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Investigating Breast Cancer: Dr. Hedvig Hricak
How Dr. Hricak works to improve imaging technology to detect cancer
Read the transcript of the conversation below:
Chris Riback: I'm Chris Riback. This is Investigating Breast Cancer, the podcast for the Breast Cancer Research Foundation and conversations with the world's leading scientists studying breast cancer prevention, diagnosis, treatment, survivorship and metastasis.
Chris Riback: Dr. Hedvig Hricak: is, among many other roles, Chairman, Department of Radiology at Memorial Sloan Kettering Cancer Center. She also recently was honored by BCRF with the 2018 Jill Rose Award for outstanding research excellence. As you will hear, Dr. Hricak is extraordinary – not just in her work helping merge imaging technology with molecular medicine, but also in her teaching across borders. Among her wonderful lines in this conversation: “The best thing in life is to give,” and “The richness of life is in diversity.” Another one: “You are only as good as your tomorrow. So you have to continuously reinvest yourself. You have to learn and believe that with your experience, you’ll make a difference in patients’ lives.” Listen to this podcast, and you’ll know exactly what she means and the difference she makes in patients’ lives.
Chris Riback: Dr. Hricak, thanks for joining me. I appreciate your time.
Dr. Hedvig Hricak: Thank you for having me.
Chris Riback: We should start, of course, with congratulations. You recently were honored with the 2018 Jill Rose Award for outstanding research excellence for your seminal contributions towards merging imaging technology with molecular medicine from BCRF. What was the event like? How did that feel?
Dr. Hedvig Hricak: The event was much more than wonderful. The event was very, very emotional as well. The reason is we all, all the 300 researchers that BCRF has so ably led by Larry Norton and by Judy, but all the attendants in that room, we are all committed to one and only cause. That is really to help women with breast cancer, to make sure that the breast cancer is, I don't like to say will ever be totally cured, but can be a chronic disease that we can all learn how to live with.
Chris Riback: What drove the emotions? Looking back on the career being surrounded by so many other people dedicated completely to the cause, the women in the audience, the women you were thinking about, what drove the emotion?
Dr. Hedvig Hricak: Personally, the emotion, my personal beginning in the truly attachment, respect, and tremendous love for the mission and scope of the BCRF. As well as my respect for the fellow BCRF researchers, but also because BCRF always in my heart and my soul reminds me of Evelyn Lauder, its founder. You know Evelyn, I have tremendous admiration for, Evelyn. I remember her enthusiasm, her warmth, her friendship, her dedication to the cause of BCRF. She was a wonderful, wonderful woman and truly a mentor. And she embraced me from the day I came to New York, and it was very very special. So yes, for me in at one moment even brought tears to my eyes was just remembering how I would not stand there if it wasn't for Evelyn. If it wasn't for support of Larry Norton and also if it wasn't for wonderful, wonderful department that I have at MSK, and our breast imaging that was always supportive of the initiatives of the grants, of the new ideas.
Dr. Hedvig Hricak: You never ever achieve anything by yourself. You always, I feel I was really lucky to be at the right place at the right time, and met such wonderful, wonderful people. Yeah, so it is, it was very emotional.
Chris Riback: Well, you sound wonderful about it right now, and it must've been just a powerful and just memorable and terrific event. So congratulations to you and to them and you know when you talk about, the benefits that you got from the help of others, that helps move us very smoothly to the benefits that you have created for others as well. Particularly, in the areas of imaging and cancer. So let's talk about that.
Chris Riback: Why is imaging for cancer, but in particular breast cancer, and this is you know some of the core of the work that you have dedicated your career to, why is that so hard?
Dr. Hedvig Hricak: First of all my expertise and my longtime passion is women's imaging, but in women's imaging it is much more in the field of gynecology. Both uterine as well as ovarian cancer. And my other expertise is in prostate cancer and for both of that my work started way, way back with the beginning of magnetic resonance. However, I deeply care for improvement in cancer imaging and of course being involved with women's imaging from the very beginning of 90's when the entire movement started. Breast cancer imaging was always very important to me.
Dr. Hedvig Hricak: Regarding your question, why is imaging for cancer, for breast cancer so hard? It's actually not hard if you have proper training and expertise. And we need to understand that that expertise in oncologic imaging and imaging breast cancer has to include knowledge about imaging technology. So for example in breast cancer, you have to know how to perform and interpret ultrasound MRI, or Magnetic Resonance Imaging, and mammography. And then that is not enough, that expertise has to include knowledge of the disease. As radiologists we need that knowledge to understand which imaging to use when. And the second critical, is that the clinical questions that needs to be answered so we can make our report clinically relevant. There are many studies in the literature that show that when the same exam of breast imaging, is re read by a specialist that has training and expertise and the clinical knowledge, they make a difference in patient management in 20 percent, and as high as 35 percent.
Chris Riback: Wow.
Dr. Hedvig Hricak: That is huge, and it shows you how important that training and expertise are. And in radiology, there is a tremendous convergence of technology, you have to know disease and interpretation, how to report requires special education as well. And that is probably a problem nationwide, that we just need more well-trained breast imagers.
Chris Riback: That's incredible, and an incredible statistic. Is the focus, do you feel like the focus is there in terms of the training? Because what a difference it makes, you know what I'm hearing you say is absolutely, getting the imaging is imperative, but it's only half the story. You then have to have the right reading and the right clinical interpretation. Is, have you sensed...
Dr. Hedvig Hricak: And the knowledge of the disease. You know everything in life is evolution and dynamic. So the way we, the questions that were asked from radiologists in breast imaging ten years ago are different than today. They're much more granular and detail today because therapy has changed. Options have changed. We are now entering the era of reproductive screening, and to be able to contribute to that reproductive screening, you as the radiologist have to evolve as well. So those are elements that are critical, it is not you can learn fifteen years ago, and you are done. Absolutely, not. Everyday you are better and better, and you evolve with the science that's coming up.
Chris Riback: So a question on that evolution and tying it back to something you were saying earlier how your personal history might've been a little bit stronger or at least originated in it sounded like gynecology and prostate cancer, but you have been able to apply your skills and learn. And I know that you are a continual learner, learn in different areas. One of the most interesting things that I've learned in these conversations with scientists and researchers like you, is how you connect, people like you connect your work across cancers. For me, you really feel like the ultimate investigators, finding clues in one part of the body and divining how they may or may not apply to other parts. That seems to be consistent with your approach. Is it? Can you talk about how your work in one are of cancer may have helped you think creatively, or act directly in other cancer areas such as breast cancer?
Dr. Hedvig Hricak: Sure, for example I already said that I started with MRI of prostate cancer, and there are great similarities in the biology between prostate cancer and breast cancer.
Dr. Hedvig Hricak: So, in both it is a challenge. One of the very acute challenges is to determine tumor aggressiveness. And whether in fact the cancer may be non-aggressive for example in prostate cancer, as you know many patients are now considered for active surveillance. Which mean, instead of being treated immediately either by surgery or radiation therapy, the tumor is monitored to determine if it is progressing. Because many more men die with cancer, than of prostate cancer. So that decision to choose active surveillance is based on a combination of laboratory tests, pathology, and MR imaging. And now today sometimes we add information from genetic testing. A very similar challenge is now evolving, emerging in breast cancer. Not all cancers, even if they are genetically very similar are going to be aggressive. So one of the tasks for the next few years is how to identify a [inaudible 00:13:28] group of breast cancer patients that perhaps does not need aggressive treatment. And it has already changed, already not everybody with breast cancer needs chemotherapy, but moving forward we may be even less aggressive.
Dr. Hedvig Hricak: Another part is, that androgen receptor imaging and androgen receptor plays a big role in prostate cancer. And We have developed androgen receptor imaging to really search and evaluate metastatic prostate cancer in prostate cancer. But we know through evolution, especially with late state metastasis in breast cancer that many of those cancer, androgen receptor, they all were expressed, androgen, or AR receptors. So now the next movement, is to apply that androgen receptor molecular imaging that was developed for prostate cancer in patients with breast cancer, because up to 70 percent of patients express androgen receptors. You can actually treat them with androgen therapy, but you have to identify which sub-population will really benefit.
Chris Riback: See, this is just another example of what is so fascinating for me about these conversations. I would never have suspected that there were ways to translate learnings from prostate cancer to breast cancer. That just wouldn't seem, to a lay person that doesn't seem intuitive and yet that's central to some of the work that you've done.
Dr. Hedvig Hricak: And some of the advances, yes.
Chris Riback: Can we talk about another area of advances that you've made, in another kind of it connects with your theme of bringing knowledge from one place, maybe you know from one part of the body to another, but also from one location to another. And that's a cross border collaboration. This is a another just wonderful aspect of your impact and it's incredible work. Tell me how does it work, how have you connected a global network of breast imaging radiologists who are working together, and I'm quoting here 'with a single goal of improving breast cancer patient outcomes worldwide. How have you created that cross border collocation?
Dr. Hedvig Hricak: Evelyn Lauder and Larry Norton were absolutely crucial in the sense of, to make this a reality. Very often in life we have a wish list, we have a hypothesis or an idea, but unless you have a resource to make that happen, it always stays a dream. So Evelyn and Larry while they very much believed in research, development, and innovations how to change the cancer care of tomorrow, they understood that we are one global world, and medicine has no wells. So, therefore, all the way back in 2004, I was awarded an educational grant for really working worldwide and making sure that women around the world have access.
Dr. Hedvig Hricak: So the effort of global education is [incredibly] important. Just like Evelyn and Larry, I deeply believe it is our social responsibility in the ethics of our profession that every patient, no matter where they are should be helped and taken care of. And we understand that resource that we have in the western world is not the same as those available in a low middle income country. However, through education and training, you can make sure that those low and middle income countries have essential access to expertise and that expertise means training radiologists, so they know how to image, when to image, and how to interpret. And everything is global, so outreach and sharing our knowledge and that's really what academia can give and I think it is our responsibility as well.
Chris Riback: It's got to be an incredibly rewarding component of what you do.
Dr. Hedvig Hricak: Yes, it is. It is, if you the letters sometimes that you receive. People you help that you'll never know their faces, it is very very rewarding.
Chris Riback: What got you into this whole thing? How did you become a scientist? Was it always science for you growing up? Did you have other aspirations at some point? Tell me more about your background.
Dr. Hedvig Hricak: So, I love science, but when I was in high school and early on, I really liked mathematics and physics, and science and any analytics. And then I thought how to apply that love for science into medicine, because medicine actually it's an ultimate science. Because you combine everything from human factors, to mathematics, to physics, to biology, and it's just. It's so diverse, and combining then that love of biology and combining that with love of physics and mathematics, I went into diagnostic radiology.
Chris Riback: Did you start your career oversees and then came here? Or was it always here in the U.S.?
Dr. Hedvig Hricak: I started my residency in my home country, Croatia, but then I repeated everything in the United States.
Chris Riback: There's another effort that you are a part of that I want to ask about quickly before, before I let you go and that's the CCNY Memorial Sloan-Kettering Partnership for Research, Training, and Outreach. The goal of this training program is focused on minority students and it just feels like a way, and you'll correct me because maybe I'm interpreting it wrong. But on the one hand you have this cross border educational effort, you know reaching out to all corners of the globe, and then similarly in I guess, based in New York City, but you'll explain to me if it goes beyond that. You're focused on bringing in minority students as well, and crossing borders and expanding reach locally as well. Am I interpreting that correctly?
Dr. Hedvig Hricak: Yes. So it is the same passion, I believe that it's really important to make special effort to reach out and provide opportunities to those who may not otherwise have them. And it is important to make that special effort to reach out and diminish disparities in our own country, not just abroad. So, majority of the students at the City College of New York, especially those from under represented minority communities, they really came from socio economically disadvantaged, often disadvantaged family. Many are first generation college students, or they are from immigrant families.
Dr. Hedvig Hricak: Now this partnership is able to done, through the NIH funded partnership, with the City College. And the main goal is to mentor and support students offering them resources, MSK for stem and that is science, technology, engineering, and math program, as well as behavior science. So they can successfully just giving opportunity, so they can successfully conduct biomedical and behavior research. And then we also mentor them, we provide them guidance with regard to their career decision. An overarching goal is to increase the number of competitively trained underrepresented minority who enroll and complete, either in the PHD or combined MD/PHD program. The richness of life is in diversity, and you have to help them get there.
Dr. Hedvig Hricak: We do a very similar program with the New York City Department of Education, and this program is now going on for 15 years. Where, it's also an outreach that helps underrepresented minority students in New York City high schools. Now, in order to be enrolled in our program they have to write an essay, and then we grade the essays together with the teachers. So it's a program that really gives back to the teachers, to city of New York, and those high schools are such a pleasure to work with. It's program in science of course, and it's going on for 15 years, and it's getting bigger and bigger every year. And more and more popular, so as a person, as you and I, the best thing in life is to give. When you give, you receive much more than you ever thought it's possible.
Chris Riback: That's terrific. It's got to be an incredible amount of fun and so that of course makes me think as I you know prepare to let you go, so you do that incredible work with those students. You have created and have helped create this cross border effort. You are a pioneer, and a leader around imaging and then the interpretation of imaging across multiple cancer forms. You've won, you know, earned I should say, enumerable awards, including the most recent one from BCRF. I certainly hope you don't think me ungrateful Dr. Hricak, but what's next?
Dr. Hedvig Hricak: Well, there's always next. One of my guiding lights, that my faculty sometimes jokes about. I always say you are only as good as your tomorrow. So you have to continuously reinvent yourself. You have to learn and believe that with your work and experience, you'll make a difference in patients' lives. Not using tools of the yesterday, but using tools of today and tomorrow. So one of our big nexts, is supporting the development of theranostics. That's a new field which is beyond molecular imaging, because it actually combines molecular imaging and therapy.
Dr. Hedvig Hricak: One big part of precision medicine in order to choose a proper treatment you really have to have all the precision details about the disease. But theranostics approach where we develop targeted molecular imaging agents, so we can image and understand cancer biology. And then we develop drugs that are directed to the same target. So and very often they're attached to the same main molecule, or the agent that will act. So this provides the ability to see not only whether the drug has bonded or reached the target, but immediately shows you the effect within a few days that that drug is having. So the theranostics, is the next big step in allowing targeted treatment to be based on evidence, and the specific features of individual patients.
Dr. Hedvig Hricak: It's a dream, it's starting with an idea and a hypothesis, but we already have theranostics on the neuro endocrine tumor, which is superb. We in Europe, they're widely using theranostics for prostate cancer treatment, it's called the PSMA theranostics, hopefully we'll have that soon in this country. And one of the big dream is now, having a theranostics for breast cancer as well. And this is where that cross fertilization across different cancer, you learn you know, you learn a little bit how to do it and then you move forwards, to another horizon.
Chris Riback: That's a wonderful way of putting it, and it sounds like, you say that it is a dream but a wise and terrific scientist recently told me that, if you have a dream with the proper support those dreams can become reality.
Dr. Hedvig Hricak: And this is exactly how the educational grants started and all the others. You have a dream, you believe in it, and you persevere, and it does become a reality.
Chris Riback: Thank you. Thank you for this work, for the conversation and everything that you have done. I really enjoyed the conversation. Thank you.
Dr. Hedvig Hricak: Thank you.
Chris Riback: To learn more about breast cancer research, or to subscribe to our podcast, go to BCRF.org/podcasts.