very young breast cancer patients experienced concern about fertility. Infertility from cancer treatments early in life is also linked to double the rate of depression, increased anxiety about finding a mate—concerns it should be noted that are equal for men and women.

For women, it’s a different story and there aren’t great options, though Dr. Woodruff was optimistic that some of the options would be productive—no pun here—based on future research. Options for women include:

  • harvesting eggs (through hormone stimulation) and fertilizing (from a donor, male spouse, or boyfriend)

  • banking eggs—though there is only a 5% chance of a live baby born from a frozen egg for any individual woman

  • adoption

  • surrogacy

  • natural pregnancy—as some women who go through cancer treatment will be able to become pregnant if they wish

  • ovarian cryopreservation—which is the removal of an entire ovary and the preservation of the tissue with dormant follicles with the hope that research will be able to mature these immature eggs in vitro.

  • There have been 14 live births globally from women whose preserved ovary was transplanted back into the woman

  • There is concern, though, that the transplanted tissue might also be re-introducing cancer cells.

The remainder of the presentation focused on how to mature these eggs in vitro, including a fascinating tidbit that the substrate for the artificial ovary is alginate, from brown algae—and that what we all know as a “pimento” in olives, is alginate in 100% of US sold olives! In any event, there has been success maturing oocyte in this substrate for mice and work is being done to explore the options for human oocyte. She also mentioned some of the challenges in moving from animal to human study.

The key take away is that there are practice guidelines to address and preserve fertility for young women being treated for cancer. The national hotline is 866-708-FERT, and the requisite iPhone App (one for everything)

It’s goodood to see this issue being addressed though certainly still a bunch of hard choices for young women undergoing cancer treatment.

“Treatment of Young Women with Breast Cancer”

Let me begin by saying that this researcher started off on a bad note when noting that breast cancers are different in young women by referring to tumor “host” differences. Caitlin turned to me and said, “by hosts, does she mean women?” Having just come off the fertility presentation, I was struck that in a context of pregnancy, we would never call women “hosts” but women with disease are legitimately reduced to “hosts” by some researchers—even this apparently young women researcher.

Okay, on to the content of the presentation. It is widely recognized that, in general, younger women present with more advanced, more aggressive, higher grade breast cancers. This presentation addressed in part the question of whether young age is a prognostic factor. The quick answer is that this is an area for future research but there is some data that’s worth reviewing.

  1. over 12,000 women under 40 are diagnosed with breast cancer in the US alone—plus 2000 with DCIS and many more worldwide.

  2. While there are differences between younger women and older women in the kind of disease found, there are relatively few differences across younger women (under 30, 31-35, 36-40)—so it appears not to be a linear progression but rather an either /or.

  3. The HERA trial found that age is neither prognostic nor predictive for women who received Herceptin

  4. Tamoxifen is equally effective by age groups—and some evidence that it is as effective as chemo. (Also evidence it can be beneficial in advanced disease.)

  5. The researcher wisely noted that young women live with the side effects of treatment longer than older women. In particular, the negative health effects of very premature menopause were noted—where for older women, maybe just slightly early menopause—including:

    1. Infertility

    2. Osteoperosis

    3. cognitive effects

    4. cardiovascular effects

    5. weight gain

  6. Younger women have significantly higher psychosocial distress

“Treatment of older women with breast cancer”

This session concluded with a talk by Dr. Arti Hurria, a breast cancer oncologist and geriatrician, talking about “Treatment of older women with breast cancer”.

Dr. Hurria began by noting that age is the number one risk factor for breast cancer and there is increased incidence and mortality with age. she noted that there is an estimated doubling of the 65+ population between 2000 and 2030 due to aging of baby boomers. Also noted that the greatest advances in decreasing the breast cancer mortality rates have been for younger women, with the largest decline for women 29-40 years old.

Across all stages and all treatment modalities (surgery, chemo, hormone therapy), older women receive less treatment. In part this is because there is less data on which to base decisions, yet there is some evidence that indicates surgery is the standard of care, with no need for axillary surgery. Similarly, radiation did not benefit overall survival (including death by breast cancer and death by any cause) or distant metastasis, though here was a lightly increased rate of local recurrence without radiation in a study with a 12 year follow up.

Aging is associated with ER+ tumors and the benefits of endocrine therapy are maintained with age, though the side effects remain serious. While aromatase inhibitors scores points compared to tamoxifen with many side effects, AromataiseI inhibitors clearly take a toll on bone health with joint pain and increased fractures. Indeed, bone health is an issue for all breast cancer patients of any age.

In assessing chemotherapy and the essential question of whether the risks of the chemo outweigh the benefit, the issue of life expectancy becomes key in weighing benefits and risks.

An 80 year old’s life expectancy can vary from 13 years for the top quartile, to 4.6 years for the bottom quartile, with an average of 8.6 years for the middle 50%. 20% of older patients were hospitalized for chemo related toxicities which highlights the need for assessment tools to identify who is at risk for comorbidity from chemo.

The presenter indicated that age alone isn’t predictive of toxicity from chemo and showed a tool of 11 functional assessments that should be included in predictions to help doctors and patients weigh the risks and benefits of chemo. They include: age, GI/GU cancer, standard dose of chemo, polychemo (multiple drugs simultaneously), anemia, and set of 6 of questions for patients about their ability to function physically, cognitively, and socially.

In assessing chemo, there is a growing body of data on older women, but not enough, and it is clear that toxicity must be weighed against benefit. The presenter advocated for shared decision making and increased participation of older patients in clinical trials in order to continue to get more data.
This entry was posted in BCA News.

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