Five BCRF investigators discuss breast cancer vaccines, metastatic breast cancer research, and improving care

Every October, BCRF’s highly anticipated annual Symposium & Awards Luncheon not only announces the Foundation’s research investment for the year ahead, but it also convenes an outstanding panel of investigators for an engaging conversation.

BCRF’s 2021 symposium was as wide-ranging as the Foundation’s research portfolio—diving into breast cancer vaccines and immunotherapy, metastatic disease, survivorship and care, mental health, and more.

The 2021 program was moderated by BCRF Scientific Director Dr. Judy E. Garber and featured these four esteemed researchers:

Watch the video above or on our YouTube.

Read the transcript below:

Dr. Judy Garber: I'm so pleased to be joined today by leading breast oncologists and researchers who are wielding the power of communication to foster collaboration and keep patient-centered care at the heart of research. Each of our speakers today is investigating a myriad of unsolved issues to improve treatment and quality of life while simultaneously strengthening the links between patients and doctors, and just as importantly, between researchers. So it's my pleasure to introduce each of our panelists this morning. And to begin with Dame Leslie Fallowfield, who is this year's Jill Rose Award winner.

Dame Lesley Fallowfield: Hello, nice to be with you. And of course, I'm very honored to be the recipient of the Jill Rose Award this year. I am a psycho-oncologist and I am the director of the Health Outcomes Research team at Brighton and Sussex University. We do three things. Essentially, we measure the quality of life in lots of big, national and international treatment trials of breast cancer. Having found the side effects of different treatments, we work on interventions to help patients deal with otherwise efficacious treatments. And the third important thrust of our work is dealing with the multitude of different communication skills problems that affect doctors, patients, and their families.

Dr. Garber: Dr. Ganz, would you introduce yourself?

Dr. Patricia Ganz: Hello, I'm Patricia Ganz. I'm a medical oncologist and the associate director for population science research at the UCLA Jonsson Comprehensive Cancer Center. I focus on the impact of cancer treatments on patients with breast cancer and really trying to develop interventions to improve outcomes for patients with breast cancer.

Dr. Garber: And this is Nora Disis from the University of Washington.

Dr. Mary Disis: Hi, my name is Nora Disis. I'm director of the University of Washington School of Medicine's Cancer Vaccine Institute. And my research focuses on breast cancer vaccines, how to make them work better in combination with chemotherapy, and also how to manipulate specific organisms in your gut, in terms of being able to stimulate your immune response to cancer vaccines, so that your immune response is more potent in being able to attack your tumor. It's very important in terms of looking at different parts of the immune system, of which our gut is one of the major immunologic organs in the body in terms of the balance of the immune system in attacking cancer.

Dr. Nikhil Wagle: Hi, my name is Nikhil Wagle. I'm a medical oncologist and cancer researcher at Dana-Farber Cancer Institute in Boston. And my work focuses on understanding the biology of metastatic breast cancer in particular to try and develop new treatments and treatment strategies. And this work is largely done through partnering with patients to enable patients to share their clinical information, their tumor samples and their voices and experiences with all researchers to try and accelerate this process. I also run a research initiative called Count Me In, which is a program that allows patients across the United States and Canada to sign up to participate in research regardless of where they live in and allows them to share their medical information, their tumor samples, their other biospecimens and most importantly, their voices with cancer researchers to be able to accelerate the research process and accelerate discoveries.

Dr. Garber: Thank you, Nick. So this is a very high-powered panel, and they're all thinking about issues in communication and the critical nature of that information for our patients and for the physicians and researchers in the community. Part of our job is to make sure—and this is a BCRF role, too—to make sure that we are making information available that might accelerate progress in research. Dame Lesley, I wonder if you could speak to us a little bit about your concept of the really important issues in patient-doctor communication, just ways that you think that work has helped to make us all better at it. What are our patients thinking about?

Dame Lesley: It's a really important thing, communication, because in the course of a clinical career spanning if you're lucky, about 40 years, a doctor is likely to conduct more interviews with patients than they are to do any other procedure. Yet, if you can trust the amount of time that's given over in medical school, to teach people things that they'll never do with the core communication skills that they need to achieve their work, you see why we've sometimes got a problem. It's not because doctors aren't nice people. Most of them are just wonderful. It's just that many of them are unaware of the types of ways in which their communication hampers understanding and good shared decision making. So one of the things I guess I always start with is that it's very difficult to have a genuine two way exchange with people, if one person holds all the power through knowledge. And so the first thing you need to do is to help people try and put complex information into understandable terms that are non-patronizing. And that is a skill in itself. A long time ago, when I was completing my PhD, my supervisor wanted me to do a talk. And I left out a whole big chunk of it. And he said, "Well, why have you left out one of the most pivotal parts of your thesis?" And I said, "Well, it's far too complicated to explain to the audience." And he said to me, "If you can't put that information into easy terms that everyone listening can understand, then you know, something, Leslie, I don't think you understand it properly yourself." And so I think sort of trying to get people to develop a repertoire of skills to explain complicated things in simple but non-patronizing language is probably one of the first things to teach everyone.

Dr. Garber: Thank you. That sounds like a very important lesson for us all to learn. Patty, you've worked in this field as well. And you've led the development of instruments for patient reported outcomes and made asking the patients about their experience part of many clinical trials, do you want to speak to that issue?

Dr. Ganz: I think it's so valuable to get the patient's input on anything that we do. And in fact, before we even start many trials today, we either do individual interviews with patients, or something that we call focus groups, where we ask them not only, you know, what's most important for them, but how feasible the trial might even be, you know, to do because if we offer something to patients, and it's not possible for them to participate in it, when they don't understand the motivation for the study, it's really very difficult. But what's been very, really gratifying for me is that much of the research that I've done, whether it's been on fatigue after breast cancer treatments, or cognitive difficulties, or depression, not only do I do that research and publish my data, but then I'm able to give it back to patients in the clinic. And really, the interventions that we study to make them more widely available. We publish our papers, but then to be able to get it back to the patient is really very important. And so I think there is a gap that occurs between the scientific publication and the dissemination. And that's something that I'm really wanting to do now in this latter stage of my career is getting it back, getting it delivered to patients.

Dr. Garber: Thank you. You know, I think, today, it's really inconceivable that we would do research without asking patients and without trying to explain to patients what we're doing, but what we have to explain has certainly become more complicated.

Dame Lesley: I wonder if I might add one thing here, which is that, yes, we're focusing here on the dyadic, the two-way exchange between a doctor or nurse and a patient. But of course, the delivery of cancer services these days has become a serious team business. We have increasingly multidisciplinary teams all of whom have a role from their specialty in discussing things with patients on one of the things that some of my team's work, and others have shown is that very often, these teams are not on message, they sometimes don't even know each other very well. They give patients different sorts of sometimes quite contradictory or inconsistent information, and give them that many patients actually do start from a background of fear and anxiety. If you hear different messages from different people, that's not going to help, again, in making sensible decisions about your treatment. So I think one of the things we need to also think about is trying to increase the continuity between multidisciplinary teams when they're talking with patients.

Dr. Garber: That is a really excellent point, seamlessly. How has the pandemic affected this? I would be concerned that, you know, we all seem busier than ever, it's harder and harder to get these teams together. If we're not being consistent. I don't know if that's part of the problem. But aside from that, what are seeing an effect of dealing with COVID on communication in these issues?

Dame Lesley: I think this is a really, really important and increasing issue for us all to have to come to terms with and deal with, I guess, within many countries, sort of remote consultations have become part of the scene anyway, if you live in very rural districts, for example, but people aren't really used to communicating in this way, it's very hard to have the sorts of easy exchanges because only one person can talk at a time. Now one of the problems from a patient's point of view, of course, is that if you are actually a clinician meeting a patient remotely for the first time, we know that you do need to get lots of visual cues from your patient as to whether they are receiving this knowledge with obvious understanding or with fear—you can get that from facial expressions and you can actually tell sort of whether or not you're pitching things correctly. So I think it's a whole new way of actually sort of communicating with each other, and with our patients, and we need to start some serious training in it, because I fear that this is going to be a thing that we're all just going to have to get used to more and more.

Dr. Garber: So Nick, Count Me In wouldn't be possible if it weren't for some of this technology. Where do you see that going for projects like yours.

Dr. Wagle: Even before the pandemic started, the idea behind Count Me In was to be able to let people participate in research, even if they didn't live next to or near the big academic center, or in a big city. And by necessity, it takes advantage of all these technological innovations, things like social media and email, and allows people to participate from wherever they are. And during the pandemic, it's allowed people to participate in research from their own homes without having to go anywhere. And I think that will continue on. It's to be able to use the the whole spectrum of communication tools to educate patients, and then also enable them to participate in research will just make things more accessible, it will allow more communities to participate, it will allow more diversity in research participation. So obviously, I want the pandemic to end as quickly as possible, but the use of many of these tools will continue. And I think that will be overall a net benefit for research and communications.

Dr. Garber: I hope so, too. I do think it may be changing the nature of this research a little bit. Dame Lesley, in your career you have studied many aspects of communication. One of the ones that I'm most interested in, of course, is in the area of genetics. And I think about this in part in this discussion, because we've talked about the fact that oncologists and surgeons and radiation oncologists always have to keep up with the latest in their fields. They've had to learn about immunology, they've had to learn about tumor genomics so they can understand targeted therapies. You know, all of this, we accept as part of our responsibility as caregivers. Inherited genetics has been a little bit different. And you ventured into those waters. Do you want to talk a little bit about about communication skills there? Because I have to say, I assume that we're all testing more and more of our breast cancer patients, not only when they have advanced disease, but at diagnosis. And it's a piece of our thinking that maybe we don't spend as much time on.

Dame Lesley: Yes, this is a really fascinating area. And I'm so grateful to the BCRF for giving us some funding to work on some quite novel educational programs aimed at clinicians to help them when they're discussing these types of things with their breast cancer patients, but also with people who are particularly BRCA1 or 2 carriers who may not have breast cancer. Echoing some of the things that other panelists have just said, what we did to start with was talk to lots and lots of BRCA support groups about the sorts of issues that had caused them difficulties when they were coming to decisions about whether they should have further risk-reducing surgery or take some preventive chemotherapy, whether they should stop their HRT, whether they should have their ovaries removed, all the sorts of myriad of things that people need to consider. We then talked to surgeons, oncologists, nurses, geneticists, and genetic counselors to find out where their problems lay. And what I referred earlier to the fact that although we deliver care on a multidisciplinary basis now, we don't always know what each other does. So we were able to develop a whole series of exercises, videos, and a program that we get all these different groups to come together on. And hopefully, we seem to be showing quite a bit of improvement before and after the workshops. But one of the things I think we must never forget also is that communication never stops with us having a consultation with a patient who may actually have a gene mutation.

Dr. Garber: Patty, do you have anything you'd like to add to any of this discussion? You've done so much work in this area. What's something you'd want us to know?

Dr. Ganz: There are a couple of things in terms of the communication about genetic predisposition. It is very challenging. And of course, because we have these large genetic testing panels now, where there may be 50, or 100, different tests that are done for different mutations, the variants of uncertain significance are really a big problem in terms of communication. And so that has been a challenge always to the genetic counselors, professions, but most physicians actually don't understand this at all. And so then there's a lot of confusion on the part of the patient. And so I think that's part and parcel of the advances that have taken place in terms of not just testing for a single gene mutation, but for many. The other is that because I take care of a lot of cancer survivors, many young women or even middle-aged women, who may have been tested 10 years ago for BRCA1 and 2 with the testing that was available at this time, and were deemed negative to not have a predisposition definitely need to be retested. Because we know that there are familial hereditary mutations in PALB2, CHEK2, ATM, and others, or even perhaps a colon cancer gene [mutation], which may predispose also to breast cancer. They need to be retested with a panel to update their testing—that's not only important for them, because they could be at risk for ovarian or some other cancer site, but for their children and other family members. So it's not one and done, particularly if it was done, you know, 10 years ago. But anyone who was tested in the past and may have been deemed not to have a hereditary genetic risk should consider retesting now with a counselor to go through this with them. So I think that's really important. I'm all in to preventing second cancers in breast cancer survivors. That's really something I'm extremely passionate about, obviously, with lifestyle and other strategies. But also to make sure there's not a hereditary risk of another cancer

Dame Lesley: Patty, don't you think we need to give a sort of clear message out there to people listening to this discussion, that whilst that is all true, the direct-to-consumer testing is a bit of an issue unless people have had appropriate counseling about the types of things that may be found about the sorts of things that might then occur. As a result of that, you do get some very strange things happening because you get sort of a patient comes in to see a clinician with all these results, particularly the variants of uncertain significance. And they haven't actually thought through or been led through what the implications might be, we ought to try and encourage people to think about a little more and seek other advice first, before actually doing it.

Dr. Garber: Nick, you've spent a lot of your career so far, you're still quite young, working in metastatic disease. Can you educate us a little bit more about what it is and the special nature of the problems and where you see hope for the future?

Dr. Wagle: Metastatic breast cancer is breast cancer that has spread beyond the breast, either after initial treatment for early-stage breast cancer. Some years later, it recurs and it recurs and comes back in other parts of the body, or in some cases, when initially diagnosed, it may be present in parts of the body beyond the breast. And what's challenging about metastatic breast cancer is although we have many treatments for metastatic breast cancer, and many new treatments for metastatic breast cancer, at present, in the vast majority of cases, we do not have a cure for metastatic breast cancer. We don't know how to completely eradicate it. And so this is the challenge. The challenge for researchers who focus on metastatic disease is to understand how we can develop treatments that can either prolong life, improve quality of life, and ultimately, if we can develop treatments or treatment strategies to help cure metastatic breast cancer, just like we can often cure early-stage disease. One of the areas that I focus on, and that BCRF has so generously supported, and many other researchers focus on is on treatment resistance. And this is one of the biggest problems in patients with advanced breast cancer, because all of these therapies that we have, ultimately the tumor is able to figure out how to outsmart those treatments and start growing again. And then we often have to go to a different therapy. And so if we can understand resistance better, how to combine therapies are using in a smarter way, we might be able to make great advances. And I think that's a very promising area of research in the coming years.

Dr. Garber: Nick, you have worked with the metastatic community in particular, and there's an opportunity for misunderstanding. We see the people we see. It's the ones we don't see often who are getting information that we don't know so much about. I'm always amazed to look at television in the United States where we see ads for the drugs that are still being researched. That people you know, want to ask your doctor, please for some CDK4/6 inhibitor, and don't all those women look healthy and happy with their metastatic disease. But it's a little odd to me still, that that's that's part of communication that we don't control. Nick, are you seeing anything there that would tell you this is something we have to pay more attention to? Or is it just part of overall good communication with our patients that they'll hear what we're saying, maybe more than all that great advancement on TV.

Dr. Wagle: I do think I do think this is a general issue. But I do think it's a particular issue. Patients with metastatic breast cancer are often you know, more sick. They have a lot of issues related to their cancer to deal with. And, you know, whatever cancer patients watches, they want to know, what is the best treatment for them? How can they improve the quality of their life? How can they minimize side effects? And unfortunately, as you're saying, I think there's a lot of confusing information out there. There's unfortunately, a lot of misinformation out there. People want to learn about what's the best treatment for them. Are these other treatments that I've heard about, are those real? Are they reasonable? Can I get access to them? There's a difference in ability to access clinical trials, depending on where people live and where they get their care. There are lots of questions around precision medicine and genetic testing, tumor testing, and whether that's valuable, and I think folks are confused because they hear all different sides of the story. And it's important for the medical community, the cancer community, to be clear about that messaging to so that patients can really understand what is what's real, what's important. And what's just noise.

Dr. Garber: Nora, you sit at the forefront of cancer immunology. Would you talk a little bit about the pieces there that are really exciting to you at this time.

Dr. Disis: The field of tumor immunology has just exploded in our understanding of how breast cancer is recognized by the immune system, how breast cancer evades that immune recognition. And we're at last able to really develop therapies based on that type of escape. So for example, you know, I've been working in the field of breast cancer vaccines nearly all my life. And the technology of vaccines has advanced to such an extent that we can now routinely immunize breast cancer patients and get high level immune responses. And we're really understanding how those immune responses can synergize with chemotherapy. It's opened up a completely new world of giving breast cancer vaccines as part of standard therapy, as well as the development of different combination immune therapies. And so you'll see many, many clinical trials now of combination of new therapies not only immune checkpoint inhibitors, but other agents that are being developed to enhance that immune response. And it's opened up a whole new world of cancer vaccines, it's probably one of the most common forms of immune therapy that people are taking up and starting to do research about. So that's very gratifying. It used to be like three people working on it. Now, there's lots and lots, which is wonderful. But the most exciting part for me, is now our ability to contemplate preventative vaccines, you know, that the idea of priming an immune response to proteins that are really involved in driving the malignant transformation of breast cancer, or even cancer interception, immunizing to resolve DCIS, or other high risk lesions. And these types of vaccines are advancing to the clinic.

Dr. Garber: I personally am always thrilled to hear anybody talk about cancer immunology and cancer vaccines for prevention. So thank you for that. It's great to have hope for this. I think, you know, in the era, despite the controversies around the COVID-19 vaccines, I don't think anyone disputes the amazing science that made the rapid development of these vaccines possible, and their efficacy has been amazing. So Nora, as a leader in cancer immunology, I wonder if you can educate us just a little bit about immunotherapies. And where do you see that going, and vaccine therapies, which are certainly immunologic, but perhaps a little bit different?

Dr. Disis: Sure. immunotherapy that we use today as standard of care, is really directed against trying to correct some of the ways that the immune system is held back from functioning properly. And what these monoclonal antibodies do is they block specific receptors and cells that are preventing your own natural immune response against your tumor from working well. This is why these immune therapies only work in a small number of patients. Because of breast cancer, only a small number of patients have that immune response there. So we know if we're going to get these types of immune therapies called immune checkpoint inhibitors. To work for more patients, we first have to get an immune response in the tumor, to be able to unleash it with those immune checkpoint inhibitors. And that's where the concept of vaccines comes in, we can create a vaccine now that we know the molecular profile of specific breast cancer subtypes, we can create vaccines that are directed against proteins that are important in driving that subtype, like HER2/neu and we can immunize patients so they develop a very robust immune response against HER2. And then we can combine that immune response with other drugs that would work to accelerate that immune response. So much like you think of a COVID vaccine, generating immune response against the COVID virus. Cancer vaccines are generating immune responses against proteins that are immunogenic in breast cancer, but not immunogenic enough, that we have lots and lots of immune cells that are capable of killing the tumor. So vaccines will help boost those immune responses and generate those immune cells that are capable of killing the tumor.

Dr. Garber: Thank you, I think, if I understand that, that our immune therapies that have that are reaching standard of care are sort of taking your foot off the brake, you have an immune response there you think, but somehow your body just won't let it loose against the tumor. It's part of why there are side effects when these immune responses may not be so specifically against the tumor, they may be against some normal cells. And it really goes back to the original discussion about how patients have to tell us if they're beginning to see those sort of autoimmune issues so that we can intervene early and make sure they don't get out of hand, that vaccines are a way to try to strengthen the immune system in a different way, where we're not seeing so much inherent responsiveness but where we can try to turn on the immune system and let it have at the tumor as well.

Dr. Disis: Vaccines may be able to generate immune cells that don't necessarily interact with normal cells. So I think vaccine therapy can be teamed up with the immune checkpoint inhibitor therapy. But as Patty talks about, you know, women will be living for long periods of time. We also see vaccine therapy as something that may be given in the adjuvant setting. So, your immune system, it really works best by cleaning up micro metastatic disease. So I give the example of when you have pneumonia, and you go to the emergency room, no one will treat you with a vaccine, right? The pneumonia is kind of too big for vaccines, but you get an antibiotic. And what the antibiotic does is it controls the pneumonia, so it doesn't get worse. What really kills the rest of the pneumonia is your immune system responding to that. So I think we're going to see more cancer vaccines, going into the adjuvant setting along with chemotherapy, where they'll work in concert with chemotherapy, we now know that many chemotherapies themselves have immune-stimulating properties. We used to think of chemotherapy as always dampens the immune system, but now we know it doesn't, and could give you a vaccine that will stimulate your immune system to recognize your cancer. So once the chemotherapy is over, your immune system continues to clean up any disease that's left. And that's what the benefit of the immune system is the development of what's called immunologic memory. So that years from now, if the cancer begins to come back, your immune system will automatically activate. And what's different about looking at using things like cancer vaccines now, is we have stronger vaccine technologies. We know what proteins are immunogenic and important in many breast cancer subtypes. And we have very specific ways of being able to measure disease like circulating tumor cells or free-tumor DNA that will allow us to see whether the immune system is acting in terms of very small levels of disease. So I think a lot of these technologies have opened up a whole new world of being able to monitor the immune system and to see how the immune system is responding to breast cancer.

Dr. Garber: I think I would say that we have, as we mentioned, many new treatments. Now, we have new treatments, because we've had research. And we've had basic research and clinical trials to show us how to use these drugs. And now the best ways to use precision oncology, as Dame Lesley was talking about, to have the right amount of treatment in the right patient. And we can look forward to a time where we have even more immunology, I guess I really have to learn it after all, and more and better molecular therapies so that we are able to improve our treatments and reduce our toxicities. But at the core, in the end, it's research that will make progress. Nick, you have a fascinating career in breast cancer research. What's most exciting to you these days?

Dr. Wagle: I think the overarching theme that excites me is the ability to learn from patients to help drive our understanding of breast cancer, and the development of new treatments or treatment strategies. And I think that that falls into a few a few key categories that make it exciting. One is the new technologies that we're able to take advantage of—technologies that allow us to look in detail at tumor specimens to understand the underlying genomics or molecular biology of the tumor to understand what makes it tick. And what are the vulnerabilities or targets the use of computing technologies and machine learning to try and understand this even better in ways that we couldn't couldn't do before. The second is a number of concepts that BCRF has been really great at championing. And that is the use of collaboration, team science, open data sharing and transparency that really allows us to pull data and increase numbers to be able to see patterns in ways that we couldn't do before. And that's one of the ideas behind Count Me In is get as many people as possible to sign up and share their information so that we have huge numbers that we can learn from and that's only possible more recently with some of these approaches that we've talked about. The third is combining all of that technology, and open data sharing and numbers with information that only patients have, right, you know, the what we've heard earlier from other panelists about patient reported data and information that only patients can tell you, you couldn't learn by looking under a microscope, or you could learn from a medical record, but you really have to learn by asking patients, and it's the integration of that information with a detailed biology that we can learn that I think is going to yield really important, important information for the advancement of breast cancer treatments. I'll add one other thing, which is exciting to me, which is, all of these approaches, I think, give us the opportunity now to improve diversity and inclusion in our breast cancer research in ways that we really have not done a great job of before. So being able to include underrepresented or historically excluded patients in this research process, and use all of these approaches on all patients with breast cancer, I think it's gonna be really important. I'm very excited to see how that type of research continues to expand.

Dr. Garber: Patty, you've thought about all these issues, and you see a lot of material come across your journal editor desk, what are the things that are most exciting to you right now?

Dr. Ganz: For me, at least my passion right now is looking at younger women with breast cancer, women less than 50, let's say or premenopausal women. Because for them, the morbidities have a treatment that we deliver that is often curative, or extends life for very long periods of time, has substantial morbidity, such as premature menopause, and all of its consequences, loss of fertility, depression, which is much more common in younger women, fatigue, cognitive difficulties, and the fact that they're in the middle of their life when they're working. They have their children, they're multitasking, it's just devastating for many women. Many women just plow through it, and they do just fine. But there's a substantial minority that have ongoing symptoms. And I also worry about accelerated aging—the treatments that we often give may do damage to various systems in the body. And so I'm really big on secondary prevention. And that is also you know, when I discussed in terms of making sure if there is a genetic abnormality, track it down, offer that for prevention for them, preventing second cancers. A lot of what we see in the Journal of the National Cancer Institute are large studies that we call observational studies. We had a very interesting paper published this last year on weight gain and BMI in breast cancer patients where they could follow women long-term. And so again, second cancers of all sorts that were obesity-related in breast cancer patients, but also second breast cancers. So other lifestyle things that could make a difference. And so a lot of what we've been doing also have been interventions. We did a mindfulness intervention that was partially supported by BCRF, as well as the federal government, and found that we could decrease depression in younger breast cancer patients. But it also decreased their problems with insomnia, with fatigue, and with hot flashes. And now we're working to find a way to disseminate that in a future clinical trial that will be able to use Zoom, or perhaps an app to deliver that to again, reach women in rural communities, communities where they might not have access to a mindfulness instructor, again to prevent these ongoing morbidities after treatment in younger women with breast cancer. So I think there's a lot that's still exciting to do. That's one thing, Lesley and I are still out there working and plugging away taking advantage of all that we've learned over so many years and, and hopefully can apply in the future.

Dr. Garber: Thank you. And thank you all. I'm going to give Dame Lesley the last word today. But I do want to remind us that, you know, breast cancer is it's an enormous area. One of the challenges always for this moment is to only highlight a few people. This has been a great year in breast cancer research. There have been new drugs approved and approved drugs being used for new indications. We know that immunotherapy has become a standard in the treatment of triple-negative breast cancer and there are amazing things like new drugs in HER2-positive disease. Really, it's been a banner year and I wouldn't want anyone to think that we're not celebrating that as well. We just have fortunately a lot of things to think about. And Dame Lesley as winner of the Jill Rose Award this year has still so much to teach us so you can't retire. But you can give us it I have a sense of what you'd like us to take away.

Dame Lesley: Well, thank you very much for that, Judy. And it's been lovely to actually be on this panel with all these lovely people saying such really important things. But one of the things I don't think we did mention that also needs some reference to is that because of some of our advances in understanding what the nature of breast cancer or the many diseases that comprise breast cancer is, we've got to a stage where we're not just actually giving patients more and more novel treatments, we're getting to the stage where we can stop giving patients quite so much surgery, quite so much radiotherapy, quite so much hormone treatment, quite so much chemotherapy. And that is something I think we need to focus on. Because very often in the context of life-threatening disease, patients seem to believe that more is better. I've got this horrible disease, give me more and more of these new drugs. And so one of the communication issues we've got, given that we now know so much more than we did a decade or so ago, is to help people believe that sometimes less is more. And I'm just very grateful that the BCRF has actually enabled so many people so many great basic scientists, clinical scientists to contribute so much to our knowledge of probably actually fulfilling Evelyn Lauder and Larry Norton's original dream of trying to cure breast cancer.

Dr. Garber: Thank you, I couldn't possibly have said it better. Thank you all so much for your time for your insights and your thoughts today. And thank you to BCRF, as always, for making this possible.

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