October 05, 2020

Breast cancer research in COVID times

By Conor McKechnie and Dodi Axelson

Breast cancer research in COVID times

In 2020 much of life has been paused. But breast cancer keeps going. In this podcast episode hear from Dr. Margaret Flowers at The Breast Cancer Research Foundation on the impact of COVID and how every woman can still look after her health.

DODI: Conor, it is October.

CONOR: It is pinch, punch, first of the month, as they say here. Or in school playgrounds, now we're back.

DODI: And a flick and a kick for being so quick, then?

CONOR: Okay, that I hadn't heard, so props to you.

DODI: I'm not usually a mean girl, but it rhymes. So, it's fun. Anyway, with the arrival of October, there are certain things we start to see come back into our daily lives around us: rituals, nature changing…

CONOR: Autumn leaves, mushrooms, frosty mornings…

DODI: That's right, and ribbons.

CONOR: And ribbons, of course. Sorry...ribbons? What kind of ribbons?

DODI: Pink ribbons!

CONOR: Ah, yes, of course, Breast Cancer Awareness Month.

DODI: That's right. And you know what?

CONOR: That's what matters in today's episode, I guess.

DODI: Cue music.

CONOR: You know, I've always wondered why the symbol for breast cancer awareness month is a curled-up pink ribbon.

DODI: To get the story behind the symbol, we have to go back to the beginning of the 1990s. 1992, to be exact, which is when Evelyn Lauder co-created the pink ribbon and launched the Estée Lauder company's breast cancer campaign that was all about raising global awareness of the disease and galvanizing communities all around the world to support research.

One year later, in 1993, this was when Evelyn Lauder launched the Breast Cancer Research Foundation, which is the engine that fuels breast cancer research and is the first and only organization dedicated exclusively to this effort. So that's where the pink ribbon comes from.

GUEST: It's just a universal symbol of a disease that touches so many of us in different ways.

DODI: That is Dr. Margaret Flowers.

MARGARET: I’m the Director of Research at the Breast Cancer Research Foundation.

DODI: And she's going to be our guide for today's episode.

CONOR: So, how did Margaret get to where she is as Director of Research at the Breast Cancer Research Foundation? Or should we say BCRF for short?

DODI: Yeah, let's bring in an acronym. Absolutely. For most of her early career, she worked with food. And she was really into the question of nutrition.

MARGARET: I came into that very easily. My father was a chef. And I just sort of followed in those footsteps. And it was a very easy career to embark on and came kind of natural to me.

DODI: She did that for about 15 years.

MARGARET: And then I realized that I didn't want to do that the rest of my life. It's hard work. And I just, you know, I enjoy cooking. But it was so much the commercial aspects of it that I knew I wanted to stay with for the rest of my working life. And I'd always been interested in nutrition as well as cooking. So, while I was still a chef, I decided to go back to school to study nutrition.

DODI: Margaret says that. And, honestly, I can relate here, because my husband does all the cooking for the family. She was really looking for a way out of the kitchen.

MARGARET: And my plan was to combine my culinary background and experience with a nutrition degree and sort of a new career that wouldn't have me on my feet all day, if I could be perfectly frank. So, I went back to school and really surprised myself by falling in love with science, cell biology, and really, molecular nutrition. When we think about nutrition, we're often thinking about calories and weight control and those kinds of things. But I became very interested in what happens at the cellular level.

DODI: She quickly realized that she wasn't so interested in a nutrition career path as much as she was interested in pursuing research.

MARGARET: I then decided that I would continue after completing a bachelor's degree to get my graduate degree, so that I could pursue research in a nutrition field. Cancer was not on my radar by any means at this point. But during the course of my PhD, I was inspired by a nutrition professor who was involved in breast cancer research himself.

DODI: And in one of that professor’s lectures, he started talking about a drug that had been approved for prevention of breast cancer.

MARGARET: That drug was tamoxifen, which had been used for treatment of a type of breast cancer called hormone-positive, which is the most common type of breast cancer. It had been approved for prevention, what we call chemoprevention, of women that had a high risk of breast cancer coming back, or because of some other risk factors, had a high risk of being diagnosed with breast cancer.

And it was the excitement in his telling this story of what this advancement meant to the field and to patients diagnosed with breast cancer, or those at risk of being diagnosed with breast cancer. And I just remembered that, at that moment, feeling very empowered.

One of the reasons that breast cancer or cancer was not on my radar was because I lost my mother to breast cancer. It had been many years before, but I was her caregiver at the end of her life. And a career in research in breast cancer felt a little too close and a little too personal. I just didn't think it was something I wanted to embark on. But that story in that moment, just kind of lit a light bulb, and I just realized at that point that I could make a difference, that I wanted to pursue breast cancer research. And I felt empowered to do that. So, that's sort of how I ended up going into breast cancer research. And it ultimately brought me here to the Breast Cancer Research Foundation.

CONOR: Can we just get a little bit geeky on something that Margaret said? What exactly are we talking about when she says nutrition at a molecular level? What is that process?

MARGARET: The saying, you are what you eat, you can take that down to the cellular level. Our cells require energy, massive amounts of energy. They're little machines, they're little factories is what they are. Our cells are little factories, and they require nutrients to do all that work. The major nutrients that our bodies rely on are proteins, fats, and carbohydrates. And those are really the building blocks of our tissues, our bones, and our energy sources. So, the impact that our nutrition has affects how our cells function in just the very basic functions of what they were designed to do.

You know, our cells or all over our body have different roles to play, and the nutrients interact with signaling molecules in the cell, that sets off a process. Think about electronic circuitry, as signals are sent from one node to the other, to the other, to the other. That's really what happens when things interact with the cell, they enter the cell. And it depends on the nutrient, it depends on what is interacting with what sort of cascade that sets off, but a lot of it ends up affecting how our genes operate, what sort of signals they send out for the types of proteins that should be made. And those are the very fundamental components of our cellular biology, our tissue health, and the health of our bodies.

DODI: I really wanted to chat with Margaret not only about October as Breast Cancer Awareness Month and the science that goes into screenings and research, but specifically this year is very special, naturally, 2020. Let's just throw out the clichés, the new normal, the year of the COVID pandemics.

MARGARET: COVID has become the most urgent health concern, and rightfully so. It's still among us and continuing to take lives. And it really has become the most urgent health care concern.

But at the same time, breast cancer has not been put on pause. Okay, so, you know, so much of life has been put on pause. But breast cancer hasn’t. And so screenings and treatments on all of this still have to continue. But what's happened in COVID? And, you know, it's changing as the pandemic evolves, globally as well as locally, but initially any type of nonemergency medical procedures, which would include normal screening, were put on pause.

And this happened in the US in March through June, I think were the most impacted, but it continues because the pandemic is still around. So, what does that mean for diagnoses? Well, we don't know. And I don't think we'll know the full impact of COVID on breast cancer screenings and treatments for a long time. There is concern that delays in initiating treatment or delays in diagnosis can result in more advanced disease and poorer outcome.

DODI: And of course, the other side of this is that COVID has had this enormous economic impact in the loss of jobs, for example.

MARGARET: And so now millions of people have become uninsured. And there's the loss of access to their regular screening. And then of course, many, many women are electively choosing not to do their screening because they're uncertain about exposures. So, it's a combination of factors that has really pushed back regular screenings,

DODI: This has impacted Margaret, personally.

MARGARET: My own screening was pushed back by about three months. Three months is not going to really impact the mortality rate of breast cancer. But when we look at the longer term delays in screenings, that can really begin to have an effect.

DODI: I can relate to this. My own screening was delayed as well.

CONOR: And so can I. My wife and my daughter, you know, we talk a lot about the importance of health and selfcare and making sure that irrespective of the availability of screening, that we're looking after ourselves.

DODI: That's right, it all plays a part. So, while I had Margaret, the nutritionist there, I wanted to know what else women should be doing during these uncertain times.

MARGARET: We should all be aware of what's normal for our breast. Because if we're aware of what's normal, then we're going to be able to notice if something is different. You want to be vigilant in your own examination of your breast, you know, palpations, as well as physical appearance. And when things don't look right, then you really do need to follow up. But the caution about breast self-exam is that it's not a substitute for mammography, and it can miss and it often does miss things that are present.

So, it's really, really important not to delay a mammography for too long. If your clinic is doing mammography, then they are taking all precautions to keep their patients safe during those visits. COVID has impacted so many aspects of our normal routines, right – diet and exercise, the things that are always recommended for general wellness, but also have an association with breast cancer risk as well as breast cancer outcomes. It's important to stay physically active, you know, that's more difficult now, when we're on some kind of isolation or social distancing, staying at home, it's a little bit harder to do that. But walking is still a wonderful exercise.

And you can still take a walk with a friend and stay socially distanced and wear your mask and have an opportunity to chat and enjoy the company of your friend, enjoy the outdoors. Especially, you know, while the weather is still so wonderful. I think we tend to feel like we need to reward ourselves for our sacrifice. And I think there's just a little bit relaxing of some of our dietary normal practices. It's important to continue to maintain a well-balanced diet.

CONOR: Spoken like a true nutritionist.

DODI: Totally. But she's right, isn't she?

CONOR: Oh, absolutely. So, what does Margaret's say about the relevance of BCRF during the current pandemic?

MARGARET: A lot of resources have been diverted to addressing the pandemic, and that includes money for research. It also includes clinical trials that are prioritizing treatments for COVID. And then there's also just the treatment of patients. All that is important, but breast cancer has not been put on pause: every two minutes someone in the US is diagnosed with breast cancer.

And so in a way, what's happening as the focus shifts towards addressing the urgency of this pandemic is that our mission has become even more urgent, because it puts more pressure on nonprofit foundations like BCRF. And especially BCRF, because we are a small organization based in New York, but we're the largest nonprofit funder of breast cancer research around the world.

So, from this little office in New York, and right now from a lot of little home offices in New York, we're dedicated to continuing that mission. We cannot risk losing the progress that has been made: 40% reduction in breast cancer deaths in the United States in the last 30 years. And that's primarily because of advances in screening and early detection and treatments. We cannot take a pause here.

CONOR: Those are some staggering numbers.

DODI: Yeah, they are.

CONOR: Okay, breast cancer is not going anywhere, and BCRF is determined to continue supporting breast cancer research. So, what does Margaret see as the really exciting things that we can expect in 2021?

MARGARET: We hear a lot about immunotherapy. And immunotherapy has it's particular class of drugs called checkpoint inhibitors. They prevent the tumor from shutting off the immune system, basically the tumor evolved to cloak itself, so it hides from the immune system. Our immune system is perfectly capable of destroying cancers.

CONOR: Right. And anything that kind of harnesses the body's immune system to help it heal itself, that's a really hot field in many disease areas at the moment.

MARGARET: Exactly. But we haven't seen the success in breast cancer as we've seen in other cancers like lung and melanoma and some others. So, it's still a challenge.

Immunotherapy isn’t going to work as a single agent most of the time for most breast cancers. And so how can we combine other therapies, chemotherapy, radiation therapy, other targeted agents that will sensitize the tumors to immunotherapy? We're going to be seeing some exciting findings from the clinical trials about combination approaches that are going to be more effective than what we see with immunotherapy alone.

DODI: So, let's come back to where we are today, to the COVID pandemic. And, you know, one of the silver linings from all of this has been watching scientists cross geographical company lines, sharing information, research progress. Any good information that should be shared for the greater good is being shared. And I wanted to know what Margaret thought of this collaboration, of this spirit in the breast cancer field. She told me that this is nothing new for the breast cancer research field.

MARGARET: Breast cancer researchers really are a collaborative group. And we're really proud of the collaboration that goes on within our BCRF community of investigators, which is about 275 investigators around the world. But you bring up a really good point about how the experience with COVID has shown us how we can be better at what we're doing.

For instance, we’re trying to find a vaccine of treatment. People are dying from this disease; how do we treat it so that we can prevent the death? And so yes, we've seen people, we've seen groups, we've seen academics and industry coming together to answer these questions and get people in clinical trials. The ability to launch a clinical trial in weeks instead of months and sometimes years is a remarkable lesson to learn. Because clinical trials are the only way to advance treatment, any kind of treatment for patients, and delays in clinical trials, launching a clinical trial, we can't measure the impact of that on patient lives.

CONOR: Really, it’s just fantastic that we're carrying on with the focus on the awareness of breast cancer around October. I mean, it's obviously something we want people to be aware of all year round. Right, we've got November coming up, which has been, you know, relabeled as Movember. And one of the things that I think we need to really pay attention to just in our minds is, while COVID is there, and isn't going any anywhere for the short term, we've got to keep the focus on these longer term diseases that really affect everybody in the same way as they did before COVID. And perhaps even more so, right?

DODI: That's right. Cancer is not taking a break, unfortunately.

CONOR: It isn't, not at all. And you know, the hospital systems are under increased pressure, and people might be holding back from going for their screenings, and for potential early diagnosis. And the long-term knock-on effect of that could actually be even worse. I mean, we could potentially see cancer mortality go up as a result of this year of delayed screening, delayed diagnosis, and so on. And that's a real worry.

DODI: So, here's what people can do. They can go to bcrf.org or they can go to any of Cytiva's social channels during October to find an easy way to donate to breast cancer research.

So, thank you, everybody for listening to this episode. Know that cancer doesn't take a break. It is important. It is an extraordinary year. Take care of yourselves.

CONOR: And thank you for listening.

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