Breast cancer research in 2010 and the Breast Cancer Deadline 2020

CURE invited Laura Nikolaides, director of research & quality care programs at the National Breast Cancer Coalition, to share her thoughts on the 2010 meeting of the San Antonio Breast Cancer Symposium and NBCC's Breast Cancer Deadline 2020.One year I want to return home from the San Antonio Breast Cancer Symposium (SABCS) with great news for my daughter Kira, who is 11. I want to tell her that there were big new discoveries, and she won't need to worry about having breast cancer or going through the harsh treatments that her mom did.But leaving this year's meeting, the 33rd, I think about what I can tell her. We may have some new combinations of drug treatment or some new schedules that are just as good as the old ones or maybe a little better. We found out that several drugs don't work like we thought they would. We may have some new options for treatment that will be less toxic. But I cannot tell her that we are any closer to knowing how to avoid the disease or how to make sure no woman will die of the disease.If we meet the National Breast Cancer Coalition's Breast Cancer Deadline 2020, I will be able to deliver that news to Kira, just before her 21st birthday. Ending breast cancer is not a new idea for NBCC. It has been our mission since 1991. But despite scientific progress, greater knowledge of the biology of breast cancer, great strides in many areas of technology and movement toward targeted, less toxic treatments, we are falling short in significantly reducing morbidity and mortality from the disease. To harness the significant discoveries that have already been made, to shift the focus of resources, institutions and scientists to the work that will lead to ending this disease and to bring back a sense of urgency, NBCC has declared a deadline for ending the disease – January 1, 2020. We know that setting a deadline alone won't end breast cancer, but we believe a change in focus will. Business as usual is not working. A deadline will help us all reset the course. To meet our deadline, NBCC advocates believe that efforts must be focused on learning how to prevent the disease and learning how to prevent or stop metastasis. How relevant was the research presented at this year's SABCS? Not so good on the first aspect, learning how to prevent the disease, a little better on the second. There was acknowledgement of the need to understand tumor dormancy and metastasis to significantly reduce mortality, but unfortunately, not a lot of answers yet.The symposium was dominated, as it is each year, by sessions on variations in drug regimens and sessions on finding new drug targets to prevent cancer growth. But we've been following this approach for many years and gaining only incremental progress. We welcome any discussion and research on possible new approaches.The first plenary on Day 1 did focus on a somewhat new area for cancer research. Rather than a focus on a genetic pathway for tumor growth, Dr. Chi Van Dang talked about pathways of tumor metabolism, specifically how tumors get and use their fuel or energy. Could this be a new approach that opens up possible treatments or even prevention tools? Maybe new knowledge of how tumors work could help us meet Breast Cancer Deadline 2020. Unfortunately, there was little discussion on the implications for therapy, whether there are existing therapies that could work, or whether there might be non-drug ways to interrupt the energy metabolism of tumor cells. And there was also no opportunity to ask questions - I wanted to ask if it is less likely that a tumor will develop resistance to the treatment if you target an energy metabolism pathway versus a growth pathway. Eight presentations on therapy for ER-positive breast cancer - aromatase inhibitors (AI) and tamoxifen - followed the opening plenary. I was disappointed to see so much emphasis given to tweaking AI and tamoxifen therapy, though some of the data presented concerned reducing the amount of treatment received or finding solutions to treatment resistance, which are both important.The last session of the morning was an award lecture on circulating tumor cells, given by Dr. Klaus Pantel. Dr. Pantel presented data to show that 36% of women who had previously treated early breast cancer and no clinical signs of disease, have tumor cells in their bone marrow. He also presented data to show that women who have circulating tumor cells in the blood were more likely to experience recurrences. Dr. Patel said a key factor in reducing deaths from breast cancer will be in learning more about these circulating tumor cells and tumor dormancy, which is currently poorly understood.Speakers in the afternoon agreed that decreasing mortality from breast cancer will require having a better understanding of tumor dormancy and recurrence. Breast cancer has been known to recur up to 25 years after the primary tumor was removed. But unfortunately, more questions were asked than answered. What we don't know is how common is tumor dormancy, where the dormant cells reside in the body and what reawakens them, the speakers said. I was gratified to hear these discussions in the areas of focus that will be crucial to meeting the Deadline, but hope research will be focused over the next few years on answering these questions.If the first day was about tweaking drug therapy for hormone receptor-positive breast cancer, the second day was about tweaking drug treatment for HER2-positive breast cancer. But I sat up and took notice during the first presentation of the day, when the speaker spoke of moving beyond drug therapy. Dr. Neil Spector, of Duke University Medical School, spoke of the problems with resistance to current HER2-positive therapy and the possibilities of future combination therapies. But he finished his talk by saying that we can't keep continuing down this path of adding more and more expensive, targeted therapies - an approach that will make treatment out of reach for everyone but the very wealthy. He said instead, that he was convinced a better strategy would be to focus on immunology, particularly the development of a HER2 vaccine. The remaining talks of the morning mostly focused on refining anti-HER2 treatment, either through combination therapy or neo-adjuvant (before surgery) therapy. Dr. Eric Winer, of the Dana-Farber Cancer Institute, followed the sessions with a discussion of the benefits of neoadjuvant studies, including the ability to look for biomarkers that will predict how well the drugs will work in a patient and the ability to compare different drugs to each other more quickly, but he cautioned that we don't know yet if a pathological complete response predicts better survival. Finally, on Day 3 of SABCS, there were at least a few presentations on bigger change, beyond drug tweaking. Looking at things in a new way, and considering new approaches, is exactly what we will need to meet Breast Cancer Deadline 2020. The day began with a non-cancer researcher, Dr. Dan Ariely, talking about the "Upside of Irrationality." Dr. Ariely, professor of behavioral economics at Duke University, challenged the 10,000 clinical oncologists, cancer researchers and advocates at the symposium to reconsider what they think they know and recognize that often pursuing what we think is a rational approach, might be completely wrong. He presented research to show how things are not always as they appear to people, and that often, people must be willing to pursue what may seem irrational to get results.I hope the group had Dr. Ariely's presentation in mind when they heard the William McGuire Memorial Lecture given by Dr. George Sledge, of the Indiana University Simon Cancer Center, later in the morning. The consensus among many cancer researchers is to continue down a path of pursuing research on genetic mutations and drivers of cancer growth and to look for drug targets. But Dr. Sledge points out that where cancer has been viewed as a biology problem, with a focus on genetics it is now increasingly clear that it is becoming a mathematical problem. He used the phrase "genomic chaos" in talking about the increasing complexity of cancer genomics - the multiple genetic drivers of each tumor and the variability among individuals. The $1000 genome for individuals will most likely be available in the next three years, he said, making data cheap, but also leading to increased complexity. He demonstrated the mathematical difficulty of recruiting enough truly similar patients for a clinical trial of a targeted drug treatment, for instance, with this increase in genetic complexity. Dr. Sledge's presentation reinforced for me that continuing down this pathway in breast cancer research, the approach that has dominated for decades, appears to be increasingly futile in terms of finding the major breakthroughs for prevention and treatment of breast cancer. And circling back to what Dr. Ariely said, maybe we need to reassess our assumptions and decide if what we think has been a rational approach in breast cancer research may have been all wrong.Dr. Sledge finished his presentation by suggesting a few possible alternative approaches, including prevention approaches, an immune based approach or a metastasis suppression gene approach.I look forward to next year's SABCS, and hope that I will be able to report to my daughter that our Deadline work has begun to cause a shift in focus. I hope I can tell her that researchers are focusing efforts on learning how to prevent breast cancer and learning how to prevent or stop metastasis of the disease from taking women's lives, the things that will matter most for her generation. If we change the focus of the extensive resources devoted to breast cancer research now, we will meet our Deadline, which will be great news for Kira and her friends.You can find out more about NBCC's The Breast Cancer Deadline 2020 at www.stopbreastcancer.org.