Three BCRF Investigators Answer Top Questions About Breast Cancer Prevention
By BCRF | January 13, 2021
By BCRF | January 13, 2021
Three BCRF-supported researchers cut through the noise on breast cancer prevention myths and addressed common questions such as these during a virtual wellness-focused symposium held in lieu of the Foundation’s annual Hamptons Paddle & Party for Pink due to COVID-19. The popular event, held each summer since 2012, was created by longtime dedicated BCRF supporters Maria Baum and her husband, Larry, along with friends Lisa and Richard Perry, to fundraise for research via a paddle boarding race in the Hamptons.
The program’s panel featured Dr. Elisa Port from Mount Sinai Hospital (moderator); Dr. Dawn Hersman from the Columbia University Medical Center; and Dr. Neil Iyengar from Memorial Sloan Kettering Cancer Center.
Watch this timely and informative symposium below or on our YouTube page. An edited transcript of the investigators’ conversation follows.
Dr. Elisa Port: I'm thrilled to be joined today by two amazing colleagues: Dr. Dawn Hershman and Dr. Neil Iyengar. They are experts in breast cancer treatment and prevention and can share the latest updates from our field. I would like to invite each panelist to give a brief overview of their area of focus. Let's begin with Neil. Dr. Iyengar has been a BCRF researcher since 2015, and his research focuses on identifying lifestyle interventions that will reduce the likelihood of developing breast cancer in women at high risk of the disease.
Dr. Neil Iyengar: Well, thank you so much Elisa for that lovely introduction. It's my great pleasure to be here. My research focuses on the intersection of energy balance, or metabolic health, with both cancer risk and cancer outcomes. We study precision lifestyle interventions, such as exercise prescriptions or specific dietary habits, and how we can use these tools, both to reduce the risk of breast cancer, as well as the risk of resistance to breast cancer therapies.
Dr. Elisa Port: Wonderful. And now Dr. Hershman. She's been a BCRF researcher since 2008 and her research project focuses on improving quality of care, reducing overuse of expensive drugs, and improving quality of life for breast cancer survivors.
Dr. Dawn Hershman: We're so thrilled to be here and share our research with you. I have been so fortunate to be funded by the Breast Cancer Research Foundation for so many years. We’ve had so many impactful and important research projects over time, that have given us information on the best ways to control side effects from medications so that patients can tolerate them and stay on their medicines, some of which involve exercise and lifestyle changes. And also, both the benefits and dangers of dietary supplement use. We've also done a lot of research in terms of ways to improve adherence to therapy and help patients understand that they not only need to take care of their breast cancer but all of their other comorbid conditions that can interact with the way their breast cancer outcomes can be.
Dr. Elisa Port: You're on really different ends of the cancer spectrum which is so wonderful. Dr. Iyengar focusing on prevention, and Dr. Hershman focusing on survivorship yet we know you both do both. Yet, both of you also take an incredibly personalized approach to care. Taking a look at each individual's biology and risk factors that relate to overall health. Tell us, specific areas of having a healthy lifestyle that Neil you focus on regarding prevention of breast cancer. And then Dawn, during cancer treatment and survivors. And how is each of your research furthering our knowledge in these areas? So, Neil first on prevention.
Dr. Neil Iyengar: I think that's a great question. We started with biology. And so, what we wanted to do was understand the changes that were occurring in the microenvironment that's in the normal breast tissue and how that related to what was going on in the body as a whole, and how those processes work together to potentially stimulate breast cancer growth. BCRF funding led us to do these exploratory studies, many years ago, that generated a new area of research where we looked at the fat tissue in the breast. People don't typically look at the fat tissue in the breast. If a pathologist looks at a mastectomy specimen, they're looking for a tumor, and that tissue was thrown out. So, when we went to our pathology group, asking to obtain the fat tissue we got buckets of it. So, we were able to look at that tissue and understand that there are several processes like inflammation, and increased production of estrogen that occurs when our metabolism is off. So, when we are not in energy balance a classic state of excess energy is obesity. But we made a few very important observations, and those were areas in that biology that we could target. Specific processes molecules that we could change, alter, or improve with interventions. So, we focus on how we can understand an individual's biology; what is their metabolic status and level of inflammation, or how much estrogen are they producing in the microenvironment. And we ask the question, can we use that information then to tailor things like exercise?
So, we use the standard parameters like your baseline fitness and your oxygen-carrying capacity. But when we take a cancer focus, we're wielding exercise as a powerful tool to target those processes. So, can we use the anti-inflammatory effects of exercise to reduce the risk of developing breast cancer? We're also trying to study why sometimes these interventions don't work. Could it be the exercise prescription was not effective? Could it be that different types of physical activity were required, or could it be that the genetic composition of the cancer doesn't respond to exercise? These are all questions that are important for us so that patients are effectively utilizing their time and doing what's effective for both reducing the risk of breast cancer and reducing the risk of resistance to treatment, because a lot of these processes translate to the post-diagnosis setting. That's kind of a general eagle eyes’ view of how we are approaching the development of lifestyle interventions with a cancer focus.
Dr. Elisa Port: Wonderful. Dawn, what do you tell patients during treatment, and ongoing survivorship? Survival rates now for breast cancer are upwards of 90 to 95 percent, so there are many survivors. How are you telling them to optimize lifestyle factors for both quantity and quality of life?
Dr. Dawn Hershman: One of the groups to add to that are patients with metastatic disease because we have such amazing treatments now. We're also seeing patients living a long time, even with advanced disease. So, on every spectrum, we're seeing patients living longer and longer. One of the areas that I've been focused on for my whole career is how to make sure that all of the research that we do, and the discoveries we make, make it to patients that we know it's supposed to work for. How do we improve the quality of care, and how do we make sure that patients are adherent to the treatments that they're supposed to get? And it's not easy because our treatments are sometimes quite harsh, even when we say oh you just need hormonal therapy. That's can be the hardest thing for somebody to get through. Five or 10 years of taking a pill that can make somebody miserable is challenging. And over time, we've learned that there are a lot of things people can do to reduce those side effects and improve their adherence to their medications, some of which is exercise. We know that exercise can make a huge difference in terms of reducing a multitude of different types of side effects.
Dr. Dawn Hershman: We've also studied a variety of different supplements. For example, we studied fish oil to see if it could reduce joint pain. We found that it actually can make a big difference for some patients. Patients that have a higher body mass index get a substantial benefit from fish oils because of inflammation, whereas thinner women don't, so we can personalize our recommendations based on the patients that come in to see us—but not all supplements are good. We've also learned that we spend a lot of time studying neuropathy and pain that comes from treatments, and it can be debilitating for patients, and we've learned that some supplements that patients with breast cancer with other forms of neuropathy take can make the neuropathy worse when they interact with chemotherapy, and it emphasizes the need to study everything that patients take. Because just because you get it without a prescription, doesn't mean it's safe. So, we're constantly looking at ways—whether it's reminding patients to take their medicines, whether it's interacting with patients through virtual visits, or making patients aware of their other comorbidities—to try to figure out how to improve not just their breast cancer survival but overall survival. And to make sure that they understand all the interactions between breast cancer and cardiovascular disease that can impact their long-term survivability.
Dr. Elisa Port: Wonderful, I think you hit the nail on the head that it's the quantity of life but thanks to research it's also quality of life. I'm so glad you brought up the supplement issue because that's something we're going to take a little bit of a deeper dive into now. Neil, first, we all receive a lot of questions about supplements not only related to breast cancer but also overall health. When women and men that get breast cancer come in to see us it's often incredibly surprising—the number and range of supplements that people can be on. We hear about everything from our patients from immune boosters to vitamin supplements. And my impression is that in particular this phenomenon became way more pronounced recently with COVID. My observation was that as the fear of contracting COVID increases people seem to be looking for ways to prevent contracting COVID, or then shortening or lessening the course, and many were turning to a wide variety of alternative therapies and potions and additives to help protect themselves. Neil, what do you tell your patients about supplements, that they're on both as it relates to breast cancer treatment and as it relates to overall health?
Dr. Neil Iyengar: This is important. I think Dr. Hershman alluded to, a lot of the important points here and that is the need to know what people are taking. That's the first thing I ask people when I meet them and that includes things that are not prescribed. That's largely because we need to be aware of a patient’s overall health and the substances that people are putting into their bodies so that we can assess for risk of potential harms and interactions. My colleagues and I, BCRF researchers, all spend a lot of time studying new treatments for breast cancer. If you think about a new drug and the process that it takes to get from discovery to approval of that drug it takes years and years of study in preclinical laboratory models, then in multiple phases in humans. That is a very high level of evidence and, unfortunately, that level of evidence is typically not applied to the development of supplements. I think some of the work that Dr. Hershman has done in terms of studying supplements has applied that kind of precision or drug-based paradigm, and that's really what we need to do.
We've studied fish oil as well, but for a different indication. We were interested in knowing whether or not fish oil helps to reduce that fat tissue inflammation that I was talking about earlier, and particularly in people who've been diagnosed with triple-negative breast cancer. And for that, indication, we found no effect of fish oil. And so, I think that's very important when we think about supplements because oftentimes, we look at a supplement and it is touted to treat multiple different things: immune-boosting, memory boosting, energy-boosting. But when we look at a drug that has been approved by the FDA and studied by multiple groups and researchers, there are very specific indications. You don't go and take the same drug for HER2+ breast cancer and apply it to the risk reduction of breast cancer, for example—those are two very different indications. Similarly, if we again take a fish oil indication while we have data now from Dr. Harshman’s group that it can be effective in certain patients dealing with joint pain. I wouldn't tell a patient to take it to prevent breast cancer. We don't have that data and that is an example of a supplement that has been studied by breast cancer researchers. The vast majority of supplements have not received that level of scrutiny, and we don't know if these supplements will interact with our treatments for breast cancer. Why bother going through all the difficulty of taking breast cancer treatment if a nonprescribed supplement is potentially going to either reverse the efficacy of that treatment or produce more toxicity. We have recent data from patients with melanoma, that certain types of probiotics can reduce the efficacy of melanoma treatment, and we didn't know that until that was specifically studied. So, how many other unanswered questions about supplements are working in the negative? That's why I think it's very important that we go over supplements that folks are interested in taking so that we can talk about the data that exists, and the data that doesn't exist and decide on the safest approach.
Dr. Elisa Port: I couldn't agree more. We have patients who come into my office just diagnosed with breast cancer, and they haven’t even had any treatment for it yet and they’ve started to prepare for their breast cancer journey by going to a doctor who recommends so many different preparers, immune boosters, etc. to heal better from surgery or recover quicker. The first thing that I say to them is when you put something in your mouth, whether it's a supplement or take something IV, you don't get to pick and choose where it goes. So, how do you know that what you're taking—with the goal of it going to your T cells and your B cells to boost your immunity—is not going to the cancer cells to give them an unfair advantage? I'm often surprised that people never thought that perhaps some of these supposedly positive effects are having a positive effect on the tumor itself or tumor cells that may be left around, even after the surgeries are done. So, I think it's very eye-opening. It's fascinating to me that people who are so careful, and even paranoid about what they put in their body are willing to take things that as you both pointed out beautifully is very unregulated, and about which not a lot is known. The supplements don't go through the same regulatory processes that drugs do. And as a result, there's not even sometimes a consistency from batch to batch even when you buy it from the same place. So, I think if people approach supplements with the same level of skepticism, as they do with other medications it would be much better.
Moving on to another question, Dr. Hershman, I'm going to ask you this one. Dr. Hershman, does having breast cancer or being a breast cancer survivor puts you at higher risk of getting COVID, or do any of the treatments that we give for breast cancer. History of radiation, being on tamoxifen, etc. make one more vulnerable?
Dr. Dawn Hershman: So that's an excellent question. I think there's nothing scarier than reading the news these days because you hear little snippets and studies, and I think it's always important to take a step back when you hear something in the news and think about where the data is coming from. So often you'll see a story in the news about cancer patients having a higher risk of dying from COVID then you realize that all the patients that were assessed were patients that were in the hospital with COVID. That is a very different patient population than the whole cancer patient population out there, and almost no studies have been done looking at the population of patients where you see the whole denominator.
What we think is true is that patients that have a compromised immune system may have a harder time recovering when they get COVID. The lung is most compromised for COVID, so patients with lung cancer may have the hardest time dealing with a COVID infection. Patients with hematologic malignancies that alter their immune system and their ability to mount an antibody response seem to have the hardest time dealing with a COVID infection. Patients that have an advanced disease where a delay in their treatment is going to cause a problem because they're no longer able to get the treatment that's keeping their cancer under control, may have a worse outcome. But there's no evidence that patients that are far out from their chemotherapy or radiation or a hormonal therapy that doesn't affect their immune system have a higher risk of getting it or do worse when they have it. We were able to look at about 50 of our breast cancer patients that got COVID, and the vast majority of them did excellent and didn't even have to come into the hospital.
So, the news out there is scary, and it can also be a little bit sensationalistic. I think if we all do what the guidelines say, which is wear a mask, wash our hands, use Purell, it makes a difference. I can tell you by doing all of that protective routine, not a single person on the caregiver side contracted COVID. So, those things work. If we want to keep ourselves healthy and safe, those are the things that we should focus on.
Dr. Elisa Port: Agreed. We got a great question. Knowing that obesity does increase one's risk for cancer or cancer recurrence, separately, what about sugar consumption? We've all heard the myths that sugar feeds breast cancer, etc., and I have many people who come in newly diagnosed saying I'm going to change my whole diet because of this diagnosis and, and maybe that will give me an advantage. Talk to us, Dawn first, about sugar and then Neil, in terms of what do you advise your patients in terms of sugar consumption?
Dr. Dawn Hershman: As much as we try to guide people in terms of supplements, we spend a lot of time trying to talk to people about healthy diets, because almost every nutrient that you would get from a supplement, you could get from a healthy diet. And so, not everybody needs the same diet. But you need to have a diet that is rich in many different types of nutrients, low in fat, and one that will keep you from gaining weight or even losing too much weight. I'm all about balance but it's not easy. There are a lot of temptations out there and trying to help patients come up with strategies to keep their body mass index in the equitable range. What we do know is that it’s not sugar in and of itself, but insulin, which is sort of related to too much sugar. You see higher insulin and patients that have diabetes or patients that may be overweight. Insulin can feed cancer cells, and there's a lot of research going into whether low glycemic diets keep your insulin levels at a steady state. I was involved in a study looking at a drug that helps do that called metformin, and whether or not metformin, in keeping your insulin levels low, can reduce the risk of breast cancer recurrence. We know that it doesn't make a difference for triple-negative breast cancer, but the jury's still out on hormone receptor-positive breast cancer. Research is being done in this area so we can understand how dietary changes can impact and interact with drug treatments maybe for the better. Neil's an expert in that so I'm going to let him address it.
Dr. Neil Iyengar: Yeah, I'm happy to address it. Dawn, you covered a lot of what there is to be said about this topic. I'll just add we have to think of diet in terms of dietary patterns, rather than specific macro or micronutrients. We know from a vast body of nutrition research outside of cancer that strategies that target specific macro or micronutrients are challenging, and not always effective. And so, when somebody tells me that they cut all sugar out of their diet, and it’s not a part of their weight loss strategy or an overall effort to maintain a healthy weight or healthy body fat percentage, then it's going to be a bit of a lost effort. As Dawn said, sugar, specifically dietary glucose, doesn't necessarily stimulate cancer cells. There are different types of sugars, like fructose, for example, that have been studied in animal models, and you may see some studies that suggest those sugars promote cancer growth, but that's never been recapitulated or shown to be true in humans in a single micronutrient kind of way. So, we also have to be very careful where that data is coming from. Is it coming from humans, model cells, or laboratory studies?
Overall, I would say that right now we have data supporting that maintaining a healthy weight or maintaining a healthy body fat percentage (roughly around 30 percent or less) may be an effective tool for reducing the risk of breast cancer itself or recurrence. There are emerging data to suggest that other nutrients like fiber, or plant-based approaches, may be helpful, but we don't know that yet until we test it in a prescribed sort of way.
I'll end by saying that the concept of diet can vary from person to person. We have data and now we're studying very different dietary approaches. We have a trial that is studying a plant-based diet in people who've been diagnosed with breast cancer and on the complete opposite end of the spectrum we have another trial, which is about to open, that is studying a ketogenic diet in patients with metastatic breast cancer. These are very different dietary patterns. And so, we're trying to understand, in whom we should be recommending which diet.
Dr. Elisa Port: I think that's so important and I think the take-home message is that there's no one dietary message that either prevents or accelerates breast cancer. I think this is important for patients to hear because so many women come in, diagnosed with breast cancer thinking it's something that they've done, and nothing could be further from the truth. There's nothing that we tell our patients to eat more of or eat less of and overall, it's the overarching meal approach to a healthy diet. Sugar is one component. So, moving on, I want to go back to talking a little bit more about your research. Dawn, how has your research continued during this time of social distancing?
Dr. Dawn Hershman: We post the work that I do at my institution—and I see a lot of trials that are done throughout the country in many institutions—with the guidance and help of the FDA and the NCI. This has transformed some of the things that we've done. We can now get consent through video, we can ship drugs directly to patients, we can use services that will go out and get blood directly from patients at home, or do an EKG in their homes, so that we can limit patient's needs to come into the hospital. We’re trying to be thoughtful about determining what’s a necessary test or really important part of the trial so that we can allow this research to go on. It has been a challenge. I mean, at our institution we completely shut down all trials for a period unless it was life-saving research and then we could get an exemption.
So much has gone down, but now it's starting to go back up again but we're hoping to learn from our experiences to try to make being part of a clinical trial easier on patients so that they can do the other things they need to do.
Dr. Elisa Port: Neil, tell us about your work.
Dr. Neil Iyengar: This deployment of remote opportunities or telemedicine to conduct research, as Dawn mentioned, has helped continue the research. As you can imagine doing a lifestyle intervention like exercise poses some challenges. Most exercise trials require either patients to do it on their own or to come in for a class or a one-on-one training session. Luckily, years ago we started testing tele-exercise where we send the treadmill to a patient's home and it is equipped with a video monitor, a heart rate monitor, blood pressure monitor, and body composition by Bluetooth and Wi-Fi technology. We have been able to open up more trials, using a tele-exercise approach and now we're expanding that to nutrition as well doing telemedicine or tele-nutrition consults and sending food or prepared meals that are part of a prescribed diet to folks who are participating in a clinical trial. It's a direction that we were initially studying but now we've seen a rapid expansion in that approach and that's been very helpful for the research.
Dr. Elisa Port: I think you both drive home the point that the biggest issues related to research are not the changes that have happened from a doctor's standpoint. I think it's amazing, you two both exemplify how many doctors have adapted to changes and found ways to continue their work in some way, shape, or form and get patients involved. Moving forward, the real danger is changes in funding to research. With everything else going on there can be distractions to focusing on our work, and how important it is, and how unbelievable the progress has been. Of course, we're all worried that if research funding for breast cancer is diminished, we'll see a stop to the progress that we've made over the last several decades, which has completely, indirectly led to the prevention of death related to breast cancer. So, it's very clear doctors are adapting and we need to make sure that those changes continue and that we're able to continue our work.
I want to switch gears to talk about things that are related to delays that have happened. We saw how operating rooms and centers shut down, and that led to many people missing their routine follow-ups or their mammograms. Let's talk a little bit about how the delay in diagnosis for changes in treatment might have an impact on what we'll see in the next couple of years as fallout from breast cancer in general. So, Dawn do you want to take this first?
Dr. Dawn Hershman: We were thoughtful and created individualized strategies to make sure patients had safe options that wouldn't affect their outcome. So, we came up with new plans for patients that ranged from giving them lower-risk chemotherapy for a while, changing patients from once-a-week treatment to every three weeks, so they didn't have to come in as often, or putting people on hormone therapy before their radiation. We did things that wouldn't affect their outcome but may increase their safety so that we could prioritize treating the patients that have higher-risk cancers.
Dr. Neil Iyengar: Yes, same I think we've learned a lot actually from this period in terms of how we can be flexible with treatment and also with how we can work within the parameters of the data that we have to use effective therapies in a way that mitigates or minimizes the risk that's associated with just stepping out of the door into the pandemic. It's transformed medicine, so I think we can take a lot of lessons from this pandemic and improve the quality of cancer or medical care in general.
Dr. Elisa Port: I'll just add to that as the surgeon of the group talking about detection, we know many people delayed their mammograms and we don't think that makes a huge difference. I've also heard people say they’ll sit this year out. I think that is a problem, because we want to get people back to their regular visits, and their cancer screening and surveillance, because I can tell you from our research, not only do mammograms save lives but they are picking up cancers earlier. We've known that for a long time, but my group showed that women who have mammograms, compared to those who spaced them out beyond the yearly interval or who never do them, were way less likely to need a mastectomy compared to a lumpectomy due to the extent of the disease. They were less likely to require chemotherapy and be much less likely to need all of their nodes removed because of spread to lymph nodes. So, there's a lot of other benefits besides saving lives, which of course, is our number one endpoint in terms of reducing the seriousness and extent of treatment from getting screened earlier.
Dr. Elisa Port: I want to get to one more question, which is about deodorant use. Does aluminum deodorant, and aluminum-based deodorant, increase your risk of breast cancer? Neil, do you want to take this one?
Dr. Neil Iyengar: I always start by saying let's evaluate the quality of the data, as there are different levels of data. When we look at populations, sometimes you can draw out patterns, behavior, exposures that may be associated with risk. The problem with that approach is that it’s not individualized. It doesn’t take into account a person’s own risk and all the competing risks, and it is useful for generating hypotheses that need to be tested. And, to respond specifically to the deodorant question there are some data from these large population observations that there may be a very weak association between using aluminum-containing deodorants and the development of breast cancer. However, there’s data to suggest that there is no association between the two. So, we don’t have enough data to conclusively make a statement about that particular relationship. I always say life is about mitigating multiple risks. You walk out onto the street, especially in Manhattan, and there are many risks right there on the street. The traffic, the people, the pollution, all of this, that we also have to consider in the context of our genetics and our biology. So, people are very complex systems, and I think we need to focus on the risk factors that we know have a greater effect on the development of cancer. So, things like obesity, things like smoking, things like even alcohol intake, where we see more data to support a relationship, before we start to focus on some of the more questionable items.
Dr. Elisa Port: Last question and I think this is an important issue to address we’ve seen a lot in the news lately about disparities in health care across different races and ethnicities, specifically as it relates to black men and women, as it relates to the outcome of COVID. Let’s talk for a moment about disparities in healthcare as it relates to breast cancer. Dawn, what have you seen what is the data show?
Dr. Dawn Hershman: I’ve looked at disparities really throughout my career, so it's certainly an issue that I feel very passionate about. There's no question that Black women tend to have worse survival outcomes than white women with breast cancer due to many factors. For many years we just focused on screening and increasing screening which does make a big difference, but even when you look at women that are diagnosed at the same stage and treated the same way, there's a difference in the outcome. We've learned that there's a different distribution of biology by different ethnicities and races. We know for sure that women of African ancestry have a higher risk of the most aggressive types of breast cancer, even though they’re less likely to be diagnosed with cancer in general. So, there are diagnosis and access-related factors, there are treatment and treatment compliance-related factors, but there are also biology and biological resistance-related factors. I think it's only when we take all of that together that we'll be able to move that needle a little bit more, but we have made a difference. There's no question that the difference between those curves over time is getting smaller.
Dr. Neil Iyengar: Yeah, I agree, and one of the things that we're studying, which again is made possible with the support of BCRF, is looking at disparities among ethnic populations within their native environment, versus the diaspora. So, we've had the opportunity to look at populations in Africa, Taiwan, and Brazil and compare the biology of the microenvironment in fat tissue but also in human cells, and differences between those who have been who have immigrated here generations ago. And what we do see is biological differences between these populations, which may suggest that lifestyle plays a significant role. Also, it suggests the need to think about our interventions in a way that's not only culturally targeted but biologically targeted to the specific population. So, this is an area that needs a lot of support and a lot more work to provide effective care that's targeted to specific populations and improve disparities.
Dr. Elisa Port: I agree. My BCRF research funds looking at treatments and novel therapies for triple-negative breast cancer, which as you pointed out Dawn disproportionately affects Black women. Two groups have a significantly higher risk for triple-negative breast cancer, and that's Black women and women with the BRCA one mutation, which affects a lot of Ashkenazi Jewish women. These are very different ethnic groups, and yet they both get a higher risk of having triple-negative breast cancer, so how can we look at that. That's what we're doing with our BCRF research. We’re comparing these groups and trying to bring those curves closer together in terms of outcomes, regardless of ethnic background. So, I think we've all shown how we've benefited from our research and our BCRF research has had a huge impact on our lives on our careers, etc. And the three of us are committed to bringing this research to fruition and to continue our work to benefit as many people as possible.
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