BCRF has long recognized that our mission is global. Around the world, an estimated 2.3 million people are diagnosed with breast cancer—and devastatingly, outcomes vary drastically depending on where patients live.
This year, BCRF is supporting 34 researchers working in 14 countries, including BCRF investigators Drs. Sonya Reid and Lawrence Shulman, who joined BCRF’s Chief Scientific Officer Dr. Dorraya El-Ashry for a conversation about the global state of breast cancer. To end breast cancer, Drs. Reid and Shulman emphasize, we must close disparities in care and outcomes and work to improve cure rates both in the U.S. and abroad.
Watch the full video above or read an edited version of their conversation below this World Health Day.
Dr. Dorraya El-Ashry: We are thrilled to be here today with our leading breast cancer experts who are searching for ways to improve outcomes in low-resource communities in the US and countries around the world. … I'm very happy to introduce you to Dr. Lawrence Shulman, a specialist in the treatment of patients with breast cancer. His research includes development of new cancer therapies and implementation of cancer treatment programs in low-resource settings. He has helped establish cancer programs in Rwanda, Haiti, and Botswana—places where historically the chance for a successful outcome was greatly diminished just because of delayed and later stage breast cancer diagnosis. And I'd like to introduce Dr. Sonya Reid, who's working to help us better understand health disparities in breast cancer, young-onset breast cancer, and hereditary breast cancer. Specifically, she is investigating genomic differences that may be contributing to the racial survival disparity in breast cancer. Dr. Reid is also focused on improving healthcare delivery to underserved communities and increasing the representation of minority patients in clinical trials. She is also actively involved in breast cancer research in Jamaica, her home country as well. Dr. Schulman, you've been treating breast cancer patients here and around the world for over 40 years. Can you paint a picture for us of what the global state of breast cancer is today, and how it has changed?
Dr. Lawrence Shulman: I entered Harvard Medical School in 1971. And that was the year that President Nixon signed the National Cancer Act and declared his war on cancer. And that was one of the things that got me excited about this field, because we were starting to develop tools to treat our patients who had different forms of cancer. But looking back over those 50 years, what we were doing in the 1970s was pretty primitive, frankly, [and] really hard on our patients physically and otherwise. The cure rates were still very low. One of the remarkable things for me, looking back now over half a century, is how far we've come. And, frankly, it's also been through the help and vision and direction of BCRF, which is funding myself and Sonya and so many breast cancer researchers not only in the US, but around the world. And so today, 50 years later, we have remarkably better treatments; we have remarkably better survival rates. And the patients who are surviving are surviving with many fewer side effects than they had all those decades ago. But as you inferred, these advances are not available uniformly around the world. In many places, they're not available at all. When I first went to Rwanda in 2011, there wasn't a single cancer doctor in the country, and there was no cancer treatment. And if you got cancer, you died. That's what the patients would tell us. And it was true. As Sonya will talk about, there are also places in the US where we're not delivering the remarkable treatments that we've now discovered. We still have a lot of work to do.
DEA: Dr. Reid, we know that who survives the disease varies greatly, even right here in the US. Can you tell us about the work that you're doing to understand why these disparities exist?
Dr. Sonya Reid: When we think about disparities it's not just overseas in low-income areas. We see that right here in our backyard. Here in Nashville, for example, close to Vanderbilt, where I work, is a county hospital. We know that sometimes patients that receive care in certain environments don't get the quality of care that they need to receive—and that does impact their outcome. So when we think about disparities, it's a combination of factors. We think about access to adequate care, their social determinants of health. Where you live, are you able to access insurance? An NCI-designated site that may or may not accept the insurance that you have? What are some of your comorbidities even starting along the journey before diagnosis? Were you able to get screening at an adequate center that has the optimal screening machine? We also know that there are perhaps biological differences. We know that Black patients, for example, are more likely to have triple-negative breast cancer, and even patients that have hormone-positive breast cancer, perhaps are having even more aggressive types of hormone positive breast cancer. Then we talk about genomics. It’s an understudied area when we think about disparities, because we know that not enough Black patients are receiving genetic testing, not enough Black patients are receiving genomic assays to guide their treatment. … It’s one of those things that you really have to take layer by layer.
DEA: Larry, your career in research also includes the development of new cancer therapies and implementation of cancer treatment programs in these low-resource settings. What inspired you in the first place to focus on that area?
LS: I've always been interested in the delivery of cancer care … and that was a lot of my focus in the first decades of my career. But in the early 1990s, I met a guy named Paul Farmer, who was actually my intern at the Brigham, and we became friends. He was devoted to bringing health care to people around the world. He was the one who asked me to develop cancer programs and Rwanda and Haiti, which I did, and through the incredible support of BCRF have been able to develop [them] over more than a decade. There’s a humanitarian mission to this, obviously. We're a global community. … It's part of our responsibility in a country that does have more resources to try to figure out ways to make those resources available to other people in the world. There are two other things I'd like to mention. One, Sonya's mentioned biologic differences. And it's a complicated landscape. For instance, I work in East Africa and we're now starting to learn that many of the Blacks in the U.S. came from West Africa, which is where the slave trade came from. And it turns out that breast cancer is biologically different in East Africa and West Africa. We're just starting to learn about that. That type of knowledge, benefits everybody everywhere. The other thing I would say is that the things that we learn about how to provide complex and effective cancer care in resource constrained settings, like Rwanda, are actually applicable in lots of places in the U.S. … There's a lot of cross-learning between some of the underserved areas in the U.S. and some elsewhere in the world.
DEA: Dr. Reid, you started your career in Jamaica, and then came to the United States. Could you share with us a little bit about that experience?
SR: Lawrence set that up very nicely, because it's the same. That really was my lesson coming to the United States. Jamaica, beautiful island, but of course [it’s] under-resourced, a developing country. I did my medical school training there and saw a lot of unfortunate circumstances where patients were just not able to even have their cancer treated because they just did not have access to treatment. Or patients coming in with maybe a fungating mass because they didn't know what to do in between feeling that lump and getting diagnosed because there was no infrastructure for screening and diagnostics. That weighed on me heavily. You learn the optimal treatment [in a textbook] but you’re not able to offer adequate care to patients. And then fast forward, I came to the United States and did my residency training here in Nashville working at a county hospital. It blew my mind that in a developed country, I saw so many similarities: where these patients were coming in with sometimes late-stage diseases because they didn't have insurance, or they were underinsured, mistrusted the medical system. I almost felt I could connect more with some of these patients because of my background in Jamaica. When I think about global oncology, I really think about it more as a shared learning for us to really be able to apply what we learn here, elsewhere, and vice versa.
DEA: Yes, and Larry, maybe you could talk a little bit to that about your biggest takeaways from what you been doing there in Africa?
LS: Those are important points. And a lot of the things that make cancer care hard for patients to take advantage of, in a place like Rwanda, is poverty. Women are more worried about putting their next meal on the table for their children than they are about going and getting breast cancer screening or other medical care. Transportation is a huge issue in Rwanda. But when you look at Philadelphia, which is where I am, only a few miles from here in West Philadelphia, there are the same issues. When we ask our patients from West Philadelphia what the biggest obstacle to get coming and getting care in a timely fashion, they tell us transportation, and they're not that far away. If you're coming to get chemotherapy, you got to have somebody to bring you. Public transportation doesn't work for people who are getting four hours of chemotherapy and don't feel well. And then who's going to take care of the kids and who's going to bring the money in and work. Poverty, transportation, prioritization, food challenges, they’re present right down the block for me. So we have several initiatives. We are using some of the same strategies that we use in Rwanda in West Philadelphia: supplying transportation, working on food insecurity, working on housing and financial toxicity. Those are all the things we've done a decade in Rwanda. And we're now just starting to do in West Philadelphia.
DEA: Sonya, let's dive a little bit deeper into the biology and specifically the genomic differences that you're investigating. What do we know so far?
SR: When we think of genomics, there's tumor genomics and then there's germline that you're born with. Germline or somatic. A lot of the differences that I've been focused on as it relates to hormone receptor–positive breast cancer focuses on tumor differences. Because hormone-positive breast cancer is the most common type of breast cancer, even among Black patients. Triple-negative breast cancer is over-represented among Black patients, but hormone receptor–positive breast cancer still accounts for just around 70 percent of all breast cancer in Black patients. We think about why Black patients are still dying more frequently from HR-positive breast cancer. We’re looking at that tumor biology to try to answer some of those questions. … We found was that Black patients were more likely to have basal subtype of hormone receptor–positive breast cancer, which is actually more similar to a triple negative type of biology, so these are patients are perhaps not benefiting from hormone blockers as you would expect them to benefit and maybe should be treated more with chemotherapy, like triple-negative breast cancer is. … And then when we look at germline, it's a struggle, because patients are still not being tested for germline mutations, despite us having so many options for prevention and treatment. What we have seen is that in certain countries, the Bahamas for example, patients have more BRCA mutations. That’s not the same in Jamaica, which has even lower rates of BRCA mutations than the United States. There’s definitely a lot of admixture when we think globally about what hereditary breast cancer looks like, even among Black patients because we know there are ancestral differences. But a lot of times, we lump everyone together when we know that there are some inherent differences. My project that's funded by BCRF and The Estée Lauder Companies is looking at a diverse cohort for differences that may be accounting for some of these disparities among hereditary breast cancer patients, both from the tumor standpoint, as well as access to treatment.
DEA: What steps do we need to take to eliminate disparities here in the U.S. and around the world?
LS: Well, I wanted to emphasize what Sonya was just saying, because I think that's one of the answers to your question, which is: We need to understand breast cancer in different populations. The Breast Cancer Research Foundation has been wonderful and funding the work that I do in Rwanda and allowing us to do this, but we do it in a scientific manner. We keep incredibly careful records, because it's not clear that somebody who has hormone receptor–positive breast cancer is going to respond the same to treatments in Rwanda, as they are in the U.S. Not only do we need to figure out how to help patients have access to the treatment that they need, but we need to learn more about the biology of their disease and how they respond to the therapies. We can't go to Rwanda and assume that the same treatments that I'm using in Philadelphia for a Caucasian white woman are going to have the same effect. That knowledge helps everybody everywhere because it expands our basic understanding of breast cancer biology.
SR: I couldn't agree more. We need diverse representation in our trials. When we’re starting trials from the get-go, we’re asking: Are they set up in a way that's going to accommodate patients that have transportation barriers? Are those clinical trials intentional about opening at trials sites that have diverse patients? Or are we unintentionally or maybe intentionally excluding some patients? If so, then 10 years from now, we're not going to have these answers, because we didn't have those patients in studies.
DEA: What impact do you expect COVID-19 to have on research and patient care around the world? And what can we do to help?
SR: I worry that disparities where I am will worsen. Across the board, there have been delays in screening. Hopefully we're catching up some. … A lot of research funding slowed down as well, not just here but globally. I saw that even in Jamaica, where things were put on hold and haven’t started to ramp back up. … We really have to double down because we were going forward, then we went back, and hopefully we can catch up and then move forward.
LS: I would add a couple of points. I agree completely with Sonya. When the pandemic started in March of 2020, the breast cancer group at Penn was meeting every Monday, Wednesday, and Friday trying to figure out how to adjust our treatments because our hospital was full of COVID patients. It made us start to question why we did a lot of the stuff we do. We analyzed every approach that we had to every aspect of breast cancer care, and that helped us think about things with a clean slate. … The other thing that happened is that we had to think about new ways to do clinical trials, because patients were very restricted in their ability to come into our major centers. …We were using telemedicine more to communicate not only with our regular patients, but with our clinical trials patients. We were thinking about ways to have patients participate in clinical trials without the burden that we often put on them with extra visits. That has the potential to reduce some disparities in clinical trial enrollment. At Penn, we're proud of the fact that we have higher enrollment of Blacks in our clinical trials than the percentage of Blacks in our community. That hasn't happened by accident. We've tried to keep some of the things that we put in place during COVID to make clinical trials more accessible and more manageable for patients. COVID has been absolutely awful, but it made us do things in ways that were unconventional.
DEA: Let's finish by looking ahead to the future of research. What are you most excited about?
SR: I'm most excited about discovery. Breast cancer is such a fascinating field. … It’s truly fascinating how many drugs we have; how we have discovered HER2-low. [The field] keeps evolving. What I'm excited about is not actually another drug; what I'm excited about is us figuring out how to utilize these thousands of drugs we now have to make sure that we get them to all the patients that need them.
LS: I would echo that. It’s a fascinating time in the last few years have been unbelievable [new] understanding of the biology of breast cancer, and using that to develop these new drugs and understand who they're going to work for and who they're not going to work for. It’s really been a paradigm shift. I'm old enough to remember what it used to be like, and things are happening very, very quickly. … The advances that we're making now are huge, but it's just such a strong link. And this is what BCRF does. There’s this link between what happens in the laboratory, and what gets translated into new drugs, new paradigms or treatment, and as Sonya was saying, understanding different subsets of breast cancer better than we've ever understood them before. Making all of those linkages. And then finally, as we've been talking about, [we’re] figuring out how to make sure we get those new advances and new treatments, to everybody equally, both in the U.S. and elsewhere in the world.
DEA: The progress over the last 30 years has just been tremendous. And it is right now at such a rapid pace and progressing so quickly. But our urgent goal needs to be—and this is part of what BCRF does—making sure that everybody, every patient, no matter where they are or from where they come from, that they get benefits equally.
LS: BCRF worked hard, as we've all worked with you, to inch up the cure rate. When we do that, we save lives. And as Sonya said earlier, and as you've said, the cure rates now are so much better than they were one decade ago, two decades ago, three decades ago. But if you wanted to turn around and save literally 100 times the number of lives from breast cancer, we need to make what we now know available across the globe. Because right now, every year, millions of women across the globe are dying from breast cancer. And if they lived in Philadelphia or Nashville, they would have survived.
SR: I truly want to emphasize that. A lot of resources go into the next big drug. And I'm so excited about drug discovery as well. But we know that patients, despite getting adequate care, still die from breast cancer. And it's still a frustrating experience when you're treating patients and you run out of options. But when we think about everything we have now, if we could get it to everyone, as Larry said, can you imagine what this conversation would look like?
Find more video interviews with BCRF investigators from our Behind the Breakthroughs series here.
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