Improving Breast Cancer Care and Narrowing the Health Disparities Gap with Dr. Dawn Hershman
By BCRF | April 19, 2022
By BCRF | April 19, 2022
Many extraordinary new treatments, diagnostic tests, and procedures for breast cancer patients have been introduced in the past decade—and more are needed and sure to come.
But even with such revolutionary science, identifying ways to improve cancer care delivery, quality of care, and quality of life for patients and thrivers remains a significant concern. And that’s exactly what Dr. Dawn Hershman is working to improve.
A BCRF Investigator since 2008, Dr. Hershman brings a dynamic blend of science, psychology, theology, philosophy, and even public policy to her work. This research centers on improving cancer care delivery and health equity—from reducing treatment side effects to improving patients’ ability to follow their treatment plans.
Dr. Hershman has published more than 250 scientific articles and has received numerous awards, including being named to the most recent Giants of Cancer Care class. Dr. Hershman is professor of medicine and epidemiology and director of breast oncology at the Herbert Irving Comprehensive Cancer Center at Columbia University Medical Center.
Chris Riback: Dr. Hershman, thanks for joining. I appreciate your time.
Dr. Dawn Hershman: Yes, thanks for having me.
Chris Riback: So when many of us think about breast cancer, we think about the worrying tests. We think about the treatment or the procedures. You think about all that but you also think about the quality of the lives of patients during and after breast cancer care, improving cancer care delivery and health equity treatment. Why is that where your focus goes?
Dr. Dawn Hershman: Yes, so very early in my career, it became very apparent to me that we had made tremendous strides in understanding better treatments, that it really had a big impact on improving outcomes of patients with breast cancer, but not everybody got them, not everybody accepted them, not everybody completed them. And there are a whole host of reasons why, and so it really made it clear to me that if I could make improvements in the treatments that work, if I could get patients better treatment that work, I could really have a big impact in terms of population survival. And who are the patients that are less likely to get some of the best treatments, the treatments that we know work?
Well, patients that maybe are less educated or have less access to go to one of the top five medical centers or patients that live in poverty and have competing interests for their time, or patients that just have a lot of other medical conditions. And so I started to investigate what are the factors that's stopping people from getting the treatment and became pretty clear that a lot of it was a fear of side effects or development of side effects. So that was sort of the push and it's taken me in a lot of different directions. What are the various different side effects out there? And what are interventions that can maybe lower side effects to get them through their treatment?
It's helped me focused on things related to adherence. How do I keep patients on their medications and what are factors that interfere? And so we've done a lot of work looking at financial factors and co-payments and insurance status and how all that financial toxicity can impact treatment. We've looked at beliefs and persistent symptoms after treatment and how to make sure that patients [and] all of their quality of life needs are addressed during their treatment and after, and it's helped us look at the ways policy decisions affect patients, whether it's related to pain medication, or whether it's related to issues related to reimbursement of oral medications or prior authorizations and how all those things can affect the quality of treatment that patients get. What started out as one thing sort of turned into many.
Chris Riback: Yes. It doesn't sound like your life is complicated at all. I think your new business card reads scientist, psychiatrist, theologist, philosopher, and public policy expert. There's no problem.
Dr. Dawn Hershman: Yes, no. No problem at all.
Chris Riback: It's so interesting to hear you outline that kind of trifecta of challenges that you said at the beginning, the barriers to folks getting the medication or treatment, accepting the treatment and completing the treatment and in researching and the different impacts along each area, whether that's socioeconomic class, education, fear, understanding, maybe other areas of support in terms of completing them.
In researching for this conversation, I saw that you were named last September to the Giants of Cancer Care class of 2021. Now, I know you have had a lot of honors in your career, but being a giant is pretty cool. I'm sure you would agree?
Dr. Dawn Hershman: I got ribbed a lot by my family for that.
Chris Riback: I would hope so. I'd be very disappointed if you hadn't. And there's another one to add to your business card, there's giant. But I also read a quote of yours about that, which was, and this is you talking, "Figuring out how to keep patients on their treatment longer can have as big of an impact on patient survival as discovering a new drug." That's a powerful statement. And in reading some of your work, I just couldn't believe that one of the major challenges is just ensuring that people actually take their medication.
Dr. Dawn Hershman: I think it was said best by C. Everett Koop, right? And he said, "Medicines don't work in patients that don't take them." So we can spend a lot of time coming up with new treatments and new ways of giving it and combinations of treatment. But if a patient doesn't take it, then we haven't actualized the potential of that medication. And one of the things that's so clear is that when we think of survival, we have to think not only of the breast cancer that we're trying to treat and the patient, we have to think about all the other medications that they're taking. And there are other comorbid conditions.
Patients don't come to us with just one thing. They come to us with many things. And one of the things that we found is that when a woman's diagnosed with breast cancer, they stop taking their high blood pressure medicines, their cholesterol medicine, sometimes they stop seeing all their other providers, because they're just so focused on their breast cancer, for good reason. But if we cure them of their breast cancer, but they die of heart disease because we haven't paid attention to all of these other things, then we haven't made as big of an impact as we think we have.
Chris Riback: How do you balance your focus on root causes versus mitigation?
Dr. Dawn Hershman: Oh, that's a great question. I mean, you have to understand in great detail what the root causes are to develop a strategy for mitigation. We live in a complicated world and root factors are sort of always shifting. And sometimes trying to come up with an intervention strategy maybe works for a short period of time, but doesn't work for a long time. We live in this great world right now where we have all of these electronic mechanisms that are fingertips to help us enhance communication with our patients, communication with other providers, communication with pharmacies and other parts of the healthcare system that haven't been really well tapped into. And I think if we can work with engineers and behavioral scientists and people with expertise in behavioral economics, we can use these new tools to help us, help our patients mitigate the barriers to whatever the problem is for them, because this is certainly no one size fits all kind intervention.
Chris Riback: And I want to ask you about that because my belief is that you are either starting or planning to start some study around the potential impact of integrating electronics and digital devices into communication. And having listened to what you said up to this point, it does seem clear why you would be advancing that, bringing all of those different hats that you wear together. But before I get to that, I will say, doctor, you do seem to practice what you preach. You have a not-uninteresting Twitter feed, which covers a lot of different areas. And one of them is you have reposted a few of the posts from the new New York City mayor, Eric Adams. And let's just be clear, these are not political posts, but they all have to do with various healthy eating programs. Talk to me is that a personal interest, medical interest or both?
Dr. Dawn Hershman: Well, so if we want people to have better health outcomes, then we need to address all the factors that are known to affect patient's longevity on every level and risk mitigation. So we know that diet and obesity and exercise increases the risk for developing breast cancer. And if we want to prevent it, we have to have good strategies in place that are accessible to everybody. And that start at with really young kids so that we can develop good strategies and for so long I think our policies haven't really addressed the importance of prevention.
Chris Riback: It makes sense. What is your comprehensive multidisciplinary program? How does it work and how have you developed it over the years?
Dr. Dawn Hershman: Yes, so I think the best research comes from really listening to stakeholders from all different types of backgrounds and I'm so privileged to work at an institution that has an amazing school of public health and great basic scientists and amazing clinicians, but also to work in New York City and really with BCRF because so many of my collaborators are other BCRF awardees with different expertise, expertise in community health and behavior and epidemiology and data science. And sometimes by taking all of these really smart people and putting them together, you can solve problems in a more creative way. And it's the creative process that gets me super excited about being able to do new things.
Chris Riback: Let's talk about some of your current studies on issues related to quality of life in the treatment of side effects including chemotherapy-induced peripheral neuropathy, a common side effect of a class of drugs called taxanes. Pain management for patients with metastatic breast cancer, chemotherapy-induced hypoglycemia, and more, what is the status of those studies, and where are you with them?
Dr. Dawn Hershman: Yes, so we have looked at a whole variety of ways of mitigating short and long-term side effects of treatment. And many have been quite successful in terms of reducing pain that comes from some of the aromatase inhibitors. We now are launching a large project looking at various different types of compression and cold gloves to the prevent the neuropathy that develops from chemotherapy to understand we have studies that suggest that patients sugars, for example, go way up during their treatment because of the steroids that we give and that may actually make their neuropathy worse. So it may even be that controlling their glucose during their treatment helps reduce some of these side effects.
We've been working a lot with pain medication and really doing a deep dive to understand what makes people stay on pain medications for too long, or, what stops them from taking pain medicine when they have pain and how can we best control pain in our patients. And we have a device that's been very successful at helping patients manage their pain because it works through an app. But more importantly, it gives them an opportunity to send their medicines back when they're done. And we've been able to get a lot of opiates off the shelves by using this device and returning it to the pharmacy.
Chris Riback: Yes. Pain management is such a complicated area. I know, I mean on the one hand, is so important because the advancement of pain must stand in the way of all of those other goals that you talked about, accepting medications, completing treatment, pain must get in the way at the same time, we all have followed the news of some of the concerns. In my understanding though, perhaps your approach to pain management involves medication, you just described it, but it seems fairly holistic. It seems to go beyond just medication. Is that accurate?
Dr. Dawn Hershman: Oh, yes. We have looked at a variety of different strategies, including acupuncture. We have several studies that have looked at acupuncture, which is extremely effective at reducing pain. And I think underutilized, mostly because of access-related issues and reimbursement-related issues. So we hope that the world is opening their eyes. We're seeing more patients' insurance plans covering it. Sometimes working with various organizations to try to figure out how to make it acceptable and widespread. So, people would much rather go to six sessions of acupuncture than to take an opiate. We need to change our reimbursement and our policies around that.
Chris Riback: That's a whole other conversation that I'm sure you have maybe a couple of points of view on and certainly must create some angst and frustration when you see opportunities available for patients that you are caring for. But we'll hold that for another conversation. For this one, the other study. What state are you at right now in terms of testing new electronic technologies to improve the patient-provider communication and enhanced pain management?
Dr. Dawn Hershman: Yes. Well, maybe I could tell you a little bit about this large initiative that we have, it's a large study that we're just undertaking that uses a variety of different tools to enhance patient-provider communication.
Chris Riback: Yes, please.
Dr. Dawn Hershman: And it sort of focuses on chronic medication adherence, which is a huge problem in medicine. It results in excess death, excess hospitalizations, emergency room visits, enormous like wasted cost to the healthcare system, and poor outcomes. And we know probably globally about two-thirds of patients that are on multiple medications, have of some type of non-adherence non-compliance or problems with their medication. We just did, also with help from BCRF, an intervention focused on video pharmacy visits, and found that like 90 percent of patients’ medications in the chart were different than what they thought they were supposed to be taking.
And that about half of patients, especially with advanced cancer were on two medications that interact with each other. So we're using video visit technology, EHR alerts, and feedback and communications with healthcare providers, with pharmacies, when patients don't fill their prescriptions to alert providers and patients and caregivers, and then apps to help remind patients when they're supposed to take their medication. Trying to come up with solutions so when they have a problem that we can also connect them with social services to help resolve that problem in terms of getting the medications. So trying to think of all the different things that are out there and use them all together to improve the way we deliver oral medications.
Chris Riback: Yes. An incredible opportunity. Also raises other challenges around who has devices, who has bandwidth, internet access, all of that. Let me ask about you, how did you get into this? And I mean, going back, where did you grow up? Was it always science for you? Did you ever have a vision that perhaps you were going to be a fiction novelist or world-class skier or anything else? Or was it science, science, science?
Dr. Dawn Hershman: No, actually, my mother is an artist, and never in my wildest dreams growing up did I ever think I was going to end up as a physician or a scientist or as a researcher.
But actually, my husband now was like, "Just take the classes, just see how you do." So I took classes at night when I was working and was like, "Oh, I can do this. This is really cool." And developed that passion and went back to medical school after working as a study coordinator for a few years. And I think that experience of sort of discovering it, discovering that it's actually super creative—science and medicine—and my husband's a documentary film editor and a filmmaker, and my mother, as I said before as an artist. Like I've always felt like an outsider a little bit when I took this path. And I guess I realized that this is a super creative path too.
I feel so lucky because one of the greatest things about what we do is one, working with amazing patients and being inspired every day by the people that we see. I always say that if I didn't take care of people with breast cancer, I would not have a single idea because every time I'm in clinic, another idea pops into my head about how we could be doing things better. But also to be able to work with so many other creative and interesting passionate people, and importantly, to be able to mentor the next generation of junior investigators. When you see somebody get their first grant or their first paper in and how excited it is they are about it. It's a total rush. And so I think that's what keeps us all going when things aren't so easy.
Chris Riback: That comes across and what you described at the outset in that. We were kidding a little bit about the range of roles that seems you play and how long your business card needs to be. It makes sense in listening to your background, the mix of right and left brain, front and back brain probably too, all comes together for holistic care. To close out, how would you describe the role that BCRF has played in your research?
Dr. Dawn Hershman: I feel like I've been part of the BCRF family in one way or another my whole career. And it's important in so many ways because one, it allows you to really be creative. Like, as I was saying before, the best part about being able to both see patients and do research is have a good idea, develop it and act in the moment. And the process we have is like you have an idea and then four years later you start the project. And because of this model where they fund people who have a track record and are creative and productive, that I have been able to leverage the funding a gazillion times over in both being able to have my junior investigators go on to get career development grants, me being able to get on larger trials and larger studies done using that initial work that we do in terms of developing an idea or an intervention through BCRF.
But it's also like introduced me to this community.
Chris Riback: That's terrific. And it's very nice of BCRF to have put together a collection of your best friends.
Dr. Dawn Hershman: Right. Just for me.
Chris Riback: Just for you. It's very, very kind. Dr. Hershman, thank you. Thank you for the work that you do and thank you for taking the time today.
Dr. Dawn Hershman: Absolutely.
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