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Investigating Breast Cancer: BCRF Symposium & Awards Luncheon

Recorded Live from New York City

Every October, BCRF-funded researchers are honored at the annual Symposium & Awards Luncheon in New York City. This is when BCRF makes its formal announcement of research grants for the upcoming year and recognizes its investigators for their devotion to ending breast cancer with their trailblazing scientific inquiry. The event provides a unique opportunity for BCRF researchers to convene, share ideas and collaborate with fellow colleagues from around the world. This year’s program began with a symposium featuring an expert panel of BCRF investigators. They discussed current breaking topics in breast cancer research, ranging from prevention and diagnosis to treatment and survivorship. We’re proud to share that discussion here in this special bonus podcast. 

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Read the transcript below:

Intro:   I’m Chris Riback. This is a special bonus episode of Investigating Breast Cancer, the podcast of the Breast Cancer Research Foundation and conversations with the world’s leading scientists studying breast cancer prevention, diagnosis, treatment, survivorship and metastasis.

Each October, BCRF-funded investigators are honored at the annual Symposium & Awards Luncheon in New York City. The event announces the Foundation’s grant investment for the coming year and recognizes BCRF investigators— many of whom we feature in these Investigating Breast Cancer conversations — for their devotion to ending breast cancer and their trailblazing scientific inquiry. The audience is comprised of researchers and BCRF supporters, and the gathering provides the rare and unique opportunity each year for BCRF researchers to be in one place to share ideas and collaborate with fellow colleagues from around the world.

This year, the program began with an extraordinary symposium. An expert panel of BCRF investigators discussed current breaking topics in breast cancer research, ranging from prevention and diagnosis to treatment and survivorship.

We’re proud to bring you that discussion here, in this special bonus podcast. The symposium panelists included:

  • Dr. Eric Winer, of Dana-Farber Cancer Institute. Dr. Winer is also the recipient of BCRF’s 2019 Jill Rose Award for Scientific Excellence.
  • Dr. Dawn Hershman of Columbia University Medical Center.
  • Dr. Neil Iyengar of Memorial Sloan Kettering Cancer Center.
  • Dr. Judy Garber, of Dana-Farber Cancer Institute. Dr. Garber also serves as BCRF Scientific Director.

The panel was moderated by BCRF’s Founding Scientific Director Dr. Larry Norton of Memorial Sloan Kettering Cancer Center.

We’ll have our regular episode of Investigating Breast Cancer in the next weeks. Now, here is Dr. Larry Norton and BCRF’s 2019 Symposium.

Dr. Larry Norton: Welcome everybody. I don't know how many years we've been doing this, but every year it gets better and better. And thank you all for being here. Other people will be coming in as the usual thing over this next hour or hour and 15 minutes that we're doing this.

We changed the format just a little tiny bit and we've asked this extraordinary group of grantees, clinician scientists to be educational in their focus as well as talking about their own research, but also to educate on very important topics.

And I'm going to pass the podium on to the group so as not to waste time as a nascent to introduce themselves as Dawn Hershman, Eric Winer, Neil Iyengar and of course, Judy Garber, who's the scientific director of the BCRF to introduce themselves and we will talk about their topics a little bit more depth than we've done in the past.

Before we get started, I've introduced my colleagues here. I just want to introduce one other person because it's an exceptional few weeks is Bill Kaelin, one of our grantees from 2006 just won the Nobel Prize. Bill.

Okay. Thank you. Very gratified by your work, extraordinary and huge impact. And I expect all the other grantees who are sitting on both sides and may have comments as we go forward. Every year I want one of you to win a Nobel Prize. All right. It's extremely important that we do that because we got to keep the momentum going in this regard.

Okay. Let's just start off with the main program. And I'd like to introduce Dawn, introduce yourself and tell us about your topic.

Dr. Dawn Hershman: I'm Dawn Hershman, I'm a professor of Medicine and Epidemiology at Columbia University and a breast cancer oncologist. Early in my career, I think one of the things that really stood out to me was the number of people that would really... We'd have all these great treatments for breast cancer even though we have a long way to go, we have some really spectacular treatments.

And it always stood out like that, a large number of people wouldn't get those treatments. They wouldn't start those treatments, they wouldn't finish those treatments, and we spent all of this time, energy and effort trying to discover and put forward new, better ways of treating breast cancer, but not everybody got them.

I remember early on, we started using anti-hormone therapy, anti-estrogen therapy, and patients would come in after we put on aromatase inhibitors in particular, just in tears because the side effects would make them miserable. They would say things like, "I can't get up from my chair. I can't go down the stairs in the morning. I know these medicines work, but I can't take them, I don't know what I'm going to do."

And it really made us start to think like, well, how many people are like this out there? How many people can't take their medication and what are the reasons why? And we started to investigate that and we found that over 50% of patients couldn't complete the five years of treatment on time the way they were prescribed.

A lot of people stopped, they took it intermittently. So it made us start to think, well, what can we do to try to help fix that problem? And when we first started to go back to the clinical trials, they were why, why is there a discrepancy in terms of what people are saying versus what we see in the clinical trials, in the clinical trials maybe only 8%, 7%, so they had a problem with side effects.

We started to realize that we weren't really measuring side effects in clinical trials because we weren't asking patients how they felt. And it really opened our eyes to the importance of asking patients while they're on treatment, what the side effects are that they're experiencing so that we can better measure it, we can have appropriate outcomes to know, but also so that we can control those side effects so that we can keep people on their treatments.

So it started a whole way of us thinking about patient-reported outcomes and incorporating that into trials and putting in the patient's voice so that we know exactly what we're talking about when we get these results. In thinking about side effects and why people stop taking their medications, we've looked at a lot of different things.

We looked at financial factors and how even small differences in the amount of money you have to pay out of pocket can make a big difference in terms of your likelihood of staying on a medicine or the type of insurance you have. But the number one reason why people stop taking their medication is side effects.

So we started to investigate all different types of things in terms of controlling side effects from the aromatase inhibitors and we looked at medications like antidepressants and certain types of medicines like we call Duloxetine or Cymbalta, they can work, but people don't want to take them because often we hear, "I don't want to take another medicine that causes side effects to control side effects from a medicine I have to take."

It's totally reasonable, so let's think about other ways we can try to control these side effects. And so we worked with Melinda Irwin who's a grantee on looking at exercise and can exercise control these side effects? And her study showed that yes, actually exercise can control some of the side effects and hopefully keep patients on their medications.

We looked at other types of compounds like Omega-3 fatty acids to control side effects and that can be effective too in some types of patients, but probably the most impactful thing we did was we studied acupuncture, and we did a very large rigorous multicenter trial looking at whether or not acupuncture could control those side effects.

And people say, "Well, of course acupuncture is going to work because patients would just get it." But it's really important to test these things because people pay a lot of money out of pocket and you can have an influence if you find out that it's actually effective.

What we found was that, we analyzed the data all different types of ways no matter how we analyzed it, acupuncture was better. And what was it better than? Well, we had an arm that was sham acupuncture, so we tried to trick people into a placebo of acupuncture and we had people wait until they got their acupuncture.

The true acupuncture actually was significantly better; it reduced those side effects by more than 50% in terms of improvement. And so if people say, "Well, why do you need to do that?" Well, the reason we need to do it is so that we can convince insurance companies to pay. And the results of those trials enabled us to pressure a fair number of the commercial insurance companies to cover those costs.

And it's important because we need to think globally and work with every patient in a personalized way to help make sure that whatever the problem is that's stopping them from getting the treatments that work, that we come up with a solution that's right for them.

Dr. Larry Norton: Excellent. Thank you so very much. Acupuncture also helps you chair these kinds of meetings by the way. I have a needle in me right now, and if it were not for that.

Eric Winer, who's the Jill Rose award recipient this year and I have a lot of nice things and some not nice things to say about him a little bit later this morning that you'll hear. Eric, what's your topic? Who are you.

Dr. Eric Winer: Who am I? I'm up in Boston and I am a medical oncologist. Oh, sorry, not close enough. Excuse me. I'm at Dana-Farber in Boston where I direct the breast cancer program. I'm a medical oncologist, I do research, I take care of patients. I try to keep everybody happy there, meaning all the people we work with.

You'll just forgive me if I just tell you a brief story, which is that the fact that I know a lot about breast cancer and very little about everything else was brought home to me many years ago by my oldest son, who at the time was about 11. This is many years ago. And he had a rash on his face, which I kept telling him was because he got chocolate all over his face whenever he ate anything that had chocolate in it.

And he went to the dermatologist, the dermatologist said, "Your father's wrong. You have perioral dermatitis." Jeffrey comes home and he says, "Dad," And he said, "you're wrong." I said, "No, Jeffrey, I still think it's like getting all that chocolate on your face." He said, "Dad, if I had breast cancer on my face, I'd listened to you, otherwise I'm going to the dermatologist."

So when your own family feels that way, what can you say? So I asked Judy and Larry what I should talk about and the answer I got was that I should talk about breast cancer treatment and what has happened with breast cancer treatment over the past five, 10, 15, 20 years. And I'll do this pretty briefly.

Twenty years ago we thought of breast cancer as one monolithic disease. We treated it all about the same. Somebody would come in and say, "What kind of breast cancer do I have?" And I'd say, you have stage one, you have stage two, you have stage three breast cancer." But in other ways, we didn't know how to tell one woman's breast cancer from another.

And the stage tells you how much cancer there is, but it doesn't tell you anything about the personality of the cancer. And where we have excelled over the last two decades is understanding more about the personality of different cancers or the biologic behavior of those cancers.

And the result is we no longer have one size fits all treatment; we have one size fits all. We have treatments for women who have HER2-positive breast cancer, and women who have estrogen-receptor-positive cancer, and women who have Triple-negative breast cancer. Now in all of these areas, we're finding out that there are sub diseases within those individual entities, so not all HER2-positive breast cancer is the same.

Certainly, not all triple-negative breast cancer is the same, and for sure the 75% of women who have estrogen-receptor-positive and HER2-negative breast cancer, that's a very mixed group of tumors and patients who have them. And so we're doing a lot better.

We're doing a lot better in terms of having better treatments for many women, and for many others, we're also learning that we can do as well by them and avoid a lot of these toxicities and side effects that Dawn was talking about by and at sometimes backing off, but backing off in a very thoughtful way so that we're not putting anyone at risk, but we're simply trying to give the most effective treatments to the patients who need them.

And for those who may not need such aggressive treatment, we're learning that in some situations we can carefully do less and there are many people around the country who have taken that approach in terms of trying to figure out which are the patients where we need to develop new drugs and new treatment approaches, and who are the patients where perhaps a little bit less is equally good?

And this isn't just in medical oncology with drugs. I looked over and saw Laura Esserman sitting someplace here, right there who is as many of you know a surgeon at the University of California at San Francisco and has run a large research program looking at both ways that we can give more and give less medical therapy, but also thinking about the surgical issues and the radiation issues.

Because the whole treatment approach we take sometimes is pretty overwhelming for people. And to the extent that we can be more specific and more tailored to our approaches, we're going to do better. And I actually think that we're really getting there. Happy to answer questions about this as time goes on.

Dr. Larry Norton: Thank you. Thank you so much. There's clear linkage here between the notion. I just want to say editorially is that I've seen the whole transformation of the treatment of breast cancer really in my career. I've been involved in medical oncology from seven years after the very beginning except for the first seven years, I've seen the whole evolution of the field.

And in breast cancer, which has really taken the lead in many respects in terms of moving forward in many ideas. We've really reached a point where we can start talking about making the therapies more effective and less toxic simultaneously by choices, appropriate therapy for the right patient by handling side effects of therapy and make sure people take their medications.

And this is really a remarkable thing because you go back 20 years ago, 25 years ago, it was just more and more and more suffer. You got to suffer to get the maximum effect, you got to push people forward in that regard, and that was a very important point in the evolution of the field, extremely important point in the evolution of the field.

Now we're at another point, which is really extremely gratifying, and we'll probably have more to talk about as we move forward. And to talk about like feeling really good, I brought Neil Iyengar. All right.

Dr. Neil Iyengar: That's a great introduction, thank you. Thank you, Larry. I hope I can make everyone feel really good this morning. I'd like to start by saying good morning and it's my great privilege and honor to be sitting on this esteemed panel and we're grateful for the support of the BCRF for really accelerating our research program.

My name is Neil Iyengar. I'm a medical oncologist and a clinical investigator at Memorial Sloan Kettering Cancer Center and we focus on how we can optimize our metabolic health for cancer and for improving response to cancer therapies. In other words, preventing resistance to cancer treatment.

So what do I mean when I say metabolic health? Well, I'm talking about factors that we might think about when we go to see a cardiologist or an endocrinologist. Things like diabetes, blood sugar levels, insulin levels, cholesterol, obesity. We know from the work of several BCRF investigators, epidemiologists here today that obesity is a leading modifiable risk factor for the development of several cancers.

At least 13 cancers are related to obesity, and that number will probably grow as we learn more. And if we think about obesity as a classic state of metabolic dysfunction, there's a lot going on. So we partnered several years ago with the insights of Cliff Hudis who many of you know, with Andy Dannenberg, a BCRF investigator who's here today as well to collaborate on really understanding the biology of why obesity can promote the growth of breast and other cancers.

If you think about the breast, it is largely composed of fat. Fat is our most metabolically active tissue. And many of you have heard about the concept of the tumor microenvironment. Well, if you look at the tumor microenvironment of breast cancer, one of the most prominent components of that microenvironment are fat cells.

And what we've learned is that in the setting of obesity, the fat tissue in the breast and elsewhere can become dysfunctional. Specifically, it can become inflamed and produce inflammatory molecules, which can directly stimulate the growth of cancer cells. In addition to that, those inflammatory molecules can stimulate the production of the enzyme aromatase, which many of you know is the key enzyme for the production of the hormone estrogen.

And so what we've found is that this fat tissue dysfunction in the breast can create a tumor microenvironment that is inflamed and pro-estrogenic and ripe for the growth of breast cancer. And this classically happens in the setting of obesity, but beyond obesity, we've also found that in up to one third of women who are not classically defined as obese, who have a normal weight, who appear to be healthy and may even be told by their physician that they're healthy, up to one third of these women also have this fat tissue dysfunction, inflammation, higher levels of aromatase in the breast fat.

And so we've learned from the research of several other BCRF investigators here today who've pioneered lifestyle interventions for the treatment of side effects, which we heard about from Dawn, that these lifestyle interventions can also improve the metabolic state of the body.

And so now we're very interested in how we can develop precision lifestyle interventions to help in the prevention and treatment of breast cancer. And what I mean by prevention or precision lifestyle interventions is building on what we heard about from Eric that this concept of one size fits all doesn't apply not only to our breast cancer treatments, but also to lifestyle interventions.

And so we're developing personalized exercise prescriptions using BCRF support to leverage technologies like tele-exercise where we're shipping treadmills out to patient's homes equipped with tablets such that they can interface through video conferencing with our exercise physiologists here in Manhattan to participate in supervised precision personalized exercise.

We're developing nutritional interventions, for example, partnering plant-based diet approach with precision exercise for women who are taking aromatase inhibitors to try to improve that health of the breast fat. And finally, if you think about the biology of tumors and how we develop new molecular therapies that are specific to the biology of tumors, we can start to think about that same paradigm for lifestyle interventions like nutrition.

Some tumors are dependent on growth factors or growth pathways that involve insulin. So we're testing diets that lower insulin, like low carbohydrate or on the other end of the spectrum high protein diets like even the ketogenic diet for supporting the treatment effect of some of our new breast cancer therapies.

And so what I hope I've conveyed to you is that one diet or one lifestyle intervention may be right for one person, but may not be the right approach for another person, similar to how we think about our breast cancer therapies. And with that approach, we hope to really develop personalized guidelines, interventions and recommendations for lifestyle interventions that could have an anti-cancer effect.

Dr. Larry Norton: Neil, thank you very much. The general theme is, which we didn't intend, but is obviously rising is personalization, doing the right thing for the individual. The right way to intervene so that people can actually take medicine they're supposed to take, the right treatment and the right exercise.

I saw a lot of heads shaking while that was going on. Fill out your questions, all right, please and hand them forward because I think we have a lot to talk about with all of these three topics. But of course the thing that's most, most specific to you are your genes, and that's something you can't escape, the genes you're born with. Judy, do you have any thoughts about genes and cancer?

Dr. Judy Garber: Is that what you wanted me to talk about? Oh, I'm Judy Garber. I'm a breast oncologist too and I do clinical cancer genetics at the Dana-Farber Cancer Institute in Boston. And I was hoping Neil would have an exercise intervention for the investigators that would help us do it.

Dr. Larry Norton: Oh, no, no, I'm-

Dr. Judy Garber: We're in a do or not do, we're in the do side, so personalized would be great. I've worked in cancer genetics for a long time. BCRF has been involved in supporting cancer genetics really almost since Mary-Claire King first mapped the first BRCA 1 gene.

And many of us collaborate, which is something else that's characterized BCRF investigators and breast cancer as a field because we needed to work together to get enough numbers to work. So we've known now for many years that breast cancer in particular, but also ovarian cancer could travel in families and be related often to a genetic factor.

And thanks to work by Mary-Claire and many others in this room, we now know about many genes. So we know about BRCA 1 and 2 that are the most common genes, which we've been testing now in many women with breast cancer and many with family histories for more than 25 years I think and finding mutations, but we've also learned that there are more genes.

And we've learned part of that through the work of people like David Livingston, Alan D'Andrea, Alan Ashworth who figured out what BRCA 1 and 2 did, that they're important in DNA repair, and then mapped down the pathways, looking at all the other genes that were involved to ask, were they also important in breast cancer?

And some of them are, and some to a lesser extent, and some of them contribute to risk of other cancers as well. So for our patients that we tested in the early days and didn't find anything, who still wonder, could there be something genetic? The answer might be that it's time to look again now at other genes.

And we've learned that our early thinking as is often the case in research, was guided by being strict, as strict as possible to try to have the closest definition so we can at least find these genes and figure out how to use them. So that was what I mean by that is people with the strongest family histories.

But we've learned that many people may not have a very strong family history. Through no fault of their own. They may have mostly male relatives in which you don't see the breast or ovarian cancer, so you've had to think about expanding who gets tested and how to make testing more accessible to the broader population of people who may not realize testing is for them.

Now we've had to make testing safer, so to work to make the penalties by your insurance companies or otherwise against discrimination against testing. And we've had time to do some of that, but now we can concentrate on making testing more available for appropriate populations.

We're not ready to tell everybody necessarily to be tested, although I don't think we're too far from that, at least every cancer patient. So there are studies that are here like the before study, which is for the Ashkenazi Jewish population looking at people who really may not realize at all that they have risks, but just by having even a Jewish grandparent, you may be Jewish enough to have a 10 fold higher chance of carrying a BRCA mutation.

And you may not find it until you're like the internist I saw on Tuesday who's had absolutely no family history, but had ovarian cancer. And that's when she learned that she has a mutation that she inherited from her father and so hadn't been seen. One in 40 if you've heard about them, that's their story.

We want to prevent this and prevent the deaths from cancer that are avoidable, not only for our breast families, but also now we've learned ovary, pancreas, advanced prostate cancer. So the guidelines for testing have expanded so that people with those diagnoses are found.

And part of that is to help prevent cancer in their families, and part of that is because there are treatments now for people whose tumors arise in the setting of a mutation that makes them vulnerable to certain kinds of exploitation by treatment.

So Eric can talk about personalized treatment, this is really personalized treatment. It's about the way the tumor came to be as much as it's biology determined by that. So these are the PARP inhibitors. And now there are drugs for people whose tumors become resistant to the PARP inhibitors and can get other drugs to try to restore sensitivity.

Many people in this room are responsible for trials showing that these drugs are effective in advanced disease, now there are studies moving them back to an earlier phase of treatment. And not only treatment, but actually, probably the reason many of us went into this field was to look for prevention strategies, and not necessarily only the prevention strategies that we all find, at least in theory, much more acceptable like diet and exercise, which you know are hard to get people to do.

So we'll leave that to Neil, but also to other strategies, immune strategies, which are very interesting. Try to get the immune revolution to also benefit prevention, but also drugs that target particular targets. Geoff Lindeman is here and his work has identified a molecule that looks to be important in BRCA 1, breast cancer development.

And now there's an international study asking, "Can we actually reduce the risk of breast cancer or at least delay it so we can put off those prophylactic mastectomies?" And in that mode, even beyond that, BCRF is investing in prevention, in prevention studies, Novel trials, and Novel approaches this year that we hope will move prevention forward so we can catch up to treatment.

Dr. Larry Norton: Superb. My goodness. The evolution of our field toward knowing much more about the individual so that we can do things that are specific to the individual rather than groups of individuals has really been extraordinary. And I think it's revolutionary to actually hear it with my colleagues actually presented the notion that it's not just a matter of what exercise... Go to the gym and exercise is not necessarily good advice, is bad exercise.

You can actually exercise too much, for example, so knowing something about that, knowing about your genes specifically for prevention strategies and moving forward. And I think we're going to have a lot of discussion of that as we move forward. What is the right therapy so you don't get stuff that's going to hurt you and not necessarily help you.

And also, frankly in my mind, leave room for advances that could then be added in. If you clog up treatment to make it too complicated, it's very hard to back down and very hard to add onto it things that may be useful going off in the future. And ways of handling the complications of therapy in such a way that people can actually adhere to regimens that can help them all depends upon analysis of the individual.

And so it's the revolution of the individual that we're hearing about, which is really remarkable. I think it's partially in my mind just to share with you, it's advances in science in terms of understanding this, but also I think it's part of the digital revolution, the idea of enormous amounts of information that can be available and that can help individuals.

We all have enormous access to information that we never had before. I have a smartphone in my pocket, I can get more information out of this than I could have any other time in history and all of us can basically do that. But the idea that information about you as an individual is power for you in terms of your health and the health of your family, I think is all part of this dramatic change really in society, a dramatic change in our way of thinking about ourselves.

Now, you'll notice I'm not wearing glasses this year because I had my cataracts done, but that also has a downside, which I got to do this all right, which I couldn't do before. This is a really, I think an overarching question I think for all this, and I'm just going to read the question because I think it's well worded.

Why do some people still get breast cancer even when they do everything right, healthy weight, diet, exercise, no drinking, family history, et cetera? There's a philosophical, sociological component of this. Who wants to start that off? Do you have to do something wrong to get breast cancer? Is breast cancer a punishment for something you've done wrong? What do you think? Judy, what do you think?

Dr. Judy Garber: No. Unfortunately, we're not able to explain most breast cancers. We can point to genes sometimes, we can think about lifestyle factors, we can talk about diet and all kinds of unhealthful behaviors, but most of that, but the Metalogic studies show that we can't attribute a cause for breast cancer.

And I think to some extent it's chance that our genes are reproducing all the time. Every time your cells turn over, you have to completely reproduce with almost exact fealty, the DNA content of your cells, all your chromosomes. And cells make mistakes and they have DNA repair systems, but as we get older, we make more mistakes, and those mistakes, if they're in the breast, can go on to be breast cancer.

If the genes are the ones that are responsible for keeping the cells on track, then it's even easier for cancers to develop. But this is true of all cancers, not just breast cancer, of childhood cancers, we can't explain those either. So I don't think that it's really possible to be organisms without some risk of cancer.

Unfortunately, too often in women, these are cancers, and I would say that I neglected in that to talk about environment because despite decades of very careful study, we've done not very well at being able to figure out, which environmental factors we could remove to reduce breast cancer risk. And I do think that there's something to that.

Dr. Larry Norton: Neil.

Dr. Neil Iyengar: I think I would like to add to that especially in the realm of lifestyle interventions like diet and exercise that we really have to be careful to distance and move away from the notion that it's something that a person did. Their diet or their exercise for example, that may have given rise to their breast cancer, that's far from the truth.

And I think that part of that might be how the message is put out there, for example, many of you may have seen the updated guidelines for exercise, for prevention and during cancer treatment published yesterday by The American College of Sports Medicine. The article in the New York Times of course suggests that we may be able to avoid cancer by exercising.

I think that that diminishes the science and the understanding of the complexity of the individual, their genetics, their environment, everything we heard about just now from Judy. And really understanding that individual biology and parent lifestyle interventions that may compliment other prevention strategies or cancer treatment strategies is something that we have to think about with much greater nuance and depth.

Dr. Larry Norton: We could talk about this one topic really forever. There's always that question, which is a recurring question always reminds me of the opening scene of... There was a book about the beginning of the space program called The Right Stuff and they made a really good movie about it. I think the book is better than the movie actually, even though the movie was really great.

And the opening scene is a bunch of test pilots sitting around because one of their colleagues testing the airplane has just crashed and died. And they all go around saying all the things that that pilot did wrong, "Oh, we know he never checked his fuel, he never checked his gauges, he never got enough sleep." They were all going round in a circle.

The fact that matters is he's a test pilot, sometimes planes are going to crash and you could do everything right and they're going to crash, but there is one other thing you can do in addition to everything we've talked about, in addition to understanding that that things can happen to you that are bad even though you've done nothing, which is support research. You're all here to support research.

All the advances we're talking about just didn't happen by just random chance, they all happened because of the sport of research, basic research, applied research, clinical trials, survivorship, the whole spectrum, which is represented by my extraordinary colleagues on both sides of this room.

So your supportive research helps you and helps your family, and I just want to point that out as an extremely important component of what you can actually do in addition to all the personal things that you can do that we've already mentioned.

I have a question here that I know was going to come up because it was just on the news yesterday and apparently made a whole big fuss, so I'm just going to answer. Is about a breast cancer vaccine that was tested in Moffitt apparently and it was presented in a very short press release as a major, really advanced.

She got a vaccine and her cancer disappeared. It wasn't breast cancer, it was ductal carcinoma in situ, which is not a cancer. It's a sign... It's a bad term because it has the word cancer carcinoma in it, but it's basically it's an indicator of the possibility the breast would turn to cancer.

She had a positive biopsy, she got a vaccine, then had re-excision and they didn't see evidence of DCIS. Sometimes do nothing if you have a positive biopsy and do a re-excision, you've got no evidence of DCIS. It needs an enormous amount more study to see whether it's something that's a value or not.

And it's received a lot of... When I got home last night after we had BCRF events last night, I had about 40 emails about, "Why can't I get this new vaccine?" So really it's very early on, it's got to be tested appropriately. It wasn't a cancer vaccine, it was a vaccine for cancer predisposition. So I just wanted to mention that because we have a bunch of people that have asked about that.

One thing I'd like to ask Eric about is there are a number of questions here about the side effects of chemotherapy. We heard about the side effects of aromatase inhibitors therapy, what's going on in decreasing the side effects of chemotherapy?

Dr. Eric Winer: It's a complicated question because there are a number of different things going on. First of course, is trying to give less chemotherapy and doing it... avoiding chemotherapy when we don't need to give it. And the second I would say is, how we give the therapy. We know that when we combine many drugs together that there are more side effects than giving drugs one at a time.

We know that sometimes it's better to combine them, but sometimes it isn't. But in terms of actually reducing the side effects that exist, there's also a great deal of research that's going on looking at that and there are many BCRF investigators who have focused their efforts in that area.

We know that treatment of nausea for example, is something that is still a problem, but it's very different than it was 20 years ago. I think one of the most challenging side effects that we see is actually neuropathy, which can both be an acute problem and a chronic problem, and so needs a great deal of study.

But that's another one where I think that much of what we need to do is pay close attention to the patient and be careful to back off on the therapy when the side effects are beginning to get to be perhaps worse than any other problem. I think it's something that when a patient is seeing a doctor, there's often a focus on treating the cancer and not so much paying attention to the side effects.

And sometimes patients don't want to waste time and the appointment to talk about side effects as much as they want to talk about where they're going with their cancer treatment. And I just remind everyone that it's really something that has to be part of medical conversations all the time because the one thing we don't want to do is treat someone effectively and then leave them seriously debilitated with side effects, and that does happen occasionally less than it ever did before.

Dr. Dawn Hershman: Just to add to that. I think one of the areas, Eric spoke about nausea, it used to be debilitating, used to be the number one reason why people couldn't get their treatment. And with a lot of research now there are so many drugs, it's just not an issue anymore. So few people really suffer.

Now, it's not totally gone, but it's so much better than it used to be.

Dr. Eric Winer: You always have to be careful when an oncologist says that something's well tolerated.

Dr. Dawn Hershman: Exactly. One of the reasons why-

Dr. Judy Garber: Except Dawn.

Dr. Dawn Hershman:  ... a lot of women didn't want to get chemotherapy is because they didn't want to lose their hair. And in the past couple of years we've made enormous progress with some treatments to preserve women's hair, and that's a really big quality of life issue for people now that we've reduced the length of some of the duration of treatments, but women would still lose their hair and that was really devastating.

And to be able to offer somebody and say, "Look, it's awful that you have to go through this, and I'm sorry you have to go through this, but there is one thing we can do to help you get through it, and maybe we can keep... maybe if you..." And what the treatment is called, scalp cooling, and Hope Rugo was one of the lead authors on that.

I know she's a BCRF researcher and others. Some of the cooling technologies to preserve hair has been a huge improvement for people.

Dr. Larry Norton: Mary-Claire, I'm got to ask you this question because this is a question of historic importance. I'll just read the question specifically. Are breast and ovarian cancer related? And if so, how?

Dr. Mary-Claire King: Thank you, Larry. I'm honored that you ask an option a medical question. They certainly are related. This reminds me to tell you one of my favorite mantras, which is that we, at least, we females are the most successful mammals there have ever been. We are fertile during a longer period of our lives than any mammal has ever been previously.

We are cognitively active post fertility longer than any mammal has ever been previously, and at the heart of both of these tremendous evolutionary success stories is estrogen. And estrogen is also at the heart of the relationship between breast cancer and ovarian cancer.

So while from the point of view of a geneticist and of course a lover of BRCA 1, it's critical to think about the ways in which mutations in BRCA 1 and its sister genes predisposed to both breast and ovarian cancer and how we can prevent both breast and ovarian cancer by being aware of those mutations.

It is, I think from the point of view of a woman, enormously important that we think about the role of estrogens in all of this. And from that perspective, the activity of BCRF in supporting the work of my colleagues here who work on the basic biology of estrogens and how by understanding that basic biology, we can hope to modulate the effects in order to preserve for us are tremendous evolutionary advantages and our cognitive activity, and our looks well, well, well past, past youth.

At the same time to be able to modulate those effects so as to reduce the risks of breast and ovarian cancer both for women with mutations in BRCA 1 and the sister genes and for women who are mutation free. Thank you, Larry.

Dr. Larry Norton: Okay. Thank you. Judy, somebody here had their BRCA test 10 years ago and it was reported to them as negative for a deleterious mutation. Should they get retested?

Dr. Judy Garber: I think for many people the answer will be yes if they had enough risk of having a positive test to have thought about it before, and the test was negative. Now the technology would let you look more completely at the BRCA 1 and 2 genes and to look at other related genes.

But this is still a question you could ask your health care provider who should know, and if not, then in New York there's no way to avoid genetics programs. They're everywhere and you can ask a genetic counselor or a genetic health professional whether you should rethink testing.

It's easy to do and still a blood test or a saliva test. It's much less expensive than it used to be and it is more complete.

Dr. Larry Norton: I would mention the whole idea of genetic counseling really started with Joan Marks working closely with Mary-Claire. Very early days when we didn't really know anywhere as much as we know now. She was a recipient of an award from BCRF many years ago really for that work, and I just want to call her out as somebody who really started a whole field that I think has been extraordinarily productive.

Can BRCA genes skip a generation? This is somebody whose mother actually had deleterious mutation and she got tested and was negative, but she's still worried about her kids getting the abnormal gene. Go ahead Judy. Quick answer.

Dr. Judy Garber: So unless my colleagues have discovered something else recently, I don't think so. Genes cannot skip a generation. They have to go from parent to child, but you do have to remember that we're not the only parent. The other parent could have inherited a gene that may not have been tested for, that also could be transmitted to the child.

But in general, if you have tested negative, you cannot pass this onto your children. They don't need to be retested to confirm that.

Dr. Larry Norton: Okay.

Dr. Eric Winer: I think what's confusing is that diseases can skip a generation because just because someone doesn't have breast cancer doesn't mean that they, for example, didn't inherit an abnormal BRCA gene or, this applies to other illnesses as well. But genes are pretty certain

Dr. Judy Garber: Certain. That's not qualified unless somebody else is willing to stand up and say otherwise, they don't skip a generation.

Dr. Larry Norton: I hate to say this, but it's very important to say it. A surprisingly high percentage of people have a father that's different than they think they do.

Dr. Eric Winer: I knew that was coming.

Dr. Larry Norton: All right.

Dr. Judy Garber: I did try to point out there was another parent.

Dr. Larry Norton: And the scary thing about that is when I ever make that statement, all the women in the audience laugh and the men stay stony silent with a heart. So I just want to emphasize that. And the whole question, I think this is going to evolve over the next two or three years even very, very quickly, the whole notion of family history being the best predictor of who should be tested and whatever.

And Mary's written extensively about this and there's a lot of discussion and we're seeing a big movement toward more testing rather than less. But I think we're going to leave that for subsequent discussions because it's really such a big topic and we should have really formal presentations on this.

Dr. Larry Norton:  Dr. Chandarlapaty recently joined the scientific advisory board BCRF as has Eric indeed, and the question really is, people are hearing a lot about blood testing for diagnosis of cancer and for screening for cancer.

Dr. Larry Norton: I've seen ads on late night TV myself in this regard for following patients who've had cancer. It all relates basically to test for DNA in the blood. What do you think of that?

Dr. Sarat Chandarlapaty: This is an amazing research opportunity for us to be able to noninvasively look for biomarkers that can tell us about cancer that may still be there or that may be getting worse on therapy. It is still very much in the research realm. However, we don't really have a current test that we can widely give to either detect cancer as a screening modality or else to modify treatment.

Not yet, but I think that that's something that we're all working on in the research setting that I think is extremely promising, showing very robust results.

Dr. Larry Norton: Okay. Thank you. Laura Esserman, UCSF has something to add to that right here.

Dr. Laura Esserman:  It's just as important that we think about personalizing screening and prevention in the same way. And we're running a large national study called The Wisdom Study to test annual screening against personalized screening. And I think these kinds of tests we have to be very thoughtful about.

We don't want to do a lot of things to people who have extremely low risk because you're likely to do more harm than good. So I think a personalized screening approach may be the perfect way to find the very populations at the highest risk where a different kind of testing are earlier detection may make a big difference and where you're going to do less harm and a lot of good.

Dr. Larry Norton: Good. Laura, thank you. Lisa Carey, are you around? Why is everybody who I'm asking is sitting way in the back here. Come up to the forward because the people have heard that you can actually design studies that are targeting DNA abnormalities and mutation status rather than the diseases, and they're calling them basket trials.

You gave a really superb talk about this yesterday to the scientists in our symposium. What's your current feeling about the notion of treating the molecular abnormality rather than treating the disease specified by the organ, which it arose?

Dr. Lisa Carey: Well, I think the world of cancer therapy is absolutely moving towards using the molecular aberrations as the guide to what targeted therapy is going to work the best because that also allows you to emphasize the effectiveness and minimize the toxicity, so there is no question that we need to do that.

It does get complicated and I think in some of the ways that Larry is mentioning, we can't underestimate the complexity of this. And there have been studies where people had super effective drugs for melanoma with particular molecular problems in their DNA and they just assumed the drug would work the same if you found that same molecular abnormality in a colon cancer and it doesn't.

And the truth is that cancer, the biology is very, very sophisticated and complicated, and so it's not easy. So you need our scientists who actually help inform what we're studying and how we're studying it. And we have to look at things in a system-wide way and not just assume that looking at one thing at a time is going to work.

Dr. Larry Norton: Excellent. Thank you. Obesity is bad for you, we all know that. But is it the obesity or is it the things you are eating to make you obese that is the bad thing? In other words, if you happen to be overweight or even on the obese side, but for some reason there's some genetic predisposition to fat accumulation in your body and you're actually, you're eating a fairly healthy diet.

This one zeroes in specifically on dairy, but I think is a general question. Is it the fat in your body or is the things you eat to make you fat that's important?

Dr. Neil Iyengar: I think that's an excellent question and it gets back to this notion of understanding individual biology. I mentioned earlier that we find this fat tissue dysfunction in up to a third of people who are normal weight, who are not defined as obese. And in fact there is a small percentage, up to 10% of individuals who do meet the definition of obesity, who actually have functioning fat tissue and healthy fat tissue.

And so I think that there are components one can develop the bad biology of obesity independent of what body weight is through their lifestyle, but that's not the whole story. There are certainly genetic predispositions, environmental factors that contribute to whether or not a person's metabolic state is actually healthy or unhealthy and is going to contribute to the growth of cancer.

So the short answer to that question is it really depends on the individual, whether or not it's their underlying metabolic state or it's their lifestyle or a combination of both.

Dr. Larry Norton: Superb answer. This is a recurring question, which I'm just going to talk about here. Do you want to answer that briefly, Joyce? Mic over there, but then I want to make a general comment.

Dr. Joyce Slingerland: A lot of people ask the question, is there good fat and is there bad fat? Am I a fat person who has okay fat? And I think we don't know a lot about how the microbiome and the specific components of our diets-

Dr. Larry Norton: Define microbiome.

Dr. Joyce Slingerland: Microbiome are all of the bacteria that are part of our normal body in our skin, in our gut, in all of the openings to our body, our nostrils, our vagina, and all of those other places. There are ways in which our body interacts with the environment that influence putting on weight, et cetera.

So there are a lot of things we don't know about fat, but one of the things that I think is really an important take home message is that interventions that reduce weight have been shown to affect survival from breast and colon cancer, so bariatric surgery in individuals who are obese has been shown to influence survival from breast and colon cancer.

And interventions, there's very active ongoing investigation to see whether lifestyle interventions with diet and exercise impact survival from breast cancer and the answers are not yet all in. But I think there's very clear evidence from biomarkers that blood tests and markers of inflammation do go down with exercise, and estrogens do go down with diet and exercise.

And so if we can influence by weight loss, the biomarkers are bad outcome of breast cancer, it's probable that we will influence things. And I think the take home message is wait, wait, wait and wait. There's probably not good fat... There may be details of good fat and bad fat, but for the majority of people, getting rid of it is what really matters most.

Dr. Larry Norton: There's a recurrent... Thank you. Just two comments, one quick editorial is that when we first started doing the symposium, we talked a lot about the cancer cell and you'd hear we're talking a lot about other kinds of tissues in the body that are very related to the cancer, white blood cells, fat cells, even bacteria that exists in the GI tract.

The whole picture of what is cancer is rapidly evolving. The leaders in the field are all around the room or dispersed among you in terms of answering these questions, and I think that's an extraordinary, exciting time biologically. The other point that I wanted to make is that... It's a recurring question is, you folks are saying a lot of smart things.

How does my doctor know these things? How do I get this information? Am I getting too much therapy? I'm getting too little therapy. What about side effects? How can this be handled? I think one of the important things that BCRF is going to be... is already involved in it, Judy already mentioned something called The B4 study, which is a study of genetic predisposition.

But a very important component of that can often sitting in the front row, instrumental and others in the room in this regard is how to disseminate information, how to educate people about themselves so that they can then ask the right questions and get the right answers that are really specific for them.

We're not very good at this yet, frankly, and I think that it's not something we've emphasized in a whole lot in the evolution of healthcare, but now's the time to do it and it's something BCRF really needs to focus in on. Eric is dying to say something, and then Dawn who's going to say something to you after that?

Dr. Eric Winer: Want to go first?

Dr. Dawn Hershman: I was just going to say, we now have many technological tools. Healthcare technology has advanced a lot to help us disseminate information better. Things like Twitter, you see like important results getting disseminated very quickly.

You see that there are social networks that help doctors that are from areas where they may not have experts to ask questions to experts to get answers quickly that we can make the world a lot smaller by using technology, and that can help us disseminate information all over the world.

Dr. Eric Winer: Great. Two quick comments. One, we are in the midst of conducting a very important national study that there may even be people in this room who are participating in, which is asking the question that if you're a woman with breast cancer and you are presently overweight, does intervening with an intervention that seeks to reduce weight, whether that changes your chance of having a recurrence of the cancer.

They're going to be 3,000 women enrolled in that study. There are already about 2,000 enrolled. It's being conducted by one of our colleagues, Jennifer Ligibel and many others working with her nationally and it's really important.

The other comment that I just wanted to make is, comes back to the importance of research. And it's not just about drugs of course. Drugs, you can only take when the FDA finally approves them, and so when something's being studied, it's not necessarily easy to just take a drug.

That's not always the case with other sorts of interventions, or circulating DNA, or a variety of different tests or interventions that don't necessarily need to be FDA approved. But I think it's very important that we're rigorous about how we evaluate these things. And I'm sure Sarat would agree with me that in terms of circulating DNA that companies are advertising.

At the moment, we have to be very careful about how we apply those kinds of things in practice until we have more information. And so just because something's available doesn't mean you should rush to get it.

Dr. Larry Norton: My favorite quote is, Mark Twain, "It's not what you don't know that gets you in trouble, it's what you know for sure that turns out to be wrong." And in healthcare, this is extremely important.

I'm just underlining what Eric has just basically said is that the big change in this regard is, I guess, also part of the digital revolution is that on the basis of almost no information, or false information, or manipulated information, or very preliminary information, you can have big changes because of the dissemination of the recommendation via social media tools and basically change the landscape in ways that we can't ask the questions really anymore and get to the definitive answers.

So it's extremely important to have definitive answers before you proceed. And there's lots of people, by the way, and New York city has become really one of the hotbeds for all sorts of alternative ways of treating cancer. People getting all sorts of infusions of things that are supposed to prevent cancer, and prevent heart disease, and other things.

You can go into any health food store and shelves, and shelves, and shelves of various products, each one of them is promising wonderful things. Be really careful. I've said this from this podium before, but I'm saying it again, is there is evidence and then there is superstition. Opinion is not valid, you really want evidence.

Science is really important, supporting science, following science, evaluating things scientifically is important for you as an individual as well as for all of us as a society. There's another question that comes up, that'd be a third card is about immunotherapy for breast cancer.

And so Jedd Wolchok is sitting right here, one of the great... We have many leaders of the field basically in this room as well, but I'd like to ask Jedd to talk about current status from your point of view, is immunotherapy for breast cancer primetime?

Grab a mic over here.

Dr. Jedd Wolchok: It only works if I stand up? Okay.

Dr. Larry Norton: Yes.

Dr. Jedd Wolchok: I'll try not to read into the fact that you introduced the immunology question with is the superstition or not. So I think-

Dr. Larry Norton: Those were two unrelated thoughts.

Dr. Jedd Wolchok: Okay. All right.

Dr. Larry Norton: That's your own paranoia there, so go ahead.

Dr. Jedd Wolchok: I guess I've been working with you for too long. So I think that we're very aware that immunotherapy has emerged as another standard way to treat some cancers, and melanoma and lung cancer, bladder cancer are some of the more well-known ones where they've made a very significant impact for some patients with those diseases.

More recently, I think it's quite clear that a subset of patients with breast cancer do benefit in a modest way, and these are of course patients with triple-negative breast cancer where we think that the biology and the genomic landscape, the pattern of mutations that make the cancer perhaps look different than the normal breast tissue is more prominent in triple-negative cancer.

And that when combined with chemotherapy, an immunotherapy that blocks a pathway called the PD1 pathway, which is essentially a molecular break on the immune system can lead to more patients having regressions. I think it's an important first step. It's clearly not the end of our investigations in how to best use immunotherapy in breast cancer.

I think we need to understand more about why other breast cancers may not be as responsive and what we might do to try to remedy that. So I think now in 2019, immunotherapy is a standard approach to treat breast cancer, specifically triple-negative breast cancer, but we have much more research to do, the importance of which was emphasized by Larry. Thank you.

Dr. Larry Norton: Thank you. I passed out a couple of cards because there were a couple of questions I think are specific to presenters. Eric, brain metastases.

Dr. Eric Winer: Is there a specific question or…?

Dr. Larry Norton: Where do we stand in the treatment of brain metastases?

Dr. Eric Winer: In certain types of breast cancer, so for example, HER2-positive and triple-negative breast cancer, brain metastases or the cancer spreading to the brain is actually relatively common during the course of someone who has advanced breast cancer. Very uncommon to be the first place that that cancer shows up again after a woman has been treated for breast cancer.

But again, in somebody who is living with advanced breast cancer, it's relatively common, and it can happen for that matter in women who have estrogen-receptor-positive breast cancer as well. Our treatments have gotten better. There's still a long way to go and we have challenges, and I talked a little about this yesterday at our retreat, but some of those challenges are that the brain probably doesn't allow drugs to get in as readily, although it does allow some drugs to get in.

There may be differences in the tumor microenvironment in the brain or in the microenvironment such that brain tissue is different for fairly obvious reasons than many other parts of your body. And there may be some specific genetic changes that occur in these tumors or tumors with specific abnormalities may tend to spread to the brain, and we need to understand all of that better.

There are many people working on new drugs for treatment of brain metastases and the FDA has recognized the importance of this. And finally, I think that we can't underestimate the importance that has been played by surgery and some new and much, much more specialized radiation techniques and treatment.

So by no means is this a happy story in breast cancer. We don't want to see patients whose cancer spreads to their brain, but people can live with that complication and live with it well at times for much longer than was ever the case in the past. And I think we will continue to make progress, but we need support.

Dr. Larry Norton: Thank you, Dawn.

Dr. Dawn Hershman: I guess two things. One, I just wanted to comment on the issue of supplements because we've done studies that have shown that certain supplements, people were taking to prevent the neuropathy that Dr. Winer was talking about, actually can make it worse. And the critical importance of doing the rigorous studies is not just tell people what to do, it's also to tell people what not to do.

So it's not just about us having a perception that these things can be harmful, there's evidence that these things can be harmful, so it's important to do the research. The question on the card was, "Should I be taking hormonal therapy for 10 years? What's the optimal duration of hormonal therapy to take?"

I think it's very confusing for people because it's hard enough to get through the first five years, let alone to get through 10 years or even longer. And that's again where the whole concept of personalized treatment comes up. A lot of the benefit for longer duration hormonal therapy is actually to prevent a new breast cancer.

So are you at risk for developing breast cancer? Do you still have your breasts? Those are important questions. I think we're moving into, do you tolerate the hormone therapy? What is your risk to begin with in terms of the cancer coming back? And I think what's really exciting is that there are a lot of molecular tests being developed that may help guide these decisions to help figure out who's actually at risk for a late recurrence so that we can guide those answers better in terms of who should be on treatment longer versus not.

Dr. Larry Norton: And that work is connecting to cell-free DNA and monitoring, and I think it's a really rapidly evolving, very exciting field. Neil, I can't resist this one because this one is about yoga. Neil Iyengar... No, it's true, he's from that family.

Dr. Neil Iyengar: So we have a few poses?

Dr. Larry Norton: He's the only person I know you can have a conversation with him while he's standing there and putting his foot behind his neck. Health benefits of yoga and potential dangers of hot yoga. What are your thoughts?

Dr. Neil Iyengar: Okay. Well, I'll start a little more generally. There has been work, important work looking at yoga and we know that from the standpoint of mental health interventions that emphasize mindfulness, as well as more structured interventions like cognitive behavioral therapy and so forth, can be effective tools for managing a lot of the side effects including anxiety or mood changes that accompany breast cancer treatment.

And certainly yoga is within that toolbelt of potential interventions that can be incredibly helpful for managing those types of side effects or not even side effects, but just general experiences of individuals who are either at high risk or have developed breast cancer.

We are learning about the specific effects of certain types of exercises or physical activity behaviors, and there has been some preliminary work looking at yoga and other types of lower intensity exercise on metabolic factors, and I think that that's an exciting area of research as well.

So for now, all I can say is that we know from the mental health standpoint that yoga is incredibly helpful for some people. And to answer the hot yoga question, I'm afraid I don't have a good answer to that right now other than it is important that we think about safety for any type of intervention, be it a drug or be it physical activity.

And that's why one of the things that we are doing is taking a drug development approach to the development of exercise in, for example, phase one trials to find the right dose of exercise, the right type and dose of exercise, phase two trials to determine if that dose is effective in helping to shrink tumors, and ultimately phase three trials to look at survival.

And this is the kind of research that we need to do to develop lifestyle interventions.

Dr. Eric Winer: I'm trying to decide if I want the treadmill shipped to my house or the personalized yoga instruction.

Dr. Judy Garber: Both.

Dr. Neil Iyengar: I would say both attractive opportunities.

Dr. Larry Norton: Eric, I think we going to have to randomize that one. I think that's clearly a randomized question.

Dr. Neil Iyengar: That will be my next [crosstalk]-

Dr. Larry Norton: We have only a couple of minutes left, so I'm going to get myself into real serious trouble here because one of the questions is, on several of the cards, why is there so little research on metastatic breast cancer? But the fact is that BCRF has had a huge imprint, and I'm going to ask Dorraya, actually, I'm shocking you.

I know you're going to beat me up for this afterward. Come on right here, I'm going to give you the mic. She's really our new Chief Scientific Officer. Recent recruit has done a spectacular job. I just want to emphasize, everybody thinks that the BCRF is like us, there it is.

BCRF in terms of the science has an extraordinary small, but extraordinary effective scientific leadership group that Dorraya is now running, Maneesh who's not... He just doesn't hand out mics, but he's also been incredibly involved. And Margaret Flowers is here somewhere, Sarah Boll.

Why are we doing so little research on metastatic breast cancer?

Dr. Dorraya El-Ashry: Hi. We don't do so little research on metastatic breast cancer at BCRF. Since 2011 alone, we have invested over $160 million in metastatic breast cancer research. And at BCRF, metastatic breast cancer research goes along two pathways. We have the Evelyn H. Lauder Founder's Fund, which is focused solely on metastatic breast cancer and incorporates both basic research, but also clinical trials, and that has a $31 million to date investments in it.

And then in our annual work program of which many of the investigators are in this room, this year alone, we have $27 million, which is more than 40 percent of the BCRF investment total for this year in metastatic breast cancer research. So if we go back over the years, at least a third of all the investment in BCRF, in research is in metastatic breast cancer research.

It is the area that was my own research area. It is near and dear to my heart and I will steward BCRF to continue to keep this as a high priority of investment in metastatic breast cancer research.

Dr. Larry Norton: Thank you. All right. We've run out of time, we've got a ton of important questions here, some of them are rather specific. I'm trying to figure out some way that I can get the answers, people to answer that question and maybe BCRF's blog or some other means that we can... Some of these have more general topics so we're going to get to it.

I thank all of you for being here, for answering these questions. My extraordinary panelists, all the scientists who are around you, thank you for being here. Let's have a great lunch.

Outro: That was BCRF’s 2019 Symposium and a special Investigating Breast Cancer podcast. Thanks for listening. To learn more about breast cancer research or to subscribe to our podcast, go to BCRF.org/podcasts.

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