Takeaways From Dr. Kaklamani From SABCS 2017

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Topics include: Treatment and Understanding

What are the highlights from the 2017 San Antonio Breast Cancer Symposium (SABCS). Dr. Virginia Kaklamani, Professor Medicine at UT Health Science Center San Antonio and Leader of the Breast Cancer Program at the Cancer Center, is a catalyst in the effort in new advancements in breast cancer. Watch as Dr. Kaklamani gives us some of the key points for breast cancer patients. 

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Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

Tamara Lobban-Jones:

Hello and welcome to this Patient Power program.  My name is Tamara Lobban-Jones.  Joining me is Dr. Virginia Kaklamani.  She is Professor of Medicine in the Department of Hematology and Oncology at the University of Texas Health Science Center in San Antonio.  She is also the leader of the breast cancer program at the cancer center in addition to the co-director of this symposium itself. 

Dr. Kaklamani, having attended the 2017 San Antonio Breast Cancer Symposium recently, what is the headline, the leading headline for you and its takeaway for patients? 

Dr. Kaklamani:

For me, the leading headline is really individualization of care.  We're seeing patients that are getting de-escalation of care, so less treatment than we typically do, because they don't need as much treatment.  We're seeing patients receiving more aggressive treatments, because they need that based on the molecular subtypes of their cancer and the genomic makeup of their tumors.  So we're really getting to the point where we're treating each patient uniquely instead of putting all patients in one basket and saying we have to treat them all the same. 

Tamara Lobban-Jones:

Excellent.  Now, one of the studies out of the meeting focused on early-stage breast cancer and increasing the chemotherapy dosage.  Can you talk a little bit about that and whether it's ready for prime time or if there is a deeper dive in clinical trials in the future?

Dr. Kaklamani:

Absolutely.  So this was a large meta-analysis that was done by the Oxford Group, and they are known for their meta-analyses in breast cancer.  That means that they take clinical trials, and they put them all together.  They perform a lot of very complex statistical analyses and come up with results that are interpreting all of those clinical trials together.  And we're talking about thousands and thousands of patients in those trials, so we can now look at one analysis on them. 

So those trials looked at dose intensity.  What that means is we either give the chemotherapy more frequently.  Instead of every three weeks, we give it every two weeks.  We either give it every week instead of every three weeks, and we sequence the drugs, so instead of giving two drugs together we give one drug and then the other.  And when we look at this dose intensity what was found was that that's preferable.  It improves outcomes.  It helps our patients live longer and have longer disease-free intervals, and that's very important. 

Now, in practice we actually, at least I do this as standard of care, so I typically use chemotherapy every two weeks instead of every three weeks, because prior studies individually showed that that is beneficial.  But I don't know that that was adopted by every single oncologist in this country, and so this trial kind of helped us pass the message through that we should be doing this for our patients. 

Tamara Lobban-Jones:

You know, and with that, just looking through the patient lens here, I'd like to talk about side effects, because often that's a huge issue for patients.  You know, can you talk a little bit about the side-effect profile and what supportive care measures are in place for these patients that are undergoing dose-intensified regimens? 

Dr. Kaklamani:

Absolutely.  The meta-analysis did not look at side effects.  They were not able to do that because of the way we collect the side effects, and this is a totally different topic for our probably 10-minute conversation.  But when we have seen the individual sides, and we have looked at the side effects we've actually seen that most patients have less side effects by doing this dose-intense regimen, because we're also giving them supportive factors. 

We're giving them medications that boost their blood counts, and so their blood counts can tolerate this more intensified chemotherapeutic regimen.  And in most of those regimens, we actually finish sooner than we would in the longer regimens. And so—for me, I describe it as that the light at the end of the tunnel is a little bit brighter, because it's closer to us than if you give the every-three-weeks chemotherapy regimen. 

One thing that I've seen, and we've never really measured this, because it's hard to measure. When I give chemotherapy every two weeks instead of every three weeks, typically the patient feels bad initially after chemotherapy and they're slowly beginning to recover, and they don't seem to have a whole week to really recover before we give them the next chemotherapy. Whereas the three-week regimen they have that whole week to kind of feel a little bit more normal.  So fatigue might be a little bit worse, although in our studies, like I said, the side effects were better with the every-two-weeks regimen. 

Tamara Lobban-Jones:

And what a great time to talk about integrative cancer care.  Acupuncture, that was a big topic at the meeting.  There were studies showing that acupuncture was alleviating joint pain related—that was caused by some of the aromatase inhibitors.  Can you talk a little bit about that and—as it did show persistent and beneficial effect?  What else do you and your colleague expect to learn from this study? 

Dr. Kaklamani:

Well, this is such an important study, right, because we're finally addressing patient's symptoms.  We may not be addressing how to treat and cure breast cancer, but we are addressing our survivors, and we have more and more survivors out there every single day that we are exposing to medications, a lot of which have a lot of toxicity.  And if the patient has a lot of toxicity from the medications, they're not going to take it. And if somebody doesn't take a medication, it's not going to work.  So it's extremely important that we address that so that we can keep compliance high.  And compliance with aromatase inhibitors is not very high, and it has to be high. 

So acupuncture, I'm a firm believer in it, not just for addressing what we call musculoskeletal issues, meaning achiness in the joints that women have, but it's been shown that in women that are on chemotherapy it helps with their nausea.  It helps them get through the chemotherapy better.  The issue that we have with all these studies is how do you—how do you standardize acupuncture? 

And you have a lot of patients, a lot of different acupuncturists all around the world that are trying to do acupuncture, which is not a very standardized procedure.  On the study they did a really good job in standardizing it, but if I tell a woman, oh, yeah, go to any acupuncturist you can find and do this, I'll have no idea what kind of acupuncture they're getting. And if it's the exact same one, they got onsite.  But it won't hurt. 

Now, insurance companies typically don't pay for acupuncture, so that's something.  The cost may be an issue, and it is for a lot of our patients.  But it has been shown that acupuncture works in helping with many symptoms, not just the musculoskeletal. 

Tamara Lobban-Jones:

Across the cancer spectrum experts are noticing molecular abnormalities have been linked to increased risk of certain cancers including breast cancer.  I have more of a personal question.  You know, for many women getting genetic screening in early gestation, these genetic panels and meeting with genetic counselors for screening, would that be a good point to get a—for those women to get a full panel?  And I understand not all women are having children, but it was something offered to me, and it was costly, but I certainly saw the benefits of it.  Is that something that in clinic or with your colleagues, is that a conversation that's being broached? 

Dr. Kaklamani:

Well, a couple years ago Mary-Claire King, who is really the mother of the BRCA1 and 2 testing, came out and advocated for testing in every single woman over the age of 25 for BRCA1 and BRCA2.  Now, this has not been implemented really for many reasons.  But what's important to recognize is the fact that around 50 percent of the individuals that are BRCA positive have no family history.  So me relying on somebody's family history basically means that I'm missing 50 percent of the individuals, and I'd rather find the BRCA mutation earlier before they develop cancer to prevent them from getting the cancer than find them as a patient when we develop cancer. 

So I don't know when the right time it is to do this genetic testing.  There's a lot of other factors.  Cost is a factor, although these tests are becoming more and more cheap.  But it's also, there's issues with, you know, if you find a genetically positive result how is that going to affect your insurance?  How is that going to affect your employment? 

Now, there are laws that help us with that.  There's the GINA law that prevents discrimination based on genetic testing, but there are no laws, for example, for life insurance.  So if you wanted to get life insurance and you had a BRCA-positive result, the company might say I'm not insuring you.  So there's a lot of other issues that come into play which kind of prevents us from going into this large-scale genetic testing.  But I think this is definitely a conversation that every woman needs to have, and for the right women that now meet the very, very general guidelines that we have we should be offering genetic testing. 

Tamara Lobban-Jones:

Just one more question related to genetic testing.  I know some of your work includes raising awareness for genetic screening for GIST cancers, and our viewers, that's gastrointestinal stromal tumors.  Can you talk about the work there and its connection to breast cancer particularly the BRCA mutation? 

Dr. Kaklamani:

So one of the major studies that was presented at the San Antonio Breast Cancer Symposium was about a PARP inhibitor, talazoparib, in women that are BRCA1 or 2 carriers and how talazoparib was better than chemotherapy.  Now, we're talking about a targeted agent which is not extremely toxic, comparing it to chemotherapy, and it's the winner. 

So that kind of helps us a figure out a lot of things.  Now BRCA1- and 2-positive breast cancer patients are the minority of our patients, but there are several BRCA-like cancers, cancers that may not be BRCA positive but they behave like they are BRCA positive.  And we looked at a study where we looked at women that had triple negative breast cancer, the most aggressive cancer we have, and we found that in the patients that we identified being BRCA-like, those patients had a better response to carboplatin, which is one of the chemotherapies that we used, compared to patients that were not BRCA-like. 

So looking at this genomic subtype of the cancer may actually help a lot in how we treat our patients and what kind of chemotherapy we give them and what kind of targeted therapy we give them because these agents are currently available for ovarian cancer, and chances are very soon they will be available to our breast cancer patients as well. 

Tamara Lobban-Jones:

Dr. Kaklamani, for some patients following the meeting, they hear all these great things and this breaking news, but then they ask themselves, okay, what questions should I be now asking?  Are there a new set of questions I should be asking?  What are your thoughts there and any call to action or any actions that patients should—breast cancer patients should be taking following this meeting? 

Dr. Kaklamani:

I think the most important thing is, can I participate in a clinical trial?  Is there a clinical trial available for me, and does it make sense for me to go on this trial?  Just 3 percent of our patients are participating in clinical trials.  That means 97 percent of the people we see with cancer do not help us advance and help them advance their care. 

We know that women that—or any cancer survivor that participates in clinical trials has a better outcome.  We've done studies on that.  So patients that participate in clinical trials live longer than patients that don't participate in clinical trials.  And that's just 3 percent of those patients that this happens to, and it's a shame. 

Not only will these patients benefit, but the advances that we're going to make are going to be made so much quicker, faster, because we will have more information about new drugs, about new genomic tests, about new subtypes of breast cancer and how to treat them.  So to me every single meeting and all this research that's going on kind of reinforces to me that I just have to work harder.  I have to work harder to come up with new clinical trials, new tests, new treatments for my patients, and my patients need to see that and, as long as it's right for them, participate in this effort so that we can move that field forward. 

Tamara Lobban-Jones:

Dr. Kaklamani, Professor of Medicine at the University of Texas Health Science Center at San Antonio, thank you for joining me.  

Please remember the opinions expressed on Patient Power are not necessarily the views of our sponsors, contributors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. That’s how you’ll get care that’s most appropriate for you.

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Page last updated on January 19, 2018